NEUROSURGICAL MANAGEMENT OF STROKE:PRACTICE TREND IN THE PHILIPPINES
GERARDO D. LEGASPI M.D.SECTION OF NEUROSURGERY
DEPARTMENT OF NEUROSCIENCESUNIVERSITY OF THE PHILIPPINES-PHILIPPINE GENERAL HOSPITAL
PHILIPPINE DEMOGRAPHICS
95 M Filipinos107 Neurosurgeons
60% in Urban Centers (Manila, Cebu,
Davao)97% General Surgeons
2 Ped Neurosurgeon1 Spine Neurosurgeon1 Vascular “hybrid” Neurosurgeon1 Endovascular Neurosurgeon
ENDOVASCULAR SERVICE
2 Neurosurgeons (Manila)
8 Interventional Radiologists6 in Manila2 in Cebu
Bulk of cases done by Neurosurgeons
2 Neurosurgeons6 Interventional Radiologists
2 Interventional Radiologists
“Yesterday, all my troubles seemed so far away”Lennon and McCartney
Aneurysm ClipICH EvacuateAVM ExciseInfarct “Pa complete”
STROKE PROFILE
1,200 cases/year 63% Infarct28% ICH 9% SAH
Overall Mortality 12%“Infantile” Stroke Unit Limited MRI/Cathlab useMainly Indigent patients
800 cases/year72% Infarct21% ICH 7% SAH
Overall Mortality 5.5%Established Stroke UnitMRI/Cathlab open 24 hrsMainly private patients
2006 PGH Stroke Data ( Diosdado Macapagal Stroke Unit)
Infarct 50%ICH 40%SAH 10%
Causes of MortalityNeurologic 86% (Herniation/Brainstem)Non-neurologic 14%
STROKE TYPES
INTRACEREBRAL HEMATOMASpontaneous supratentorial ICH
INFARCTSArterial stenosis/occlusion
SUBARACHNOID HEMORRHAGEAneurysms/AV Malformations
Intracerebral Hematoma
Affects 10-20 people /100,000 /yearworldwide
Asians (Chinese and Japanese) 30-35%Americans (African-Americans) 10-15%.
Philippine dataManila - 30% of stroke admissions
(7 teaching hospitals ) Cebu City 25-30% of all stroke admissions ( 6 PCP
training hospitals )
SURGERY FOR SUPRATENTORIAL ICH
STICH I Neutral ResultsSTICH II On going
<48 hours GCS : Motor 5/Eye opening 2Purely Lobar 1 cm from the surface 10-100cc
2006
Patients may benefit with surgery: Basal ganglia or thalamic GCS > 4 Supratentorial ICH > 30 cc (Level IV-V, Grade C)
SSP 2006 Recommendation
Surgery for pts in coma but not herniated – • hematoma is located on the BG,cerebellum• family is willing to accept the consequences of persistent vegetative state / irreversible coma• Goal is reduction of mortality (survival)
Courtesy of Dr. Carlos Chua
INTRACEREBRAL HEMATOMA
1,200 cases/year
ICH 28% Operated 21%
Overall Mortality 17.5%
800 cases/year
ICH 21% Operated 20%
Overall Mortality 12.9%
Distinct Critical Events in ICH(1st 24 hrs)
Unstable clot
Hematoma enlargement Thrombin-induced Neurotoxic edema
Timing of Sx InterventionUltra early Morgenstern, 2001• POOR outcome• complicated by rebleeding
Early
“Early”
Kaneko, 1983 • 83% GOOD outcome
Zuccarello, 1999• 56% GOOD outcome STICH, Mendelow, 2005
• NEUTRAL
0 3 6 12 18 24 30 HRS
Rebleeding
Author / Yr No of Cases Surgical method % Poor Outcome
M S M SMcKissock,1961 91 89 Craniotomy 66 80Juvela, 1989 26 26 Craniotomy 81 96Auer, 1989 50 50 Endoscopic aspiration 74 58Batjer, 1990 13 8 Craniotomy 83 78Chen, 1992 63 64 Craniotomy / stereo /
ventricular drainage50 63
Morgenstern, 1998 16 15 Craniotomy 69 50Zucarrello, 1999 11 9 Craniotomy /
stereotactic aspiration64 44
7 RCTs on Surgery for Supratentorial ICH
Fernandez,H et al. Stroke 2000; 31:2511-2516Courtesy of Dr. Carlos Chua
Benefit of Surgery in Certain Subgroup of ICH Pts
Study No Case Surgical technique
Outcome (%)
Kaneko, 1977
38 Putaminal • Microsurgery• < 7 hrs
Good = 89Poor = 11
Kaneko, 1983
100 Putaminal •Microsurgery•< 7hrs
Good = 83 Poor = 17
Fujitsu, 1990
24 Rapidly deterioratin
g,putaminal
• Microsurgery• < 4 days
Good = 70Poor = 30
Nievas, 2005unpublished
59 Rapidly deterioratin
g,putaminal, > 30cc
• Microsurgery keyhole clot aspiration
Mortality = 16.9Patient selection & surgical technique DOES MATTER !
Putaminal Hemorrhage
