NEUROSURGICAL MANAGEMENT OF STROKE:PRACTICE TREND IN THE PHILIPPINES GERARDO D. LEGASPI M.D. SECTION OF NEUROSURGERY DEPARTMENT OF NEUROSCIENCES UNIVERSITY OF THE PHILIPPINES-PHILIPPINE GENERAL HOSPITAL

PHILIPPINE DEMOGRAPHICS 95 M Filipinos 107 Neurosurgeons 60% in Urban Centers (Manila, Cebu, Davao) 97% General Surgeons 2 Ped Neurosurgeon 1 Spine Neurosurgeon 1 Vascular “hybrid” Neurosurgeon 1 Endovascular Neurosurgeon

ENDOVASCULAR SERVICE 2 Neurosurgeons (Manila) 8 Interventional Radiologists 6 in Manila 2 in Cebu Bulk of cases done by Neurosurgeons

2 Neurosurgeons 6 Interventional Radiologists 2 Interventional Radiologists

“Yesterday, all my troubles seemed so far away” Lennon and McCartney Aneurysm Clip ICHEvacuate AVM Excise Infarct “Pa complete”

STROKE PROFILE 1,200 cases/year 63% Infarct 28% ICH 9% SAH Overall Mortality 12% “Infantile” Stroke Unit Limited MRI/Cathlab use Mainly Indigent patients 800 cases/year 72% Infarct 21% ICH 7% SAH Overall Mortality 5.5% Established Stroke Unit MRI/Cathlab open 24 hrs Mainly private patients

2006 PGH Stroke Data ( Diosdado Macapagal Stroke Unit) Infarct 50% ICH 40% SAH 10% Causes of Mortality Neurologic 86% (Herniation/Brainstem) Non-neurologic 14%

STROKE TYPES INTRACEREBRAL HEMATOMA Spontaneous supratentorial ICH INFARCTS Arterial stenosis/occlusion SUBARACHNOID HEMORRHAGE Aneurysms/AV Malformations

Intracerebral Hematoma Affects people /100,000 /year worldwide Asians (Chinese and Japanese) 30-35% Americans (African-Americans) 10-15%. Philippine data Manila - 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 Results STICH II On going <48 hours GCS : Motor 5/Eye opening 2 Purely Lobar 1 cm from the surface cc

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 hematoma is located on the BG,cerebellum family is willing to accept the consequences family is willing to accept the consequences of persistent vegetative state / irreversible of persistent vegetative state / irreversible coma coma Goal is reduction of mortality (survival) 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 (1 st 24 hrs) Unstable clot Hematoma enlargement Thrombin-induced Neurotoxic edema Timing of Sx Intervention Ultra early Morgenstern, 2001 POOR outcome complicated by rebleeding Early “Early” Kaneko, % GOOD outcome Zuccarello, % GOOD outcome STICH, Mendelow, 2005 NEUTRAL HRS Rebleeding

Author / YrNo of CasesSurgical method% Poor Outcome MSMS McKissock, Craniotomy 6680 Juvela, Craniotomy 8196 Auer, Endoscopic aspiration 7458 Batjer, Craniotomy 8378 Chen, Craniotomy / stereo / ventricular drainage 5063 Morgenstern, Craniotomy 6950 Zucarrello, Craniotomy / stereotactic aspiration RCTs on Surgery for Supratentorial ICH Fernandez,H et al. Stroke 2000; 31: Courtesy of Dr. Carlos Chua

Benefit of Surgery in Certain Subgroup of ICH Pts StudyNoCaseSurgical technique Outcome (%) Kaneko, Putaminal Microsurgery < 7 hrs Good = 89 Poor = 11 Kaneko, Putaminal Microsurgery < 7hrs Good = 83 Poor = 17 Fujitsu, Rapidly deteriorating, putaminal Microsurgery < 4 days Good = 70 Poor = 30 Nievas, 2005 unpublishe d 59 Rapidly deteriorating, putaminal, > 30cc Microsurgery keyhole clot aspiration Mortality = 16.9 Patient selection & surgical technique DOES MATTER ! Putaminal Hemorrhage