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 ICH Evacuate 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 10-20 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 10-100cc

SSP 2006 Recommendation Patients may benefit with surgery: Basal ganglia or thalamic GCS > 4 Supratentorial ICH > 30 cc (Level IV-V, Grade C) 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 Thrombin-induced Neurotoxic edema Unstable clot Distinct Critical Events in ICH (1st 24 hrs) Rebleeding Hematoma enlargement Thrombin-induced Neurotoxic edema 0 3 6 12 18 24 30 HRS Ultra early Morgenstern, 2001 POOR outcome complicated by rebleeding Timing of Sx Intervention Kaneko, 1983 83% GOOD outcome Early Zuccarello, 1999 56% GOOD outcome STICH, Mendelow, 2005 NEUTRAL “Early”

7 RCTs on Surgery for Supratentorial ICH Author / Yr No of Cases Surgical method % Poor Outcome M S McKissock,1961 91 89 Craniotomy 66 80 Juvela, 1989 26 81 96 Auer, 1989 50 Endoscopic aspiration 74 58 Batjer, 1990 13 8 83 78 Chen, 1992 63 64 Craniotomy / stereo / ventricular drainage Morgenstern, 1998 16 15 69 Zucarrello, 1999 11 9 Craniotomy / stereotactic aspiration 44 Courtesy of Dr. Carlos Chua Fernandez,H et al. Stroke 2000; 31:2511-2516

Rapidly deteriorating, Benefit of Surgery in Certain Subgroup of ICH Pts Putaminal Hemorrhage Study No Case Surgical technique Outcome (%) Kaneko, 1977 38 Putaminal Microsurgery < 7 hrs Good = 89 Poor = 11 Kaneko, 1983 100 < 7hrs Good = 83 Poor = 17 Fujitsu, 1990 24 Rapidly deteriorating, putaminal < 4 days Good = 70 Poor = 30 Nievas, 2005 unpublished 59 putaminal, > 30cc keyhole clot aspiration Mortality = 16.9 Patient selection & surgical technique DOES MATTER !

Endoscopic Evacuation Selection criteria Thalamic hemorrhage with IVH due to hypertension GCS 12 and below Surgery performed within 24 hours Excluded are patients who were comatose, on antiplatelet/anticoagulants,medical conditions Mariano et al St. Luke’s Medical Center

Surgical Technique Frontal Burr hole (ipsilateral or contralateral) Rigid endoscopes Lactated Ringer’s solution as irrigation Suction/Irrigation Clear up frontal horn first, look for landmarks(foramen of Munro,choroid plexus, or septum pellucidum) Hemostasis by washing and cautery Intraventricular ICP probe inserted Continuous EVD

CLOT THALAMIC SUBSTRATE

Preliminary Results of Endoscopy for TH Good ICP control, EVD removed by day 3 postop 14/15 patients improvement in level of consciousness, 1 got worse (rebleed), no mortality The hospital stay was 30% shorter and recovery was faster than previously treated patients (range 1 to 4 weeks) Only I patient needed a permanent VP shunt