1. 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

2. 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

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

4. 2 Neurosurgeons 6 Interventional Radiologists 2 Interventional Radiologists

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

6. 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

7. 2006 PGH Stroke Data ( Diosdado Macapagal Stroke Unit) Infarct 50% ICH 40% SAH 10% Causes of Mortality Neurologic 86% (Herniation/Brainstem) Non-neurologic 14%

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

9. 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 )

10. 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

11. 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

12. 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%

13. 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, 1983 83% GOOD outcome Zuccarello, 1999 56% GOOD outcome STICH, Mendelow, 2005 NEUTRAL 0 3 6 12 18 24 30 HRS Rebleeding

14. Author / YrNo of CasesSurgical method% Poor Outcome MSMS McKissock,1961 9189 Craniotomy 6680 Juvela, 1989 26 Craniotomy 8196 Auer, 1989 50 Endoscopic aspiration 7458 Batjer, 1990 138 Craniotomy 8378 Chen, 1992 6364 Craniotomy / stereo / ventricular drainage 5063 Morgenstern, 1998 1615 Craniotomy 6950 Zucarrello, 1999 119 Craniotomy / stereotactic aspiration 6444 7 RCTs on Surgery for Supratentorial ICH Fernandez,H et al. Stroke 2000; 31:2511-2516 Courtesy of Dr. Carlos Chua

15. Benefit of Surgery in Certain Subgroup of ICH Pts StudyNoCaseSurgical technique Outcome (%) Kaneko, 1977 38 Putaminal Microsurgery < 7 hrs Good = 89 Poor = 11 Kaneko, 1983 100 Putaminal Microsurgery < 7hrs Good = 83 Poor = 17 Fujitsu, 1990 24 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