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
ICH Evacuate
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 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. 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

12. INTRACEREBRAL HEMATOMA
1,200 cases/year
ICH %
Operated 21%
Overall Mortality %
800 cases/year
ICH %
Operated 20%
Overall Mortality %

13. 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
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”

14. 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:

15. 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 !

16. 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

17. 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

18. CLOT
THALAMIC SUBSTRATE

19. 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