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