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Neurosurgical Stroke Management trends - Philippines

Neurosurgical Stroke Management trends - Philippines. PART II. SUBARACHNOID HEMORRHAGE. ANEURYSMS Current Western Trend 50-90% coiled Clipping/Coiling trend reversed in 8 yrs Philippines Phil Gen Hospital 120 cases/yr 7% coiled Coiling rate higher in other private centers.

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Neurosurgical Stroke Management trends - Philippines

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  1. Neurosurgical Stroke Management trends - Philippines PART II

  2. SUBARACHNOID HEMORRHAGE ANEURYSMS Current Western Trend 50-90% coiled Clipping/Coiling trend reversed in 8 yrs Philippines Phil Gen Hospital 120 cases/yr 7% coiled Coiling rate higher in other private centers

  3. INTRACEREBRAL HEMATOMA 2007 Jan to Oct Total Aneurysms 107 Clipped 98 Coiled 9 (10%) 2007 Jan to Oct Total Aneurysms 14 Clipped 11 Coiled 3 (25%)

  4. ANEURYSMS CURRENT “HOT” ISSUES Management approach for UIA Treat or not? Endovascular and Microsurgical indications (“or” not “vs”)

  5. UNRUPTURED INTRACRANIAL ANEURYSMS ISUIA II Prospective Study Treat Anterior >7mm Posterior circln Observe Anterior <7mm Editorial Comments 17% were intracavernous, included to increase accrual rate Aneurysms known to have very low bleeding rate Actual rate may have been underestimated

  6. ANEURYSM TREATMENT ICA Stenosis ICA Aneurysm Egas Moniz 1927

  7. Unruptured Intracranial Aneurysms Small ones (<7mm) may also rupture Young pxs with HPN specially post circulation and pcomm Nahed et al 2005 May grow if > 5mm, MCA, Multiple and associated w previous SAH Myazawa 2006

  8. Unruptured Intracranial Aneurysms May show racial/regional differences in rupture rates Japan UIA study 2.7% annual rate (ISUIA 1%) Morita et al 2005 50% will opt for surgery Loftus 2007

  9. UNRUPTURED INTRACRANIAL ANEURYSMS Even if < 7mm, should be evaluated for factors that may increase the likelihood of bleeding and be watched closely.

  10. ENDOVASCULAR OR SURGICAL TREATMENT ENDOVASCULAR TREATMENT ISAT Absolute risk reduction 6.9% < 100% occlusion in 6% Metaanalysis (Fraser et al 2006) 19 studies Surgery Endovasc Complications 11% 19% Reoperation 3.4% 12.5 % <100% occlusion (8.3-70.4%)

  11. Treatment of Ruptured Aneurysms Endovascular procedures are less traumatic Surgical clipping is more effective

  12. Developments in Endovascular Treatment Faster than Surgery Balloons GDC coil 3D coils Bioactive coils Liquids (Onyx,Neuracryl) Stent and Balloon assisted

  13. COVERED STENTS FOR ANEURYSM OSTIUM OCCLUSION

  14. ANEURYSMS Generally with good outcome with coiling Increasing cases 2004-2006 : 20-30/yr 2007 : 59 (Jan-Aug) (Boston Scientific) 2011 : 166 Modality shows good promise for comparable long term results with surgery

  15. ENDOVASCULAR TREATMENT WILL BE/(IS?) FIRST LINE OPTION ROLE OF SURGERY IN ANEURYSM TX Angioarchitecture deemed difficult for coiling Giant aneurysms/Fusiform Aneurysms +/- Bypass Surgery Hematoma evacuation then clipping Proximal occlusion of parent artery Economically not feasible Logistically not feasible

  16. Developments in Microsurgery Minimally invasive techniques New clip models/instruments Better microscopes Intraoperative Evaluation Doppler micro probes ICG/Infrared 800

  17. CERAMIC ANEURYSMS CLIPS

  18. ANEURYSMS Philippine Experience for Open Surgery Outcome at par with world standards Still primary option in government hospitals Residents still do a lot of cases PGH: 60-70/yr Trend towards “Keyhole Craniotomy” Incorported into residency training

  19. SUPRAORBITAL MICROPTERIONAL

  20. Keyhole view ANEURYSM

  21. ARTERIAL REMODELLING

  22. Implication of Increased Coiling Less cases for Neurosurgical residents Eventually open surgery for aneurysms will be in high volume centers only More complex cases for surgery Extinction of General NS doing aneurysms ?

  23. VASOSPASM TREATMENT Statins Erythropoeitin Nicardipine prolonged release implants

  24. ARTERIOVENOUS MALFORMATION Not commonly seen Less surgical experience now for most neurosurgeons Tend to be sent to SRS even if with Hge Personal : Surgical if with hemorrhage and accessible Awake cranio for eloquent location SRS for “highly eloquent” (BS,BG) All modalities for treatment are available Microsurgery Radiosurgery ( 1 Gamma/3X Knife/ none in PGH) Endovascular Surgery ( 8 centers)

  25. “Awake” Craniotomy

  26. AVM MANAGEMENT NO TREATMENT MICROSURGERY ENDOVASCULAR SURGERY RADIOSURGERY

  27. FACTORS TO CONSIDER Effectivity Mortality Morbidity Time element Cost

  28. MICROSURGICAL –SMALL AVMS(<3CM) New Def Severe Dead Rebld Occl Sundt 1991 4.8% 2.2% 0% 0% 100% (n=84) Morgan 2000 2.7% 0% 0% 99% (n=110) Schramm 2004 5.4% 2.4% 0.9% 0.9% 98.2% (n=116)

  29. PGH Series 83 patients reviewed 2001-2005 (72 surgical and 12 endovascular) 44% present as hemorrhage Size Small (<3cm) 68% Medium (3-<6cm) 28% Large (= or >6cm) 10% Outcome for Surgery SM Grade 1-3 Morbidity 0-8% (across the grades) Mortality 0% Gigataras et al Asia Neurology Dec 2006

  30. EMBOLIZATION FOR AVM PGH: 16 - 20cases/ yr Cure in 10% Partial targeted embolization in the rest

  31. EMBOLIZATION EMBOLIZATION SERIES Oblit Rt Morb Mor 1995-2007 2.6-47% 1.9-15% 1.2-5.8% New Onyx Embo Material (5 series) Obliteration rate 16-20 % Rebleed 4-7% Deficit 4.6-24% Mortality 0-3.2%

  32. EMBOLIZATION Carries a risk, has mortality Cure is 10-15% range Its usage has benefit but there are attendant risks Not as a routine measure Dilemna: Is it worth adding the risk of embolization on top of the risks of micosurgery?

  33. RADIOSURGERY

  34. RADIOSURGERY-OBLITERATION RATE SERIES Author Year Obliteration F/U Pollock 1996 65% 11-44 mos Yamamoto 1998 50% Metaanlysis Friedman 1998 79% 3 yrs Niranjan 1999 65.5% 3 yrs Massager 2000 73% 3 yrs BS Hadjpanayis 2000 87% <10cc/25% >10cc 2.7 yrs MC Liscak 2007 74% 1-8 yrs +E

  35. Risk of Rebleeding after Radiosurgery Kjellberg 1988 (n=360) 8.5% Steinberg 1990 (n=86) 12.0% Lunsford 1991 (n=227) 4.0% Colombo 1994 (n=180) 8.3% Friedman 1998 (n=348) 7.2% Karlsson 1998 (n=112) 4.5% w re RS Pollock 1998 (n=220) 7.2% Niranjan 1999 (n=80) 8.0%

  36. Mortality after Radiosurgery Kemeny 1989 0% (Gamma Knife) Steinberg 1990 3.0% (Proton Beam) Lunsford 1991 3.5% (GK) Colombo 1994 2.8% (LINAC) Friedman 1995 0.6% (LINAC) Yamamoto 1998 1.5% (GK) Hadjipanagis 2000 3% Motor cortex Kurita 2000 13.3% Brainstem

  37. ARTERIOVENOUS MALFORMATION RADIOSURGERY Basal Ganglia,Thalamus Cure rate 61.9% Complication 19% Hemorrhage Rate 14.2% in 2 years Andrada,Sousa et al 2005 Motor Cortex Oblit Rate <3cc 87% Cxs 3% 3-10cc 64% Death 3% > 10cc 25% Hadjipanayis, Lunsford et al 2000

  38. Brainstem Kurita H (GK) JNNP 2000 n=80 with 52 mos f/u Nidus volume 1-2cc Oblit Rate 52.2% EMBO+SRS 50% Rebleed 16.7% Recurrence 20% Mortality 13.3% Massager and Lunsford (GK) JNS 2000 n=87 with 3 yrs f/u, 1.3cc Nidus vol. Obliteration rate 63% at 2 yrs 73% at 3 yrs Rebleeding rate 3.4% Mortality 1.1%

  39. LESSONS LEARNED We need all three modalities SMALL AVMS Microsurgery has the highest exclusion rate-with less mortality and comparable rate of complications of all 3 modalities LARGER AVMS RS carry markedly higher risk, exclusion rate is higher in microsurgery

  40. RS role significant in selected cases The role of embolization as a routine presurgical adjunct is not yet clear The main application of embolization is transformation of a high risk large AVMs to lower risk operable ones

  41. RECOMMENDATIONS AVMs Spetzler Martin Gr I-III Usually for microsurgey, specially when ruptured, unless highly eloquent in location (brainstem,basal ganglia) 10% may be amenable to embolization AVMs S/M IV & V No treatment if asymptomatic. If symptomatic and high risk, embolization is recommended to relieve symptoms or as a pre-surgical step

  42. AVM MANAGEMENT Trainees should be ensured of surgical cases if excision is coming out to be the better option Choose carefully the cases for SRS/embolization If surgeons lose the skill we might end up with less than ideal management options

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