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NEUROSURGICAL MANAGEMENT OF STROKE:PRACTICE TREND IN THE PHILIPPINES

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

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NEUROSURGICAL MANAGEMENT OF STROKE:PRACTICE TREND IN THE PHILIPPINES

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  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 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 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 28% Operated 21% Overall Mortality 17.5% 800 cases/year ICH 21% Operated 20% Overall Mortality 12.9%

  13. 0 3 6 12 18 24 30 HRS Unstable clot Distinct Critical Events in ICH (1st 24 hrs) Rebleeding Hematoma enlargement Thrombin-induced Neurotoxic edema 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 Courtesy of Dr. Carlos Chua Fernandez,H et al. Stroke 2000; 31:2511-2516

  15. Benefit of Surgery in Certain Subgroup of ICH Pts Putaminal Hemorrhage 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

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