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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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Subarachnoid hemorrhage
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


Intracerebral hematoma
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%)


Aneurysms
ANEURYSMS

CURRENT “HOT” ISSUES

Management approach for UIA

Treat or not?

Endovascular and Microsurgical indications (“or” not “vs”)


Unruptured intracranial aneurysms
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


Aneurysm treatment
ANEURYSM TREATMENT

ICA Stenosis ICA Aneurysm

Egas Moniz 1927


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


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


UNRUPTURED INTRACRANIAL ANEURYSMS

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


Endovascular or surgical treatment
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%)


Treatment of Ruptured Aneurysms

Endovascular procedures are less traumatic

Surgical clipping is more effective


Developments in Endovascular Treatment

Faster than Surgery

Balloons

GDC coil

3D coils

Bioactive coils

Liquids (Onyx,Neuracryl)

Stent and Balloon assisted



Aneurysms1
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


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


Developments in Microsurgery

Minimally invasive techniques

New clip models/instruments

Better microscopes

Intraoperative Evaluation

Doppler micro probes

ICG/Infrared 800



Aneurysms2
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


SUPRAORBITAL

MICROPTERIONAL


Keyhole view
Keyhole view

ANEURYSM



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 ?


VASOSPASM TREATMENT

Statins

Erythropoeitin

Nicardipine prolonged

release implants


Arteriovenous malformation
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)



Avm management
AVM MANAGEMENT

NO TREATMENT

MICROSURGERY

ENDOVASCULAR SURGERY

RADIOSURGERY


Factors to consider
FACTORS TO CONSIDER

Effectivity

Mortality

Morbidity

Time element

Cost


Microsurgical small avms 3cm
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)


Pgh series
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


Embolization for avm
EMBOLIZATION FOR AVM

PGH: 16 - 20cases/ yr

Cure in 10%

Partial targeted embolization in the rest


Embolization
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%


Embolization1
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?



Radiosurgery obliteration rate series
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


Risk of rebleeding after radiosurgery
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%


Mortality after radiosurgery
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


Arteriovenous malformation1
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


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%


Lessons learned
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


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


Recommendations
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


Avm management1
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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