indikasi bedah pada stroke

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Surgical Indicationof Stroke

Handoyo PramusintoNeurological Surgery Division

Sardjito Hospital

N Engl J Med, Vol. 344, No. 19 , May 10, 2001

www.nejm.org


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Case Presentation

57 year old female

,

Slurred speech

Collapsed

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Physical Exam

T 99.4 P52 BP 195/99 RR13

Pu ils-2 mm reactive

Neck-no JVD, bruits

CV-bradycardia, no murmurSkin-warm and dry

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Neurological Exam

Neurological exam:

no a reflex withdraws to ain

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GCS

Eyes-1

-

Motor-4

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CT Scan

Intracerebral hemorrhage 6


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Blood Clot

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Pathophysiological features

Common site

A. Cerebral lobe

C. Thalamus

D. Brain stem (pons predominantly)

E. Cerebellum

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Intracerebellum hemorrhage10


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Intraventricular hemorrhage

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Subarachnoid hemorrhage

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Key Clinical QuestionsWhich ICH patient require surgery?

o ume o ema oma

Location

Clinical presentation ( GCS, BP )

Facility ( ICU )

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Key ConceptsTwo key concepts:

Intracranial pressure

Elevated when ICP >20 mm Hgere ra per us on pressure

CPP=MAP-ICP

Must maintain ICP > 70 mm Hg

Example: MAP = 100, ICP = 20

CPP in above example = 80 mmHg

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Increased ICP TreatmentIntracranial Pressure (ICP): considered amajor contributor to mortality whenelevated

Controlling ICP is considered essential

Osmotherapy

HyperventilationBarbiturate coma

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OsmotherapyOsmotherapy-Mannitol

Reduces cerebral edema by decreasing

Rebound effect-use less than 5 days

20% solution

0.5-1.0 mg/kg maintain serum osmolarity310-320 mOsm/L

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HOB Elevation

Elevate head of bed-decrease ICP

Mechanical-helps drain blood by gravityDoes not allow blood to pool in cranium,

which may occur if patient is left laying flat

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ICP MonitorsAHA recommends ICP monitors in

patients with a GCS less than 9 and allbe deteriorating due to elevated ICP

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Non-Surgical ICH PtsSmall Hemorrhages (10 cm3)

Minimal neurological deficitsGCS < 4 (excluding cerebellar

hemorrhage with brain stem

compression)

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Key Learning PointsMost ICH patients are non-surgical

Consult your neurosurgeon early

-

There are promising new therapiessuch as Factor VII on the horizon


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DiagnosisCT scan infarction or hemorrhage

Location and size of the hematoma

Hydrocephalus

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CT scan demonstrating the R MCA territory infarction

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CT scan on day one, demonstrating evolving R MCAinfarction with mass effect and compression of the

ventricular system.

Clinical examination revealed right midriazis

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CT scan, one day after hemicraniectomy

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CT scan, one month posthemicraniectomy, with resolution of

previous midline shift

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ManagementEvaluation & management inthe ER

Decreased level ofof reflexes the protect airway Intubation !

Urgent CT scan, NS

consultationHyperventilation, intravenousmannitol and intraventricularcatheter for drainage.

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Management

Intensive monitoring ofneurologic &cardiovascular status

the first 24 hrs

GCS, hourly

BP

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Mass effect & intracranialhypertension

Hematoma, edema tissue,

Management

o s ruc ve y rocep a usherniation !

Use of hyperventilation andosmotic agent improved thelong-term outcome

Corticosteroids should beavoid !

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ManagementManagement ofblood pressure

Elevation of blood

pressure expansionof hematoma poor

outcome !

AHA guideline

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ManagementVentricular blood andhydrocephalus

Blood in ventricles obstructive hydrocephalus

high mortality rate !

External drainage

Clots in the catheter andinfection

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ManagementSurgical evacuation

Reduce mass effect, block the release of

neuropathic product from the hematomaurgery or supra en or a emorr age

Hankey et al:

126 not undergo surgery

123 surgical evaculation through an open

craniotomysurgery higher rate of death (83% vs 70%) / 6m

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ManagementCerebellar hematoma

Can be approached with

minor damageecompress on o ra n

stem

Surgical GCS < 14,

volume > 40 ml

Conservative treatment

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