Subject: Surgery

Topic: Stroke
Date: 11.04.2009
Lecturer: Dr. Alvarez
Transcriber: Sir Jerry
Subject Head: dakoko
No. of Pages:

OUTLINE
I.
II.
III.
IV.
V.

VI.
VII.
VIII.

Overview
Classification of Stroke
Acute Ischemic Stroke
Acute Hemorrhagic Stroke
Surgical considerations
A. Problems Needing Surgery
B. Rationale For Surgery
C. Selection Of Patients
D. Surgical Techniques
E. Outcomes Of Surgery
Recommendations
Conclusions
Questions

Hi to everyone. Hi to my hot hot girlfriend Lyn, whom without her, I cannot possibly get my brain
juices to work. Hi to Wardwork, commed, CPC, psych, etc groups. Hi to former dorm mates from DB
and SH. Hi to lyn and jane for my outfit. Jen for catering to my hopia needs. Hi to bean for helping
me study stroke, PVD and antibiotics. Hi to bobot for PSP stuff. hi to the people who went to daniels
party and buying food and drinks. Hello to my team mates and thanks for the good games we
always have. Mommy for helping me move my very large refrigerator to my new dorm. Ate twinkle
for letting me stay without paying for a few days. Ronald and khash who always listen to my jokes
without prejudice and for the kickass sounds I got from them which helped me a lot in making this.
My editor who is so considerate despite me being always late and he always forgives me a lot and
he is not angry at all for me being so late with this tranx and is so cool and all that stuff; he is without
a doubt the BEST editor among all editors; and is arguably THE EDITOR AMONG EDITORS. Most
of all thank you Jesus for being there when we need you and for blessing us with your powers of
love and grace.
Please help save our economy by buying bags from the 2 best distributors of bags ever known to
walk the face of the earth and beautiful as well, LYN and JANE. They cost, I think, around 300 each
bag and they are very awesome, and if you dont have one, then you are not cool at all.

SOURCE: Lecture, Some notes from Victor (Adams) hehehe...

STROKE
I.

OVERVIEW
A. clinical syndrome characterized by rapidly developing symptoms and/or signs of focal and at times global (as
in coma) loss of cerebral function, with symptoms lasting more than 24 hrs, or leading to death with no
apparent cause other than that of vascular origin.
B. if caused by a tumor/trauma, it is not stroke

Disorders of Platelets, Vessel Wall, and Coagulation

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II.

CLASSIFICATION OF STROKE
o Hemorrhagic stroke causing compressive mass lesion, ischemic stroke can be hemorrhagic as the
embolus may lyse, there is a sudden flow of blood, then vessel ruptures hemorrhage

III.

May be in the parenchyma (intracerebral) or over the brain (subarachnoid)

o intracerebral hemorrhage/hematoma 10%, parenchyma involved
o subarachnoid hemorrhage 7 %, involved the subarachnoid covering the brain

Ischemic stroke causing focal or diffuse infarction, not enough blood for the brain

May be thrombotic or embolic

o Embolic - very common, may be from the heart
o Thrombotic large-vessel (31%) carotid thrombus, small-vessel (20%)

Can convert to hemorrhagic stroke (hemorrhagic conversion) when the necrotic vessels breakdown
due to loss of blood supply of the vessels

Cellular cascades not having enough oxygen is worse than not having glucose since glucose can be converted
from other sources (gluconeogenesis)

No oxygen mitochondria cant produce enough ATP, cant maintain integrity of pumps/cell membrane/electrical
integrity of membrane (Na/Ca ) cell death

Spreading of neuron depolarization cellular mechanisms are deteriorated; when neurons depolarizes another
neurons; Worsens the ischemic events.

Associated injury other things that may not involved the brain.
The development of CVDs depend on collateralization (alternate blood supply offered to the ischemic
tissue). If neurons have sufficient collaterals, ischemia may not occur immediately.

Primary event refers to the problem (that causes stroke).

Secondary insults refers to other diseases/conditions that gives additional injury following a stroke.
(e.g. A patient had a stroke and fell resulting to head trauma.)

Comorbid states conditions that have already existed in the patient

Treatment should be done to prevent stroke from recurring thus address the risk factors present in
the patient (e.g. high cholesterol level, Hpn and heart disease)
o

Secondary prevention - prevention of a second stroke

Primary prevention preventing stroke from ever occurring

ACUTE ISCHEMIC STROKE

Note: hospitalization should extend to phase II and outpatient should be in phase III
This diagram is the same for Intracerebral hemorrhage

Acute Ischemic Stroke starts upstream (risk factors and causes)

2 causes of ischemic stroke
o Occlusion of blood supply (nagbara)
o Lack of blood supply (kinulang ng dugo)
The upstream events are more important in treatment than the primary insult.
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Primary injury diminution of blood flow

o The brain suffers, causing neurologic deficit depending on the area of the brain affected.
A. Arterial stenosis/occlusion
1. Atherothromboembolic
2. Arteritides
B. Venous occlusion
C. Hemodynamic/Pulmonary failure
1. Cardiac arrest
2. Drowning
o

penumbra collateral flow of with some viable neurons. Even if without blood but there is depolarization, neuron
will still be destroyed

Zones in focal ischemia

o Central Core (< 10ml/100mg/min): blood flow insufficient to maintain cell function
o Penumbra (10-20ml/100mg/min): blood flow sufficient to maintain cell viability but not electrical
activity
o Normal Brain (50ml/100mg/min)

Cellular Cascades
o Calcium overload
o Lipid peroxidation
o Free radical damage
o Proteolysis
o DNA damage
o Mitochondrial pore transition
o Apoptosis/necrosis

Secondary Injury
A. LOCAL (CNS)
Cerebral ischemia
Cerebral edema
Intracranial hypertension
Cerebral herniation
Seizures

B. SYSTEMIC
Hypoxia
Hypotension
Hypovolemia
Electrolyte imbalance
Acid-base abnormalities
Infection
Anemia

Co-morbid state 1 (primarily CNS in origin)

1. Previous stroke
2. Brain injury/surgery
3. Hydrocephalus
4. Seizure disorder
Co-morbid state 2 (systemic diseases)
1. Hypertension
2. Diabetes Mellitus
3. Heart diseases
4. Hematologic disorders
5. Hepatorenal problems
6. Gastrointestinal problems
7. Malnutrition
8. Chronic infections
9. Endocrinopathy
MORBIDITY
1. Stroke? TIA vs. Stroke
2. Nature? Ischemia vs. Hemorrhage
3. Localization? Stroke Syndromes
4. Etiology?
5. Risk Factors?
The Causes of Acute Ischemic Stroke
I.
Arterial Occlusion
A.
Large Artery Thrombosis
a)
Carotid Stenosis/Occlusion
b)
Carotid Dissection
c)
Vertebral Thrombosis/
B.
Intracranial Artery Thrombosis
a)
ICA, ACA, MCA, BA Thrombosis
b)
Moya-moya Disease
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II.

Cerebral Embolism
A.
Cardiogenic
B.
Arterial
C.
Miscellaneous

Normal pressure autoregulation is from 50 to 150 mm Hg range. Within the normal autoregulation range, the blood
vessels will dilate or constrict as CPP rises to increase cerebrovascular resistance and keep CBF constant. However,
below or above the normal autoregulation limit, the blood vessel caliber follows flow passively, leading to collapse of
vessels at low pressure and forced dilatation or pressure breakthrough, at high pressures.
ARTERIAL OCCLUSION - MOYA-MOYA DISEASE
- Compensatory enlargement of collateral vasculature which gives the classic angiographic appearance (puff of
smoke)
- A compensatory thing
- Sometimes and most of the time, it is not sufficient
- Vessels near the carotid apex
- Vessels on the cortical surface
- Vessels in the leptomeninges
- Branches of the external carotid artery supplying the dura and skull base

Diagnostics (just go through this = nice to know?)

MRI with
o Diminished flow voids in the internal carotid and middle and anterior cerebral arteries coupled with
prominent collateral flow voids in the basal ganglia and thalamus..
o Narrowing of circle of Willis
o Ischemic parenchymal changes

CEREBRAL EMBOLISM
- Embolic problems usually come from the heart
- A mural thrombus from the ventricle (probably left) can throw an embolus to the brain
- A growth/vegetation (like a colony of bacteria) from the heart valve can also throw embolus
- Having too many holes in the ventricles can cause wrong flow, leading to embolization

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Problems
o Non-perfusion
o Mass Effect / Herniation
Brain ischemia leads to swelling

Insufficient oxygen
$
Decreased production of ATP
$
ATP-generated cellular pumps, especially the Na-K pump, will not work
$
K efflux and Na influx uncontrolled
$
Water goes with sodium
$
Edema
The edematous portion of the brain pushes on the normal portion, leading to shifting in volumes and
herniation, which can be fatal

Hemorrhagic Transformation

Rationale for surgery/intervention

o Re-establish/Restore Cerebral Blood Flow
Within the first 6 hours, this is medical done using thrombolytic agents (review your basic pharmacology)
However, using TPA (thrombolytic agent) causes hemorrhage (6 to 7 % incidence)
o

Eliminate/Relieve Increased ICP

To prevent herniation
Medically, manitol can be given.
If there is kidney problem, use furosemide.
If medical management doesnt work, then HEMICRANIECTOMY can be done (removal of part of the skull)

Evacuate Hematomas

Reduce metabolism ( Hypothermia )

More theoretical than practical
- Reduced metabolism = reduced energy demand = increased survival despite reduced energy
supply
- This is impractical due to expensive technology and very tedious methods of control

(1)
(2)
(3)
Herniations/edema schematic (figure above)
A hematoma or edema in the cerebellum can push into the brainstem
The cerebrum can herniate downward or into the midline pushing on the contralateral part of the
brain
All of these are potentially fatal conditions and have to be managed very well

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The changes in the

Intracranial volume is
logarithmically proportional to
the changes in intracranial
pressure.

A small increase in volume

can greatly increase pressure

Increased pressure in the

brain can cause:
o Direct distortion of the
brain
o

Compression of veins,
leading to reduction in
venous drainage. The
blood will accumulate in
the arteries, and like a
balloon, it will burst.

The brain can also expand

and push into the cranium,
leading to compression

Selection of Surgical Candidates

A. Reperfusion Procedures
1. Intraarterial thrombolysis
2. Angioplasty/ Stenting
3. Clot bust
B. Revascularization Procedures
1. EC-IC bypass
2. Synangiosis ( EDAS )
C. Hemicraniectomy
Neurologic Criteria
1. Beyond 6 hours
- Manage medically within first 6 hours
2. Young patient
3. GCS deterioration
- GCS score should be above 7/15
- Below 7, there will be reperfusion injury and hemorrhagic conversion and death
4. Minimal co-morbidities
5. No clotting problems (like thrombocytopenia [parang weird kasi may throbus sya tapos may ganun])

CT Scan Criteria
1. ASPECTS or 1/3 MCA Rule
- Means that if the stroke involves one hemisphere, thats one whole.
- Good if only 1/3 of that side is involved
- If the whole is affected, you remove the cranium
<di ko din naiintindihan sinabi nya, almost exact words yan>

2. No hemorrhage
- Can cause reperfusion injury. This is a sign of hemorrhagic conversion.
Surgical Intervention
1. Removal of thrombus
Application of methods from plumbers... oo, tubero....

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2. Balloon Catheter and Stenting

If the chicharon is on the wall, a balloon or a stent can be used.
When you put a stent, it is fixed there (permanent). The stent will provoke thrombosis (foreign body), so you will have to give
antiplatelets like Aspirin (Aspilet), which is very cheap but very effective and as long as the dosage is 80mg, it has very little AF.

Insertion of stents
- Insert a catheter with unexpanded stent
- Deploy catheter using a balloon
- Once the catheter is deployed, it cannot be removed.

ACTUAL RESULTS

Before
After
Very Effective!!!
2. Endarterectomy
GOLD STANDARD (when you remove the chicharon, theres no more chicharon! Obviously)
In more affluent countries, non operative procedures are getting more popular (balloon catheter, stenting, etc)
This is cheaper than the non operative procedures (hence, this is more popular in the Philippines)

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3. STA-MCA Bypass
More commonly, the M3 branch is the recipient artery
Connection of the Superficial temporal artery to Middle cerebral artery
Very difficult to do (put 8 stitches on a very small-calibre tube)
Prone to occlusion and thrombosis during operation
Requires very tedious patient selection and has to be done by a very astig (adj. astigger, astiggest, meaning super
coooool) surgeon.
Done under the microscope
4. Encephaloduroarteriosynangiosis (EDAS)
a. Treatment of Moya-moya disease
b. Connecting a good artery with a bad artery (same principle in STA-MCA bypass)
c. You have to make sure that the outflow tract is ok (the good artery should be really good)
d. Patient selection and evaluation using excellent angiographic techniques are critical to success.

5. Hemicraniectomy
a. For patients who didnt respond to Medical intervention beyond 4 to 6 hours
b. A part of the skull is removed to give space to the swelling brain
c. The brain expands out of the removed part of the skull
d. The skull is sutured back in place after the brain becomes normal
Notice the
hyperintense
skull

Now you dont

Now you see it

BEFORE

AFTER

6. Intracranial Pressure Monitor

A device/pressure transducer that you insert either into the epidural space or the ventricles (in the brain) to know
the intracranial pressure
Guide in giving Manitol and other medicines
Not very reliable in the sense that the pressure in the brain is NOT HOMOGENOUS (the brain is a complex fluid
solid whatever thing)
Intracranial pressure readings here doesnt precisely correlate to the clinical picture
The clinical picture is more informative and useful

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IV.

ACUTE HEMORRHAGIC STROKE

CAUSES
A.
Subarachnoid Hemorrhage
I. Aneurysmal Rupture most common cause
II. AV Malformation
III. Extensions
B.
Intracerebral Hemorrhage
I. Hypertensive most common intracerebral
II. Other Causes
i. AV Malformation
ii. Aneurysm
iii. Tumors
iv. Drugs
A. Subarachnoid hemorrhage
Bleeding in the subarachnoid space
Aneurysm surgery is done under the microscope
On the CT scan, you will see a star-like structure. If seen in a patient has a stroke, not a meningitis (no fever,
no signs of infection), then that star is the subarachnoid hemorrhage.
The circle of Willis is the favourite site of aneurysms; the anterior Circle of Willis is the more favoured within
the circle of Willis. They are, however, all bad locations.
1. Evaluation
Catheter Cerebral Angiography
GOLD STANDARD
Relatively more invasive

2. Problems
Vasospasm/ Ischemia
If you bathe the arteries in the space with blood , they become excited, causing vasospasm
that leads to constriction/occlusion that causes ischemia and stroke
Rebleeding
After a ruptured aneurysm, at some point, the bleeding will stop (due to clots, etc)
However, there is a chance of rebleeding
nd
st
the 2 time around is always worse than the 1 time around (hanudaw???)
Hydrocephalus
The subarachnoid space is filled with CSF and bloody CSF will get clogged and will not get
absorbed and recirculated, they will accumulate in the ventricles (hydrocephalus)
Hematoma
Sometimes, hematomas are helpful but they can cause mass effect
3. Surgical Procedures
A. Angioplasty
a. Subarachnoid Wash
b. Subarachnoid Nimodipine
B. Clipping/Wrapping
C. Coiling
D. CSF Diversion

Rationale for surgery:

A. Restore blood flow
B. Prevent rebleeding
C. Restore CSF flow
D. Reduce mass effect / ICP

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4. Selection of patients
Aneurysm Surgery
Neurologic Criteria
o Hunt-Hess Grade 1-2
o Age below 80 yrs
o Minimal co-morbidities

Imaging Criteria
o Aneurysm size
o Shape
o Sites / Sides
o Circulation
o Number
o Hematoma
o Difficult to coil

Clipping

This is the route through where the catheter

passes into the brain

Endovascular Procedures for Aneurysms

Neurologic Criteria
o Hunt & Hess Score >3
o Advanced age (over 80 yrs)
o Severe co-morbidities

Imaging Criteria
o Difficult to clip
o Easy to coil
o Multiple / bilateral
o Unruptured

Coiling a metal coil is introduced through a

microcatheter and then a magical electric
current is used to cut the coil

If the aneurysm is in the wall and not at the bifurcation,

sometimes there is a wide neck. Its better to put a stent and then
a catheter is introduced through the holes of the stent and the coil
is put in. this is to prevent the coil from migrating and causing
another stroke.

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B. Intracerebral hemorrhage
Hypertension is the most notorious cause. Prevention and early management is still paramount.

The ventriculo-striate (?) arteries are very fine vessels that branch from the middle cerebral artery and are the
favorite site of hemorrhage. (prone to rupture)
If you have to guess the site and cause of Intracerebral hemorrhage, say ventriculo-striate (?) arteries and
hypertension so you will look smart. (pogi points)
1. Selection of patients
A. Neurologic status
i. GCS score 7/15 or higher
ii. GCS score deterioration
iii. Recent or no Brainstem signs
iv. Minimal co-morbidities
v. Age below 80 yrs.
(siguro naman sa pagbasa mo nito eh nasusuya ka na)
a. Eye opening
ii. Spontaneous 4
Mild
iii. To words .. 3
Moderate
iv. To pain .... 2
Severe
v. None. 1
b. Verbal
vi. Oriented 5
vii. Confused... 4
viii. Inappropriate..3
ix. Incomprehensible.2
x. None...... 1
c. Motor
xi. Obeys. 6
xii. Localizes 5
xiii. Withdraws..... 4
xiv. Flexion... 3
xv. Extension.. 2
xvi. None.. 1

GCS 13-15
GCS 9-12
GCS 3-8

B. Imaging Criteria
i. Site
ii. Size
iii. Mass effect
iv. Ventricular extension can become subarachnoid hemorrhage
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Imaging
Computerized axial tomography (CT Scan)
- Using the maximum width, length and thickness
measured on the CT images, hematoma volume can be
estimated by using the formula: (A x B x C)/2
A = Maximum Width
B = length
C = Thickness (based on the number of CT scan
slices times thickness each slice)

2. Surgical Techniques
a. Aspiration/Thrombolysis for small and medium but deep lesions
b. Craniotomy/Evacuation Of Hematoma for large lesions
c. Endoscopic Evacuation
d. Ventriculostomy/Thrombolysis

Stereotaxis or stereotactic aspiration

o How old people used to aspirate hematomas
o A stereotactic frame is set on the head
o You do a CT-scan on the head with the frame
o Compute the parameters respective to the frame
o Aspirate 30 to 50% of the hematoma. Dont aspirate all of it because this will cause a great
drop in intracerebral pressure. You dont want this. Also, the thrombus prevents some
bleeding so removing it can cause bleeding. Just lyse the remaining hematoma, OK?
o This technology is obsolete, there is now a frameless thing used.

C. Arteriovenous Malformation
A bag of worms inside the brain
An artery goes through the malformation then directly into the draining vein
The blood flow into the vein is arterialized meaning the pressures in the vein become almost the same
as that in the arteries.
The arteries are supposed to have higher pressures to encourage blood flow; since the pressures are not
the same, there is anomalous blood flow.
The parenchyma is not supplied anymore because of the shunt
1. Problems
a. Bleeding
st
b. Seizures no supply of blood into the brain; a teenager with a 1 time seizure is highly suspicious of
AV-mal
c. Mass effect
d. Ischemia
2. Rationale for surgery
a. Control seizures Anticonvulsants
b. Prevent bleeding
c. Restore blood flow
d. Eliminate mass effect

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3. Selection of surgical candidates

a. Neurologic Criteria
i. Intractable seizures
ii. Hematoma
iii. Cerebral ischemia (Steal phenomenon)
iv. Mass effect
v. Good neurologic status
vi. Minimal co-morbidities
b. Imaging / Angiographic Criteria
i. Spetzler Grade the most important
Size
0-3 cm
1 point
3-6 cm
2 points
>6 cm
3 points
Location
Non-eloquent
0 points
Eloquent 1 point
Venous drainage
Superficial 0 points
Deep
1 point

Lower score = GOOD prognosis

Higher score = POOR prognosis

*Eloquent brain includes sensorimotor, language, or visual cortex, hypothalamus or thalamus, internal capsule, brainstem,
cerebellar peduncles or cerebellar nuclei

ii. Vascular supply

iii. Venous drainage
iv. Aneurysms
*Knot out the arteries first to prevent AV-mal rupture

Treatment: Embolization
o Endovascular procedure using a tube to introduce particles or glue to clamp the malformation

V.

Recommendation
Early neurosurgical referral

VI.

Conclusion
Neurosurgical intervention plays an important role in the management of stroke
-END OF TRANSCRIPTION-

From the transcriber

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