Surgical Indication

of Stroke
Handoyo Pramusinto

Neurological Surgery Division

Sardjito Hospital

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

www.nejm.org

Case Presentation
57 year old female
Sudden onset, severe headache
Slurred speech
Collapsed

Physical Exam
T 99.4 P52 BP 195/99 RR13
Pupils-2 mm reactive
Neck-no JVD, bruits
CV-bradycardia, no murmur
Skin-warm and dry
3

Neurological Exam
Neurological exam:
no gag reflex, withdraws to pain,

GCS
Eyes-1
Verbal-1
Motor-4

CT Scan

Intracerebral hemorrhage

Blood Clot

Pathophysiological features
Common site
A. Cerebral lobe
B. Basal ganglia
C. Thalamus
D. Brain stem (pons predominantly)
E. Cerebellum

Intracerebellum hemorrhage
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Intraventricular hemorrhage
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Subarachnoid hemorrhage
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Key Clinical Questions

Which ICH patient require surgery?
Volume of hematoma
Location
Clinical presentation ( GCS, BP )
Facility ( ICU )

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Key Concepts
Two key concepts:
Intracranial pressure
Elevated when ICP >20 mm Hg
Cerebral perfusion 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 Treatment

Intracranial Pressure (ICP): considered a
major contributor to mortality when
elevated
Controlling ICP is considered essential
Osmotherapy
Hyperventilation
Barbiturate coma

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Osmotherapy
Osmotherapy-Mannitol
Reduces cerebral edema by decreasing
cerebral fluid volume
Rebound effect-use less than 5 days
20% solution
0.5-1.0 mg/kg maintain serum osmolarity
310-320 mOsm/L

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HOB Elevation
Elevate head of bed-decrease ICP
Mechanical-helps drain blood by gravity
Does not allow blood to pool in cranium,
which may occur if patient is left laying flat

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ICP Monitors
AHA recommends ICP monitors in
patients with a GCS less than 9 and all
patients whose condition is thought to
be deteriorating due to elevated ICP

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Non-Surgical ICH Pts

Small Hemorrhages (10 cm3)
Minimal neurological deficits
GCS < 4 (excluding cerebellar
hemorrhage with brain stem
compression)

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Key Learning Points

Most ICH patients are non-surgical
Consult your neurosurgeon early
Steroids-no benefit
There are promising new therapies
such as Factor VII on the horizon

Diagnosis
CT scan infarction or hemorrhage
Location and size of the hematoma
Presence of ventricular blood
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 MCA

infarction 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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Management
Evaluation & management in
the ER
Decreased level of
consciousness or impairment
of reflexes the protect airway
Intubation !
Urgent CT scan, NS
consultation
Hyperventilation, intravenous
mannitol and intraventricular
catheter for drainage.
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Management
Intensive monitoring of
neurologic &
cardiovascular status
Instability is highest during
the first 24 hrs
GCS, hourly
BP

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Management
Mass effect & intracranial
hypertension
Hematoma, edema tissue,
obstructive hydrocephalus
herniation !
Use of hyperventilation and
osmotic agent improved the
long-term outcome
Corticosteroids should be
avoid !
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Management
Management of
blood pressure
Elevation of blood
pressure expansion
of hematoma poor
outcome !
AHA guideline

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Management
Ventricular blood and
hydrocephalus
Blood in ventricles
obstructive hydrocephalus
high mortality rate !
External drainage
Clots in the catheter and
infection
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Management
Surgical evacuation
Reduce mass effect, block the release of
neuropathic product from the hematoma
Surgery for supratentorial hemorrhage ?
Hankey et al:
126 not undergo surgery
123 surgical evaculation through an open
craniotomy
surgery higher rate of death (83% vs 70%) / 6m

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Management
Cerebellar hematoma
Can be approached with
minor damage
Decompression of brain
stem
Surgical GCS < 14,
volume > 40 ml
Conservative treatment

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