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Section of Neurosurgery Department of Surgery

July 2008

Role of neurosurgery in the management of stroke
Gohar Javed
Aga Khan University

Muhammad Zubair Tahir
Aga Khan University

S. Ather Enam
Aga Khan University,

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Recommended Citation
Javed, G., Tahir, M., Enam, S. (2008). Role of neurosurgery in the management of stroke. Journal of the Pakistan Medical Association,
58(7), 378-84.
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4 The the help of the flap taken from temporal fascia or any other other alternative is surgical treatment.6 Strokes can have minor consequences especially lacunar Decompressive Craniectomy: As an alternative and small cortical strokes or they can be lethal if they therapy. ischaemic stroke and surgical treatment of stroke along with recommendations haemorrhagic stroke. Karachi. large bone flap. Haemorrhagic stroke comprises of two main types. Aga Khan University Hospital.5 Current available medical treatment of intraparenchymal haemorrhage (ICH). In this review the recent advances in accommodate the swollen brain. CT Brain showing large right MCA territory infarct with significant midline shift and twenty four hours or leading to death. The aim of treatment in stroke patients is to prevent further neurologic deterioration and prevent recurrence. Ischaemic stroke or cerebral infarction from latest randomized trials will be discussed. surgical decompression techniques have been involve major arterial distribution such as whole middle proposed to relieve the high ICP. but they are often The poor outcome associated with ischaemic stroke devastating. In this review the recent advances in surgical treatment of stroke will be discussed along with recommendations from the latest randomized trials. Syed Ather Enam Department of Neurosurgery. To deal with the lethal complication of haemorrhage (SAH). However there is recent reconsideration of this form of treatment and ongoing trials are showing some promising results. hypothermia surrounding the brain.2 Spontaneous intracranial haemorrhages Surgical treatment of ischaemic stroke: account for about 20% of all strokes. barbiturate coma. hypertonic saline. However there is recent reconsideration of this the necrotic infarcted brain parenchyma. Ipsilateral to the side of infarction Despite all advances in medical treatment. Abstract Stroke is the second leading cause of death worldwide. The rationale of form of treatment and ongoing trials are showing some this therapy is to create compensatory space to promising results. where there is ischaemic stroke includes thrombolysis and anti bleeding within the brain itself and subarachnoid coagulation. accounting for a disproportionately large is attributed to malignant oedema that causes early rise in proportion of morbidity and mortality among stroke intracranial pressure (ICP) and subsequent brain herniation patients. The other alternative is surgical treatment. This involves removal of cerebral artery (MCA) territory infarction (Figure 1). medical treatment offers rupture in the cerebrospinal fluid filled subarachnoid space mannitol. accounting for approximately 70-80% of all strokes. thereby normalizing 378 J Pak Med Assoc .7 No attempt is made to remove 1 evidence. Muhammad Zubair Tahir. which is characterized by vessel malignant oedema and raised ICP. However no medical therapy has The aim of treatment in stroke patients is to prevent proven effective in preventing brain herniation and further neurological deterioration and prevent recurrence. lasting for more than Figure 1.1 We can divide stroke mass effect. Introduction Stroke is the second leading cause of death worldwide. is the most common. which still lacks class available graft (duroplasty). and death. Despite all advances in medical treatment. which still lacks class 1 evidence. improving patient outcome. mortality in such (hemicraniectomy) followed by dural reconstruction with large infarcts is estimated to be between 50% and 78%. morbidity and mortality in stroke patients is still very high. into two broad categories namely.Review Article Role of neurosurgery in the management of stroke Gohar Javed.3 and hyperventilation.1 The World Health Organization defines stroke clinically as "rapidly developing clinical signs of focal disturbance of cerebral function.

in the surgery group compared with 5. The benefits of carotid surgery appear to be patients originated from 2 centres only.11 However.23). the decompressive surgery. and 50%. respectively). because of slow recruitment and organizing a pooled Decompressive surgery was first reported as a analysis of individual data from this trial and the two other potential treatment for large hemispheric infarction in case ongoing European trials of decompressive craniectomy in reports as early as 1956. cases of cerebral infarction due to main-trunk occlusion had randomized.15 Based on the results of several reports suggesting that Prospective analyses as the North American patients more than 60 years may not benefit from Symptomatic Carotid Endarterectomy Trial (NASCET). the data safety symptomatic carotid atherosclerosis. DESTINY only included patients Asymptomatic Carotid Atherosclerosis Study (ACAS). the proportion of patients with a MRS score provide improved outcomes by avoiding the consequences less than 3 at the 6-month and 1-year follow-up. the treatment of large MCA ischaemic strokes. and 18 to 60 years of age.9 effective in improving the prognosis of patients with acute cerebral infarction within 3hours after the onset. was 25% of brainstem compression from transtentorial herniation. patient Carotid endarterectomy: Carotid artery surgery enrollment was interrupted as per protocol.8 But this form of treatment remains controversial in of death after craniectomy compared with medical therapy the absence of randomized controlled trials.intracranial pressure. There was a 52.0001). DECIMAL (Decompressive Craniectomy In emergency revascularization. Recurrent stenosis occurs at the rate of 5 .10. 47% of include serious medical risks of anaesthesia and recent large patients in the surgical arm versus 27% of patients in the parenchymal infarction.2%. Vol. After 6 and 12 months. 7. Among the 38 patients that early decompression reduces mortality and may randomized. stenting and Germany. First.10% per this makes DESTINY an oligocentre rather than a year after operation but is not always symptomatic. the European Carotid Surgery Trial (ECST) demonstrated DECIMAL is a Sequential-Design trial conducted in superior reduction in the incidence of stroke among France involving patients between 18 and 55 years of age symptomatic and a select group of asymptomatic patients with malignant MCA infarction to compare functional undergoing carotid endarterectomy (CEA).12 design that used mortality after 30 days as the first end point. multicentre. (47%) patients randomized to conservative therapy survived Possible contraindications to carotid endarterectomy after 30 days (P = 0. DESTINY showed that brain ischaemia secondary to haemodynamic insufficiency.10 When this end point was reached.7 The largest case series suggested malignant MCA infarction. In addition DESTINY does not provide Operative mortality is less than 2% and the risk of stroke is data on older patients with malignant MCA infarction. Fifteen of seventeen (88%) alone. No. DESTINY has several shortcomings. controlled. conservative treatment arm had a modified Rankin Scale Carotid artery surgery helps prevent subsequent score of 0 to 3 (P = 0. July 2008 379 . early decompressive craniectomy increased by more than half the number of Recently three multicentre randomized controlled patients with minimal to moderate disability and trials have been conducted with favourable outcomes in significantly reduced (by more than half) the mortality rate patients who underwent decompressive craniectomies for compared with that after medical therapy. carotid endartrectomy.6% and Patients who underwent early hemicraniectomy had a 22. The National Institute of Middle Cerebral Artery Infarcts) from France and Neurological Disorders and Stroke (NINDS) reported that HAMLET (Hemicraniectomy After Middle Cerebral Artery thrombolytic therapy by intravenous administration of a Infarction With Life Threatening Odema Trial) from recombinant tissue plasminogen activator (t-PA) was Netherland.13 Carotid artery surgery has also been used when the patients randomized to hemicraniectomy versus 7 of 15 patient has acute carotid occlusion and minor stroke. These are DESTINY (Decompressive Surgery for the Treatment of The other surgical options for ischaemic stroke are Malignant Infarction of the Middle Cerebral Artery) from embolectomy. clinical trial based on a sequential a low revascularization rate and a poor prognosis.02).14 multicentre trial. reverting brain shifts and preventing monitoring committee recommended stopping the trial secondary neuronal insult. less than 4%. only (P<0. DESTINY is a prospective. durable. 58.6 established CEA as the therapeutic gold standard for After randomization of 38 patients. 81% of diseased artery. A statistically has been shown to significantly decrease the risk of a significant reduction in mortality was reached after 32 subsequent stroke compared to the best medical therapy patients had been included. hemicraniectomy reduces mortality in large hemispheric arterial embolism or propagating thrombosis from the stroke.8% absolute reduction surgery. As a matter of fact. in the no-surgery group respectively (P = 0.18 and P mortality rate of 16% compared to 34% for delayed = 0. In this trial. These studies outcomes with or without decompressive craniectomy.

treating a case of ICH is whether or not surgery is required Sakai et al reported their surgical results in patients in a particular case? The answer to this question is better with acute cerebral main-trunk occlusion in the anterior defined in the case of infra-tentorial haematomas than in circulation. In issue.20 Similarly prognosis condition characterized by progressive. 14 less than 13. pathological site. Sub-arachnoid haemorrhage itself may not require The current indications of revascularization surgery any surgical treatment but some of its causes or include patients with impaired collaterals causing regional complications require surgery.middle collateral blood flow to the territory of occluded or severely cerebral artery (MMA-MCA) anastomoses. encephaloduroarteriosynangiosis (EDAS) carotid . failed to reveal any benefit of external transposition. revascularization was achieved. Vermian haematomas more often require evacuation all the patients. idiopathic occlusion for brain stem haematomas is poor except in those cases of of the bilateral supraclinoid internal carotid arteries (ICA). The indirect stenosed cerebral arteries. Surgical interventions have been Transluminal Angioplasty Study (CAVATAS) will attempt divided into direct and indirect bypass techniques. both usually done by end to side anastomosis of superficial consist of laying dural flap with intact blood supply directly temporal artery branch with middle cerebral artery distal to on to cerebral cortex. however. Other clinical situations in which an EC-IC coiling. Moyamoya therapy. within 24 hours after the onset.21 The results of surgery were found to be in 1957 and subsequent angiographic characterization and favorable in 13 out of 20 patients with CT guided 380 J Pak Med Assoc . Vascular malformations may require surgical bypass procedure may be considered includes. hydrocephalus or a Glasgow coma score of artery in 1 patient. However technical innovations in interventional naming by Suzuki and Takaku in 1969.internal carotid artery (EC-IC) bypass surgery. With a morbidity rate of >70% in untreated patients. a selected patients with acute cerebral main-trunk occlusion hemispheric haematoma can be observed and managed in the anterior circulation. Hydrocephalus or malignant oedema developing cerebral aneurysms not amenable to direct surgical clipping after sub-arachnoid hemorrhage may also require surgery. The Carotid Revascularization Endarterectomy versus Stent surgical intervention has become the standard therapy in Trial (CREST) and the Carotid and Vertebral Artery patients with MMD. Aneurysms causing sub cerebral blood flow compromise and failed maximal arachnoid haemorrhage require obliteration by clipping or medical therapy.17 stroke.middle cerebral artery (STA-MCA). prospective evaluation is pending. The to address the efficacy of percutaneous angioplasty and direct bypass techniques proposed include superficial stenting compared with CEA. However. conservatively. Revascularization surgery: Bypass surgery provides occipital artery-MCA. The occlusion occurred in Surgery is required in cerebellar haematomas if there the internal carotid artery in 10 patients. A large international cooperative techniques consist of multiple cranial bur holes. giant excision. temporal artery . Although retrospective analyses of angioplasty and disease is diagnosed and staged by using catheter stenting suggest that their clinical efficacy is comparable to angiography. and 3 had a carotid endarterectomy. and in the anterior cerebral fourth ventricle.18 Twenty six patients were surgically treated supra-tentorial clots. omental study. moderate to severe compression of cerebral artery in 15 patients. Since its first description by Takeuchi and Shimizu than 20 mm. and as compared to hemispheric hematomas of comparable size. Size of the haematoma is a more controversial had an embolectomy. pontine haemorrhage that are not comatose to begin with. several thousand radiology have renewed the debate about the optimal cases have been documented worldwide. Their study Surgery is required for a hemispheric hematoma which is 40 concluded that early surgical revascularization can be an x 30 mm or more and a vermian hematoma which is 35 x 25 effective and safe treatment modality in appropriately mm or more in their largest dimensions. neurological improvement was obtained.16 However two Surgical treatment of haemorrhagic stroke particular groups were not addressed: those for whom the Intra parenchymal brain haemorrhage is more best available medical therapy had failed and those with common than sub arachnoid haemorrhage as a cause of clearly documented haemodynamic compromise. and reconstruction (where the parent vessel must be The first question that a surgeon has to address while sacrificed) and other progressive vasculopathies. and middle meningeal artery. that of endarterectomy. even if it is more than 30 mm in its Revascularization in Moya Moya Disease: maximum diameter but is not causing any significant Moyamoya disease (MMD) is a rare cerebrovascular compression of the fourth ventricle. in the middle is tight posterior fossa.19. and anterior cerebral artery have normal pupils and the size of the haematoma is less (ACA). and encephaloduroarteriomyosynangiosis (EDAMS). proximal middle cerebral artery. Nine patients underwent anastomosis. in the setting of symptomatic arterial occlusions and inaccessible stenosis.

Prognostic score was calculated as: (10 x admission Glasgow coma score) . Secondary outcome included mortality. Any favorable outcome seen with minimally invasive methods was offset by the craniotomy procedures. Surgery offered as a life saving procedure after patient developed signs of herniation. multicentre study addressing this issue is Craniotomy: In STICH trial. The only large. modified Rankin scale or Barthel index. A more organized patients were managed conservatively. 7. knowledge.Age (years) - (0. Significant benefit of surgery was not found in terms of mortality.23 In this trial 1033 patients from 83 centres in 27 favorable outcome for the hematomas within 1 cm of the countries mainly from Europe. So the best indication of treatment. a . One of the inclusion criteria for this trial is "if the responsible neurosurgeon is uncertain about the benefits of either treatment". Glasgow coma op scan. Variables were age. randomized. b . This may be because of a paucity of large. randomized.23 Does that prove that there are no well defined indications for surgery in supra tentorial ICH? The answer to this question lies in the inclusion criteria of STICH trial. severity of neurological deficit and type of intended operation. multi-centre studies. Asia and Africa were brain surface (Figure 3). no one can wait in a middle aged otherwise fit patient who Figure 3. The other theoretical consideration randomized into two treatment groups.Preop scan. When should a surgeon be more certain about the decision to operate in a case of supra tentorial ICH? Although there is no support from the literature. Results of other randomized trials before STICH also failed to show any benefit of surgery in ICH. In one group. the Barthel index and the modified Rankin scale. This majority of craniotomies are probably the reason why the only advantage of early surgery 3b observed in this study is for the hematomas located within one centimeter of the surface (easier removal of superficial hematomas through craniotomies). is the consistency of the hematoma. while in the other group patients underwent surgery within 24 hours of 3a randomization in addition to conservative treatment. Another reason is The methods for hematoma evacuation can be probably a trend towards minimally invasive surgery with divided into two categories: craniotomy / craniectomy and resultant modification of the indications. Vol. haematoma volume.22 surgery in supra-tentorial hematomas is certainty of the The indications of surgery in supra-tentorial ICH are surgeon about the results of surgery according to his/her less obvious. craniotomy and International Surgical Trial for Intra Cerebral Haemorrhage evacuation of ICH has been found to be associated with (STICH). 58.64 x volume [ml]) Primary outcome was death or disability using the extended Glasgow outcome scale 6 month after the ictus. July 2008 381 .stereotactic aspiration of pontine tegmental hypertensive relatively superficial medium size (15-30 cc) clot located in haemorrhages when compared to the conservative a non eloquent part of the brain. This leads to another question. which were performed in the majority of the patients. minimally invasive procedures. experience and circumstances. So the uncertain results attest to the "uncertainty" of the surgeons. CT Brain showing large left basal ganglia bleed with mass effect and intraventricular shows rapid deterioration of level of consciousness due to a spillage of blood. This means that there should be a number of cases in which a surgeon is more certain about the results of surgery. thrombolytic or anticoagulant treatment. lobar versus basal ganglia / thalamic haematoma or both. No.

96 +/. In other group the patients were treated respect to waiting time of surgery.27 Studies have functional independence measure (FIM) score.001). hematoma evacuation rate and mortality. Barthel index and improvement in muscle power functional outcome. stereotactic aspiration and craniotomy stereotactically placed catheter was used to instill urokinase in non comatose patients. depending upon the with the use of neuroendoscope. All these are considered to be bad prognostic signs. as functional outcome. A smaller bony opening is availability and urgency of the situation endoscopic required to accommodate a cortical incision. Outcome combination of craniotomy and operating microscope may after fibrinolytic stereotactic evacuation of clot may be be another advantage over blind procedures which form a comparable to other methods of treatment. with but is resistant to suction without fibrinolysis if operated by urokinase or t-PA or mechanical e. However. Stereotaxy adds precision to the procedure by Neuro observation.26 In a study deep seated hematoma in clinically good patients should be evaluating stereotactic treatment of intra cerebral observed (Figure 2). Minimally Invasive Surgery: This can be described in two broad categories namely blind procedures and endoscopy. from India has reviewed 12 patients who were treated with decompressive hemicraniectomy with evacuation of hypertensive ICH. a advantageous for deep seated lesions. Visibility provided by the screw.30 The surgical technique becomes less invasive craniotomy group. to be better than the stereotaxy and craniotomy for the 50.g. when compared to external ventricular complications were re bleeding and infection. No months after surgery. length of operation time. conservatively. The tube can be 382 J Pak Med Assoc .56 +/. The only difference was better Neurological outcome was compared with respect to reduction of haematoma volume over 7 days. respect to haematoma volume reduction or outcome. 7 of 11 with intra ventricular extension of haematoma and 4 of 8 with haematoma volume greater than 60 cc made good functional recovery. while fibrinolysis makes a clot of firm consistency more hematoma should be easily evacuated through craniotomy amenable to suction.3%) Neuroendoscopic evacuation of intra ventricular and highest complication rate (16. Fibrinolysis may be chemical e.24 (236. Blind Procedures: Blind procedures are essentially burr hole aspirations. Three out of seven with pupillary abnormalities. This makes it less suitable for urgent situations. with Archimedes minimally invasive procedures. there was no difference in were significantly better in endoscopy group as compared to mortality. however. CT Brain showing small deep seated right basal ganglia bleed. highest mortality (13. There was no difference in mortality as well blood loss.25 Interestingly 11 out of 12 patients were discharged alive.13 +/-137. Managed non operatively and fibrinolysis.29 P<001). usually less than a centimeter in width. P < .31 Use of a metallic Decompressive Craniectomy: Not much is tube allows both endoscope as well as other instruments to available on this topic in the literature. Neuroendoscopy: Neuroendoscopy has been found Craniotomy had the longest operating time (229.g.001).24 The three randomized treatment to liquefy and drain the ICH in 6 hourly intervals over 48 groups (with 30 patients in each group) were compared with hours.18 minutes. The most major haemorrhage. with or without the help of stereotaxy Figure 2.57 minutes.45 ml. P<0. which is evacuation of the hematoma is preferable over craniotomy. ultrasonic aspirator or oscillating cutters. Therefore. In surgical group a endoscopic surgery.6%). Barthel also compared the results of frame based and frameless index score and muscle power (MP) of affected limbs 6 stereotaxy for the evacuation of supra tentorial ICH. Stereotactic aspiration had the longest difference has been found between the two techniques with waiting time before evacuation (172. haematoma by means of a plasminogen activator (SICHPA) One study from China has prospectively compared randomized 70 patients in two groups. Therefore decompressive hemicraniectomy with clot evacuation can be life saving with good functional outcome in patients with a large size ICH is extending into the ventricles and is associated with papillary abnormalities.93. It is particularly significant part of minimally invasive surgery. was found to be associated with better score. A retrospective study be used through the tube at the same time. The FIM drainage alone.28. with most significant blood loss evacuation of basal ganglia ICH in non comatose patients.

Clinical alert: benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. Brain edema after stroke. Ross SA. Dissection can be done arrangement may be agreed upon. Arch Neurol. controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). of haemorrhagic stroke such as spontaneous sub dural Early hemicraniectomy in patients with complete middle cerebral artery infarction. plays a definitive role in improving the quality of stroke Flexible endoscope has been introduced through aqueduct patient care. Horn M. Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Touzé E. Delayed craniotomy 2007.. hydrocephalus after spontaneous ICH. 93:313-8. while burr hole 10. Sequential-design. This is especially 2. Stroke. Craniotomy is 9. Steiner T. von Kummer R. In addition. 19 :655-64. the ventricular system. Couvreur G. Physical proximity of the neurology and neurosurgery transparent viewing dissector coupled with endoscope. and controversies. Kirollos RW. Mortality by cause for eight regions of the world: may be required in those cases which develop acute Global Burden of Disease Study. Vahedi K. Hacke W. 29 :1888-93. Steiner HH. Gupta R. Ultra early craniotomy 6. Spetzler RF. Mikulik R. haematoma or extra dural haematoma. centres as well as other hospitals for the neurosurgery and 18. Surgery.Stroke. Ogiwara T. Association/American Stroke Association guidelines 5. Connolly ES. Molina CA. N Engl J Med. It behoves therefore in tertiary analysis in light of the International Cooperative Study. neurology to work together. 38 :3302-7. increased risk of recurrent bleeding. July 2008 383 . van Hille PT. 58. Youkey JR. Aschoff A. Stroke. Jüttler E. Hacke W. outcomes. Stroke. Goldstein LB. Unterberg A. Awad IA. Hemicraniectomy for massive the outcome. 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