Yesaya, Julius, Harsan, Lutfi, Binsar, Made, Ferry

Neuroscience Center Siloam Hospitals Faculty of Medicine Pelita Harapan University

: 17.000 islands, 240 millions population, 190 neurosurgeons, 4 training centers

Overseas

Stroke
NonHemorrhagic Hemorrhagic

Bypass

HemiCraniectomy

Endarterectomy

Hypertensive (80 %)

Nonhypertensive

Conservative

Operative

Aneurysm

AVM

Cavernoma

Mass effect

Superficial

Hydrocephalus

Hemorrhagic
Surgical aspect : Hypertensive stroke Aneurysm AVMs Cavernous Angioma

Vascular Neurosurgery STROKE

Non-Hemorrhagic
Surgical aspect : Bypass anastomosis STA-MCA Endarterectomy Hemicraniectomy

STROKE
Hemorrhagic
Surgical aspect : Hypertensive Stroke Aneurysm AVMs Cavernous Angioma

STROKE
Hemorrhagic
Surgical aspect : Hypertensive Stroke Aneurysm AVMs Cavernous Angioma

Clipping

Coiling

STROKE
Hemorrhagic
Surgical aspect : Hypertensive stroke Aneurysm AVMs Cavernous Angioma

Pre Evacuation

Post Evacuation

STROKE
Hemorrhagic
Surgical aspect : Hypertensive Aneurysm AVMs Cavernous Angioma

Anastomosis STA-MCA

Non-Hemorrhagic
Surgical aspect : Bypass-Anastomosis STA-MCA Endaterectomy Hemicraniectomy

STROKE

Surgical aspect : Bypass-Anastomosis STA-MCA Endaterectomy Hemicraniectomy

Non-Hemorrhagic

STROKE

 Definition : An interruption of the blood vessel to any part of the brain.

Hemorrhagic Stroke
An incident of vascular bleeding into the brain

Non-Hemorrhagic Stroke / Ischemic Stroke (sudden vascular insufficiency)

Thrombus (a blood clot formed within a vessel) Embolus ( a blood clot is carried along in the blood stream)

Location: 50% : Basal Ganglia - Putamen (Common) - LenticularNuclei - Internal Capsule, - Globus Pallidus 15% : Thalamus 10% : Cerebellum 10-20% : Subs Alba 1-6% : Brain Stem

1.

Lesion with mass effect, edema, midline shift (herniation).

Notes: Volume consideration : 10-30 cc, moderate volume < 10 cc, not significant > 85 cc, difficult to survive

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2.

High ICP sign because of Obstructive Hydrocephalus.

Thalamic Bleeding with 3rd Ventricle Obstruction

Pre-VP Shunt

Post-VP Shunt

Brain dead caused by acute hydrocephalus

3. Superficial location and disturb important function.

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Signs & Symptoms Hemiplegi, hemiparesis, hemihypesthesi Cognitive failure Difficulty in speaking Paralyses of cranial nerves Unconsciousness H/A

 Aneurisma AVMs Cavernoma

 Description :
An Abnormal collection of blood vessels where in arterial blood flows directly into draining veins without the normal interposed capillary bed. No brain parenchym contained within the nidus. Are hamartomatous lesions of the brain, characterized by elongated feeding arteries that directly communicate with draining veins. Are masses of abnormal vessels and there is no true capillary bed in the body of the malformation. Neither arteries nor veins only abnormal vessels. Components: nidus, feeding artery, draining vein.

 Size of the AVM nidus Location of the AVMs Number and distribution of the feeding arteries and venous drainage Amount of flow through the AVMs Hematoma surround the AVMs

Kill her or She will kill your patient !!!!!!!

Definition:
Vascular anomaly characterized by the presence of sinusoidal-like capillary vessels.

Epidemiology:
Comprise 5-13% of CNS vascular malformation Location: Mainly Supra tentorial, 1023% are in posterior fossa, mostly in the pons.

Supra Tentorial Lesion

Infra Tentorial Lesion

Male,23 yo. Presenting quadriparesis and paralyze of nerve III,VI,VIII,X. MRI showed Cavernoma in posterior part of the pons.

Rebleeding

: 25% on day 1 15-20% on day 14 50 % within 6 months Vasospasm : day 3 14 Acute hydrocephalus = 15 20 % Hyponatremia (natriuresis and diuresis) Cardiac arrhythmia due to hypothalamic ischemia 3 days later : First Bleeding : Headache Severe Headache & Convulsion

Cerebral Aneurysm
Presentation:
Major :
SAH (most common) Intracerebral hemorrhage (20-40 %) Intraventricular hemorrhage(13-28%)

Minor :
Mass effect, Seizure, H/A

Grade 0 I II III IV V Aneurysm is not ruptured

Criteria

Index of Perioperative Mortality (%) 05 05 2 10 10 15 60 70 70 - 100

Asymptomatic or minimal H/A and slight nuchal rigidity Moderate to Severe H/A, Nuchal rigidity, but no neurologic deficit other than cranial nerve palsy Somnolence, confusion, medium focal deficit Stupor, hemiparesis medium or severe, possible early decerebrate rigidity, vegetative disturbances Deep coma, decerebrate rigidity, moribund appearance

CT grading:

1 = None; 2 = < 1 mm think; 3 = > 1 mm, clot;

* All Patients w/ VASOSPASM were grade 3 0r 4

4=

ICH, IVH

Most powerful tool in reducing rebleeding risk :

Surgical Clipping Endovascular coiling CLIPPING COILING

CHARACTERISTICS Size Small <10 mm W/ Small Neck W/ Large Neck Large (10 24 mm) Giant ( 25 mm) Location o ACoA o Distal ACA o MCA o PCoA o Paraclinoid ICA o Basilar Apex o PCA o PICA Complexity Atheroma / Calcification Intraluminal Thrombus

COILING

CLIPPING

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POST OPERATIVE SERVICE

Assistant : Closuring Craniotomy Operator : Having Massage