1. “KEYHOLE” CRANIOTOMY EARLIER MORE EXTENSIVE

2. Ultrasound Guided Aspiration +/- Thrombolytic Agent

3. DECOMPRESSIVE CRANIECTOMY FOR ICH Decompressive Craniectomy +/- evacuation of ICH Improve ICP, hemodynamics and metabolic parameters Murthy et al: Neurocrit. Care 2005 12 pxs, GCS 5-8, 92% survived 54.5% good outcome Schaller et al; Brain Res 2003 May be better with evacuation of ICH? Dierssen et al ACTA Neurochirg 1983

4. Decompressive Craniectomy Most minimally invasive?

5. OCCLUSIVE STROKE Intracranial Stenosis Intraarterial Thrombolysis Angioplasty with stenting EC-IC Bypass for chronic ischemia Predicted to increase in numbers Need to retrain the neurosurgeons Indications Skills

6. 62/f Neurologist INTRAARTERIAL THROMBOLYSIS (rTPA) on the 6 th hour L MCA Occlusion

7. 10 th hour 30 th hour

8. Angioplasty with IC Stent

9. IMPLICATION OF INTRAVASCULAR FOREIGN BODIES?

10. MALIGNANT MCA INFARCTION DECOMPRESSIVE CRANIECTOMY

11. DECOMPRESSIVE HEMICRANIECTOMY EFFECT ON ICP AND PtiO2 ICP PtiO2

12. Decompressive Craniectomy Increasing in acceptance and usage PGH: Site of RCT Only one ongoing as of now Factors to increase good outcome Younger (55 y) Earlier (<48 hrs) Non fulminant course /Dilemna of doing it too early or too late

13. Decompressive Craniectomy HeMMI: Hemicraniectomy for Malignant Middle Cerebral Artery Infarcts. Jamora,R, Chua, A., Collantes, E., Manila/Philippines Year started2004 Study size actual26 (12 Medical) Study size planned56 Age15-65 Timing of surgery<72 hrs

14. Decompressive Craniectomy RCT s in Hemicraniectomy Improved survival Is this enough? For most families it is