Mohammad Kurniawan

The professional practice and training of neurology in the Asian and Oceanian Region: A cross-sectional survey by the Asian and Oceanian Association of Neurology (AOAN)

OBJECTIVEnTo survey AOAN member countries regarding their organizational structure, postgraduate neurology training program, and resources for neurological care provision.nnnMETHODOLOGYnA cross-sectional survey using a 36-item questionnaire was conducted among country representatives to AOAN from August 2015 to August 2016.nnnRESULTSnA total of 18/20 AOAN member countries participated in the survey. All the countries have organized association with regular meetings, election of officers and neurology training program. In 9/18 countries, professionals other than neurologists were eligible for affiliation. In 11/18 countries, prior Internal medicine training (or equivalent postgraduate housemanship) is prerequisite to neurology program. Recertification examination is not a practice, but submission of CME is required in 7/18 countries to maintain membership. 12/18 countries publish peer-reviewed journals with at least 1 issue per year. Subspecialty training is offered in 14/18 countries. The ratio of neurologist to population ranges from 1:14,000 to as low as 1:32 million with 9/18 having <1 neurologist per 100,000 population. 6/18 countries have at least 1 specialized center solely for neurological diseases. In government-funded hospitals, the lag time to be seen by a neurologist and/or obtain neuroimaging scan ranges from 1day to 3months. All except one country have several medical- and lay- advocacy or support groups for different neurological conditions.nnnIMPLICATIONSnThe data generated can be used for benchmarking to improve neurological care, training, collaborative work and research in the field of neurosciences among the AOAN member countries. The paper presented several strategies used by the different organizations to increase their number of neurologists and improve the quality of training. Sharing of best practices, academic networking, exchange programs and use of telemedicine have been suggested.

Cerebral small vessel disease in Indonesia: Lacunar infarction study from Indonesian Stroke Registry 2012–2014

Background and Purpose: Stroke is the number one cause of morbidity and mortality in Indonesia. Lacunar infarction is one of cerebral small vessel disease spectrum. This study aimed to present stroke epidemiology in Indonesia and risk factors associated with cerebral small vessel disease. Methods: A multicenter prospective cross-sectional study of 18 hospitals in Indonesia was conducted using Stroke Case Report Form from 2012 to 2014. Stroke was diagnosed based on clinical findings confirmed with non-contrast computed tomography of the brain. Subjects were classified into two large groups: ischemic (lacunar and non-lacunar) and hemorrhagic (intracranial and subarachnoid hemorrhage). Other risk factors were assessed on admission. Results: We enrolled 5411 patients, of whom 3627 (67.03%) had ischemic stroke and 1784 (32.97%) had hemorrhagic stroke. Male patients were prevalent in both large groups, although found less in subarachnoid hemorrhage group. Among patients with hemorrhagic stroke, 1603 (89.54%) of them had intracerebral hemorrhage and 181 (10.46%) had subarachnoid hemorrhage. From 3627 ischemic stroke patients, 1635 (45.07%) of them had lacunar infarction. We found that age above 55u2009years old, male gender, hypertension, dyslipidemia, and diabetes were important risk factors associated with lacunar stroke (pu2009<u20090.05). Conclusion: Ischemic stroke was the leading cause of stroke in Indonesia. In total, 45% of the total ischemic stroke patients had lacunar infarction. Important risk factors associated with lacunar infarction were hypertension, dyslipidemia, diabetes, age over 55, and male population.

XANAP: A real-world, prospective, observational study of patients treated with rivaroxaban for stroke prevention in atrial fibrillation in Asia

ROCKET AF and its East Asian subanalysis demonstrated that rivaroxaban was non‐inferior to warfarin for stroke/systemic embolism (SE) prevention in patients with non‐valvular atrial fibrillation (NVAF), with a favorable benefit–risk profile. XANAP investigated the safety and effectiveness of rivaroxaban in routine care in Asia‐Pacific.

Association of High Blood Homocysteine and Risk of Increased Severity of Ischemic Stroke Events

&NA; Stroke is the leading cause of death and disability in the world as well as in Indonesia. Initial stroke severity is an important factor that affects short‐ and long‐term stroke outcomes. This cross‐sectional study was conducted in Cipto Mangunkusumo Hospital from July 2017 to January 2018 to investigate the factors that affect stroke severity. A total of 77 acute ischemic stroke patients were divided into three groups, which include low blood homocysteine levels (< 9 &mgr;mol/L), moderate blood homocysteine levels (9‐15 &mgr;mol/L), and high blood homocysteine levels (> 15 &mgr;mol/L). The acquired data were analyzed using Kruskal‐Wallis test and a significant difference of initial National Institute of Health Stroke Scale (NIHSS) and blood homocysteine levels (H = 13.328, p = 0.001) were seen, with a mean rank of 25.86 for low blood homocysteine levels, 33.69 for moderate blood homocysteine levels, and 48.94 for high blood homocysteine levels. The patients were then divided into two groups based on the NIHSS (≤5 and > 5) to calculate the risk correlation of blood homocysteine levels and NIHSS by using regression. We found that patients with high blood homocysteine levels had 14.4 times higher risk of having NIHSS > 5 compared with those with low blood homocysteine levels (p = 0.002, 95% confidence interval [CI] [2.714‐76.407]), and 3.9 times higher risk compared with those with moderate blood homocysteine levels (p = 0.011, 95% CI [1.371‐11.246]). We concluded that homocysteine is a risk factor for a higher stroke severity. Future studies to evaluate the usefulness of homocysteine‐lowering therapy in stroke patients are recommended.

Middle Cerebral Artery Pulsatility Index as Predictor of Cognitive Impairment in Hypertensive Patients

Background: Cognitive impairment is a manifestation of cerebrovascular disease regarding hypertension and other degenerative diseases which has become a global health issue due to increased life expectancy. Recently, the gold standard used for diagnosing vascular cognitive impairment (VCI) has required a combination of the neurophysiological approach and magnetic resonance imaging (MRI). The Neurosonological approach, involving measuring the pulsatility index (PI) of the middle cerebral artery (MCA) using Trans Cranial Doppler (TCD), can hopefully be used as an affordable alternative predictor of VCI in patients with hypertension. Methods: A cross-sectional study was conducted at the Outpatient Clinic of the Department of Neurology in Ciptomangunkusumo Hospital, Jakarta. Sixty-six hypertensive subjects with no macrovascular complication were selected and screened using the Montreal Cognitive Assesment-Indonesia version (MoCA-Ina) to determine their cognitive status. Subjects were categorized into two groups; subjects with scores ≥26 were classified as the normal cognitive group, while subjects with scores <26 were classified as the cognitive impairment group. Both groups then underwent TCD examination to determine bilateral MCA PI. Results: There was a significant difference between MCA PI in both groups; it was higher in the cognitive impairment group than normal group (p < 0.001). Subjects with an increased left MCA PI were more likely to suffer cognitive impairment than those with an increased right MCA PI. Conclusion: MCA PI can be used as a predictor for cognitive impairment in hypertensive subjects.

Translational research: May transplantation of human umbilical cord blood mononuclear cells become an adjuvant therapy for delayed thrombolysis in brain ischemia?

Mononuclear cells Become an Adjuvant Therapy For Delayed Thrombolysis in Brain Ischemia? Ramli Y,Alwahdy A.S , Kurniawan M,Juliandi B,Wuyung P.E. Neurology Department , Medical Faculty University of Indonesia, Institut Pertanian Bogor,Biology Department. Pathology Anatomy Department,University of Indonesia/ Ciptomangunkusumo National Hospital, Jakarta,Indonesia. Correspondence: ule842002@yahoo.com, telephone no: +628176636381

The Peak Flow Velocity of The Orbital Doppler Sonography in Healthy Volunteers: a Preliminary Study

Background: The comparabilty of vascular cells,physiology and pathology between theeye and the central nervous system making duplex sonography the preferable practice for vascular examination. Unfortunately, it has not been commonly performedon day by day basis and Indonesians normal valueof the orbital vessels is not yet determined. Objective: To determine the value of peak flow velocity of central retinal artery and vein, posterior cilliary and ophtalmic arteries in healthy volunteers. This study is expected to provide normal valuesof the orbital vessel for the early detection of microvascular abnormalities. Method: Consecutive sampling of 40healthyvolunteers of 21 to 35 years old is examined using orbital ultrasonography of GE logic E machine with 10 mHz linear transducer in Cipto Mangunkusumo National Hospitals Neurosonology Laboratory in Jakarta. The peak flow velocity of the central retinal artery and vein, the posterior cilliary and the ophtalmic arteries were assessed. Results: The peak flow velocity of the central retinal artery was 17.56u200a±u200a8.52, the central retinal vein was 9.76u200a±u200a4.53, the ophtalmic artery was 38.14u200a±u200a12.79, and the posterior cilliary artery was 16.59u200a±u200a7.28. Conclusion: Duplex sonography is an effective non-invasive method to determine extensive range of vascular disorders.This study producednormal value of indonesians peak flow velocity of the orbital vesselsby doppler sonograph to be used as a screening toolfor the early detection of microvascular abnormalities including stroke and hypertension.

The Role of Carotid Ultrasonography In Revealing Subclavian Steal Syndrome

Background: Subclavian steal syndrome (SSS) is quite rare; the prevalence is estimated to be between 0.6%–6%. As much as 80% of patients may present as asymptomatic. It is important to diagnose SSS promptly, as further management including vascular surgical treatment may be planned early on. Carotid Doppler (CD) ultrasonography is may demonstrate reversal of flow to establish diagnosis of SSS. Method: This is a descriptive study where subjects are all non-hemorrhagic stroke patients in CiptoMangunkusumo Hospital in 2014, upon whom CD of the internal carotid arteries (ICA) and vertebra-basilar arteries (VA) was performed. When there is a clinical suspicion of SSS, techniques are done to demonstrate reversal of flow. Results: 576 subjects were found to be eligible, among which two subjects (0.3%) were confirmed to have SSS. Subjects are male, ages >55 years old, presenting with neurological deficits associated with compromised posterior circulation i.e. symptoms of cerebellar function at onset; the first subject, presented with sudden dizziness, the second subject presented with slurred speech. Subjects also suffered from stage two hypertension and dyslipidemia. CD in both subjects showed reverse flow of the left VA. CT-angiography of one subject showed stenosis and distal occlusion of the left VA. Conclusion: SSS is a phenomenon with low prevalence, yet it is important to detect and diagnose this phenomenon. Careful ultrasonography examination should be done the clinical suspicion arise, as it plays an important role in demonstrating reversal of flow.

Cerebral Vasomotor Reactivity in Person with and without Vascular Risk Factor

Background: Cerebral vasomotor reactivity is the ability of cerebral circulation to maintain constant regulating blood flow towards any variation or stimulus in systemic condition. Cerebral vasomotor reactivity can be measured by using Transcranial Doppler ultrasonography combined with breath holding test, where then resulted as breath holding index. Vascular pathology in cerebral artery due to diabetes, hypertension, and smoking may impaired cerebral vasomotor reactivity. Objective: to measure the differentiation of breath holding index as an indicator of cerebral vasomotor reactivity in person with and without vascular risk factor (smoking, hypertension, and diabetes). Methods: Cross sectional study, with consecutive sampling. Cerebral vasomotor reactivity was measured using Transcranial Doppler ultrasound which resulted as Breath holding index in proximal part of middle cerebral artey (MCA-M1). Results: Breath holding index in right MCA-M1 normal subject was 1.437u200a+/−u200a0.14 and 1.081u200a+/−u200a0.601 in subject at risk (pu200a=u200a0.092). Breath holding index in left MCA-M1 normal subject was 1.214u200a+/−u200a0.715 and 0.942u200a+/−u200a0.721 in subject at risk (pu200a=u200a0.34). Conclusion: Subjects with vascular risk factor has trend of lower breath holding index value compared to normal subjects. Transcranial doppler ultrasound combined with breath holding test is a simple procedure to measure cerebrovascular reactivity.