PROCEEDING BOOK Page i
PROCEEDING BOOK Page i PERTEMUAN ILMIAH NASIONAL PERDOSSI ACEH
Workshop dan Simposium 2018
PERTEMUAN ILMIAH NASIONAL PERDOSSI ACEH Workshop dan Simposium
2018
PROCEEDING BOOK Page ii Reviewer : Dr.dr. Imran, Sp.S, M.Kes
Editor : Dr.dr. Syahrul Sp.S(K)
Dr.dr. Endang Mutiawati, Sp.S(K) Dr.dr. Dessy R Emril, Sp.S(K)
Layout : dr. Muhammad Ansari Adista, M.Pd.Ked.
dr. Laila Fajri
Cover : dr. Muhammad Nazli Ferdian
PROCEEDING BOOK Page iii Daftar Isi
KATA SAMBUTAN KETUA PANITIA ... xiii
KATA SAMBUTAN KETUA UMUM PERDOSSI PUSAT ... xv
Kepanitiaan ... xvii
Daftar Pembicara ... xxiii
Daftar Sponsor ... xxv
Jadwal Workshop ... xxvi
Jadwal Simposium... xxxi
A. Plenary Lectures ... 1
PL 1. Neurobiology of Parkinson’s Disease (PD) ... 1
PL 2. Where does Parkinson's Disease Begin? ... 3
PL 3. Carotid Stenosis Prevalence in Saudi Arabia and the Management of Carotid disease ... 6
PL 4. Medico-legal Issues and Patient Safety in Epilepsy, Parkinson and Movement Disorders, Neuro-oncology and Neuroimaging ... 7
B. Simposium Neuroimaging (SNI) ... 11
SNI 1. How to set up ideal stroke system for thrombolysis and thrombectomy ... 11
SNI 2. Diagnosis and prevention of deep vein thrombosis in ischemic stroke ... 13
SNI 3. Brain and Spinal cord Volume Loss in Multiple Sclerosis ... 15
SNI 4 . Early monitoring of vasospasm in subarachnoid hemmorhage with transcranial doppler ... 17
PROCEEDING BOOK Page iv SNI 5. Monitoring Cerebral Vasomotor Reactivity (CVR)
in Ischemic Stroke ... 19
SNI 6. Small vessel disease, based on neuroimaging for prompt treatment ... 20
C. Simposium Parkinson and Movement Disorder (SPMD) ... 24
SPMD 1. PDD : How to diagnose and treat ... 24
SPMD 2. RLS or Akhatisia : How to differentiate and treat ... 26
SPMD 3. Movement disorders in metabolic diseases : overview ... 54
SPMD 4. Movement disorder in intensive care ... 66
SPMD 5. Controversies in Parkinson: is levodopa remains the standard of treatment in Parkinson? ... 67
SPMD 6. Non Motor Fluctuation in Parkinson Diseases 69 SPMD 7. Movement disorder versus epilepsy : how to make it easy to diagnose ... 71
D. Simposium Epilepsi (SE) ... 73
SE 1. How AEDs work? ... 73
SE 2. Why, how and when to start and stop AEDs ... 74
SE 3. When and how to use AEDs (monotherapy and combination) ... 76
SE 4. Seizure: Epileptic or non-epileptic? ... 90
SE 5. Management of epilepsy in primary health care ... 92
SE 6. Referal system in epileptic patients ... 99
SE 7. Epilepsy with cephalgia ... 111
PROCEEDING BOOK Page v SE 8. Epilepsy with metabolic comorbidities (renal, liver
dysfunction etc) ... 112
SE 9. Epilepsy with other comorbidities (CNS infection, CVD, head trauma) ... 119
SE 10 Epilepsy with psychiatric comorbidity ... 123
E. Simposium Neuroonkologi (SNO) ... 124
SNO 1. Update of neuroimaging in brain tumour... 124
SNO 2. Interventional pain management in cancer pain ... 137
SNO 3. How to deal with chronic pain in cancer patients ... 143
SNO 4. Thrombosis management in CNS tumour ... 144
SNO 5. Stroke mimics ... 151
F. WORKSHOP NEUROIMAGING (WSNI)... 155
WSNI 1. TCCD Application for ischaemic stroke ... 155
WSNI 2. Peripheral nerve and USG diagnostic ... 157
G. WORKSHOP NEUROONKOLOGI (WSNO) ... 158
WSNO 1. Pathophysiology and management of brain metastases... 158
H. WORKSHOP PARKINSON MOVEMENT DISORDERS ... 160
WSPMD1. Voluntary movements and involuntary movements ... 160
WSPMD 2. APPROACH TO DYSTONIA ... 162
WSPMD 3. Psychogenic Movement Disorders ... 164
I. Poster (P) ... 166
PROCEEDING BOOK Page vi P1. Hubungan Antara Hiperkoagulasi dengan Kesintasan 12 Bulan Pemantauan pada Astrositoma... 166 P2. Cognitive Performance in Patient With Temporal Lobe Epilepsy ... 168 P3. Psychogenic Movement Disorder(PMD) : A Case Report ... 170 P4. Hubungan Kadar Magnesium Serum Dengan Derajat Klinis Pasien Perdarahan Intraserebral Akut Supratentorial ... 172 P5. Hubungan Kadar Thyroid Stimulating Hormone Dengan Fungsi Kognitif ... 174 P6. Perbedaan Kadar Antitrombin III, Fibrinogen, dan Troponin I Antara Pasien Stroke Iskemik Akut Dengan Stroke Hemoragik Akut (preliminary study) ... 176 P7. Ensefalitis Anti Reseptor N-Metil D-Aspartat (Ensefalitis Anti Reseptor NMDA) dengan Manifestasi Episode Psikosis Akut pada Wanita Usia Muda ... 178 P8. Hubungan Merokok Terhadap Berat Ringannya Migrain Berdasarkan MIDAS (Migraine Disability Assessment)... 180 P9. Non-Ketotic Hyperglycaemia Hemichorea ... 182 P10. Tatalaksana Agresif Pada Tumor Medula Spinalis ... 184 P11. Stroke Kardioemboli Pada Usia Muda Dengan Massa Intrakardiak ... 186 P12. Krisis Miastenia Pada Pasien Paska Timektomi Timoma Tipe B1 ... 188 P13. Konservatif Management Ruptur AVM ... 190
PROCEEDING BOOK Page vii P14. Hubungan Antara Vertigo Perifer Dengan Rasio Neutrofil Limfosit ... 192 P15. The Promising Use of Statin as Adjuvant Therapy in Parkinson’s Disease ... 194 P16. Hubungan Merokok Dengan Frekuensi Serangan Dan Intensitas Nyeri Pada Pasien Migren Kronis ... 196 P17. Toksoplasmosis Serebri Pada Pasien HIV : Sebuah Laporan Kasus... 198 P.18 Keberhasilan Terapi Plasmapharesis dan Thymektomi Pada Pasien Myasthenia Gravis : Serial Case Report ... 200 P19. Korelasi Antara Variabilitas Tekanan Darah Dengan Outcome Pada Pasien Stroke Iskemik ... 202 P20. Efikasi Flukonazole sebagai Terapi Induksi pada Meningoensefalitis Kriptokokus yang disebabkan C.
Neoformans Pada Pasien HIV (Laporan Serial Kasus) 203 P21. Faktor-Faktor Yang Mempengaruhi Karnofsky Performance Status Pada Pasien Tumor Intrakranial di RSUPN dr. Cipto Mangunkusumo Jakarta Periode Tahun 2015-2016 ... 205 P22. Nilai Diagnostik Skor Stroke Dave Unhas Pada Penderita Stroke Kardioemboli Dengan Fibrilasi Atrial di RSUP Dr.Wahidin Sudirohusodo ... 207 P23. Perbandingan Kadar Kolesterol Total dan Lipoprotein Densitas Rendah Pada Pasien Epilepsi yang Diterapi Dengan Fenitoin dan Asam Valproat Monoterapi ... 209 P24. Hubungan Kadar Serum Kalsium Dengan Derajat Keparahan Stroke Iskemik Akut Berdasarkan Skor National Institutes of Health Stroke Scale (NIHSS) Awal . 211
PROCEEDING BOOK Page viii P25. Hubungan Kadar Plasma D-Dimer Dengan Derajat Klinis Penderita Stroke Iskemik Akut Berdasarkan Skor National Institutes of Health Stroke Scale (NIHSS) ... 213 P26. Gejala Awal Ataksia Herediter Autosomal Dominan ... 215 P27. Respon Klinis Terapi Immunoglobulin Intravena Dosis Parsial Pada Pasien Sindroma Guillain-Barre .... 217 P28. Heat Stroke With Multiorgan Failure Management:
Case Report... 218 P29. Perbandingan Skor Ansietas Dan Agorafobia Pada Pasien Benign Paroxysmal Positional Vertigo Sebelum Dan Sesudah Manuver Epley ... 220 P30. Pemberian Alteplase Dosis 0,6 mg/kg Pada Stroke Iskemik Hiperakut di RSUP. H. Adam Malik, Medan Tahun 2017 (Serial Kasus) ... 222 P31. Hubungan Dislipidemia Dengan Derajat Keparahan Neuropati Diabetik Perifer Pada Penderita Diabetes Melitus Tipe 2 di Brain Center Rumah Sakit Wahidin Sudirohusodo ... 224 P32. Pengaruh Terapi Senam Otak Terhadap Peningkatan Fungsi Kognitif Pasien Lanjut Usia (Lansia) di Panti Sosial Tresna Werdha Gau Mabaji Gowa ... 226 P33. Hubungan Antara Derajat Hipertensi Dengan Gangguan Kognitif ... 228 P34. Gambaran Elektroensefalografi (EEG) Pada Pasien Skizofrenia Yang Mendapat Obat Antipsikotik di RSUPN Dr. Cipto Mangunkusumo ... 230 Kata kunci: Skizofrenia, EEG, obat antipsikotik ... 231
PROCEEDING BOOK Page ix P35. Gambaran Gelombang P300 Pada Pasien Dengan Gangguan Fungsi Kognitif di RSUP Dr.Wahidin Sudirohusodo ... 232 P36. Trend Stroke di RS Atma Jaya Tahun 2014-2017 234 P37. Hubungan Hiponatremia Terhadap Luaran Klinis Pasien Stroke Perdarahan di RSUP Dr. Sardjito Yogyakarta Periode Januari - Juli 2018 ... 236 P38. Shift Malam, Kebiasaan Konsumsi Kopi, dan Stres Meningkatkan Risiko Kualitas Tidur Buruk Pada Mahasiswa Klinik Fakultas Kedokteran Unika Atma Jaya, jakarta ... 238 P39. Herpes Simplex Encephalitis (Case Report) ... 240 P40. Gambaran Pola Tidur Pada Anak Penyandang Autism Spectrum Disorder ... 241 P41. Comperation Between Concomitant Therapy and Single Therapy For Maintenance Therapy of Neuromyelitis Optica (Serial Case) ... 243 P42. Distinctive MRI Brain Lesions of NMOSD and MS Confirmed With Clinical Feature: Serial Case ... 245 P43. Studi Transcranial Doppler: Evaluasi Pengaruh Musik Pop Terhadap Perubahan Blood Flow Velocity Serebral ... 247 P44. Laporan kasus: Status Epileptikus Refrakter Onset Baru Pada Ensefalitis Limbik... 249 P45. Stroke Hemoragik Pada Kehamilan: Sebuah Laporan Kasus ... 251 P46. Pengaruh Letak Lesi Terhadap Tingkat Intelegensi Pada Pasien Epilepsi ... 253
PROCEEDING BOOK Page x P47. Hubungan Pemakaian Kontrasepsi Hormonal Pada Wanita Usia Produktif Dengan Kejadian Meningioma Periode Januari 2017 – Desember 2018 ... 255 P48. Gambaran Tumor Asal Yang Metastase Ke Intrakranial di RSUP Dr. Kariadi Bulan Januari Tahun 2016 – Bulan September 2018 ... 256 P49. Prevalensi EEG pada Cerebral Palsy di RS Dr Kariadi Semarang Periode Januari 2018 – Juni 2018 .. 258 P50. Profil Tumor Spinal di RSUP Dr. Kariadi Semarang Periode Januari – Desember 2017 ... 259 P51. Profil Penyulit Pasien Post Operasi Tumor Otak di ICU RS Dr. Kariadi Semarang... 261 P52. Profil Pemeriksaan Transcranial Dopler (TCD) di RSUD Dr.Moewardi Surakarta ... 263 P53. Hubungan Tingkat Fungsi Kognitif dengan Derajat Penyakit Parkinson di RSAU Salamun Kota Bandung 265 P54. Pengaruh Volume Tumor Terhadap Kualitas Hidup Pasien Tumor Otak Di RS Dr. Kariadi Bulan September Tahun 2017 – Bulan September 2018... 267 P55. Efikasi Radiofrekuensi Ablasi Dalam Manajemen Nyeri Pada Penderita Neuralgia Trigeminal Di RSUP Dr.
Kariadi Semarang Periode Oktober 2017 – Oktober 2018 ... 268 P56. Gambaran Gangguan Kognitif pada Pasien Stroke Iskemik di RSUD Dr. Zainoel Abidin Banda Aceh ... 270 P57. Hubungan Morfologi Plak pada Stenosis Arteri Intrakranial dengan Kejadian Stoke Iskemik ... 272 P58. Generilized Tonic-Clonic Seizure (GTCS) ... 274 P59. Meningioma Aplastik ... 280
PROCEEDING BOOK Page xi P60. Hubungan Tekanan Darah Sistolik dengan Outcome Stroke Pada Pasien Dengan dan Tanpa Intrakranial Large Artery Stenosis... 282 P61. Neurobehavioral Disorder As Early Symptom in Brain Tumor ... 284 P62. Hemochorea/Hemibalism Associated With Hyperglycemia : A Case Report ... 286 P63. Sindrom Kernohan : Hemiparesis Ipsilateral pada Perdarahan Sudural Sub Akut ... 288 P64. Fahr’s Disease : Serial Case ... 290 P65. Karakteristik Penyakit Parkinson di Poliklinik Saraf RSUD Dr. Zainoel Abidin Banda Aceh ... 292 P66. Pengaruh Volume Perdarahan Terhadap Tekanan Intrakranial (TIK) Pada Pasien Stroke Hemoragik Menggunakan TCD Di RSUD Dr. Zainoel Abidin Banda Aceh ... 294 P67. Parkinsonisme Sekunder Pada Kraniofaringioma Suprasella Dewasa Muda ... 295 P68. Profil Penderita Tumor Otak di RSUD Dr. Moewardi Surakarta Periode Januari 2016 – Desember 2017 ... 297 P69. Serial Kasus: Meduloblastoma Rekuren Pada Dewasa ... 299 P70. Tatalaksana Nyeri Pada Pasien Acute Mieloblastic Leukemia (AML) ... 301 P71. Comparison of Cognitive Functions in Geriatric Patients With Parkinson and Geriatric Patients Without Parkinson at Outpatient Clinic in Neurology Department Dr. Moewardi Hospital Surakarta ... 303
PROCEEDING BOOK Page xii P72. Tumor Otak Pada Anak ( Suatu jenis Primitif Neuroectodermal Tumor ) ... 305 P73. Profil Gangguan Fungsi Kognitif Pada Pasien Rawat Inap Neurologi Di RSUD Dr. Zainoel Abidin Banda Aceh ... 307 P74. Perbandingan Gambaran MRI pada Spondilitis TB Dibanding dengan Metastase Pada Tulang Belakang... 309
PROCEEDING BOOK Page xiii KATA SAMBUTAN KETUA PANITIA
Assalamu'alaikum Wr Wb, Sejawat yang berbahagia,
Kami menyampaikan ucapan selamat datang kepada Sejawat dan keluarga untuk berpartisipasi pada acara Pertemuan Ilmiah Nasional (PIN) PERDOSSI 2018 di Banda Aceh Provinsi Aceh dari tanggal 1-3 November 2018. Selama berada di kota Serambi Mekkah, Sejawat dan keluarga dapat mengunjungi destinasi wisata yang sangat menarik terutama destinasi wisata Tsunami dalam nuansa Islami, kuliner masakan khas Aceh, berbagai panorama yang sangat indah dan wisata Kilometer Nol Indonesia di Pulau Weh Sabang.
PERDOSSI Cabang Aceh bersama Departemen Neurologi Fakultas Kedokteran Universitas Syiah Kuala (UNSYIAH)/RSUD dr Zainoel Abidin Pemerintah Aceh mendapat kepercayaan dan kehormatan dari PP PERDOSSI sebagai Panitia Pelaksana acara Pertemuan Ilmiah Nasional PERDOSSI 2018.
Kegiatan ilmiah yang meliputi workshop, simposium, presentasi poster dan makalah bebas dengan tema Improving Holistic
PROCEEDING BOOK Page xiv Management for a Better Quality of Life bersama Kelompok Studi Neuroimaging, Neuroonkologi, Epilepsi serta Parkinson dan Gangguan Gerak dengan narasumber pembicara nasional dan internasional.
Kami sangat mengharapkan dengan PIN PERDOSSI 2018 yang dilaksanakan di Provinsi Aceh dapat meningkatkan kualitas layanan Neurologi secara komprehensif terutama dalam bidang Neuroimaging, Neuroonkologi, Epilepsi, Parkinson dan Gangguan Gerak.
Ucapan terimakasih yang tulus dan dalam kami sampaikan kepada PP PERDOSSI atas kepercayaannya, Sejawat Neurologist dan keluarga atas partisipasi aktifnya, Panitia PIN PERDOSSI 2018 Banda Aceh, Mitra Farmasi dan semua pihak yang telah membantu terselenggaranya acara PIN PERDOSSI 2018 di Provinsi Aceh.
Wassalamu'alaikum wr.wb.
Dr. dr. Syahrul, SpS(K) Ketua Panitia
PROCEEDING BOOK Page xv KATA SAMBUTAN KETUA UMUM PERDOSSI PUSAT
Assalamu'alaikum wr.wb.
Salam sejahtera untuk kita semua.
Puji syukur kita panjatkan kehadirat Allah SWT atas limpahan rahmat-Nya kepada kita semua terutama dalam melaksanakan tugas keprofesian kita. Selain KONAS dan MUKERNAS, PIN (Pertemuan Ilmiah Nasional) adalah program kerja PP PERDOSSI dalam upaya peningkatan profesionalisme anggota secara berkesinambungan.
Semester ke-2 tahun 2018 ini PERDOSSI Cabang Banda Aceh mendapat kehormatan sebagai panitia pelaksana PIN untuk kelompok studi: Neuroimaging, Neuroonkologi, Epilepsi serta Parkinson dan Gangguan Gerak (Movement Disorder). Dalam praktik neurologi, masalah- masalah yang terkait dengan neuroimaging, kasus tumor saraf, epilepsi, dan gangguan gerak cukup banyak ditemukan. Sehingga materi yang akan disuguhkan oleh PIN PERDOSSI ACEH ini memiliki arti signifikan bagi anggota PERDOSSI dalam meningkatkan kompetensi dan profesionalisme dalam pelayanan neurologis kasus-kasus terkait.
PROCEEDING BOOK Page xvi Dengan diberi pengarahan oleh Ketua II PP PERDOSSI serta dibantu oleh ketua Kelompok Studi yang bersangkutan, tentu panitia pelaksana PIN PERDOSSI ACEH sudah menyiapkan menu ilmiah menarik bagi para peserta. Adapun kegiatan ilmiah yang disajikan adalah workshop, simposium, presentasi poster dan makalah bebas serta proceeding book. Panitia juga memberikan kesempatan kepada para peserta Program Pendidikan Dokter Spesialis (PPDS) Neurologi untuk mempresentasikan hasil penelitiannya, sebagai persyaratan akademik yang ditentukan. Narasumber seluruh kegiatan ilmiah dipilih dari para ahli di bidangnya masing- masing.
Mari kita hadiri PIN ini sebagai ajang ilmiah dan silaturrahmi di Kota Banda Aceh yang madani, lengkap dengan situs-situs sejarah Islam dan wisata tsunami.
Wassalamu'alaikum wr.wb.
Prof. Dr. dr. Moh. Hasan Machfoed, Sp.S(K), M.S.
Ketua Umum PERDOSSI
PROCEEDING BOOK Page xvii Kepanitiaan
Pelindung :
Gubernur Provinsi Aceh Ketua Umum PERDOSSI Rektor UNSYIAH
Ketua IDI Wilayah Aceh Penasehat :
Walikota Banda Aceh Dekan FK UNSYIAH
Direktur RSUZA Banda Aceh
Ketua 2 Bid. P2KB & Koord. Pokdinas & Pembinaan Profesi
Ketua PERDOSSI Banda Aceh Pengarah :
Ketua POKDI Neuroimaging Ketua POKDI Neuroonkologi Ketua POKDI Epilepsi
Ketua POKDI Movement Disorder
Ketua Umum : Dr.dr. Syahrul, Sp.S(K) Wakil Ketua : Dr.dr. Endang Mutiawati Rahayuningsih, Sp.S(K)
Sekretaris : Dr.dr. Dessy R.Emril, Sp.S(K) Bendahara : dr. Nova Dian Lestari, Sp.S Wakil Bendahara : dr. Yuliawati, Sp.S
Ade Purnama Sari Sie Sekretariat
Koordinator : dr. Ika Marlia, M.Sc, Sp.S Anggota : dr.Yuliawati, Sp.S
dr. Syahroni,Sp.S dr. Rizkidawati
PROCEEDING BOOK Page xviii dr. Khairunnisa
dr. Juwita, M.Biomed Mardina Juniati Aida Setiawati Mastur
Edy Saputra Sie Dana & Pameran
Koordinator : Dr.dr. Dessy R.Emril, Sp.S(K) Anggota : Dr.dr. Endang Mutiawati, Sp.S(K)
dr. Fajriman,M.Kes, Sp.S dr. Nasrul Musadir, Sp.S dr. Farida, Sp.S(K)
Sie Ilmiah ( Makalah Bebas, Poster Ilmiah dan Proceeding Book )
Koordinator : Dr.dr.Imran,Sp.S.,M.Kes Anggota : Dr. dr. Suherman, Sp.S
dr. Nursanty, Sp.S dr. Zuraini, Sp.S dr. Ervina Susanti, Sp.S
dr. Ichwannuddin, Sp.S dr. Widyawan S., M.Kes, SpN
dr. M. Ansari Adista, MPd.Ked.
dr. M. Aris Chandra dr. Deri Rivano
dr. Laila Fajri dr. Zefri Suhendar Pokdi Neuroimaging
Ketua : dr. Farida,Sp.S(K) Anggota : dr. Erlinawati, Sp.S
dr. Khairinnisa Hasibuan, Sp.S
PROCEEDING BOOK Page xix dr. Melda Fitria
dr. M.Ansari Adista, M.Pd.Ked.
Pokdi Neuroonkologi
Ketua : dr. Elsa Susanti, Sp.S Anggota : dr. Intan Sahara Zein, Sp.S
dr. Rahmadani Zulfitri, Sp.S dr. Safridawati
dr. Lailatul Fitri Pokdi Epilepsi
Ketua : dr. Nova Dian Lestari .Sp.S Anggota : dr. Nur Astini, Sp.S
dr. Sri Hastuti, Sp.S dr. Khamsaton Nisa, SpS dr. Hidayaturrahmi, M.Kes dr. Natasya Wanda Yuniza Pokdi Movement Disorder
Ketua : dr. Mursyida,Sp.S
Anggota : Dr.dr. Dessy R Emril, Sp.S dr. Basli Sp.S
dr. Cut Diana M. T., M.Ked(Neu), SpS dr. Ellya Nurfida
dr. Mahda Liana Rizki Sie Publikasi dan Dokumentasi
Ketua : dr. Farida, Sp.S (K) Anggota : dr. Nasrul Musadir, Sp.S
dr. Maulina Sri R, M.Ked(Neu) Sp.S dr. Melda Fitria
dr. Khatab
PROCEEDING BOOK Page xx dr. Muhammad Nazli Ferdian dr. Aries Chandra
Ahmad Husnul Huluk, S.Ked
Fauzan Azima, S.Ked
Nadya Paramitha Siregar, S.Ked Yudi Aulia S.Ked
Sie Acara, Tempat & Perlengkapan Koordinator : dr. Nur Astini, Sp.S Anggota : dr. Sri Hastuti,Sp.S
dr. Mursyida, Sp.S dr. Asri Astuti, Sp.S
dr. M.Mizfaruddin, M.Kes, Sp.S dr. Herlina Sari,Sp.S
dr. Abdul Muis,Sp.S
dr. Kun Marisa, SpS
dr. Tarmizi, Sp.S dr. M. Isra Ikhwana dr. Deri Rivano
dr. Hidayaturrahmi, M.Si
dr. Safridawati
dr. Muhammad Nazli Ferdian dr. Zefri Suhendar
dr. Andi Muttaqien
Gala Dinner
Koordinator : dr. Nursanti, Sp.S
dr. Mursyida, Sp.S
dr. Farida, Sp.S(K)
dr. Isra Ikhwana dr. Dedy Savradinata dr. Khatab
PROCEEDING BOOK Page xxi dr. Ipak Nistriana
dr. Lailatul Fitri
Sie Rapat PP & Rapat POKDI :
Koordinator : dr. Ika Marlia, M.Sc, Sp.S Anggota : dr. Khamsaton Nisa, SpS
dr. Widyawan Syahputra, M.Kes, SpN dr. Rahmadani Zulfitri,Sp.S
dr. Khairunnisa dr. Laila Fajri dr. Dedy Savradinata dr. Juwita, M.Biomed dr. Mahda Liana Rizki Sie Akomodasi/Transportasi :
Koordinator : dr. Nasrul Musadir, Sp.S
Anggota : dr. M. Mizfaruddin, M.Kes, Sp.S dr. Minar Mushari, Sp.S
dr. Anwar, Sp.S dr. Januar, Sp.S
dr. Fajriman, M.Kes, Sp.S
dr. Cut Diana M T., M.Ked(Neu), Sp.S dr. Ipak Nistriana
dr. Mahda Liana Rizki dr. Isra Ikhwana dr. Khatab
dr. Dedy Savradinata dr. Andi Muttaqien Sie Konsumsi & Ladies Program
Koordinator : dr. Asri Astuti, Sp.S
Anggota : dr. Cut Diana M.T., M.Ked(Neu), SpS
PROCEEDING BOOK Page xxii dr. Eva Rahmi,M.Ked(Neu), Sp.S dr. Maulida, M.Sc, Sp.S
dr. Syamsidar,Sp.S
dr. Eva Mutia, M.Ked(Neu), Sp.S dr. Ellya Nurfida
dr. Natasya Wanda Yuniza Ny. Ery Nasrul
Ny. Intan Syahrul
Ny. Reno Suherman
Ny. Beby Imran Ny. Yessy Minar Ny. Rina Syahroni
PROCEEDING BOOK Page xxiii Daftar Pembicara
Prof. Dr. dr. Moh. Hasan Machfoed. Sp.S (K) M.S.
Prof. Dr. dr. Hasan Sjahrir, Sp.S(K) Prof. Yoshikazu Ugawa (Japan)
Prof. Dr. Teguh Asaad Suhatno Ranakusuma, Sp.S(K)
Dr. Fahmi Mohammed Al-Senani, MBBS., MSc., MHA (Saudi Arabia)
Dr. dr. Syahrul, Sp.S(K)
Dr. dr. Salim Haris Sp.S(K), FICA
Dr. dr. Fenny L.Yudiarto Sp.S (K).,FAAN Dr. dr. Yuliarni Syafrita, Sp.S(K)
Dr. dr. D.P.G. Purwa Samatra, Sp.S(K) Dr. dr.Herlyani Khosama, Sp.S(K) Dr. dr. Kurnia Kusumastuti, Sp.S(K) Dr. dr. Anna Marita Gelgel, Sp.S(K) Dr. dr. Uni Gamayani, Sp.S(K) Dr. dr. Nova Dian Lestari, Sp.S Dr. dr. Diah Kurnia Mirawati, Sp.S(K) Dr. dr. Rini Andriani, Sp.S
Dr. dr. Tiara Aninditha, Sp.S(K)
Dr. dr. Dessy Rakhmawati Emril, Sp.S(K) Dr. dr. Endang Mutiawati, Sp.S(K)
Dr. dr. Endang Kustiowati, SpS(K).M.Si.Med.
Dr. dr. Suryani Gunadharma, SpS(K).M.Kes.
Dr. dr. Fitri Octaviana Sp.S(K), M.Pd.Ked.
Dr. dr. Rini Andriani Sp.S Dr. dr. Astri Budikayanti Sp.S(K) Dr. dr. Tiara Aninditha Sp.S(K) Dr. dr. Imran, M.Kes. Sp.S.
dr. Rivan Danuaji, Sp.S., M.Kes.
dr. Isti Suharjanti, Sp.S (K) dr. Farida Sp.S (K)
PROCEEDING BOOK Page xxiv dr. Indah Aprianti Putri, M.Sc Stroke Medicine, Sp.S.
dr. Eko Arisetijono, Sp.S (K) dr. Andradi Suryamiharja, Sp.S (K) dr. Banon Sukoandari, Sp.S
dr. Muhammad Akbar , Sp.S(K)., Ph.D., DFM.
dr. Muhammad Hamdan Sp.S(K) dr. Sobaryati, Sp.S-KIC.,M.Kes.
dr. Subagya, Sp.S(K)
dr. Haflin Soraya Hutagalung, M.Ked(Neu)., Sp.S.
dr. Machlusil Husna,Sp.S(K)
dr. Wardah Rahmatul Islamiyah Sp.S.
dr. Aris Catur Bintoro, Sp.S(K) dr. Nurul Machillah, Sp.Rad dr Rusdy Ghazali, Sp.S., PhD dr. Henry Riyanto, Sp.S
dr. Joice Rosewitasari A. Djohansjah Sp.S., M.Si.
dr. Girianto Tjandrawidjaja, Sp.S dr. Rakhmad Hidayat, Sp.S(K)
dr. Indah Aprianti Putri, M.Sc. Stroke Medicine, Sp.S dr. Melke J. Tumboimbela, Sp.S(K)
dr. George Dewanto, Sp.S, FAAN dr. Henry Riyanto Sofyan Sp.S dr. M.Riswan, Sp.PD-KHOM
PROCEEDING BOOK Page xxv Daftar Sponsor
PT. Novartis Indonesia
PT. Citra Pharma Indonesia PT. Dexa Medica
PT. Ikapharmindo PT. Mersifarma PT. Eisai Indonesia
PT. Jhonson & Jhonson
PT. Glaxo Wellcome Indonesia PT. Abbott
PT. Phapros Tbk PT. Mulya Husada Jaya PT. Andaya Medika PT. Merck
PT. Kalbe PT. Ferron
PT. Transfarma Medica Indah/Menarini Company PT. Roche Indonesia
PT. Anugerah Pharmindo Lestari PT. Aventis Pharma (SANOFI) PT. Boehringer Ingelheim PT. Anugerah Pharmindo Lestari
PROCEEDING BOOK Page xxvi Jadwal Workshop
Thursday Novemver 1 2018 Kyriad Muraya Hotel
WORKSHOP NEUROIMAGING
TIME PROGRAMS
07.30-08.00 Registration 08.20-08.40 Pretest 08.40-09.10
TCCD Application for ischaemic stroke
dr. Girianto Tjandrawidjaja, Sp.S 09.10-09.40
Deep vein thrombosis diagnostic with USG
dr. Rakhmad Hidayat, Sp.S(K) 09.40 - 10.00 Coffee Break
10.00 - 10.30
The examination of Micro Embolic Signal (MES) with bubble
dr. Indah Aprianti Putri, M.Sc. Stroke Medicine, Sp.S
10.30 - 11.00
Monitoring vasospasm and
intracranial pressure with Transcranial Doppler (TCD)
dr.Farida, Sp.S(K) 11.00 - 11.30
Peripheral nerve and USG diagnostic dr. Rivan Danuaji, M.Kes., Sp.S 11.30 - 12.00
External Carotid Doppler (ECD) for carotid disease
dr. Melke J. Tumboimbela, Sp.S(K) 12.00 - 13.30 Prayer and Lunch
PROCEEDING BOOK Page xxvii 13.30 - 15.30 Hands On (Instructors)
15.30 - 16.00 Post Test 16.00 - 16.15 Closing
WORKSHOP OF NEUROONCOLOGY
TIME PROGRAMS
07.00 - 07.45
Registration 07.45 -
07.50
Opening 07.50 -
08.00
Pretest 08.00 -
08.50
First Session Pathophysiology and management of brain metastases
Seizure management in neurooncology
Dr. dr. Rini Andriani Sp.S
Dr. dr. Astri
Budikayanti Sp.S(K)
Group A Group B
08.50 - 08.55
switch group 08.55 -
09.45
Group B Group A
09.45 - 10.00
Coffee break 10.00 -
10.50
Second Session Management of cancer pain
Opioid switching in cancer pain
Dr. dr. Dessy R.
Emril, Sp.S(K)
dr. Henry Riyanto Sofyan Sp.S
PROCEEDING BOOK Page xxviii
Group A Group B
10.50 - 10.55
switch group 10.55 -
12.00
Group B Group A
12.00 - 13.30
Prayer and Lunch 13.30 -
14.10
Session 5
Breaking the bad news & palliative management in brain tumor
Dr. dr. Tiara Aninditha Sp.S(K) 14.10 -
14.30
Postest 14.30 -
14.45
Closing
WORKSHOP EPILEPSI
TIME PROGRAMS
07.00-07.45 Registration 07.45-08.00 Opening 08.00-08.15 Pretest
08.15-09.30 Status Epileptic : definition, pathophysiology and diagnostic Dr.dr. Endang Kustiowati, SpS(K).M.Si.Med.
09.30-09.45 Coffee Break
09.45-11.00 EEG presentation of convulsive and non-convulsive status epileptic
PROCEEDING BOOK Page xxix Dr.dr. Suryani Gunadharma,
SpS(K).M.Kes.
11.00-12.15 Management of convulsive and non- convulsive status epileptic
Dr. dr. Fitri Octaviana Sp.S(K), M.Pd.Ked.
12.15-12.45 Discussion
12.45-14.00 Prayer and Lunch 14.00-15.30 Hands On
15.30-15.45 Postest 15.45-16.00 Closing
WORKSHOP MOVEMENT DISORDER
TIME PROGRAMS
07.00-07.45 Registration 07.45-08.00 Opening 08.00-08.15 Pretest 08.15 - 09
15
Mexhanisms of voluntary and involuntary movements in humans
Prof. Yoshikazu Ugawa (Japan)
09.15-09.30 Coffee Break 09.35 -
10.20
Extrapiramidal system and neurotransmitter:
role in movement disorders Video Session
dr.Banon Sukoandari, Sp.S 10.20 -
11.05
Diagnostic approach and phenomenology examination
Video Session
PROCEEDING BOOK Page xxx dr. Subagya, Sp.S(K)
11.05-11.50 Hypokinetic (Parkinson disease, focus in sign- symptoms and diagnostic)
Video Session
dr. Banon Sukoandari, Sp.S 11.50-12.30 Tremor and Myoclonus
Video Session dr. Subagya, Sp.S (K) 12.30 -
14.00
Prayer and Lunch 14.00 -
14.45
Distonia Video Session
dr. George Dewanto, Sp.S, FAAN 14.45 - 15.
30
Chorea Video Session
dr. Muhammad Hamdan, Sp.S(K) 15.30 -
16.15
Gait Disorders Video Session
dr. Muhammad Hamdan, Sp.S(K) 16.15 - 17.
05
Psycogenic/functional movement disorders Video Session
dr. George Dewanto, Sp.S, FAAN 17.05 -
17.15
Post Test 17.15 Closing
PROCEEDING BOOK Page xxxi Jadwal Simposium
PLENARY LECTURE Friday, 2 November 2018 Hermes Hotel, Banda Aceh
Tme Topic Speaker
07.30 - 07.45
Neurobiology of Parkinson Disease
Prof. Dr. dr. Moh.
Hasan Machfoed. Sp.S (K) M.S.
07.45 - 08.00
Where does
Parkinson's Disease Begin?
Prof. Yoshikazu Ugawa (Japan)
Saturday, 3 November 2018 Hermes Hotel, Banda Aceh
Tme Topic Speaker
07.30 - 07.45
Carotid Stenosis Prevalence in Saudi Arabia and the
Management of Carotid disease
Dr. Fahmi Mohammed Al- Senani, MBBS., MSc., MHA
07.45 - 08.00
Medico-legal Issues and Patient Safety in Epilepsy, Movement Disorders, Neurooncology and Neuroimaging
Dr. dr. Syahrul, Sp.S(K)
PROCEEDING BOOK Page xxxii SIMPOSIUM
Friday, 2 November 2018 Hermes Hotel, Banda Aceh ROOM ACEH-1
TIME TOPIC SPEAKER
10.00- 10.20
Management of advanced Parkinson diseases
dr. Andradi
Suryamiharja, Sp.S (K) 10.20 -
10.40
PDD : How to diagnose and treat
dr. Banon Sukoandari, Sp.S
10.40 – 11.00
RLS or Akhatisia : How to differentiate and treat
dr. Muhammad Akbar , Sp.S(K)., Ph.D., DFM.
11.15 - 11.35
How AEDs work? Dr.dr.Herlyani Khosama, Sp.S(K) 11.35-
11.55
Why, how and when to start and stop AEDs
Dr.dr. Kurnia
Kusumastuti, Sp.S(K) 11.55 –
12.15
When and how to use AEDs (monotherapy and combination)
dr.Machlusil Husna,Sp.S(K) 14.30-
14.50
Advanced neuroimaging in migraine
dr. Isti Suharjanti, Sp.S (K)
14.50- 15.20
Brain loss in multiple sclerosis
Dr. dr. Fenny L.Yudiarto Sp.S (K).,FAAN 15.20 –
15.30
Early monitoring of vasospasm in sub-
dr. Farida Sp.S (K)
PROCEEDING BOOK Page xxxiii arachnoid hemmorhage
with transcranial doppler ROOM ACEH - 2
TIME TOPIC SPEAKER
10.00- 10.20
How to set up ideal stroke system for thrombolysis and thrombectomy
Dr. Fahmi Mohammed Al-Senani, MBBS., MSc., MHA
(International Speaker) 10.20 -
10.40
Thrombolysis guided with TCD/TCCD
Dr.dr. Salim Haris Sp.S(K), FICA
10.40 – 11.00
Diagnostic and prevention Deep Vein Thrombosis in ischaemic stroke
Dr. dr. Syahrul, Sp.S(K)
11.15 - 11.35
Liquid biopsy in brain tumour
Dr.dr. Rini Andriani, Sp.S
11.35- 11.55
Update of
neuroimaging in brain tumour
dr. Nurul Machillah, Sp.Rad
11.55 – 12.15
2016 WHO
Classification of CNS Tumour
dr Rusdy Ghazali, Sp.S., PhD
14.30- 14.50
Diagnosis and management of cerebellar ataxia
dr. Muhammad Hamdan Sp.S(K)
PROCEEDING BOOK Page xxxiv 14.50-
15.20
Movement disorders in metabolic diseases : overview
Movement disorder in intensive care
15.20 – 15.30
Movement disorder in intensive care
dr. Sobaryati, Sp.S- KIC.,M.Kes.
Saturday, 3 November 2018 Hermes Hotel, Banda Aceh ROOM ACEH-1
TIME TOPIC SPEAKER
08.20 - 08.40
Pain-induced cancer; is it a nature or complication of the disease?
Dr.dr. Tiara Aninditha, Sp.S(K)
08.40 - 09.00
Opioid management in cancer pain
dr. Henry Riyanto, Sp.S
09.00 - 09.20
Interventional pain management in cancer pain
Dr.dr. Dessy
Rakhmawati Emril, Sp.S(K)
09:30 – 09.50
Nenoin; new critical trial 2018. Management of peripheral neuropathy symptoms with a fix dose combination of vitamin B1, B6 and B12
dr. Pagan Priambudi, MSi, SpS
09.50- 10.10
Mixed pain; focusing on low back pain. Insight of
the DOLOR study
dr. Yusuf Wibisono, SpS(K)
PROCEEDING BOOK Page xxxv 10.10 -
10.30
Controversies in Parkinson: is levodopa remains the standard of treatment in Parkinson?
dr. Subagya, Sp.S(K)
10.30 – 10.50
Non Motor fluctuation in Parkinson diseases
dr. Haflin Soraya Hutagalung,
M.Ked(Neu)., Sp.S.
10.50 - 11.10
Movement disorder versus epilepsy : how to make it easy to diagnose
Dr. dr. D.P.G. Purwa Samatra, Sp.S(K) 11. 20 –
11.40
Epilepsy with psychiatric comorbidity
Dr. dr. Nova Dian Lestari, Sp.S 11.40 –
12.00
Epilepsy with metabolic comorbidities (renal, liver dysfunction etc)
Dr. dr. Diah Kurnia Mirawati, Sp.S(K) 12.00 –
12.20
Epilepsy with other comorbidities (CNS infection, CVD, head trauma)
dr. Aris Catur Bintoro, Sp.S(K)
12.20 – 12.40
Epilepsy with cephalgia Prof. Dr. dr. Hasan Sjahrir, Sp.S(K) ROOM ACEH-2
TIME TOPIC SPEAKER
08.20 - 08.40
Seizure: Epileptic or non- epileptic?
Dr.dr. Anna Marita Gelgel, Sp.S(K 08.40 -
09.00
Management of epilepsy in primary health care
Dr.dr. Uni Gamayani, Sp.S(K)
09.00 - 09.20
Referal system in epileptic patients
dr. Wardah Rahmatul Islamiyah Sp.S.
PROCEEDING BOOK Page xxxvi 09:30 –
09.50
Selected Benefit of Pentoxifyline in Acute Ischemic Stroke Management
Dr. dr. Salim Harris, Sp.S (K), FICA
09.50- 10.10
Update Haemorrheology of Stroke Treatment
Dr. dr. Al Rasyid, Sp.S(K)
10.10 - 10.30
ECST -2 trial and carotid imaging
dr. Indah Aprianti Putri, M.Sc Stroke Medicine, Sp.S.
10.30 – 10.50
Monitoring Cerebrovascular
Reactivity (CVR) in ischaemic stroke
Dr. Rivan Danuaji, Sp.S., M.Kes.
10.50 - 11.10
Small vessel disease, based on neuroimaging for prompt treatment
dr. Eko Arisetijono, Sp.S (K)
11. 20 – 11.40
Role of neurologist in paliative care
dr. Joice Rosewitasari A. Djohansjah Sp.S., M.Si.
11.40 – 12.00
How to deal with chronic pain in cancer patients
Dr. dr. Endang Mutiawati, Sp.S(K) 12.00 –
12.20
Thrombosis management in CNS tumour
dr. M.Riswan, Sp.PD-KHOM 12.20 –
12.40
Stroke Mimics Dr. dr. Imran, Sp.S.
M.Kes.
PROCEEDING BOOK Page 1 A. Plenary Lectures
PL 1. Neurobiology of Parkinson’s Disease (PD) Prof. Dr. dr. Moh. Hasan Machfoed. Sp.S (K) M.S.
Department of Neurology
School of Medicine – Airlangga University Dr. Soetomo Hospital – Surabaya
Parkinson's disease (PD) is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The cause of Parkinson's disease is generally unknown, but believed to involve both genetic and environmental factors. The motor symptoms of the disease result from the death of cells in the substantia nigra, a region of the midbrain. This results in not enough dopamine in these areas.
The main pathological characteristics of PD are cell death in the brain's basal ganglia. It affects up to 70% of the dopamine secreting neurons in the substantia nigra pars compacta, and the presence of Lewy bodies (accumulations of the protein alpha-synuclein) in many of the remaining neurons.
This loss of neurons is accompanied by the death of astrocytes and a significant increase in the number of microglia in the substantia nigra.
Under normal circumstances, there is a balance between the dopamine-1 (D-1) receptor and 2 (D-2) in the putamen.
This balance is followed by various basal ganglia components such as Globus Pallidus externa (GPe), interna (GPi), substantia nigra/compacta, thalamus and cerebral cortex. PD occurs when there is a disturbance in the balance between the
PROCEEDING BOOK Page 2 components mentioned above. Understanding the neurobiology of PD is very useful for therapeutic strategies.
Keyword: Neurobiology Parkinson’s Disease
PROCEEDING BOOK Page 3 PL 2. Where does Parkinson's Disease Begin?
Prof. Yoshikazu Ugawa
Department of Neuro-Regeneration, Fukushima Medical University
In the present symposium, I will introduce several recent papers on the issue not solved yet. I recommend you read the papers listed at the end of this abstract if you are interested in my talk.
Classical concept of Parkinson’s disease:
Classically or in the textbook, Parkinson’s disease involves mainly substantia nigra (SN) and shows four main motor symptoms: tremor, rigidity, akinesia, and instability. It is pathologically characterized by lewy bodies in several brain regions, which is composed of synuclein.
Premotor or non-motor symptoms:
The above concept was clinically challenged by non-motor symptoms seen before motor symptoms. It suggests that non- motor systems may be affected earlier than the motor systems. A few non-motor symptoms at the earlies stage are constipation, hyposomnia, and REM related behavioral disorders (RBD). They may be produced by lesions at gut, olfactory bulb, and brainstem, respectively.
Braak hypothesis proposes a new idea:
Based on many autopsied specimens of PD patients, Professor Braak proposed an attractive new hypothesis that Parkinson’s disease begins at the gut and lewy bodies propagate to the dorsal motor nucleus of vagus through vagal nerves and sympathetic pathways, especially in idiopathic PD patients.
Clinical and animal experimental supporters:
PROCEEDING BOOK Page 4 Most of pathological studies thereafter confirmed the Braak hypothesis, and I will show some of them. Clinical findings also mostly support his hypothesis, especially vagotomy made a risk of PD occurrence decrease, which supports the idea that lewy bodies propagate through vagus nerves. Animal experiments also supported his idea, especially chronic gastric intake of rotenone produced lewy body accumulation in SN. However, a few studies challenged those positive results. I will show several examples of pro and con results.
My tentative conclusion: My conclusion is very simple.
Parkinson’s disease is not one entity and is a kind of syndrome.
References
1. Nat Rev Dis Primers. Article number: 17013 doi:10.1038/nrdp.2017.13 Parkinson’s Complex:
2. Parkinsonism Is Just the Tip of the Iceberg J. William Langston. Ann Neurol 2006: 591-596
3. Constipation preceding Parkinson’s disease: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2015;0:1–7.
4. Mov Disord 31 ; 135-138, 2016 Saito et al
5. Stages in the development of Parkinson’s disease-related Pathology. Cell Tissue Res (2004) 318: 121–134
6. Staging of brain pathology related to sporadic Parkinson’s disease. Neurobiology of Aging 24 (2003) 197–211
7. Staging of brain pathology related to sporadic Parkinson’s disease. Eur Neurol. 1997;38 Suppl 2:2-7.
8. Pathogenesis of Parkinson disease—the gut–brain axis and environmental factors. Klingelhoefer, L. & Reichmann, H.
Nat. Rev. Neurol. 11, 625–636 (2015)
PROCEEDING BOOK Page 5 9. Pan-Montojo F, Anichtchik O, Dening Y, Knels L, Pursche S, et al. (2010). Progression of Parkinson’s Disease Pathology Is Reproduced by Intragastric Administration of Rotenone in Mice.
10. PLoS ONE 5(1): e8762. doi:10.1371/journal.pone.0008762 11. Environmental toxins trigger PD-like progression via
increased alpha-synuclein release from enteric neurons in mice. SCIENTIFIC REPORTS | 2 : 898 | DOI:
10.1038/srep00898
12. Direct evidence of Parkinson pathology spread from the gastrointestinal tract to the brain in rats. Acta Neuropathol.
128, 805–820 (2014)
13. Vagotomy and Subsequent Risk of Parkinson’s Disease.
ANN NEUROL 2015;78:522–529
14. Does Vagotomy Reduce the Risk of Parkinson’sDisease?
ANN NEUROL 2015;78:1011-1012
15. The dorsal motor nucleus of the vagus is not an obligatory trigger site of Parkinson’s disease: a critical
16. analysis of a-synuclein staging. Neuropathology and Applied Neurobiology (2008), 34, 284–295
17. Neuropathological Basis of Nonmotor Manifestations of Parkinson’s Disease. Mov Disord 31: 1114-1119, 2016 18. Effects of oral administration of rotenone on gastrointestinal
functions in mice. Neurogastroenterol Motil 25:e183–e193.
doi:10.1111/nmo.12070 77. 2013
19. Does Parkinson’s disease start in the gut? Acta Neuropathol DOI 10.1007/s00401-017-1777-8
PROCEEDING BOOK Page 6 PL 3. Carotid Stenosis Prevalence in Saudi Arabia and the Management of Carotid disease
Dr Fahmi M. Al-Senani, MBBS, MHA, MSc
Atherosclerosis is the leading cause of death worldwide, causing most ischemic strokes and myocardial infarctions. The prevalence of carotid disease worldwide differs, probably due to genetic and environmental factors. In Saudi Arabia, 12% of all stroke patients have significant cervical internal carotid artery stenosis.
A clear designation of symptomatic vs asymptomatic carotid stenosis must be made since both are managed differently.
Recurrent strokes are a major issue with symptomatic internal carotid artery stenosis usually requiring early intervention in the form of carotid artery surgery or endovascular stenting. Whereas asymptomatic carotid artery disease is becoming a much more benign disease and more commonly managed by maximizing best medical management, usually consisting of statins, anti- hypertensive medications and antiplatelets.
For symptomatic carotid artery disease, to maximize the benefits of carotid endarterectomy surgery between day 2 to 14 usually intensifies clinical benefit with earlier interventions showing more benefit. Carotid artery stenting is also an excellent management strategy for younger patients, less tortuous vessels and patients with significant coronary artery disease. Stenting is an excellent option for patients with high carotid bifurcations.
Asymptomatic restenosis rates and perioperative strokes are slightly higher with stenting.
PROCEEDING BOOK Page 7 PL 4. Medico-legal Issues and Patient Safety in Epilepsy, Parkinson and Movement Disorders, Neuro-oncology and Neuroimaging
Dr.dr.Syahrul, Sp.S(K)
Complications from the neurological disease are common, causing significant functional damage and a severe detrimental impact on quality of life. The highlight of medico-legal issues and patient safety in epilepsy, Parkinson and movement disorders, neuro-oncology, and neuroimaging, are the priority for all neurologist as a part of this noble profession. The neurologist must do the duty in good faith, for the benefit of the patient and with consent. Reframing medico-legal and case coding system of patient safety case could be achieved by identifying the most influential team, organization, and system. The result is hoped to be able to improve health care quality and utility.
Epilepsy is an abnormality of the central nervous system that is characterized by recurrent seizures due to abnormal, excessive or asynchronous neuronal activity in the brain. Some of the most common medical negligence claim made by patients against doctors are about incorrect diagnosis and failure to diagnose or treat epilepsy. Other allegations that were also made by patients are about an allergic reaction or the appearance of side effects to certain medications and drug-to-drug interaction between antiepileptic drugs (AEDs) with patient's other medications.
Moreover, AEDs also possess teratogenic potential, particularly Valproate. Patients also claimed that physicians failed to convey relevant information about their safety issues, such as the risk of drowning in a bath, burns from cooking, and risk of death from seizures. Therefore, a carefully planned procedure including changes in treatment regimen and educational program is aimed
PROCEEDING BOOK Page 8 to help in solving these issues and provide safe care for people with seizures and epilepsy. Biotechnology has equipped us with mobile health and wearable devices that can be used as early detection for seizures in ambulatory patients during their routine activities.
Parkinson disease is a chronic movement disorder that can significantly impair driving skills, causing safety concerns, development of cognitive impairment, also defects in thinking, language, and problem-solving. The best management can be done with the multidisciplinary combination such as close monitoring, medication, education, support and therapy, exercise, and nutrition. The benefit of this interdisciplinary care approach is to have patients receiving treatment from specialists with different skills, all working together as a team to deliver the best care possible. Effective communication between different specialists can guarantee that no time is lost and patients will receive coordinated and holistic care tailored to their needs.
Safety issues that are a big concern for Parkinson's patients are the risk falls and driving safety. Several measures could be taken to reduce the risk of falling. Firstly, patients are encouraged to installed shower or tub grab-bars. Secondly, ensuring adequate lighting in the house, especially at night. Next, loose rugs should be secured in order to prevent the risk of tripping. Other measures that can be taken to provide safe driving for patients include close monitoring and health evaluation, especially if and when the motor and cognitive symptoms worsen.
The safety of neuro-oncology patients could be preserved with clinical and psychological benefits. Advancement in modern and minimally invasive surgery could be done without compromising patient care. At the same time, it can provide financial savings.
The safety of neuro-oncology patient has been demonstrated. It
PROCEEDING BOOK Page 9 is important to underline the fact that by performing surgery on neuro-oncology patients, morbidity rates might increase due to the exposure of nosocomial infections, medical errors, and thromboembolic complications. Thus, improving surgical outcomes and preserving the quality of life is considered as a primary target for neuro-oncology patients. Training healthcare professionals involved in clinical governance and patient safety could benefits patients, for instance, improvement of micro- neurosurgical techniques. A revolution in intracranial surgery would result in an improvement of neuro-anesthesia protocol.
Neuroimaging is a crucial tool that can be utilized to improve diagnosis and effective patient management. More importantly, it is a widely used tool by a physician to improve service for the privately insured population. However, there is increasing concern from the inappropriate imaging referral. This problem arises due to the expanding financial pressure from the fee-for- service payment model. Such problem results in shorter patient visits, leaving the referring physicians insufficient time to evaluate patients or talk to the patient about the appropriateness of imaging. Additional obstacle includes compelling patients demand, patients fear of poor physician evaluations and risk of medical malpractice. The lack of knowledge on when and how to use neuro-imaging may also lead to inappropriate imaging referrals. Collaborative partnership plays a significant role. As a result, it is essential to create an objective measurement of ethical, privacy, and legal implication for future neuroimaging development.
In summary, the neurologist must ensure that their decisions will correspond with medico-legal, patient safety, scientific, humanities, and the best interest of the patient and their family members. The neurologist should counsel the patient and the
PROCEEDING BOOK Page 10 family members and explain all aspects of disease and treatment in a simple language. Therefore, physicians could win the patient's confidence.
Key words: medico-legal issues, patient safety, epilepsy, Parkinson, movement disorders, neuro-oncology, neuroimaging
PROCEEDING BOOK Page 11 B. Simposium Neuroimaging (SNI)
SNI 1. How to set up ideal stroke system for thrombolysis and thrombectomy
Dr Fahmi M. Al-Senani, MBBS, MHA, MSc
Stroke is a complex multisystem disease that requires a multidisciplinary approach to achieve best clinical outcomes.
Throughout the stroke patients’ journey, he/she interacts (directly or indirectly) with tens to hundreds of individuals, departments, hospitals, organizations and healthcare authorities.
Managing the interactions between the multiple elements of the stroke patients journey is crucial to holistic stroke care. The fragmentation of the treatment of multiple medical disorders, including stroke results in worse clinical outcomes, higher costs and less patient/family satisfaction with the stroke care they received.
Building a system to address these is complex. The systems approach to healthcare dictates that the complexity of setting up an ideal system is managed by looking at the problem as a whole and the relationships between the elements, not by focusing on each individual element. This starts with tracing the stroke patients journey through the healthcare system, from stroke symptom onset in the community, recognition of symptoms, calling for help, transfer to the appropriate institution, triage, medical evaluation, imaging, reperfusion therapies, acute stroke unit, rehabilitation and finally returning the individual to society.
A well-developed stroke system of care is built around the patient, is evidence and value based in nature. It should also focus of the final clinical outcomes of the stroke patient, that the patient prioritizes as important and not by the individual clinical encounter. Working with the end in mind, the International
PROCEEDING BOOK Page 12 Consortium for Health Outcomes Measurement (ICHOM) has developed a “standard set” for stroke outcomes, which covers many clinical and process outcomes, but is heavily weighted in Patient Reported Outcome Measures (PROM), were patient’s self-report outcomes that are important to them.
Forward thinking healthcare systems are developing reimbursement strategies based on clinical outcomes, and not on clinical encounters. This systems approach will allow for better cross-department communication and collaboration.
An acute stroke unit is the location where almost all stroke patient should be admitted to. Admission to stroke units is the single most beneficial acute intervention for the vast majority of stroke patients. It has been shown to reduce morbidity and mortality and improves quality of life. They also reduce hospital stay and the overall cost of stroke. Admitting patients with acute strokes to stroke units is synonymous with admitting acute coronary syndrome patients to coronary care units; you would never think of admitted an MI to the general medical ward.
Many national guidelines strongly recommend admitting patients to acute stroke units.
A permanent geographical location, a stroke program director and a stroke charge nurse are paramount. Units can be established at no cost simply by moving patients into the newly designated space. Having strong administrative support is key to opening and managing the unit.
The stroke unit is the nucleus of the hospitals’ stroke program &
is the location for multi-disciplinary care using protocols and pathways to ensure uniform stroke care
PROCEEDING BOOK Page 13 SNI 2. Diagnosis and prevention of deep vein thrombosis in ischemic stroke
Dr. dr. Syahrul, Sp.S(K)
Department of Neurology, Medical Faculty of Syiah Kuala University
General Hospital dr. Zainoel Abidin, Banda Aceh
Venous thromboembolism (VTE), including deep vein thrombosis (DVT) is a frequent cause for complications in patients during the acute recovery phase of stroke and immobile patients following acute ischemic stroke. DVT has also been linked as the leading cause for mortality and morbidity for patients during these periods.
DVT can be diagnosed using a simple screening measurement using plasma D-dimer level. A D-dimer level ≤1092 ng/mL can exclude the diagnosis of DVT in stroke patients. However, a further diagnostic testing is necessary to confirm the diagnose of DVT if the D-dimer level >1092 ng/mL. The recommended prophylaxis pharmacological treatment for VTE includes;
apixaban, aspirin, dabigatran etexilate, fondaparinux sodium, low molecular weight heparin (LMWH) and rivaroxaban.
LMWH or unfractionated heparin is the recommended choice for VTE prophylaxis in acute ischemic stroke. Enoxafarin is preferable to unfractionated heparin for VTE prophylaxis.
Another prophylaxis therapy that can be used for prevention of VTE is the Intermittent pneumatic compression (IPC). Together with LMWH and heparinoids, IPC can reduce the risk of VTE in immobile patients with acute ischemic stroke. However, the usage of the anti-emboli stockings is contradicted for patients within three days of stroke onset. It has been shown that VTE prophylaxis could reduce the incidence of DVT.
PROCEEDING BOOK Page 14 Key words : Diagnosis, prevention, Venous thromboembolism deep vein thrombosis, ischemic stroke.
PROCEEDING BOOK Page 15 SNI 3. Brain and Spinal cord Volume Loss in Multiple Sclerosis
Dr. dr. Fenny L.Yudiarto Sp.S (K).,FAAN Diponegoro University, Semarang-Indonesia
Multiple sclerosis (MS) is an inflammatory disease of the brain and the spinal cord that leads to demyelination and neurodegeneration. Plaques of inflammatory demyelination within the CNS are the pathologic hallmark of MS. Myelin destruction is an essential element of the plaque. When clinically showed MS and with conventional MRI found normal appearing white matter (NAWM), but on pathological evaluation in these areas suggestive of decreased myelin integrity and diminished axonal density within non-lesional regions. Atrophy is considered to be the consequence of neurodegeneration in MS and can be measured in vivo using MRI as a reduction of central nervous tissue volume
MS plaques are not confined to the white matter. Gray matter lesions are detected by MRI and by examination of pathologic specimens. Almost all of the gray matter nuclei within the CNS can be affected, as observed in a cohort of mostly progressive MS patients. Some areas that can be affected by MS, including motor cortex, the spinal cord and cerebellum are particularly vulnerable, resulting in demyelination in up to 28.8%
of the gray matter on average. As might be expected, inflammatory lesions within the gray matter are associated with neuronal loss and transected axons, which are more common in active lesions. While gray matter lesions seem to be more common in patients with progressive forms of MS.
Spinal cord degeneration that have been observed in up to 83% of patients with MS, with 60% occurring in the cervical
PROCEEDING BOOK Page 16 region. Spinal cord lesions are of diagnostic as well as prognostic importance in MS.
Diurnal fluctuations in brain morphometry also need to be taken into consideration. Brain volume is greater in the morning and the brain parenchymal fraction was found to change significantly in patients with MS, depending on the time of day that the MRI was performed. Not only is the time of the day relevant, but also the period of the menstrual cycle may be of importance. Women in period with a significant grey matter volume peak and cerebrospinal fluid loss at the time of ovulation.
Considering that MS is a typical disease in females of fertile age, this observation may be of importance in assessing brain atrophy in patients with MS. There are a direct association between cortical atrophy and cognitive impairment, and whole brain and central atrophy predicted EDSS at 10 years. Neuroimaging particularly important to assess brain volume in MS. The MRI equipment used for the patient’s assessment may influence the results of brain atrophy measurements. Some protocol should be into account such as; the position of the patient is perfect; the time of day, time of the month and hydration are adjusted to get the best result of imaging. To measure brain volume, there are many tools can be used such as, manually, brain parenchymal fraction, Freesurfer, NeuroQuant, Structural Image Evaluation using Normalization of Atrophy (SIENA) and MSMetrix.
Target treatment in MS is NEDA-4 (No Evidence Disease Activity); no relapses, no EDSS (Expanded Disability Status Scale) progression, no MRI activity, and no brain volume loss >0.4% annually.
Keywords: Multiple sclerosis, brain volume
PROCEEDING BOOK Page 17 SNI 4 . Early monitoring of vasospasm in subarachnoid hemmorhage with transcranial doppler
dr. Farida Sp.S (K)
Department of Neurology, Medical Faculty of Syiah Kuala University
General Hospital dr. Zainoel Abidin, Banda Aceh
Subarachnoid hemorrhage (SAH) represents hemorrhage in the space between arachnoidea and pia mater, due to aneurysm burst, spontaneously or as a consequence of trauma. It is condition that occurs more common in women than men, and its most common complications are rebleeding and vasospasm.
As a result of vasospasm, develops ischemia in the portion of brain tissue that can cause additional neurological deficit.
Vasospasm develops in the period from the third to fifth day after the hemorrhage, and reach its maximum frequency 7- days and usually last for 2-3 weeks. Usually is focal or may have a diffuse distribution. Death as a result of vasospasm occurs in 7% of patients, and the same number of patients having severe, permanent neurological deficit.
Condition of intracerebral hemodynamics and vasospasm can be monitored by TCD method. Transcranial Doppler Sonography (TCD) is a noninvasive ultrasound diagnostic method that allows monitoring of the state of intracerebral hemodynamics, evaluation and management of vasospasm after SAH which allows the prevention of delayed cerebral ischemia. The performance of TCD is sharp increase in mean blood flow velocities (MBFV) in the first few days after SAH is associated with poor prognosis (>20 cm/s per day). Studies show prognostic relevant threshold of increased MBFV in the Media Cerebral Artery by critical MBFV of 120 cm/s or above, a very critical
PROCEEDING BOOK Page 18 MBFV >140 cm/s. Increased blood flow means stronger vasospasm and often in these cases appears and consequent ischemic neurologic deficit.
In addition to MBFV, to diagnose vasospasm using TCD, it is also necessary to examine the lindegaard ratio (LR). This LR works to differentiate whether MBFV is caused by vasospasm or hyperdynamic flow. The extracranial MBFV value of Internal Carotid Artery is MBFV measured in the internal carotid artery.
LR value <3 is indicating hyperdynamic flow, while LR ratio> 3 is indicating vasospasm.
Keywords: subarachnoid hemmoraghe, vasospasm, transcranial doppler.
PROCEEDING BOOK Page 19 SNI 5. Monitoring Cerebral Vasomotor Reactivity (CVR) in Ischemic Stroke
dr. Rivan Danuaji, M.Kes. Sp.S.
Ultrasound has developed rapidly as one of the imaging tools, including in the field of neurology. Ultrasound, and also doppler, is currently a routine tool used and it is very helpful for neurologists to make a diagnosis, guide it in injection, monitor the progress of therapy, and can also determine the prognosis of an illness. Neuromuscular ultrasound is an emerging technology for the evaluation of conditions affecting nerve and muscle, including on focal neuropathies, nerve engtrapment, and vessel disorder. Ultrasonographic can also detect changes that occur in the nerves and muscles of those with more diffuse polyneuropathies and motor neuron diseases. understanding of the anatomy, pathophysiology and basis of ultrasound will greatly help the use of ultrasound devices in everyday neurological practice. At this neuroimaging workshop at the Aceh PIN this time will be explained how ultrasound can help with conditions of neurological disease, both diagnostic, monitoring and prognostic determination, which has not been discussed by previous speakers where they focus on the use of ultrasound, and doppler, on the vascular system.
Keyword: Ultrasound, doppler, neuromuscular, neurologist field, PIN Aceh
PROCEEDING BOOK Page 20 SNI 6. Small vessel disease, based on neuroimaging for prompt treatment
dr. Eko Arisetijono, Sp.S (K) Div Neurovascular
Dept/SMF Neurologi FK Universitas Brawijaya/ RS Saiful Anwar Malang
Small Vessel Disease adalah salah satu katagori dari penyakit serebrovaskular yang mengenai arteri perforating,pembuluh darah kapiler dan vena-vena kecil di otak. SVD memiliki patogenesis yang berbeda beda,tetapi mempunyai gambaran neuroimaging yang hampir mirip termasuk adanya gambaran infark lakunar,lacune,white matter hiperintensity,perivascular space dan cerebral microbleeds.
Gambaran radiologis pada SVD sangat menentukan untuk jenis etiologi yang pada akhirnya akan mempengaruhi pengobatan.
SVD akan sangat mempengaruhi terjadi stroke lebih lanjut,mempengaruhi kemampuan kognitif,adanya gangguan psikitari dan kualitas hidup. Ada penelitian yang mencoba mencari hubungan antara terjadnyan SVD ini dengan beberapa penyaklit yang kita kenal sebagai penyakit degeneratif seperti Alzheimer’s disease dan beberapa proses degeneratif lainnya.
Istilah SVD mengacu pada sindroma klinis,gangguan kognitif,gambaran neuroimaging dan neuropatologi yang mendasarkan pada adanya gangguan pada arteri yang kecil,arteriol,kapiler,vena -vena di otak.SVD biasanya mengenai pembuluh darah di daerah basal ganglia,white matter perifer,arteri leptomeningeal,thalamus,white matter serebelum perifer dan pembuluh darah di baang otak. Yang tidak terkena biasanya adalah pembuluh darah kortikal.
PROCEEDING BOOK Page 21 SVD merupakan penyebab dari 20% stroke,dan penyebab utama dari dementia vascular dan Alzheimer’s disease.
Dementia saat ini merupakan salah satu perhatian utama dalam kesehatan masyarakat sejalan dengan meningkatnya usia harapan hidup di banyak negara,sehingga kualiutas hidup menjadi perhatian kita khususnya kualitas hidup yang berhubungan dengan fungsi otak. Dementia disebabkan paling banyak oleh Alzheimer’s disease dan penyebab paling banyak kedua adalah SVD. Alzheimer’s disease seringkali muncul bersamaan dengan stroke pada populasi usia lanjut.Baik SVD maupun AD mempunyai faktor resiko yang hampir mirip yaitu:
usia,merokok,aktivitas fisik yang kurang ,obesitas dan DM.stroke dan Gangguan pembuluh darah arteri perifer.Pada pasien dengan AD memberikan gambaran lesi serebrovaskular lebih banyak daripada pasien non AD. Diduga adanya peran yang besar dari Cerebral Amyloid angiopathy yang mendasari terjadinya AD maupun SVD. CAA mempengaruhi adanya gangguan perfusi otak.(Rincon 2014). Belum ada terapi spesifik untuk manajemen SVD selain mendasarkan pada patofisiologi yang terjadi pada kasus SVD tersebut. Selain itu dampak akibat terapi yang diberikan yang kurang tepat akibat kurangnya pemahaman klinis pada kondisi patofisiologi yang berbeda malah akan memperburuk kondisi pasien. Pemberian jenis antiplatelet yang tepat pada kasus SVD sangat tergantung pada gambaran neuroimaging yang didapatkan. Beberapa obat yang dapat diberikan pada kasus SVD meliputi,aspirin,clopidogral dan cilostazol. Pemberian Cilostazol mempunyai resiko paling minimal pada kasus SVD khususnya pada kasus yang tidak bisa didapatkan studi neuroimaging yang lengkap.
Gambaran neuroimaging pada SVD berupa infark lakunar, white matter Hyperintensities,Lacune,perivascular
