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

Surveillance of stroke: a South-East Asia Region (SEAR) perspective

Surveillance of stroke is critical to track its burden and assess progress in prevention and treatment. We reviewed the literature to evaluate stroke surveillance efforts in the South-East Asia Region (SEAR) countries, identify progress and assess gaps. Epidemiological data on all the major parameters such as the incidence, prevalence and mortality of stroke were available for India and Thailand but for none of the other SEAR countries. Most of the epidemiological data came from investigator-initiated studies. National stroke surveillance was present only in India in the form of a National Stroke Registry Programme and Thailand has a national database that was used to obtain epidemiological data for stroke. Research on novel methods for stroke registration, such as using information technology, was absent. This review identified serious gaps in the monitoring and surveillance of stroke in SEAR countries. Systematic efforts are needed to fill those gaps.

The Role of Iron-Chelating Therapy in Improving Neurological Outcome in Patients with Intracerebral Hemorrhage: Evidence-Based Case Report

Current primary intracerebral hemorrhage (ICH) treatments focus on limiting hematoma volume by lowering blood pressure, reversing anticoagulation, or hematoma evacuation. Nevertheless, there is no effective strategy to protect the brain from secondary injury due to ICH. Excess heme and iron as by-products of lysing clots in ICH might contribute to this secondary injury by triggering perihematomal edema. We present a clinical situation of an ICH case where iron-chelating therapy might be beneficial, as supported by scientific evidence. We looked through four databases (Pubmed, Cochrane, Embase, and Google Scholar) to find studies assessing the efficacy of iron-chelating therapy in ICH patients. Validity, importance, and applicability (VIA) of the included articles were appraised using worksheets from the Oxford Centre for Evidence-Based Medicine. Two out of five eligible studies were valid, important, and applicable to our patient. Both studies showed the positive effects of iron-chelating therapy on neurological outcome, as measured by National Institutes of Health Stroke Scale (NIHSS) score and modified Rankin Score (mRS). The beneficial effects of deferoxamine were demonstrated within the moderate volume (10-30 mL) subgroup, with a positive relative risk reduction (RRR) and low number needed to treat (six persons). Based on our appraisal, we considered iron-chelating therapy as an additional therapy for ICH patients, given its benefits and adverse effects. More specific studies using a larger sample size, focusing on moderate-volume ICH, and using standardized neurological outcomes are encouraged.

Performance of door-to-CT time of code stroke in Indonesian tertiary referral center hospital

Background

This study was aimed to analyze the performance of door-to-CT scan (DTC) time of code stroke at the central referral hospital in Indonesia. Data from 310 patients were obtained in this cross-sectional study. Inclusion criteria were: notified with code stroke within the period between November 2016 and April 2019. Bivariate and multivariate analyses were carried out to find which factors affecting DTC time.

Results

A tendency of decreasing DTC time was reported from November 2016 until April 2019. The median DTC time at study endpoint was 19.5 (1–210) minutes. Chi-square analysis showed that CT scan location was the factor associated with DTC (OR: 12.6, 95% CI 6.8–23.35, p < 0.001). Logistic regressions analysis also showed significant relationship of CT scan location and DTC (OR: 24.27, 95% CI 17.71–30.81, p < 0.05).

Conclusions

Refinement of the code stroke implementation and CT scan placement in the Emergency Department (ED) are effective in reduction of DTC time, and as a result, improving acute stroke management.

Risk Factors of Asymptomatic Carotid Artery Disease in Geriatric Evaluated Using Carotid Intima-Media Thickness (IMT) Measurement, the First Indonesian Population Study

Introduction Carotid artery disease in geriatric is one of the important etiologies of stroke, which topped the cause of mortality in Indonesia. Specific prevention should be done as early as asymptomatic disease occurred. Initial assessment can be performed using ultrasound by measuring the intima-media thickness (IMT) of carotid artery, which can evaluate earlier progression of the atherosclerosis process. Unfortunately, we do not have risk factors categorization that show us which geriatric population fall under high-risk stratification to be screened.

Method Study was done to Indonesian geriatric population. Asymptomatic carotid disease was tested positive if IMT was > 0.9 mm without any previous neurological symptoms. Correlation of the result was statistically tested with risk factors of atherosclerotic process, such as sex, body mass index, presence of hypertension, diabetes mellitus, and hypercholesterolemia

Results Study obtained 104 subjects and showed the prevalence of asymptomatic carotid disease was 37.5%. Two risk factors: diabetes mellitus and hypercholesterolemia were statistically significant (p = 0.01) with odds ratio (OR) 3.56 (1.31–9.64, 95% confidence interval [CI]) and OR 2.85 (1.25–6.51, CI 95%), respectively. Logistic regression showed the risk was 69.2% by having two of these comorbidities, 47.2 or 42.5% if diabetes mellitus or hypercholesterolemia was present.

Conclusion As diabetes mellitus and hypercholesterolemia were proved to be significant risk factors for asymptomatic carotid artery disease, we recommend performing ultrasound screening to measure carotid artery IMT for geriatric population who had diabetes mellitus and/or hypercholesterolemia for asymptomatic carotid artery disease to be diagnosed and further treated.

Stroke Burden and Stroke Services in Indonesia

Stroke is a major cause of death and disability in Indonesia. Stroke requires high quality, fast and precise management to prevent and avoid disability and death. Stroke can be prevented by adequately controlling for risk factors and encouraging healthy life styles. Efforts are needed to organize health promotion programs at the community level. More and a better distribution of neurologists and neurointerventionalists is needed. All hospitals should have a CT scan machine and stroke units. Telemedicine for stroke patient is very promising endeavor for an integrated acute stroke management system.

Dementia Prevalence, Comorbidities, and Lifestyle Among Jatinangor Elders

Introduction: Research on dementia prevalence and the potentially related risk factors from Indonesia is scarce. We sought to identify the prevalence of dementia, health risk factors, and lifestyle in Jatinangor elders.

Methods: A total of 686 participants completed questionnaires on lifestyle, health risk factors, and cognitive and functional tests from September 2013 to December 2013. We determined the prevalence of dementia; and the associations between health, leisure activities, dietary pattern, and dementia were analyzed using logistic regression.

Results: The prevalence of dementia was 29.15%. The risk factors differed between age groups. Those aged 60–74 years and who have a lower education level, lower occupational attainment, and less active intellectual and recreational activities were associated with higher dementia risk. Those aged > 75 years living in a rural area and who take less fruit were associated with a higher risk of dementia.

Conclusions: The prevalence of dementia in Jatinangor is high. The identified modifiable risk factors are a potential target for intervention and valuable for designing public health policies.

Angiotensin converting enzyme polymorphism and ischemic stroke

OBJECTIVE

To assess the polymorphism of angiotensin converting enzyme (ACE) in ischemic stroke in an Egyptian sample.

METHODS

One hundred subjects (70 ischemic stroke patients, and 30 healthy controls) were included in case control cross sectional study during the period from January 2017 to January 2018, at Neurology Department, Menufia University Hospital, Shibin EL-Kom, Egypt. Patients underwent complete neurological assessment, national institute health stroke scale (NIHSS), and Toast classification. All subjects underwent genotyping of ACE gene polymorphism.

RESULTS

There are 42.9% from the patients versus 33.3% from controls showed geno typing of Insertion/Deletion (I/D) and Allele D is more frequent regarding I allele in ischemic stroke patients but this difference did not reach significant level to be risk factor. The I/D polymorphism was the predominant type in SVS and LVS while DD was the predominant type in cardio-embolic one. There were no significant differences between NIHSS in different ACE gene polymorphism.

CONCLUSION

In spite of ACE genotyping differences among Egyptian ischemic stroke patients, we cannot consider it a predisposing factor to stroke occurrence or severity.

TOAST Subtypes of Ischemic Stroke and Its Risk Factors: A Hospital-Based Study at Cipto Mangunkusumo Hospital, Indonesia

BACKGROUND AND PURPOSE

Stroke is a leading cause of death and disability, with ischemic stroke as the highest prevalent cases in Indonesia. Ischemic stroke can be classified further into five subtypes according to TOAST classification. Numerous studies have revealed that stroke risk factor has variable correlation with different stroke subtype. Currently, there is no data regarding this phenomenon in Indonesia. The aim of study is to identify characteristic of ischemic stroke subtypes and the risk factors in TOAST classification.

METHODS

A retrospective, cross-sectional study of patients diagnosed with ischemic stroke at Cipto Mangunkusumo Hospital from January till December 2016. Demographic data, ischemic stroke subtypes, risk factors, and other relevant data were documented. Bivariate and multivariate analysis was done using SPSS 23.

RESULTS

235 recorded data patients were included. Large artery atherosclerosis (LAA) was the most prevalent stroke subtypes at 59,6%, followed with small vessel disease (SVD) at 26,7%, undetermined etiology at 9,8%, cardioembolism (CE) at 2,1%, and other determined etiology at 0,9%. Hypertension was the most common vascular risk factor. However, it was only significant in SVD (p=0,023) and undetermined etiology subtypes (p<0,001). Significant risk factor in LAA was diabetes (55%; p=0,016) while in CE subtypes was atrial fibrillation (60%;p<0,001). In multivariate analyses, hypertension (OR 3; 95% CI 1,12-8,05) was the only variable that was related to SVD while in CE it was atrial fibrillation (OR 113,5; 95% CI 13,6-946,5).

CONCLUSION

LAA was the most common stroke ischemic subtypes. Associated risk factor in LAA was diabetes while in SVD and undetermined etiology subtypes it was hypertension. Atrial fibrillation was associated with cardioembolism.