Endovascular Thrombectomy for Acute Ischemic Stroke in Indonesia: Challenging and Strategic Planning.

High rates of morbidity and mortality indicate that stroke is a major health concern. Unfortunately, the management of ischemic stroke is hindered by several obstacles, particularly in developing countries such as Indonesia, where the burden of morbidity and mortality remains high. In this literature review, we intend to conduct a thorough investigation and analysis of the obstacles to stroke thrombectomy in developing countries, with a focus on Indonesia. Even though numerous studies and recent advances in thrombectomy techniques have been developed, many centers around the world continue to struggle to implement them. The majority of these institutions are located in developing nations like Indonesia. It faces numerous obstacles, including a lack of public awareness, infrastructure, human resources, and financial difficulties. The absence of early education and large-scale campaigns contributes to the dearth of public awareness. Inadequate imaging facilities, prehospital and referral systems, as well as disparities in healthcare expenditure and accessibility, contribute to the absence of infrastructure. Inadequate numbers of neurointerventionists, neurologists, and neurosurgeons, as well as a disparate distribution of these professionals, contribute to human resource issues. Inadequate national insurance coverage, high import tariffs on medical devices, and the high cost of healthcare have a negative impact on the financial situation. We provide related strategies regarding the current situation in Indonesia based on the recent evidence and comparison with developed countries. Academic institutions, medical associations, and government agencies must collaborate to overcome these challenges.

Clinical and Morphological Factors for Ruptured Anterior Communicating Artery Aneurysms.

Introduction: The anterior communicating artery (ACoA) aneurysm, the most frequent cerebral aneurysm to rupture, carries a significant clinical burden, yet the factors influencing its rupture are limited in Indonesia. This study aims to determine the clinical and morphological features associated with ruptured ACoA compared to non-AcoA aneurysms among Indonesians. Patients and Methods: We retrospectively reviewed our center's aneurysm patient registry from January 2019 to December 2022, and compared the clinical and morphological features between ruptured ACoA aneurysms and ruptured aneurysms elsewhere with univariate and multivariate analyses. Results: Of the 292 patients with 325 ruptured aneurysms, 89 were from ACoA. The mean age of patients was 54.99 years, with female preponderance in the non-ACoA group (non-ACoA: 73.31%, ACoA: 46.07%). On univariate analysis, ages ≥60 [ages 60-69: OR = 0.311 (0.111-0.869), p=0.026; ages ≥70: OR = 0.215 (0.056-0.819), p=0.024], female gender [OR = 0.311 (0.182-0.533), p<0.001], and smoking [OR=2.069 (1.036-4.057), p=0.022] exhibited significant association with ruptured ACoA aneurysm. On multivariate analysis, only the female gender was independently associated with ruptured ACoA aneurysm (aOR 0.355 [0.436-1.961], p=0.001). Conclusion: In our study, ruptured ACoA aneurysm was inversely associated with advanced age, female gender, presence of daughter aneurysm, and directly associated with smoking. After multivariate adjustment, the female gender showed an independent association with ruptured ACoA aneurysm.

Clinical prediction score for prolonged length of hospital stay in aneurysmal subarachnoid hemorrhage.

BACKGROUND: Length of stay (LOS) is an important indicator of the optimization of health services and hospital financing efficiency in aneurysmal subarachnoid hemorrhage (aSAH) patients. The purpose of this study was to develop a scoring model to predict the LOS of patients with aSAH. METHOD: A clinical scoring was developed based on retrospectively collected data from the cerebral aneurysm registry of the National Brain Center Hospital, Jakarta, from January 2019 to June 2022. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted prolonged LOS. LOS predictors were obtained based on the regression coefficients and converted into a point score model. RESULTS: Of the 209 aSAH patients observed, 117 patients had prolonged LOS (> 14 days of hospital stay). A clinical score was developed with a range of 0-7 points. Four variables were chosen as predictors of prolonged LOS: the presence of high-grade aSAH (1 point), aneurysm treatment (endovascular coiling: 1 point; surgical clipping: 2 points), cardiovascular comorbidities (1 point), and hospital-acquired pneumonia (3 points). The score showed good discrimination with an area under the receiving operating characteristics curve (AUC) of 0.8183 (SE 0.0278) and a p-value for the Hosmer-Lemeshow (HL) goodness-of-fit of 0.9322. CONCLUSION: This simple clinical score reliably predicted prolonged LOS in aneurysmal subarachnoid hemorrhage cases and may aid clinicians in improving patient outcomes and decreasing healthcare costs.

Microcatheter Stabilization Technique Using Partially Inflated Balloon for Coil Embolization of Paraclinoid Aneurysms.

PURPOSE: Coil embolization of paraclinoid aneurysms should be simple, safe, and effective considering the benign nature of the aneurysm. Here, we present a microcatheter stabilization technique using a partially inflated balloon for the treatment of paraclinoid aneurysms. MATERIALS AND METHODS: This retrospective study included 58 patients who underwent balloon-assisted coiling (BAC) for unruptured paraclinoid aneurysms at a tertiary neuro-intervention center between January 2019 and March 2020. We applied a technique to stabilize the microcatheter's position using the modified BAC technique in paraclinoid aneurysms showing various projections around the ophthalmic curve of the internal carotid artery. The basic concept of the technique is to place a partially inflated balloon just distal to the aneurysm neck and support the distal curve of the microcatheter using the proximal bottom of the balloon. Immediate radiological outcomes were analyzed, and clinical outcomes were evaluated with modified Rankin Scale (mRS) scores. RESULTS: The BAC was successfully performed in 51 of 58 patients (88%). We treated the remaining 7 patients by switching to stent-assisted coiling. We obtained a 37% mean packing density resulting in favorable occlusion in all 58 aneurysms (complete occlusion in 35 and residual neck in 23). There were no intraprocedural thromboembolic or hemorrhagic events except one that revealed an asymptomatic infarction after the procedure (1.7%). Magnetic resonance angiography follow-up was performed in 37 patients at an average of 11.8 months, in which 11 minor recurrences (29.7%) were found. There was no major recurrence nor retreatment. The mRS score was 0 in all patients during a mean follow-up of 17.7 months (range, 12-25 months). CONCLUSION: The modified balloon-assisted coiling technique using a partially inflated balloon was safe and effective and could serve as an option for treating paraclinoid aneurysms.

Tailored antiplatelet agent medication in clopidogrel hyporesponsive patients before stent-assisted coiling: single-center experience.

PURPOSE: In patients requiring stent procedures, resistance or hyperresponsiveness to antiplatelet medications is often observed. This study aims to evaluate the efficacy and safety of tailoring medications in these patients. METHODS: This retrospective study included 223 patients who underwent endovascular treatment for intracranial aneurysm between October 2018 and October 2019. Patients were categorized as hyporesponsive, hyperresponsive, and normoresponsive groups according to the initial PRU response. For the hypo- or hyperresponders, we tailored medication by modifying the dose or changing the drug. PRUs before and after tailoring were compared in each group. PRU reponses in patients who underwent Cytochrome P450 2C19 (CYP2C19) genotyping were also determined. RESULTS: Of the 73 clopidogrel-resistant patients, the mean PRU values after tailoring showed a greater decrease in the group that switched to prasugrel (n = 56), from 223 to 131, than in the clopidogrel reloading group (n = 17), from 238 to 209. In 31 hyperresponders, PRU increased from 49 to 94 after the dose adjustment. CYP2C19 genotyping showed that PRU tended to increase as the number of mutated alleles increased. There were five (2.3%) ischemic events (three transient ischemic attacks and two minor strokes) in a mean follow-up of 8 months, but no hemorrhage. CONCLUSIONS: The stent-assisted coiling was successfully performed with acceptable range of ischemic events and without hemorrhage in all patients, including those who applied tailored medication. Low-dose prasugrel was effective for obtaining appropriate PRU values for initial medication as well as for clopidogrel-resistant patients. The genetic test did not provide reliable results in determining clopidogrel resistance.