Magna Neurologica is a journal that publishes original articles, review articles, and case reports. It releases two issues per year, in January and July. Magna Neurologica is a peer-reviewed and open-access journal, published by the Department of Neurology, Faculty of Medicine Universitas Sebelas Maret, that serves as a comprehensive platform for disseminating groundbreaking research in the field of neurology. Through the publication of original articles, reviews, and intriguing case reports, the journal promotes advancements in basic neurosciences and clinical neurology. Additionally, Magna Neurologica welcomes brief communications on medicine, the latest developments in diagnostic procedures of neurology diseases, treatments, and other critical health issues related to neurology. The journal also fosters scholarly discourse and collaboration within the neurological community by encouraging letters and commentaries on its published articles. Subjects suitable for publication in Magna Neurologica span a wide range of topics, including neuroepidemiology, neurovascular disorders, neuroinfections, neurobehavioral studies, neuroimmunology, neurodegenerative diseases, and more. From neurosurgery to neuroanatomy, the journal provides a comprehensive platform for researchers and practitioners worldwide to contribute in the elaboration knowledge of neurological sciences. To ensure the journal's quality and global relevance, the editorial board members are carefully selected. The journal's rigorous peer-review process is enriched by reviewers from five countries; South Korea, Iraq, United States of America, Italy, and Indonesia, reflecting a diverse range of expertise and perspectives.
Department of Neurology Faculty of Medicine Universitas Sebelas Maret
This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).
ISCHEMIC STROKE IN A PATIENT WITH SUSPECTED CERVICAL CANCER: A THERAPEUTIC DILEMMA BETWEEN ANTICOAGULANT OR ANTIPLATELET STRATEGIES IN A RESOURCE-LIMITED SETTING: A RARE CASE REPORT
Background: Approximately 5% of strokes with no identifiable cause are linked to previously undiagnosed malignancies. The involvement of multiple vascular territories observed on brain imaging may indicate a hypercoagulable state related to cancer. Early identification is crucial for prompt cancer diagnosis. Case: A 40-year-old woman with no established classic stroke risk factors presented with progressive left-sided weakness and difficulty with speech over three days. She had a history of persistent vaginal bleeding lasting four months. Non-contrast brain CT revealed multiple infarcts affecting the right frontoparietal region, left frontal lobe, and bilateral posterior as well as left anterior internal capsules. An abdominal ultrasound identified a 9.35 × 4.74 cm hypoechoic mass extending from the cervix to the uterus with bladder infiltration, findings highly suggestive of cervical carcinoma. Discussion: Ischemic stroke associated with female reproductive malignancies is rare, with an incidence of around 0.3%. It is mainly caused by cancer-related hypercoagulability due to tumor-derived mucin, procoagulants, and inflammatory cytokines. Multifocal infarcts across various vascular territories may indicate a hypercoagulable state and suggest an underlying malignancy. There is no standardized anticoagulant protocol. Low-molecular-weight heparin (LMWH) is commonly used, though its effectiveness varies. Use of direct oral anticoagulants (DOACs) and antiplatelets is increasing, showing similar safety and efficacy. Conclusion: To date, there is no definitive antithrombotic of choice for cancer-associated ischemic stroke. The selection of antithrombotic therapy should be carefully tailored based on individual risk factors and the patient's clinical condition.
Copyright (c) 2026 Yang Yang Endro Arjuna, Vonny Fibrianty Goenawan, Vivien Puspitasari, Yohanes Chandra Kurniawan https://creativecommons.org/licenses/by/4.0/
REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (rTMS) AS A NON-INVASIVE NEUROMODULATION FOR THE SPECTRUM OF NON-MOTOR SYMPTOMS IN PARKINSON’S DISEASE: A SYSTEMATIC REVIEW
Background: Non-motor symptoms are an essential component of Parkinson’s disease (PD) and represent a major contributor to disability and quality of life. Repetitive transcranial magnetic stimulation (rTMS) has been explored as a non-invasive adjunctive therapy; however, evidence remains heterogeneous and limited to specific symptom domains. Objective: This systematic review aimed to synthesize randomized controlled trial (RCT) evidence on the efficacy and safety of rTMS for non-motor symptoms in PD. Methods: RCTs published between 2017 and 2026 were identified from PubMed, Nature Portfolio, and SpringerLink. Twelve studies with PD were included, comparing active rTMS with sham. Outcomes encompassed sleep disturbances, depression, anxiety, pain, apathy, constipation, and cognitive impairment. Risk of bias was evaluated using Cochrane RoB 2.0. Results: Twelve RCTs (566 patients) with PD were included. rTMS showed the most consistent benefits for sleep disturbances and depressive symptoms, particularly with low-frequency stimulation targeting the right dorsolateral prefrontal cortex (DLPFC). Evidence for anxiety, pain, apathy, and cognitive outcomes was moderate and variable, with effects dependent on stimulation parameters and cortical targets; cognitive benefits were largely confined to executive domains. Preliminary evidence suggested a potential emerging role for rTMS in improving constipation via prefrontal modulation of the gut–brain axis. Overall, rTMS was well tolerated, with only mild and transient adverse events reported and no serious safety concerns. Conclusion: rTMS is a safe and well-tolerated neuromodulation approach with potential domain-specific benefits for non-motor symptoms in PD, particularly sleep and depression. This review contributes to the current understanding of symptom-targeted rTMS applications in PD.
Repetitive Transcranial Magnetic Stimulation (rTMS)
Copyright (c) 2026 Izzati Paramadina, Ninda Pradani Futana, Sulistyani https://creativecommons.org/licenses/by/4.0/
MELATONIN SUPPLEMENTATION IN MULTIPLESCLEROSIS: A SYSTEMATIC REVIEW
Background: Multiple sclerosis (MS) is a chronic neurodegenerative disease marked by progressive inflammation and demyelination, in which symptom management remains challenging. Melatonin has potential antioxidant and anti-inflammatory effects, but evidence of its efficacy in MS is limited. Objective: This systematic review evaluated the effects of melatonin supplementation on inflammatory biomarkers and symptom-related outcomes in patients with MS using randomized controlled trials (RCTs). Methods: This systematic review was conducted on November 10, 2025, using PubMed, Scopus, and ScienceDirect, including English-language RCTs published within the past ten years. Study quality was assessed using the Cochrane Risk of Bias 2 tool, and the review followed PRISMA guidelines with PROSPERO registration (CRD420251273486). Results: A total of 12 RCTs involving 406 participants were included. Inflammatory biomarkers demonstrated heterogeneous responses, particularly for TNF-α and IFN-1β, with no significant changes observed in C-reactive protein (CRP), whereas oxidative stress biomarkers showed more consistent improvement. Regarding clinical outcomes, melatonin supplementation was associated with improvements in certain symptoms, including pain and fatigue, although findings varied across studies. Cognitive performance particularly executive function, information processing speed, and visuospatial memory showed relatively consistent improvement, while no significant changes were observed in global neurological disability or overall quality of life. Conclusion: Melatonin supplementation in patients with MS demonstrates consistent benefits in reducing oxidative stress and provides limited improvement in symptoms such as pain, fatigue, and cognitive function; however, it does not confer significant benefits on global disability or overall quality of life.
Copyright (c) 2026 Muvida, Yunandia Rahmawati, Helen Anince Heretringgi https://creativecommons.org/licenses/by/4.0/
MONOCULAR QUADRANTANOPIA CAUSED BY INTRAOCULAR METASTASIS MIMICKING OCULAR TUBERCULOSIS: A NEURO-OPHTHALMOLOGIC DIAGNOSTIC PITFALL
Background: Monocular quadrantanopia is an uncommon visual field defect that is typically associated with prechiasmal lesions. In tuberculosis-endemic regions, intraocular lesions are frequently attributed to ocular tuberculosis. However, intraocular metastases may present with similar clinical and radiological characteristics, creating significant diagnostic challenges and potentially delaying appropriate management. Case: A 34-year-old man presented with headache and visual field loss in the superior temporal quadrant of the right eye. Neurological examination revealed monocular superior temporal quadrantanopia without additional deficits, while funduscopy showed a superior intraocular lesion. Orbital MRI demonstrated a solid posterior choroidal lesion with mild contrast enhancement, and brain MRI revealed multiple intraaxial supratentorial and infratentorial lesions. Although ocular tuberculosis was initially diagnosed based on epidemiological context and imaging, subsequent investigations excluded tuberculosis. Further systemic evaluation identified a primary lung malignancy, confirming that the intraocular and intracranial lesions represented metastatic disease. Discussion: Quadrantanopia usually results from retrochiasmal lesions, but focal intraocular pathology can mimic neurogenic visual field defects. Distinguishing ocular tuberculosis from intraocular metastasis is difficult because of overlapping clinical and imaging findings. Minimal perilesional edema, absent diffusion restriction, and poor response to antituberculosis therapy should raise suspicion for metastatic disease, underscoring key neuro-ophthalmologic diagnostic pitfalls in infection-endemic settings worldwide regions. Conclusion: Intraocular metastasis should be considered in patients presenting with atypical monocular visual field defects, even when tuberculosis is strongly suspected. Awareness of this diagnostic pitfall is essential to avoid misdiagnosis and delays in appropriate treatment.
Copyright (c) 2026 Ervina Rahma Meila Sari, Dinda Husna Azalia Soesetyo, Mahaputri Inas Indrajati, Raden Andi Ario Tedjo, Taufiq Wildan Laksono https://creativecommons.org/licenses/by/4.0/
SPINAL CORD INFARCTION AS A RARE NEUROLOGICAL COMPLICATION OF ANTERIOR STEMI FOLLOWING FIBRINOLYTIC THERAPY: A CASE REPORT
Background: Spinal cord infarction (SCI) is a rare cause of acute neurological deficits and an exceedingly uncommon embolic complication of acute myocardial infarction (AMI). The primary mechanism involves cardioembolism originating from a left ventricular (LV) mural thrombus. We report a rare case of SCI presenting as acute paraplegia following fibrinolysis for anterior ST-elevation myocardial infarction (STEMI). Case: A 53-year-old man presented with typical chest pain. Electrocardiography demonstrated anterior STEMI, and fibrinolytic therapy with streptokinase was administered immediately. Six hours later, he developed sudden bilateral lower-limb weakness, sensory loss from the toes to the T10 level, and urinary retention. Neurological examination showed complete paraplegia (motor strength 0/0) with loss of pain and temperature sensation below T10, while vibration and proprioception were preserved, consistent with Anterior Spinal Artery Syndrome (ASAS). Spinal magnetic resonance imaging revealed T1-hypointense and T2-hyperintense lesions in the anterior horn at the T10 level, confirming anterior spinal artery infarction. Discussion: Acute paraplegia after fibrinolysis was strongly suspected to result from an embolic shower caused by destabilization of an LV mural thrombus, leading to occlusion of the radiculomedullary artery and subsequent ASAS. Because neurological recovery is often limited, prompt anticoagulation and early rehabilitation are essential to optimize outcomes. Conclusion: SCI is a rare but serious complication of anterior STEMI associated with LV thrombus formation, which may cause cardiogenic embolism through the artery of Adamkiewicz. Clinicians should maintain a high index of suspicion for spinal cord stroke in post-STEMI patients, particularly after fibrinolytic therapy, to facilitate timely diagnosis and management.
Copyright (c) 2026 Novia Heriza, Subandi https://creativecommons.org/licenses/by/4.0/
ALTERNATIVE MANAGEMENT OF DECOMPRESSION ILLNESS IN BREATH-HOLDING DIVERS USING NPPV
Background: Decompression illness (DI) is a syndrome caused by the formation of gas bubbles during rapid decompression. DI can manifest with neurological manifestations. Divers are at risk of developing DI even in shallow water. Case: A 25-year-old woman lost consciousness after a training dive. She lost consciousness shortly after surfacing, having previously dived to a depth of four meters. She vomited once and denied seizures. This was her third training dive; the second occurred two days prior, and the first ten days prior. The patient was in good health and had no history of heart or lung problems. A non-contrast head CT scan and MRI revealed ischemic lesions in the bilateral thalamus and cerebellum. Chest X-ray (CXR), transthoracic echocardiography (TTE), echocardiography, and bubble contrast scans showed no abnormalities. The patient was treated with 100% oxygen via non-invasive positive pressure ventilation (NPPV – CPAP mode) and showed improvement in her neurological deficits after 10 days. Discussion: DI is associated with vascular or extravascular bubbles that form as a result of rapid decompression. Pure oxygen inhalation using HBOT is the main therapy for DI. But, in the absence of HBOT, NPPV can be considered for its effectiveness to achieve a mean arterial pO2 concentration above 500 mm Hg. Conclusion: Recognizing the signs and symptoms of DI is important because they are nonspecific. Oxygen: 100% oxygen should be administered to those suspected of having DI.
Copyright (c) 2026 Priyanka Ganesa Utami, Eka Musridharta, Mursyid Bustami, Ita Muharram Sari, Sardiana Salam https://creativecommons.org/licenses/by/4.0/
EFFECTS OF IMMERSION LEVEL AND INTERVENTION TIMING IN VR-BASED STROKE REHABILITATION: A META-ANALYSIS OF UPPER LIMB RECOVERY
Background: Virtual Reality (VR) has emerged as a contemporary modality in neurorehabilitation, utilizing interactive environments and multisensory feedback to support neuroplasticity and motor learning. However, the influence of stroke phase and VR immersion level on therapeutic effectiveness has not been systematically synthesized. Objective: To systematically synthesize the effectiveness of VR-based interventions on upper limb motor function after stroke and critically evaluate the moderating effects of stroke phase and VR immersion level on rehabilitation outcomes. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines, with searches across major scientific databases. Experimental studies, including randomized controlled trials (RCTs) and quasi-experimental studies, assessing upper limb motor function using the Fugl-Meyer Assessment–Upper Extremity (FMA-UE) were included. Risk of bias was evaluated using the Cochrane Risk of Bias tool. A random-effects model was applied to calculate pooled Mean Differences (MDs), with subgroup analyses based on stroke phase and VR immersion level. Results: Eleven studies (10 RCTs and 1 quasi-experimental study) involving 388 participants were included. VR-based interventions demonstrated a statistically significant improvement in upper limb motor function compared with conventional therapy (MD = 8.97; 95% CI 6.11–11.82; p < 0.00001). Significant effects were consistently observed in both the chronic phase (MD = 9.96) and the subacute phase (MD = 8.36). Both non-immersive and immersive VR yielded clinically meaningful benefits, with no significant difference between immersion levels (p = 0.97). Conclusion: Virtual Reality based neurorehabilitation significantly enhances post-stroke upper limb motor recovery, with consistent effectiveness regardless of stroke phase or device immersion level. These findings support VR as a flexible and clinically applicable adjunct to standard rehabilitation, although standardized intervention protocols and long-term outcome evaluations remain necessary.
Copyright (c) 2026 Zafira Zahra Aulia Rahma, Naufal Dzulhijar, Syakira Zahra Maulida https://creativecommons.org/licenses/by/4.0/
BLOOD-BASED BIOMARKERS FOR PREDICTING POST-STROKE PROGNOSIS: A SCOPING REVIEW OF PENTRAXIN-3, NEUROPENTRAXIN-1, AND NEUROPENTRAXIN-2
Background: Stroke remains a major global health challenge, with substantial losses in disability-adjusted life-years, particularly in low-middle-income countries. Predicting post-stroke outcomes remains challenging because outcomes are driven by complex and overlapping processes, including inflammation, vascular injury, and neurodegeneration. Consequently, blood-based biomarkers, such as the pentraxin group that reflect underlying pathophysiology, have gained attention. However, existing evidence is fragmented and heterogeneous, underscoring the need for systematic mapping of the pentraxin group as biologically informed prognostic tools. Objective: This systematic scoping review aims to map and synthesize existing evidence on the prognostic value of blood-based biomarkers Pentraxin-3 (PTX3), Neuropentraxin-1 (NPTX1), and Neuropentraxin-2 (NPTX2) in predicting clinical outcomes after stroke. Methods: This PRISMA-ScR–guided scoping review systematically mapped evidence on blood-based biomarkers: PTX3, NPTX1, and NPTX2, for post-stroke prognosis from 6 databases and used NOS for quality assessment. Results: A total of 18 studies were included in the final scoping review. Lower serum NPTX2 levels were significantly associated with post-stroke cognitive impairment. Studies investigating PTX3 demonstrated substantial heterogeneity in sampling timing, cutoff definitions, and follow-up duration. Across studies, higher PTX3 concentrations were independently associated with increased mortality (AUC ~0.73–0.81, P value <0.0001), greater baseline neurological severity as measured by the National Institutes of Health Stroke Scale (NIHSS), and poorer functional outcomes assessed by the modified Rankin Scale (mRS). Conclusion: Despite the large heterogeneity of studies, the overall evidence supports PTX3, NPTX1, and NPTX2 as less-invasive prognostic blood-based biomarkers for post-stroke outcomes. However, studies on NPTX1 and NPTX2 are still very limited.
Copyright (c) 2026 Elizabeth Divina, Siti Alyaa Salma Ghozali, Pukovisa Prawiroharjo https://creativecommons.org/licenses/by/4.0/
A ‘DEADLY’ BENIGN TUMOR: RAPIDLY FATAL RECURRENCE OF ATYPICAL MENINGIOMA
Background: Meningioma is the most common primary CNS tumor. While most are benign (WHO grade I), approximately 15–20% are grade II (atypical) and 1-2% are grade III (anaplastic), carrying a higher recurrence risk. Rapidly fatal recurrence of grade II meningioma remains infrequently reported, particularly in resource-limited settings such as Indonesia. Case Report: A 65-year-old woman with a history of atypical meningioma (WHO grade II) resection eight months earlier presented with decreased consciousness, severe headache, projectile vomiting, and left-sided hemiparesis. Due to the unavailability of the operative report and postoperative imaging from the initial procedure, the Simpson grade and extent of resection could not be determined. Non-contrast head CT revealed a recurrent extra-axial mass in the right temporal region with edema and a midline shift of ±15 mm, suggestive of malignant progression. The patient received supportive therapy without reoperation or adjuvant radiotherapy. Despite a transient improvement, the clinical course deteriorated progressively and led to death on day 19. Discussion: Rapid decompensation is explained by the Monro-Kellie doctrine, whereby the expanding recurrent mass exhausted intracranial compensatory reserve, culminating in fatal herniation. The absence of documented Simpson grade, serial postoperative MRI, adjuvant radiotherapy, and molecular profiling contributed to delayed detection and fatal outcome. Geographic inaccessibility, financial constraints, and low health literacy further impeded surveillance. Conclusion: Grade II meningioma should not be regarded as benign. A structured surveillance protocol; MRI within 48 hours postoperatively, at 4 months, and annually thereafter, combined with Simpson grade documentation and consideration of adjuvant radiotherapy, is essential to prevent fatal recurrence.
Copyright (c) 2026 Tasya Lianda Sari, Cindy Yusliani, Riza Pratama Putra, Arindi Maretzka https://creativecommons.org/licenses/by/4.0/
TIME COURSE OF BOTULINUM TOXIN ANALGESIA IN PERIPHERAL NEUROPATHIC PAIN: A SYSTEMATIC REVIEW AND META-ANALYSIS
Background: Peripheral neuropathic pain (PNP) is frequently refractory to systemic therapies. Botulinum toxin (BTX) has emerged as a targeted option, but its time course of analgesic effect remains incompletely defined. Objective: To characterize the onset, peak, and durability of BTX analgesia in PNP. Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted according to PRISMA guidelines. A search was performed on December 19, 2025, covering studies published from 2006 to 2025. Included etiologies comprised diabetic neuropathy, trigeminal neuralgia, postherpetic neuralgia, and other PNP conditions. Pain outcomes were synthesized across predefined time windows: early (≤4 weeks), intermediate (6–12 weeks), and late (≥24 weeks). Random-effects meta-analyses using standardized mean differences (SMDs) were conducted at approximately 4 and 12 weeks. Results: Eighteen RCTs were included (n=916); four (n=129) and three (n=99) contributed to the 4- and 12-week meta-analyses, respectively. BTX-A significantly reduced pain versus placebo at 4 weeks (SMD −2.79, 95% CI −4.67 to −0.90; I² = 93%) and 12 weeks (SMD −2.54, 95% CI −4.55 to −0.53; I² = 92%). Analgesia began within 1–2 weeks and peaked at 6–12 weeks. Excluding one outlier reduced heterogeneity from I² = 92% to 55% while preserving significance. Evidence beyond 24 weeks was limited. Conclusion: BTX-A demonstrates a time-dependent and etiology-specific analgesic effect, with onset within 1–4 weeks, peak at 6–12 weeks, and waning after 12–16 weeks. These findings inform patient counselling and reinjection planning, typically at approximately 3-month intervals.
Copyright (c) 2026 Endang Ulupi Khoirunnisa, Yessi Mekarsari, Sih Reka Prawidya https://creativecommons.org/licenses/by/4.0/
ACUTE ISCHEMIC STROKE RISK FACTORS STRATIFICATION MODEL IN ISOLATED VERTIGO PATIENTS: TWO-YEARS COHORT RETROSPECTIVE STUDY
Background: Vertigo is a common complaint in medical settings, with the most important differential diagnosis to exclude being vertebrobasilar ischemic stroke. However, there have been no cohort studies evaluating the risk of stroke following hospitalization for acute vertigo without other neurological symptoms (isolated vertigo). Objective: To assess the long-term risk of stroke in patients with a history of hospitalization due to isolated vertigo. Methods: This retrospective cohort study was conducted at Dr. Moewardi Hospital in Surakarta, utilizing secondary data from electronic medical records for the years 2024–2025. A total of 268 patients hospitalized for vertigo and 223 control patients (elective gastrointestinal endoscopy patients) were selected based on similar age distribution. Stroke incidence data were analyzed using Kaplan-Meier methods and Cox regression, with adjustments for demographic variables and vascular risk factors. Results: Over a 2-year period, stroke occurred in 16 vertigo patients (5.8%) and 2 control patients (1.1%). After adjustment, vertigo patients had a 3.25-fold higher risk of stroke compared to the control group (HR: 3.25; 95% CI: 2.18–4.15; p = 0.002). Stroke risk significantly increased in patients with ≥3 vascular risk factors (HR: 5.01). Approximately 68% of strokes occurred within the first year. Conclusion: Isolated vertigo significantly increases the risk of ischemic stroke, particularly in patients with risk factors during the first year following the initial symptoms of isolated vertigo.
Copyright (c) 2026 Faizal Muhammad, Rivan Danuaji https://creativecommons.org/licenses/by/4.0/
CLINICAL AND SOCIODEMOGRAPHIC FACTORS ASSOCIATED WITH QUALITY OF LIFE IN EPILEPSY PATIENTS AT DORIS SYLVANUS HOSPITAL PALANGKA RAYA
Background: Epilepsy is a chronic neurological disorder that affects patients' physical, psychological, and social aspects, influencing their quality of life (QoL). Identifying clinical and sociodemographic factors related to QoL is essential for comprehensive management. Objective: To analyze the relationship between clinical and sociodemographic factors and the quality of life of epilepsy patients at the Neurology Polyclinic of RSUD dr. Doris Sylvanus Palangka Raya. Methods: This analytical observational study with a cross-sectional design involved 53 respondents selected through consecutive sampling. Data were collected using the QOLIE-31 to assess QoL, the MARS-5 to assess medication adherence, the MSPSS to assess social support, and a validated knowledge questionnaire. Relationships between variables were analyzed using the Spearman correlation test with a significance level of p < 0.05. Results: Most respondents were adults aged 19-45 years (83.0%), male (52.8%), and had secondary education. The mean QOLIE-31 score was 52.24 (SD 20.02), indicating moderate QoL. Significant correlations were found between seizure frequency (r = -0.506; p < 0.001), comorbidity (r = -0.368; p = 0.007), medication adherence (r = 0.483; p < 0.001), social support (r = 0.396; p = 0.004), and knowledge level (r = 0.587; p < 0.001) with QoL. Age at diagnosis (p = 0.119) and epilepsy duration (p = 0.397) were not significantly related. Conclusion: Quality of life in epilepsy patients is significantly associated with seizure frequency, comorbidity, medication adherence, social support, and knowledge level. Improving adherence and psychosocial support can enhance patients' overall well-being.
Ravenalla Abdurrahman Al Hakim Sampurna Putra Solihin
Copyright (c) 2026 Ariqah Ghaniyah Lembah, Ranintha Br. Surbakti, Ravenalla Abdurrahman Al Hakim Sampurna Putra Solihin, Farah Fauziyah Radhiyatulqalbi Ahmad, Nuch Sabunga https://creativecommons.org/licenses/by/4.0/
Acute Malignant Transformation as A Rare Complication of Middle Cerebral Artery Infarction
Background: Malignant ischemic stroke is a stroke characterized by extensive acute edema resulting in a space-occupying lesion. This transformation occurs in 10% of ischemic strokes with a mortality rate up to 80%. Hence, it is crucial to early detection and timely treatment. Case: A 51-year-old male was diagnosed with ischemic stroke, presented with NIHSS 11 and ASPECTS 4. Within 26 hours, the patient's level of consciousness declined progressively from a GCS of 15 to a GCS of 10. Serial brain imaging using CT scan and MRI revealed infarct expansion, a space-occupying lesion, and further midline shift. During decompressive craniectomy, extensive edema was found without hemorrhage, suggesting malignant ischemic stroke. After 6 months, the patient had undergone cranioplasty, with no significant complaints, but left hemiparesis remained. Discussion: Malignant ischemic stroke occurs within 5 days after onset. Diagnosis of malignant complication should be considered in ischemic stroke patients with younger age, higher NIHSS, not receiving thrombolysis, neurological status decline in 4-6 hours after onset, wide hypoattenuation in MCA territory, and signs of progressive space-occupying lesion in brain imaging. Management of malignant ischemic stroke consists of managing intracranial pressure with pharmacology and decompressive craniectomy. Conclusion: Malignant transformation is a rare complication of ischemic stroke. Early and accurate diagnosis is crucial to determine the prognosis. Pharmacological therapy and decompressive craniectomy surgery are considered life-saving therapies, but are not able to reduce morbidity in the patient.
Copyright (c) 2026 Annisa Bunga Nafara, Ika Yulieta Margaretha Permatasari https://creativecommons.org/licenses/by/4.0/
Oligodendrocyte Differentiation from Human iPSCs: Strategies Based on Signaling Pathways, Transcription Factors, and Novel Modulators for Research and Therapy
Background: Oligodendrocytes (OLs) are vital for central nervous system (CNS) function, producing myelin sheaths and maintaining axonal integrity. However, their limited accessibility in human disease-relevant contexts has historically hindered progress in research. The advent of induced pluripotent stem cell (iPSC)-derived OLs has transformed the study of myelin-related diseases and regenerative therapies. Objective: This review aims to provide a comparative overview of strategies for generating OLs from human iPSCs, emphasizing their mechanisms, efficiency, scalability, and translational applications. Methods: We analyzed three major differentiation approaches described in recent literature. Signaling-based protocols replicate developmental processes by modulating TGF-β, SHH, and Wnt pathways. Transcription factor-driven methods accelerate lineage specification by directly inducing OL fate. Modulator-enhanced strategies incorporate epigenetic, metabolic, or environmental cues to improve efficiency and adaptability. Results: Each approach offers distinct strengths and limitations. Signaling-based methods closely mimic in vivo development but require long culture times. Transcription factor-driven strategies enable rapid OL generation, although sometimes at the expense of physiological relevance. Modulator-enhanced protocols represent an emerging avenue, offering flexibility and potential for higher efficiency. Collectively, these strategies expand opportunities for disease modeling, therapeutic screening, and cell replacement therapies. Conclusion: Advances across signaling, transcriptional, and modulatory domains have significantly advanced iPSC-based OL generation. Integration of these approaches may enable more efficient, scalable, and physiologically relevant OL production. Such progress holds significant potential to accelerate the development of myelin targeted therapeutics and enhance translational research in demyelinating diseases.
transcription factor-myelin regeneration
Copyright (c) 2026 Maria Maylyn Evangelina Wong, Michelle Angelica Subrata https://creativecommons.org/licenses/by/4.0/
ISCHEMIC STROKE PRESENTING AS ISOLATED DIZZINESS IN A PATIENT WITH TYPE 2 DIABETES MELLITUS AND CONGESTIVE HEART FAILURE: A CASE REPORT
Background: Ischemic stroke may manifest with a wide range of clinical symptoms, including atypical presentations such as dizziness, especially in patients with complex cardiovascular and metabolic risk profiles. This case report describes the clinical course and management of ischemic stroke in a patient with pre-existing cardiovascular disease and type 2 diabetes mellitus. Case: A 61-year-old woman with a history of cardiovascular disease and type 2 diabetes mellitus presented with sudden disorientation and persistent dizziness. On the second day of hospitalization, she developed right-sided weakness, facial asymmetry, and slurred speech. A head CT scan revealed infarctions in the left occipital lobe and left corona radiata. Due to the unavailability of thrombolytic therapy at the local hospital, the patient was managed conservatively with 80 mg aspirin, 75 mg clopidogrel, citicoline, and insulin. Discussion: Dizziness/vertigo is recognized but is often an overlooked symptom of ischemic stroke, particularly in posterior circulation strokes. Approximately 20% of ischemic strokes involve the vertebrobasilar system, where vertigo is a predominant symptom. Type 2 diabetes mellitus and cardiovascular comorbidities significantly increase the risk of ischemic events. Patients presenting with dizziness or vertigo are at higher risk of subsequent stroke or cardiovascular events compared to those without these symptoms. Conclusion: This case underscores the importance of recognizing dizziness as a potentially subtle and early manifestation of ischemic stroke, especially in patients with complex cardiovascular and metabolic risk profiles, such as type 2 diabetes mellitus. Prompt evaluation and appropriate management are crucial for preventing progression and improving outcomes.
Copyright (c) 2026 Elsa Lase, Rio Tasti Surpa Rahmat Bintan, Kamila Auliya https://creativecommons.org/licenses/by/4.0/
FACTORS INFLUENCING THE INCIDENCE OF REFRACTORY EPILEPSY: A SCOPING REVIEW
Background: Epilepsy affects around 50 million people worldwide, with an incidence of 100 cases per 100,000 people annually in developing countries where access to adequate treatment is limited. Refractory epilepsy occurs in 20-40% of cases of patients whose seizures remain uncontrolled despite 1-2 years of adequate anti-seizure medication (ASM) therapy with good adherence. This condition poses significant challenges for management. Objective: This scoping review aimed to systematically identify the factors associated with refractory epilepsy. Methods: A scoping review was conducted in accordance with the PRISMA-ScR guidelines and the PEO/PET framework. A systematic PubMed search identified studies published between 2020 and 2025 on factors influencing refractory epilepsy. Eligible studies underwent a three-phase screening process (title, abstract, and full-text review). Results: Twenty studies met the inclusion criteria, comprising seven review articles and thirteen clinical studies, most of which were observational. Recurrent associations between refractory epilepsy and several factors were identified, such as one large cohort of 5,794 patients reporting seizure onset within the first year of life to be the strongest predictor of refractory epilepsy, while another study showed that structural etiology increased the odds more than threefold (OR 3.47; 95% CI: 1.15-10.43). Psychiatric comorbidities, developmental delay, abnormal EEG or neuroimaging findings, and systemic contributors such as inflammation and metabolic disorders were also found to be commonly associated with refractory epilepsy. Conclusion: The most frequently reported factors for developing refractory epilepsy across studies were younger age at first seizure, structural etiology, and genetic factors.
Copyright (c) 2026 Naufal, Desin Pambudi Sejahtera, Ishana Nafeeza Mukhtar, Atitya Fithri Khairani, Nur Chayati https://creativecommons.org/licenses/by/4.0/
Vitamin D Receptor Gene Polymorphisms in Multiple Sclerosis Susceptibility: Updated Systematic Review and Meta-Analysis
Background: The relationship between Vitamin D Receptor (VDR) gene polymorphisms and the risk of developing Multiple Sclerosis (MS) has been explored in numerous studies. However, the results were inconclusive. Therefore, this study aimed to investigate the relationship between VDR gene polymorphisms and susceptibility to MS. Objective: This study aimed to systematically evaluate the association between Vitamin D Receptor (VDR) gene polymorphisms and susceptibility to Multiple Sclerosis (MS) through a meta-analysis of existing studies. Methods: This study is a meta-analysis conducted in accordance with the PRISMA guideline. The literature search was conducted using the PubMed and Google Scholar databases from January 2014 to December 2024. Studies included in this meta-analysis were assessed using the Newcastle-Ottawa Scale (NOS). The association between VDR polymorphisms and the risk of MS was evaluated using pooled odds ratios (ORs) and 95% confidence intervals (CIs). Results: Six studies (868 cases/982 controls) were included. The TaqI polymorphism showed that TT vs TC + CC was associated with reduced risk of MS (OR 95% CI = 0.43 [0.21 - 0.86], p = 0.02), while CC vs TT + TC was associated with an increased risk of MS (OR 95% CI = 1.89 [1.51 - 2.36], p < 0.00001). T vs C was associated with reduced risk of MS (OR 95% CI = 0.69 [0.49 - 0.98], p = 0.04) while C vs T was associated with an increased risk of MS (OR 95% CI = 1.45 [1.02 – 2.05], p < 0.04). Conclusion: In summary, our meta-analysis revealed a significant association between VDR gene polymorphism and MS susceptibility in certain genetic models of the VDR gene.
Copyright (c) 2026 Han Yang, Baarid Luqman Hamidi, Esti Nur Ekasari, Krisandi Hartanto, Rudi Ilhamsyah https://creativecommons.org/licenses/by/4.0/
Cell Based Treatment for Spinocerebellar Ataxia: A Clinical Case Report
Background: Spinocerebellar ataxia (SCA) is a dominant and monogenic central nervous system disorder, characterized by progressive motor disorders affecting coordination, balance, speech, and ADL. The prevalence is 2.7 out of 100,000 people. Currently, cell-based therapy is being developed for clinical improvement in SCA. Case: A 48-year-old woman with weakness in both legs and arms, difficulty walking, dysmetria, and dysarthria since 2015. Examination of SARA scoring is severe ataxia, EMG showed polyradiculopathy, muscle denervation, and suspicion of posterior ramus lesions; complete blood laboratory and tumor markers were routine. MRI brain contrast and whole spine contrast radiology imaging were also performed. Clinical improvement was achieved in 2016 following stem cell injection in Thailand (dose and type of cells unknown). However, clinical worsening occurred from 2020 to 2024. The patient received Umbilical Cord Mesenchymal Stem Cells (MSC) in October 2024, administered intrathecally at a dose of 20 million cells. Discussion: The first injection showed significant clinical improvement. The second injection showed no clinical improvement, but no worsening of symptoms was found. The difference in results may be due to variations in the route of administration, cell type, cell quality, and the dose administered. Conclusion: The administration of umbilical cord mesenchymal stem cells (UC-MSCs) in SCA is considered safe, with minimal complications, and can suppress disease progression, although it does not produce clinical improvement.
Copyright (c) 2026 Damar Dyah Mentari, Rivan Danuaji https://creativecommons.org/licenses/by/4.0/
Fahr Disease in Elderly Patients with Bronchopneumonia and History of Ischemic Stroke: A Case Report and Literature Review
Background: Fahr's Disease (Fahr's Syndrome) is a rare condition characterized by idiopathic bilateral basal ganglia calcifications, typically occurring in the lateral parts of the globus pallidus, dentate nuclei, and caudate nuclei. Diagnosis is based on clinical features of neuropsychiatric and somatic symptoms in conjunction with radiological findings. We report an unusual case of Fahr's disease in a 70-year-old woman with bronchopneumonia and a history of chronic ischemic stroke identified through a CT-SCAN. Case: The patient was a 70-year-old female, admitted to our emergency department with bronchopneumonia, who presented with declining consciousness and focal seizures for 3 hours before entering the hospital. Her brain’s CT scan revealed calcification in the bilateral lentiform nuclei, bilateral cerebellar dentate nuclei, and left corona radiata, consistent with Fahr's disease. The patient was also diagnosed with bronchopneumonia and chronic ischemic stroke. Discussion: Fahr's Disease is linked to abnormal calcium metabolism, leading to calcifications in the basal ganglia. While chronic ischemic stroke may not directly cause Fahr's Disease, it increases the risk of cerebrovascular events in affected individuals. The correlation between infection and Fahr's Disease is poorly understood, although it may exacerbate neurological symptoms. Conclusion: Basal ganglia calcification in Fahr's disease may be associated with an increased risk of stroke and bronchopneumonia, which can worsen the patient's condition. Further research is needed to understand the relationship between Fahr's disease, ischemic stroke, and infections.
Copyright (c) 2026 Miftahul Hasanah, Aditya Putra Priyahita https://creativecommons.org/licenses/by/4.0/
Haemorrhagic Transformation in Ischemic Stroke Induced by Polycythemia Vera: A Case Report
Background: Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by the overproduction of red blood cells. This can lead to hyperviscosity, which significantly increases the risk of thrombosis, which in turn increases the risk of ischemic stroke. There is currently no reported case of haemorrhagic transformation of PV-induced acute ischemic stroke in Indonesia. Case: A 62-year-old female was admitted to the emergency department after a sudden onset of left-sided weakness one hour before admission. She has a history of polycythemia vera, with prior hemoglobin levels reaching 22 g/dL, and had a previous ischemic stroke one year prior. On physical examination, the patient was alert, with a GCS of 15, blood pressure of 168/94 mmHg, left-sided hemiparesis, dysarthria, and facial drooping. Laboratory tests revealed elevated hemoglobin 16.8 g/dL, hematocrit 56%, platelets 466,000/µL, and leukocytes 20.4 x 10³/µL. A non-contrast head CT showed a hypodense lesion in the right temporoparietal lobe with a hyperdense spot, consistent with hemorrhagic transformation of a thromboembolic infarction in the right middle cerebral artery (MCA) region, an infarct in the left thalamus, and cerebral atrophy. Discussion: PV-induced ischemic strokes involve a confluence of hyperviscosity, endothelial activation, and platelet aggregation. The thickened blood compromises microcirculatory flow, particularly in the cerebral vascular, increasing embolic risks. HT occurs due to the reperfusion of ischemic tissues following the breakdown of the blood-brain barrier (BBB). Conclusion: Hemorrhagic transformation can develop in PV-induced acute ischemic stroke. Effective management requires a multidisciplinary approach, integrating acute stroke care, rigorous hematologic control, antihypertensive therapy, lifestyle modifications, and antiplatelet treatment.
Copyright (c) 2026 Zalafi Kartika Azka, Irfan Pranowo https://creativecommons.org/licenses/by/4.0/
Epilepsy as the Main Clinical Manifestation of Congenital Hypothyroidism: A Rare Case Report
Background: Congenital hypothyroidism (CH) is defined as a deficiency of thyroid hormones present at birth and is one of the most common causes of intellectual disability. CH shows several manifestations, but it is rarely reported that CH manifests as epilepsy. To our knowledge, this rare manifestation of congenital hypothyroidism has only been reported four times previously. The potential association between CH and epilepsy remains unclear. Case: We reported a rare case of a 1-year-old child who presented to the emergency department with complaints of recurrent seizures. Laboratory results showed increased TSH levels and decreased FT4 levels. Electroencephalography (EEG) results were expected. The patient was diagnosed with epilepsy and congenital hypothyroidism. The patient received stabilization therapy in the ER and was admitted to the PICU for 7 days. During hospitalization and a seven-day evaluation at home, the patient did not experience any further seizures. Discussion: Epilepsy and congenital hypothyroidism can affect each other through three known pathogeneses: mitochondrial dysfunction, oxidative stress, and failure of amino acid regulation in the brain. Long-term use of some anti-epileptic drugs is known to reduce thyroid hormone levels. Conclusion: Thyroid hormones play an essential role in various aspects of epilepsy. Thyroid function screening in patients with epilepsy may be advisable, especially in patients with developmental disorders and relevant symptoms.
Copyright (c) 2025 Lailita Dwi Cahyanti, Aslin Nur Ainiyah, Zidnal Mafaz, Ditya Arisanti https://creativecommons.org/licenses/by/4.0/
Acute Hemiballismus Due to Vascular or Diabetic Striatopathy: A Rare Case Report from KHZ Musthafa General Hospital, Tasikmalaya
Background: Hemiballismus is a hyperkinetic movement disorder characterized by sudden, involuntary, high-amplitude ballistic movements of the arm and leg on one side of the body, often due to contralateral central nervous system dysfunction. The most common causes are ischemic stroke and hyperosmolar hyperglycemic syndrome. Stroke-related movement disorders are rare, with an incidence of 0.4%–0.54%, while the prevalence of hyperglycemia-induced, known as diabetic striatopathy (DS), affects approximately 1 in 100,000 individuals, predominantly older women. Case: A 63-year-old male presented with sudden, involuntary left arm movements for one week, starting with throwing-like motions, followed by stiffness, tremors, rapid arm drop, and facial grimacing on the left side. The condition was accompanied by left leg weakness. He had a history of uncontrolled type 2 diabetes mellitus. Physical examination showed left hemiballismus with motor strength 5/5/3/2 and a positive Babinski reflex on the left. Blood tests revealed a random glucose of 686 mg/dL, HbA1C of 15%, and 126 mmol/L sodium. A non-contrast CT scan showed multiple bilateral lacunar infarcts in the basal ganglia region. Discussion: Hemiballismus occurs sporadically and is caused by multiple bilateral lacunar infarcts in the basal ganglia, with risk factors including type 2 diabetes mellitus and advanced age. Other causes, such as stroke and genetic factors, may still be considered. Conclusion: Hemiballismus is a rare form of movement disorder. Vascular and metabolic disorders are the most common causes of hemiballismus. In this case, acute hemiballismus occurred in an elderly stroke patient with type 2 diabetes mellitus as a risk factor.
Copyright (c) 2025 Nasyifa Nurul Fitriany, Billy Muchamad Ramdani, Indra Gunawan Affandi https://creativecommons.org/licenses/by/4.0/
Non-Traumatic Subarachnoid Hemorrhage with Brain Abscess due to Eisenmenger Syndrome: A Rare Case Report
Background: Non-traumatic subarachnoid hemorrhage in patients with congenital heart disease, such as Eisenmenger syndrome, may involve multiple organs and carries a risk of cerebral abscess due to multiorgan mechanisms. Case: A 20-year-old male with untreated congenital heart disease since childhood was admitted with severe headache, neck stiffness, projectile vomiting, fatigue, lip curling, slurred speech, and stroke-like symptoms. Neurological deficits included right-dominant tetraparesis, accompanied by cyanosis and clubbing of fingers. CT scan revealed a subarachnoid hemorrhage extending into the perimesencephalic cistern with a thick-walled hypodense lesion, suspected to be a brain abscess. Laboratory findings revealed secondary erythrocytosis, characterized by elevated hematocrit and erythrocyte levels. Discussion: In this case, the subarachnoid hemorrhage was non-traumatic and perimesencephalic, likely caused by a mycotic aneurysm associated with Eisenmenger syndrome. The brain is a frequent target of septic emboli linked to mycotic aneurysms that trigger hemorrhage. Hemodynamic instability contributes to arterial endothelial degeneration, while hyperviscosity from congenital heart disease and septic embolism facilitates aneurysm formation. Rupture of such aneurysms leads to a sudden rise in intracranial pressure, worsening neurological outcomes. Conclusion: Subarachnoid hemorrhage in Eisenmenger syndrome is strongly associated with mycotic aneurysms from septic emboli, which may progress to cerebral abscess due to diffuse hypoxia from impaired cardiac output. Early diagnostic evaluation is crucial to establish the etiology, and heightened vigilance is needed in Eisenmenger cases, given the elevated risk of subarachnoid hemorrhage through septic emboli and aneurysm rupture.
Copyright (c) 2026 Muhammad Ikhlas Muttaqin Aditiarman, Dhesty Fadhilah Faatin, Ni Nyoman Ayu Susilawati https://creativecommons.org/licenses/by/4.0/
Guillain-Barre Syndrome Associated with Disseminated Tuberculosis: A Case Report
Background: Guillain-Barre syndrome (GBS) is a life-threatening, acute, immune-mediated polyneuropathy associated with preceding infections. Tuberculosis (TB), although it has a high incidence rate, is rarely reported to be associated with GBS. Case: We report the case of a 20-year-old female admitted to our hospital with a progressive symmetrical paraparesis, which further developed to paraplegia, along with a month-long history of constitutional symptoms. After investigation, the patient was diagnosed with an acute motor and sensory axonal neuropathy (AMSAN) variant of GBS and disseminated TB. The patient was treated with plasmapheresis, and first-line anti-tuberculosis therapy was initiated. The patient demonstrated significant improvement in muscle strength in response to the treatment. The pathogenesis of GBS in TB is believed to be due to molecular mimicry, leading to nerve damage or direct invasion of the nerve root by tubercular bacilli. Discussion: Guillain-Barre syndrome could be induced by tuberculosis, and treatment for both could improve the outcome. Thus, early diagnosis is critical. Further investigations must be conducted to understand the association of GBS and TB. Conclusion: Guillain-Barre syndrome could be induced by tuberculosis, and treatment for both could improve the outcome. Thus, early diagnosis is critical. Further investigations must be conducted to understand the association of GBS and TB.
Copyright (c) 2025 Elsa Primadona Sulfana Putri, Idzni Mardhiyah, Sri Wahyu Evianti https://creativecommons.org/licenses/by/4.0/
Outcome of Aneurysmal Subarachnoid Haemorrhage at Posterior Communicating Artery with Obstructive Hydrocephalus Post Successful Surgical Clipping and External Ventricular Drainage: A Case Report
Background: Approximately 25% of patients with SAH die before hospital admission. Proper posterior communicating artery (PCoA) aneurysm-related SAH is rare, with an incidence of about 1%. It is typically treated with coil embolization via digital subtraction angiography (DSA). In this case, decompressive craniectomy and external ventricular drainage (EVD) were performed, followed by aneurysm clipping, resulting in an excellent outcome. Case: A 63-year-old woman presented with a sudden severe headache, vomiting, somnolence, and right-sided limb weakness. Head CT angiography revealed SAH from a ruptured saccular aneurysm with a daughter aneurysm on the PcoA, Modified Fisher scale 2, and intraventricular hemorrhage (IVH) with a modified Graeb score of 3. The patient underwent decompressive craniectomy, EVD placement, and aneurysm clipping. On postoperative day two, she was alert but had left oculomotor nerve palsy and global aphasia. Head CT showed an acute infarction. Nicardipine was administered for a hypertensive emergency. Intravenous ceftazidime and gentamicin were used to treat nosocomial pneumonia. Nutritional support, physiotherapy, and speech therapy were provided. Discussion: Clipping was chosen for higher aneurysm obliteration rates and better oculomotor nerve recovery, despite a higher risk of postoperative cerebral ischemia than coiling. Due to high Modified Fisher and Graeb scores, EVD was necessary. Hemodynamic management and pneumonia treatment were critical. Early intervention, multidisciplinary care, and close postoperative monitoring are essential to reduce mortality and improve outcomes in PcoA aneurysm-related SAH. Conclusion: Decompressive craniectomy, EVD, and clipping combined with optimal hemodynamic management and complication control resulted in satisfactory outcomes in this rare PcoA aneurysm SAH case.
Copyright (c) 2026 Dyah Fiharjatin, Tommy Rachmat Setyawan, Rakhian Listyawan, Fajar Maskuri https://creativecommons.org/licenses/by/4.0/
A Rare Case of Anomic Aphasia and Gerstmann Syndrome Induced by Hemorrhagic Stroke
Background: Aphasia is a language disorder caused by brain damage, such as a stroke. Anomic aphasia, a rare subtype, impairs the ability to name objects or people while preserving fluency and comprehension. It is often associated with Gerstmann syndrome, which is characterized by acalculia, finger agnosia, left-right disorientation, and semantic aphasia. This report presents a case of a 61-year-old male with anomic aphasia and Gerstmann syndrome following a hemorrhagic stroke. Case: A 61-year-old male patient presented with sudden difficulty recalling the names of family members and objects. Imaging revealed an intracerebral hemorrhage in the left parietotemporooccipital lobe. The patient also exhibited left-right disorientation and finger agnosia, indicative of Gerstmann syndrome. The Aphasia Test for Rehabilitation Information Diagnosis (TADIR) confirmed the diagnosis of anomic aphasia. Although conservative treatment led to partial improvement, naming difficulties and associated deficits persisted. Discussion: Anomic aphasia primarily involves difficulties with naming, typically resulting from lesions in the dominant hemisphere, particularly the temporal and parietal lobes. Its coexistence with Gerstmann syndrome underscores the complexity of overlapping neurological deficits. The TADIR test was crucial in diagnosing and managing the patient's condition. Conclusion: This case highlights the importance of a thorough evaluation in aphasia cases, especially when rare syndromes like Gerstmann syndrome are involved. Early and accurate diagnosis enables targeted interventions that can improve patient outcomes.
Copyright (c) 2025 Daniel Mahendrakrisna, Bagus Ngurah Mahasena Putera Awatara, Gede Suputra, Ni Wayan Nurlina Ekasari, Dian Kusumastuti Anggraeni Putri, Anak Agung Ayu Putri Laksmidewi https://creativecommons.org/licenses/by/4.0/
Successful Pudendal Nerve Block and Radiofrequency in 4 Years Scrotal Pain Resistant to Treatment and Three Varicocelectomies: A Case Report
Background: Only a small percentage of patients (2-10%) report pain symptoms during varicocele or post-varicocelectomy. The cause of the pain remains unclear and is still a matter of debate. Neither conservative nor surgical treatments provide a conclusive solution for pain. Nerve blocks can serve as a diagnostic and therapeutic tool in cases where the origin of pain is unknown. Case: A 30-year-old male presented with 4 year history of chronic scrotal pain, worsening over the past three weeks. The pain, rated 6/10 on the Numeric Rating Scale (NRS), was unrelieved by rest or analgesics and worsened at night and with prolonged sitting (NRS 7/10), significantly impacting daily activities. He had bilateral recurrent varicocele and underwent three varicocelectomies and ureteroscopy. Oral analgesics and neuropathic pain medications provided only temporary relief. The neurological examination revealed hyperalgesia in the distribution of the pudendal nerve. The imaging results were expected. Discussion: A notable reduction in pain was observed following an ultrasound-guided diagnostic pudendal nerve block with 2 mL of 2% lidocaine, confirming pudendal neuralgia related to varicocele or post-varicocelectomy. The pain is likely due to compression of the pudendal nerve branch by an enlarged pampiniform plexus. Pulsed radiofrequency is utilized to provide longer-lasting pain relief. No complications were reported after the treatment. Conclusion: Pudendal nerve blocks can alleviate scrotal pain and may be an alternative to genitofemoral and ilioinguinal nerve blocks. This is the first report of a successful pudendal nerve block for scrotal pain associated with varicocele or varicocelectomy.
Copyright (c) 2026 Yang Yang Endro Arjuna, Tasya Meidy Pradhana, Yusak Mangara Tua Siahaan https://creativecommons.org/licenses/by/4.0
Civamide Nasal Spray: A Breath of Fresh Air in Migraine and Cluster Headache Therapy? Insights from A Systematic Review
Background: Migraines and cluster headaches are severe neurological disorders characterized by complex pathophysiological mechanisms, particularly involving the trigeminal nerve and vascular inflammatory responses. Both conditions primarily affect the trigeminal nerve, a key pathway in pain transmission, and are closely associated with vascular inflammation. Migraines are typically characterized by recurrent, unilateral, and intense headaches, whereas cluster headaches are marked by excruciating pain, often localized around the eye. These disorders are multifactorial, with various mechanisms contributing to their initiation and persistence. Civamide nasal spray, which modulates neural pathways, has emerged as a promising therapeutic option for targeted pain relief. This study aims to evaluate the effectiveness of Civamide nasal spray in managing these debilitating headaches. Objective: To assess the efficacy of civamide nasal spray in treating migraine and cluster headache attacks. Methods: This study followed the Synthesis without Meta-analysis (SWiM) guideline. A systematic search was conducted using a predefined query in Medline, Google Scholar, and Cochrane Central Library. Eight independent reviewers screened studies for eligibility based inclusion criteria and assessed the risk of bias using the Cochrane RoB 2.0 tool. Results: Two eligible studies were analyzed. Participants receiving civamide demonstrated a greater reduction in weekly headache frequency compared with those receiving a placebo. Additionally, civamide treatment was associated with decrease in pain intensity. Conclusion: The findings suggest that civamide nasal spray effectively reduces both the frequency and severity of headaches. Nonetheless, further investigations, particularly evaluating its long-term preventive use, are required to establish its clinical role in migraine and cluster headache management.
Copyright (c) 2026 Cyntia Arum, Danar Dwi Anandhika, Nabil Hajar, Moh. Iqbal Setiawan, Fatima Khiarun Nisa, Suwandhi, Firza Yoga Baskoro, Hera Dwi Priharti https://creativecommons.org/licenses/by/4.0/
New-Onset Intracranial Hemorrhage in A Patient with Glioblastoma Multiforme: A Case Report
Background: Glioblastoma multiforme (GBM) is the most common and aggressive primary brain tumor in adults. GBM is a high-grade glioma of the central nervous system associated with high morbidity and/or mortality, often accompanied by Intracranial Hemorrhage (ICH). Case: This study reports a 62-year-old male patient presenting with sudden-onset weakness in the left extremities, which worsened over the past week, without any history of trauma. A non-contrast computed tomography (CT) scan of the head revealed the presence of ICH. Laboratory findings showed leukocytosis and mild hyponatremia. The patient had previously been diagnosed with glioblastoma in the right parietal region, confirmed through magnetic resonance imaging (MRI), which revealed multiple lesions with solid-cystic components. The patient had undergone tumor removal surgery via craniotomy for further histopathological examination. A repeat craniotomy was performed to evacuate the ICH. Following the evacuation of the hemorrhage, clinical improvement was observed. Discussion: GBM classically presents with symptoms of increased intracranial pressure and gradually progressive neurological deficits. GBM also enhances vascular endothelial growth factor (VEGF) activity, contributing to the increased incidence of ICH. Acute presentation with ICH and rapid clinical deterioration is rare. The current treatment options for GBM are multimodal, including surgical resection, radiation therapy, and chemotherapy. Conclusion: GBM presenting with ICH is uncommon but life-threatening. This case underscores the need for high clinical suspicion and immediate neuroimaging in patients with known or suspected GBM presenting with acute neurological decline. Timely surgical intervention can improve outcomes.
Copyright (c) 2026 Adam Arya Pratama, Meritania Ridianti Putri, Hanis Setyono https://creativecommons.org/licenses/by/4.0
Paraplegia due to A Rare Spinal Metastasis of Hepatocellular Carcinoma: A Case Report
Background: Paraplegia caused by spinal cord compression is a rare but serious condition that can occur in cancer patients, including metastasis from hepatocellular carcinoma (HCC). Hepatocellular carcinoma metastasis to the spine can compress the spinal cord, disrupt nerve function, and lead to motor and sensory impairment in the lower limbs, ultimately resulting in paraplegia. Case: An 86-year-old man presented with progressive weakness in both lower limbs. He had not previously complained of weakness; his family attributed it to the natural effects of old age. However, the patient frequently complained of low back pain that did not improve with analgesics. Further investigation of the lesion revealed sensory impairment equivalent to the T8 dermatome. A complete physical examination showed an enlarged liver without stigmata of liver disease. CT scan revealed an extradural lesion at the T4 region and a compression fracture at the T8 region. The patient then underwent ultrasonography (USG), which identified a hepatoma suggestive of hepatocellular carcinoma (HCC). Discussion: Spinal cord compression as an initial presentation of HCC is uncommon and often delays diagnosis, especially in the absence of typical liver symptoms. MRI played a key role in identifying the extradural mass. Early recognition and management are crucial in preventing irreversible neurological damage. Treatment may include corticosteroids, radiotherapy, or surgery to relieve symptoms and improve quality of life; however, the prognosis remains poor without prompt intervention. Conclusion: These findings highlight the importance of early detection and comprehensive management in cases of paraplegia due to HCC metastasis to minimize neurological complications and improve patient survival.
Copyright (c) 2026 Nerissa Arviana, Hendra Gunawan, Nilna Nur Faizah, William Luth https://creativecommons.org/licenses/by/4.0/