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CNS Infections

PP01 The neurotropism of Zika virus and neurological disorders

Prof Sue Barnett1, Ms Jennifer Barrie1, Dr Ben Brennan1, Ms Stephanie Cumberworth1, Dr Maddie Cunningham1, Dr Claire Donald1, Prof Chris Linington1, Dr Verena Schultz1, Prof Hugh Willison1

1University of Glasgow, Institute of Infection, Immunity and Inflammation, Glasgow, United Kingdom

PP02 Electroencephalographic findings and clinical outcome in patients with tuberculous meningitis

Dr Khine Lwin1, Prof Aye Aye Sann1

1University of Medicine 2, Yangon, Myanmar

PP03 Cerebral vasculitis associated with chronic Schistosoma mansoni infection in Asia

Dr Aye Myat Nyein1, Prof Aye Aye Sann1, Prof Nu Nu Aye2, Prof Chong Tin Tan3

1Department of Neurology, North Okkalapa General and Teaching Hospital, University of Medicine 2, Yangon, Myanmar, 2Department of Radiology, North Okkalapa General and Teaching Hospital, University of Medicine 2, Yangon, Myanmar, 3Division of Neurology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

PP04 Clinical Profile of Tuberculous Meningitis

Dr Ye Sithu1

1Yangon General Hospital, Yangon, Myanmar

PP05 Factors Associated with Unfavourable Outcome Among Adult Community Acquired Bacterial Meningitis in a Tertiary Hospital in Kuala Lumpur

Dr Subramaniam Mohan Raj1, A/Prof Wan Nur Nafisah1, Dr Periyasamy Petrick1

1Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

PP06 Myelitis Zoster as CNS Varicela Zoster Virus Reactivation: A Rare Complication

Dr Melya Arianti1, Dr Kartika Maharani1, Dr Darma Imran1, Dr Riwanti Estiasari1

1Neurology Department / University of Indonesia / Cipto Mangunkusumo Hospital, Jakarta, Indonesia

PP07 Subacute sclerosing panencephalitis patients admitted to Yangon General Hospital

Dr Sai Kyaw Win1, Dr Yi Mon Khine1, Dr Phyo Hlaing Kyaw2, Dr Lynn Aung Yan2, Dr Zaw Myint Moe2, Dr Mar Ohn1

1University of Medicine 1, Yangon, Myanmar, 2Yangon General Hospital, Yangon, Myanmar

Epilepsy

PP08 48-hour Video-EEG Monitoring for Epilepsy Presurgical Evaluation is Cost-effective and Safe in Resource-limited Setting

Dr Si Lei Fong1, Prof Lim Kheng Seang1, Dr Minh-An Thuy Le2, Dr Sherrini Ahmad Bazir4, A/Prof Vairavan Narayanan3, Ms Noraini Ismail1, Ms Sweh- Fern Loo1, Ms Kohila Krishnan1, Prof Chong- Tin Tan1

1Division of Neurology, Department of Medicine, University Malaya, Kuala Lumpur, Malaysia, 2Department of Neurology, Faculty of Medicine, University of Medicine and Pharmacy of Ho Chi Minh City, Ho Chi Minh City, Vietnam, 3Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, 4Subang Jaya Medical Centre, Subang Jaya, Malaysia

PP09 Outcome of Status Epilepticus with Intravenous or Oral Antiepileptic Drug in Indonesian Population: A Prospective Study

Dr Adrian Ridski Harsono1, Dr Rineke Twistixa Arandita1, Dr Astri Budikayanti1, Dr Winnugroho Wiratman1, Dr Luh Ari Indrawati1, Dr Fitri Octaviana1

1Department of Neurology, Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia

PP10 Cognitive Impairment in Epilepsy Patients at Indonesia National Referral Hospital

Dr Diatri Nari Lastri1, Ms Adisti Putri1, Ms Rineke Arandita1, Dr Astri Budikayanti1, Dr Winnugroho Wiratman1, Dr Luh Ari1, Dr Fitri Octaviana1

1Department of Neurology, Universitas Indonesia, Cipto Mangunkusumo National Refferal Hospital, Jakarta, Indonesia

PP11 Effect of CYP3A5*3 Genetic Polymorphism on Serum Concentration of Carbamazepine in Myanmar Epilepsy and Trigeminal Neuralgia Patients

Dr Thin Thin Htun1

1Department of Pharmacology, University of Medicine, Mandalay, Myanmar

General Neurology

PP12 Working up peripheral neuropathy in under-resourced regions- a case in point.

Dr Habib Ul Rahman Habib1

1French Medical Institute for Mothers and Children, Kabul, Afghanistan

PP13 Normative Values and Cognitive Function Screening in Children aged 4 to 15 years old: A Study with SYSTEMS-R

Dr Niken Indah Hapsari1

1University of Indonesia, Jakarta, Indonesia

PP14 Paraneoplastic cerebellar degeneration cases with different cancer and antibodies

Dr Kyawt Oo Kay Thi Htay1, Dr Kyaw Phyo Hlaing1, Dr Ohnmar Ohnmar2, Dr Htet Htet Lin2, Dr Yin Min Aye1, Dr San Oo2

1Neuromedical Department, Yangon General Hospital, Yangon, Myanmar, 2University of Medicine 1, Yangon, Myanmar

PP15 A Mixed Cryoglobulinaemia case: A rare treatable cause of Neuropathy

Dr Khine Yee Mon1, A/Prof Ohnmar Ohnmar1, Dr Moe Zaw Myint1, A/Prof Sein Win2, A/Prof Yin Min Aye1, Prof Zaw Than Htun3, Prof Win Min Thit1

1Department of Neurology, University of Medicine (1) / Yangon General Hospital, Yangon, Myanmar, 2Department of Haematology, Yangon General Hospital, Yangon, Myanmar, 3Department of Medical Research, Myanmar

PP16 A Young Diabetic Patient with a Rare Genetic Disease

Dr May Zin Myint1, Dr See Muah Lee2, Dr Aftab Ahmad3, Dr Lim Ling Choo2

1National University Hospital, Singapore, 2Ng Teng Fong General Hospital, Singapore

PP17 Isolated Sphenoparietal vein and Cavernous Sinus Thrombosis Presentation in the Postpartum: A Rare Presentation

Dr Han Lin Naing1, Prof Mathew Alexandar1, Dr DK Nur’Ashikin Hj Tengah1, Dr DK Norazieda PHM Yassin1, Dr Sunithi Mani1

1Brunei Neuroscience Stroke and Rehabilitation Center, Bandar Seri Begawan, Brunei Darussalam

PP18 Value of Traditional Plasmapheresis in Management of overlap Miller-Fisher Variant

Dr Nan Kaythi Nwe1

1NOGH, Neurology Department, Yangon, Myanmar

PP19 Role of Attribution Models in Supporting Diagnosis of Primary Neuropsychiatry Systemic Lupus Erythematosus (NPSLE): A Case Report

Mr M. Iskandarsyah Agung Ramadhan1, Ms Arundina Sanyoto1

1Lewoleba General Hospital, Lewoleba, Indonesia

PP20 The study of oxalipaltin induced peripheral neuropathy in gastrointestinal cancer patient at Medical Oncology Department, Yangon General Hospital

Dr Myo Myint Maw1, Dr Wai Wai Lwin2, Dr Ohnmar Ohnmar3, Dr Yan Lynn Aung4, Dr Kyaw Thiha Soe5

1Medical Oncology Department, Yangon General Hospital, Yangon, Myanmar, 2Medical Oncology Department, Yangon General Hospital, Yangon, Myanmar, 3Neurology Department, Yangon General Hospital, Yangon, Myanmar, 4Neurology Department, Yangon General Hospital, Yangon, Myanmar, 5Medical Oncology Department, Yangon General Hospital, Yangon, Myanmar

PP21 Different presentations of Neuro Sjogren’s syndrome

Dr Zin New Win1, Dr Zin Phyu Tun2, Dr Htet Htet Lin2, Dr Khin Myat Po Po Kyaw1, Dr Ohmar Ohmar2, Dr Win Min Thit1

1Yangon General Hospital, Yangon, Myanmar, 2University of Medicine 1, Yangon, Myanmar

Headache and Pain

PP22 ZAPTed (Zygomatic Arch and Point Triggers) Protocol for Botulinum Toxin Injections in the Management of Refractory Trigeminal Neuralgia

A/Prof Arun Aggarwal1

1RPAH, Sydney, Australia

Movement Disorder

PP23 Self-Limiting Opsoclonus after Suggested Dengue Infection : A Case Report

Dr Rineke Twistixa Arandita1, Dr Adrian Ridski Harsono1, Dr Dyah Tunjungsari1, Dr Amanda Tiksnadi1

1Department of Neurology, Universitas Indonesia, Cipto Mangunkusumo National Refferal Hospital, Central Jakarta, Indonesia

PP24 The Characteristics of Hemifacial Spasm Patients in Dr. Mohammad Hoesin Palembang Hospital

Dr Bayu Haswatty1, Dr Angga Pradian1, Dr Selly Marisdina1, Dr Henry Sugiharto1, Dr RM Faisal1

1Sriwijaya University, Palembang, Indonesia

PP25 Parkinson’s Advanced Symptoms Unit: outcomes from a ‘’wrap-around’’ model of care

Dr N Archibald, Dr R Fowkes, Dr Aye Myat Moe 1Department of Neurology, James Cook Hospital, Middlesbrough, United Kingdom

PP26 Liquid levodopa/carbidopa/ascorbic acid solution [LCAS] – A cheap but underutilized treatment option in advanced Parkinson’s disease in Asian countries

Dr Arshia Bhardwaj, Assistant Prof Nishit Sawal1

1Government Medical College and Hospital, Sector 32, Chandigarh, India

PP27 Neuropsychiatric symptoms in Parkinson’s disease and beliefs, knowledge of caregivers

Dr Zarni Myint Shwe1, Dr Nyi N Aung2, Dr Aung P Htwe2, Dr Khin M PP Kyaw1, Prof Win M Thit1

1Neurology Department, Yangon General Hospital, Yangon, Myanmar, 2Department of Medicine, Yangon General Hospital, Yangon, Myanmar

Multiple Sclerosis

PP28 Clinical Profile of Neuromyelitis Optica Spectrum Disorder in Myanmar

Dr Htet Htet Lin1, Dr Sein Mya Mya Aye2, Dr Win Min Thit3

1Department of Neurology, University of Medicine (1), Yangon, Myanmar, 2Consultant Neurologist, Yangon, Myanmar, 3Department of Neurology, Yangon General Hospital, Yangon, Myanmar

Neurocritical Care

PP29 Our Experience In Establishment of In-house Neurology Driven Therapeutic Plasma Exchange (TPE) Infrastructure In Resource-Limited Public Hospital In Malaysia

Dr Shirley Lee1, Dr Fu Liong Hiew1, Dr Shanthi Viswanathan1

1General Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP30 Establishment of South East Asia Regional Therapeutic Plasma Exchange Consortium for Neurological Disorders

Dr Sing Keat Wong1, Dr Shanti Viswanathan1, Dr Appiwattanakul Metha2, Ms Ashwini Nayak3, Dr Badrul Islam4, Dr Bhupendra Khatri5, Dr David Pangeran6, Mr Himanshu Bambardekar3, Dr Kartika Maharani6, Dr Kevin Tan7, Prof Mathew Alexander8, Dr Mohammad Enayet Hussain9, Dr Mohd Sufian Adenan1, Dr Nabil Anaz Anzani Danapaul10, Mr Najib Khalife11, Prof Ohnmar Ohnmar12, Dr Beng Hooi Ong13, Dr Riwanti Estiasari6, Dr Sari Nurul Hanifa6, Dr Sasitorn Siritho14, Dr Chen Fei Ng15, Dr Sylvanie Ratna6, A/Prof Thirugnanam Umapathi7, Prof Win Min Thit12, Dr Yetty Ramli6, Ms Yvonne Lee YL16, Dr Fu Liong Hiew1

1Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia, 2Department of Neurology, Prasat Neurological Institute, Bangkok, Thailand, 3Terumo BCT Asia Pte. Ltd, Singapore, 4Laboratory Sciences and Services Division (LSSD), The International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh, 5The Regional MS Center, Center for Neurological Disorders, Wheaton Franciscan Health Care, 3237 S 16th St, Milwaukee, WI 53215, USA, 6Department of Neurology, Cipto Mangunkusumo Hospital/Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia, 7Department of Neurology, National Neuroscience Institute, Singapore, 8Brunei Neuroscience Stroke and Research Centre, Pantai Jerudong Specialist Centre, Bandar Seri Begawan, Brunei Darussalam, 9Department of Neurology, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh, 10Biomed Global, Kuala Lumpur, Malaysia, 11Global Medical Affairs, TerumoBCT, Leuven, Belgium, 12Department of Neurology, University of medicine 1/Yangon General Hospital, Yangon, Myanmar, 13Department of Neurology, Sultanah Bahiyah Hospital, Alor Setar, Malaysia, 14Division of Neurology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bumrungrad International Hospital, Bangkok, Thailand, 15Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia, 16Health Economic and Market Access, Terumo BCT Asia Pte Ltd, Petaling Jaya, Malaysia

Neuroimaging

PP31 Accuracy of Clinical Examination, Lumbosacral Radiography, and Electrodiagnosis of Suspected Patients with Lumbar HNP in Dr. Mohammad Hoesin General Hospital

Dr Marissa Sylvia Regina1, Dr Luther Theng1, Dr Theresia Christin1, Dr R. M Faisal1

1Sriwijaya University/Dr. Mohammad Husein General Hospital, Indonesia, Indonesia

PP32 Clinical and Radiological Diagnosis of Superficial Siderosis - A Rare Disease

Dr Moe Pearl Shwe1, Dr Jennifer Haung2, Dr David Tang2, Dr Kay Wei Ping Ng1

1National University Health Services, Singapore, 2Neurology Department, Ng Teng Fong General Hospital, Division of Neurology, National University Hospital, Singapore

Neuromuscular / Neurophysiology

PP33 Developing a model to ascertain risk of secondary generalisation in patients who present with ocular symptoms in Myasthenia Gravis

Mr Kannan Ramanathan1, Dr Kalpana Prasad2, Dr Kamal Verma2, A/Prof T Umapathi2, A/Prof Josiah Chai2

1Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 2National Neuroscience Institute, Singapore

PP34 Characteristics of Visual Evoked Potential in Optic Neuritis Patients at Sanglah General Hospital

Mr Gde Putra Dhyatmika1, Dr Komang Arimbawa1, Dr Purna Putra1

1Udayana University, Denpasar, Indonesia

PP35 Evaluation of treatment results in peripheral facial palsy by using clinical and nerve conduction study.

Dr Viet Nga Phan1, Dr Duc Thuan Nguyen1, Dr Trung Duc Le1, Dr Tien Trong Nghia Hoang2

1Military Hospital 103, Hanoi, Viet Nam, 2Military Hospital 175, Ho Chi Minh City, Viet Nam

PP36 Focal myositis developing in a patient with amyopathic dermatomyositis

Dr Jasmine Shimin Koh1, Dr Stanley Angkodjojo2, Dr Thirugnanam Umapathi1

1National Neuroscience Institute, Singapore, 2Singapore General Hospital, Singapore

PP37 A treatable condition that should not miss: Satoyoshi syndrome - Case Report

Dr Swe Kyinn1, Dr Aye Aye San1, Dr Phyu Phyu Lay1, Dr Kyaw Soe Naing1, Dr Hnin Yee Lwin2

1Department of Neurology, University of Medicine (2), Yangon, Myanmar, 2Department of Medicine, Insein General Hospital, Yangon, Myanmar

PP38 Multicentre Study Investigating the Association between Antecedent Infections with Flaviviruses and other Arboviruses and Guillain-Barre Syndrome in Singapore

Mr Joshua Ian Lim1, Ms Yiu-Wing Kam2, Dr Christen Lim3, Dr Lisa F.P. Ng2,4, Dr Thirugnanam Umapathi5

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2Singapore Immunology Network, Agency for Science, Technology and Research, Singapore, 3National University Hospital, University Medicine Cluster, Singapore, 4Institute of Infection and Global Health, University of Liverpool, United Kingdom, Liverpool, United Kingdom, 5National Neuroscience Institute, Department of Neurology, Singapore

PP39 Characteristics of Nerve Conduction Velocity and Distal Latency Examination of Sensory Nerves in Morbus Hansen Patients at Sanglah General Hospital

Mr Yudhi Nusartha1, Dr Komang Arimbawa1, Dr Eka Widyadharma1, Dr Purna Putra1

1Udayana University, Denpasar, Indonesia

PP40 “Nosocomial” treatment-induced neuropathy of diabetes in hospitalized patients with poorly controlled diabetes mellitus

Dr Chloe Pawa1, Dr Shimin Jasmine Koh1, Mr Wei Min James Tung2, A/Prof Umapathi Thirugnanam1

1National Neuroscience Institute, Singapore, 2Lee Kong Chian School of Medicine, Singapore

PP41 “Covert” Sural-sparing Pattern in Guillain-Barre Syndrome (GBS)

Mr Jonathan Pong1, Dr Shimin Jasmine Koh2, Dr Genevieve Lynn Yu2, A/Prof N. Thirugnanam Umapathi2

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2National Neuroscience Institute, Singapore

PP42 A case of HMGCR antibody-associated myopathy with axial weakness and camptocormia

Dr Kalpana Prasad1

1National Neuroscience Institute, Singapore

PP43 Pain and proximal weakness in three patients with marked decline in HbA1c- spectrum of Treatment-Induced Neuropathy of Diabetes Mellitus (TIND)

Ms Si Min Seah1, Dr Lynn Genevieve Tan-Yu2, Dr Yexian Jonathan Lai2, Dr Ngai Kun Loh2, Dr Thirugnanam Umapathi2

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2Department of Neurology, National Neuroscience Institute, Singapore

PP44 Case reports on familial Amyloid Polyneuropathy

Dr Oo Soe Thinzar1, Dr Myint Shwe Zarni1, Dr Aung Yan Lynn1, Dr Aung Ohnmar2, Dr Aye Yin Minn1, Dr Oo San2

1Yangon General Hospital, Yangon, Myanmar, 2University of Medicine (1) Yangon, Yangon, Myanmar

PP45 Nerve biopsy: Is it still useful in diagnosis of peripheral neuropathies?

Dr Aung Thiha1, Dr Ya Min Kyaw2, Dr San San Hlaing1, Dr Than Than1, Dr Naw Mu Lah Eh Min1

1Department of Pathology, University of Medicine, Mandalay, Mandalay, Myanmar, 2Department of Neuromedicine, Mandalay General Hospital, Mandalay, Myanmar

PP46 A Near Miss to be Treatable: Neural Lipid Storage Disease with Myopathy in a Myanmar Lady

Dr Zin Phyu Tun1, Dr Htwe Htwe Lin2, A/Prof Ohnmar Ohnmar1, A/Prof Myo Khaing2, Prof Moe Moe Zaw2, Prof Win Min Thit1

1University of Medicine 1/Yangon General Hospital, Yangon, Myanmar, 2University of Medicine Mandalay/Mandalay General Hospital, Mandalay, Myanmar

PP47 Recurrent falls in an elderly man due to peripheral sensory ataxia

Dr Khin Hnin Su Wai1, Dr James Tung2, Dr Jasmine Koh1, Dr Genevieve Lynn Yu, Prof Thirugnanam Umapathi1

1Department of Neurology, National Neuroscience Institute, Singapore, 2Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore

PP48 Myasthenia Gravis in association with extrathymic maligancies

Dr Khine Zar Win1, Dr Phyu Phyu Lay1

1Neurology Department, Yangon, Myanmar

Neuro-ophthalmology / Neuro-otology

PP49 Pupil involving isolated third cranial nerve palsy due to prolactinoma

Dr Aye Kyaw Maung1, Dr Hnin Ei Phyu2

1University of Medicine, Mandalay, Myanmar, 2University of Medicine, Mandalay, Myanmar

PP50 A case report on non-Hodgkin lymphoma presenting with unusual ocular manifestation

Dr Hnin Ei Phyu1

1Mandalay General Hospital, Mandalay City, Myanmar

Stroke

PP51 Strokes and Transient Ischemic Attacks in Young Adults in Brunei Darussalam: Demographics, Risk Factors, Etiology and Thrombolysis

Dr Jessie Colacion1, Dr Han Lin Naing1, Dr Naomi Harun1, Dr Norazieda Yassin1, Prof Mathew Alexander1, Dr Siti Nur'Ashikin Tengah1

1Brunei Neuroscience, Stroke and Rehabilitation Centre, Pantai Jerudong Specialist Centre, Bandar Seri Begawan, Brunei Darussalam

PP52 Characteristics in non-vitamin K antagonist oral anticoagulant (NOAC-) related intracerebral hemorrhage

Dr Stefan T. Gerner1, Prof Dr Hagen B. Huttner1, Prof Dr Stefan Schwab1, RETRACE II study group2

1Dpt. of Neurology, University Hospital Erlangen, Erlangen, Germany, 2ClinicalTrials.gov Identifier: NCT03093233, Germany

PP53 Age-dependent clinical outcomes in primary versus oral anticoagulation-related intracerebral hemorrhage

Prof Dr Hagen B. Huttner1, Dr Maximilian I. Sprügel1, Dr Stefan T. Gerner1, Prof Dr Stefan Schwab1, RETRACE I + II study group 1Dpt. of Neurology, University Hospital Erlangen, Erlangen, Germany, 2RETRACE I, NCT01829581; RETRACE II, NCT03093233, Germany

PP54 10 Thrombolysis Deliveries by the Tele-stroke International Network to Commemorate Her Majesty Queen Sirikit’s 84th Birthday

Dr Saysavath Keosodsay1, Prof Aurauma Chutinet2, Dr Pongpat Vorasayan2, Dr Jitlada Samajarn2, Dr Wasan Akarathanawat2, Dr Naruchorn Kijpaisalratana2, Dr Naly Norsakpeseuth1, Dr Snong Thongsna1, Ms Pakkawan Vongvasinkul2, Prof Nijasri C. Suwanwela2

1Mittaphab Hospital, Vientiane, Lao People's Democratic Republic, 2Chulalongkorn Stroke Center of Excellence, Bangkok, Thailand

PP55 Screening Stroke in Emergengy Room by Los Angeles Prehospital Stroke Screen (LAPSS) in Two Central Hospital in Laos

Dr Southanalinh Keovilayhong1, Dr Ketmany Phetsiriseng1, A/Prof Mayfong Maysay2

1Mittaphab hospital, Lao People's Democratic Republic, 2University of Health Sciences, Lao People's Democratic Republic

PP56 The Role of High Dose Citicoline in Acute Ischemic Stroke

Prof Phyu Phyu Lay1, Dr Aye Myat Nyein2

1University of Medicine 2, Yangon, Myanmar, 2University of Medicine 2, Yangon, Myanmar

PP57 Correlation Between White Blood Cell Count on Admission and Clinical Severity in Acute Ischemic Stroke: A Retrospective Cross-Sectional Study

Dr Navuddh Oam1, Dr Sem Suos1, Dr Veasna Teav1, Dr Chhoeun Proum1, Prof Dr Navuth Chum1

1Khmer Soviet Friendship Hospital, Phnom Penh, Cambodia

PP58 Risk factors, and vascular infarct predicted in Acute Ischemic Stroke using Oxford Stroke classification Project at two central hospitals

Dr Oua Phimmasarn1

1University of Health Sciences, Vientiane, Lao People's Democratic Republic

PP59 Complication of Stroke during Hospitalization in Central Hospitals in Vientiane Capital, Laos

Dr Appasone Phoumindr1

1University of Health Sciences, Vientiane Capital, Lao People's Democratic Republic

PP60 Diagnostic performance of FAAS stroke screening tool in patients who presented to the emergency room with neurological symptoms in Thailand

Dr Warongporn Phuenpathom1, Dr Aurauma Chutinet2, Dr Prakitchai Tantipong3, Dr Surachet Eiamthanasinchai4, Dr Nijasri C. Suwanwela5

1Chulalongkorn University, Bangkok, Thailand, 2Chulalongkorn University, Bangkok, Thailand, 3Nopparatrajathanee Hospital, Bangkok, Thailand, 4Surin Hospital, Surin, Thailand, 5Chulalongkorn University, Bangkok, Thailand

PP61 Spinal Cord Infarction as Complication of Percutaneous Coronary Intervention

Dr Dewie Susan1, Dr Wilasari Novantina1, Dr Selly Marisdina1, Dr Andika Okparasta1, Dr Adrian Masno1, Dr RM Faisal1

1Sriwijaya University/Dr. Moehammad Husein Hospital, Palembang, South Sumatera, Indonesia

PP62 Intracerebral hemorrhage in Brunei: 1- year demographic data at Brunei Neuroscience, Stroke and Rehabilitation Centre (BNSRC)

Dr Chee Shin Yong1, Mr Dawn Anthony1, Dr Norazieda Yassin1

1Brunei Neurosciences Stroke and Rehabilitation Centre (BNSRC), Brunei Darussalam

PP01

The neurotropism of Zika virus and neurological disorders

Prof Sue Barnett1, Ms Jennifer Barrie1, Dr Ben Brennan1, Ms Stephanie Cumberworth1, Dr Maddie Cunningham1, Dr Claire Donald1, Prof Chris Linington1, Dr Verena Schultz1, Prof Hugh Willison1

1University of Glasgow, Institute of Infection, Immunity and Inflammation, Glasgow, United Kingdom

Objective: The recent global outbreak of Zika virus infection has been linked to severe neurological phenotypes affecting the peripheral (PNS) and central nervous systems (CNS), including Guillain-Barre syndrome (GBS) and microcephaly. What is not clear in the current epidemic is whether these symptoms are the consequence of direct infection of neural cells by Zika virus or a post-infectious autoimmune syndrome, or both. Little is it know about which neural cell types are principally vulnerable to productive Zika infection. We aim to investigate these questions using murine myelinating culture. Materials and methods: To examine Zika virus tropism we used CNS and PNS myelinating cultures from wild type and interferon receptor (Ifnar1) knockout mice to examine neuronal and glial tropism and short-term consequences of direct infection with a Brazilian variant of ZIKV. In bypassing systemic immunity using ex vivo culture, and the type I interferon response in Ifnar1 deficient cells, we were able to evaluate the intrinsic infectivity of neural cells. Results: We demonstrate that; ZIKV infection is enhanced in the absence of the type I interferon responses and: CNS cells are more susceptible to infection than PNS cells. In particular, we demonstrate that CNS axons and myelinating oligodendrocytes are especially vulnerable to infection and injury. Notably, Schwann cells appear highly resistant to infection. Conclusion: These results have implications for understanding the pathobiology of neurological symptoms associated with ZIKV infection. Since myelination is affected this may perturb development in infected individuals. Moreover, ZIKV resistance by Shwann cells suggests there is an autoimmunity mechanism for GBS. Furthermore, we provide a quantifiable ex vivo infection model that can be used for fundamental and therapeutic studies on viral neuro-invasion and its consequences.

PP02

Electroencephalographic findings and clinical outcome in patients with tuberculous meningitis

Dr Khine Lwin1, Prof Aye Aye Sann2

1University of Medicine 2, Yangon, Myanmar, 2University of Medicine 2, Yangon, Myanmar

Objective: Tuberculosis of central nervous system is the most severe manifestation of extrapulmonary TB. Although the incidence of tuberculous meningitis(TBM) is low in high income countries, it remains one of the most severe and eventually fatal infectious conditions especially in immunosuppressant patients. TBM is a meningoencephalitis and is reported to produce more EEG abnormalities than other meningitis. In Myanmar, TBM is commonly seen in young adults, who are working age group and strength of country. Because of increased prevalence and variable outcome, understanding the factors that can predict prognosis of TBM is important. So, we aimed to show association between EEG findings and clinical outcome in patients with TBM. Materials and Methods: We conducted hospital based longitudinal study from January 2017 to December 2017. Total 48 patients with TBM were evaluated by history taking and physical examination. Electroencephalography(EEG) was performed within 2 weeks of diagnosis and outcome was assessed by Barthel Index(BI) score at 4 weeks after anti-TB treatment. BI ≥12 was categorized as good and BI <12 was categorized as poor outcome group and Fisher’s exact test was for analysis. Results: Mean age of study population was 40.8(16-78) year and 50% were age(20-39)year. 70.8%(n=34) were male. Abnormal EEG finding was detected in 91.7%(n=44). Good outcome was detected in 8.3%(n=4) and poor outcome was observed in 91.7%(n=44). There was no statistically significant relation between outcome and EEG findings. Conclusion: EEG abnormality is common in TBM but there was no evidence of association between EEG findings and outcome in patients with tuberculous meningitis.

PP03

Cerebral vasculitis associated with chronic Schistosoma mansoni infection in Asia

Dr Aye Myat Nyein1, Prof Aye Aye Sann1, Prof Nu Nu Aye2, Prof Chong Tin Tan3

1Department of Neurology, North Okkalapa General and Teaching Hospital, University of Medicine 2, Yangon, Myanmar, 2Department of Radiology, North Okkalapa General and Teaching Hospital, University of Medicine 2, Yangon, Myanmar, 3Division of Neurology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Objective: Estimated prevalence of schistosomiasis is 250 million worldwide with the majority occurring in sub-Saharan Africa and South America. In Asia, three species of Schistosoma are known to cause the disease. Schistosoma mansoni infection has been paid little attention in Asia including Myanmar. Methods: Case report Results: We report a case of 54-year-old Rakhine woman with history of diabetes for 10 years presenting with acute onset of cognitive impairment for two days. Multiple small hypodense lesions were found in non-contrast CT (Brain) and she was treated as ischaemic stroke. Her cognition improved and she was discharged. Three weeks later, she suffered from dysarthria, right-sided hemiplegia and right-sided UMN facial palsy. Contrast enhancement was noted at left frontal lobe with associated restricted diffusion on CEMRI and beaded appearance along left ACA and segmental narrowing beyond terminal ICA (both sides) on MRA. As she visited Rakhine state 1 year ago where there was schistosomiasis outbreak during that time and persistent eosinophilia was observed on repeated haematological testing, serology testing was performed and found to be positive for Schistosoma mansoni infection. Her neurological condition was static without aggravation with PO Praziquantel with high dose PO steroids. Conclusion: This is the first report of cerebral manifestation of chronic Schistosoma mansoni infection in Asia. Schistosomiasis must be investigated in case of the vascular-ischaemic events especially in young population and in patients residing or returning from the endemic areas regardless of the latency period.

PP04

Clinical Profile of Tuberculous Meningitis

Dr Ye Sithu1

1Yangon General Hospital, Yangon, Myanmar

Objective: Tuberculous meningitis (TBM) is the most dangerous form of tuberculosis. Early diagnosis of TBM is important because clinical outcome depends on timing of therapy and development of serious complications like hydrocephalus. The objective is to describe clinical profile of TBM patients and assess their activities of daily living on admission and at three weeks after antituberculous treatment (antiTB). Materials and Methods: It was a cross-sectional observational study carried out at Yangon General Hospital (YGH) from January 2017 to December 2017. Total 63 TBM patients were enrolled and diagnosis was made by using Mycobacterium tuberculosis (MTB) isolated from cerebrospinal fluid (CSF Acid-fast bacilli stain positive or CSF PCR positive for MTB) or Thwaites’ diagnostic score. Clinical features, CSF findings and neuroimaging features were assessed. Activities of daily living on admission and at 3 weeks after antiTB were assessed by Barthel Index. Results: Among 63 TBM patients, 68% had classical triads of meningitis. Cranial nerves palsies and hydrocephalus were present in 52% and 27% respectively. Only 14% of patients were positive for CSF PCR for MTB. On admission, good Barthel index patients (B.I >12) were 11% whereas poor Barthel index patients (B.I ≤12) were 89% . At 3 weeks after antiTB, good B.I were 54% whereas poor B.I were 46%. In comparison according to McNemar Test, P value is <0.001 and statistically significant. Conclusion: Although CSF PCR for MTB has low sensitivity despite high specificity, early recognition and timely institution of antiTB were effective in reducing morbidity and improving functional status in TBM patients.

PP05

Factors Associated with Unfavourable Outcome Among Adult Community Acquired Bacterial Meningitis in a Tertiary Hospital in Kuala Lumpur

Dr Subramaniam Mohan Raj1, A/Prof Wan Nur Nafisah1, Dr Periyasamy Petrick1

1Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Objective: Community acquired bacterial meningitis among the adult population predisposes to high morbidity and mortality, apart from causing neurological sequalae. This study was conducted to identify the factors associated with unfavourable outcome of adult community acquired bacterial meningitis in UKMMC, Kuala Lumpur. Methodology: This was a retrospective-observational study with a prospective arm, conducted among adult patients admitted for community acquired bacterial meningitis from the year 2008 till 2018, involving 135 patients. Outcomes were categorised based on Glasgow Outcome Scale (GOS). Data was collected and analysed using IBM SPSS v25. Ethical approval was obtained from the UKM Research and Ethics Committee. Results: Majority of the patients were male (58.5%), aged above 55 years (52%), Malays (40%) and had non-communicable disease (60%). Fever was the commonest symptom (82.2%) along with elevated CRP (78.5%). Unfavourable outcome was seen in 39.3% of patients. Lumbar puncture was refused by 20.1% of patients. Age (χ²=5.29, p<0.05), presence of non-communicable disease (χ²=4.02, p<0.05), seizure at presentation (χ²=4.21, p<0.05), low GCS on arrival (χ²=7.00, p<0.05), elevated CSF opening pressure (χ²=10.38, p<0.05), CSF glucose : serum glucose ratio < 0.5 (χ²=5.26, p<0.05), mechanical ventilation (χ²=10.79, p<0.05), ICU admission (χ²=9.22, p<0.05) and length of hospital stay (χ²=20.56, p<0.05) had significant association with unfavourable outcome. Conclusion: Early detection of non-communicable diseases and the importance of lumbar puncture has to be made aware to the public. Presenting symptoms and GCS on arrival needs to be accurately assessed and recorded. Clinicians should ensure adequate CSF investigation is sent for all patients suspected of meningitis. Keywords: community acquired bacterial meningitis, unfavourable outcome, adult bacterial meningitis, cerebrospinal fluid (CSF), Glasgow outcome scale (GOS)

PP06

Myelitis Zoster as CNS Varicela Zoster Virus Reactivation: A Rare Complication

Dr Melya Arianti1, Dr Kartika Maharani1, Dr Darma Imran1, Dr Riwanti Estiasari1

1Neurology Department / University of Indonesia / Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Reactivation of dormant Varicella Zoster Virus (VZV) generally manifests as shingles zoster skin lesions. Complications in the form of myelitis might occur through the distribution of VZV centripetally to the central nervous system (CNS). Myelitis zoster has an incidence rate of only 0.1-3%. Sensory, motor, and autonomic deficits will greatly reduce the quality of life. A 45-year-old immunocompetent woman with numbness at the location of the left armpit, radiating to the left torso to the left side of the leg, followed by a sense of being tied at the breast folding level, weakness of both legs, later followed by the inability of micturition and defecation. These complaints begin with a sequence of severe sensory, motor, and autonomic deficits, which begins after herpes zoster skin lesions on the left side of the back within ten days. Symptomatic partial acute transverse myelitis was found. Cervicothoracic hyperintense lesion C7-Th3 found intramedullary in T2WI MRI, CSF PCR VZV was negative. Management of 1000 mg of methylprednisolone for five days showed clinical improvement. Clinical recovery of the ability of micturition and defecation without catheterization, was able to walk without help but leaving sensory symptoms after two months. Myelitis zoster is a very rare case. PCR and VZV DNA in CSF are the diagnostic gold standard. However, with negative findings, the diagnosis can still be made by a temporal relationship between symptoms of acute myelitis preceded by herpes zoster skin lesions and evidence of spinal cord lesion in the MRI. There is no standardized treatment guideline, but high-dose steroids and intravenous acyclovir provide a good outcome. Keywords: Myelitis, CNS Zoster, VZV Reactivation, Zoster Complication

PP07

Subacute sclerosing panencephalitis patients admitted to Yangon General Hospital

Dr Sai Kyaw Win1, Dr Yi Mon Khine1, Dr Phyo Hlaing Kyaw2, Dr Lynn Aung Yan2, Dr Zaw Myint Moe2, Dr Mar Ohn1

1University of Medicine 1, Yangon, Myanmar, 2Yangon General Hospital, Yangon, Myanmar

Case Series: Case 1 was a 17-year old boy with myoclonus and poor performance for 4 months. Vaccination history was not reliable but no history of measles before. CSF RE was normal except elevated measles antibody titres (first serum: 1:4096, second serum: 1:2048 and CSF: 1:32). MRI brain was normal. EEG revealed delta slowing with long interval GPEDs. He expired in 4 months. Case 2 was a 17-year old boy presented similarly. Vaccination history was unknown. He had no history of measles. EEG revealed delta slowing with periodic EEG complexes time locked with myoclonic jerks. CSF RE was normal except elevated measles antibody titers (first serum: 1:2048, second serum: 1:2048 and CSF: 1: 128). MRI brain showed white matter hyperintensities in splenium of corpus callosum and right inferior temporal region. He also expired. Third case is a 26-year old young man with similar signs and symptoms for 3 months. He had history of measles at 16 years of age. No history of measles vaccination. MRI brain and CSF were normal except elevated measles antibody titers (first serum: 1:1024, second serum: 1:2048 and CSF: 1:128). EEG revealed the same. He was in vegetative state on discharge. Conclusion: Here we presented adult SSPE cases admitted in 6-month period. All three patients came from remote rural areas. The first two had low-socioeconomic and education status. They all had poor prognosis.

PP08

48-hour Video-EEG Monitoring for Epilepsy Presurgical Evaluation is Cost-effective and Safe in Resource-limited Setting

Dr Si Lei Fong1, Prof Lim Kheng Seang1, Dr Minh-An Thuy Le2, Dr Sherrini Ahmad Bazir4, A/Prof Vairavan Narayanan3, Ms Noraini Ismail1, Ms Sweh- Fern Loo1, Ms Kohila Krishnan1, Prof Chong- Tin Tan1

1Division of Neurology, Department of Medicine, University Malaya, Kuala Lumpur, Malaysia, 2Department of Neurology, Faculty of Medicine, University of Medicine and Pharmacy of Ho Chi Minh City, Ho Chi Minh City, Vietnam, 3Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, 4Subang Jaya Medical Centre, Subang Jaya, Malaysia

Objective: Video-EEG monitoring is one of the key investigations in epilepsy pre-surgical evaluation but limited by cost. This study aimed to determine the efficacy and safety of a 48-hour (3-day) video EEG monitoring, with rapid pre-monitoring antiepileptic drugs withdrawal. Materials and Methods: This is a retrospective study of epilepsy cases with VEM performed in University Malaya Medical Center (UMMC), Kuala Lumpur, from January 2012 till April 2019. Results: A total of 137 cases were included. The mean age was 34.5 years old (range 15-62) and 76 (55.8%) were male. On the first 24-hour of recording (D1), 81 cases (59.1%) had seizure occurrence, and 109 (79.6%) by day 2. One-hundred and nine VEMs (79.6%) were diagnostic, in guiding surgical decision or further investigations. Of these, 21 had less than 2 seizures recorded in the first 48 hours but were considered as diagnostic because of concordant interictal ± ictal activities, or a diagnosis was made. Three patients developed complications, including status epilepticus required anaesthetic agents (n=1), seizure clusters (n=2) with postictal psychosis or dysphasia, and all recovered subsequently. Conclusion: 48-hour video EEG monitoring is cost-effective in resource limited setting. Keywords: epilepsy surgery, video-EEG monitoring, refractory epilepsy

PP09

Outcome of Status Epilepticus with Intravenous or Oral Antiepileptic Drug in Indonesian Population: A Prospective Study

Dr Adrian Ridski Harsono1, Dr Rineke Twistixa Arandita1, Dr Astri Budikayanti1, Dr Winnugroho Wiratman1, Dr Luh Ari Indrawati1, Dr Fitri Octaviana1

1Department of Neurology, Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Objectives Convulsive status epilepticus (CSE) has estimated mortality rate of 2-40%. Guidelines recommend intravenous (IV) newer antiepileptic drug (AED) such as valproic acid (VPA) and levetiracetam (LVT) as second line of CSE management. Phenytoin (PHT) is the only available IV AED in Indonesia. We aimed to describe the outcome of CSE in our hospital. Material & Method This prospective, non-randomized study was undertaken in adult patient with CSE who failed to achieve cessation after first-line diazepam treatment administration. Patients then received IV AED (PHT) or oral AED (VPA, LVT, or topiramate (TPM)) in adequate dosage as second line AED. Mortality rate and time of CSE cessation were measured. Result Between January and March 2019, 18 cases were enrolled and 38,9% had metabolic disorders as major etiology; CSE cessation was achieved with single AED in 55,6% cases, which 60% received IV PHT. Median time from administration to cessation for all AED, IV AED and oral AED were 30 minutes (0 to 4320 minutes), 20 minutes (0 to 60 minutes) and 210 minutes (30 to 4320 minutes) respectively. About 44,4% cases experienced non-convulsive status epilepticus (NCSE) after the CSE cessation, which 66,7% received oral AED. Overall mortality rate and mortality rate with NCSE was 61,1% and 54,5% respectively. Conclusion IV PHT has been more likely to terminate CSE as second line treatment with lower median time in CSE cessation. Despite the median cessation time was 30 minutes, the mortality rate was still high with near half of the patients experiencing NCSE.

PP10

Cognitive Impairment in Epilepsy Patients at Indonesia National Referral Hospital

Dr Diatri Nari Lastri1, Ms Adisti Putri1, Ms Rineke Arandita1, Dr Astri Budikayanti1, Dr Winnugroho Wiratman1, Dr Luh Ari1, Dr Fitri Octaviana1

1Department of Neurology, Universitas Indonesia, Cipto Mangunkusumo National Refferal Hospital, Jakarta, Indonesia

Objectives The consequences of epilepsy are often as serious as having the disorder itself. Cognitive impairment (CI), being one of many consequences that occurs, can be found in one or more cognitive domains. This study aimed to know the profile of CI in epilepsy patients at Cipto Mangunkusumo Hospital. Material & Method This was a retrospective cross-sectional study. Data of complete neurobehavior examination in epileptic patients from January 2014 until January 2019 were collected. There were 5 domains of cognitive function tested which were Speech, Memory, Attention, Executive Function, and Visuospatial. Demographic characteristics, age of epilepsy onset, seizure type, treatment, and radiologic findings were recorded. Result There were 55 patients included. Mean of age was 40.2 + 13.8 yo. CI was found in 51 (97.3%) patients;memory (90.9%),executive function (54.5%),visuospatial (30.9%), attention (23.6%) and speech (20%). Median of domain was 2 and affected in 62.7%. Patients who suffered >2 domains of CI had younger onset (20.1+15.8 yo vs 29.5+17.6 yo) and significantly longer duration of epilepsy (18.3 + 12.8 years vs. 11.7 + 10.4 years), also significantly associated with higher risk if patient used AED polytherapy (OR 3.6, p 0.047). MRI findings and seizure type were not associated factor of having >2 domains of CI. Conclusion CI in patients with epilepsy affected several cognitive domains. The most common were memory and executive function. Duration of epilepsy and AED polytherapy were significantly associated with and at higher risk to had more than 2 affected domains.

PP11

Effect of CYP3A5*3 Genetic Polymorphism on Serum Concentration of Carbamazepine in Myanmar Epilepsy and Trigeminal Neuralgia Patients

Dr Thin Thin Htun1

1Department of Pharmacology, University of Medicine, Mandalay, Myanmar

Objective: CYP3A5 is one of the enzymes involves in metabolism of carbamazepine (CBZ) and its polymorphism may influence the concentration of CBZ. Thus, this study was aimed to find out the effect of CYP3A5*3 polymorphism on the serum steady state concentration of CBZ. Methods: Twenty-eight epilepsy and 15 trigeminal neuralgia patients taking CBZ for at least 3 months were included. Their clinical data were recorded and trough serum steady state concentrations of CBZ were measured by Chemiluminescence Microparticle Immunoassay method and its clearance (CL/F) was calculated by JPKD v3.0 software. The CYP3A5*3 genetic polymorphism was assessed using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay. Patients were divided according to their genotype into CYP3A5 expressors (with *1/*1 & *1/*3 genotypes) and non-expressors (with *3/*3). The two groups were compared for serum drug concentration, adjusted serum concentration and clearance of CBZ. Results: Among 42 patients, 21 patients were CYP3A5 expressors (2 for *1 ⁄ *1 and 19 for *1 ⁄ *3) and 21 patients were non-expressors. Although measured concentration of CBZ in non-expressors was not significantly higher than those of expressors (P=0.43), adjusted concentration of CBZ was significantly higher in that group (0.99 ± 0.3 vs 0.73 ± 0.2 µg/mL per mg/kg/day, P=0.002) compared with expressors. The mean CL/F was significantly lower in non-expressor group (0.04 ± 0.01 vs 0.06 ± 0.01 L/hr/kg, P=0.000). Conclusion: Decreased clearance of CBZ in non-expressors indicates poor metabolizing activity of the enzyme in CYP3A5*3 polymorphism which in turn increases the serum concentration of CBZ.

PP12

Working up peripheral neuropathy in under-resourced regions- a case in point.

Dr Habib Ul Rahman Habib1

1French Medical Institute For Mothers and Children, Kabul, Afghanistan

A 38 year-old male car mechanic from Afghanistan presented 1 year ago with distal numbness of the right toes that ascended and, over the next 6 weeks, progressed to cause weakness and numbness of the both legs. A papulovesicular rash on the legs, extending to lower trunk, and fever were noted at that time. The rash resolved in 2-3 weeks. He had ischemic discoloration of fingers associated with numbness and weakness of both hands two months later He also complained of distal burning sensations and poor vision. few weeks later he lost left eye vision acutely. He has been wheelchair bound for the last 9 months. Examination revealed distal predominant asymmetric weakness with worse foot drop on the right. Both ankle reflexes were absent. There was marked glove and stocking sensory loss, and thermal skin injuries in the leg . The distal ends of left hand digits II and V showed dry gangrene. Multiple vasculitic skin lesions were seen in the pulps of the right fingers. Vision was only counting fingers on the left. There were no overt symptoms or signs of dysautonmia. Nerve conduction studies showed severe, asymmetric sensorimotor axonal polyneuropathy. Routine urine analysis and blood work-up were unremarkable except for raised CRP but normal ESR ANA, dsDNA, ANCA, Anti CCP, RF, C3, C4, HIV, HCV serologies were negative. Hepatitis B viral counts however were very high. Other tests, including cryoglobulinaemia and sural nerve biopsy, were not available locally. Patient could not afford to travel elsewhere for these . The clinical diagnoses considered was Hepatitis B-related vasculitic mononeuritis multiplex. The differential diagnosis of leprosy was considered less likely. The patient has been started on entecavir and high dose corticosteroids .

PP13

Normative Values and Cognitive Function Screening in Children aged 4 to 15 years old: A Study with SYSTEMS-R

Dr Niken Indah Hapsari1

1University of Indonesia, Jakarta, Indonesia

Objective: Cognitive development of children is closely related to age and education levels. Children has risk of cognitive impairment so that cognitive function screening tool will be needed. SYSTEMS-R is one of the cognitive function screening tools that used in children aged 4 to 15 years old in Australia. It has a sensitivity value of 83% and specificity of 76%. The purpose of the study is to get a normal value and cut off score based on age and education levels in Indonesia. Materials and Methods: A cross-sectional design and observasional study with primary data from 631 children from 6 schools in Jakarta from January to April 2019 had been performed. Results: The subjects consisted of 298 boys (47.2%) and 333 girls (52.8%). The lowest score was found in age 4 (12;5-22) and the highest was in age 15 (35;28-40). Based on education levels, the lowest score of 14;5-26 was found in kindergartens and the highest of 35;28-40 was found in 3rd grade of the junior high school. The average time in sampling requires 06.23±01.32 minutes. The SYSTEMS-R scores increase with age and education levels (p<0.005). The cut off score of each age group and education levels increases (p<0.005). Conclusions : The relationship was statistically and clinically significant between SYSTEMS-R score with age and education levels (p<0.005). A lower score of cut off score can indicate a cognitive impairment that further neurological examination may be needed.

PP14

Paraneoplastic cerebellar degeneration cases with different cancer and antibodies

Dr Kyawt Oo Kay Thi Htay1, Dr Kyaw Phyo Hlaing1, Dr Ohnmar Ohnmar2, Dr Htet Htet Lin2, Dr Yin Min Aye1, Dr San Oo2

1Neuromedical Department, Yangon General Hospital, Yangon, Myanmar, 2University of Medicine 1, Yangon, Myanmar

Method: 2 case reports Case summary/Result: A 58-year old lady presented with rapidly progressive gait instability and head tremor in 2 months. On examination, she had titubation, scanning dysarthria, gaze evoked nystagmus, bilateral Intention tremor, with truncal and gait ataxia. No signs and symptoms of increased intracranial pressure. There was no associated pyramidal signs, peripheral neuropathy or parkinsonism features. She had normal cognition and other system examination were normal with no lymphadenopathy or any lump. There was no significant drug and past medical history. Routine hematology, biochemistry and thyroid function were normal. Infection screening were negative. MRI brain with contrast and CSF examination were normal. Serum PCA-1 antibody (Anti-Yo) was positive. CT (chest, abdomen and pelvis) were normal but mammogram revealed right breast mass and biopsy showed invasive duct carcinoma. She had mastectomy done and received intravenous methylprednisolone and intravenous immunoglobulin with minimal response. Our second case was similar but a 58-year old man, presented with progressive cerebellar signs and symptoms. After ruling out structural, metabolic and toxic causes of cerebellar pathology, he was found out to have mediastinum lymphoma with anti-CV2 antibody. He denied to proceed any biopsy or medical treatment. Conclusion: We presented 2 cases of paraneoplastic cerebellar degeneration with different cancers and antibodies.

PP15

A Mixed Cryoglobulinaemia case: A rare treatable cause of Neuropathy

Dr Khine Yee Mon1, A/Prof Ohnmar Ohnmar1, Dr Moe Zaw Myint1, A/Prof Sein Win2, A/Prof Yin Min Aye1, Prof Zaw Than Htun3, Prof Win Min Thit1

1Department of Neurology, University of Medicine (1) / Yangon General Hospital, Yangon, Myanmar, 2Department of Haematology, Yangon General Hospital, Yangon, Myanmar, 3Department of Medical Research, Myanmar

Method: A case report Case summary/Result: A 74-year old man presented with asymmetric painful rapidly progressive weakness with tingling and numbness of hands and feet in two months with loss of appetite and weight loss, which led him to wheel-chair bound. He had past history of recent stroke 4 months before with complete recovery. He was an ex-smoker. He had no history of fever, skin rash, joint problems, hypertension, diabetes mellitus, oedema, Raynaud’s phenomenon and asthma. Examination revealed no cranial neuropathy, but right foot drop and bilateral ulnar palsy. Investigations revealed normochromic normocytic anemia with leucopenia without eosinophilia and proteinuria and hematuria with normal renal function. His lipid profile was normal. ENA and ANCA profile were negative. Myeloma panel revealed raised serum free kappa light chains. His corrected calcium, skeletal survey and bone marrow biopsy did not suggest myeloma. His HIV, hepatitis B and C were negative. ECG and echocardiogram were normal. Nerve conduction study confirmed bilateral ulnar and right peroneal neuropathy. Left sural nerve biopsy showed vasculitis. Blood for cryoglobulin was positive. With diagnosis of cyroglobulinaemic vasculitis, he received high dose steroid and IV cyclophosphamide followed by azathioprine. After six months of treatment, he was significantly improved and could walk independently. Azathioprine was stopped for neutropenia. While planning to start another immunosuppressant, he had left MCA partial circulation infarct with right sided weakness and motor dysphasia. Conclusion: We present a mixed Cryoglobulinaemia case with Kappa light chain MGUS causing peripheral vasculitic neuropathy and recurrent stroke.

PP16

A Young Diabetic Patient with a Rare Genetic Disease

Dr May Zin Myint1, Dr See Muah Lee2, Dr Aftab Ahmad3, Dr Lim Ling Choo2

1National University Hospital, Singapore, 2Ng Teng Fong General Hospital, Singapore

Introduction MELAS (mitochondrial encephalopathy, lactic acidosis and stroke-like-episodes) maybe under diagnosed due to its various clinical manifestations. Common neurological manifestations include stroke-like-episodes, seizures, dementia, headaches and myopathy. We report a case of a young lady with diabetes mellitus who presented with lactic acidemia and neurological features characteristic of MELAS. Case report A 37-year-old lady presented with acute giddiness, confusion and visual disturbances. She had diabetes mellitus since age of 22 and was on metformin, glipizide and insulin. Clinically, there was absence of acanthosis nigricans .Her BMI was 14. Anti-glutamic acid and anti-islet-cell antibodies were negative. She suffered from frequent episodic headaches and bilateral sensorineural hearing impairment. Her conversational skills were slow and her educational grades were below-average. Her mother had diabetes and deafness although her two sisters did not have similar features. There was no evidence of diabetic crisis, metabolic derangements nor infection at presentation. However, MRI brain showed cerebral atrophy with acute infarcts in left occipital lobe and hippocampus but normal cerebral arteries. Overall findings raised suspicion of underlying neurodegenerative disorder. Copper and caeruloplasmin tests were normal. Serum and cerebrospinal fluid lactate were elevated. Clinical diagnosis of MELAS was made. She was prescribed Co-Enzyme Q and L-carnitine. Metformin was stopped. Result M3243 A> G mutation test was positive. Conclusion When reviewing young diabetic patients with neurological manifestations, it is important to find salient features and family history to exclude mitochondrial diseases. This has implications on long-term management such as avoiding metformin and valproate. Due to known maternal transmission, female patients should undergo genetic counselling.

PP17

Isolated Sphenoparietal vein and Cavernous Sinus Thrombosis Presentation in the Postpartum: A Rare Presentation

Dr Han Lin Naing1, Prof Mathew Alexandar1, Dr DK Nur’Ashikin Hj Tengah1, Dr DK Norazieda PHM Yassin1, Dr Sunithi Mani1

1Brunei Neuroscience Stroke and Rehabilitation Center, Bandar Seri Begawan, Brunei Darussalam

Background: CVT is one of the major causes of stroke in the young with risk factors such as pregnancy/puerperium and prothrombotic states Objectives: To present the clinical conundrum, value of MR imaging, treatment and outcome in a case of CVT Case Summary: A 37y old lady, 5w postpartum presented with sudden onset right hemiparesis/language dysfunction. On arrival GCS was 11(E4V2M5), sluggish DTR in Right upper & lower limbs. MRI/MRV had shown an infarct involving the left Caudate/Lentiform nucleus, insula and anterior operculum with thrombosis of the left sphenoparietal vein/partial thrombosis of the left cavernous sinus with proptosis of left eye, which became clinically apparent only 2 days later with chemosis of the left eye, papilledema/impaired eye movements. She was treated with Enoxaparin 40 mg bid, Mannitol to reduce cerebral edema and Levetiracetam to prevent seizures. Clinically, she was slow to improve, developed behavioral changes, EEG was normal, F/U imaging in 2-3 days had shown hemorrhages in the infarct, persistence of edema and thrombosis. She was subsequently started on Acetazolamide 2g daily and anticoagulation was changed to Warfarin. She had mood changes, treated with Escitalopram and took about 4-5 weeks to clinically improve. Result: At discharge, she had a subtle right facial weakness and mild reduced word output. At 3 months F/U, she has no neurological deficits and mental functions are normal. Conclusion: The heterogeneity of Postpartum CVT and improvement of mRS from 5 to 1 at 3m is a take home message of good outcomes in venous strokes.

PP18

Value of Traditional Plasmapheresis in Management of overlap Miller-Fisher Variant

Dr Nan Kaythi Nwe1

1NOGH, Neurology Department, Yangon, Myanmar

Method: Case report Case summary: A 57-year-old lady presented with 3 days history of limbs weakness but without preceding history of infection. Vital signs were normal but she was drowsy. Patient had bilateral ptosis with horizontal nystagmus with no other cranial nerve palsy. Examination revealed flaccid quadriparesis with power 4/5 on upper and 3/5 on lower limbs symmetrically without sensory and sphincter involvement. Investigations revealed normal blood count, electrolytes and CRP. CSF revealed cytoalbuminologic dissociation with normal cell counts and elevated protein level 1.5 times. MRI brain was normal. Electrophysiologic findings were consistent with mixed motor and sensory axonal polyneuropathy with sural sparing. Anti-GQ1b IgG and anti-GD1a IgG antibodies were negative. Clinical features of bilateral ophthalmoplegia, pure motor flaccid quadriparesis, drowsiness and slurred speech together with electrophysiologic and CSF findings all favored the diagnosis of overlap Syndrome with Miller-Fisher, Bickerstaff’s encephalitis and AMSAN variant of GBS. Treatment includes IVIg and plasmapheresis. Firstly, standard plasmapheresis was tried. However, central line insertion was failed because of restlessness as patient was in a state of encephalitis. Therefore, traditional plasmapheresis (one unit of blood was withdrawn, plasma was removed and patient’s own packed cell was given back) was applied for total 10 days. After treatment, motor symptoms improved with 5/5 on all four limbs. However, encephalitis features and ophthalmoplegia remained static until 1 month after event. Conclusion: Traditional plasmapheresis is effective for improvement in motor weakness but not for encephalitis features in patient with overlap Miller-Fisher variant. It is still effective in treatment of autoimmune neurological disorders in poor resource areas or unfavorable condition to undergo standard plasmapheresis (e.g. hemodynamically unstable or in-cooperative patients).

PP19

Role of Attribution Models in Supporting Diagnosis of Primary Neuropsychiatry Systemic Lupus Erythematosus (NPSLE): A Case Report

Mr M. Iskandarsyah Agung Ramadhan1, Ms Arundina Sanyoto1

1Lewoleba General Hospital, Lewoleba, Indonesia

Objective: Currently there is no gold standard in attributing neuropsychiatric manifestations in patients with SLE (NPSLE) as SLE-related (primary) or non-SLE-related (secondary). For this reason, prevalence of NPSLE was reported to be extremely varied. In fact, determining the attribution of neuropsychiatric manifestations is essential for optimal treatment. Several attribution models of NPSLE had been proposed based on clinical and other supportive findings. This case report highlights on how these models would be helpful in diagnosing primary NPSLE despite of the low-resource settings. Materials and Methods: We presented the first case ever of NPSLE recorded in Lewoleba General Hospital located in remote island of Lembata, Indonesia. The clinical course and application of NPSLE attribution models in this case will be described and discussed. Results: In October 2018, a 27-year-old woman with suspicion of SLE was hospitalized due to severe anemia. Despite of no disturbance on consciousness upon her arrival, she developed acute confusional state (ACS) on the fourth day of admission. Late-performed antinuclear antibody (ANA) test showed high titer (>1:1,000) hence diagnosed with NPSLE. She was given pulse dose methylprednisolone and haloperidol afterwards. In the impossibility of performing cerebrospinal fluid analysis and neuroimaging, we applied attribution models to determine if ACS in this patient was related to SLE activity. All the criteria in Systemic Lupus International Collaborating Clinics (SLICC) models were met while Italian attribution system score was 8; both were suggestive for primary NPSLE. She was planned to get referred pro receiving cyclophosphamide but her consciousness was deteriorating for a few days before exitus letalis. Conclusions: As there are no gold standards offered, NPSLE attribution models such as SLICC models and Italian scoring system can be used to distinguish primary and secondary NPSLE. These models can be applied in facilities or center which are inexperienced in handling NPSLE.

PP20

The study of oxalipaltin induced peripheral neuropathy in gastrointestinal cancer patient at Medical Oncology Department, Yangon General Hospital

Dr Myo Myint Maw1, Dr Wai Wai Lwin2, Dr Ohnmar Ohnmar3, Dr Yan Lynn Aung4, Dr Kyaw Thiha Soe5

1Medical Oncology Department, Yangon General Hospital, Yangon, Myanmar, 2Medical Oncology Department, Yangon General Hospital, Yangon, Myanmar, 3Neurology Department, Yangon General Hospital, Yangon, Myanmar, 4Neurology Department, Yangon General Hospital, Yangon, Myanmar, 5Medical Oncology Department, Yangon General Hospital, Yangon, Myanmar

Objectives: The objectives of this study are to determine the occurrence and degree of severity of oxaliplatin induced peripheral neuropathy (OXAPN) and to identify asssociation between cumulative dose of oxaliplatin and degree of severity of peripheral neuropathy in gastrointestinal cancer patients at Medical Oncology Department, YGH. Materials and Methods: This study was hospital base prospective descriptive study of oxaliplatin induced peripheral neuropathy in 49 patients with gastrointestinal cancer between January 2017 and June 2018 at MedicalOncology Department, YGH. Treatment consisted of oxaliplatin containing chemotherapeutic regimens for adjuvant or palliative setting. The occurrence and severity of OXAPN was assessed clinically according to National Cancer Instiute Common Terminology Criteria for Adverse Events (NCI CTCAE) as well as by nerve conduction study. Result: The occurrence of acute OXAPN was 88%, all of which were CTCAE grade I. Persistent grade I,II,III peripheral neuropathy occurrred in 19(39%), 5(10%), and 3(6%) of patients respectively. Neuropathy mainly occurred in extremities affecting both upper and lower limbs. The occurrence and severity of peripheral neuropathy was directly related to total cumulative dose of oxaliplatin. In nerve conduction study results, peripheral neuropathy was mainly sensory axonal polyneuropathy affecting both upper and lower extremities in most cases and these results show sever peripheral neuropathy in 16(32%) and moderate peripheral neuropathy in 3(6%) of patients. Conclusion: Both acute and persistent form of OXAPN occurred significantly in this study population. Severe functionally disabling grade II and III peripheral neuropathy occurred in 10% and 6% of patients respectively. The occurrence as well as severity of OXAPN were directly related to the total cumulative dose of oxaliplatin.

PP21

Different presentations of Neuro Sjogren’s syndrome

Dr Zin New Win1, Dr Zin Phyu Tun2, Dr Htet Htet Lin2, Dr Khin Myat Po Po Kyaw1, Dr Ohmar Ohmar2, Dr Win Min Thit1

1Yangon General Hospital, Yangon, Myanmar, 2University of Medicine 1, Yangon, Myanmar

Case series: A 14 year-old girl presented with progressive tingling and numbness of both upper and lower limbs in glove and stock pattern for 1 year. There was also impaired proprioception and joint position sense, left upper limb ataxia and sensory ataxia. Nerve conduction study (NCS) revealed loss of all sensory action potential without motor nerve involvement, consistent with sensory neuronopathy. ANA was 1/800, anti-SSA/anti-Ro 52 were strongly positive and Schirmer test was also positive. So, this case was sensory neuronopathy with underlying neuro Sjogren’s syndrome. Second case was a 35 year-old lady came with flaccid quadriparesis with glove and stock pattern sensory involvement, and bilateral lower motor neuron facial palsy progressive in 5 months. CSF examination showed raised protein with normal cell count. NCS revealed inexcitable motor and sensory in all tested nerves. ANA was 1/400, anti-SSA/anti-Ro 52 were strongly positive and Schirmer test was also positive. This was a case of possible confluent multiple mononeuropathy of neuro Sjogren’s syndrome. Third case was a 41-year old lady presenting with spastic quadriparesis due to cervical myelitis who had past attacks of thoracic myelitis and bilateral optic neuritis 2 years ago. CSF oligoclonal band was negative but antiaquaporin 4 antibody was positive. ANA was 1/800, anti-SSA/anti-Ro 52 was strongly positive and also positive Schirmer test. So she was diagnosed as neuromelitis optica (NMO) associated with neuro Sjogren’s syndrome. Conclusion: Here we presented case series of different presentations of neuro Sjogren’s syndrome: sensory neuronopathy, multiple mononeuropathy and myelitis. .

PP22

ZAPTed (Zygomatic Arch and Point Triggers) Protocol for Botulinum Toxin Injections in the Management of Refractory Trigeminal Neuralgia

A/Prof Arun Aggarwal1

1RPAH, Sydney, Australia

Objective: Trigeminal Neuralgia is a disabling chronic pain condition that is characterised by recurrent episodes of severe, lancinating pain to the face. The condition generally responds well to pharmacotherapy and / or surgery. In a minority of case these treatment modalities are ineffective or unsuitable and other treatment modalities need to be considered. Methods: Botulinum toxin type A has been used effectively in the treatment of a several pain syndromes such as chronic migraine. There are also a number of reports of its use in trigeminal neuralgia, with doses ranging from 50 to 170 units. In addition, a number of different injection techniques have been described. We assessed the clinical effects of botulinum toxin type A injections in 5 patients with refractory idiopathic trigeminal neuralgia. All patients exhibited increased sensitivity to touch (allodynia) over the appropriate facial region. Patients were infiltrated with up to 35 units of botulinum toxin with 10 units into the region below the zygomatic arch and the additional 25 units into facial triggers zones in a grid like fashion. We propose that this standardised injection protocol be termed the “ZAPTed” protocol. Results: The Numerical Rating Scale was used to establish the efficacy of the injections. All 5 patients reported significant benefit from the botulinum toxin injections, with a reduction in pain by greater than 75%, even though they had previously been unresponsive to medical and in some cases, invasive treatments.. Conclusion: This confirms previous reports that botulinum toxin injections are a useful therapeutic tool in the management of refractory trigeminal neuralgia. The doses required are much smaller than previous reports using this therapeutic option. The treatment effect using a standardise injection protocol was also more effective and longer lasting.

PP23

Self-Limiting Opsoclonus after Suggested Dengue Infection : A Case Report

Dr Rineke Twistixa Arandita1, Dr Adrian Ridski Harsono1, Dr Dyah Tunjungsari1, Dr Amanda Tiksnadi1

1Department of Neurology, Universitas Indonesia, Cipto Mangunkusumo National Refferal Hospital, Central Jakarta, Indonesia

Introduction Opsoclonus Myoclonus Syndrome (OMS) is rarely found in adults, mostly correlate with the parainfectious or paraneoplastic syndrome. It’s characterized by chaotic uncontrolled movement of the eyes and involuntary jerk-like movements of the body caused by the contractions of a group of muscles. Dengue infection often correlates with some neurological manifestation such as meningoencephalitis or transverse myelitis, whereas, OMS is still a rare thing to occur. Case A 25-year-old-male, complaint of spinning sensation 3 weeks prior to admission. He also complained of seeing oscillating objects in any directions. Two weeks before, he had fever and thrombocytopenia, diagnosed with dengue fever. On neurological examination, There was increased physiological reflex both on all extremities and positive Hoffman Tromner without any weakness or Babinski sign. There was definite opsoclonus, worsened when the eyes converged. Limb and truncal ataxia were also present, with some jerking movements in the bilateral upper limb. No abnormalities on the brain MRI. CSF profile showed mild increasing protein level. The patient was discharged 2 weeks later with significantly improved symptoms without any specific treatments. Conclusion OMS associated with Dengue virus infection is a rare neurological condition. There is still no guideline treatment for this condition and is often treated symptomatically. In our case, OMS and other symptoms were improved spontaneously without any specific treatment, suggesting the parainfectious process. Keywords: Opsoclonus Myoclonus Syndrome, OMS, Dengue Infection

PP24

The Characteristics of Hemifacial Spasm Patients in Dr. Mohammad Hoesin Palembang Hospital

Dr Bayu Haswatty1, Dr Angga Pradian1, Dr Selly Marisdina1, Dr Henry Sugiharto1, Dr RM Faisal1

1Sriwijaya University, Palembang, Indonesia

Objective: Hemifacial spasm (HFS) is characterized by involuntary unilateral contractions of the muscles innervated by the ipsilateral facial nerve. The incidence and characteristic of HFS have rarely been reported in Indonesia. This study aims to determine the characteristics of patients with HFS treated in the Neurology department of Dr. Mohammad Hoesin Palembang Hospital. Materials and Methods: We conducted a cross sectional observational study of 15 patients with hemifacial spasm from outpatient and hospitalization medical record of Dr. Mohammad Hoesin Palembang Hospital period January - December 2018. The characteristics of patient, onset and location of HFS, clinical stage, comorbidities, management and the result of additional examination were analyzed. Results: About 80% of the patients are women with the age range of 41-60 years. The most frequent onset of initial spasm is 3-6 year (53,3%) and dominated at the right side of the face (66,7%), with the most common comorbidities are hypertension (93,3%). All of the patients belonged to the Jankovic 2 criteria with 46.7% has severe grading with HFS-7 criteria. Approximately 66,7% patients are treated with carbamazepine. Fibrillation is found in spontaneous activity from ENMG examination in all patients. Most chemical shift imaging in nuclear magnetic resonance and MRA results showed narrowing of the vertebral artery on the ipsiateral side. Conclusion: HFS is more common in women over aged 40 years who predominantly occur on the right side of the face, with hypertension as the most comorbidities. Additional investigation showed vascular compression of the facial nerves as a cause of HFS.

PP25

Parkinson’s Advanced Symptoms Unit: outcomes from a ‘’wrap-around’’ model of care

Dr N Archibald, Dr R Fowkes, Dr Aye Myat Moe 1Department of Neurology, James Cook Hospital, Middlesbrough, United Kingdom

Background Parkinson’s disease (PD) is common complex and costly. PD affects 1 in 100 people over the age of 65 and with an aging population, prevalence is rising. Complications include dementia, psychosis, and motor fluctuations and falls leading to emergency admissions to medical and psychiatric care, making them key determinants of quality of life, and also accounting for the high costs of hospital care. Services which can manage these complications in a timely and effective manner are key to treating people with advanced PD. In Teesside, UK, we have established A Parkinson’s Advanced Symptoms Unit (PASU)- a rapid access, community-based multidisciplinary service to provide specialist care in a ‘’wrap-around’’ model, integrating clinic and community, as well as physical and mental health care. Methods Data on the number of acute admissions to hospital and nursing homes, cost of treatment and patient experience between 2015 to 2018 was collected from two parallel cohorts consisting of patients attending the PASU (n=180) and those who had not accessed the service (n=490). Results PASU patients had reduced numbers of emergency admissions to medical and psychiatric care and reduced length of stay. Hip fracture rates and admissions to nursing care reduced by 50%. Service user experience was positive with improvements in self-management and quality of life. Cost-savings were seen when compared to a standard model of care. Conclusion The PASU service model proves to be an efficient model that reduces cost, adverse outcomes and improve quality of life for complex PD patients.

PP26

Liquid levodopa/carbidopa/ascorbic acid solution [LCAS] – A cheap but underutilized treatment option in advanced Parkinson’s disease in Asian countries

Dr. Arshia Bhardwaj, Assistant Prof Nishit Sawal1

1Government Medical College and Hospital, Sector 32, Chandigarh, India

Objectives: Advanced Parkinson’s disease manifests with “on-off” phenomenon, dyskinesias and increasing symptom severity. Managing it in developing countries is difficult given the low per capita incomes and expensive drugs. Liquid levodopa/carbidopa is a cheap modality not widely used in developed world as they can afford other drugs and deep brain stimulation [DBS]. However, patients in developing countries do not have access to either and have to rely on oral levodopa – the cheapest drug available which however is not very effective in advanced stages of the disease. Materials and Methods: 3 patients of Parkinson’s disease with symptoms not controlled with levodopa tablets were shifted to LCAS solution. Results: All 3 patients showed varying degree of improvement with LCAS as tabulated in table 1. Conclusions: Advanced Parkinson’s disease treatment is polypharmacy which includes levodopa/dopamine agonists/amantadine/rasagiline or selegiline. However, cost factors prevent wide availability of these drug combinations in developing world to majority of population [Table 2]. Liquid levodopa/carbidopa/ascorbic acid solution is a cheap and effective way to treat advanced Parkinson’s. This is because of faster gastric emptying, better levodopa absorption, smoother blood levodopa concentrations and resultant clinical benefits like fewer dyskinesias, less on-off phenomenon and a better quality of life. Patients can ambulate independently more frequently which leads to lesser depression and better bone mass. Liquid levodopa may be redundant and outdated in the Western world where patients have higher incomes and better access to health insurance and other facilities like DBS but it remains a promising yet underutilized treatment in the developing world.

PP27

Neuropsychiatric symptoms in Parkinson’s disease and beliefs, knowledge of caregivers

Dr Zarni Myint Shwe1, Dr Nyi N Aung2, Dr Aung P Htwe2, Dr Khin M PP Kyaw1, Prof Win M Thit1

1Neurology Department, Yangon General Hospital, Yangon, Myanmar, 2Department of Medicine, Yangon General Hospital, Yangon, Myanmar

Background: Neuropsychiatric symptoms have a significant impact on patients and caregivers, but these symptoms are under-recognized due to lack of standard assessment method and incomplete understanding. Objectives: To describe the neuropsychiatric symptoms in Parkinson’s disease patients and the beliefs, knowledge of caregivers. Methods: This cross sectional study involved PD patients from Yangon General Hospital, Myanmar. Patients who reported neuropsychiatric symptoms were invited and neuropsychiatric symptoms were assessed using neuropsychiatric inventory questionnaire in Myanmar version. Structured interview on beliefs and knowledge was done on caregivers. Results: A total of 40 PD patients with a mean age of 58.7±7.7 years were included. The mean disease duration was 5.1±4.5 with a mean MMSE score of 26.3±1.5 and H&Y stage of 2.1±0.7. The most common neuropsychiatric symptoms were depression (62%) and anxiety (58%).Two or more psychiatric symptoms were reported in 61% of patients. Eight patients (20%) experienced hallucinations mainly in visual form. The caregivers were predominantly spouse (65%) or children (23%), with others(12%). Among caregivers, only 42% realized that the psychiatric symptoms were manifestations of PD. Mental illness, attention seeking behavior, stress, emotional problem and witchcraft were identified as beliefs and knowledge of caregivers. Conclusion: Neuropsychiatric symptoms should be considered as an integral part of Parkinson's disease. There is a striking lack of knowledge about neuropsychiatric manifestations in Parkinson's disease among caregivers. Therefore, a multidisciplinary approach is essential in management of PD also through raised awareness and enriched knowledge on neuropsychiatric symptoms.

PP28

Clinical Profile of Neuromyelitis Optica Spectrum Disorder in Myanmar

Dr Htet Htet Lin1, Dr Sein Mya Mya Aye2, Dr Win Min Thit3

1Department of Neurology, University of Medicine (1), Yangon, Myanmar, 2Consultant Neurologist, Yangon, Myanmar, 3Department of Neurology, Yangon General Hospital, Yangon, Myanmar

Objectives: The purpose of the study is to describe demographic features, clinical presentations, MRI findings and CSF findings in neuromyelitis optica spectrum disorder cases (NMOSD). Materials and methods:We conducted cross sectional study of 82 patients who fulfilled the 2015 Neuromyelitis Optica Spectrum Disorder Criteria from June 2016 to June 2019 at Department of Neurology, Yangon General Hospital, Myanmar. Results: The female to male ratio was 6:1 with mean age of onset was 36.09±11.9.Mean duration of disease was 3 years.50 patients (61% ) were presenting with optic neuritis and 71 patients (86%) presented with myelitis . Various presentations other than optic neuritis and myelitis were noted. Brain stem syndrome, area postrema syndrome and cerebellar symptom were presented with 9.5,10.7 and 9.5 percent respectively.NMO IgG was positive in 69 patients(84%). MRI brain was normal in upto 47%, supratentorial lesion in 13.3% and infratentorial lesion in 10.8%. Long segment myelitis were found to be 67.5% in MRI spine.Mean CSF protein value was 44.67±34 mg/dl, mean sugar value was 83.97 ±23.12mg/dl, mean cell count was 12.02±13 cells/cumm. Conclusion: Because of limited data on neuromyelitis optica spectrum disorder in Asia region whether geographical difference cause difference in clinical presentation, severity and prognosis is still uncertain. In Myanmar, studies of neuromyelitis optica spectrum disorder is limited.With availability of NMO IgG antibody in Myanmar we can now diagnose and this is the first Myanmar data on clinical profile of neuromyelitis optica spectrum disorder.

PP29

Our Experience In Establishment of In-house Neurology Driven Therapeutic Plasma Exchange (TPE) Infrastructure In Resource-Limited Public Hospital In Malaysia

Dr Shirley Lee1, Dr Fu Liong Hiew1, Dr Shanthi Viswanathan1

1General Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Objectives: In recent years, there is rising evidence to advocate the use of therapeutic plasma exchange (TPE) in various immune-mediated central and peripheral demyelinating neurological disorders. However, the accessibility and availability of TPE in Malaysia remains low due to its cost and limited health resources. Therefore, we aimed to establish a cost-effective, in-house neurology driven TPE infrastructure and provide a framework that can be replicated at other centers to overcome this predicament. Materials and Methods: We reviewed the spectrum of immune-related neurological disorders seen in Kuala Lumpur Hospital from 1990- 2015 to justify the need of own a neurology driven TPE infrastructure. A central TPE development group and technical and specification committee were formed to identify the necessary measures needed to set up the TPE service. Results: Funding was approved for acquisition of a centrifugal TPE machine, related consumable items and for annual maintenance. A local TPE protocol and check list was constructed to ensure safe and uniform delivery of TPE service. We arranged for training and privileging for TPE nursing staffs to ensure competence in the handling of TPE. Also, the local TPE registry was established to collect information on indications, procedure parameters, complications and outcome efficacy to facilitate on regular auditing to improve services. A total of 38 patients from May 2015 to end of 2017 underwent TPE via centrifugal system at our TPE suite with good tolerability. Conclusion: With limited resources, it is still possible to establish a safe, successful and sustainable TPE service with concerted efforts.

PP30

Establishment of South East Asia Regional Therapeutic Plasma Exchange Consortium for Neurological Disorders

Dr Sing Keat Wong1, Dr Shanti Viswanathan1, Dr Appiwattanakul Metha2, Ms Ashwini Nayak3, Dr Badrul Islam4, Dr Bhupendra Khatri5, Dr David Pangeran6, Mr Himanshu Bambardekar3, Dr Kartika Maharani6, Dr Kevin Tan7, Prof Mathew Alexander8, Dr Mohammad Enayet Hussain9, Dr Mohd Sufian Adenan1, Dr Nabil Anaz Anzani Danapaul10, Mr Najib Khalife11, Prof Ohnmar Ohnmar12, Dr Beng Hooi Ong13, Dr Riwanti Estiasari6, Dr Sari Nurul Hanifa6, Dr Sasitorn Siritho14, Dr Chen Fei Ng15, Dr Sylvanie Ratna6, A/Prof Thirugnanam Umapathi7, Prof Win Min Thit12, Dr Yetty Ramli6, Ms Yvonne Lee YL16, Dr Fu Liong Hiew1

1Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia, 2Department of Neurology, Prasat Neurological Institute, Bangkok, Thailand, 3Terumo BCT Asia Pte. Ltd, Singapore, 4Laboratory Sciences and Services Division (LSSD), The International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh, 5The Regional MS Center, Center for Neurological Disorders, Wheaton Franciscan Health Care, 3237 S 16th St, Milwaukee, WI 53215, USA, 6Department of Neurology, Cipto Mangunkusumo Hospital/Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia, 7Department of Neurology, National Neuroscience Institute, Singapore, 8Brunei Neuroscience Stroke and Research Centre, Pantai Jerudong Specialist Centre, Bandar Seri Begawan, Brunei Darussalam, 9Department of Neurology, National Institute of Neurosciences and Hospital, Dhaka, Bangladesh, 10Biomed Global, Kuala Lumpur, Malaysia, 11Global Medical Affairs, TerumoBCT, Leuven, Belgium, 12Department of Neurology, University of medicine 1/Yangon General Hospital, Yangon, Myanmar, 13Department of Neurology, Sultanah Bahiyah Hospital, Alor Setar, Malaysia, 14Division of Neurology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bumrungrad International Hospital, Bangkok, Thailand, 15Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia, 16Health Economic and Market Access, Terumo BCT Asia Pte Ltd, Petaling Jaya, Malaysia

Objectives: The use of Therapeutic Plasma Exchange (TPE) for neurological disorders in Southeast Asia (SEA) is heterogenous in many aspects. We aimed to establish a SEA TPE consortium to improve delivery of TPE service for neurological disorders as well as to identify regional collaboration program and establishment of a regional database. Materials and Methods: A pre-meeting survey to regional key opinion leaders (KOLs) was conducted to gather insights on disease spectrum, contextual practice challenges and the need for a regional TPE consensus. Feasibility of forming a regional consortium was included. Results: A total of 14 neurologists from Indonesia, Laos, Malaysia, Myanmar, Singapore, Thailand and Vietnam responded. Challenges identified include limited healthcare funding in support of diagnostic workup, TPE therapy, as well as development of clinical infrastructure and expertise capacity building. There was favorable interest in developing a working plan contextualized to this region, including cooperation towards formation of regional SEA TPE consortium. Strategies to overcome challenges were discussed. This included the need for a comprehensive referral system and network of regional TPE centers suited to local needs, supported by innovative TPE delivery programs. Other important goals identified were setting up of a regional biomarker testing facility, identify funding methods for diagnostic antibody testing, enhancing engagement between patients and doctors to improve understanding on the use of TPE and production of educational materials.

Conclusion: Collaborative efforts from members of SEA counties is crucial towards the formation of a regional TPE consortium for neurological disorders.

PP31

Accuracy of Clinical Examination, Lumbosacral Radiography, and Electrodiagnosis of Suspected Patients with Lumbar HNP in Dr. Mohammad Hoesin General Hospital

Dr Marissa Sylvia Regina1, Dr Luther Theng1, Dr Theresia Christin1, Dr R,M Faisal1

1Sriwijaya University/Dr. Mohammad Husein General Hospital, Indonesia, Indonesia

Objective: Low back pain is a common health problem often complained around the world with prevalence of 12% -35%. One of the common cause is degeneration process that develops into nucleus pulposus herniation (HNP). Various studies have been using MRI as a gold standard standard examination for diagnosed Lumbar HNP, but this modality is expensive, not well distributed in Indonesia, less effective and efficient, so we have to find other imaging modalites as screening modalities. Therefore, we aimed to assess the accuracy of lumbosacral radiography with erect lateral projection, electrodiagnosis and neurology clinical examination compared to MRI as the gold standard examination in patient with lumbar herniated nucleus pulposus as a screening modality. Materials and Methods: We conducted a cross sectional design of 59 patients with symptoms of lumbar herniated nucleus pulposus between February and July 2018 in Mohammad Hoesin General Hospital Palembang. Results: The Accuracy, sensitivity, and specificity of lumbosacral radiography with erect lateral projection in diagnosis patient with lumbar HNP are 81,4%, 80% and 100%, electrodiagnosis are 88,8%, 88%, and 100% and neurology clinical examination are 70,3%, 70% and 75%. Combined of all examinations and demography data which is age> 50 years old have the sensitivity and specificity are 100% and 96%. Conclusion: Demography data which is age>50 years old, lumbosacral radiography with erect lateral projection, electrodiagnosis and neurology clinical examination can be used as modalities screening for diagnosis lumbar HNP.

PP32

Clinical and Radiological Diagnosis of Superficial Siderosis - A Rare Disease

Dr Moe Pearl Shwe1, Dr Jennifer Haung2, Dr David Tang2, Dr Kay Wei Ping Ng1

1National University Health Services, Singapore, 2Neurology Department, Ng Teng Fong General Hospital, Division of Neurology, National University Hospital, Singapore

OBJECTIVE: Superficial siderosis is a rare disease of the central nervous system. We describe its clinical and radiological features in a case report with images. MATERIAL AND METHOD: A 76 years old previously healthy man was admitted for investigation of recurrent falls over the past 5 years. Clinical examination revealed truncal ataxia, bilateral dysmetria, and broad-based gait. Upward gaze was limited. He had increased tone in the upper and lower limbs with brisk reflexes. He also had bilateral hearing impairment. Gradient recalled echo (GRE) images on MRI brain showed hypointensities along the surfaces of the cerebrum, brainstem and cerebellum, consistent with superficial siderosis. MRI spine showed an epidural haematoma at the level of T1-3, with diffuse superficial siderosis also noted along the spinal cord. CT angiogram of the brain was normal. CT spinal angiogram was offered, but the patient declined. Results: Superficial siderosis is a rare disease caused by hemosiderin deposition in the subpial membranes of the brain, spinal cord and cranial nerves. It is characterized by a triad of signs including sensorineural hearing loss, cerebellar ataxia, and myelopathy. Hemosiderin deposition can result from chronic extravasation of blood into the subarachnoid space, leading to dissemination by the cerebrospinal fluid. GRE T2-weighted MRI can show the hemosiderin deposition to clinch the diagnosis. Early identification and intervention of the source of subarachnoid hemorrhage should be attempted. As in our case, if no intracranial source is identified, CT myelography and whole spine MRI should be done to look for spinal cord sources. CONCLUSION: Superficial siderosis is a rare condition which can present with both cerebellar and pyramidal signs. MRI of the entire spine is helpful to look for potentially reversible bleeding sources that may allow for intervention to prevent further neurological deterioration.

PP33

Developing a model to ascertain risk of secondary generalisation in patients who present with ocular symptoms in Myasthenia Gravis

Mr Kannan Ramanathan1, Dr Kalpana Prasad2, Dr Kamal Verma2, A/Prof T Umapathi2, A/Prof Josiah Chai2

1Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 2National Neuroscience Institute, Singapore

Objective: Myasthenia gravis (MG) is a neuromuscular junction transmission disorder that is characterized by fatigable weakness of the skeletal muscles. Patients who present with ocular symptoms such as diplopia and ptosis alone are diagnosed as ocular myasthenia gravis (OMG). However, over 50% of OMG patients will develop generalised myasthenia (GMG) within two years. As there is currently no evidence-based method of predicting secondary generalisation, we aim to identify the risk factors and to develop a prediction model. Materials and Methods: 142 patients from National Neuroscience Institute (NNI), Singapore diagnosed with OMG at presentation were retrospectively reviewed. To determine the effect of the different variables on secondary generalisation to GMG within 2 years, univariate binary logistic regression was used to derive odds ratio (OR) and confidence interval (CI). Variables with P-value ≤ 0.1 were then used in multivariate binary logistic regression analysis to formulate a predictive model. Results: 37 patients (26.1%) developed generalisation within two years. From univariate analysis, seropositivity (either Anti-AChR or Anti-MuSK) was found to increase the risk of conversion to GMG (OR 0.995; 95% CI 0.968-1.02, p=0.019) while treatment with corticosteroids before generalisation was found to be protective (OR 11.4; 95% CI 1.49-87.4, p=0.040). Subsequently a predictive model was built, and the receiver operating curve was generated. The area under the curve was 0.705 (95% CI 0.613 – 0.796, p <0.001). Conclusion: An evidence-based method of predicting secondary generalisation is plausible and required further studies.

PP34

Characteristics of Visual Evoked Potential in Optic Neuritis Patients at Sanglah General Hospital

Mr Gde Putra Dhyatmika1, Dr Komang Arimbawa1, Dr Purna Putra1

1Udayana University, Denpasar, Indonesia

Objective: Optic neuritis is an inflammation of the optic nerve. Inflammation may occur due to primary demyelinization processes e.g. multiple sclerosis, or secondary due to other causes. Visual Evoked Potential (VEP) is an objective examination that can detect the optic nerve lesion. Characteristics of VEP findings in optic neuritis patient is elongation of VEP latency that can last for several years. This study is conducted to determine the characteristics of VEP in optic neuritis patients at Sanglah General Hospital, Denpasar, Bali, Indonesia. Material and Methods: A descriptive cross-sectional study was performed, involving subjects with optic neuritis admitted to Neurology clinic at Sanglah General Hospital on 2017-2018. All VEP recordings was interpreted by one electrophysiology consultant. The collected data then processed. Results: From 28 optic neuritis patient admitted, there were 13 male and 15 female with average age of 37.39 years old. The average latency of P100 wave (in miliseconds) at O1 was 138.67±55.32 (left) and 136.0±42.3 (right); at Oz was 130.36±51.13 (left) and 131.13±40.56 (right); at O2 was 131.38±49.82 (left) and 129.91±38.79 (right). Mean amplitudes were 5.54 and 5.43 for left and right eye respectively. The conclusions of VEP recordings were 28.6% left optic nerve lesion, 7.1% right optic nerve lesion, 46.4% left and right optic nerve lesion, and 17.9% normal VEP recording. Conclusion: Optic neuritis patients at Neurology clinic in Sanglah General Hospital on 2017-2018 was predominantly female with average age 37.39 years old. The characteristics of VEP in this group was prolonged of P100 latency with low amplitudes. The conclusion of VEP recordings was predominantly left and right optic nerve lesion.

PP35

Evaluation of treatment results in peripheral facial palsy by using clinical and nerve conduction study.

Dr Viet Nga Phan1, Dr Duc Thuan Nguyen1, Dr Trung Duc Le1, Dr Tien Trong Nghia Hoang2

1Military Hospital 103, Hanoi, Viet Nam, 2Military Hospital 175, Ho Chi Minh City, Viet Nam

Objectives: Evaluation of the pre-and post-treatment two weeks by clinical and electrodiagnostic data changes of patients suffer from peripheral facial palsy. Materials and Methods: The prospective study with describing and monitoring the treatment outcome of 62 patients peripheral facial palsy at Neurology Department Military Hospital 103 from June 2016 to Octobre 2018. Results: Clinical symptoms: orbicularis oculi was recovered in 93,55% patients; orbicularis oris was recovered in 74,19% and 100% of patients were recovered sensory and autonomic function. Evaluation follows HB score: CB I was 11,6% patients; HB II was 36,5% and HB III was 51,9% patients. There was a recovery of nerve conduction study after treatment: Rate of patients who had Blink reflex increase from 0% to 19,35% (p<0,0001). Decrease TGT—latency of R1, R2, and R2’(p<0,05). Significantly different facial.VDD nerve conduction after treatment (p<0,001). There was a statistically significant correlation between etiology, early hospital administration from the first week of the onset with the result. Conclusion: There was a recovery of facial nerve function on clinical and nerve conduction study after treatment two weeks.

PP36

Focal myositis developing in a patient with amyopathic dermatomyositis

Dr Jasmine Shimin Koh1, Dr Stanley Angkodjojo2, Dr Thirugnanam Umapathi1

1National Neuroscience Institute, Singapore, 2Singapore General Hospital, Singapore

Objective: To describe a case of a 60-year-old woman, recently diagnosed to have amyopathic dermatomyosis who later developed focal tuberculous myositis. Case report (Method/Results): She first presented with a two-month history of synovitis, early morning stiffness and painful erythematous maculopapular rash over her fingers and arms. She also reported exertional dyspnoea, weight loss, poor appetite, and alopecia. Clinical examination revealed mechanic’s hands, Gottron’s papules and periungal erythema. She did not have weakness. Serum ANA, anti-dsDNA, antibodies against MDA5 (melanoma differentiation-associated gene 5) and Ro-52 antigens were raised. Serum creatine kinase and electromyography were normal. Skin biopsy of the right arm, including direct immunofluorescence, showed non-specific inflammation. She was diagnosed with amyopathic dermatomyositis and superimposed undifferentiated connective tissue disease. She improved with prednisolone 30mg daily and mycophenolate mofetil (MMF) 500mg twice daily. MMF was stopped after a month due to raised liver enzymes. Four months after start of immunosuppressive treatment, she developed unilateral right thigh swelling, persistent fever and elevated inflammatory markers. Multiple sets of blood cultures were sterile and she did not respond to several courses of broad-spectrum antibiotic therapy. MRI of the right thigh showed myositis and fasciitis in the right quadriceps, hamstrings and gluteal muscles. She underwent a right quadriceps muscle biopsy which revealed inflammatory myositis with prominent perimysial and fascial granulomatous inflammation. Mycobacterium tuberculosis (TB) PCR was positive in the muscle. She improved with TB treatment and reduction of immunosuppression. Conclusion: Focal tuberculous myositis is rare and can occur in the absence of pulmonary or disseminated TB, especially in immunocompromised patients.

PP37

A treatable condition that should not miss: Satoyoshi syndrome - Case Report

Dr Swe Kyinn1, Dr Aye Aye San1, Dr Phyu Phyu Lay1, Dr Kyaw Soe Naing1, Dr Hnin Yee Lwin2

1Department of Neurology, University of Medicine (2), Yangon, Myanmar, 2Department of Medicine, Insein General Hospital, Yangon, Myanmar

Method : A case report Case summary: 17 year old girl from Chin State presented with generalized muscle spasm for two days. On arrival, she had generalized painful muscle contraction. 4 years ago, she had similar attack which was relieved by injection analgesic within 2 hours. On examination, patient was in a state of generalized muscle spasm. Other features detected were short stature, alopecia, lack of eyebrow, axillary and pubic hair (alopecia universalis). Patient also admitted history of primary amenorrhoea. Serum CK level was more than 2000 with neutrophil leukocytosis and increased ESR. EEG showed chewing artifact with one episode of sharp wave over anterior temporal area. The patient was treated as acute encephalomyelitis with IV antibiotics, steroids, muscle relaxant and benzodiazepine. On 4th day, all abnormal muscle contractions disappeared. MRI of brain and cervical spine was normal. Thyroid function tests, antinuclear antibody and extractable nuclear antibody were all negative. Serum lactate was normal (1.1 mmol/L) and serum LH and FSH were normal. The ultrasonography of abdomen showed hypoplastic uterus (4.8x2.5x1.1 cm) with endometrial thickness 2.5 mm. A patient with short stature, alopecia, hypoplastic uterus and muscle spasm all fitted in with Satoyoshi syndrome. Further examination revealed exercise induced muscle contraction which is one feature of Satoyoshi. NCS and EMG were normal. The skeletal X Ray (upper limb and lower limb) was also normal. Patient was treated with prednisolone for 2 months and six months later, patient was totally symptom free, got near normal scalp hair growth but no other secondary sex hair growth. Recheck ultrasonography of abdomen showed normal sized uterus (5.4x2.1x2.4 cm) with normal endothelial thickness (4.5 mm). The patient was having regular menstruation and no more muscle spasm upto now. Conclusion: We presented a rare case of Satoyoshi syndrome, a treatable condition that should not miss.

PP38

Multicentre Study Investigating the Association between Antecedent Infections with Flaviviruses and other Arboviruses and Guillain-Barre Syndrome in Singapore

Mr Joshua Ian Lim1, Ms Yiu-Wing Kam2, Dr Christen Lim3, Dr Lisa F.P. Ng2,4, Dr Thirugnanam Umapathi5

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2Singapore Immunology Network, Agency for Science, Technology and Research, Singapore, 3National University Hospital, University Medicine Cluster, Singapore, 4Institute of Infection and Global Health, University of Liverpool, United Kingdom, Liverpool, United Kingdom, 5National Neuroscience Institute, Department of Neurology, Singapore

Objective: This study aims to investigate the relationship between Guillain-Barre Syndrome (GBS) and antecedent Flaviviruses and other arbovirus infections in South and South- East Asia. Materials and Methods: The study involves GBS patients and controls recruited from hospitals in Singapore, Myanmar, Laos, Vietnam, Thailand, Pakistan, Sri Lanka and India. Participants were examined for evidence of recent Dengue (DENV), Zika (ZIKV) and Chikungunya (CHIKV) infection. The diagnosis of GBS was established via clinical assessment and electrophysiology. Participants’ sera and urine were obtained for microbiological investigations. Molecular and serological investigations were done to look for infection with ZIKV, DENV serotypes 1-4, and CHIKV. 14 patients and 2 hospital controls were recruited from Dec 2017 to Jan 2019. Results: Only 1 patient had evidence of recent ZIKV infection. Serum and urine had been negative for ZIKV on initial sampling; however this patient had positive serum ZIKV PCR on serial sampling. There was no significant IgM response for DENV, ZIKV, or CHIKV on serial serological sampling. The positive ZIKV PCR in the convalescent rather than acute sera makes ZIKV unlikely to be the culprit antecedent infection. The remaining cases had no evidence of recent ZIKV, DENV or CHIKV infections. As expected in an endemic region, the cases and controls had evidence of previous exposure to various combinations of ZIKV, DENV and CHIKV. Conclusion: Our preliminary data suggests that Flaviviruses and other arboviruses are not significant antecedent infections of GBS in Singapore. More prospective data from on-going recruitment as well as from our international collaborators will be presented at the ASNA meeting.

PP39

Characteristics of Nerve Conduction Velocity and Distal Latency Examination of Sensory Nerves in Morbus Hansen Patients at Sanglah General Hospital

Mr Yudhi Nusartha1, Dr Komang Arimbawa1, Dr Eka Widyadharma1, Dr Purna Putra1

1Udayana University, Denpasar, Indonesia

Objective: Morbus Hansen (MH) is one of the main causes of nontraumatic neuropathy which clinically manifests as skin and peripheral nerve lesions. Early detection of leprosy and treatment by multidrug therapy are the most important steps in preventing deformity and disability. The frequent anesthetic skin lesions are absent in the pure neuritic leprosy presentation form. Therefore, we aimed to investigate the characteristics of nerve conduction study of sensory nerves among MH patients Materials and Methods: This study is a cross-sectional descriptive study. Every patient who has been diagnosed with MH between May 2018 and September 2018 from clinical or supportive examination, then performed ENMG examination. Each patient will be assessed for distal latency and nerve conduction velocity in the peripheral nerves of four of the extremities. ENMG examination includes sensory examination of the radial, median, ulnar, and suralis nerves. Results: This study involved 21 MH patients. The number of male samples was 11, and female were 10. The average age of the sample is 39 years, with the youngest age being 21 years old and 60 years old was the oldest. A total of 16 patients with multibacillary type and 5 patients with paucibacillary. From ENMG examination, it was found that the most sensory nerve conduction disturbances in the ulnar and median nerves. Conclusion: MH was obtained with almost the same number of men and women with multibacillary type at the most frequent. Ulnar and median sensory nerve were most common sensory nerves that affected.

PP40

“Nosocomial” treatment-induced neuropathy of diabetes in hospitalized patients with poorly controlled diabetes mellitus

Dr Chloe Pawa1, Dr Shimin Jasmine Koh1, Mr Wei Min James Tung2, A/Prof Umapathi Thirugnanam1

1National Neuroscience Institute, Singapore, 2Lee Kong Chian School of Medicine, Singapore

Objective Treatment-induced neuropathy of diabetes (TIND) is an acute, painful small-fiber neuropathy that develops following an abrupt improvement in glycaemia control. Recent reports suggest TIND is not uncommon in tertiary neuropathy clinics with a reported prevalence of 10.9%. TIND in hospitalized patients with poor initial glycaemia control, which we refer to as “nosocomial” TIND, has not been studied. Materials / Methods We describe the clinical features and glycemic control indices in 5 patients with poorly controlled DM who developed “nosocomial” TIND. TIND was defined using recently published criteria. Pre-meal capillary blood glucose recordings performed during the period of HbA1c decline was used to calculate glycaemic variability. The study was approved by the hospital’s institutional review board. Results All the “nosocomial” TIND patients were hospitalized for prolonged periods for serious medical conditions which warranted good glycaemia control, namely severe sepsis, diabetic ketoacidosis, stroke, heart failure and traumatic head injury. They had raised, double-digit HbA1c levels at admission that subsequently dropped precipitously with tight in-patient glycaemia control protocols. These patients had multiple, largely asymptomatic, hypoglycaemic episodes. Glycaemic variability also appeared to be high in this cohort. Conclusion TIND may be a significant cause of morbidity in hospitalized diabetic patients with poor glycaemia control. Not all patients developed both autonomic and painful neuropathies, raising the possibility of forme-fruste TIND. We are now conducting prospective studies to verify the prevalence of “nosocomial” TIND and to understand risk factors other than sudden, marked improvement in blood sugar control.

PP41

“Covert” Sural-sparing Pattern in Guillain-Barre Syndrome (GBS)

Mr Jonathan Pong1, Dr Shimin Jasmine Koh2, Dr Genevieve Lynn Yu2, A/Prof N. Thirugnanam Umapathi2

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2National Neuroscience Institute, Singapore

Objective: We previously established i) Relative sural-sparing in GBS, defined as a greater reduction of median or ulnar sensory nerve action potential (SNAP) compared to sural SNAP, is seen in the initial nerve conduction studies(NCS) of more than one-third of both demyelinating and axonal subtypes and ii) Disruption of blood-nerve barrier at entrapment sites rather than terminal nerve endings is the likely cause of sural-sparing. We seek to understand “covert” sural-sparing in GBS in those whose initial NCS did not fulfil sural-sparing criteria but serial studies revealed disproportionate involvement of median or ulnar SNAPs relative to sural SNAP. Materials / Methods: We reviewed serial NCS of patients enrolled into our prospective GBS database. Patients with relative sural-sparing pattern on initial NCS were delineated as shown: (Normal Median or Ulnar SNAP-patient’s Median or Ulnar SNAP)/(Normal Median or Ulnar SNAP) > (Normal Sural SNAP-patient’s Sural SNAP)/(Normal Sural SNAP) Serial NCS of those without initial sural-sparing were examined for serial preferential improvement in median or ulnar SNAP compared to that of sural, ie “covert” sural-sparing. Results: 56/86 (65%) patients had relative sural-sparing at initial NCS. There were 9 AIDP, 11 AMAN/AMSAN, 28 Fisher syndrome(FS) and 8 unclassified. Of the remaining 30 patients, 4 had “covert” sural-sparing. These were 1 AIDP, 2 AMAN/AMSAN and 1 FS. Conclusion: Serial studies reveal “covert” sural-sparing in those with initial normal or early NCS. Sural-sparing is a fundamental electrodiagnostic footprint of all GBS subtypes and, depending on the sensitivity of the methods used, is present in at least 2/3 of GBS patients.

PP42

A case of HMGCR antibody-associated myopathy with axial weakness and camptocormia

Dr Kalpana Prasad1

1National Neuroscience Institute, Singapore

Objective: To highlight an uncommon clinical feature of 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibody-associated myopathy. Method: We describe a case which emphasizes an unusual clinical presentation in HMGCR antibody-associated myopathy. Results: A 58-year-old man presented with a history of gradually progressive involuntary flexion of thoracic spine with stooped posture for 8 years and mild proximal weakness in limbs for 3 years. Clinical examination revealed moderately severe axial weakness with camptocormia, and mild proximal weakness in limbs. Serum creatine kinase was elevated, and ranged from 347 to 525 U/L. Serum aldolase was raised at 14 U/L. EMG was suggestive of an irritable myopathy. MRI thoracolumbar spine showed oedema with high T2 and STIR signal within the paraspinal/paravertebral muscles suggestive of paraspinal myositis. Muscle biopsy of right thigh and left deltoid was suggestive of inflammatory myopathy in view of fibre size variability, necrotic and regenerating fibres, and upregulation of MHC-1 stain. Myositis-associated and myositis-specific antibodies were negative. Anti-HMGCR antibody was positive. There was no history of statin exposure. He has been on treatment with intravenous immunoglobulin and steroid. Conclusions: Patients with HMGCR antibody-associated myopathy usually present with symmetric proximal weakness in limbs. Our case report highlights that chronic axial weakness with camptocormia can be the predominant clinical feature of HMGCR antibody-associated myopathy.

PP43

Pain and proximal weakness in three patients with marked decline in HbA1c- spectrum of Treatment-Induced Neuropathy of Diabetes Mellitus (TIND)

Ms Si Min Seah1, Dr Lynn Genevieve Tan-Yu2, Dr Yexian Jonathan Lai2, Dr Ngai Kun Loh2, Dr Thirugnanam Umapathi2

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2Department of Neurology, National Neuroscience Institute, Singapore

Objective We describe three patients who developed painful proximal weakness, contemporaneous to marked decline in blood sugars. Case report (Method/Results) Patient 1 presented with subacute, severe neuropathic pain over the proximal left leg that later spread to the right leg. Neuropathic pain worsened and became distal-predominant over several weeks. This was associated with hypoglycemic spells and orthostatic dizziness. He was recently diagnosed with diabetes mellitus, and had prolonged hospitalization with intensive glycemic control whereby HbA1c plunged from 12% to 6% over a few weeks. He also lost substantial weight. Clinical and electrodiagnostic evaluation confirmed lumbosacral plexoradiculopathy. Patient 2 presented with subacute painful left foot drop. Clinical, electrophysiologic and radiological findings were consistent with non-compressive left L5-S1 and right L4 radiculopathy. HbA1c declined from 13.1% to 10% over 4 weeks after 4 oral hypoglycemic agents were started. She also experienced significant weight loss. The third patient presented with severe pain and weakness over proximal aspects of both lower limbs. She had a HbA1c decline of 7% over 4 months and developed severe maculopathy, nephrotic syndrome with worsening renal function and orthostatic hypotension. Clinical, electrodiagnostic and histological evaluation revealed extensive infarction of lower limb muscles. All 3 patients required multiple neuropathic pain medications including opioids. Conclusion The first two patients had diabetic lumbosacral radiculoplexus neuropathy and the third diabetic muscle infarction. Common to all three cases are severe subacute pain, high initial HbA1c, abrupt HbA1c decline and weight loss. We speculate if the above diabetic complications are different entities in the spectrum of TIND.

PP44

Case reports on familial Amyloid Polyneuropathy

Dr Oo SoeThinzar1, Dr Myint Shwe Zarni1, Dr Aung Yan Lynn1, Dr Aung Ohnmar2, Dr Aye Yin Minn1, Dr Oo San2

1Yangon General Hospital, Yangon, Myanmar, 2University of Medicine (1) Yangon, Yangon, Myanmar

Method: 2 case reports Case summary/Result: A 45 year-old man of Shan ancestry, had symptoms of tingling sensation with allodynia in the lower limbs started at 35 years of age, which gradually had extended to the proximal lower extremity, upper extremities and trunk. He also had dysautonomia with postural dizziness, postprandial diarrhea alternating with constipation, impotence and decreased sweating. Examination revealed distal hair loss, distal muscles wasting and weakness with absent sensation symmetrically and positive Rhomberg test. His genetic test done 4 years ago in Bangkok showed mutation (Val30Met) in the TTR (transthyretin) gene. He has his older brother, presented similarly at 30 years of age who received investigations and treatment in Singapore with sural nerve biopsy showing amyloid deposits and genetic test revealing same mutation in the TTR (transthyretin) gene, who underwent cadaveric liver transplant and taking diflunisal. Their mother had similar symptoms of peripheral neuropathy and chronic kidney disease after 60 years of age and passed away without receiving proper medical care. Second case, a 39-year-old man, also from Shan State, presented with progressive limbs weakness and severe peripheral neuropathic pain progressive in 4 years associated with severe dysautonomia, amounting him to severe disabling bed-bound state. He had no family history. His nerve conduction study revealed severe axonal sensorimotor polyneuropathy. After excluding other common causes of peripheral neuropathy, left sural nerve biopsy done and turned out amyloid deposits. His myeloma panel was normal. Conclusion: We presented 2 cases of familial amyloid neuropathies, one with familial and one with sporadic.

PP45

Nerve biopsy: Is it still useful in diagnosis of peripheral neuropathies?

Dr Aung Thiha1, Dr Ya Min Kyaw2, Dr San San Hlaing1, Dr Than Than1, Dr Naw Mu Lah Eh Min1

1Department of Pathology, University of Medicine, Mandalay, Mandalay, Myanmar, 2Department of Neuromedicine, Mandalay General Hospital, Mandalay, Myanmar

Background: Indications for nerve biopsy have decreased during the last 20 years. However, there are still some major clinical indications including diagnosis of vasculitis, amyloid and multifocal leprosy. We have two case reports which were diagnosed by nerve biopsy. Case Reports: The first case was 38 year old male, with complaint of tingling, numbness, weakness and distal muscle wasting of four limbs for four years. Clinical and neurophysiology findings were suggestive of sensory and motor axonal polyneuropathy. Other investigations and skin scraping smear were normal. Nerve biopsy of sural nerve was done and examined under ordinary light microscopy. Focal and diffuse deposits of hyalinized eosinophilic material were seen. Under Congo red stain, pink to reddish, amyloid was seen and amyloid neuropathy was confirmed. The second case was 25 years old man with problem of weakness, tingling, numbness and wasting of small muscles of right hand for years. Examination and neurophysiology findings were suggestive of right ulnar neuropathy with nerve thickening at the elbow. No detectable cutaneous lesions were seen. Other investigations were normal. Skin scraping smear for Mycobacterium leprae was negative. Nerve biopsy of dorsal ulnar cutaneous nerve was done and acid fast bacilli were seen with modified Ziehl Neelsen stain and final diagnosis was Hansen’s disease. Conclusion: Nerve biopsies were done in limited cases of peripheral neuropathies. However it remains a ‘last resort’ for identification of unexpected or rare neuropathies, in difficult diagnostic cases. Keywords:Nerve biopsy, pheripheral neuropathy, amyloid neuropathy, Hansen’s disease

PP46

A Near Miss to be Treatable: Neural Lipid Storage Disease with Myopathy in a Myanmar Lady

Dr Zin Phyu Tun1, Dr Htwe Htwe Lin2, A/Prof Ohnmar Ohnmar1, A/Prof Myo Khaing2, Prof Moe Moe Zaw2, Prof Win Min Thit1

1University of Medicine 1/Yangon General Hospital, Yangon, Myanmar, 2University of Medicine Mandalay/Mandalay General Hospital, Mandalay, Myanmar

Method: A case report Case Summary/Result: A 32-year old lady presented with right arm weakness at age 27 which was gradually progressive and at age 28, left arm and both lower limbs became weak. She emphasized her weakness worsened about 15-30 minutes after walking. Muscle weakness and atrophy were asymmetrical and proximal dominant. Neck muscles were also involved. No ocular, bulbar, muscle pain or sensory symptoms. She had history of ICD implantation at age 27 because of arrhythmia. Parents were healthy and non-consanguineous. She had normal birth history and milestones. Her elder sister had similar muscle weakness and heart disease. Serum creatinine kinase was 851 U/L. Left rectus femoris muscle biopsy revealed myopathic changes with lipid droplets in almost all fibers predominantly in type 1 fibers indicating lipid storage myopathy. At that point, we were quite happy because our differential diagnoses were (1) primary carnitine deficiency which would show dramatic improvement with high-dose oral L-carnitine supplementation, (2) multiple acyl-coenzyme A dehydrogenase deficiency (MADD) which is riboflavin responsive and (3) neutral lipid storage disease with myopathy (NLSDM) which has no effective treatment up to now, which mean 2/3 would be treatable. So, we performed biochemical assay for fatty acid beta-oxidation pathway and genetic analysis which showed that carnitine palmytoyl transferase II and B oxidative enzymatic activities were normal and there was homozygous mutation in PNPLA2 gene in exon 4, c.478_479insCTCC (p.Q160Pfs) which confirmed neural lipid storage disease with myopathy. Conclusion: This is first case report of NLSDM due to PNPLA2 gene mutations in Myanmar.

PP47

Recurrent falls in an elderly man due to peripheral sensory ataxia

Dr Khin Hnin Su Wai1, Dr James Tung2, Dr Jasmine Koh1, Dr Genevieve Lynn Yu, Prof Thirugnanam Umapathi1

1Department of Neurology, National Neuroscience Institute, Singapore, 2Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore

Objective: Chronic immune sensory polyradiculopathy (CISP) is an uncommon and possibly under-recognized within the chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) spectrum. We report a case of CISP causing recurrent falls. Case report (Method/Results): A previously healthy elderly man presented with subacute, progressive hands and feet numbness associated with unsteady gait and falls for past 2 months. Examination showed diffuse hyporeflexia, mild proximal weakness with severe and disproportionate proprioceptive and vibration loss in both legs. Romberg’s test was positive and gait was very ataxic. Babinski’s sign was absent. There was no bladder or bowel impairment and no cranial nerve deficits. Pupils were normal size and reactive. Differential diagnoses included sensory neuronopathy and CIDP. Nerve conduction study (NCS) showed normal sensory responses with no conduction slowing and was not congruent with the initial suspicion of sensory neuronopathy or CIDP, raising the possibility of a lesion affecting the sensory roots proximal to the dorsal root ganglion. Magnetic resonance imaging (MRI) of spine and blood tests (Vitamin B12, copper, syphilis and HIV serologies) did not indicate dorsal column pathology. Spinal tap revealed cytoalbuminologic dissociation. Somatosensory evoked potential (SSEP) testing suggested proximal conduction defect. He was treated aggressively with steroids and repeated courses of intravenous immunoglobulins and gradually improved. He was able to walk unaided after few months. Conclusion: We highlight a treatable cause of sensory ataxia, where routine NCS is normal and further assessment with SSEP and spinal tap is of high yield in clinching the diagnosis. We also emphasize the importance of early recognition and treatment for better outcomes.

PP48

Myasthenia Gravis in association with extrathymic maligancies

Dr Khine Zar Win1, Dr Phyu Phyu Lay1

1Neurology Department, Yangon, Myanmar

Objective: MG is considered a paraneoplastic disorder and associated with thymoma. However, it can be associated with extrathymic malignancies. We would review the association of MG and extrathymic malignancies. Method: Case report Case summary: A 67 years old woman had presented with difficulty in swallowing, bilateral ptosis with fatigue since 2017. She had been treated with generalised MG. Her condition progressed despite regular taking treatment. Meanwhile, She had no symptoms of systemic malignancy including weight loss, decreased appetite, cough, or hemoptysis. She did not smoke. But, she suffered from intractable back pain at that time. After 2 years, numbness and weakness of lower limbs without spincter involvement occurred. Examination revealed bilateral ptosis, muscle weakness in both upper and lower limbs with hyperreflexia were noted. Weakness is more severe in lower limbs. We performed standard repetitive nerve stimulation (RNS) test which showed decremental response. Acetylecholine receptor antibodies was negative but ANA was strongly positive and also anticentromere and Anti-Ro 52 were positive. CT (thoracolumbar spine) showed osteoblastic metastastic at lower cervical, throughout thoracic and lumbar spine and sternum. NECT chest and neck revealed malignant lung lesion in left lower lobe but no evidence of thymoma was noticed. CT (head) showed osteoblastic metastasis throughout the skull bone without cerebral metastasis. Lung biopsy disclosed large cell anaplastic carcinoma in LLL bronchus. She received radiation therapy. Conclusion: We suggest that extrathymic malignancies may be associated with MG. It means MG can be a paraneoplastic Syndrome of non-small cell lung cancer. We should consider cancer screening in late- onset MG.

PP49

Pupil involving isolated third cranial nerve palsy due to prolactinoma

Dr Aye Kyaw Maung1, Dr Hnin Ei Phyu2

1University of Medicine, Mandalay, Myanmar, 2University of Medicine, Mandalay, Myanmar

Method: A case report. Purpose: This is a case presentation of pupil involving isolated third cranial nerve palsy in 30-year-old lady with prolactinoma (Macroadenoma). Recovery of third cranial nerve palsy following medication for prolactinoma has been documented in this case. Case presentation/Result: We present the case of a 30-year-old Myanmar lady who had suffered from partial pupil involving isolated third cranial nerve palsy on her right eye. She presented to us with sudden diplopia, unilateral ptosis and headache. Examination revealed anisocoria, right partial ptosis, extraocular muscle movement limitation in adduction, elevation and depression on right eye. Other cranial nerves examinations were intact. Neuroimaging showed macroadenoma of pituitary gland. Serum prolactin level raised up to 6933ng/ml. She was consulted with Neuro-Surgeon and Endocrinologist. Three weeks after treatment with cabergoline, third cranial nerve palsy had completely recovered back to normal. Conclusion: Prolactinoma rarely causes compressive third cranial nerve palsy. A review of literature revealed four cases of prolactinoma presenting with partial third cranial nerve palsy. Therefore, eye care providers and neurologists should be aware of possibility of third cranial nerve palsy in parasellar region tumors.

PP50

A case report on non-Hodgkin lymphoma presenting with unusual ocular manifestation

Dr Hnin Ei Phyu1

1Mandalay General Hospital, Mandalay City, Myanmar

Method: A case report Case summary/Result: A 47-year old man presented with painful right eye associated with right hemicranial headache and reduced vision in right eye. He had past medical history of autoimmune hemolytic anemia. Examination revealed congestion and proptosis of the right eye. There were also complete ophthalmoplegia, reduced visual acuity with absent light reflex on right eye. Peripheral blood film showed hemolytic picture. MRI of the brain showed multiple ring enhancing lesions with right orbital infection. We treated him as cerebral toxoplasmosis and tuberculoma but patient was not responded to our treatment. Rechecked MRI of the brain revealed similar ring enhancing lesions and right choroidal detachment with inflammatory mass at superolateral part of the right globe. Patient was referred to the eye surgeon and evisceration of right eye was done on the background of non-seeing eye with intractable eye pain. Biopsy of excited tissue showed suppurative inflammation with giant cell reaction. But similar symptoms occurred on the remaining left eye. This time, blood film showed pancytopenia and bone marrow trephine biopsy showed leukemic lymphoid cells (? Acute lymphoblastic leukemia or leukemic infiltration of non-Hodgkin lymphoma). Patient was transferred out to Department of Hematology and was started on chemotherapy for non-Hodgkin lymphoma. After completion of 8th cycle of chemotherapy, patient had no more eye pain and could do his daily activities without support. Conclusion: We present a case of non-Hodgkin lymphoma with unusual ocular manifestation.

PP51

Strokes and Transient Ischemic Attacks in Young Adults in Brunei Darussalam: Demographics, Risk Factors, Etiology and Thrombolysis

Dr Jessie Colacion1, Dr Han Lin Naing1, Dr Naomi Harun1, Dr Norazieda Yassin1, Prof Mathew Alexander1, Dr Siti Nur'Ashikin Tengah1

1Brunei Neuroscience, Stroke and Rehabilitation Centre, Pantai Jerudong Specialist Centre, Bandar Seri Begawan, Brunei Darussalam

Objectives: Strokes in young adults are reported as uncommon, comprising 10-15% of all stroke patients. However, it has a disproportionately larger economic impact compared to strokes in older adults. We aim to investigate the demographics, risk factors, etiologies and thrombolysis rate of strokes and transient ischemic attacks among young adults admitted to the Brunei Neuroscience, Stroke and Rehabilitation Centre (BNSRC) from December 2018 to May 2019. Materials and Methods: We restrospectively reviewed the medical files of patients admitted for stroke and TIA in BNSRC. A total of 39 (17%) of the 233 inpatients, aged ≤ 45 years old with completed strokes and TIA where included. Ischemic stroke etiologies were classified according to the Trial of Org 10172 in Acute Stroke Treatment. Results: The mean (SD) age was 39.2 + 5.3 years; 74% were males. There were 34 (15.2%) patients with completed strokes, of which 64.7% were ischemic strokes. There were high incidence rates of hypertension (61.5%), diabetes mellitus (33.3%), dyslipidemia (25.6%), cardiac pathologies (15.4%), and methamphetamine abuse (15.4%). Majority (53.8%) of the patients have ≥ 2 risk factors. Of the patients with ischemic strokes, small vessel disease was the most common etiology (40.9%), followed by cardioembolic (22.7%) then large artery atherosclerosis (18.2%). The median National Institutes of Health Stroke Scale on admission was 9 (interquartile range, 4-12). Intravenous thrombolysis was given on 2 (10%) patients, both were discharged within 7 days and none developed symptomatic intracerebral hemorrhage. Conclusion: This study shows the most recent representative profile of cerebrovascular events in young adults admitted to a stroke and rehabilitation centre in Brunei Darussalam. Demographics, incidence and thrombolysis rates are comparable with international data. Although, there is an alarmingly high incidence of hypertension among other traditional/nontraditional vascular risk factors, as well as presence of multiple comorbidities in the identified patient population.

PP52

Characteristics in non-vitamin K antagonist oral anticoagulant (NOAC-) related intracerebral hemorrhage

Dr Stefan T. Gerner1, Prof Dr Hagen B. Huttner1, Prof Dr Stefan Schwab1, RETRACE II study group2

1Dpt. of Neurology, University Hospital Erlangen, Erlangen, Germany, 2ClinicalTrials.gov Identifier: NCT03093233, Germany

Objectives: Given inconclusive studies it is debated whether clinical and imaging characteristics, as well as functional outcome, differ among patients with intracerebral hemorrhage(ICH)-related to vitamin K antagonists(VKA) versus non-vitamin K antagonist(NOAC)-related ICH. Notably, clinical characteristics according to different NOAC-agents and -dosages are not established. Materials and methods: Multicenter observational cohort study integrating individual patient data of 1,328 patients with oral anticoagulation(OAC)-associated ICH – including 19 0NOAC-related ICH-patients, recruited from 2011-2015 at 19 tertiary centers across Germany. Imaging, clinical characteristics and 3-months modified Rankin scale (mRS) outcomes were compared in NOAC- vs. VKA-related ICH patients. Propensity score matching was conducted to adjust for clinically relevant differences in baseline parameters. Subgroup-analyses were performed regarding NOAC-agent,-dosing and present clinically relevant anticoagulatory activity (last intake <12h/24h or NOAC-Level >30ng/ml). Results: Despite older age in NOAC-patients, there were no relevant differences in clinical and hematoma characteristics between NOAC- and VKA-related ICH regarding baseline hematoma volume (median[IQR]: NOAC 14.7[5.1-42.3]ml vs. VKA 16.4[5.8-40.6]ml; p=0.33), rate of hematoma expansion(HE)(NOAC 49/146[33.6%] vs. VKA 235/688[34.2%]; p=0.89), and the proportion of patients with unfavorable outcome at 3 months (mRS=4-6: NOAC 126/179[70.4%] vs. VKA 473/682[69.4%]; p=0.79). Subgroup-analyses revealed that NOAC-patients with clinically relevant anticoagulatory effect had higher rates of intraventricular hemorrhage (No.[%]: present 52/109[47.7%] vs. absent 9/35[25.7%]; p=0.022) and HE (present 35/90[38.9%] vs. absent 5/30[16.7%]; p=0.040), whereas type of NOAC-agent or different NOAC-dosing regimens did not result in relevant differences in imaging characteristics or outcome. Conclusion: If effectively anticoagulated, there are no differences in hematoma characteristics and functional outcome among patients with NOAC- or VKA-related ICH. (Also accepted in Stroke 2019)

PP53

Age-dependent clinical outcomes in primary versus oral anticoagulation-related intracerebral hemorrhage

Prof Dr Hagen B. Huttner1, Dr Maximilian I. Sprügel1, Dr Stefan T. Gerner1, Prof Dr Stefan Schwab1, RETRACE I + II study group 1Dpt. of Neurology, University Hospital Erlangen, Erlangen, Germany, 2RETRACE I, NCT01829581; RETRACE II, NCT03093233, Germany

Objective: This study determined the influence of age on bleeding characteristics and clinical outcomes in primary spontaneous (non-OAC), vitamin K antagonist-related (VKA-) and non-vitamin K antagonist oral anticoagulant-related (NOAC-) intracerebral hemorrhage (ICH). Materials and methods: Pooled individual patient data of multicenter cohort studies were analyzed by logistic regression modelling and propensity-score (PS)-matching to explore the influence of advanced age on clinical outcomes among non-OAC-, VKA- and NOAC-ICH. Primary outcome measure was functional outcome at 3 months assessed by the modified Rankin Scale, dichotomized into favorable (mRS=0-3) and unfavorable (mRS=4-6) functional outcome. Secondary outcome measures included mortality, hematoma characteristics, and frequency of invasive interventions. Results: In non-OAC-ICH 25.7% (276/1,076), in VKA-ICH 32.8% (760/2,314) and in NOAC-ICH 45.3% (86/190) of the patients were of older age (p<0.001). After adjustment for treatment interventions, elderly ICH patients comprised worse functional outcome at three months (OR in non-OAC-ICH:3.86 [2.75-5.40]; p<0.001; VKA-ICH:1.56[1.28-1.90]; p<0.001; NOAC-ICH: 2.72 [1.37-5.42]; p=0.004). Anticoagulation was significantly associated with worse functional outcome below the age of 70 years, (OR:2.00[1.35-2.96]; p=0.001), but not in patients of ≥70 years (OR:1.20 [0.90-1.59]; p=0.218). The difference in volume of ICH enlargement between OAC-ICH and non-OAC-ICH gradually decreased with increasing patient age. Conclusion: As compared to elderly ICH-patients, in patients <70 years OAC-ICH showed worse clinical outcomes compared to non-OAC-ICH because of larger baseline ICH-volumes and extent of hematoma enlargement. Treatment strategies aiming at neutralizing altered coagulation should be aware of these findings. (Also accepted in Stroke 2019)

PP54

10 Thrombolysis Deliveries by the Tele-stroke International Network to Commemorate Her Majesty Queen Sirikit’s 84th Birthday

Dr Saysavath Keosodsay1, Prof Aurauma Chutinet2, Dr Pongpat Vorasayan2, Dr Jitlada Samajarn2, Dr Wasan Akarathanawat2, Dr Naruchorn Kijpaisalratana2, Dr Naly Norsakpeseuth1, Dr Snong Thongsna1, Ms Pakkawan Vongvasinkul2, Prof Nijasri C. Suwanwela2

1Mittaphab Hospital, Vientiane, Lao People's Democratic Republic, 2Chulalongkorn Stroke Center of Excellence, Bangkok, Thailand

Objective: To study the feasibility of thrombolytic therapy administration under tele-stroke consultation system and outcome in 10 acute ischemic stroke patients at Mittaphab Hospital, Laos PDR. Methods: Acute ischemic stroke patients who presented at Mittaphab Hospital within 4.5 hours after onset without contraindication of thrombolytic therapy between December 2016 and July 2017 were studied. Immediate teleconsultation, with 24-hour availability, between neurologist at Mittaphab hospital and the Chulalongkorn stroke team was performed in all cases and the decision of thrombolysis was made. Results: There were 10 patients in the study. The mean duration from onset to the hospital was 123(30-225) minutes. The mean door to needle time was 108(55-185) minutes. The mean National Institute of Health stroke scale (NIHSS) before thrombolysis was 11(3-20). For stroke risk factors: atrial fibrillation, hypertension, and smoking, each was found in 50% of the cases. Dyslipidemia was found in 30%. Two patients had the previous stroke and one patient had diabetes. The mean NIHSS at discharge was 5(0-11). The mean modified Rankin scale s was 2.56(0-5) and 6 patients were dependent at discharge, The mean Barthel index was 70(35-100). At discharge, 60% of patients were markedly improved. One patient developed massive cerebral infarction due to large vessel occlusion and was sent home in a terminal condition. Hemorrhagic infarction was found in one patient but none developed symptomatic intracerebral hemorrhage or major bleedings. Conclusion: Tele-stroke consultation from Thailand can facilitate thrombolytic therapy for acute ischemic stroke patients at Mittaphab Hospital. This is the first case series of acute ischemic stroke in Lao’s PDR who received thrombolytic treatment.

PP55

Screening Stroke in Emergengy Room by Los Angeles Prehospital Stroke Screen (LAPSS) in Two Central Hospital in Laos

Dr Southanalinh Keovilayhong1, Dr Ketmany Phetsiriseng1, A/Prof Mayfong Maysay2

1Mittaphab hospital, Lao People's Democratic Republic, 2University of Health Sciences, Lao People's Democratic Republic

Background and purpose: In Laos, there are no screening test for patients suspected stroke. The Los Angeles Stroke Screen (LAPSS) has been proved superior to the FAST in identifying stroke in Caucasian countries. We applied LAPSS in emergency department to improve stroke awareness and reduce duration of door to needle time in the peripheral area. Objective: To identify sensitivity, specificity of LAPSS based on imaging study and final diagnostic confirm by Neurologist Methods: Medical staffs in Emergency department were trained by Neurology resident to rapidly screen patients with suspected stroke based on LAPSS. For patients met the base LAPSS was determined by “Target stroke criteria”. LAPSS form stroke identification results were compared with emergency department and final discharges diagnoses. Sensitivity and specificity analysis were calculated for LAPSS identification of stroke. Results: From April to October 2016, a total of 214 patients had completely filled LAPSS data sheet, 64,48% were clinically diagnosed with stroke by LAPSS. The sensitivity and specificity of LAPSS in this study was 93.93% and 96.77% respectively. The sensitivity was slightly different between two groups: 91.42% for non-MD and 92.03% for MD, but the specificity was very high: 100% for MD and 96.96% for non-MD. After adjusting for age factor by excluding patients of >45 years old, the sensitivity was decreased to 91.89% with specificity unchanged. 74.77% of examiner finished form at 5 minutes. Conclusion: The LAPSS can be consider as good material to detect stroke patients in the peripheral area and refer to the Stroke Unit.

PP56

The Role of High Dose Citicoline in Acute Ischemic Stroke

Prof Phyu Phyu Lay1, Dr Aye Myat Nyein2

1University of Medicine 2, Yangon, Myanmar, 2University of Medicine 2, Yangon, Myanmar

Background & Objective: Although intravenous rtPA is only approved for the management of acute ischemic stroke, because of it's some limitations for usage, the neuroprotective agents that can be used in acute ischemic stroke patients are needed. Currently Citicoline is a neuroprotective agent with good safety profile and promising alternative to improve stroke recovery. The objective of this study was to identify the role of high dose Citicoline (2G/12 hour) in acute Ischemic Stroke in Myanmar people. Methods: Cross-sectional descriptive study was carried out in all patients presented within 24 hours of onset of symptoms of Ischemic Stroke diagnosed by CT (Head) at Pinlon Private Hospital in Yangon from 1st January to 28th February, 2019. Intravenous Citicoline 1G /12 hour for 5 days followed by oral Citicoline 1G/12 hour for 6 weeks were given. The efficacy endpoint was the percentage of patients with motor sensory function recovery after treatment at 6 weeks and 5 days. Results: It included 50 patients with acute Ischemic Stroke. The most frequent age group was 61 - 80 years (68%) with the mean age of 68.2 years. Female (62%) was more common than male (38%). 96% of patients had Clinical improvement. Among them, 30% had complete motor sensory function recovery after treatment. Conclusions: Citicoline shows beneficial effects in acute Ischemic Stroke in terms of improvement of motor sensory function recovery after treatment.

PP57

Correlation Between White Blood Cell Count on Admission and Clinical Severity in Acute Ischemic Stroke: A Retrospective Cross-Sectional Study

Dr Navuddh Oam1, Dr Sem Suos1, Dr Veasna Teav1, Dr Chhoeun Proum1, Prof Dr Navuth Chum1

1Khmer Soviet Friendship Hospital, Phnom Penh, Cambodia

Objective: The extent of initial leukocytosis during a stroke can predict greater initial stroke severity and discharge disability. This study aimed to analyze the correlation between white blood cells (WBC) on admission and clinical severity based on National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) for discharge disability. Materials and Methods: This retrospective cross-sectional study using consecutive sampling involved with acute ischemic stroke within 48 hours of onset. Data were collected using medical charts and analyzed the correlation between WBC and clinical severity based on NIHSS0 at admission, NIHSS72 after 72 hours, and mRS at discharge using Fisher’s exact test. The Spearman rank correlation was used for the correlation between WBC and clinical outcome. Statistical significance was defined if p<0.05. Results: of 101 patients were included in our study, 68.8% were male; the median age 65 years (IQR 55-75); the median NIHSS0 score was 8 (IQR 5.5-11), the median NIHSS72 score was 7 (IQR 5-10), and the median mRS score was 3 (IQR 3-4). The median WBC at admission was 9100/mm3 (IQR 7000-10750mm3). Elevated WBC levels predicted a worst clinical features and a poor functional outcome (NIHSS0 p=0.001, NIHSS72 p<0.0001, mRS p<0.0001). The correlation between WBC and outcome remained significant after multivariate analysis (NIHSS0 p=0.03; NIHSS72 p=0.009; mRS p=0.002). Conclusion: An elevated WBC in acute ischemic stroke is a significant independent predictor of poor clinical severity, outcome, and disability at discharge, yet WBC count doesn’t have any predictive value on hospital mortality in patients with ischemic stroke.

PP58

Risk factors, and vascular infarct predicted in Acute Ischemic Stroke using Oxford Stroke classification Project at two central hospitals

Dr Oua Phimmasarn1

1University of Health Sciences, Vientiane, Lao People's Democratic Republic

Introduction: The Oxford Stroke Classification Project (OSCP) is classification system divided to four subgroups (LACI, TACI, PACI, POCI). It is a simple method that predicts the site and size of the infarct in acute ischemic stroke patients. We describe the data of four clinically identifiable subgroups of acute ischemic stroke patients in 2 central hospitals in Laos PDR . Methods: This study is a cross sectional study to focus on risk factors and using OSCP classification in acute stroke patients who admitted in to Neurology wards which Glasgow coma scale >10 from March to June 2018 at two central hospitals. Used epidata program to analyze the data, describe data in frequency, percentages. Result: In all 105 patients with first acute Ischemic Stroke and recurrent Ischemic Stroke: 17 (16.19%) had total anterior circulation infarct (TACI) ; 45 (42.86%) had more restricted and predominantly cortical stroke ( Partial anterior circulation infarct, PACI); 13(12.38%) had infarct associated with the vertebrobasilar arterial ( posterior circulation infarct, POCI); and 30(28.57%) had infarct of the deep perforating arteries ( Lacunar infarcts, LACI). There was higher frequency of hypertension in patients with PACI (39.76%); Diabetes with PACI 42.86%; Dyslipidemia 43.33% and more slightly in male 42.86% then followed by LACI. In AF patients were more likely in PACI 52.86% followed by TACI 31.53%; those in the TACI more slightly younger group of age. Conclusions: The finding have important implications for the planning of stroke treatment trials and suggested that various therapies could be directed specially at the subgroups.

PP59

Complication of Stroke during Hospitalization in Central Hospitals in Vientiane Capital, Laos

Dr Appasone Phoumindr1

1University of Health Sciences, Vientiane Capital, Lao People's Democratic Republic

Objective: Stroke is the third leading cause of death in the LAOS according to WHO report in 2012. Many studies have shown the higher rate of mortality and morbidity associate to stroke complication and the length of stay in the Hospital. This study describes the most frequency complication of stroke as well as its social demography in 4 Centrals Hospitals in Vientiane Capital aiming to set up the basic data for future management in the country as it is the first-time-in-history to study about this topic. Materials and Methods: It was a Cross Sectional Descriptive Study of stroke patients hospitalized in 4 centrals Hospital: Mahosot, Setthathiraj, Mittaphab and 103 Hospital from 1 October 2016 to 31 October 2017. All patients were diagnosed stroke and admitted at the ward where they were observed every day until being discharged Results: 400 stroke patients were admitted, 251 were male (62.7%) and mean age was 61.5+14.9 years old. Ischemic stroke was higher than hemorrhage with 269 cases (70.29%). The most frequent risk factors were Hypertension, Hyper-cholesterol and High-LDL with 309, 279 and 202 cases respectively. Among 400 patients, 134 founded complication with 44% in Hemorrhage Stroke and 31% in Ischemic Stroke. The most frequent complication was High Intra-cranial pressure 50 cases, 70% founded in the first day of admit. It was founded in Hemorrhage stroke more than Ischemic with statistic relation ( p-value = 0.007). The mean length of stay in the hospital was 5 days. Conclusion: Ischemic stroke was higher than Hemorrhage. The most common risk factor was Hypertension. The most frequent complication was High intra cranial pressure and found mostly in Hemorrhage stroke.

PP60

Diagnostic performance of FAAS stroke screening tool in patients who presented to the emergency room with neurological symptoms in Thailand

Dr Warongporn Phuenpathom1, Dr Aurauma Chutinet2, Dr Prakitchai Tantipong3, Dr Surachet Eiamthanasinchai4, Dr Nijasri C. Suwanwela5

1Chulalongkorn University, Bangkok, Thailand, 2Chulalongkorn University, Bangkok, Thailand, 3Nopparatrajathanee Hospital, Bangkok, Thailand, 4Surin Hospital, Surin, Thailand, 5Chulalongkorn University, Bangkok, Thailand

Background: Rapid screening and intervention are the keys to successful early treatment of stroke. In Thailand, the conventional FAST stroke screening tool has generally been used by triage nurses to promptly detect acute stroke. However, the FAST score has limitation in detection of the posterior circulation stroke. Previous studies showed that adding ataxia could increase the sensitivity of posterior circulation stroke detection. Therefore, we studied the performance of new stroke screening tool, FAAS score, among acute ischemic stroke patients. Objectives: To evaluate and compare the diagnostic performance between FAAS and the conventional FAST score. Study design: Multicenter cross-sectional study. Materials and methods: The new FAAS and conventional FAST score were used by triage nurses in patients who presented with acute neurological symptoms within 7 days at the emergency department of King Chulalongkorn Memorial Hospital, Nopparatrajathanee Hospital and Surin Hospital. Final diagnosis was made by neurologist using clinical and neuroimaging information. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and the ROC curve were calculated using STATA version 14. Results: Total 146 patients were enrolled. 127 patients (86 %) had acute ischemic stroke and 19 patients (14%) had other diagnoses. We found that the sensitivity of FAAS stroke screening tool was higher than the conventional FAST (96.85% vs 95.28%, p = 0.125). The new FAAS stroke screening tool could detect the posterior circulation ischemic stroke better than the conventional FAST score (94.12% vs 82.35%, p=0.063). Conclusions: The new FAAS stroke screening tool is sensitive to use for detection of acute stroke especially posterior circulation stroke.

PP61

Spinal Cord Infarction as Complication of Percutaneous Coronary Intervention

Dr Dewie Susan1, Dr Wilasari Novantina1, Dr Selly Marisdina1, Dr Andika Okparasta1, Dr Adrian Masno1, Dr RM Faisal1

1Sriwijaya University/Dr. Moehammad Husein Hospital, Palembang, South Sumatera, Indonesia

Objective: Spinal cord infarction due to coronary invasive intervention is rarely seen. But when stroke occurs, it may result in significant patient morbidity, prolonged hospitalizations, and high medical costs. In this case report we wish to highlight the mortality and morbidity of this entity. Material and Method: Case report Results : A 63-year-old man, diagnosed with coronary artery disease and congestive heart failure due to ischaemic dilated cardiomyopathy, presented with sudden weakness of all extremities, paresthesia, lumbar pain and urinary retention during Percutaneous Coronary Intervention procedure. Magnetic resonance imaging showed hyperintensity from C3 to Th2 consistent with spinal cord infarction differentiate diagnose with myelitis transversal. Result of Liquid Cerebrospinal showed no elevation of cell and protein and the culture was sterile. Double antiplatelet therapy and a physiotherapy program were started. After 2 weeks, clinical manifestations had improved. Follow up head MRI showed hyperintensity from C3 to C6, with owl eye sign T2 axial slice, but no vertebral body infarct. Conclusion: Spinal cord infarction secondary to coronary intervention is rare, but when it presents the mortality and morbidity are high.

PP62

Intracerebral hemorrhage in Brunei: 1- year demographic data at Brunei Neuroscience, Stroke and Rehabilitation Centre (BNSRC)

Dr Chee Shin Yong1, Mr Dawn Anthony1, Dr Norazieda Yassin1

1Brunei Neurosciences Stroke and Rehabilitation Centre (BNSRC), Brunei Darussalam

Objectives: Stroke is the commonest cause for adult disability in the world and is the fourth commonest cause of death in Brunei. There are 2-main Neurology centers in Brunei, one of which is the BNSRC. We aim to describe the demographics of patients admitted with intracerebral haemorrhage (ICH) to BNSRC. Materials and Methods: We conducted a retrospective analysis of all patients admitted to the center from 1/1/2018 to 31/12/2018 with intracerebral hemorrhage. Data was collected from a review of all patients’ case files. Results: There were 59 patients, of which 52.5% were male. The mean age was 53.8 years with a median age of 54 years. The hemorrhages were non-lobar in 79.7% (74.5% in the basal ganglia, 14.9% in the thalamus and 10.6% in the pontine/medullary region) and lobar in 20.3%. The etiology of ICH was attributed to Hypertension in 94.9%. Other etiologies included cortical venous thrombosis and cavernoma. In the patients with hypertension, 30.3% were newly diagnosed and of the remaining patients with known hypertension, 38.5% were found to have defaulted their anti-hypertensive medications. At discharge, modified Rankin score of 0-2 was 11.9%, 3-5 was 76.2% and 6 was 11.9%. Conclusion: Patients with intracerebral hemorrhage carry a high morbidity and mortality in Brunei. Hypertension is a highly modifiable risk factor and efforts are being made to improve diagnosis and management in the country e.g. implementation of a nation-wide screening.