Dialysis Disequilibrium Syndrome (DDS) is a set of neurological signs and symptoms that can occur during or following dialysis. Osmotic fluid gradient alteration caused by the dialysis process can cause cerebral edema. This process relates to the changes of high gradient urea in both the blood and central nervous system (CNS), which can modulate extracellular fluid influx into brain cells. A 77-year-old woman presented with chronic kidney disease (CKD) and hypertension with headache and tonic-clonic seizure following initial hemodialysis. In this case, we identified that adjustment to the hemodialysis prescriptions such as duration, blood flow rate, and target reduction of blood urea would be the key to avoid seizure following hemodialysis.

Latar Belakang: Tetanus disebabkan toksin diproduksi bakteri C.tetani yang mengancam nyawa dan menjadi masalah kesehatan dunia. Kurangnya pengetahuan mengenai resiko infeksi tetanus menyebabkan masyarakat meremehkan luka yang berpotensi tetanus. Kasus: Wanita, 89 tahun datang ke unit gawat darurat dengan keluhan trismus, kekakuan seluruh tubuh terutama bagian leher, disfagia, dan nyeri pada perut dan punggung punggung, riwayat demam, dan telapak kaki kanan tertusuk kayu 5 hari SMRS tanpa injeksi anti-tetanus. Riwayat kejang dan vaksinasi tetanus disangkal. Pasien kompos mentis, gelisah dengan nyeri berat. Trismus 1cm, risus sardonikus, meningismus, uji spatula positif, opistotonos, disertai perut seperti papan. Luka 2x1cm disertai nanah pada plantar pedis dextra. Pasien diberikan anti-tetanus serum, ampicillin sulbactam, metronidazole, dan terapi simptomatik lainnya. Pada hari ke-2 perawatan, terdapat kejang umum tonik dan terdapat perburukan dan pasien dinyatakan meninggal. Diskusi: Manifestasi klinis pada tetanus disebabkan oleh tetanolisin dan tetanospasmin yang berikatan dengan sinaptobrevin/vesicle-associated membrane protein (VAMP), menyebar retrograde ke lower motor neuron kemudian berikatan dengan inhibitor-GABA. Port d entry pada kasus, luka tertusuk kayu dengan tetanus derajat III. Skor Dakar dan Phillips pasien 5 dan 20 (severitas sangat berat, mortalitas >50%). Kesimpulan: Prognosis penyakit tetanus bervariasi tergantung usia, masa inkubasi, klinis, dan komplikasi, sehingga diperlukan diagnosis dan tatalaksana sedini. Kata Kunci: tetanus, C.tetani, toksin, GABA, spasme otot

Background: Corona virus disease 2019 (COVID-19) is a pandemic disease with a wide spectrum of symptoms.  Neurological symptoms are often found in this disease. Stroke on the other hand is a multifactorial disease that can be caused by a lot of underlying problems. Case: We report a case of a 67 years old man with a weakness on the right side that was worsened one day before arrival in hospital and a shortness of breath. the patient had history of stroke before, and controlled hypertension. Head Ct-scan showed a stroke infarct, and Swab RT-PCR showed + SARS-CoV-2. Discussion: Infection may become the risk factor of stroke. inflammatory mediators such as TNF-a , and CRP  support the procoagulant state which leads to stroke. Conclusion: COVID-19 may increase the risk of stroke due to the inflammation state that leads to procoagulant state

Vestibular symptoms are symptoms that interfere with daily activities. Diagnosing these symptoms often relies on radiologic examinations that lead to a false negative. Proper clinical approach and study showed higher accuracy than radiologic examination on vestibular disease. These clinical approaches are based on time, triggers, and targeted analysis. The new vestibular symptoms will be classified into acute vestibular syndrome, episodic vestibular syndrome, and chronic vestibular syndrome. An acute vestibular syndrome is a vestibular symptom that lasts for days up to weeks. The episodic vestibular syndrome is vestibular symptoms that periodically appear. The chronic vestibular syndrome is a vestibular symptom that appears from months to years. Diagnosing vestibular symptoms must be precisely made. The proper termination is the best way to facilitate doctors in communicating with each other. Using this classification is a precise and easy way to detect vestibular etiology.  This review is made for clinicians to determine and differentiate the etiology of the vestibular syndrome and gives information in uniforming nomenclature of vestibular symptoms.

DIFFERENCE IN OUTCOME OF ACUTE ISCHEMIC STROKE PATIENT WITH NORMAL LEUKOCYTE AND LEUKOCYTOSISABSTRACTIntroduction: Inflammation is an independent risk factor for ischemic stroke, which needs to be inhibited to reduce worsening occlusion of arteries due to atherosclerotic plaques. Increased leukocyte count is considered an acute damage marker of brain tissue that experiences ischemia and is used to determine the severity and prognosis of acute ischemic stroke.Aims: To analyse association between the number of leukocytes in acute onset ischemic stroke patients during admission and discharge.Methods: A prospective analytical observational study with a cohort design on acute ischemic stroke patients in Wangaya Regional Hospital, Denpasar-Bali between January and September 2018. Clinical manifestations were assessed using National Institutes of Health Stroke Scale (NIHSS). Data was collected through medical records and analysed using Chi-square test and Mann-Whitney.Results: Seventy-six subjects devided into 2 groups;  normal  leucocytes and  leucocytosis group,  38 patients respectively. The normal leucocytes group was dominated with male subject (78.9%) and mean leucocytes count was 7,612/mm3. While leucocytosis group was dominated with female subjects (63.2%) and mean leucocytes count was 12,294/ mm3. Mean NIHSS at admission in normal leucocytes group and leucocytosis group was 5 (moderate) and 8 (moderate) respectively. Mean NIHSS at discharge in normal leucocytes group and leucocytosis group was 3 (low) and 11 (moderate) respectively.Discussion: Patients with acute onset ischemic stroke with normal leukocyte count during admission, tend to have better clinical outcome two times fold compared to the patients with leucocytosis.Keywords: Leukocytes, leucocytosis, acute ischemic stroke, NIHSSABSTRAKPendahuluan: Inflamasi merupakan faktor risiko independen terjadinya stroke iskemik, yang perlu dihambat untuk mengurangi perburukan oklusi pada pembuluh darah akibat plak aterosklerotik. Peningkatan kadar leukosit dianggap menunjukkan kerusakan akut jaringan otak yang mengalami iskemia dan digunakan untuk mengetahui tingkat keparahan dan prognosis stroke iskemik akut.Tujuan Mengetahui hubungan antara kadar leukosit terhadap manifestasi klinis pasien stroke iskemik onset akut pada saat masuk dan keluar perawatan.Metode: Penelitian observasional analitik prospektif dengan rancangan kohort terhadap pasien stroke iskemik onset akut yang dirawat di RSUD Wangaya, Denpasar, pada bulan Januari hingga September 2018. Manifestasi klinis subjek dinilai berdasarkan derajat beratnya stroke menggunakan National Institutes of Health Stroke Scale (NIHSS). Data dikumpulkan melalui rekam medis dan di analisis dengan uji Chi-square dan Mann-Whitney.Hasil: Didapatkan 76 subjek yang dibagi menjadi 2 kelompok, yaitu masing-masing 38 subjek pada kelompok dengan leukosit normal dan kelompok dengan leukositosis. Kelompok subjek leukosit normal, didominasi oleh subjek laki- laki (78,9%) dan rerata kadar leukosit 7.612/mm3, sedangkan pada kelompok leukositosis mayoritas perempuan (63,2%) dan rerata kadar leukosit 12.294/mm3. Rerata skor NIHSS saat masuk pada kelompok leukosit normal adalah 5 (moderat) dan  pada kelompok dengan leukositosis adalah 8 (moderat). Adapun rerata skor NIHSS pada kelompok leukosit normal saat pasien keluar adalah 3 (ringan) dan 11 (moderat) pada kelompok leukositosis.Diskusi: Subjek stroke iskemik akut dengan kadar leukosit awal yang normal cenderung memiliki perbaikan manifestasi klinis pada saat keluar RS dua kali lebih baik daripada subjek dengan leukositosis.Kata kunci: Leukosit, leukositosis, stroke iskemik akut, skor NIHSS