Interventional Neurology In Indonesia

Interventional neurology is a subspecialty of neurology that uses catheter technology, radiological imaging, and clinical expertise to diagnose and treat diseases of the central nervous system (Qureshi AI, 2004).  The term Interventional neurology is described first time by Dr. Kori in  his article on  the Neurology journal. According to this article, interventional neurology is a subspecialty that performs interventional procedure including computed tomographic and magnetic resonance imaging guided for nerve blocks, biopsies, aspirations, and destructive procedures; intra-arterial procedures including carotid angioplasty, carotid thrombolysis, embolizations, chemotherapy, and blood–brain barrier modification; interventional neurosonology; eletromyographic guided procedure including Botulinum toxin injections, trigger point injections; and  nerve finder guided procedures to be included in this subspecialty (Kori SH, 1993).

However, the term interventional neurology in the last two decades is more focused and limited to the procedures that are recognized as part of the training requirements of the “Endovascular Surgical Neuroradiology” fellowship according to Accreditation Council for Graduate Medical Education (ACGME). According to ACGME, endovascular surgical neuroradiology is a subspecialty that uses minimally invasive catheter-based technology, radiologic imaging, and clinical expertise to diagnose and treat diseases of the central nervous system, head, neck, and spine (www.agme.com).

Historically,  interventional neurology has a long journey before arriving at this point.  Actually, neurologists have already had a long history of involvement in the cerebral angiography. However, the roots of neurologist involvement in therapeutic endovascular procedures have not been previously documented.  The cerebral angiography was done first time by Egas Moniz from Portugal. He is a Professor of Medicine and subsequent Chair of  Neurology at University of Lisbon in Portugal. Dr. Egas Moniz performed cerebral angiography since 1927 through direct carotid puncture and publish his paper  at the First International Neurology congress in Bern in 1931. The role of neurologists in diagnostic imaging was further enhanced by Karl Theodore Dussik who was a neurologist at Allgemeine Poliklinik (General Polyclinic) and University of Vienna Medical School. He was the first to propose the use of ultrasound as a diagnostic device in a paper he wrote in 1941 (Qureshi AI, 2011).

In the next two decades afterward, there is an ongoing transition in the approach ; from the direct carotid puncture to femoral approach. The changing patterns also resulted in a great change where neurologists are excluded from performing these procedures. By the early 1970s, cerebral angiography through direct carotid puncture by neurologists was an obsolete practice.

In United State of America, the first procedure done by Dr. Gomez, an interventional neurologist, is in 1993 at the cardiac cathlab. However, on June 2000, the ACGME had officially approved the Guidelines for Training in endovascular surgical neuroradiology. Subsequently, the program requirements for neurology were approved by the ACGME in May 2003 (Qureshi AI, 2011).

Interestingly, Dr. Shakir Husain, who joined the fellowship in Interventional Neuroradiology at the Institute of Neuroradiology, University Hospital  Zurich, Switzerland, has completed his fellowship in 1999. His fellowship is under the supervision of Prof. Valavanis. This shows us that Dr. Shakir, a neurologist, has completed the interventional neuroradiology program one year before the ACGME in the USA had officially approved neurology to enter the field (www.acgme.org). Since then, he has designed a fellowship program in Stroke & Interventional Neurology and started it in the year 2004 at Sir Ganga Ram Hospital, New Delhi. He has now joined Max Super Specialty Hospital, Saket, New Delhi and has taken the Fellowship program with him (www.delhicorse.com).

In Indonesia, interventional neurology evolved after dr. Fritz Sumantri Usman completed his fellowship in  2008 from Sir Ganga Ram Hospital New Delhi, India. The Director of the program is  Dr. Shakir Husain. After dr Fritz begun his journey in neurointerventional procedures, many Indonesian neurologists are interested in that area. In almost every year, there are several Indonesian neurologists join that fellowship program. Currently, there are twenty one Indonesian interventional neurologist have completed the program. They are spread in several cities in Indonesia, mostly in Java. There are three of them in Surabaya (Tabel 1).

        Table 1. The spread of Interventional Neurologist in Indonesia (May, 2014)

City	Province	Number of Interventional Neurologist
Jakarta	DKI Jakarta	4
Tangerang	Banten	2
Bogor	West java	1
Bandung	West Java	1
Solo	Central java	1
Surabaya	East Java	3
Makasar	South Sulawesi	1
Bukit Tinggi	West Sumatra	1
Medan	North Sumatra	2
Lokshumawe	Aceh	1
Denpasar	Bali	1
Pekan Baru	Riau	1
Semarang	Middle Java	1
Jayapura	Papua	1
Total		21

Just like in other countries, there are some political issues in Indonesia regarding the development of neurointervention, the relatively new subspecialty of neurology, in Indonesia. The Issue is centered at the intriguing question whether neurologist have the competence to perform neurointerventional procedure. Fortunately, in 2006, the Indonesian collegiums of neurology stated clearly that neurologist  have the competence to perform in this field. Meanwhile, the first neurologist start studying this subspecialty started his program in 2007, exactly after the collegiums approved.

Recent development of neurointervention in Indonesia shows that there are a considerable number of neurointerventional procedures performed by neurologist. In fact, the neurointerventional procedures performed by neurologist is proved to be safe and show a very low complication (Usman FS et.al, 2012). Almost all the interventional procedures have been performed  including carotid and vertebral artery stenting, coiling aneurysm, tumor embolization, embolization of the dural and carotid fistula and brain arteriovenous malformation. This is undeniably a promising development in the area of neurointervention in Indonesia.

To sum up, the title of Dr. Kori’s article : "Interventional Neurology, a subspecialty whose time has come" very fits  to illustrate the situation in Indonesia.  Furthermore, it is also very relevant to quote Edgell RC et. al., to describe the potential of neurointervention in the future Indonesia, as they said that “currently, Interventional neurology is  subspecialty that is here to stay and thrive. “ (Kori SH, 1993; Edgell RC et.al., 2012).