State-of-the-Art Review: Demyelinating Diseases in Indonesia

Abstract

Demyelinating diseases are more common in Indonesia than previously believed. However, it is still a challenge for a country such as Indonesia to implement the scientific medical advances, especially in the diagnostic process of demyelinating diseases, to achieve the best possible outcome for these groups of patients, within the constraints of what is socially, technologically, economically, and logistically achievable. In this review, we address the 4 major classes of demyelinating disease: multiple sclerosis (MS), neuromyelitis optica (NMO), anti-MOG-associated encephalomyelitis (MOG-EM), and acute disseminated encephalomyelitis (ADEM), and discuss their prevalence, demographics, clinical diagnosis workup, and imaging features in the Indonesian population, as well as the challenges we face in their diagnosis and therapeutic approach. We hope that this overview will lead to a better awareness of the spectrum of demyelinating diseases of the central nervous system in Indonesia.

Figure 1

MRI of two different MS patients in our center: (a, b) a 30-year-old female with SPMS, disease duration of 10 years, showing periventricular (arrowhead) and juxtacortical (arrow) lesions on axial FLAIR images and (c) 27-year-old female with RRMS, disease duration of 3 years, showing infratentorial lesions on axial T2WI.

Figure 2

Sagittal FLAIR images from different MS patients in our center: (a) a 28-year-old female with RRMS, disease duration of 13 years; (b) a 29-year-old female with RRMS, disease duration of 1 year; (c) a 38-year-old female with RRMS, disease duration of 12 years, showing periventricular lesions with the characteristic “Dawson finger” appearance, indicating extension along the medullary veins.

Figure 3

Cervical spinal cord MRI of an MS patient in our center, a 29-year-old female with RRMS: (a) sagittal unenhanced T1WI, (b) contrast-enhanced T1WI, and (c) T2WI TIRM revealing a short-segment, mildly contrast-enhancing spinal cord lesion at the level of C5-6 (arrows). Corresponding axial images showing the same lesion (arrowheads) on (d) unenhanced T1WI, (e) contrast-enhanced T1WI and (f) T2WI TIRM.

Figure 4

Cervical spinal cord MRI of an NMO patient in our center, a 32-year-old female, with left-sided hemiparesis for two weeks, showing (a) T2WI-hyperintense longitudinally extensive myelitis, spanning across more than 3 vertebral segments; (b) hypointense on unenhanced T1WI; and (c) with peripheral enhancement on contrast-enhanced T1WI (arrowheads). Corresponding axial (d) T2WI, (e) unenhanced T1WI, and (f) contrast-enhanced T1WI, showing the involvement of more than 50% of the cord surface area (arrows).

Figure 5

Axial FLAIR images from a 28-year-old female with NMO, disease duration of 2 years, with bilateral visual impairment and general weakness, showing high signal white matter lesions in typical periependymal regions (arrowhead).

Figure 6

Axial brain MRI of a 1-year-old ADEM patient, who presented with stiffness of bilateral upper and lower extremities, with history of recent upper respiratory tract infection, showing large, bilateral, diffuse lesions, predominantly affecting the deep white matter, the corpus callosum, and bilateral cerebellar peduncles. The lesions are hypointense on unenhanced T1WI (a), hyperintense on T2WI (b), and partially suppressed on FLAIR (c–e).

Figure 7

Axial FLAIR brain MRI of an 18-year-old male with ADEM, who presented with tetraparesis, predominantly on the left side. There were multiple hyperintense lesions on the left cerebellar peduncle, left cerebellum, and bilateral cerebral white matter.

Figure 8

Distribution map of MRI facilities in Indonesia, showing the total number of MRI unit in each province [43].