IMPORTANT: We currently have a number of bugs related to image cropping and are actively trying to resolve them. In the meantime, we have disabled cropping. Apologies for any inconvenience. Stay informed: radiopaedia.org/chat

Balo concentric sclerosis

Case contributed by Dayu Gai
Diagnosis almost certain

Presentation

Worsening left hemiparesis for several days.

Patient Data

Age: 12 years
Gender: Female
mri

There are multiple lesions in the supra and infratentorial brain. The dominant lesion is in the right centrum semiovale, with concentric rings of heterogeneous T1 hypointensity and T2/FLAIR hyperintensity.  This lesion demonstrates patchy enhancement, with vivid abormal diffusion restriction (ADC value: ~250).  There are multiple other smaller lesions, the larger ones which demonstrate a similar pattern - left centrum semi ovale, left cerebral crus, left hemipons.  No susceptibility artifact.  Normal visualized intracranial MRA.  Incidental fluid filled sphenoid.

Case Discussion

The concentric onion ring pattern of these lesions is characteristic of Balo concentric sclerosis.  This is a variant of demyelination with the alternating intralesional intensities representing myelinated and demyelinated axons 1. The regions of true diffusion restriction reflect active demyelination.  Over time, the onion ring plaques coalesce to form more homogeneous T2 hyperintense plaques. 

Although typically described in young adults, pediatric cases are not uncommon 2.

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.