Basic and advanced imaging of a case of Balò's concentric sclerosis.

To cite: Ripellino P, Stecco A, Leone MA, et al. BMJ Case Reports Published online: [please include Day Month Year] doi:10.1136/ bcr-2012-008413 DESCRIPTION In January 2012 a 51-year-old woman was admitted to our department for a slow increasing right hemiparesis with right brisk deep tendon reflexes. She suffered from Sjogren syndrome, fibromyalgia and hepatitis B virus (healthy carrier). Conventional MRI scans (figure 1A,B) were typical for Balò’s sclerosis. The patient rejected a brain biopsy. In order to better define the lesion, we therefore performed advanced radiological techniques such as diffusion, spectroscopy and perfusion. In the diffusion sequences (figure 2A) a concentric ring of unrestricted diffusion appeared clearly distinguishable. The spectroscopic image (figure 2B) of the lesion documented increased choline peak and decreased N-acetyl aspartate peak, but normal peaks in the normal appearing white matter near the lesion. The perfusion analysis (figure 2C), based on four different regions of interest (figure 2D), suggested a decreasing gradient of perfusion from the centre to the periphery of the lesion, supporting the hypothesis that the centre of the ring corresponds anatomically to a deep venous vessel. Authors are not aware of previous report of perfusion studies in Balò’s sclerosis. Cerebrospinal fluid analysis detected oligoclonal bands, without anti-aquaporin-4 antibodies. Figure 1 At diagnosis. (A) Axial fluid attenuated inversion recovery sequence and (B) sagittal T2-sequence evidence the typical concentric ring lesion in the white matter.