Presentation
Sent from an outside hospital with reported "brain mass". History of intellectual disability and seizures.
Patient Data
Hyperintense lesion on T2WI centered in the left frontal pericallosal/periventricular white matter. Several concentric rings of preserved myelin, best seen on sagittal T1 3-D and axial T2WI. Relative to the size of the lesion, there is no mass effect on the surrounding sulci or ventricular system. No corresponding enhancement.
Hyperintense lesion on T2WI in the right ventral pons with subtle internal hyperintensity on T1WI - may represent a second smaller lesion of demyelination.
Small right choroidal fissure cyst and small developmental venous anomaly of the right parietal lobe.
MR spectroscopy of the left frontal lesion shows no significant elevation in choline relative to NAA to suggest high-grade neoplasm. There is slight reduction in NAA relative to creatine which is nonspecific.
Case Discussion
This case represents the typical appearance of Baló concentric sclerosis. The characteristic alternating bands of demyelination and preserved myelin, with little to no mass effect, despite the lesion size, suggest the diagnosis in this case.
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