Baló's concentric sclerosis - A rare entity within the spectrum of demyelinating diseases

Baló's concentric sclerosis (BCS) is a rare, inflammatory demyelinating disease of the central nervous system (CNS). Historically, BCS was thought to be uniformly fatal and diagnosis was based on postmortem findings. With advances in modern neuroimaging, BCS is currently defined by the presence of concentric layered patterns composed of alternating rings of varying intensity. They are best appreciated on gadolinium-enhanced T1-weighted sequences and predominantly occur in the supratentorial cerebral white matter with sparing of cortical U-fibers. The lamellar pattern of the lesions likely reflects bands of demyelination and relative myelin preservation with minimal axonal loss. While BCS falls within the spectrum of atypical demyelinating diseases, there is ongoing debate over whether BCS is a phenotypical variant of multiple sclerosis (MS) or a separate entity. Corticosteroids comprise first-line therapy but there is ongoing controversy regarding appropriate maintenance therapy. First-line MS disease-modifying therapies such as interferon beta-1a are appropriate for patients who fulfill diagnostic criteria for relapsing-remitting MS. Fingolimod should likely be avoided as Baló-like lesions have been reported during its administration or after withdrawal. Monoclonal antibodies such as natalizumab and rituximab are potentially effective at reducing BCS relapses, but alemtuzumab may be relatively ineffective because humoral immunity does not play a central role in BCS pathogenesis.

When tumefactive demyelination is truly a tumor: case report of a radiographic misdiagnosis

Oligodendrogliomas are slow-growing tumors that account for 15–20% of gliomas. This case report describes the case of an adult male patient diagnosed initially with tumefactive demyelination and multiple sclerosis, which was subsequently found to be a well-differentiated low-grade oligodendroglioma. This case emphasizes the importance of timely diagnosis in oligodendrogliomas and other brain tumors for the prompt initiation of appropriate therapy, to minimize the likelihood of disease progression, ensure symptom management and escalation of unnecessary treatments for multiple sclerosis.

A challenging case of concurrent multiple sclerosis and anaplastic astrocytoma

Background:

Cases of gliomas coexisting with multiple sclerosis (MS) have been described over the past few decades. However, due to the complex clinical and radiological traits inherent to both entities, this concurrent phenomenon remains difficult to diagnose. Much has been debated about whether this coexistence is incidental or mirrors a poorly understood neoplastic phenomenon engaging glial cells in the regions of demyelination.

Case Description:

We present the case of a 41-year-old patient diagnosed with a left-sided frontal contrast enhancing lesion initially assessed as a tumefactive MS. Despite systemic treatment, the patient gradually developed signs of mass effect, which led to decompressive surgery. The initial microscopic evaluation demonstrated the presence of MS and oligodendroglioma; the postoperative evolution proved complex due to a series of MS-relapses and tumor recurrence. An ulterior revaluation of the samples for the purpose of this report showed an MS-concurrent anaplastic astrocytoma. We describe all relevant clinical aspects of this case and review the medical literature for possible causal mechanisms.

Conclusion:

Although cases of concurrent glioma and MS remain rare, we present a case illustrating this phenomenon and explore a number of theories behind a potential causal relationship.

A case of oligodendroglioma and multiple sclerosis: Occam's razor or Hickam's dictum?

Tumefactive appearing lesions on brain imaging can cause a diagnostic dilemma. We report a middle-aged man who presented with right-sided optic neuritis. A brain MRI showed enhancement of the right optic nerve, and non-enhancing white matter lesions including a 3 cm right frontal lesion with adjacent gyral expansion. Cerebrospinal fluid analysis showed five oligoclonal bands not present in serum. Glatiramer acetate was started for suspected tumefactive multiple sclerosis (MS). A follow-up brain MRI 6 months later showed persistence of the frontal gyral expansion. A brain biopsy led to the diagnosis of an oligodendroglioma, isocitrate dehydrogenase-mutant and 1 p/19q co-deleted (WHO grade II), managed with surgical resection and radiotherapy. Postoperative brain MRI showed a new enhancing periventricular lesion, making the choice of optimal disease-modifying therapy for MS challenging. This case highlights the possibility of coexistence of MS and oligodendroglioma, and emphasises the importance of a tissue diagnosis when atypical MS imaging features are present.

Baló's concentric sclerosis

Baló's concentric sclerosis is often regarded as a rare variant of multiple sclerosis. Patients with this disorder present with acute or subacute neurological deterioration, with MRI showing one or more concentrically multilayered ring-like lesions usually in the cerebral white matter. Historically, Baló's concentric sclerosis was thought fatal in all cases. However, the availability of MRI has led to a better appreciation of the variable natural history of patients presenting with radiologically evident Baló lesions and the clinical association with multiple sclerosis and, less often, with other neurological disorders. Important advances have increased understanding of the immunopathogenic mechanisms associated with the formation of Baló lesions. However, how to treat an acute lesion and when or whether to start treatment are less well understood, although for patients with Baló lesions who also fulfil standard diagnostic criteria for multiple sclerosis, our opinion is that treatment with multiple sclerosis disease-modifying therapy would seem reasonable.

First use of alemtuzumab in Balo's concentric sclerosis: a case report

Balo's concentric sclerosis (BCS) is a rare demyelinating disorder of the central nervous system. The humanised monoclonal antibody alemtuzumab has shown efficacy in another demyelinating disorder, relapsing-remitting multiple sclerosis. We aimed to explore its efficacy in treatment-refractory BCS. A 52-year-old male with radiologically confirmed progressive BCS resistant to steroids, plasmapharesis and cyclophosphamide was administered a standard protocol of alemtuzumab. Treatment failed to slow his decline; he died 6 months after administration. Why alemtuzumab induced no clinical or radiological impact may be multifactorial. We review the evidence directing BCS therapy and propose the next steps for exploring this potentially fatal condition.

Magnetic Resonance Imaging in Balo's Concentric Sclerosis

Concentric high signal intensity zones on T2-weighted magnetic resonance images of brain strongly suggest Balo's concentric sclerosis (BCS), a rare but recognized variant of multiple sclerosis. Differentiating BCS from multiple sclerosis or neoplasm can be difficult clinically. The pathognomonic MRI appearance can dramatically influence the course of the disease, allowing earlier diagnosis and therapy of the disease which was once considered to have an invariably fulminant and fatal course.

Cerebral ependymoma in a patient with multiple sclerosis case report and critical review of the literature

BACKGROUND

The concurrence of multiple sclerosis (MS) and brain tumors is a rare but well-recognized condition. The radiologic evidence of the progressive evolution of a mega-plaque in a tumor has never been described. We report the first case of such an occurrence.

METHODS

A 27-year-old woman with a diagnosis of MS was referred to us for an intense frontal headache. Magnetic resonance imaging showed a mass lesion in correspondence of a black hole lesion previously diagnosed. The patient was operated on, with complete removal of the tumor documented by an intraoperative MRI. The histologic examination evidenced an ependymoma. Postoperative radiotherapy was performed.

RESULTS

The patient is well and recurrence-free at 2 years follow-up.

CONCLUSIONS

The present case, documenting the transformation of a mega-plaque into a tumor, suggests a cause-effect relationship between MS and brain tumors.

From the archives of the AFIP: Oligodendroglioma and its variants: radiologic-pathologic correlation

Oligodendroglioma is the third most common glial neoplasm and most commonly arises in the frontal lobe. It occurs in males more frequently, and the peak manifestation is during the 5th and 6th decades. Children are affected much less commonly. The clinical presentation is often of several years duration with most patients presenting with seizures, reflecting the strong predilection of this tumor to involve the cortical gray matter. Current histopathologic classification schemes recognize two main types of tumors: well-differentiated oligodendroglioma and its anaplastic variant. Less commonly, neoplastic mixtures of both oligodendroglial and astrocytic components occur and are termed oligoastrocytomas, with both well-differentiated and anaplastic forms. Surgical resection is the mainstay of initial treatment, and many patients experience a long progression-free period. Recent genotyping has revealed chromosomal loss of 1p and 19q as a genetic signature in most oligodendrogliomas, and these tumors respond favorably to chemotherapy. Hence, radiation therapy is now generally reserved for partially resected tumors and cases that failed to benefit from chemotherapy. At cross-sectional imaging, the tumor characteristically involves the cortical gray matter and frequently contains calcification. Robust enhancement is not a common feature and suggests transformation to a higher histologic grade. Advanced magnetic resonance imaging techniques and metabolic imaging play increasingly important roles in both pre- and postoperative assessment of these complex neoplasms.

Oligodendroglioma and multiple sclerosis. A case report

BACKGROUND

The concurrence of multiple sclerosis (MS) and glioma is uncommon. Approximately 30 cases have been reported, but in only six of them the tumour was pure or mixed oligodendroglioma. The appearance of new neurological symptoms and signs in a patient with multiple sclerosis is usually attributed to a relapse of this disease and neuroradiological studies are not always performed. When done, the finding of a new focal mass lesion is usually interpreted as a pseudotumoural plaque.

CASE REPORT

A 37-year-old man was admitted because of partial simple seizures and an enlarging intracranial mass. He had been diagnosed of MS eleven years earlier. A MRI study performed eight years before admission showed a large mass in the right frontal lobe which was thought to be a pseudotumoural plaque. Two years later, he developed simple partial motor seizures that were initially controlled with valproic acid. He remained well until three months before admission, when seizures reappeared with a poor response to valproic acid. A new MRI study showed an heterogeneous right frontal enlarging mass lesion. A primary neoplasm was suspected and a subtotal removal was performed. The pathological diagnosis was oligodendroglioma with a periferic demyelinating area.

CONCLUSION

Atypical MRI lesions in a patient with MS must be carefully interpreted. Pseudotumoural plaques have been described both clinically and radiologically to be hardly distinguishable from a tumoural lesion and histological confirmation is often required. The association between MS and glioma is uncommon but it must be kept in mind when a mass lesion develops in a patient with MS.

[Multiple sclerosis, spinal cord ependymoma and intracranial meningioma: case report]

We report the association a multiple sclerosis (MS), spinal cord tumour and intracranial tumor in a 63 years-old female patient with a 10 years history of relapsing/remitting MS. Symptoms usually remitted in response to costicosteroid therapy. In 1997 the patient presented with paraparesis and paresis of right arm which did not respond to corticotherapy. A spinal RMI revealed in the cervical spinal an intra spinal cord tumour, further diagnosed as ependymoma, and a parietal region meningioma. We call attention to this rare association of central nervous system tumour and MS, enphasizing the need for investigation of new and uncommon symptoms during the evolution of MS.

Oligodendrocyte and axon pathology in clinically silent multiple sclerosis lesions

Oligodendrocyte and axon pathology was studied in 11 autopsy cases of clinically silent multiple sclerosis. A total of 54 lesions, either demyelinated or late remyelinated, were distributed through the whole brain and spinal cord with 39% of the lesions located in periventricular areas. Determination of axon density revealed an average reduction of 64% and 59% in demyelinated and remyelinated lesions with an extreme variation between different plaques and cases. Oligodendrocytes were identified by immunocytochemistry for myelin oligodendrocyte glycoprotein (MOG) and in situ hybridization for proteolipid protein (PLP) mRNA. Oligodendrocytes were almost completely lost in demyelinated lesions; remyelinated lesions revealed preservation of a considerable number of oligodendrocytes within the lesions. At the border between plaques and the periplaque white matter, similar oligodendrocyte numbers as in remyelinated lesions were found. Different factors including lesion site, axonal preservation and remyelination may thus contribute to the clinical nonappearance of multiple sclerosis lesions.

Balo's concentric sclerosis diagnosed intravitam on brain biopsy

A 28-year-old woman presented with acute right hemiparesis evolving to bilateral hemiplegia and a mute state within 1 week on a background of paranoid psychosis of 8 years duration. CT scan revealed multiple bilateral hypodense enhancing lesions in the central white matter. Biopsy of the lesion showed lamellar alternating zones of demyelination and remyelination, typical of Balo's concentric sclerosis, an acute variant of multiple sclerosis. Immunohistochemical staining for neurofilament showed greater damage to the axis cylinders by the disease than generally perceived by silver stains. Steroid therapy produced a gratifying and sustained improvement. Follow up CT scans and psychometry revealed regression of the demyelinating lesions and improvement of the cognitive state.