Balo concentric sclerosis …

Neuroimmunology

Updated 10.29.2025
Released 06.28.1996
Expires For CME 10.29.2028

Balo concentric sclerosis

Authors: Jikku Zachariah DO, Thomas Scott MD

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Editor: Anthony T Reder MD

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Balo concentric sclerosis

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Introduction

Overview

Balo concentric sclerosis is often thought of as a distinct demyelinating syndrome and an atypical variant of multiple sclerosis. The author argues that no absolute evidence differentiates Balo concentric sclerosis from other acute, aggressive forms of multiple sclerosis. However, there are many indications that a district pathology may become clear in the future. This article discusses how the spectrum of Balo concentric sclerosis has evolved with the discovery of nonfatal cases using MRI. Additionally, it describes the spectrum of symptoms and provides an overview of the current concepts behind the formation of its rings. The author speculates that much can be inferred about the mechanism of tissue destruction in multiple sclerosis from pathological observations in Balo concentric sclerosis. This update includes the most recent descriptions of MRI findings, comparing Balo concentric sclerosis to prototypic multiple sclerosis.

Key points

	• The hallmark of Balo concentric sclerosis is alternating bands of demyelinated and relatively preserved myelin that create a distinctive target-like “concentric ring” or “onion bulb” pattern on MRI and pathology.
	• The concentric ring pattern of Balo concentric sclerosis may be explained by activated microglia and macrophages migrating centrifugally and concentrating in rings. These cells release nitric oxide and oxygen radicals leading to failure of energy production and cell death.
	• Balo concentric sclerosis shares features with other forms of acute demyelination, including multiple sclerosis, neuromyelitis optica spectrum disorders, and myelin oligodendrocyte glycoprotein–associated demyelinating disease.
	• There is growing consensus that Balo concentric sclerosis represents a distinct hyperacute multiple sclerosis variant with pattern III immunopathology (oligodendrocytopathy).
	• The clinical spectrum of Balo concentric sclerosis ranges from monophasic self-limiting disease to relapsing-remitting patterns.
	Many cases with a Balo concentric sclerosis pattern noted by magnetic resonance imaging do not progress to multiple sclerosis and have a limited course. Modern case series show a much more favorable prognosis than historically reported.
	• IV methylprednisolone is recommended as the first-line treatment for an acute attack. Emerging data on B-cell depleting therapies (rituximab, ocrelizumab) show remarkable clinical and radiological long-term remission.

Historical note and terminology

Balo concentric sclerosis is a CNS disease characterized by pathological and MRI features consisting of alternating concentric rings of demyelinated and relatively myelinated tissue. The evidence that the MRI pattern is tantamount to Balo concentric sclerosis by pathological criteria is based on biopsied cases. The unusual and puzzling pattern has led to a distinctive place in multiple sclerosis nosology following its description by Balό (05). When Balό gave this rare pattern the name “leukoencephalitis periaxialis concentrica,” it became inevitable that future neurologists would link his name to the entity. Nonetheless, the first description of this pathological pattern should be attributed to Marburg who wrote about it 21 years earlier as part of the spectrum of changes found in acute multiple sclerosis (48).

Currently, whether Balo concentric sclerosis is a distinct entity is somewhat controversial. A few reviewers have lumped Balo leukoencephalitis periaxialis, Schilder encephalitis periaxialis diffusa, and Marburg encephalitis periaxialis scleroticans under the single term “concentric sclerosis” (16). The distinction between Balo concentric sclerosis, tumefactive multiple sclerosis, and prototypic multiple sclerosis has been described as overlapping syndromes (24). Because about half of the published cases occur in the setting of typical multiple sclerosis (31), Balo concentric sclerosis has frequently been thought to be a variant of multiple sclerosis. A large case series followed 10 patients with Balo concentric sclerosis from a multiple sclerosis clinic monitoring 2600 patients with multiple sclerosis between 2013 and 2024 (17). All patients had a positive type-2 pattern of oligoclonal bands (unique IgG bands in the CSF that are not present in serum), and the most common symptoms were limb weakness and paresthesia. This study supports the classification of Balo concentric sclerosis as a variant of multiple sclerosis due to overlapping characteristics. Because a significant number of patients with Balo concentric sclerosis lesions have severe and disabling attacks, this view suggests that Balo concentric sclerosis occurs when unfavorable pathological factors are found in a small portion of patients, many of whom progress to multiple sclerosis. Importantly, not all patients with a Balo-like presentation subsequently develop multiple sclerosis.

Clinical manifestations

Presentation and course

The pathology of Balo concentric sclerosis was initially described as a subacute progressive fatal demyelinating disease that spared the spinal cord and gray matter (04). Even today, if left untreated, many patients with Balo concentric sclerosis have aggressive disease that can lead to death within the first year. Patients with Balo concentric sclerosis often present with progressive encephalopathy, fever, behavioral changes, cognitive deficits, headache, seizures, increased intracranial pressure, and focal neurologic deficits that most commonly are localized to the supratentorial compartment. A stroke-like onset has been reported (55). The course of Balo concentric sclerosis may be monophasic, relapsing, or progressive. A picture reminiscent of Devic syndrome has been observed in association Balo concentric sclerosis pathological changes in the spinal cord (29; 01; 38) and rarely optic nerves (26; 54). Balo concentric sclerosis lesions also have been described in the brainstem (21).

In general, the following are the three most common clinical presentations:

(1) Tumor-like: mass effect, edema, rapidly progressive focal deficits

(2) Stroke-like: acute onset mimicking cerebrovascular event

(3) MS-like: relapsing-remitting course with typical multiple sclerosis symptoms

After the introduction of MRI, Balo concentric sclerosis was additionally diagnosed in patients with a benign course. The first diagnosis of Balo concentric sclerosis by MRI occurred in 1986 (19), and since then, over 100 cases have been reported. Rarely, MRI changes in Balo concentric sclerosis can be seen with little clinical symptomatology. For this summary, the author reviewed 65 cases reported by MRI between 1993 and 2009 (23; 66; 73; 20; 42; 13; 14; 12; 74; 67; 36; 56; 69; 57; 47; 09; 11; 30; 53; 31; 22; 63; 02; 76; 33; 43; 55; 10). Asians were overrepresented in these reports. Genders were represented nearly equally (55% women), and the average age of disease onset was 34 years, ranging from 4 to 59 years. The clinical courses were variable, and the impact of treatment was not clear. During the acute stage of disease, some patients received corticosteroids, immunosuppressants, plasmapheresis, or intravenous immunoglobulin. Chronic treatments included disease-modifying therapies conventionally used in multiple sclerosis, azathioprine, and mitoxantrone. Some patients were either not treated or treatment was not reported. In addition to case studies, a series of Balo concentric sclerosis patients were examined for the presence or absence of many key findings described in prototypic multiple sclerosis using 7T MRI, with the investigators concluding that considerable overlap exists (06).

Prognosis and complications

Prior to the institution of MRI, Balo concentric sclerosis was largely diagnosed by a clinical signature of a subacute, monophasic illness that led to death. Subsequently, the course has been shown to be much more benign. Of reported cases reviewed by the author, approximately 14% died, were severely disabled, or were progressing and severely affected at the time of report. About 19% of patients developed a course compatible with relapsing-remitting multiple sclerosis; about 3% could have been diagnosed with Devic disease; 26% were followed for longer than 2 years and had displayed no future clinical activity (possible monophasic course); and 38% were stable but had been followed for less than 2 years (most for 1 year or less). This sample is likely too small to draw strong conclusions but fits within the spectrum of clinical outcomes reported for tumefactive multiple sclerosis (34; 44).

In a relatively large series of Balo concentric sclerosis, a benign long-term course was observed despite the presence of additional MRI changes that were consistent with multiple sclerosis (10). In this series of seven Chinese patients, five had both Balo concentric sclerosis and classical multiple sclerosis lesions by MRI, but only three patients relapsed during a follow-up period of 4 to 13.5 years. Some observations suggest a milder course of Balo in rare pediatric cases, perhaps due to maturational differences in the immune system or brain (41). A 7T MRI study revealed that intralesional veins (central vein sign) tend to be found, along with other characteristics shared with prototypical multiple sclerosis. However, distinctly found among the Balo group were the absence of cortical and U fiber lesions and the presence of microhemorrhages in some lesions.

Clinical vignette

Case 1. A 42-year-old European-American woman developed gradual weakness and incoordination of her left arm and leg in November 2003. A brain MRI scan led to a stereotaxic brain biopsy that was read as consistent with Balo concentric sclerosis.

Balo concentric sclerosis (1)

Enhanced T2-weighted (left) and T1-weighted (right) scans of 42-year-old woman who developed gradual weakness and incoordination of her left arm and leg. A brain MRI scan lead to a stereotaxic brain biopsy that was read as consist...

The patient was treated with intravenous immunoglobulin but did not improve. After a brief consultation at the Multiple Sclerosis Center, she was managed with interferon-beta-1a subcutaneously three times a week and oral azathioprine. In January 2006, she again was seen at the Multiple Sclerosis Center. She had been clinically stable except for one episode compatible with benign paroxysmal positional vertigo in 2005. A follow-up MRI scan performed in September 2006 revealed that her Balo concentric sclerosis lesion had transformed into a large non-enhancing area of T2-signal abnormality without rings.

Balo concentric sclerosis (2)

Enhanced T2-weighted (left) and T1-weighted (right) follow-up scan of 42-year-old woman diagnosed with Balo concentric sclerosis 3 years earlier. This follow-up scan revealed that her Balo concentric sclerosis lesion had transform...

No new lesions were identified. This author believes that this case is consistent with the phenotype that is currently very common.

Case 2. A 3-year and 11-month-old African-American girl awoke crying in March 2003. She then developed a flaccid paralysis of the left arm and leg over several hours. While being evaluated in the emergency department, she had a focal seizure involving the left arm. A T2-weighted MRI scan showed a large, right occipital lesion that involved the splenium and enhanced strongly in its periphery. A biopsy of the lesion revealed demyelination. A lumbar puncture showed no abnormality of cells, a normal IgG index, and no oligoclonal bands. The patient was well until July 2003 when she developed right facial twitching. The following day the patient’s right face was weak, and her speech was slurred. She was admitted to the hospital where an MRI scan showed a new large left parietal lesion consistent with Balo concentric sclerosis.

Balo concentric sclerosis (3)

This 4-year-old patient had a history of flaccid paralysis of the left arm and leg and focal seizure of the left arm. Prior MRI showed a large right occipital lesion that involved the splenium and enhanced strongly in its peripher...

Thereafter, she had multiple severe exacerbations followed by a progressive course that resulted in quadriparesis and dementia. In October 2005, studies sent to Jefferson Medical College in Philadelphia, Pennsylvania were compatible with a diagnosis of metachromatic leukodystrophy. Leukocyte DNA analysis showed no copies of the common pseudodeficiency allele or late infantile mutation, and she was felt to be heterozygous for the common adult mutation. Subsequently, the patient was lost to follow-up. The author believes case 2 represents an unusual coincidence of idiopathic inflammatory demyelinating disease in the setting of abnormal myelin that leads to MRI changes of Balo concentric sclerosis and an aggressive form of disease (32; 60).

Biological basis

Etiology and pathogenesis

Whether there are etiologic differences between Balo concentric sclerosis and other idiopathic inflammatory demyelinating diseases is unknown. In the author’s opinion, Balo concentric sclerosis is best thought of as a descriptive pathological and radiological term. The author speculates that Balo concentric sclerosis is an uncommon subgroup of tumefactive multiple sclerosis, or in many cases a monophasic demyelinating disorder similar to acute disseminated encephalomyelitis. (See also MedLink Neurology clinical summary, Tumefactive multiple sclerosis.) Whether there is a unique immunological basis for the Balo concentric sclerosis pattern has been poorly investigated.

Macroscopically, Balo concentric sclerosis lesions are composed of areas of myelin preservation alternating with zones of myelin destruction (77). In areas of myelin loss, oligodendrocytes are depleted, and axons are transected. In the central core of the lesion, myelin is generally preserved. Usually, the outer border of the demyelinated region is sharp, but its inner margin is not well defined (43). Findings on 7T MRI scanning suggest that proximity to blood vessels may play a role in supporting the concept of early vascular pathology causing “ischemic preconditioning” as a necessary step in ring formation (07; 24). In favor of a multiphasic evolution of pathology, an early ischemic phase in lesion development was suggested by magnetic resonance spectroscopy (MRS) in a single case study (59). There was a transiently elevated lactate peak (typically seen in ischemic stress), and this was followed 6 weeks later by an elevated lipid peak, corresponding to proposed demyelination.

Pathological studies have confirmed that Balo concentric sclerosis demonstrates acute plaque pathology consistent with the multiple sclerosis type III immunopathological pattern characterized by cerebral white matter distal oligodendrocyte loss within demyelinated areas (28). This case series demonstrates that radiological Balo features correlate strongly with underlying pattern III immunopathology in which oligodendrocytes are primary targets (39). Although classification of multiple sclerosis into four distinct, persistent, pathological patterns is controversial, type III pathology has been felt to result from damage to oligodendrocytes by oxidative stress. Upregulation of inducible nitric oxide synthase in macrophages and microglia occurs within demyelinated bands, and upregulation of protective proteins such as hypoxia inducible factor (HIF-1 alpha) and heat shock protein 70 (HSP-70) are found in oligodendroglia and other glial cells at the edge of actively demyelinating lesions and within the preserved regions of myelin (71). These findings have been used to explain the pattern of concentric bands. In areas of preserved myelin, astrocytic proliferation has been described (43). A Portuguese study also highlighted the features of hypoxic damage in demyelinated lamellae, whereas preserved lamellae showed upregulated molecules protecting against hypoxic-ischemic injury (18).

Studies combining immunohistochemistry, electron microscopy, and quantitative microscopy in multiple sclerosis have suggested that microglia and macrophages damage myelin and axons by releasing nitric oxide and oxygen radicals, which functionally inhibit the main catalytic subunit of complex IV, cytochrome c oxidase-1 (COX-1), in mitochondria. This has been hypothesized to lead to loss of mitochondrial energy production, which could easily compromise cellular hemostasis, resulting in tissue loss (46). In Balo concentric sclerosis, as well as in multiple sclerosis, defects of mitochondrial respiratory chain complex IV are present in demyelinated lesions involving oligodendrocytes, astrocytes, and axons, but not involving microglia (45). One theoretical mechanism for the pattern of bands of myelin that are alternately preserved and destroyed is that tissue destruction induced by COX-1 inhibition results in a counter-regulatory elaboration of protective proteins such as HIF-1 alpha and HSP-70 in the oligodendrocytes of neighboring tissues. In the areas with high HIF-1 alpha and HSP-70 concentration, inflammatory infiltrates of microglia and macrophages may be tolerated until they migrate to another region. In an area without a sufficient concentration of protective proteins, demyelination could occur again, resulting in an alternating, concentric pattern (71).

A slightly different explanation for the pattern of alternating demyelinated and myelinated rings postulates the use of a mathematical model based on nonlinear chemotaxis of effector monocytes and microglia with a resulting variable density of damaged oligodendrocytes (35). The proposed model postulates that if the flux of one diffusing substance is dependent on the gradient of another, an inhomogeneous distribution of attracting and modifying substances (such as chemokines and cytokines--not specified by the model) would occur. This would control the speed and concentration of activated macrophages and microglia across the area of disease involvement. Areas that become demyelinated would have a high concentration of effector cells, whereas preserved areas would demonstrate a low concentration. The production of chemokines and cytokines by migrating cells themselves might accentuate this inhomogeneity, attracting more cells to areas where cells existed in high concentrations.

In contrast to the conventional notion of early CD4+ T-cell involvement in demyelinating lesions, observations that microglia and macrophages are the earliest cell infiltrates into areas of damaged myelin have been published (25). The parallels between the pathological changes described above for Balo concentric sclerosis and those found in areas of early destruction and active inflammation in multiple sclerosis makes it easy to speculate that Balo concentric sclerosis is a model for immune-mediated tissue destruction in multiple sclerosis. The etiology of the earliest lesion in multiple sclerosis is yet unknown.

One theory concerning the initial pathological events in Balo concentric sclerosis postulates that there is an antibody-mediated astrocytopathy involving loss of aquaporin-4 and connexins (37; 51). Oligodendrocyte injury mediated by the above inflammatory mechanisms then follows during an antibody-independent event (in favor of a degenerative secondary phase).

An extensive review of cerebrospinal fluid examinations in a large cohort of patients with Balo concentric sclerosis revealed that, unlike prototypical multiple sclerosis, approximately two of three patients were negative for oligoclonal bands and for elevation of IgG synthesis (27). Pleocytosis was a more common finding among Balo patients versus multiple sclerosis. Oligoclonal bands among Balo patients were frequently transient. The investigators suggest that Balo concentric sclerosis pathology is more similar to neuromyelitis optica and MOG-related demyelination than to multiple sclerosis.

Diagnostic workup

Although the diagnosis of Balo concentric sclerosis is usually first considered based on a characteristic MRI pattern, published cases demonstrate variability in what has been accepted as being suggestive of Balo concentric sclerosis lesions. Evolution of Balo concentric sclerosis lesions into a homogeneous or granular appearance may account for part of this variability. Case reports have illustrated MR images demonstrating six or more thin concentric bands or exhibiting only one or two thick bands. Some cases are undoubtedly reported as tumefactive multiple sclerosis (68). The lesions may be multiple or single and vary in size from less than a centimeter to lesions that involve most of the supratentorial white matter (20). The MRI evolution of Balo concentric sclerosis rings takes at least two distinct patterns. Chen and colleagues reported that bands spread centripetally, with new bands forming around established bands (12). Others (67; 31) have argued that all rings emerge simultaneously. One particularly illustrative case demonstrated the slow evolution of a centrifugal pattern of concentric alternating bands over 57 days using four sequential MRIs (38). The chronic time course of Balo concentric sclerosis appears to vary. Serial scans have shown regression of lesions, with conversion to homogeneous signals (31), prolonged maintenance of the rings, (57), and complete disappearance of the rings (10). 7T MRI scanning in a single patient has suggested possible superiority versus 1.5T MRI in imaging the rings (07). A small series of patients with Balo concentric sclerosis were examined for the presence or absence of many key findings described in prototypic multiple sclerosis using 7T MRI (Behrens et at 2018). The investigators concluded that some findings were frequently present in both syndromes, suggesting a common pathophysiology (a central vein sign, Dawson fingers), and there was a suggestion that juxtacortical lesions and cortical involvement were perhaps absent in Balo concentric sclerosis, as distinct from multiple sclerosis.

A relatively large series of patients verified the consistent evolution of enhancing concentric ring formation on serial MRI scans, also noting inflammatory oligodendrocytopathy typical of type III multiple sclerosis in all biopsied cases (17 out of 17) (28). Most patients were tested for NMO and MOG antibodies (n=21/40), and all tested negative.

Balo concentric sclerosis frequently occurs without associated cerebrospinal fluid oligoclonal bands or evidence of temporal and spatial diversity. The finding of oligoclonal bands seems to be associated with recurrent attacks. In general, visual evoked potentials are normal, although prolonged P100s do not exclude the diagnosis.

Although biopsies have often been performed to confirm a demyelinating etiology or to exclude tumor or infection, this is usually unnecessary. The use of 18F-2-fluoro-2-deoxy-D-glucose positron emission tomography may be helpful in excluding hypermetabolic lymphomas and high-grade gliomas from the differential diagnoses as demyelinating lesions are usually hypometabolic (75).

Management

Most acute attacks of Balo concentric sclerosis have been treated with corticosteroids, but the results of such therapy are anecdotal (class IV evidence only). It has been suggested that early treatment within days of diagnosis with high-dose corticosteroids may improve outcomes (50). If acute attacks of Balo concentric sclerosis do not clearly respond to corticosteroids, many approaches to immunotherapy, including plasma exchange, may possibly be beneficial. Many reported therapeutic trials involving only one or a few patients were based on experience with other severe bouts of demyelinating disease. For example, there are single case reports of IVIG possibly being effective and success with B-cell depletion strategies (58; 18; 64). A case series of 14 patients with Balo concentric sclerosis showed favorable clinical course and remarkable stability under anti-CD20 therapy (61). A rituximab case study reported isolated Balo concentric sclerosis that responded clinically and radiologically to long-term rituximab therapy and demonstrated long-term remission (58).

The acute attack of Balo concentric sclerosis may be isolated, may be followed by a relapsing-remitting course, or may lead to a progressive and potentially fatal outcome. This variability makes the choice of treatment following the acute attack problematic. Those individuals with isolated attacks or long periods of clinical quiescence may not need chronic therapy.

Patients with the most aggressive courses generally die within the first year of illness. As more aggressive therapies become available for the treatment of immune-mediated diseases of the CNS, it is possible that death and severe disability will be a less frequent outcome. An example of an aggressive course is that of a 16-year-old boy who responded partially to intravenous corticosteroid but worsened once treatment was withdrawn (42). He improved after administration of intravenous cyclophosphamide and ACTH and was then clinically stable for a 2-year period while taking azathioprine. Clinical stability was reported in a single case of plasma exchange followed by natalizumab (07). A single patient with aggressive disease seemed to respond poorly to steroids and plasma exchange followed by cyclophosphamide and alemtuzumab, supporting the concept that in some patients the inflammatory lesions of Balo concentric sclerosis are independent of lymphocyte mediated processes (08).

The author is not aware of long-term data systematically studying any therapy. Until this is possible, treatment must be based on the presence of progression, the likelihood of recurrent attacks, and the severity of the first attack. Reviewing MRI scans carefully for multiple sclerosis-like lesions in the brain and spinal cord, restudying patients with MRI for new areas of demyelination, and performing lumbar punctures for the presence of oligoclonal bands, especially several months after the initial attack, may provide insight into the likelihood of recurrent or progressive disease. Visual-evoked potentials, MOG-IgG, and aquaporin-4 antibodies may also be helpful in selected cases. From the author’s review of published cases, multiple large Balo concentric sclerosis lesions possibly portend a worse prognosis and may indicate patients for whom aggressive therapy should be instituted. If the course of Balo concentric sclerosis is similar to tumefactive multiple sclerosis, then chronic treatment seems reasonable (40; 03).

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Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Authors

Jikku Zachariah DO

Dr. Zachariah of Penn State Hershey Medical Center received speaker honorariums from BMS, EMD Serono, Sanofi, and TG Therapeutics.
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Thomas Scott MD

Dr. Scott of Allegheny Neurological Associates has no relevant financial relationships to disclose.
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Editor

Anthony T Reder MD

Dr. Reder of the University of Chicago received honorariums from Genentech, Genzyme, and TG Therapeutics for service on advisory boards and as a consultant and stock options from NKMax America for advisory work and an unrestricted lab research grant from BMS.
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Former Authors

Michael I Kaufman MD

Patient Profile

Age range of presentation: 2 to 64 years
Sex preponderance: female>male, >1:1
Heredity: none
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

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Balo concentric sclerosis

Associated Disorders

Marburg disease
Multiple sclerosis
Schilder diffuse sclerosis

Differential Diagnosis

acute disseminated encephalomyelopathy
acute multiple sclerosis, Marburg variant
tumefactive multiple sclerosis
atypical Devic syndrome
lymphoma
- glioma
- metastatic cancer
- abscess
- progressive multifocal leukoencephalopathy
- human herpes virus 6 encephalitis

Balo concentric sclerosis …

Balo concentric sclerosis

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Diagnostic workup

Management

Special considerations

Pregnancy

Media

References

Contributors

Authors

Editor

Former Authors

Patient Profile

ICD & OMIM codes

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to access the full version.

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Balo concentric sclerosis

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Diagnostic workup

Management

Special considerations

Pregnancy

Media

References

Contributors

Authors

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Viral and retroviral myositis

Upadacitinib

Guillain-Barre syndrome in children

Efgartigimod alfa-fcab

Efgartigimod alfa and hyaluronidase-qvfc

Ofatumumab

Neuropathies associated with cryoglobulinemia

Rheumatoid arthritis: neurologic manifestations

This is an article preview.
Start a Free Account
to access the full version.