Role of Multiparametric Magnetic Resonance Imaging of the Brain in Differentiating Neurocysticercosis From Tuberculoma

Introduction: The two most common infectious causes of ring-enhancing lesions are neurocysticercosis (NCC) and tuberculoma. It is a challenge to differentiate NCC and tuberculomas radiologically since they show the same imaging findings on computed tomography (CT). Hence, this study was performed to assess the role of magnetic resonance imaging (MRI) as an additional advanced modality to aptly characterize the lesion. Conventional MRI with additional advanced imaging sequences like diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC), magnetic resonance spectroscopy (MRS), and post-contrast T1-weighted imaging (T1WI) aids in characterizing the lesion and helps in differentiating NCC and tuberculomas. Objectives: To compare the findings of DWI, ADC cut-off values, spectroscopy, and contrast-enhanced MRI in differentiating NCC from tuberculoma. Materials and methods: Individuals who matched the inclusion criterion underwent an MRI of the brain (plain and contrast) in a 1.5 Tesla, 18-channel, magnetic resonance scanner (Magnetom Avanto®, Siemens Healthineers, Erlangen, Germany). The following imaging sequences were included: T1WI (axial and sagittal), T2-weighted imaging (axial and coronal), fluid-attenuated inversion recovery, DWI at 0, 500, and 1000 mm(2)/s b-values with corresponding ADC values, and single-voxel MRS. Based on MRI features such as number, size, location, margins of lesions, scolex, surrounding edema, DWI features with corresponding ADC values, enhancement pattern of lesions, and spectroscopy findings, we evaluated and differentiated the lesions as NCC or tuberculoma. Radiological diagnoses were correlated in terms of clinical symptoms and response to treatment. Results: In our study, 42 subjects were included, of which the total number of NCC cases was 25 (59.52%) and tuberculoma was 17 (40.47%). The mean age of patients included was 42.85 ± 14.76 years (21 to 78 years). On post-contrast imaging, all 25 cases of NCC (100%) showed thin ring enhancement whereas the majority of tuberculomas (64.7%) showed thick irregular ring enhancement. On MRS, all 25 cases (100%) of NCC showed an amino acid peak and all 17 cases (100%) of tuberculoma showed a lipid lactate peak. On DWI, out of 25 NCC cases, restriction of diffusion was absent in the majority of cases (88%) and out of 17 cases of tuberculoma, restriction of diffusion was present in 12 cases (70.5%) (T2 hyperintense tuberculoma, indicative of caseating tuberculoma with central liquefaction) and was absent in the rest. In our study, the mean ADC value of NCC lesions (1.30 ± 0.137 x 10(-3) mm(2)/s) was found to be greater than that of tuberculoma (0.74 ± 0.090 x 10(-3) mm(2)/s). ADC value of 1.2 x 10(-3) was obtained as a cut-off to differentiate NCC and tuberculoma. The ADC cut-off value of 1.2 x 10(-3) mm(2)/s showed a sensitivity of 92% and specificity of 94.1% in differentiating NCC from tuberculoma. Conclusions: Conventional MRI with additional advanced imaging sequences like DWI, ADC, MRS, and post-contrast T1WI aids in characterizing the lesion and thereby helps in differentiating NCC and tuberculomas. Hence, multiparametric MRI assessment is useful in making a prompt diagnosis and eliminating the need for a biopsy.