Diffusion-weighted imaging and susceptibility-weighted imaging in differentiating ring-enhancing primary central nervous system lymphoma from infections

Abstract

Introduction

Differentiating ring-enhancing primary central nervous system lymphoma (PCNSL) from infections is critical yet challenging in clinical practice. This study aimed to evaluate the effectiveness of diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) in differentiating ring-enhancing PCNSL from infections.

Material and Methods

We retrospectively reviewed 78 ring-enhancing lesions in 32 patients who underwent brain magnetic resonance imaging (MRI). Qualitative and quantitative assessments of the peripheral and central regions of ring-enhancing lesions were independently performed. The qualitative assessment involved evaluating restricted diffusion on DWI and intralesional susceptibility signal (ISS) on SWI. The quantitative assessment involved comparing the apparent diffusion coefficient average (ADC_avg) ratio and apparent diffusion coefficient minimum (ADC_min) ratio of the peripheral and central regions with the final diagnosis.

Results

The lesions consisted of PCNSL (n = 21), tuberculosis (n = 17), and toxoplasmosis (n = 40). The qualitative assessment showed that diffusion was significantly more restricted at the periphery in PCNSL (p < .001) and that ISS positivity was significantly higher both peripherally (p < .001) and centrally (p = .001) in PCNSL than in infections. The quantitative assessment revealed that PCNSL had significantly lower ADC_avg (peripheral, p < .001; central, p = .01) and ADC_min ratios (peripheral, p < .001; central, p = .025) compared to infections. A peripheral ADC_avg ratio of <1.25 demonstrated the best diagnostic accuracy (area under the curve: 0.966, 95% confidence interval [CI]: 0.93–1.00, sensitivity: 85.7%, specificity: 89.5%, and accuracy: 88.5%) for differentiating PCNSL from infections.

Conclusion

Restricted diffusion on DWI, positive ISS on SWI, and ADC ratio measurements of ring-enhancing lesions demonstrate significant potential as adjunctive imaging features for distinguishing PCNSL from CNS infections.