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Background: Differentiation between cerebral abscesses and necrotic brain tumors showing ring enhancement can be confusing at times by conventional MRI. The introduction of advanced imaging techniques, such as MR spectroscopy and diffusion WI, have contributed to the differentiation.The purpose of this study is to test the hypothesis that MR spectroscopy and diffusion weighted can be used to differentiate between necrotizing or cystic brain tumor and brain abscesses.Methods: The study was conducted on 45 patients (necrotic or cystic tumor (30 cases); brain abscess (15 cases) showing ring-shaped contrast enhancement on conventional MRI. 1.5-T 1H-MR Spectroscopy and diffusion WI were performed and the results were ensured by stereotactic biopsy or aspiration procedures in surgically indicated cases and/or follow up.Results: 14 patients (out of 15) with pyogenic abscess had lactate, amino acids, and acetate peaks; Succinate peak is seen as extra peak in three of these patients, and lipid peaks are also seen as extra peaks in 3 patients. One patient with brain stem abscess after 20 days treatment by antibiotics shows only lactate and lipid peaks. 2 of them show mild increase in choline with decrease in NAA (brain tissue contamination).17 out of 30 patients with cystic or necrotic tumor showed only lactate peak in MRS. While 13 patients show lactate and lipid peaks, four of them show additional high choline peak with low NAA and creatine peak (contamination with brain tissue).The results were confirmed by Sterotactic biopsy in 27 cases and aspiration in 13 cases and follow up for all cases.The sensitivity, specificity, PPV, NPV and overall accuracy of diffusion and MRS were 88%, 100%, 100%, 93.3% and 95.5% respectively.Conclusion: 1H-MRS and diffusion WI are fast, easy to perform, noninvasive, and provide additional information that can accurately differentiate between necrotic/cystic tumors and cerebral abscesses

1H proton MR spectroscopy and diffusion-weighted imaging in discrimination between pyogenic brain abscesses and necrotic brain tumors