Advanced Imaging Applications in Tumefactive Demyelination – Literature Review With an Illustrative Case Report

ABSTRACT Background and Purpose Solitary tumefactive demyelinating lesions (TDLs) represent an uncommon but clinically significant manifestation of central nervous system demyelination and pose a major diagnostic challenge due to their radiologic resemblance to high‐grade gliomas, primary central nervous system lymphoma, and other mass‐like lesions. Accurate non‐invasive differentiation is essential to avoid unnecessary biopsy and inappropriate oncologic treatment. This review aims to synthesize the role of advanced MRI techniques in improving diagnostic confidence in TDLs. Methods A narrative review of the literature was performed, focusing on advanced MRI modalities used in the evaluation of TDLs, including proton MR spectroscopy, diffusion tensor imaging, magnetization transfer imaging, and dynamic susceptibility contrast perfusion imaging. Relevant studies were analyzed to identify characteristic imaging patterns and their underlying pathophysiologic correlates. An illustrative case was incorporated to contextualize these findings. Results Advanced MRI techniques demonstrate distinct imaging signatures in TDLs that reflect inflammatory demyelination rather than neoplastic processes. Proton MR spectroscopy typically reveals elevated choline with preserved or relatively less reduced N‐acetylaspartate and the presence of lipid–lactate peaks. Diffusion imaging shows variable restriction corresponding to active inflammatory fronts. Magnetization transfer imaging highlights myelin disruption, often with characteristic peripheral signal changes. Perfusion imaging consistently demonstrates low relative cerebral blood volume, reflecting the absence of neoangiogenesis, in contrast to high‐grade tumors. Integration of these modalities improves diagnostic specificity and reduces reliance on invasive procedures. Conclusions Advanced multimodal MRI provides critical complementary information for differentiating TDLs from neoplastic mimics. A combined imaging approach, supported by pathophysiologic understanding, can enhance diagnostic accuracy and guide appropriate clinical management. Incorporation of illustrative cases further strengthens the practical application of these techniques in routine clinical practice.