To analyze the imaging characteristics and causes of misdiagnosis in intraparenchymal epidermoid cysts (IEC), providing reference for clinical diagnosis and treatment.

Eight patients with IEC confirmed by surgical pathology in Neurosurgery Department of Zhujiang Hospital of Southern Medical University from January 2015 to April 2025 were selected retrospectively. Based on preoperative imaging data, the clinical characteristics, imaging manifestations, diagnosis results and causes of miscarriage of justice were systematically analyzed.

Among the 8 cases, the lesions were located in the frontal lobe, temporal lobe, and cerebellum in 2 cases each, and in the occipital lobe and brainstem in 1 case each; 7 cases involved the cortex or subcortical area, and 1 case involved the superficial area behind the brainstem. One case had irregular solid shape, with CT showing mainly calcified density and MRI showing mainly high signal on T1WI and slightly low signal on T2WI; 7 cases were cystic, with CT showing hypodense or slightly hypodense, MRI showing hypo- or slightly hypointense on T1WI and hyperintense signals on T2WI, accompanied by internal flocculent shadows (one case showed vortex like changes), of which 5 cases were associated with local moth-eaten parenchymal destruction. Six cases of MRI examination showed uneven FLAIR signal reduction, 2 cases had no diffusion restriction on DWI, 1 case had white matter fiber bundle displacement and partial interruption around DTI lesion, 1 case had scattered lipid droplets in the skull, and 3 cases showed no enhancement in the enhanced scan. Preoperative diagnosis revealed inaccurate localization in 4 cases and incorrect characterization in 3 cases.

IECs are extremely rare and exhibit complex imaging features, leading to frequent misdiagnosis. Comprehensive analysis integrating clinical presentation and multimodal imaging characteristics can improve preoperative diagnostic accuracy, reduce misdiagnosis, and provide crucial information for treatment strategies.