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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 133-139

Quantitative analysis of diffusion-weighted imaging and signal-to-noise ratio on the efficacy of albendazole liposome in the treatment of cerebral alveolar echinococcosis


1 Department of Imaging Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
2 Department of Medical Imaging, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China
3 School of Computer Engineering and Science, Shanghai University, Shanghai, China

Date of Submission11-Oct-2021
Date of Acceptance07-Dec-2021
Date of Web Publication17-Aug-2022

Correspondence Address:
Jian Wang
Department of Imaging Center, The First Affiliated Hospital of Xinjiang Medical University, No. 137, South Liyushan Road, Urumqi 830054, Xinjiang,
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/RID.RID_10_21

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  Abstract 


OBJECTIVE: To investigate the feasibility of diffusion-weighted imaging (DWI) and signal-to-noise ratio (SNR) of lesions in evaluating the efficacy of albendazole liposomes in the treatment of cerebral alveolar echinococcosis (CAE).
MATERIALS AND METHODS: Sixteen patients with CAE who met the inclusion criteria from April 2017 to December 2020 were enrolled. All patients underwent routine magnetic resonance sequence examination and DWI examination. The b-value were 1000 s/mm2 and 3000 s/mm2. The apparent diffusion coefficient (ADC) value and SNR of lesions before and after treatment were compared. The data of each group were statistically analyzed by Wilcoxon signed-rank sum test.
RESULTS: After 1 year of treatment with albendazole liposomes, the SNR of lesions on T2WI sequence increased. There was a significant difference between the SNR of the same lesion before and after follow-up (P < 0.05). The ADC values of lesion parenchyma and edema area before and after treatment were compared. The difference between them was statistically significant in the both b values (ADC of parenchyma, P < 0.05; ADC of edema area, P < 0.001). Through binary linear classification, it was found that under the same b value, the effect of drugs on the edema area was more obvious than that on the parenchyma area; under different b values, the higher the b value, the higher the ability to evaluate the curative effect of drug therapy.
CONCLUSION: Albendazole liposome is effective in the treatment of CAE, and long-term imaging follow-up of patients with CAE treated with albendazole liposome is necessary. When the change in conventional images is inapparent, the quantitative analysis of ADC value and SNR of lesions on T2WI can provide an objective basis for the evaluation of the curative effect of drug treatment in CAE.

Keywords: Albendazole liposome, apparent diffusion coefficient, cerebral alveolar echinococcosis, diffusion-weighted imaging, signal-to-noise ratio


How to cite this article:
Xing H, Du X, Abulikemu N, Yang J, Gao X, Liu J, Jiang C, Li J, Wang J. Quantitative analysis of diffusion-weighted imaging and signal-to-noise ratio on the efficacy of albendazole liposome in the treatment of cerebral alveolar echinococcosis. Radiol Infect Dis 2021;8:133-9

How to cite this URL:
Xing H, Du X, Abulikemu N, Yang J, Gao X, Liu J, Jiang C, Li J, Wang J. Quantitative analysis of diffusion-weighted imaging and signal-to-noise ratio on the efficacy of albendazole liposome in the treatment of cerebral alveolar echinococcosis. Radiol Infect Dis [serial online] 2021 [cited 2022 Oct 6];8:133-9. Available from: http://www.ridiseases.org/text.asp?2021/8/4/133/353890




  Introduction Top


Cerebral alveolar echinococcosis (CAE) is an important zoonotic infectious disease caused by Echinococcus multilocularis larvae.[1] At present, it is mainly prevalent in the Northern Hemisphere and mainly distributed in animal husbandry areas in China. Humans are accidentally infected mainly by ingesting insect eggs discharged from the feces of specific hosts (such as foxes and dogs).[2] The most common affected organ of alveolar echinococcosis (AE) is the liver, the clinical manifestations are usually not special, and the lung and brain are the most common distant metastatic organs.[3],[4] Brain involvement is usually the last stage of the disease. At present, the preferred treatment for CAE is radical resection, but some patients may die or have considerable postoperative complications due to the surgical approach or the condition has progressed to not suitable for surgical treatment. Therefore, patients with CAE with incomplete resection or nonsurgical treatment should be treated with albendazole in time. Albendazole is thefirst choice for the treatment of CAE recommended by the current guidelines, and albendazole should be taken for a long time or even for life.[5] Moreover, the therapeutic effect of liposomal albendazole, which can reduce the dosage and dose-dependent side effects, is better than that of albendazole tablets, which can reduce the intake of albendazole, the occurrence of adverse reactions, and side effects of drugs. Therefore, regular follow-up of CAE patients who are taking albendazole liposomes is extremely important. Through imaging findings, the prognosis of lesions can be evaluated and more effective assistance can be provided to clinical work. Ineffective treatment can be terminated, and unnecessary toxicity and medical expenses can be reduced. Therefore, follow-up imaging can provide timely and accurate efficacy evaluation methods for CAE patients and more reliable evaluation basis for clinicians.
  Materials and Methods Top


General information

Sixteen patients who were diagnosed with CAE in theFirst Affiliated Hospital of Xinjiang Medical University from April 2017 to December 2020 were enrolled. Among them, 12 patients had multiple lesions and four patients had single lesions. In total, lesions with b value of 1000 s/mm2 were 34 and with b value of 3000 s/mm2 were 30. All patients were prepared for albendazole liposome treatment, and during the follow-up, the patients were able to take drugs on time and in quantity, 5–40 ml/kg, twice a day, orally, with a follow-up period of 1 year or more. Inclusion criteria were as follows: (1) a history of AE (liver and lung) in other parts of the body, and a comprehensive diagnosis of CAE after brain magnetic resonance examination; (2) they can be followed up regularly and take albendazole liposomes on time; (3) the expected life cycle is more than 12 months; and (4) the diameter of CAE lesions was more than 5 mm. Exclusion criteria were as follows: (1) CAE patients with contraindications on magnetic resonance imaging (MRI); (2) patients who unable to cooperate with MRI examination; (3) patients with other types of space occupying lesions located in the brain parenchyma after examination; (4) patients who cannot take medicine regularly as required; and (5) images that cannot be processed after diffusion-weighted imaging (DWI).

Image acquisition

All CAE patients were scanned with 3.0T dual-gradient superconduction MRI scanner (GE, Signa Hdx, GE Medical Systems, America) and 8-channel phased array head coil. Conventional MRI plain scan, enhanced scan, and DWI scan were performed on patients. The scanning direction of data acquisition was horizontal axis. The single-shot spin echo plane echo sequence was collected. The scanning parameters were as follows: layer spacing was 0.0 cm, layer thickness was 5.0 cm, the number of scanning layers was 26, the scanning field of view was 24 cm × 24 cm, nex 2, matrix 128 × 128, and the gradient sensitivity factor b values are 1000 s/mm2 and 3000 s/mm2.

Indicators observation

Import DWI images with b values of 1000 s/mm2 and 3000 s/mm2, T2WI images, and axial T1 WI-enhanced images into the GE Function tool 6.3 postprocessing software in the GE ADW 4.4 workstation to postprocess the images. The apparent diffusion coefficient (ADC) values of the parenchyma area, edema area, and contralateral relative normal area in the same lesion before and after drug treatment were measured in the largest layer of the lesion. During measurement, T2WI sequences were taken as the reference and regions of interest (ROIs) were defined as 8–15 mm2. Areas that affect ADC value measurement, such as necrosis and calcification bone, were avoided. We took three to eight ROIs for each lesion which with diameter > 5 mm and take the average value as the final ADC value. The signal-to-noise ratio (SNR) was obtained according to the ratio of the signal intensity (SI) of the largest layer of the lesion on T2WI to the standard deviation (SD) of the SI of background noise, that is, SNR = SI/SD. The discrimination of the examination image, the delineation of the region of interest, and the measurement of ADC value and SNR value before and after treatment were accomplished by two senior imaging physicians independently. If the opinions are inconsistent, higher senior physicians will cooperate to re-evaluate the lesion.

Statistical methods

Statistical analysis

Statistical analyses were performed by SPSS statistical software, version 22.0 (IBM, USA). The ADC value of each lesion area and SNR of lesion parenchyma area were not-normally distributed and the variance were uneven.”. And the paragraph should be revised to: “ Statistical analyses were performed by SPSS statistical software, version 22.0 (IBM, USA). The median (M) and interquartile range (P25-P75) were used for statistical description and the Wilcoxon signed-rank sum test was used for statistical comparison. P< 0.05 indicated that the difference was statistically significant.

Binary linear analysis

The binary linear classification was performed by the Python two-dimensional drawing tool Matplotlib for visual classification of ADC values of each lesion area before and after treatment.


  Results Top


Magnetic resonance imaging follow-up results before and after treatment

The follow-up of CAE lesions was evaluated by imaging [Figure 1]. There were 34 pairs of lesions with b value of 1000 s/mm2, which were mainly distributed in bilateral cerebral hemispheres, with frontal lobe accounting for 58.8%, parietal lobe accounting for 11.7%, cerebellar hemisphere accounting for 8.8%, and other parts accounting for 20.7%. There were 30 pairs of lesions with b value of 3000 s/mm2, including 63.3% in the frontal lobe, 6.7% in the parietal lobe, 10% in the cerebellar hemisphere, and 20% in other parts. After albendazole liposome treatment, the volume changes of CAE lesions were varied. In the b = 1000 s/mm2 group, about 50% of the lesions showed an increase in the volume, and changes were inapparent in 35.3% of the lesions, while 14.7% of them showed a slight reduction in the volume of lesions. In the b = 3000 s/mm2 group, 50% of the lesions increased in volume, while 36.7% had no obvious changes, and 13.3% of the lesions decreased in volume slightly. After drug treatment, the signal of lesions was slightly higher than that of before the treatment on T2WI. One year after albendazole liposome treatment, the change of SNR value in the same lesion parenchyma area was statistically significant (P < 0.05), as shown in [Table 1].
Figure 1: T2WI (a), DWI with b = 1000 s/mm2 (b), DWI with b = 3000 s/mm2 (c) images of CAE lesion. DWI: Diffusion-weighted imaging, CAE: cerebral alveolar echinococcosis.

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Table 1: Statistical analysis of signal-to-noise ratio of lesion parenchymal area in T2-weighted imaging before and after treatment


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Comparison of apparent diffusion coefficient values of cerebral alveolar echinococcosis lesions before and after treatment

Comparison of apparent diffusion coefficient values with b = 1000 s/mm2 in each lesion area before and after treatment

After 1 year of albendazole liposome treatment, the differences of ADC value with b = 1000 s/mm2 in the parenchyma and edema area of same lesion between before and after treatment was statistically significant (parenchyma area P < 0.05 and edema area P < 0.001). The ADC value of the same lesion parenchyma and edema area after treatment was higher than that of before treatment. There was no significant change in the contralateral relative normal area before and after treatment (P > 0.05), as shown in [Table 2].
Table 2: Statistical analysis results of apparent diffusion coefficient value with b=1000 s/mm2 in each region of interest of cerebral alveolar echinococcosis patients before and after treatment


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Comparison of apparent diffusion coefficient values with b = 3000 s/mm2 in each lesion area before and after treatment

After 1 year of albendazole liposome treatment, the differences of ADC value with b = 3000 s/mm2 in the parenchyma and edema area of the same lesion between before and after treatment were statistically significant (parenchyma area P < 0.05 and edema area P < 0.001). The ADC value of the same lesion parenchyma and edema area after treatment was higher than that of before treatment. There was no significant change in the contralateral relative normal area before and after treatment (P > 0.05), as shown in [Table 3].
Table 3: Statistical analysis results of apparent diffusion coefficient value with b=3000 s/mm2 in each region of interest of cerebral alveolar echinococcosis patients before and after treatment


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Analysis results of binary linear classification

Visual classification results in the parenchyma and edema area with b = 1000 s/mm2

Classification of treatment-effective and ineffective lesions based on ADC values (b = 1000 s/mm2) of parenchymal and edema area was performed by binary linear classification, as shown in [Figure 2]. It can be seen that albendazole liposomes are effective in the treatment of CAE.
Figure 2: Classification results in parenchyma and edema area of CAE lesionwith b = 1000 s/mm2 (left: parenchyma area; right: edema area). The horizontal coordinate represents the value of ADC before treatment as X1, and the vertical coordinate represents the value of ADC after treatment as X2. The blue line represents the dividing line of whether the drug has therapeutic effect on this area, with green dot () and red cross () indicates valid and invalid conditions, respectively. Therefore, the green dot above the boundary indicates the value of effective after taking medicine (i.e. X2 > X1), and the red cross below the boundary indicates the value of ineffective after medication (i.e. X2 < X1). It can be seen that albendazole liposomes are effective in the treatment of CAE in both area. CAE: cerebral alveolar echinococcosis.

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Visual classification results in the parenchyma and edema area with b = 3000 s/mm2

Classification of treatment-effective and ineffective lesions based on ADC values (b = 3000 s/mm2) of parenchymal and edema area was performed by binary linear classification, as shown in [Figure 3]. It can be seen that albendazole liposomes are effective in the treatment of CAE.
Figure 3: Classification results in parenchyma and edema area of CAE lesion with b = 3000 s/mm2 (left: parenchyma area; right: edema area). The horizontal coordinate represents the value of ADC before treatment as X1, and the vertical coordinate represents the value of ADC after treatment as X2. The blue line represents the dividing line of whether the drug has therapeutic effect on this area, with green dot () and red cross () indicates valid and invalid conditions, respectively. Therefore, the green dot above the boundary indicates the value of effective after taking medicine (i.e. X2 > X1), and the red cross below the boundary indicates the value of ineffective after medication (i.e. X2 < X1). It can be seen that albendazole liposomes are effective in the treatment of CAE in both area. CAE: Cerebral alveolar echinococcosis, ADC: Apparent diffusion coefficient.

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Binary linear classification results of different b values in evaluating the curative effect of lesion parenchyma and edema area

In this study, the changes of parenchymal and edema area of the same lesion under different b values after taking albendazole liposome for 1 year were studied under the conditions of b = 1000 s/mm2 and b = 3000 s/mm2, as shown in [Figure 4]. It can be seen that when b = 3000 s/mm2, efficiency of albendazole liposomes in the treatment of parenchymal and edema areas is more obvious than when b = 1000 s/mm2.
Figure 4: Visual classification results of different b values on the demonstration of treatment efficacy in parenchyma and edema area of CAE lesion (left: parenchyma area; right: edema area). The horizontal coordinate represents the value of ADC before treatment as X1, and the vertical coordinate represents the value of ADC after treatment as X2. The black line represents the dividing line of whether the drug has therapeutic effect on this area, with dot () and cross () indicates valid and invalid conditions, and green and red indicates b = 1000 s/mm2 and b = 3000 s/mm2, respectively. Therefore, the green dot above the boundary indicates that the drug is effective in the parenchymal or edema area of the lesion (i.e. X2 > X1) at b = 1000 s/mm2, and the green cross below the boundary indicates that the drug has no effect on the lesion parenchyma or edema area (i.e. X2 < X1) at b = 1000 s/mm2; The red dot above the boundary indicates that the drug is effective in the parenchymal or edema area (i.e. X2 > X1) at b = 3000 s/mm2, and the red cross below the boundary indicates that the drug has no effect on the parenchymal or edema area of the focus (i.e. X2 < X1) at b = 3000 s/mm2. CAE: Cerebral alveolar echinococcosis, ADC: Apparent diffusion coefficient.

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Visual classification results of treatment efficacy in the parenchyma, edema, and contralateral relative normal area under the same b value

The treatment efficacy in parenchymal, edema, and contralateral area of the lesion under the same b value has been compared, as shown in [Figure 5]. It can be seen that both b values can demonstrate the curative effect of albendazole liposome on the parenchymal and edema area of CAE lesion, and the therapeutic effect on the edema area is slightly greater than that on the parenchymal area of the lesion, but the curative effect on the contralateral relative normal area is not obvious.
Figure 5: Visual classification results of treatment efficacy in lesion parenchyma, edema and contralateral area under the same b value (left: b = 1000s/mm2; right: b = 3000s/mm2). The horizontal coordinate represents the value of ADC before treatment as X1, and the vertical coordinate represents the value of ADC after treatment as X2. The black line represents the dividing line of whether the drug has therapeutic effect on this area, with dot () and cross () indicates valid and invalid conditions, and green, blue, red indicates parenchymal, edema and contralateral relative normal area, respectively. There are more effective dots than ineffective crosses, which indicates that albendazole liposomes are effective in the treatment of CAE. The vertical distance from a dot to the dividing line indicates the change degree of ADC value before and after treatment. The longer the distance from a dot to the diving line, the greater the value of X2-X1, that is, the better the treatment effect. On the contrary, the longer the distance from a cross to the diving line, the smaller the value of X2-X1, that is, the treatment is invalid and the side effects are greater. There is little difference between the dots and crosses in red, while the dots in blue and green are more than crosses. The crosses represent invalid treatment in blue are closer to the dividing line than the green crosses and dots represent valid treatment in blue are more farther from the dividing line than green dots. Therefore, the effect of albendazole liposome on the edema area is better than that of the parenchyma area. ADC: Apparent diffusion coefficient, CAE: Cerebral alveolar echinococcosis.

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  Discussion Top


AE has a mortality rate of more than 90% in untreated cases. It is listed as one of the neglected zoonotic diseases (WHO, 2005) and included in the list of 17 neglected tropical diseases (WHO, 2010).[6] A considerable proportion of AE cases may not seek early treatment because of vague and tolerable chronic symptoms, and due to the slow growth of lesions, CAE patients usually have a long-term incubation period of 5–15 years, during which patients usually have no symptoms.[7] When AE complicated with brain metastasis, it has reached the advanced stage of the disease and missed the best opportunity for surgery. For CAE that cannot be cured by surgery, patients with postoperative recurrence or other organ AE need a long-term oral anti-echinococcosis drug therapy. The results of Liu John etal.[8] showed that albendazole had a good short-term follow-up effect in the treatment of AE, which may be due to the destruction of surrounding infiltrating layer tissue and the cessation or weakening of larval invasion caused by the drug effect.

After taking albendazole liposome in CAE patients, it was observed that the volume of some lesions increased slightly, the signal on T2WI increased, and the signal on DWI decreased. In the case of unresectable lesions, despite treatment, the size of the lesions can remain stable or slightly increase in volume, which may reflect the rigidity of the lesions caused by drug treatment to inhibit parasites (rather than killing parasites) and their fibrous response. In this study, the long-term follow-up of albendazole liposomes in the treatment of CAE found that the volume of lesions changed differently after taking drugs. In addition, whether the b value was 1000 s/mm2 or 3000 s/mm2, the volume of most lesions increased slightly, and the volume of a small number of lesions changed little or decreased. Moreover, in the initial stage of CAE treatment, the rich tissues of reticuloendothelial system such as liver absorb most of albendazole liposomes, so the concentration of albendazole reaching the brain is relatively low. Besides, due to the vasoconstriction around granulation tissue, the blood supply to parasites is further damaged, and the jelly-like vesicles in the focus are diluted. Therefore, the signal on T2WI was slightly higher than that before treatment, and the SNR value of the same lesion after treatment increased compared with that before treatment, which was statistically significant. After a period of treatment with albendazole liposomes in CAE patients, the drug reaches the focus through the blood–brain barrier, resulting in the death, slow growth, or inhibition of hydatid bodies.[9] Albendazole liposome treatment destruct the integrity of the cell membrane in CAE lesions which cause cracks on the cell membrane and let to the acceleration of the cell membrane and nucleus fragmentation. Thereby, the diffusion rate of water molecules may be accelerated and resulting in the decrease of DWI signal. Besides, the necrosis and apoptosis of the cells in the CAE lesions also reduced the cell density, resulting in the increase of ADC value.[10] CAE has a large number of dense vesicles and vesicle clusters, resulting in the narrowing of cell space and the limited expansion of water molecules. Moreover, the more energy the vesicles and vesicle clusters need, the more the number of organelles in the cells and the more obvious the restriction of water molecule diffusion; After taking albendazole liposome, the integrity of CAE cell membrane was damaged due to the cytotoxic effect of the drug. At the same time, it induces hydatid apoptosis and necrosis, reduces cell density, destroys the internal arrangement structure of the lesion, and reduces the number of intracellular organelles and protein content, to increase the water diffusion of the damaged hydatid tissue and reduce the lesion signal of DWI sequence. The ADC value increased in varying degrees compared with that before treatment, indicating that albendazole liposomes have a positive effect in the treatment of CAE. CAE has the characteristics of invasive growth. In addition to angiogenic edema, the edema around the focus is partly caused by the infiltration of Echinococcus multilocularis.[11] Albendazole liposomes are more likely to have an effect on budding newborn worms. Therefore, albendazole liposomes have better effect on the edema area than the parenchymal area of the lesion. Therefore, the therapeutic response of CAE can be judged according to the change of ADC value. Because the metabolism of necrotic cells stops and the function is lost, a series of morphological changes appear. Therefore, DWI technology can respond to the curative effect of drug treatment earlier and more sensitively. This study also shows that some patients with high ADC value before drug treatment have a poor effect after taking albendazole liposome. The analysis may be due to some small lesions with lazy internal cells, less consumption of glucose uptake and glycogen storage, or small areas of necrosis and cystic degeneration, resulting in low sensitivity of lesions to ingested drugs.

In this study, compared with the b = 1000 s/mm2, the ADC values at b = 3000 s/mm2 of parenchyma, edema, and contralateral relative normal area were relatively low. By analyzing the visual binary linear classification of the therapeutic efficacy of albendazole liposomes under different b values, it is concluded that the higher the b value, the better the therapeutic efficacy of the parenchymal and edema area of CAE lesions, and the more conducive to judging the therapeutic efficacy of patients. Zeng et al.[12] and others found that high b-value DWI is a potential tool for detecting glioma invasion, which may help neurosurgeons and radiation therapists make accurate treatment plans and predict the prognosis of glioma patients. High b values provide an opportunity to gain insight as a simple and effective tumor grade and potentially improve patient prognosis through accurate early diagnosis, auxiliary lesion characterization, and promoting early treatment planning. Integrating DWI map into clinical practice helps better manage decision-making and treatment.

This study is an exploratory study, and there are few relevant literature that can be used for reference. There is no systematic follow-up report of MRI examination of albendazole in the treatment of CAE at home and abroad. The sample size of this study is small and the patients have a history of AE in other parts, so the control group cannot be set up. If the nontreatment group or other control group is set up, it is not conducive to the treatment of this group of patients, which is not allowed by medical ethics.


  Conclusion Top


The therapeutic value of albendazole liposomes in CAE is worthy of affirmation, so it is also very important to follow up after drug treatment. DWI technology was used for quantitative follow-up of CAE to provide effective assistance for clinical decision-making. DWI and SNR of lesions are worthy to judge the efficacy of albendazole liposomes in the treatment of CAE.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Isik N, Silav G, Cerçi A, Karabagli P, Elmaci I, Kalelioglu M. Cerebral alveolar echinococcosis. A case report with MRI and review of the literature. J Neurosurg Sci 2007;51:145-51.  Back to cited text no. 1
    
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Kern P, Menezes da Silva A, Akhan O, Müllhaupt B, Vizcaychipi KA, Budke C, et al. The echinococcoses: Diagnosis, clinical management and burden of disease. Adv Parasitol 2017;96:259-369.  Back to cited text no. 2
    
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Bansiwal RK, Sharma R, Attri AK. A large primary hydatid cyst of thigh: A case report. Indian J Surg 2011;73:158-60.  Back to cited text no. 3
    
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Zhang YF, Xie ZR, Ni YQ, Mao R, Qi HZ, Yang YG, et al. Curative effect of radiotherapy at various doses on subcutaneous alveolar echinococcosis in rats. Chin Med J (Engl) 2011;124:2845-8.  Back to cited text no. 4
    
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Kvascevicius R, Lapteva O, Awar OA, Audronyte E, Neverauskiene L, Kvasceviciene E, et al. Fatal liver and lung alveolar echinococcosis with newly developed neurologic symptoms due to the brain involvement. Surg J (N Y) 2016;2:e83-8.  Back to cited text no. 5
    
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Craig PS, Giraudoux P, Wang ZH, Wang Q. Echinococcosis transmission on the Tibetan Plateau. Adv Parasitol 2019;104:165-246.  Back to cited text no. 6
    
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Stauga S, Schmiedel S. Inoperable cerebral alveolar echinococcosis controlled with high dosages of albendazole adjusted with monitoring of blood levels. J Travel Med 2012;19:198-201.  Back to cited text no. 7
    
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Liu YH, Wang XG, Gao JS, et al. Continuous albendazole therapy in alveolar echinococcosis: long-term follow-up observation of 20 cases. Trans R Soc Trop Med Hyg 2009;103:768-78.  Back to cited text no. 8
    
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Du X, You Y, Wang J, Jiang C, Yibanu A, Ma J, et al. Preliminary study of albendazole liposome treatment of cerebral alveolar echinococcosis by 1 H MR spectroscopy. Radiol Infect Dis 2018;5:63-8.  Back to cited text no. 9
    
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Malayeri AA, El Khouli RH, Zaheer A, Jacobs MA, Corona-Villalobos CP, Kamel IR, et al. Principles and applications of diffusion-weighted imaging in cancer detection, staging, and treatment follow-up. Radiographics 2011;31:1773-91.  Back to cited text no. 10
    
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Wang J, Jiang C, Yao W. Proton spectroscopy characteristic analysis of MR. Chin J Radiol 2014;48:89-92.  Back to cited text no. 11
    
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Zeng Q, Ling C, Shi F, Dong F, Jiang B, Zhang J, et al. Glioma infiltration sign on high b-value diffusion-weighted imaging in gliomas and its prognostic value. J Magn Reson Imaging 2018;48:643-51.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 1], [Table 2], [Table 3]



 

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