{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T04:13:56Z","timestamp":1788408836528,"version":"build-2803163510"},"reference-count":17,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Insights Imaging"],"abstract":"Abstract<\/jats:title>\n \n Objective<\/jats:title>\n To characterize MRI matrix signal and CT calcification patterns across WHO-IWGE stages, compare them with lesion mimicking cystic echinococcosis (CE), and derive an MRI-based subclassification for inactive cysts.<\/jats:p>\n <\/jats:sec>\n \n Materials and methods<\/jats:title>\n This retrospective multicenter study included 105 patients (174 CE cysts) imaged between 2012 and 2024, plus 30 mimickers. Inclusion required axial T1-weighted imaging with chemical-shift in-phase\/opposed-phase acquisitions and at least two T2-weighted sequences. Two radiologists independently reviewed all examinations, and a consensus was reached. Cysts were classified as inactive if no free-fluid T2 hypersignal was present on index MRI and corroborated by follow-up imaging and\/or adjunct ultrasound in equivocal cases. Diagnostic performance indices were calculated to identify inactivity.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Fatty T1 hyperintensity was more frequent in inactive than active\/transitional cysts (20\/97 (21%) vs 2\/77 (3%);\n p<\/jats:italic>\n \u2009<\u20090.001). The \u201cmatrix flip-flop\u201d sign was observed in 61\/97 (63%) inactive cysts and in only two CE3b lesions (2\/77 (3%);\n p<\/jats:italic>\n \u2009<\u20090.001). Both signs showed high specificity for inactivity (75\/77; 97.4%, 95% CI: 90.9\u201399.7). Matrix calcifications were associated with inactivity (46\/97 (47%) vs 2\/77 (3%);\n p<\/jats:italic>\n \u2009<\u20090.001) and were rare among mimickers (2\/30 (7%);\n p<\/jats:italic>\n \u2009=\u20090.006). Homogeneous non-fatty T1 hyperintensity characterized mimickers (23\/30 (77%) vs 10\/174 (6%);\n p<\/jats:italic>\n \u2009<\u20090.001). A three-tier inactive subclassification (early\/intermediate\/late) was derived from matrix T2 evolution.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n Matrix MRI\/CT features\u2014particularly fatty foci and the matrix flip-flop sign\u2014provide ancillary evidence of CE inactivity and help distinguish CE from mimickers. T2 signal supported an MRI-based framework for stage-adapted \u201cwatch-and-wait\u201d follow-up.<\/jats:p>\n <\/jats:sec>\n \n Key Points<\/jats:title>\n \n \n \n \n Question<\/jats:bold>\n MRI features of cystic echinococcosis remain insufficiently studied, particularly matrix signal abnormalities that may affect diagnosis and viability assessment on routine imaging.\n <\/jats:p>\n <\/jats:list-item>\n \n \n Findings<\/jats:bold>\n T1- and T2-weighted matrix CE cysts analysis identified fatty foci and the newly described matrix flip-flop sign as specific features of inactive cysts.\n <\/jats:p>\n <\/jats:list-item>\n \n \n Critical Relevance<\/jats:bold>\n Assessment of underrecognized MRI and CT cyst-matrix features can help stage cystic echinococcosis, assess viability, and distinguish cystic echinococcosis cysts from mimickers.\n <\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n 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