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An epidermoid cyst follows CSF on T2W, T1W images (hyperintense on T2W, hypointense on T1W images). It is isointense (higher than CSF) on FLAIR. Diffusion-weighted imaging is important to differentiate an epidermoid cyst from an arachnoid cyst. Epidermoid cyst shows restricted diffusion (bright on DWI, intermediate on ADC) whereas arachnoid cyst do not.
This patient had a history of intracranial epidermoid cyst surgery now with a recurrence adjacent to midbrain and medulla oblongata.