What are the radiological features of central nervous system involvement in Lyme disease, and how can they be differentiated from other conditions like multiple sclerosis?

CNS Lyme disease presents in two forms: cranial neuritis and parenchymal involvement. Cranial neuritis is characterized by thickening and enhancement of cranial nerves, most commonly CN VII, but CNs III to VIII can be involved. The parenchymal form shows multiple small white matter lesions, which can mimic multiple sclerosis, often with nodular or ring enhancement. Meningeal enhancement may also be present. Key diagnostic features include a history of tick exposure and serological confirmation. Clinical pearls include the high prevalence of CN VII involvement and the potential for reversible lesions with appropriate antibiotic treatment. Common pitfalls include misdiagnosis as multiple sclerosis due to similar imaging findings.