A novel visual ranking system based on arterial spin labeling perfusion imaging for evaluating perfusion disturbance in patients with ischemic stroke

Autoři: Sangjoon Lee aff001;  Dong Woo Park aff001;  Tae Yoon Kim aff001;  Dong Sun Kim aff001;  Ji Young Lee aff002;  Young-Jun Lee aff002;  Chun Ki Kim aff003
Působiště autorů: Department of Radiology, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea aff001;  Department of Radiology, Hanyang University College of Medicine, Hanyang University Hospital, Seoul, Republic of Korea aff002;  Department of Nuclear Medicine, Hanyang University College of Medicine, Hanyang University Hospital, Seoul, Republic of Korea aff003
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article
doi: 10.1371/journal.pone.0227747


We developed a visual ranking system by combining the parenchymal perfusion deficits (PPD) and hyperintense vessel signals (HVS) on arterial spin labeling (ASL) imaging. This study aimed to assess the performance of this ranking system by correlating with subtypes classified based on dynamic susceptibility contrast (DSC) imaging for evaluating the perfusion disturbance observed in patients with ischemic stroke. 32 patients with acute or subacute infarcts detected by DSC imaging were reviewed. Each patient’s brain was divided into 12 areas. ASL ranks were defined by the presence (+) or absence (-) of PPD/HVS as follows; I:–/–, II:–/+, III: +/+, and IV: +/–. DSC imaging findings were categorized based on cerebral blood flow (CBF) and time to peak (TTP) as normal (normal CBF/TTP), mismatched (normal CBF/delayed TTP), and matched (decreased CBF/delayed TTP). Two reviewers rated perfusion abnormalities in the total of 384 areas. The four ASL ranks correlated well with the DSC subtypes (Spearman’s r = 0.82). The performance of ASL ranking system was excellent as indicated by the area under the curve value of 0.94 using either matched or mismatched DSC subtype as the gold standard and 0.97 using only the matched DSC subtype as the gold standard. The two methods were in good-to-excellent agreement (maximum κ-values, 0.86). Inter-observer agreement was excellent (κ-value, 0.98). Although the number of patients was small and the number of dropouts was high, our proposed, ASL-based visual ranking system represented by PPD and HVS provides good, graded estimates of perfusion disturbance that agree well with those obtained by DSC perfusion imaging.

Klíčová slova:

Angiography – Blood flow – Cerebral arteries – Cerebral blood flow assay – Imaging techniques – Ischemic stroke – Magnetic resonance imaging – Arterial spin labelling


1. Baird AE, Warach S. Magnetic resonance imaging of acute stroke. J Cereb Blood Flow Metab. 1998;18:583–609. doi: 10.1097/00004647-199806000-00001 9626183

2. Alsop DC, Detre JA. Multisection cerebral blood flow MR imaging with continuous arterial spin labeling. Radiology. 1998;208:410–416. doi: 10.1148/radiology.208.2.9680569 9680569

3. Niibo T, Ohta H, Yonenaga K, Ikushima I, Miyata S, Takeshima H. Arterial spin-labeled perfusion imaging to predict mismatch in acute ischemic stroke. Stroke. 2013;44:2601–2603. doi: 10.1161/STROKEAHA.113.002097 23868269

4. Chalela JA, Alsop DC, Gonzalez-Atavales JB, Maldjian JA, Kasner SE, Detre JA. Magnetic resonance perfusion imaging in acute ischemic stroke using continuous arterial spin labeling. Stroke. 2000;31:680–687. doi: 10.1161/01.str.31.3.680 10700504

5. Wang DJ, Alger JR, Qiao JX, Hao Q, Hou S, Fiaz R, et al. The value of arterial spin-labeled perfusion imaging in acute ischemic stroke: comparison with dynamic susceptibility contrast-enhanced MRI. Stroke. 2012;43:1018–1024. doi: 10.1161/STROKEAHA.111.631929 22328551

6. Yun TJ, Paeng JC, Sohn CH, Kim JE, Kang HS, Yoon BW, et al. Monitoring Cerebrovascular Reactivity through the Use of Arterial Spin Labeling in Patients with Moyamoya Disease. Radiology. 2016;278:205–213. doi: 10.1148/radiol.2015141865 26197057

7. Tada Y, Satomi J, Abe T, Kuwayama K, Sogabe S, Fujita K, et al. Intra-arterial signal on arterial spin labeling perfusion MRI to identify the presence of acute middle cerebral artery occlusion. Cerebrovasc Dis. 2014;38:191–196. doi: 10.1159/000365653 25300901

8. Yoo RE, Yun TJ, Rhim JH, Yoon BW, Kang KM, Choi SH, et al. Bright vessel appearance on arterial spin labeling MRI for localizing arterial occlusion in acute ischemic stroke. Stroke. 2015;46:564–567. doi: 10.1161/STROKEAHA.114.007797 25523057

9. Zaharchuk G, Bammer R, Straka M, Shankaranarayan A, Alsop DC, Fischbein NJ, et al. Arterial spin-label imaging in patients with normal bolus perfusion-weighted MR imaging findings: pilot identification of the borderzone sign. Radiology. 2009;252:797–807. doi: 10.1148/radiol.2523082018 19703858

10. Detre JA, Alsop DC, Vives LR, Maccotta L, Teener JW, Raps EC. Noninvasive MRI evaluation of cerebral blood flow in cerebrovascular disease. Neurology. 1998;50:633–641. doi: 10.1212/wnl.50.3.633 9521248

11. Wittsack HJ, Ritzl A, Fink GR, Wenserski F, Siebler M, Seitz RJ, et al. MR imaging in acute stroke: diffusion-weighted and perfusion imaging parameters for predicting infarct size. Radiology. 2002;222:397–403. doi: 10.1148/radiol.2222001731 11818605

12. Nael K, Meshksar A, Liebeskind DS, Coull BM, Krupinski EA, Villablanca JP. Quantitative analysis of hypoperfusion in acute stroke: arterial spin labeling versus dynamic susceptibility contrast. Stroke. 2013;44:3090–3096. doi: 10.1161/STROKEAHA.113.002377 23988646

13. Huck S, Kerl HU, Al-Zghloul M, Groden C, Nolte I. Arterial spin labeling at 3.0 Tesla in subacute ischemia: comparison to dynamic susceptibility perfusion. Clin neuroradiol. 2012;22:29–37. doi: 10.1007/s00062-011-0126-x 22270833

14. Bokkers RP, Hernandez DA, Merino JG, Mirasol RV, van Osch MJ, Hendrikse J, et al. Whole-brain arterial spin labeling perfusion MRI in patients with acute stroke. Stroke. 2012;43:1290–1294. doi: 10.1161/STROKEAHA.110.589234 22426319

15. Wang DJ, Alger JR, Qiao JX, Gunther M, Pope WB, Saver JL, et al. Multi-delay multi-parametric arterial spin-labeled perfusion MRI in acute ischemic stroke—Comparison with dynamic susceptibility contrast enhanced perfusion imaging. Neuroimage Clin. 2013;3:1–7. doi: 10.1016/j.nicl.2013.06.017 24159561

16. Wang R, Yu S, Alger JR, Zuo Z, Chen J, Wang R, et al. Multi-delay Arterial Spin Labeling Perfusion MRI in Moyamoya Disease—Comparison with CT Perfusion Imaging. Eur Radiol. 2014;24:1135–1144. doi: 10.1007/s00330-014-3098-9 24557051

17. Alsop DC, Detre JA, Golay X, Gunther M, Hendrikse J, Hernandez-Garcia L, et al. Recommended implementation of arterial spin-labeled perfusion MRI for clinical applications: A consensus of the ISMRM perfusion study group and the European consortium for ASL in dementia. Magn Reson Med. 2015;73:102–116. doi: 10.1002/mrm.25197 24715426

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2020 Číslo 1