FDG-PET and ASL MRI identify largely overlapping hypermetabolic and hyperperfusion changes in limbic autoimmune...

Arterial spin labeling (ASL) MRI has been anecdotally used to assess brain perfusion in autoimmune encephalitis (AE) and its relationship with [¹⁸F]FDG-PET dysmetabolism has been scarcely investigated.Considering the physiological coupling of metabolism and perfusion, we aimed to evaluate the degree of correspondence between ASL-MRI and [¹⁸F]FDG-PET in AE.

A retrospective cohort of five patients underwent ASL-MRI and [¹⁸F]FDG-PET during the acute stage and at follow-up. We assessed the presence of regions with hypermetabolism on [¹⁸F]FDG-PET and hyperperfusion on ASL-MRI and evaluated concordance and spatial overlap of these metrics. Clinical assessment scale in AE and modified Rankin Scale were obtained at baseline and follow-up.

In two patients [¹⁸F]FDG-PET and ASL-MRI were unremarkable; in three patients there were anatomically overlapping areas of hypermetabolism and hyperperfusion (average DICE similarity coefficient 0.358). Following immunotherapy, metabolic and perfusion changes consistently demonstrated a progressive normalization, aligning with clinical improvement.

We identified suboptimal anatomical correspondence of abnormalities assessed with [¹⁸F]FDG-PET and ASL-MRI. Hyperperfusion and hypermetabolism might reflect differently AE-related pathophysiological correlates, but they both demonstrate ability to monitor disease activity. ASL-MRI is a promising marker of disease activity in AE and a favorable alternative to [¹⁸F]FDG-PET due to its cost-effectiveness, safety, and wide availability.