Non-contrast MRI reliably captures perfusion abnormalities in status epilepticus

To determine whether non-contrast pseudo-continuous arterial spin labeling (pCASL) detects status epilepticus (SE)-related perfusion abnormalities and shows quantitative correspondence with dynamic susceptibility contrast (DSC) perfusion magnetic resonance imaging (MRI), and to compare single-slice and volumetric approaches for asymmetry assessment.

Adult patients from a prospectively recruited single-center SE cohort were included in this retrospective analysis when MRI was performed within 48 h after clinical SE onset and both pCASL and DSC perfusion sequences were available. Visual assessment was pCASL-led, with corresponding DSC-derived cerebral blood flow (CBF) and cerebral blood volume (CBV) maps subsequently evaluated. Perfusion asymmetry was quantified using mirrored contralateral reference regions. Single-slice peak-abnormality and volumetric segmentation approaches were applied to pCASL, DSC-derived cerebral blood flow (CBF), and cerebral blood volume (CBV).

Of 982 individuals with SE, 180 underwent MRI including pCASL and DSC within 48 h. pCASL-led assessment identified SE-related perfusion abnormalities in 75 of 180 (42%): hyperperfusion in 65, hypoperfusion in 6, and pCASL-DSC discordance in 4. Corresponding DSC abnormalities were present in 71 of 75 (95%). Thus, quantitative asymmetry analysis was performed in 71 unilateral evaluable cases. In the hyperperfusion subgroup, pCASL asymmetry correlated significantly with DSC-derived CBF using both volumetric and single-slice assessment (ρ = .558 and ρ = .571, respectively; both p < .001), and with DSC-derived CBV (ρ = .495 and ρ = .374, respectively; p < .001 and p = .003). Single-slice and volumetric pCASL asymmetry showed strong correspondence (ρ = .773, p < .001). No significant difference was observed between single-slice and volumetric pCASL asymmetry after correction for multiple comparisons.

Non-contrast pCASL detected SE-related peri-ictal perfusion abnormalities and showed significant quantitative correspondence with DSC-derived CBF and CBV in parenchymal hyperperfusion. Single-slice pCASL asymmetry showed strong agreement with volumetric assessment, supporting its use as a pragmatic approach for clinically oriented evaluation.