Arterial Spin Labeling (ASL) in Neuroradiological Diagnostics – Methodological Overview and Use Cases

Nico Sollmann; Gabriel Hoffmann; Severin Schramm; Miriam Reichert; Moritz Hernandez Petzsche; Joachim Strobel; Lorenzo Nigris; Christopher Kloth; Johannes Rosskopf; Corinna Börner; Michaela Bonfert; Maria Berndt; Georg Grön; Hans-Peter Müller; Jan Kassubek; Kornelia Kreiser; Inga K. Koerte; Hans Liebl; Ambros Beer; Claus Zimmer; Meinrad Beer; Stephan Kaczmarz

doi:10.1055/a-2119-5574

RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren, Table of Contents

Rofo 2024; 196(01): 36-51
DOI: 10.1055/a-2119-5574

Review

Arterial Spin Labeling (ASL) in Neuroradiological Diagnostics – Methodological Overview and Use Cases

Arterial Spin Labeling (ASL) in der neuroradiologischen Diagnostik – Methodischer Überblick und Anwendungsfälle

Nico Sollmann

¹Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

³TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

⁴cBrain, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-Universität München, Munich, Germany

,

Gabriel Hoffmann

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

³TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

,

Severin Schramm

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

,

Miriam Reichert

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

,

Moritz Hernandez Petzsche

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

,

Joachim Strobel

⁵Department of Nuclear Medicine, University Hospital Ulm, Ulm, Germany

,

Lorenzo Nigris

⁴cBrain, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-Universität München, Munich, Germany

,

Christopher Kloth

¹Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany

,

Johannes Rosskopf

¹Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany

⁶Section of Neuroradiology, Bezirkskrankenhaus Günzburg, Günzburg, Germany

,

Corinna Börner

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

⁷LMU Hospital, Department of Pediatrics – Dr. von Hauner Children’s Hospital, Division of Pediatric Neurology and Developmental Medicine, Ludwig-Maximilians-Universität München, Munich, Germany

⁸LMU Center for Children with Medical Complexity – iSPZ Hauner, Ludwig-Maximilians-Universität München, Munich, Germany

,

Michaela Bonfert

⁷LMU Hospital, Department of Pediatrics – Dr. von Hauner Children’s Hospital, Division of Pediatric Neurology and Developmental Medicine, Ludwig-Maximilians-Universität München, Munich, Germany

⁸LMU Center for Children with Medical Complexity – iSPZ Hauner, Ludwig-Maximilians-Universität München, Munich, Germany

,

Maria Berndt

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

,

Georg Grön

⁹Department of Psychiatry and Psychotherapy III, University Hospital Ulm, Ulm, Germany

,

Hans-Peter Müller

¹⁰Department of Neurology, University Hospital Ulm, Ulm, Germany

,

Jan Kassubek

¹⁰Department of Neurology, University Hospital Ulm, Ulm, Germany

¹¹German Center for Neurodegenerative Diseases (DZNE), Ulm University, Ulm, Germany

,

Kornelia Kreiser

¹Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany

¹²Department of Radiology and Neuroradiology, Universitäts- und Rehabilitationskliniken Ulm, Ulm, Germany

,

Inga K. Koerte

⁴cBrain, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-Universität München, Munich, Germany

¹³Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Boston, United States

¹⁴Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, United States

,

Hans Liebl

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

¹⁵Department of Radiology, Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Germany

,

Ambros Beer

⁵Department of Nuclear Medicine, University Hospital Ulm, Ulm, Germany

¹⁶MoMan – Center for Translational Imaging, University Hospital Ulm, Ulm, Germany

¹⁷i2SouI – Innovative Imaging in Surgical Oncology, University Hospital Ulm, Ulm, Germany

,

Claus Zimmer

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

³TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

,

Meinrad Beer

¹Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany

¹⁶MoMan – Center for Translational Imaging, University Hospital Ulm, Ulm, Germany

¹⁷i2SouI – Innovative Imaging in Surgical Oncology, University Hospital Ulm, Ulm, Germany

,

Stephan Kaczmarz

²Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

³TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

¹⁸Market DACH, Philips GmbH, Hamburg, Germany

› Author Affiliations

Abstract

Background Arterial spin labeling (ASL) is a magnetic resonance imaging (MRI)-based technique using labeled blood-water of the brain-feeding arteries as an endogenous tracer to derive information about brain perfusion. It enables the assessment of cerebral blood flow (CBF).

Method This review aims to provide a methodological and technical overview of ASL techniques, and to give examples of clinical use cases for various diseases affecting the central nervous system (CNS). There is a special focus on recent developments including super-selective ASL (ssASL) and time-resolved ASL-based magnetic resonance angiography (MRA) and on diseases commonly not leading to characteristic alterations on conventional structural MRI (e. g., concussion or migraine).

Results ASL-derived CBF may represent a clinically relevant parameter in various pathologies such as cerebrovascular diseases, neoplasms, or neurodegenerative diseases. Furthermore, ASL has also been used to investigate CBF in mild traumatic brain injury or migraine, potentially leading to the establishment of imaging-based biomarkers. Recent advances made possible the acquisition of ssASL by selective labeling of single brain-feeding arteries, enabling spatial perfusion territory mapping dependent on blood flow of a specific preselected artery. Furthermore, ASL-based MRA has been introduced, providing time-resolved delineation of single intracranial vessels.

Conclusion Perfusion imaging by ASL has shown promise in various diseases of the CNS. Given that ASL does not require intravenous administration of a gadolinium-based contrast agent, it may be of particular interest for investigations in pediatric cohorts, patients with impaired kidney function, patients with relevant allergies, or patients that undergo serial MRI for clinical indications such as disease monitoring.

Key Points:

ASL is an MRI technique that uses labeled blood-water as an endogenous tracer for brain perfusion imaging.
It allows the assessment of CBF without the need for administration of a gadolinium-based contrast agent.
CBF quantification by ASL has been used in several pathologies including brain tumors or neurodegenerative diseases.
Vessel-selective ASL methods can provide brain perfusion territory mapping in cerebrovascular diseases.
ASL may be of particular interest in patient cohorts with caveats concerning gadolinium administration.

Zusammenfassung

Hintergrund Arterial spin labeling (ASL) ist eine Technik der Magnetresonanztomographie (MRT), die eine Markierung des einströmenden Bluts der hirnversorgenden Arterien als endogenen Tracer verwendet, um Informationen über die Hirnperfusion zu generieren. Die Technik ermöglicht eine Untersuchung des zerebralen Blutflusses (CBF).

Methode Diese Übersichtsarbeit möchte einen methodischen und technischen Überblick über die ASL-Techniken vermitteln und Beispiele für klinische Anwendungsfälle anhand von verschiedenen Erkrankungen des zentralen Nervensystems (ZNS) vorstellen. Ein besonderer Fokus liegt dabei auf jüngsten Entwicklungen im Bereich der super-selektiven ASL (ssASL) und zeitaufgelösten ASL-basierten Magnetresonanz-Angiographie (MRA) sowie auf Erkrankungen, die üblicherweise nicht zu charakteristischen Veränderungen gemäß konventioneller struktureller MRT führen (beispielsweise Gehirnerschütterungen oder Migräne).

Ergebnisse Der aus ASL generierte CBF kann einen klinisch relevanten Parameter in Zusammenhang mit verschiedenen Pathologien des ZNS darstellen, wie zum Beispiel bei zerebrovaskulären Erkrankungen, Neoplasien oder neurodegenerativen Erkrankungen. Des Weiteren wurde ASL zur Untersuchung des CBF bei mildem Schädel-Hirn-Trauma oder auch bei Migräne angewendet, so dass potenziell bildbasierte Biomarker etabliert werden könnten. Neuere Entwicklungen ermöglichen zudem die Akquisition von ssASL über eine selektive Markierung einzelner hirnversorgender Arterien, was eine räumlich aufgelöste Kartierung von Perfusionsterritorien basierend auf dem Blutfluss eines spezifischen vorausgewählten Gefäßes zulässt. Daneben wurde auch eine ASL-basierte MRA umgesetzt, die eine zeitaufgelöste Darstellung einzelner intrakranieller Gefäßäste möglich macht.

Schlussfolgerung Perfusionsbildgebung mittels ASL kann insbesondere vielversprechend sein bei Untersuchungen in pädiatrischen Kohorten, bei Patienten mit eingeschränkter Nierenfunktion, Patienten mit relevanten Allergien oder Patienten mit wiederholten MRT-Bildgebungen aufgrund klinischer Indikationen wie beispielsweise zum Krankheitsmonitoring, da die Technik gänzlich ohne Gabe eines Gadolinium-haltigen Kontrastmittels auskommt.

Kernaussagen:

ASL ist eine Technik der MRT, welche die Markierung von einströmendem Blut als endogenem Tracer zur Perfusionsbildgebung verwendet.
ASL ermöglicht die Untersuchung des CBF ohne die Gabe von Gadolinium-haltigem Kontrastmittel.
Quantifizierungen des CBF mittels ASL wurden im Rahmen verschiedener Pathologien einschließlich Hirntumore und neurodegenerative Erkrankungen untersucht.
Gefäß-selektive ASL-Methoden ermöglichen Kartierungen der Hirnperfusion bei zerebrovaskulären Erkrankungen.
ASL kann insbesondere bei Patienten mit Kontraindikationen für die Gabe von Gadolinium von großer Bedeutung sein.

Zitierweise

Sollmann N, Hoffmann G, Schramm S et al. Arterial Spin Labeling (ASL) in Neuroradiological Diagnostics – Methodological Overview and Use Cases. Fortschr Röntgenstr 2024; 196: 36 – 51

Key words

arterial spin labeling - perfusion - cerebral blood flow - cerebrovascular disease - ischemia

Full Text

References

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