Perfusion imaging with arterial spin labeling (ASL)-MRI predicts malignant progression in low‑grade (WHO grade II) gliomas

Christina M Flies, Tom J Snijders, Tom Van Seeters, Marion Smits, Filip Y F De Vos, Jeroen Hendrikse, Jan Willem Dankbaar

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PURPOSE: Predicting malignant progression of grade II gliomas would allow for earlier initiation of treatment. The hypothesis for this single-centre, case-control study was that the perfusion signal on ASL-MRI predicts such malignant progression in the following 12 months.

METHODS: Consecutive patients with the following criteria were included: ≥ 18 years, grade II glioma (biopsied or resected) and an ASL-MRI 6-12 months prior to malignant progression (cases) or stable disease (controls). Malignant progression was defined either radiologically (new T1w-contrast enhancement) or histologically (neurosurgical tissue sampling). Three controls were matched with each case. Some patients served as their own control by using earlier imaging. The ASL-MRIs were reviewed by two neuroradiologists and classified as positive (hyper-intense or iso-intense compared to cortical grey matter) or negative (hypo-intense). In patients with epilepsy, a neurologist reviewed clinicoradiological data to exclude peri-ictal pseudoprogression. The statistical analysis included diagnostic test properties, a Cohen's Kappa interrater reliability coefficient and stratification for previous radiotherapy.

RESULTS: Eleven cases (median age = 48, IQR = 43-50 years) and 33 controls (43, 27-50 years) were included. Malignant progression appeared at 37 months (median, IQR = 17-44) after first surgery. Thirty ASL-MRIs were assessed as negative and 14 as positive. None of the MRIs showed signs of peri-ictal pseudoprogression. ASL significantly predicted subsequent malignant progression (sensitivity = 73%; specificity = 82%; OR = 12; 95%-CI = 2.4-59.1; p = 0.002). The interrater reliability coefficient was 0.65. In stratified analysis, ASL-MRI predicted malignant progression both in patients with previous radiotherapy and in those without (Mantel-Haenszel test, p = 0.003).

CONCLUSION: Perfusion imaging with ASL-MRI can predict malignant progression within 12 months in patients with grade II glioma.

Original languageEnglish
Pages (from-to)2023-2033
Number of pages11
Issue number12
Early online date11 Jun 2021
Publication statusPublished - Dec 2021


  • Arterial spin labeling
  • Low-grade glioma
  • Malignant progression
  • Perfusion MRI


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