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Meta-analysis finds no significant differences between pCASL and DSC perfusion MRI in hyperacute ischemic strokeMRI technique shows promise for stroke imaging but evidence remains limited

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Key Takeaway
Consider pCASL MRI perfusion findings in hyperacute stroke as preliminary; evidence remains limited for reliability and comparability.

A systematic review and meta-analysis examined the reliability of pseudocontinuous arterial spin-labeling (pCASL) MRI in ischemic stroke and its comparability with other perfusion techniques. The analysis included data from 383 participants with ischemic stroke, comparing pCASL against dynamic susceptibility contrast (DSC) MRI, computed tomography perfusion (CTP), and positron emission tomography (PET). The primary outcome was test-retest reliability of pCASL-derived cerebral blood flow measurements.

For the hyperacute phase of ischemic stroke, the analysis found no significant differences between pCASL and DSC MRI for infarct core relative CBF (95% CI, -0.11 to 0.13) or for hypoperfusion volumes (95% CI, -0.28 to 0.68). The single study assessing test-retest reliability reported no significant differences in repeated absolute CBF measurements over time, with excellent reliability across regions, though specific effect sizes and absolute numbers were not reported.

Safety and tolerability data were not reported. Key limitations include a small number of included studies that prevented meta-analysis for the primary outcome, only 1 low-quality, high-risk-of-bias study assessed test-retest reliability, and evidence on comparability with other techniques was limited. No PET studies were identified for comparison. The authors note robust conclusions could not be drawn due to limited evidence.

For clinical practice, this analysis suggests pCASL may show promise for perfusion assessment in hyperacute ischemic stroke when compared with DSC MRI, but the evidence base remains insufficient to support definitive conclusions about its reliability or broader comparability with established techniques. Further high-quality studies are needed before clinical implementation can be recommended.

Researchers conducted a review of existing studies to examine a specific type of MRI scan called pseudocontinuous arterial spin-labeling (pCASL). This technique measures blood flow in the brain without needing an injected dye. The review focused on how reliable this method is for people who have had an ischemic stroke and how it compares to other common imaging tests like contrast-enhanced MRI or CT perfusion scans.

The analysis included data from 383 stroke patients across multiple studies. The main finding was that in the very early hours after a stroke (the hyperacute phase), pCASL measurements of damaged brain tissue and low blood flow areas showed no significant differences compared to a standard contrast MRI method. This suggests the two methods might give similar results for these specific measurements during that critical time window.

However, the researchers strongly caution that the overall evidence is very thin. Only one study, which was considered low quality, looked at whether pCASL gives consistent results when repeated. There were not enough studies to draw firm conclusions about how pCASL compares to other techniques in different stages after a stroke or to methods like PET scans. No safety concerns were specifically reported in the review.

Readers should understand that this review highlights early, incomplete evidence. It suggests pCASL could be a useful tool for stroke imaging, but the findings are not yet strong enough to change clinical practice. More and better-quality studies are necessary to confirm if this dye-free MRI technique is truly reliable and comparable to current standard methods.

What this means for you:
Early review finds a dye-free MRI method may work for stroke imaging, but evidence is too limited for firm conclusions.

Study Details

Study typeMeta analysis
Sample sizen = 383
EvidenceLevel 1
PublishedApr 2026
View Original Abstract ↓
BACKGROUND: Pseudocontinuous arterial spin-labeling (pCASL) is a noninvasive, gadolinium-free MRI technique for assessing brain perfusion. PURPOSE: The test-retest reliability of pCASL-derived CBF measurements in ischemic stroke (IS) were evaluated and pCASL metrics were compared with those from DSC, CTP, and PET. DATA SOURCES: Systematic searches were conducted in MEDLINE, EMBASE, and LILACS. Risk of bias and methodologic quality were evaluated using QUADAS-2 and Quality Appraisal for Reliability Studies tools. STUDY SELECTION: Eleven studies, encompassing 383 participants with IS were included. DATA ANALYSIS: Random-effects meta-analysis with inverse variance method and heterogeneity assessed using statistics were used. DATA SYNTHESIS: No PET studies were identified. Only 1 low-quality, high-risk-of-bias study assessed test-retest reliability, finding no significant differences in repeated absolute CBF measurements over time and excellent reliability across regions. Most studies comparing pCASL with DSC, and all comparing pCASL with CTP, had a low risk of bias. In the hyperacute phase of IS, pCASL and DSC showed no significant differences in infarct core relative CBF (95% CI, -0.11 to 0.13; = 0%) or hypoperfusion volumes (95% CI, -0.28 to 0.68; = 69%). Evidence on the comparability of pCASL with other DSC or CTP metrics was limited. LIMITATIONS: The small number of included studies prevented a meta-analysis for the primary outcome and limited conclusions for secondary outcomes. CONCLUSIONS: Robust conclusions about the test-retest reliability of pCASL or the comparability of metrics obtained with this technique and DSC, CTP, or PET in different phases after IS could not be drawn.
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