ArticleNeuroradiology2026
Diagnostic value of 3D pCASL perfusion in glioma grading according to the WHO 2021 classification: a retrospective study of 530 cases.
Article in Neuroradiology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
purposeTo evaluate the diagnostic performance of three-dimensional pseudo-continuous arterial spin labeling (3D pCASL) for preoperative grading of gliomas within the 2021 WHO classification framework and to assess protocol-specific tumor blood flow thresholds for differentiating CNS WHO grade 2 from grade 3-4 tumors.
methodsThis retrospective single-center study included 530 patients with newly diagnosed supratentorial glial tumors examined between 2011 and 2024. Nineteen non-diffuse CNS WHO grade 1 tumors were retained for descriptive purposes only and excluded from all grading analyses; the primary analytical cohort therefore comprised 511 gliomas (grade 2, n = 75; grade 3, n = 152; grade 4, n = 284). Diagnoses were reassigned within the WHO 2021 framework using the histological and molecular information available for each patient; tumors lacking molecular information required for an integrated WHO diagnosis were designated NOS. All patients underwent 3.0 T MRI with 3D pCASL. Maximum tumor blood flow (maxTBF) and normalized TBF relative to white matter (nTBF WM) and gray matter (nTBF GM) were measured using approximately 30-mm² hotspot ROIs.
resultsIn gliomas, maxTBF, nTBF WM, and nTBF GM differentiated grade 2 from grade 3-4 tumors, with AUCs of 0.848, 0.833, and 0.84, respectively. The maxTBF threshold was 63.3 mL/100 g/min; AUCs were 0.743-0.768 for grade 2 versus grade 3 and 0.668-0.715 for grade 3 versus grade 4. After exclusion of NOS cases, glioblastomas and grade 4 astrocytomas did not differ significantly in maxTBF or nTBF (pfdr > 0.05). 3D pCASL also differentiated non-enhancing glioblastomas from grade 2 astrocytomas (maxTBF, pfdr = 0.0018; nTBF, pfdr = 0.0036-0.006), with AUCs of 0.78-0.86, a maxTBF cutoff of 64.1 mL/100 g/min, and specificity up to 96%. maxTBF and nTBF moderately correlated with Ki-67 (r = 0.44-0.50; pfdr < 0.001).
conclusions3D pCASL provides high diagnostic accuracy for differentiating grade 2 gliomas from high-grade gliomas and grade 2 from grade 3 tumors within the WHO 2021 framework, while remaining fully non-invasive and requiring no contrast agent.
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