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©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
Prognostic value of arterial spin-labeling perfusion in anoxic brain injury: A retrospective cohort study
Bryce D Beutler, Daniel Antwi-Amoabeng, Dane Weinert, Ishan Shah, Mark B Ulanja, Alastair E Moody, Xiaomeng Lei, Alexander Lerner, Mark S Shiroishi, Reza Assadsangabi
Bryce D Beutler, Dane Weinert, Alexander Lerner, Reza Assadsangabi, Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
Daniel Antwi-Amoabeng, Department of Internal Medicine, Christus Ochsner St. Patrick Hospital, Lake Charles, LA 70601, United States
Ishan Shah, Department of Neurosurgery, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
Mark B Ulanja, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH 44195, United States
Alastair E Moody, Department of Anesthesiology, University of Utah, Salt Lake, UT 84132, United States
Xiaomeng Lei, Department of Radiology, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, United States
Mark S Shiroishi, Department of Radiology, Los Angeles General Medical Center, Los Angeles, CA 90033, United States
Author contributions: Beutler BD writing original draft; data curation; Antwi-Amoabeng D and Ulanja MB formal analysis and data curation; Weinert D conceptualization and data curation; Shah I formal analysis, writing review and editing; Moody AE writing review and editing and validation; Lei X formal analysis and validation; Lerner A conceptualization; Shiroishi MS writing review and editing; Assadsangabi R conceptualization; supervision.
Institutional review board statement: This study was approved by the Institutional Review Board of the University of Southern California, Keck School of Medicine, with a waiver of informed consent granted due to its retrospective design and use of de-identified patient data.
Informed consent statement: This study was approved by the Institutional Review Board of the University of Southern California, Keck School of Medicine, with a waiver of informed consent granted due to its retrospective design and use of de-identified patient data.
Conflict-of-interest statement: The authors declare no actual or potential conflicts of interest.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Bryce D Beutler, Academic Fellow, Department of Radiology, University of Southern California, Keck School of Medicine, 1500 San Pablo Street, Los Angeles, CA 90033, United States.
brycebeutler@hotmail.com
Received: June 24, 2025
Revised: July 4, 2025
Accepted: August 5, 2025
Published online: August 28, 2025
Processing time: 67 Days and 7 Hours
BACKGROUND
Anoxic brain injury is a potentially lethal condition characterized by cerebral hypoperfusion and irreversible neuronal injury. Arterial spin-labeling (ASL) perfusion and diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI) have been proposed as tools to detect cerebral ischemic changes and may aid in the assessment of anoxic injury.
AIM
To explore the relationship between regional ASL perfusion patterns and clinical outcomes following cardiac arrest.
METHODS
We performed a retrospective review to identify patients with clinical suspicion of anoxic brain injury who underwent MRI within 15 days of cardiac arrest. Receiver operator characteristic (ROC) analysis and univariate logistic regression were used to evaluate associations between ASL perfusion scores, DWI signal intensity, and the following clinical features: (1) Myoclonus status epilepticus (MSE) within 24 hours; (2) Absent extensor or motor reflexes (EMR) at day 3 post-arrest; and (3) Absent brainstem reflexes (BSR) within 15 days.
RESULTS
Twenty-eight patients met inclusion criteria. Increased ASL signal in the left occipital lobe was significantly associated with MSE (P = 0.038), while a trend was observed between right frontal ASL signal and EMR (P = 0.078). ROC analysis showed that ASL scores ≥ 7 were associated with higher odds of absent BSR (OR 2.14, P = 0.53), though this did not reach statistical significance. DWI signal intensity did not show significant associations with clinical outcomes. The overall discriminatory performance of ASL for predicting outcomes was limited (AUC ≈ 0.52).
CONCLUSION
This exploratory study suggests that regional ASL hyperperfusion, particularly in the left occipital and right frontal lobes, may be associated with adverse clinical signs following cardiac arrest. However, most findings did not reach statistical significance, and the study was underpowered to detect small-to-moderate effects. These preliminary results should be interpreted with caution and considered hypothesis-generating. Larger, prospective studies are warranted to clarify the prognostic value of ASL perfusion imaging in anoxic brain injury.
Core Tip: Anoxic brain injury is a devastating clinical entity characterized by severe cerebral hypoperfusion with resultant neuronal cell death. Arterial spin-labeling (ASL) perfusion and diffusion-weighted imaging magnetic resonance imaging has recently been used to detect global and focal cerebral ischemic changes that may play a role in the assessment of anoxic brain injury. In this retrospective cohort study, we found that elevated ASL signal involving the left occipital lobe and right frontal lobe is predictive of poor outcomes, suggesting that ASL signal may have important prognostic implications in the setting of anoxic brain injury.
