CBF quantification using ASL is an important MR technique for the evaluation of suspicious enhancing lesions for patients’ status post chemotherapy treatment. The quantification requires an estimate of equilibrium magnetization of blood which is often obtained using a set of proton density (PD) reference images; however, this approach can lead to errors in CBF based on tissue variation in PD which could then lead to inaccurate assessment of pseudo-progression (PsP) versus true progression (TP). Our work showed that PD variation led to a reduced diagnostic performance of CBF particularly in the region of enhancing lesions with pathologic proven TP.
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