It is known that if labeling parameters are not properly adjusted in the presence of prolonged arterial transit delays (ATDs), perfusion may be underestimated using arterial spin labeling (ASL), yielding false negatives and possibly unnecessary interventions. In this study we evaluate the cases where the prolonged ATDs due to cerebrovascular disease posed challenges to perfusion quantification using ASL. Some possible solutions, which we term ‘extreme ASL’, were explored and discussed.
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