Does arterial spin labelling represent a valid alternative to other MR perfusion techniques in neuro-oncology?

This review examines the distinctive role of arterial spin labelling (ASL) in neuro-oncology. ASL is a completely non-invasive MRI technique that quantifies cerebral perfusion without exogenous contrast agents, making it an attractive alternative to dynamic susceptibility contrast (DSC) and dynamic contrast-enhanced (DCE) perfusion-particularly WHEN gadolinium cannot be administered or when serial follow-up studies are required. Unlike DSC, ASL is immune to magnetic susceptibility artefacts, and, unlike DCE, it does not demand lengthy acquisitions or complex post-processing. The available evidence indicates that ASL performs well in grading gliomas and in characterizing brain metastases, lymphomas, and meningiomas. Its superiority over other perfusion methods becomes most apparent in longitudinal follow-up of cerebral gliomas, where it reliably tracks haemodynamic changes, and in assessing tumour-related conditions such as epilepsy and paraneoplastic syndromes. Overall, ASL offers a repeatable and dependable assessment of tumour perfusion and vascularity, thereby supporting more accurate diagnosis, grading, and treatment monitoring in neuro-oncology.