Apparent posterior cerebral artery territory perfusion asymmetry on arterial spin labeling MRI is a common non-pathologic finding in patients with a unilateral fetal posterior cerebral artery

PURPOSE: To determine the frequency of apparent posterior cerebral artery (PCA) territory asymmetry seen on arterial spin labeling (ASL) imaging in patients with a unilateral fetal PCA, but without underlying clinical or imaging pathology to suggest true hypoperfusion. METHODS: A search of radiology reports from 1/2017 through 6/2020 was performed with the inclusion term "fetal PCA.” Eighty patients were included with unilateral fetal PCA confirmed on MRA or CTA, with brain MRI including ASL imaging, and without conventional imaging abnormality or clinical symptoms referable to the PCA territories. Cases were evaluated by two independent readers for visually apparent PCA perfusion asymmetries. ASL imaging consisted of pseudocontinuous ASL with 1.5 s labeling duration and 2 s post-labeling delay adapted from white paper recommendations. RESULTS: Thirteen of 80 cases (16.2%) had apparent hypoperfusion in the PCA territory contralateral to the side of the fetal PCA. Agreement between readers was near perfect (97.5%, κ = 0.91). This finding was more common in patients who were older, scanned on a 3.0 T magnet, and who had non-visualization of the posterior communicating artery contralateral to the fetal PCA. CONCLUSION: Apparent PCA hypoperfusion on ASL is not uncommon in patients with a contralateral fetal PCA who have no clinical or conventional imaging findings to suggest true hypoperfusion. This phenomenon is likely due to differential blood velocities between the carotid and vertebral arteries that result in differential arterial transit times and labeling efficiency. It is important for radiologists to know that apparent hypoperfusion may arise from variant circle of Willis anatomy.