Despite this and other evidence for clinical impact on the management of brain tumor patients, technical aspects of DSC-MRI have not been standardized, which has hindered its widespread adoption and utilization for assessment of treatment response in multicenter therapeutic trials. Geer et al found that the addition of DSC-MRI increased the confidence of neuroradiologists and treating physicians in their assessment of tumor status in 40% and 56% of cases, respectively, with treatment modification in 8.5% of patients, 26 highlighting the potential clinical impact of DSC-MRI. 18вЂ“25 Use of DSC-MRI has consequently exploded over the past few decades, particularly in neuro-oncology. Since these beginnings, studies have shown that DSC-MRI may be more useful than standard MRI at predicting treatment-naГЇve glioma grade 3вЂ“8 and survival, 9вЂ“13 distinguishing posttreatment pseudoprogression (PsP) and radiation necrosis from recurrent tumor, 14вЂ“17 and predicting response to anti-angiogenic therapy. DSC-MRI was used to perform the first вЂњfunctionalвЂќ MRI experiments of task-induced brain activation, 2 and produce the first MRI-based CBV maps of gliomas. This technique, now widely known as dynamic susceptibility contrast (DSC) MRI, uses the magnetic susceptibility properties of paramagnetic contrast agents (gadolinium chelates or superparamagnetic nanoparticles) and T2 or T2*-weighted acquisitions. 1 The signal intensity-time curve could be converted into a concentration-time curve, enabling voxel-wise computation of cerebral blood volume (CBV). In 1990, Rosen et al demonstrated transiently decreased brain signal intensity after bolus administration of gadolinium-based contrast agent (GBCA).

When single-dose contrast agent usage is desired, no-preload, full-dose bolus dosing using low FA (30В°) and field strength-dependent TE provides excellent performance, with reduced contrast agent usage and elimination of potential systematic errors introduced by variations in preload dose and incubation time. In summary, full-dose preload, full-dose bolus dosing using intermediate (60В°) FA and field strength-dependent TE (40вЂ“50 ms at 1.5 T, 20вЂ“35 ms at 3 T) provides overall best accuracy and precision for cerebral blood volume estimates. After reviewing the basis for controversy over DSC-MRI protocols, this paper provides evidence-based best practices for clinical DSC-MRI as determined by the Committee, including pulse sequence (gradient echo vs spin echo), BTIP-compliant contrast agent dosing (preload and bolus), flip angle (FA), echo time (TE), and post-processing leakage correction. Recently, the DSC-MRI Standardization Subcommittee of the Jumpstarting Brain Tumor Drug Development Coalition issued an updated consensus DSC-MRI protocol compatible with the standardized brain tumor imaging protocol (BTIP) for high-grade gliomas that is increasingly used in the clinical setting and is the default MRI protocol for the National Clinical Trials Network. Despite the widespread clinical use of dynamic susceptibility contrast (DSC) MRI, DSC-MRI methodology has not been standardized, hindering its utilization for response assessment in multicenter trials.

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