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Lesions, perilesional perfusion, and metabolic abnormalities were segmented and coregistered. Spatial overlap was quantified using DICE scores to compare functional modalities with each other (perfusion\u2010to\u2010metabolism: DICE\n P\u2010to\u2010M<\/jats:sub>\n ), with the lesion (metabolism\u2010to\u2010lesion: DICE\n M\u2010to\u2010L<\/jats:sub>\n ; perfusion\u2010to\u2010lesion: DICE\n P\u2010to\u2010L<\/jats:sub>\n ), and, in seizure\u2010free children, with the resection cavity (lesion\u2010, metabolism\u2010, perfusion\u2010to\u2010resection cavity: DICE\n L\u2010\/M\u2010\/P\u2010to\u2010Post<\/jats:sub>\n ). We also assessed the temporal stability of perilesional ASL abnormalities and the presence of remote ipsilateral\/contralateral abnormalities. Equivalence testing used the Wilcoxon signed\u2010rank equivalence test with FDG\u2010PET as reference; Cohen\n \u03ba<\/jats:italic>\n quantified agreement for remote abnormalities.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Fifteen children were included; median ages at FDG\u2010PET and ASL were 7.7 and 7.5\u2009years; 53% required sedation. Median perilesional volumes were 11\u2009339\u2009mm\n 3<\/jats:sup>\n (FDG\u2010PET) and 10\u2009791\u2009mm\n 3<\/jats:sup>\n (ASL); both were larger under sedation (\n p<\/jats:italic>\n \u2009<\u2009.001). Perilesional volumes were equivalent (\n p<\/jats:italic>\n \u2009=\u2009.037). Median DICE\n M\u2010to\u2010L<\/jats:sub>\n and DICE\n P\u2010to\u2010L<\/jats:sub>\n were .3 and .4; equivalence was confirmed (\n p<\/jats:italic>\n \u2009<\u2009.001). Median DICE\n P\u2010to\u2010M<\/jats:sub>\n was .7, indicating strong ASL\u2013FDG\u2010PET concordance. In seizure\u2010free children following surgery, DICE\n M\u2010to\u2010Post<\/jats:sub>\n and DICE\n P\u2010to\u2010Post<\/jats:sub>\n were both .6 and equivalent (\n p<\/jats:italic>\n \u2009=\u2009.01). ASL findings were stable over time (DICE = .27\u2013.75;\n n<\/jats:italic>\n \u2009=\u20094 with repeat ASL). Remote ipsilateral abnormalities were common (ASL 73%, FDG\u2010PET 67%;\n \u03ba<\/jats:italic>\n \u2009=\u2009.53), with poor contralateral agreement (\n \u03ba<\/jats:italic>\n \u2009=\u2009.12).\n <\/jats:p>\n <\/jats:sec>\n \n Significance<\/jats:title>\n ASL yielded perilesional findings equivalent to FDG\u2010PET and showed comparable overlap with the resection cavity in seizure\u2010free children. As a radiation\u2010free technique embedded into routine MRI, ASL reduces logistics and avoids an additional sedation session. These findings support ASL as a practical alternative to FDG\u2010PET for presurgical workup, especially when FDG\u2010PET access is limited.<\/jats:p>\n <\/jats:sec>","DOI":"10.1002\/epi.70199","type":"journal-article","created":{"date-parts":[[2026,3,14]],"date-time":"2026-03-14T10:52:41Z","timestamp":1773485561000},"page":"2940-2953","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Arterial spin labeling<\/scp>\n performs comparably to 2\u2010[\n 18<\/sup>\n F]fluoro\u20102\u2010deoxy\u2010D\u2010glucose positron emission tomography for presurgical evaluation in pediatric lesional epilepsy"],"prefix":"10.1002","volume":"67","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2224-0083","authenticated-orcid":false,"given":"Antonio Giulio","family":"Gennari","sequence":"first","affiliation":[{"name":"Department of Neuropediatrics University Children's Hospital Zurich Zurich Switzerland"},{"name":"MR\u2010Research 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Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0166-2770","authenticated-orcid":false,"given":"Raimund","family":"Kottke","sequence":"additional","affiliation":[{"name":"Department of Radiology University Children's Hospital Zurich Zurich Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1089-221X","authenticated-orcid":false,"given":"Niklaus","family":"Krayenb\u00fchl","sequence":"additional","affiliation":[{"name":"Division of Pediatric Neurosurgery University Children's Hospital Zurich Zurich Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7815-3048","authenticated-orcid":false,"given":"Michael","family":"Messerli","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine University Hospital Zurich Zurich Switzerland"},{"name":"University of Zurich Zurich 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