Objective Abnormalities in regional or global cerebral perfusion have been reported in SLE but their value in distinguishing lupus from non-lupus related diffuse neuropsychiatric events has not been determined. We examined whether the addition of dynamic susceptibility-contrast-enhanced T2*-weighted perfusion MRI (DSC-MRI), a non-invasive assessment of brain haemodynamic status, to the standard MRI examination suggested by the EULAR recommendations, may be of added value in the clinical diagnosis and attribution of neuropsychiatric SLE (NPSLE).

Patients and methods Seventy-six SLE patients (53 NPSLE, 23 non-NPSLE) and 31 healthy controls underwent conventional MRI (cMRI) and DSC-MRI. Attribution of NPSLE to lupus (primary NPSLE: n=37) or not (n=16) was based on multidisciplinary assessment including cMRI results and response to treatment. Cerebral blood volume (CBV) and cerebral blood flow (CBF) values were estimated in 18 normal-appearing white matter (NAWM) and deep grey matter (NADGM) areas. Perfusion differences among subgroups and their diagnostic utility were assessed using Analysis of Variance, Receiver Operating Characteristics, and Binary Logistic Regression analysis.

Results The most common manifestations were mood disorder, cognitive disorder and headache. The most common manifestations were mood disorder, cognitive disorder and headache. Primary NPSLE patients had lower cerebral blood flow and volume in several NAWM areas compared to controls (p<0.0001), and lower cerebral blood flow in the semioval centre bilaterally compared to non-NPSLE and non-primary NPSLE patients (p<0.001). A cut-off for cerebral blood flow of 0.77 in the left semioval centre discriminated primary NPSLE from non-NPSLE/non-primary NPSLE with 80% sensitivity and 67%–69% specificity. Blood flow values in the left semioval centre showed substantially higher sensitivity than cMRI (81% versus 19%–24%) for diagnosing primary NPSLE and the combination of the two modalities yielded 94%–100% specificity in discriminating primary from non-primary NPSLE.

Conclusion Primary NPSLE is characterised by significant hypoperfusion in white matter and deep grey matter areas that appear normal on conventional MRI sequences. Addition of cerebral blood flow in the semioval centre to conventional MRI techniques described in the EULAR NPSLE recommendations improves the diagnosis of primary NPSLE.