Acetazolamide-Challenged Arterial Spin Labeling Detects Augmented Cerebrovascular Reserve After Surgery for Moyamoya

Stroke ◽  
2021 ◽  
Author(s):  
Vaishnavi L. Rao ◽  
Laura M. Prolo ◽  
Jonathan D. Santoro ◽  
Michael Zhang ◽  
Jennifer L. Quon ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Arterial Spin Labeling ◽  
Pediatric Patients ◽  
Stroke Risk ◽  
Anterior Cerebral Artery ◽  
Spin Labeling ◽  
Cerebrovascular Reserve ◽  
Revascularization Surgery

Background and Purpose: Cerebrovascular reserve (CVR) inversely correlates with stroke risk in children with Moyamoya disease and may be improved by revascularization surgery. We hypothesized that acetazolamide-challenged arterial spin labeling MR perfusion quantifies augmentation of CVR achieved by revascularization and correlates with currently accepted angiographic scoring criteria. Methods: We retrospectively identified pediatric patients with Moyamoya disease or syndrome who received cerebral revascularization at ≤18 years of age between 2012 and 2019 at our institution. Using acetazolamide-challenged arterial spin labeling, we compared postoperative CVR to corresponding preoperative values and to postoperative perfusion outcomes classified by Matsushima grading. Results: In this cohort, 32 patients (17 males) with Moyamoya underwent 29 direct and 16 indirect extracranial-intracranial bypasses at a median 9.7 years of age (interquartile range, 7.6–15.7). Following revascularization, median CVR increased within the ipsilateral middle cerebral artery territory (6.9 mL/100 g per minute preoperatively versus 16.5 mL/100 g per minute postoperatively, P <0.01). No differences were observed in the ipsilateral anterior cerebral artery ( P =0.13) and posterior cerebral artery ( P =0.48) territories. Postoperative CVR was higher in the ipsilateral middle cerebral artery territories of patients who achieved Matsushima grade A perfusion, in comparison to those with grades B or C (25.8 versus 17.5 mL, P =0.02). The method of bypass (direct or indirect) did not alter relative increases in CVR (8 versus 3.8 mL/100 g per minute, P =0.7). Conclusions: Acetazolamide-challenged arterial spin labeling noninvasively quantifies augmentation of CVR following surgery for Moyamoya disease and syndrome.

Arterial spin-labeling cerebral perfusion changes after revascularization surgery in pediatric moyamoya disease and syndrome

2019 ◽  
Vol 23 (4) ◽  
pp. 486-492 ◽  
Author(s):  
Jennifer L. Quon ◽  
Lily H. Kim ◽  
Robert M. Lober ◽  
Maryam Maleki ◽  
Gary K. Steinberg ◽  
...  
Keyword(s):  
Basal Ganglia ◽  
Middle Cerebral Artery ◽  
Moyamoya Disease ◽  
Arterial Spin Labeling ◽  
Cerebral Perfusion ◽  
Spin Labeling ◽  
Middle Cerebral Artery Territory ◽  
Moyamoya Syndrome ◽  
Hemodynamic Changes ◽  
Revascularization Surgery

OBJECTIVEMoyamoya disease is a dynamic cerebrovascular condition that often requires vascular surveillance. Arterial spin labeling (ASL) is an MR perfusion method that is increasingly used for stroke and other various neurovascular pathologies. Unlike perfusion-weighted MRI, ASL uses endogenous water molecules for signal and therefore obviates gadolinium use; and provides direct, not relative, quantitative cerebral blood flow (CBF) measures. Presently, the potential role of ASL for evaluating postoperative pediatric moyamoya patients is relatively unexplored. This study investigated the role for ASL in evaluating cerebral hemodynamic changes in children who underwent revascularization surgery.METHODSThis retrospective study examined 15 consecutive pediatric patients with moyamoya disease (n = 7) or moyamoya syndrome (n = 8) presenting between 2010 and 2014 who underwent revascularization and in whom 3T ASL was performed pre- and postoperatively. Postoperative MRI at least 3 months after revascularization procedure was used for analysis. Quantitative CBF in various vascular territories was interrogated: anterior, middle, and posterior cerebral arteries, and basal ganglia supplied by the lenticulostriate collaterals, resulting in evaluation of 20 brain regions.RESULTSAfter revascularization, CBF in the high middle cerebral artery territory significantly increased (p = 0.0059), accompanied by a decrease in CBF to the ipsilateral lenticulostriate-supplied basal ganglia (p = 0.0053). No perfusion changes occurred in the remaining cerebral vascular territories after surgery.CONCLUSIONSASL-based quantitative CBF showed improved cerebral perfusion to the middle cerebral artery territory after revascularization in children with both moyamoya syndrome and disease. Reduced perfusion to the basal ganglia might reflect pruning of the lenticulostriate collaterals, potentially from effects of revascularization. ASL can quantitatively evaluate hemodynamic changes in children with moyamoya after revascularization, and it may be a useful adjunct to routine clinical MRI surveillance.

scholarly journals Posterior cerebral artery stenosis and posterior circulation revascularization surgery in pediatric patients with moyamoya disease

2018 ◽  
Vol 21 (6) ◽  
pp. 632-638 ◽  
Author(s):  
Tomomi Kimiwada ◽  
Toshiaki Hayashi ◽  
Reizo Shirane ◽  
Teiji Tominaga
Keyword(s):  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Pediatric Patients ◽  
Posterior Cerebral Artery ◽  
Posterior Circulation ◽  
Initial Diagnosis ◽  
Occipital Artery ◽  
Anterior Circulation ◽  
Before And After ◽  
Revascularization Surgery

OBJECTIVESome pediatric patients with moyamoya disease (MMD) present with posterior cerebral artery (PCA) stenosis before and after anterior circulation revascularization surgery and require posterior circulation revascularization surgery. This study evaluated the factors associated with PCA stenosis and assessed the efficacy of posterior circulation revascularization surgery, including occipital artery (OA)–PCA bypass, in pediatric patients with MMD.METHODSThe presence of PCA stenosis before and after anterior circulation revascularization surgery and its clinical characteristics were investigated in 62 pediatric patients (< 16 years of age) with MMD.RESULTSTwenty-three pediatric patients (37%) with MMD presented with PCA stenosis at the time of the initial diagnosis. A strong correlation between the presence of infarction and PCA stenosis before anterior revascularization was observed (p < 0.001). In addition, progressive PCA stenosis was observed in 12 patients (19.4%) after anterior revascularization. The presence of infarction and a younger age at the time of initial diagnosis were risk factors for progressive PCA stenosis after anterior revascularization (p < 0.001 and p = 0.002, respectively). Posterior circulation revascularization surgery, including OA-PCA bypass, was performed in 9 of the 12 patients with progressive PCA stenosis, all of whom showed symptomatic and/or radiological improvement.CONCLUSIONSPCA stenosis is an important clinical factor related to poor prognosis in pediatric MMD. One should be aware of the possibility of progressive PCA stenosis during the postoperative follow-up period and consider performing posterior circulation revascularization surgery.

ADDITIONAL SURGERY FOR POSTOPERATIVE ISCHEMIC SYMPTOMS IN PATIENTS WITH MOYAMOYA DISEASE

Neurosurgery ◽  
2009 ◽  
Vol 64 (1) ◽  
pp. E195-E196 ◽  
Author(s):  
Toshiaki Hayashi ◽  
Reizo Shirane ◽  
Teiji Tominaga
Keyword(s):  
Magnetic Resonance ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Transient Ischemic Attack ◽  
Anterior Cerebral Artery ◽  
Additional Surgery ◽  
Indirect Revascularization ◽  
Ischemic Attack ◽  
Revascularization Surgery

Abstract OBJECTIVE In patients with moyamoya disease, surgery to revascularize the ischemic brain is a recommended treatment. However, there are a few patients who require additional revascularization surgery because of progression of the disease. Even patients who show no postoperative ischemic symptoms at first may experience late deterioration. We performed additional surgery for such lesions using occipital artery (OA)–posterior cerebral artery (PCA) bypass with indirect revascularization. The efficacy of the procedure is reported. METHODS We treated 3 patients with moyamoya disease who showed a transient ischemic attack after revascularization surgery. Three female patients, ranging in age from 6.0 to 35.2 years (mean age, 23.8 years) at the time of surgery, with ischemic symptoms (leg monoparesis in 2, visual impairment in 1) underwent the additional revascularization procedure. Preoperatively, all patients underwent indirect and/or direct revascularization surgery for initial treatment. All patients showed progression of the disease, especially in the PCA. OA–PCA bypass with encephalogaleodurosynangiosis and burr hole surgery were performed for postoperative ischemic symptoms. RESULTS All patients showed clinical and radiological improvement. The transient ischemic attack was improved in all 3 patients. They did not complain of transient ischemic attack in the recent follow-up period. Follow-up magnetic resonance imaging showed no additional cerebral infarction. Magnetic resonance angiography showed widening of the OA and development of peripheral collateral vessels. Postoperative single-photon emission computed tomographic studies showed marked increase of uptake in both anterior cerebral artery and PCA territories. Cerebral vasodilatory capacity evaluated by an acetazolamide test also showed marked improvement. One patient showed postoperative cerebral edema as a result of focal cerebral hyperperfusion. CONCLUSION OA–PCA anastomosis with indirect revascularization was effective for postoperative ischemia that showed symptoms in the anterior cerebral artery and PCA territories as a result of progression of a PCA lesion.

Abstract WP48: Relationship of Cerebral Blood Flow by Pseudo-continuous Arterial Spin Labeling and Stenosis in Middle Cerebral Artery Territory in Patients Evaluated for Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Eric Lai ◽  
Raja Rizal Azman Raja Aman ◽  
Hui Zhang ◽  
Pui-Wai Chiu ◽  
Queenie Chan ◽  
...  
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Arterial Spin Labeling ◽  
Spin Labeling ◽  
Arterial Stenosis ◽  
Vascular Territory

Purpose: Correlation of arterial stenosis with cortical and subcortical cerebral blood flow (CBF) in the middle cerebral artery (MCA) territory. Methods: 126 patients with acute cerebrovascular symptoms from March to June 2015 underwent MRI and MR Angiography (MRA) in a University hospital using a 3.0 Tesla scanner. Sequences included T1W, T2W, FLAIR, DWI, MRA, Pseudocontinuous Arterial Spin Labeling (pcASL, post-labeling delay 1.525 s). 13 patients (corrupted pcASL data) were excluded, with 113 patients (mean age: 67.74±14.19) evaluated (61 acute ischemic stroke, 52 patients transient ischemic attack). Institutionally developed software was used to determine CBF. MCA stenosis was graded into 4 categories by a neuroradiologist: 0 (no stenosis), 1 (mild <50%), 2 (moderate 50-70%) and 3 (severe >70%). Mean and standard deviation of MCA categories (leptomeningeal and perforating) CBF and corresponding degree of MCA stenosis were measured. Spearman correlation coefficients between CBF of cortical and subcortical regions and degree of MCA stenoses were calculated using SPSS (version 23.0). Results: The table showed the descriptive statistics. There was significant correlation between CBF of cortical region of MCA vascular territory and degree of stenosis of MCA in both left (r s = -0.296, p =0.001) and right (r s = -0.306, p =0.001) side. In the contrary, there was no correlation between subcortical CBF of MCA vascular territory and degree of stenosis of MCA in both sides. Conclusion: pcASL is a feasible non-invasive method to measure CBF in clinical setting. In MCA territory, the cortical blood flow correlated (fairly) with large vessel stenosis but not subcortical flow. We conclude that cortical CBF correlated with large artery stenosis, though being attenuated by collateral blood supply. No such relationship in subcortical CBF might be due to differential grey and white matter CBF flow, variable MCA stenotic location, and perforators originating from other territories.

Robust visualization of middle cerebral artery main trunk by enhanced acceleration-selective arterial spin labeling (eAccASL) for intracranial MRA

2018 ◽  
Vol 81 (5) ◽  
pp. 3185-3191 ◽  
Author(s):  
Yuta Akamine ◽  
Makoto Obara ◽  
Osamu Togao ◽  
Shuhei Shibukawa ◽  
Masami Yoneyama ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Arterial Spin Labeling ◽  
Spin Labeling ◽  
Main Trunk

The Accessory Middle Cerebral Artery: Anatomic Report

2008 ◽  
Vol 63 (suppl_1) ◽  
pp. ONS10-ONS14 ◽  
Author(s):  
Cassius V.C. Reis ◽  
Joseph M. Zabramski ◽  
Sam Safavi-Abbasi ◽  
Ricardo A. Hanel ◽  
Pushpa Deshmukh ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Inferior Frontal Gyrus ◽  
Cerebral Aneurysms ◽  
Optic Chiasm ◽  
Inferior Surface ◽  
Increased Risk ◽  
Accessory Middle Cerebral Artery

Abstract Objective: An accessory middle cerebral artery (MCA) usually originates between the A1 and proximal A2 segment of the anterior cerebral artery, reaches the sylvian fissure, and supplies the territory of the MCA. This anomaly has been associated with cerebral aneurysms and Moyamoya disease. We report an accessory MCA arising from the A2 segment. Methods: A cadaveric head, fixed in formalin solution and injected with red and blue silicone on its vascular tree to trace intracranial and extracranial vessels, was dissected. Results: An accessory MCA was found arising from the A2 segment of the anterior cerebral artery and feeding the basal and inferior surface of the inferior frontal gyrus. In our specimen, the vessel was associated with intracranial aneurysms at other locations. Conclusion: Although anomalies of the MCA are rare, neurosurgeons must be familiar with such anatomic variations. An accessory MCA can be associated with Moyamoya disease and aneurysms at its junction with the anterior cerebral artery. Patients with this anomaly may, therefore, have an increased risk for developing aneurysms and other neurovascular complications. By obstructing the surgical view, an accessory MCA may increase the difficulty of exposing lesions in the vicinity of the optic chiasm.

scholarly journals Collateral perfusion using arterial spin labeling in symptomatic versus asymptomatic middle cerebral artery stenosis

2017 ◽  
Vol 39 (1) ◽  
pp. 108-117 ◽  
Author(s):  
Xin Lou ◽  
Xiaoxiao Ma ◽  
David S Liebeskind ◽  
Ning Ma ◽  
Chenglin Tian ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Arterial Spin Labeling ◽  
Three Dimensional ◽  
Spin Labeling ◽  
Asymptomatic Group ◽  
Asymptomatic Patients ◽  
The Difference ◽  
Continuous Arterial Spin Labeling ◽  
Antegrade Flow

The purpose was to assess the difference of collaterals in symptomatic versus asymptomatic patients with unilateral middle cerebral artery (MCA) stenosis by comparing cerebral blood flow (CBF) at two post labeling delays (PLD) using three-dimensional pseudo-continuous arterial spin labeling (3D pCASL). Eighty-one patients (49 symptomatic and 32 asymptomatic) with unilateral MCA stenosis ≥50% who underwent pCASL with two PLDs were included. Mean CBF and CBF subtraction images between two PLDs of MCA territories were compared in symptomatic and asymptomatic groups, respectively. Compared with the asymptomatic group, patients with symptomatic MCA stenosis had significantly lower CBF in the MCA territory of stenotic side at each PLD. The CBF of stenotic territory showed greater increase than that of normal side from PLD 1.5 to 2.5 s. The CBF of asymptomatic MCA territory increased similarly with that of symptomatic MCA territory from PLD of 1.5 to 2.5 s in stenotic side, while symptomatic patients experienced significantly slower antegrade flow. On CBF subtraction images, asymptomatic patients showed larger volume of differences between PLD of 1.5 and 2.5 s compared with those of symptomatic patients ( p = 0.037). The results suggest that more robust collateral perfusion on two-delay 3D pCASL is present in asymptomatic patients compared with symptomatic patients.

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