J Korean Neurosurg Soc.  2013 Oct;54(4):302-308. 10.3340/jkns.2013.54.4.302.

The Usefulness of the Ivy Sign on Fluid-Attenuated Intensity Recovery Images in Improved Brain Hemodynamic Changes after Superficial Temporal Artery-Middle Cerebral Artery Anastomosis in Adult Patients with Moyamoya Disease

• Lee JK
• Yoon BH
• Chung SY
• Park MS
• Kim SM
• Lee DS

• KMID: 1499335
• DOI: http://doi.org/10.3340/jkns.2013.54.4.302

Abstract

OBJECTIVE
MR perfusion and single photon emission computerized tomography (SPECT) are well known imaging studies to evaluate hemodynamic change between prior to and following superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis in moyamoya disease. But their side effects and invasiveness make discomfort to patients. We evaluated the ivy sign on MR fluid attenuated inversion recovery (FLAIR) images in adult patients with moyamoya disease and compared it with result of SPECT and MR perfusion images.
METHODS
We enrolled twelve patients (thirteen cases) who were diagnosed with moyamoya disease and underwent STA-MCA anastomosis at our medical institution during a period ranging from September of 2010 to December of 2012. The presence of the ivy sign on MR FLAIR images was classified as Negative (0), Minimal (1), and Positive (2). Regions were classified into four territories: the anterior cerebral artery (ACA), the anterior MCA, the posterior MCA and the posterior cerebral artery.
RESULTS
Ivy signs on preoperative and postoperative MR FLAIR were improved (8 and 4 in the ACA regions, 13 and 4 in the anterior MCA regions and 19 and 9 in the posterior MCA regions). Like this result, the cerebrovascular reserve (CVR) on SPECT was significantly increased in the sum of CVR in same regions after STA-MCA anastomosis.
CONCLUSION
After STA-MCA anastomosis, ivy signs were decreased in the cerebral hemisphere. As compared with conventional diagnostic modalities such as SPECT and MR perfusion images, the ivy sign on MR FLAIR is considered as a useful indicator in detecting brain hemodynamic changes between preoperatively and postoperatively in adult moyamoya patients.

Keyword

Adult moyamoya; Ivy sign; MR FLAIR; STA-MCA anastomosis

MeSH Terms

Adult*
Anterior Cerebral Artery
Brain*
Cerebral Arteries*
Cerebrum
Hemodynamics*
Humans
Moyamoya Disease*
Perfusion
Temporal Arteries
Tomography, Emission-Computed, Single-Photon

Figure

• 

  Fig. 1 The ivy sign is referred to as leptomeningeal high-signal intensity on FLAIR images along cerebral sulci. White arrows indicate ivy signs on bilateral hemispheres of moyamoya patient (A). Regions on bilateral hemispheres were classified into four territories16) (AJNR Am J Neuroradiol 20 : 336-343, 1999) : Red line - ACA, Green line - the anterior-MCA, Pupple line - the posterior MCA, Yellow line - PCA (B). ACA : Anterior cerebral artery, MCA : Middle cerebral artery, PCA : posterior cerebral artery, FLAIR : fluid-attenuated inversion recovery.

• 

  Fig. 2 A 36-year-old man with moyamoya disease who got the bilateral STA-MCA anastomosis surgery in our hospital. In the preoperative TFCA image, white arrows indicate moyamoya vessels on bilateral ICA (A). No vascular supply to intracranial region via ECA (B). STA-MCA anastomosis was done on bilateral hemisphere and well intracranial blood flow was checked from STA to MCA via anastomosis site in the postoperative TFCA image (C). TFCA : transfemoral cerebral angiography, STA : superficial temporal artery, ICA : internal carotid artery, ECA : external carotid artery, MCA : middle cerebral artery.

• 

  Fig. 3 Same patient with Fig. 2. Ivy sign was checked on bilateral hemispheres by indicating white arrows (A) and compared preoperative MR with postoperative MR FLAIR image, ivy sign was disappeared on bilateral hemispheres by indicating white arrows (B). Like MR FLAIR images, compared with preoperative SPECT and postoperative SPECT, CVR was increased on bilateral hemisphere before surgical treatment by indicating white arrowheads (C and D). SPECT : single photon emission computerized tomography, CVR : cerebrovascular reserve, FLAIR : fluid-attenuated inversion recovery.

• 

  Fig. 4 A 64-year-old woman with moyamoya disease. White arrowheads indicate the decreased CVR with SPECT images (A). The patient got the surgery, and decreased CVR was normalization on SPECT images after 1 month (B). CVR : cerebrovascular reserve, SPECT : single photon emission computerized tomography.

• 

  Fig. 5 Same patient with Fig. 4. We compared ivy sign on MR FLAIR image with MTT on MR perfusion image. Preoperatively, white arrows indicate the ivy signs on MR FLAIR image (A) and those were decreased on MR FLAIR images after surgery (B). MTT prolongation was observed on MR perfusion images in the right MCA territory in the preoperative state by indicating white arrows, and after surgery, MTT prolongation was improved on MR perfusion images like ivy signs on MR FLAIR images (C and D). MTT : mean transit time, FLAIR : fluid-attenuated inversion recovery.

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