Yonsei Med J.  2015 Sep;56(5):1322-1327. 10.3349/ymj.2015.56.5.1322.

Ivy Sign on Fluid-Attenuated Inversion Recovery Images in Moyamoya Disease: Correlation with Clinical Severity and Old Brain Lesions

• Seo KD
• Suh SH
• Kim YB
• Kim JH
• Ahn SJ
• Kim DS
• Lee KY

• KMID: 2163624
• DOI: http://doi.org/10.3349/ymj.2015.56.5.1322

Abstract

PURPOSE
Leptomeningeal collateral, in moyamoya disease (MMD), appears as an ivy sign on fluid-attenuated inversion-recovery (FLAIR) images. There has been little investigation into the relationship between presentation of ivy signs and old brain lesions. We aimed to evaluate clinical significance of ivy signs and whether they correlate with old brain lesions and the severity of clinical symptoms in patients with MMD.
MATERIALS AND METHODS
FLAIR images of 83 patients were reviewed. Each cerebral hemisphere was divided into 4 regions and each region was scored based on the prominence of the ivy sign. Total ivy score (TIS) was defined as the sum of the scores from the eight regions and dominant hemispheric ivy sign (DHI) was determined by comparing the ivy scores from each hemisphere. According to the degree of ischemic symptoms, patients were classified into four subgroups: 1) nonspecific symptoms without motor weakness, 2) single transient ischemic attack (TIA), 3) recurrent TIA, or 4) complete stroke.
RESULTS
TIS was significantly different as follows: 4.86+/-2.55 in patients with nonspecific symptoms, 5.89+/-3.10 in patients with single TIA, 9.60+/-3.98 in patients with recurrent TIA and 8.37+/-3.39 in patients with complete stroke (p=0.003). TIS associated with old lesions was significantly higher than those not associated with old lesions (9.35+/-4.22 vs. 7.49+/-3.37, p=0.032). We found a significant correlation between DHI and motor symptoms (p=0.001).
CONCLUSION
Because TIS has a strong tendency with severity of ischemic motor symptom and the presence of old lesions, the ivy sign may be useful in predicting severity of disease progression.

Keyword

Moyamoya disease; FLAIR; MRI; ivy sign; old lesion; supraclinoid carotid stenosis

MeSH Terms

Adolescent
Adult
Aged
Brain/metabolism/*pathology
Cerebral Arteries/*pathology
Child
Child, Preschool
Collateral Circulation
Disease Progression
Female
Humans
Magnetic Resonance Imaging/*methods
Male
Meninges/*pathology
Middle Aged
Moyamoya Disease/complications/*pathology
Severity of Illness Index
Stroke
Young Adult

Figure

• 

  Fig. 1 Fluid-attenuated inversion-recovery MRI of 11-year-old child with recurrent left side motor weakness. The ivy score of the right hemisphere is 3 in the anterior and posterior MCA territory, 2 in the ACA territory, and 1 in the PCA territory. The ivy score of the left hemisphere is 2 in the ACA and posterior MCA territory, and 1 in the anterior MCA and PCA territory. ACA, anterior cerebral artery; MCA, middle cerebral artery; PCA, posterior cerebral artery.

• 

  Fig. 2 Fluid-attenuated inversion-recovery MRI of 57-year-old adult with right side motor weakness due to ischemic stroke. The ivy scores of the both hemisphere are 1 in the anterior, posterior MCA and ACA territories, and 0 in the PCA territory. ACA, anterior cerebral artery; MCA, middle cerebral artery; PCA, posterior cerebral artery.

• 

  Fig. 3 Box-and-whisker plot showing total ivy score in patients classified according to the severity of clinical symptoms (A) and dichotomized by severity for each group of patients (B). TIA, transient ischemic attack.

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