Korean J Radiol.  2019 Jun;20(6):985-996. 10.3348/kjr.2018.0651.

Arterial Spin Labeling MRI for Quantitative Assessment of Cerebral Perfusion Before and After Cerebral Revascularization in Children with Moyamoya Disease

Affiliations
  • 1Department of Radiology, Gyeongsang National University Changwon Hospital, Changwon, Korea.
  • 2Department of Radiology, Seoul National University Hospital, Seoul, Korea. choiyounghun@gmail.com
  • 3Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
  • 4Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.

Abstract


OBJECTIVE
To determine the correlation between cerebral blood flow (CBF) on arterial spin labeling (ASL) MRI and the degree of postoperative revascularization assessed on digital subtraction angiography in children with moyamoya disease (MMD).
MATERIALS AND METHODS
Twenty-one children (9 boys and 12 girls; mean age, 8.4 ± 3.6 years; age range, 3-16 years) with MMD who underwent both pseudocontinuous ASL MRI at 1.5T and catheter angiography before and after superficial temporal artery encephaloduroarteriosynangiosis were included in this retrospective study. The degree of revascularization in the middle cerebral artery (MCA) territory was evaluated on external carotid angiography and was graded on a 3-point scale. On ASL CBF maps, regions of interest were manually drawn over the MCA territory of the operated side at the level of the centrum semi-ovale and over the cerebellum. The normalized CBF (nCBF) was calculated by dividing the CBF of the MCA territory by the CBF of the cerebellum. Changes in nCBFs were calculated by subtracting the preoperative nCBF values from the postoperative nCBF values. The correlation between nCBF changes measured with ASL and the revascularization grade from direct angiography was evaluated.
RESULTS
The nCBF value on the operated side increased after the operation (p = 0.001). The higher the degree of revascularization, the greater the nCBF change was: poor revascularization (grade 1), −0.043 ± 0.212; fair revascularization (grade 2), 0.345 ± 0.176; good revascularization (grade 3), 0.453 ± 0.182 (p = 0.005, Jockheere-Terpstra test). The interobserver agreement was excellent for the measured CBF values of the three readers (0.91-0.97).
CONCLUSION
The nCBF values of the MCA territory obtained from ASL MRI increased after the revascularization procedure in children with MMD, and the degree of nCBF change showed a significant correlation with the degree of collateral formation evaluated via catheter angiography.

Keyword

Moyamoya; Arterial spin labeling; Cerebral blood flow; Cerebral perfusion; Pediatric; Angiography

MeSH Terms

Angiography
Angiography, Digital Subtraction
Catheters
Cerebellum
Cerebral Revascularization*
Cerebrovascular Circulation
Child*
Female
Humans
Magnetic Resonance Imaging*
Middle Cerebral Artery
Moyamoya Disease*
Perfusion*
Retrospective Studies
Temporal Arteries

Figure

  • Fig. 1 Imaging example of ROI placement for CBF measurements in ASL images.A. ROIs created manually over MCA territory along level of centrum semi-ovale on operated side and contralateral side. B. Additional ROIs drawn in cerebellum for normalization on right and left cerebellar hemispheres. Absolute CBFCbll was defined as mean of right and left CBFCbll. ASL = arterial spin labeling, CBF = cerebral blood flow, CBFCbll = CBF of cerebellum, MCA = middle cerebral artery, ROI = region of interest

  • Fig. 2 Graph displaying nCBF changes measured with ASL according to angiographic revascularization degree(poor revascularization [grade 1], −0.043 ± 0.212; fair revascularization [grade 2], 0.345 ± 0.176; good revascularization [grade 3], 0.453 ± 0.182 [p = 0.001]). nCBF = normalized CBF

  • Fig. 3 Representative DSA and ASL images showing good postoperative outcome in 12-year-old girl with unilateral MMD who underwent right EDAS with right EC(P)S.A. Baseline DSA image showing lateral projection from right external carotid injections. B. Postoperative DSA image after surgery shows superficial temporal artery hypertrophy (arrow) and abundant collateral flow at greater than 2/3 of MCA territory; grade 3, good revascularization grade. C. Baseline ASL image shows decreased perfusion and ATA signals (arrowheads) reflecting late-arriving flow via collateral pathways. D. Postoperative ASL image shows increased perfusion with decreased ATA signals in right MCA territory, corresponding to DSA results. ATA = arterial transit artifact, DSA = digital subtraction angiography, EC(P)S = encephalogaleo (periosteal) synangiosis, EDAS = encephaloduroarteriosynangios is, MMD = moyamoya disease

  • Fig. 4 Representative DSA and ASL images showing poor postoperative outcome in 16-year-old girl with bilateral MMD who underwent right EDAS with bifrontal EC(P)S.A. Baseline DSA image showing lateral projection from right external carotid injections demonstrates preexisting transdural collaterals, indicating advanced stage of disease. B. Postoperative DSA image shows impaired collateral flow at less than 1/3 of MCA territory; grade 1, poor revascularization grade. C. Baseline ASL image shows decreased perfusion in both MCA territories. D. Postoperative ASL image shows impaired perfusion, corresponding to DSA results.


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