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Xia J, Yu C, Li L, Pan J. Arterial transit artifacts and carotid Plaque-RADS may predict symptoms in patients with carotid stenosis. Magn Reson Imaging 2024; 111:131-137. [PMID: 38703972 DOI: 10.1016/j.mri.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 05/06/2024]
Abstract
AIM To analyze the correlation of carotid stenosis severity, the Plaque Reporting and Data System (RADS) score, arterial transit artifacts (ATAs), and cerebral blood flow (CBF) with clinical cerebral ischemic symptoms in patients with carotid artery stenosis (CAS). MATERIALS AND METHODS Sixty-one patients with unilateral internal carotid artery stenosis or occlusion (≥50% stenosis) diagnosed by ultrasound, Computed Tomography(CT) angiography, or Magnetic Resonance(MR) angiography in Yichang City Central People's Hospital from January 2022 to February 2024 were retrospectively enrolled and divided into two groups according to the presence or absence of symptoms. Both groups underwent MR plaque imaging and arterial spin labeling (ASL)-based 3.0 T MRI to compare the differences in stenosis degree, Plaque-RADS score, ATA grade, and CBF between the two groups. Binary regression analysis was used to identify the parameters with statistically significant differences between the two groups and to evaluate their diagnostic efficacy using the area under the workup curve of the subjects. RESULTS The Plaque-RADS score, ATA grade, and CBF differences in the anterior cerebral artery(ACA)blood supply region were correlated with symptoms, and the areas under the ROC curves for the CBF differences in the ACA blood supply region, Plaque-RADS score, ATA grade and a joint model that combines all three to predict symptoms in CAS patients were 0.672, 0.796, 0.788 and 0.919, respectively. CONCLUSIONS CBF, Plaque-RADS and ATAs were identified as independent risk factors for symptoms in patients with CAS and have a certain predictive value for symptoms, and the combined predictive value is greater, potentially providing a more effective imaging modality for clinical treatment and evaluation.
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Affiliation(s)
- Juan Xia
- The First College of Clinical Medical Science, China Three Gorges University, Yichang, China; Department of Radiology, Yichang Central People's Hospital, Yichang, Hubei, China
| | - Chengxin Yu
- The First College of Clinical Medical Science, China Three Gorges University, Yichang, China; Department of Radiology, Yichang Central People's Hospital, Yichang, Hubei, China.
| | - Liang Li
- Department of Radiology, Yichang Central People's Hospital, Yichang, Hubei, China
| | - Junlong Pan
- Department of Radiology, Yichang Central People's Hospital, Yichang, Hubei, China
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Ito Y, Sugiyama T, Terasaka S, Matsuzawa H, Harada K, Nakayama N, Ito M, Maruichi K, Fujimura M. Differences between Acute Embolic and Atherosclerotic Middle Cerebral Artery Occlusion in Multiphase Arterial Spin-labeling Imaging. Neurol Med Chir (Tokyo) 2024; 64:197-204. [PMID: 38432944 PMCID: PMC11153842 DOI: 10.2176/jns-nmc.2023-0237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/10/2024] [Indexed: 03/05/2024] Open
Abstract
Arterial spin-labeling magnetic resonance imaging (ASL-MRI) is widely used for evaluating collateral development in patients with acute ischemic stroke (AIS). This study aimed to characterize the findings of multiphase ASL-MRI between embolic and atherosclerotic large vessel occlusion (LVO) to aid in the differential diagnosis. Among 982 patients with AIS, 44 who were diagnosed with acute, symptomatic, and unilateral occlusion of the horizontal segment of the middle cerebral artery (MCA) were selected and categorized into embolic stroke (ES) and atherosclerosis (AT) groups. Using ASL-MRI (postlabeling delay [PLD] of 1.5, 2.0, and 2.5 s) at admission, the ipsilateral to contralateral ratio (ICR) of the signal intensity and its time-course increasing rate (from PLD 1.5 to 2.0 and 2.5, ΔICR) were measured and compared between the two groups. The mean ICR was significantly higher in the AT group than in the ES group (AT vs. ES: 0.49 vs. 0.27 for ICR1.5, 0.73 vs. 0.32 for ICR2.0, and 0.92 vs. 0.37 for ICR2.5). The ΔICR of PLD 1.5-2.0 (ΔICR2.0) and 2.5 (ΔICR2.5) were also significantly higher in the AT group than in the ES group (AT vs. ES: 50.9% vs. 26.3% for ΔICR2.0, and 92.6% vs. 42.9% for ΔICR2.5). Receiver operating characteristic curves showed moderate-to-strong discriminative abilities of each ASL-MRI parameter in predicting MCA occlusion etiology. In conclusion, multiphase ASL-MRI parameters may aid in differentiating intracranial LVO etiology during the acute phase. Thus, it is applicable to AIS management.
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Affiliation(s)
- Yasuhiro Ito
- Department of Neurosurgery, Kashiwaba Neurosurgical Hospital
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | | | | | - Kuniaki Harada
- Department of Neurosurgery, Kashiwaba Neurosurgical Hospital
| | - Naoki Nakayama
- Department of Neurosurgery, Kashiwaba Neurosurgical Hospital
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | | | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
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Kikuchi K, Togao O, Yamashita K, Isoda T, Nishimura A, Arimura K, Nakamizo A, Yoshimoto K, Ishigami K. Brain volume measured by synthetic magnetic resonance imaging in adult moyamoya disease correlates with cerebral blood flow and brain function. Sci Rep 2024; 14:5468. [PMID: 38443400 PMCID: PMC10914740 DOI: 10.1038/s41598-024-56210-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/04/2024] [Indexed: 03/07/2024] Open
Abstract
Moyamoya disease (MMD) is characterized by progressive arterial occlusion, causing chronic hemodynamic impairment, which can reduce brain volume. A novel quantitative technique, synthetic magnetic resonance imaging (SyMRI), can evaluate brain volume. This study aimed to investigate whether brain volume measured with SyMRI correlated with cerebral blood flow (CBF) and brain function in adult MMD. In this retrospective study, 18 adult patients with MMD were included. CBF was measured using iodine-123-N-isopropyl-p-iodoamphetamine single photon emission computed tomography. Cerebrovascular reactivity (CVR) to acetazolamide challenge was also evaluated. Brain function was measured using the Wechsler Adult Intelligence Scales (WAIS)-III/IV and the WAIS-R tests. Gray matter (GM), white matter, and myelin-correlated volumes were evaluated in six areas. Resting CBF was positively correlated with GM fractions in the right anterior cerebral arterial and right middle cerebral arterial (MCA) territories. CVR was positively correlated with GM fraction in the right posterior cerebral arterial (PCA) territory. Full-Scale Intelligence Quotient and Verbal Comprehension Index scores were marginally positively correlated with GM fractions in the left PCA territory. Processing Speed Index score was marginally positively correlated with GM fraction in the right MCA territory. The SyMRI-measured territorial GM fraction correlated with CBF and brain function in patients with MMD.
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Affiliation(s)
- Kazufumi Kikuchi
- Department of Molecular Imaging and Diagnosis, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Osamu Togao
- Department of Molecular Imaging and Diagnosis, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koji Yamashita
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takuro Isoda
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Arimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Akira Nakamizo
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kousei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Shan M, Liu K, Ma Y, Zhang Q, Yun W, Zhang M. Arterial transit artifact as a short-term prognostic indicator in acute ischemic stroke. BMC Neurol 2024; 24:58. [PMID: 38336633 PMCID: PMC10854094 DOI: 10.1186/s12883-024-03560-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Arterial transit artifact (ATA) observed on arterial spin labeling (ASL) was recently suggested to be associated with improved functional outcomes following acute ischemic stroke (AIS). AIS is a heterogeneous disease with diverse pathogenic mechanisms depending on the stroke subtype. This study aimed to investigate the association between ATA and 3-month functional outcomes in AIS patients according to etiology subtypes. METHODS Consecutive patients with AIS were included. All patients underwent ASL MRI with postlabeling delay (PLD) of 1.5 and 2.5 s. ATA was assessed from the ASL images of both PLDs. Stroke etiologic subtypes were determined according to the modified TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification. Short-term functional outcomes were evaluated using the 3-month modified Rankin scale (mRS). Log-binomial regression was applied to analyze the association between ATA and functional outcomes at 3 months after stroke. RESULTS Ninety-eight AIS patients (62.73 ± 13.05 years; 68 men) were finally included. ATA was detected in forty-six patients and most frequently seen in the large-artery atherosclerosis (LAA) subtype (35/46). The ATA group exhibited a lower percentage of patients with mRS > 2 compared to the group without ATA (36.5% vs. 19.6%; P < 0.001). ATA was independently associated with better 3-month clinical outcomes (adjusted risk ratio, 0.35[95% CI, 0.16-0.74]) in the multivariate log-binomial regression model. After stratification by TOAST subtypes, a significant association was found between ATA and better outcomes in the LAA subtype (adjusted risk ratio, 0.20[ 95% CI, 0.05-0.72]) but not in cardioembolism and small artery occlusion (SVO) subtype. CONCLUSION ATA is associated with better outcomes at 3 months in patients with AIS, especially in the LAA subtype, but this association attenuated in the cardioembolism and SVO subtypes.
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Affiliation(s)
- Min Shan
- Department of Neurology, the Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou Second People's Hospital, Changzhou Medical Center, Nanjing Medical University, No.29, Xinglong Lane, Tianning District, Changzhou, 213004, Jiangsu Province, China
| | - Kaili Liu
- Department of Radiology, the Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou Second People's Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, Jiangsu Province, China
| | - Yi Ma
- Department of Radiology, the Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou Second People's Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, Jiangsu Province, China
| | - Qingxiu Zhang
- Department of Neurology, Nanjing Drum Tower Hospital Affiliated to Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Wenwei Yun
- Department of Neurology, the Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou Second People's Hospital, Changzhou Medical Center, Nanjing Medical University, No.29, Xinglong Lane, Tianning District, Changzhou, 213004, Jiangsu Province, China.
| | - Min Zhang
- Department of Neurology, the Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou Second People's Hospital, Changzhou Medical Center, Nanjing Medical University, No.29, Xinglong Lane, Tianning District, Changzhou, 213004, Jiangsu Province, China.
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Lewén A, Fahlström M, Borota L, Larsson EM, Wikström J, Enblad P. ASL-MRI-guided evaluation of multiple burr hole revascularization surgery in Moyamoya disease. Acta Neurochir (Wien) 2023; 165:2057-2069. [PMID: 37326844 PMCID: PMC10409847 DOI: 10.1007/s00701-023-05641-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 04/25/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE Moyamoya (MM) disease is characterized by progressive intracranial arterial stenosis. Patients commonly need revascularization surgery to optimize cerebral blood flow (CBF). Estimation of CBF and cerebrovascular reserve (CVR) is therefore necessary before and after surgery. However, assessment of CBF before and after indirect revascularization surgery with the multiple burr hole (MBH) technique in MM has not been studied extensively. In this study, we describe our initial experience using arterial spin labeling magnetic resonance perfusion imaging (ASL-MRI) for CBF and CVR assessment before and after indirect MBH revascularization surgery in MM patients. METHODS Eleven MM patients (initial age 6-50 years, 1 male/10 female) with 19 affected hemispheres were included. A total of 35 ASL-MRI examinations were performed using a 3D-pCASL acquisition before and after i.v. acetazolamide challenge (1000 mg in adults and 10 mg/kg in children). Twelve MBH procedures were performed in seven patients. The first follow-up ASL-MRI was performed 7-21 (mean 12) months after surgery. RESULTS Before surgery, CBF was 46 ± 16 (mean ± SD) ml/100 g/min and CVR after acetazolamide challenge was 38.5 ± 9.9 (mean ± SD)% in the most affected territory (middle cerebral artery). In cases in which surgery was not performed, CVR was 56 ± 12 (mean ± SD)% in affected hemispheres. After MBH surgery, there was a relative change in CVR compared to baseline (preop) of + 23.5 ± 23.3% (mean ± SD). There were no new ischemic events. CONCLUSION Using ASL-MRI we followed changes in CBF and CVR in patients with MM. The technique was encouraging for assessments before and after revascularization surgery.
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Affiliation(s)
- Anders Lewén
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala University Hospital, SE 751 85, Uppsala, Sweden.
| | - Markus Fahlström
- Department of Surgical Sciences, Neuroradiology, Uppsala University, Uppsala, Sweden
| | - Ljubisa Borota
- Department of Surgical Sciences, Neuroradiology, Uppsala University, Uppsala, Sweden
| | - Elna-Marie Larsson
- Department of Surgical Sciences, Neuroradiology, Uppsala University, Uppsala, Sweden
| | - Johan Wikström
- Department of Surgical Sciences, Neuroradiology, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala University Hospital, SE 751 85, Uppsala, Sweden
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Peer S, Singh P. Intraluminal arterial transit artifact as a predictor of intracranial large artery stenosis on 3D time of flight MR angiography: Expanding the application of arterial spin labeling MRI in ischemic stroke. J Clin Imaging Sci 2023; 13:17. [PMID: 37405363 PMCID: PMC10316254 DOI: 10.25259/jcis_27_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/24/2023] [Indexed: 07/06/2023] Open
Abstract
Objectives The objective of this study was to evaluate the diagnostic value of "intraluminal arterial transit artifact" in the prediction of intracranial large artery stenosis and to determine if this finding is predictive of ischemic stroke in the territory of the involved artery. Material and Methods The presence of arterial transit artifact (ATA) within the lumen of an intracranial large vessel was noted on three-dimensional time of flight (3D-TOF) magnetic resonance angiography (MRA) (ATA group). The patients with stenosis but with no ATA (no-ATA group), patients with total occlusion (total occlusion group), and patients with no stenosis/occlusion (normal group) were included in the analysis. Results There were four groups of patients included in the final analysis, the ATA group (n = 22), the no-ATA group (n = 23), the normal group (n = 25), and the total occlusion group (n = 9). Among patients with any demonstrable stenosis (n = 45), the presence of ATA within the stenotic segment was predictive of stenosis of ≥56% (Sensitivity of 100% [85.2-100, 95% CI], specificity of 100% [86.4-100, 95% CI]), with area under curve of 1.0 (0.92-.0, 95% CI). The presence of intra-arterial ATA signal was significantly associated with ischemic stroke as compared with the no-ATA group (86.36% vs. 26.08%, P = 0.0003). Intraluminal ATA was found to be an independent predictor of infarction in the territory of the involved artery. Conclusion Intraluminal ATA is predictive of stenosis of at least 56% in the involved artery on 3D-TOF MRA. Intraluminal ATA sign may be an independent predictor of infarction in the territory of the involved artery.
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Affiliation(s)
- Sameer Peer
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bathinda, Punjab, India
| | - Paramdeep Singh
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bathinda, Punjab, India
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Wu D, Zhou Y, Zhang G, Shen N, Lu J, Yan S, Xie Y, Gao L, Liu Y, Liu C, Zhang S, Zhu W. Collateral circulation predicts 3-month functional outcomes of subacute ischemic stroke patients: A study combining arterial spin labeling and MR angiography. Eur J Radiol 2023; 160:110710. [PMID: 36701823 DOI: 10.1016/j.ejrad.2023.110710] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 12/02/2022] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Collateral circulation could help preserve the blood supply and protect penumbra in ischemic stroke (IS), critical for late-window therapeutic decisions and clinical outcomes. In this study, we aimed to investigate the prognostic value of two collateral indexes measured by arterial spin labeling (ASL) and MR angiography (MRA) in subacute IS patients. MATERIALS AND METHODS Fifty-five subacute IS patients with large artery atherosclerosis were retrospectively collected. Arterial transit artifact (ATA) on ASL and good circulation (GC) on MRA were ranked as markers of leptomeningeal collaterals and fast collaterals, respectively. Volume and relative cerebral blood flow (rCBF) of infarct and hypoperfusion area were calculated. Stroke severity was determined by baseline- and discharge- National Institute of Hospital Stroke Scale (NIHSS). Functional independence (FI) was defined as 3-month modified Ranking Scale ≤2. Univariate analyses and multivariable logistic regression analyses were conducted to identify the independent predictors of FI. RESULTS Thirty-eight patients (69.1 %) presented ATA and 29 (52.7 %) patients presented GC. Univariate analyses showed that baseline-NIHSS, discharge-NIHSS, rCBF of infarct, presence of ATA and GC were associated with FI (P < 0.05). After multivariable adjustment, ATA (adjusted Odds Ratio [OR]: 13.785, 95 % CI: 2.608-72.870, P = 0.002) and GC (adjusted OR: 8.317, 95 % CI: 1.629-42.454, P = 0.011) remained independent predictors of FI. Besides, patients with both ATA and GC had the highest frequencies of FI while patients with neither of them showed the lowest (94.7 % vs 14.3 %, P < 0.001), indicating a positive synergistic effect between ATA and GC. CONCLUSION The combination of ASL and MRA simultaneously reflects leptomeningeal collaterals and fast collaterals, providing a useful method to predict functional outcomes of subacute IS patients.
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Affiliation(s)
- Di Wu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiran Zhou
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guiling Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nanxi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Lu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Department of CT & MRI, The First Affiliated Hospital, College of Medicine, Shihezi University, Shihezi, China
| | - Su Yan
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Xie
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Luyue Gao
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yufei Liu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chengxia Liu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shun Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Wenzhen Zhu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Neuroimaging in Moyamoya angiopathy: Updated review. Clin Neurol Neurosurg 2022; 222:107471. [DOI: 10.1016/j.clineuro.2022.107471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/23/2022]
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Ozpar R, Dinc Y, Nas OF, Inecikli MF, Parlak M, Hakyemez B. Arterial transit artifacts observed on arterial spin labeling perfusion imaging of carotid artery stenosis patients: What are counterparts on symptomatology, dynamic susceptibility contrast perfusion, and digital subtraction angiography? J Neuroradiol 2022; 50:407-414. [PMID: 36067966 DOI: 10.1016/j.neurad.2022.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE To investigate possible relationships between the presence and location of arterial transit artifacts (ATA) and clinical symptoms, digital subtraction angiography (DSA), and dynamic susceptibility contrast (DSC) perfusion imaging abnormalities in patients with carotid artery stenosis (CAS). METHODS Forty-seven patients who underwent arterial spin labeling (ASL) and DSC perfusion imaging in the same period diagnosed with > 50% unilateral internal carotid artery (ICA) stenosis by DSA performed 24 h after perfusion imaging were included. The presence of ATA, localization and hypoperfusion were evaluated using ASL interpretation. Maps derived from DSC perfusion, symptomatology, stenosis rates, and collateralization findings observed in DSA were investigated. Probable relationships were evaluated. RESULTS ATA on ASL were detected in 68.1% (32/47); 40.6% (13/32) of ATAs were observed in the distal middle cerebral artery (MCA) trace, 50% (16/32) in the intracranial ICA and MCA traces, and 9.4% (3/32) in the intracranial ICA trace. When classifications based on the ATA presence and localization was made, qualitative and quantitative CBF, MTT, and TTP abnormalities, symptomatology, stenosis rates, and collateralization findings significantly differed between groups (p < 0.05). CONCLUSION The presence and localization of ATA in patients with CAS may provide essential insights into cerebral hemodynamics and the CAS severity. ATAs observed only in the distal MCA trace may represent early-stage perfusion abnormalities and a moderate level of stenosis. ATA in the ICA trace may related to a more advanced level of perfusion abnormalities, critical stenosis rates, symptom or collateralization presence.
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Affiliation(s)
- Rifat Ozpar
- Department of Radiology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey.
| | - Yasemin Dinc
- Department of Neurology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey
| | - Omer Fatih Nas
- Department of Radiology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey
| | - Mehmet Fatih Inecikli
- Department of Radiology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey
| | - Mufit Parlak
- Department of Radiology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey
| | - Bahattin Hakyemez
- Department of Radiology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey
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Del Poggio A, Godi C, Calloni SF, Ragusi M, Iadanza A, Falini A, Anzalone N. Multiple hypointense veins on susceptibility weighted imaging as a promising biomarker of impaired cerebral hemodynamics in chronic steno-occlusive disease: a multiparametric MRI study. Neuroradiology 2022; 64:2235-2243. [PMID: 35699773 DOI: 10.1007/s00234-022-02994-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Patients with steno-occlusive arterial disease may develop cerebral hypoperfusion with possible neurologic sequelae. The aim of the study is to verify the possible role of SWI, as a marker of cerebral hypoperfusion, in the identification of patient subgroups with significant chronic occlusions/stenoses at risk of critical cerebral hypoperfusion. METHODS We retrospectively identified 37 asymptomatic patients with chronic intra-extracranial occlusion/stenosis of the anterior circulation from a prospective brain MRI register between 2016 and 2020. All patients underwent 3 Tesla MRI. The imaging protocol included the following: SWI, 3D-FLAIR, DWI sequences, and 3D-TOF MRA. SWI findings were graded for the presence of asymmetric intracranial cortical veins (grades 1 to 4). The presence of collateralization was assessed with concomitant multiphase-CTA. FLAIR was evaluated for the presence of distal hyperintense vessels (DHVs), a described marker of flow impairment, and possible collateralization. Cerebral blood flow and arterial transit artifacts (ATAs) were evaluated at pCASL in 29 patients. RESULTS SWI showed multiple hypointense vessels (MHVs) in 22/37 patients in the cerebral hemisphere ipsilateral to vessel occlusion/stenosis. SWI-MHV grade 1 was found in 15 patients (40.5%), grade 2 in 18 patients (48.7%), and grade 3 in 3 patients (8.1%); in one patient, SWI was graded as 4 (2.7%). A significant relationship was found among MHV, DHV, collaterals, ATAs, and hypoperfused areas on pCASL and with patients' previous neurological symptoms. CONCLUSION SWI-MVH correlates with chronic cerebral flow impairment and is related to hypoperfusion and collateralization. It may help identify a subgroup of patients benefitting from revascularization.
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Affiliation(s)
- Anna Del Poggio
- Department of Neuroradiology and CERMAC, San Raffaele Hospital, Via Olgettina 60, Milan, Italy.
| | - Claudia Godi
- Department of Neuroradiology and CERMAC, San Raffaele Hospital, Via Olgettina 60, Milan, Italy
| | - Sonia Francesca Calloni
- Department of Neuroradiology and CERMAC, San Raffaele Hospital, Via Olgettina 60, Milan, Italy
| | - Maria Ragusi
- Department of Neuroradiology and CERMAC, San Raffaele Hospital, Via Olgettina 60, Milan, Italy
| | - Antonella Iadanza
- Department of Neuroradiology and CERMAC, San Raffaele Hospital, Via Olgettina 60, Milan, Italy
| | - Andrea Falini
- Department of Neuroradiology and CERMAC, San Raffaele Hospital, Via Olgettina 60, Milan, Italy.,San Raffaele Vita-Salute University, Milan, Italy
| | - Nicoletta Anzalone
- Department of Neuroradiology and CERMAC, San Raffaele Hospital, Via Olgettina 60, Milan, Italy.,San Raffaele Vita-Salute University, Milan, Italy
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Wang M, Wang Y, Zhang W, Zhao X, Yang Y, Zhang B. Preoperative Collateral Perfusion Using Arterial Spin Labeling: A Predictor of Surgical Collaterals in Moyamoya Angiopathy. Front Neurosci 2022; 16:839485. [PMID: 35368266 PMCID: PMC8964430 DOI: 10.3389/fnins.2022.839485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/25/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives Various degrees of surgical collateral circulation are often found in moyamoya angiopathy (MMA) patients after revascularization. Little is known about arterial spin labeling (ASL) that affects surgical collateral circulation. This study aimed to investigate the effect of ASL on surgical collaterals in patients with MMA after combined bypass surgery. Methods MMA patients with complete radiological and clinical information, who had undergone combined bypass, were enrolled in this study. Surgical collaterals were classified as good or poor based on the Matsushima standard. Cerebral perfusion on ASL was quantitatively analyzed as relative cerebral blood flow (rCBF). The qualitative collateral score was calculated using a four-grade scale. Univariable and multivariable logistic regressions were performed to identify the predictors for surgical collaterals after combined bypass. Results In total, 66 hemispheres of 61 patients (47 years old ± 8.66) were prospectively included (29 and 37 hemispheres with good and poor surgical collaterals, respectively). The presurgical collateral score was significantly lower in patients with good surgical collaterals (13.72 scores ± 7.83) than in those with poor surgical collaterals (19.16 scores ± 6.65, P = 0.005). The presurgical rCBF and modified Rankin scale (mRS) scores were not significantly different between the two groups (PrCBF = 0.639, PmRS = 0.590). The collateral score was significantly elevated (good: 13.72 scores ± 7.83 vs. 20.79 scores ± 6.65, P < 0.001; poor: 19.16 scores ± 6.65 vs. 22.84 scores ± 5.06, P < 0.001), and the mRS was reduced (good: 1.66 scores ± 1.14 vs. 0.52 scores ± 0.83, P < 0.001; poor: 1.49 scores ± 0.90 vs. 0.62 scores ± 0.76, P < 0.001) in patients after revascularization. Multivariable logistic regression showed that preoperative collateral scores [odds ratio (OR): 0.791; 95% confidence interval (CI): 0.695, 0.900; P < 0.001], age (OR: 0.181; 95% CI: 0.039, 0.854; P = 0.031), sex (OR: 0.154; 95% CI: 0.035, 0.676; P = 0.013), and hypertension (OR: 0.167; 95% CI: 0.038, 0.736; P = 0.018) were predictors of surgical collaterals after combined revascularization. Conclusion The preoperative collateral score based on ASL could be a predictor for surgical collaterals in patients with MMA after combined bypass surgery. Combined with age, sex, and hypertension, it may have a better predictive effect.
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Affiliation(s)
- Maoxue Wang
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Yi Wang
- Department of Neurosurgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Wen Zhang
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | | | - Yongbo Yang
- Department of Neurosurgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- *Correspondence: Yongbo Yang,
| | - Bing Zhang
- Department of Radiology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- Institute of Brain Science, Nanjing University, Nanjing, China
- Bing Zhang,
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12
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Iodice A, Signa S, Severino M, Tortora D, Zanetti A, Amico G, Piatelli G, Bertamino M, Pavanello M. Combined medical therapy and neurosurgical revascularization preventing stroke in post-varicella angiopathy: Case report and review of literature. Brain Dev 2021; 43:1051-1056. [PMID: 34332825 DOI: 10.1016/j.braindev.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Post varicella angiopathy (PVA) is an underdiagnosed but potentially severe disease in both pediatric and adult settings. No guidelines are available for the medical and neurosurgical management of this condition. We report the first pediatric case with headache and PVA who was treated with surgical revascularization before the onset of ischemic events. METHODS This case report was conducted via retrospective chart review. A literature review was also completed, in order to identify previously described PVA undergone to revascularization. RESULTS We report on a 9-year-old boy presenting with a long history of headache and PVA involving the distal left middle cerebral artery. The arterial lesion rapidly worsened over a 10 months' period with formation of focal moyamoya-like collaterals, despite an adequate intravenous antiviral treatment. The pattern of headaches significantly changed with a clear left-side lateralization and a "re-build-up" phenomenon on EEG. The patient was treated with left superficial temporal artery - middle cerebral artery (STA-MCA) bypass and encephalo-duro-arterio-myo-pericranial-synangiosis. This combined treatment resulted in an immediate and persistent improvement of brain perfusion, accompanied by prompt resolution of neurological symptoms. Two cases who presented with Suzuki stage III (unilateral or bilateral) moyamoya PVA and recurrent strokes or transient ischemic attacks despite adequate pharmacological prophylaxis have been surgically treated using both indirect and direct revascularization technique. The outcome was good in both cases. CONCLUSION Surgical revascularization may have a role in the treatment of PVA and may prevent stroke. Given the lack of standardized treatment algorithms, individualized regimens should be formulated on a case-specific basis.
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Affiliation(s)
| | - Sara Signa
- Dipartimento di Neuroscienze, riabilitazione, oftalmologia, genetica e scienze materno-infantili (DINOGMI) Università di Genova, Genoa, Italy; Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alice Zanetti
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giulia Amico
- Dipartimento di Neuroscienze, riabilitazione, oftalmologia, genetica e scienze materno-infantili (DINOGMI) Università di Genova, Genoa, Italy; Medical Genetic Unit,IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Marta Bertamino
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Marco Pavanello
- Neurosurgery Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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13
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Wang DJJ, Le Bihan D, Krishnamurthy R, Smith M, Ho ML. Noncontrast Pediatric Brain Perfusion: Arterial Spin Labeling and Intravoxel Incoherent Motion. Magn Reson Imaging Clin N Am 2021; 29:493-513. [PMID: 34717841 DOI: 10.1016/j.mric.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Noncontrast magnetic resonance imaging techniques for measuring brain perfusion include arterial spin labeling (ASL) and intravoxel incoherent motion (IVIM). These techniques provide noninvasive and repeatable assessment of cerebral blood flow or cerebral blood volume without the need for intravenous contrast. This article discusses the technical aspects of ASL and IVIM with a focus on normal physiologic variations, technical parameters, and artifacts. Multiple pediatric clinical applications are presented, including tumors, stroke, vasculopathy, vascular malformations, epilepsy, migraine, trauma, and inflammation.
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Affiliation(s)
- Danny J J Wang
- USC Institute for Neuroimaging and Informatics, SHN, 2025 Zonal Avenue, Health Sciences Campus, Los Angeles, CA 90033, USA
| | - Denis Le Bihan
- NeuroSpin, Centre d'études de Saclay, Bâtiment 145, Gif-sur-Yvette 91191, France
| | - Ram Krishnamurthy
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive - ED4, Columbus, OH 43205, USA
| | - Mark Smith
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive - ED4, Columbus, OH 43205, USA
| | - Mai-Lan Ho
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive - ED4, Columbus, OH 43205, USA.
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Early Neurological Deterioration and Hypoperfusion Volume Ratio on Arterial Spin Labeling in Patients with Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 30:105885. [PMID: 34107416 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105885] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/04/2021] [Accepted: 05/09/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Arterial spin labeling (ASL) is a magnetic resonance imaging (MRI) technique used to quantify cerebral blood perfusion by labeling blood water as it flows throughout the brain. Hypoperfusion volume ratio (HVR) can be calculated using proportional hypoperfusion volume on ASL-based cerebral blood flow (CBF). This study aimed to explore the relation between HVR and early neurological deterioration (END) in AIS patients. SUBJECTS AND METHODS Patients with AIS were recruited consecutively, and ASL and regular MRI scans were performed. HVR was calculated from 1.5 and 2.5s post labeling delay (PLD) ASL-CBF maps. END was defined as ≥2 points increment of NIHSS within 72 hours of stroke onset. Univariate and multivariate analysis were used to evaluate the relation between HVR and END. Receiver operating characteristic (ROC) curves were used to determine the ability of HVR in predicting END. RESULTS Of the 52 enrolled patients, 18 (34.5%) were determined with END. In patients with END, the median hypoperfusion volume was 20 mL [Inter Quartile Range)IQR, 6-72.5 mL] at 1.5s PLD, and 11.2 mL (IQR, 5.3-26 mL) at 2.5s PLD; Sixteen (88.9%) patients had HVR ≥50%, and 13 (72.2%) patients hypoperfusion volume at 2.5s PLD ASL were greater than diffusion-weighted imaging (DWI) infarct volume. In patients without END, median hypoperfusion volume was 7 mL (IQR, 4-30 mL) at 1.5s PLD, and 4 mL (IQR, 1.5-8.5 mL) at 2.5s; Eleven (32.4%) patients had HVR ≥50%, and 10 (29.4%) patients hypoperfusion volume at 2.5s PLD ASL were greater than DWI infarct volume. The proportion of HVR ≥50% and hypoperfusion volume >DWI infarct volume were more frequent in patients with END than patients without (all P<0.001). After adjusted for age, admission NIHSS, proportion of hypoperfusion volume > DWI infarct and arterial transit artifact (ATA) by logistic regression analysis, HVR ≥50% (OR=13.1, P=0.003) was an independent risk factor for END. ROC analysis demonstrated that the HVR could predict END with an area under the curve of 0.794 (P=0.001). CONCLUSIONS HVR obtained from the 1.5 and 2.5s PLD ASL may be a useful predictor of END in AIS. The value of HVR may be a marker for hemodynamic impairments.
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15
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Lee SB, Lee S, Cho YJ, Choi YH, Cheon JE, Kim WS. Monitoring Cerebral Perfusion Changes Using Arterial Spin-Labeling Perfusion MRI after Indirect Revascularization in Children with Moyamoya Disease. Korean J Radiol 2021; 22:1537-1546. [PMID: 34132076 PMCID: PMC8390823 DOI: 10.3348/kjr.2020.1464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/19/2021] [Accepted: 03/12/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the role of arterial spin-labeling (ASL) perfusion MRI in identifying cerebral perfusion changes after indirect revascularization in children with moyamoya disease. MATERIALS AND METHODS We included pre- and postoperative perfusion MRI data of 30 children with moyamoya disease (13 boys and 17 girls; mean age ± standard deviation, 6.3 ± 3.0 years) who underwent indirect revascularization between June 2016 and August 2017. Relative cerebral blood flow (rCBF) and qualitative perfusion scores for arterial transit time (ATT) effects were evaluated in the middle cerebral artery (MCA) territory on ASL perfusion MRI. The rCBF and relative time-to-peak (rTTP) values were also measured using dynamic susceptibility contrast (DSC) perfusion MRI. Each perfusion change on ASL and DSC perfusion MRI was analyzed using the paired t test. We analyzed the correlation between perfusion changes on ASL and DSC images using Spearman's correlation coefficient. RESULTS The ASL rCBF values improved at both the ganglionic and supraganglionic levels of the MCA territory after surgery (p = 0.040 and p = 0.003, respectively). The ATT perfusion scores also improved at both levels (p < 0.001 and p < 0.001, respectively). The rCBF and rTTP values on DSC MRI showed significant improvement at both levels of the MCA territory of the operated side (all p < 0.05). There was no significant correlation between the improvements in rCBF values on the two perfusion images (r = 0.195, p = 0.303); however, there was a correlation between the change in perfusion scores on ASL and rTTP on DSC MRI (r = 0.701, p < 0.001). CONCLUSION Recognizing the effects of ATT on ASL perfusion MRI may help monitor cerebral perfusion changes and complement quantitative rCBF assessment using ASL perfusion MRI in patients with moyamoya disease after indirect revascularization.
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Affiliation(s)
- Seul Bi Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Seunghyun Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
| | - Yeon Jin Cho
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Young Hun Choi
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Eun Cheon
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Woo Sun Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
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16
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Agarwal V, Singh P, Ahuja CK, Gupta SK, Aggarwal A, Narayanan R. Non-invasive assessment of cerebral microvascular changes for predicting postoperative cerebral hyperperfusion after surgical revascularisation for moyamoya disease: an arterial spin labelling MRI study. Neuroradiology 2020; 63:563-572. [PMID: 33098435 DOI: 10.1007/s00234-020-02583-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/13/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Cerebral hyperperfusion syndrome (CHPS) can result after anastomotic surgery as the reperfusion is established in chronically ischemic cerebral territories in patients of moyamoya disease (MMD). In this study, we have evaluated the feasibility of arterial spin labelling (ASL) perfusion MRI to predict cerebral hyperperfusion syndrome based on changes of cerebral blood flow (CBF) after revascularisation surgery in patients of MMD. METHODS Our prospective study included 25 patients with MMD who underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass with or without dural/muscle synangiosis. ASL MRI was performed before and 1-7 days after surgery. On the side planned for operation, 5-mm ROI circle was drawn on the predetermined regions in frontal lobe, temporal lobe, parietal lobe and basal ganglia in proximal and distal territories of MCA to calculate ipsilateral CBF values (CBFi). An attempt was made to select the same location on contralateral side (non-operative) (CBFc) for each measurement for calculation of hemispheric normalised CBF (nCBFh) ratios. To adjust for inter individual variation among MR imagers and CBF, additional regions of interest were drawn within the cerebellum (CBFcbl) for cerebellar CBF normalised ratios (nCBFCbl). RESULTS Of the 25 patients (26 operated hemispheres), 5 patients showed significant immediate postoperative symptoms suggestive of CHPS. Based on our findings, sensitivity and specificity of ASL perfusion to detect CHPS were evaluated. ASL was found to have 47-100% sensitivity and 45-88% specificity to detect CHPS. We have tried to calculate the prevalence of CHPS in postoperative patients of moyamoya disease, which in our study ranged from 6.83 to 40.70%. CONCLUSION Based on our results, we concluded that ASL perfusion is an appropriate alternative to standard nuclear medicine studies to monitor the changes in perfusion after STA-MCA bypass surgery in moyamoya patients. ASL MR perfusion can be used to identify changes in cerebral blood flow (CBF) for early detection of cerebral hyperperfusion syndrome in patients with otherwise normal conventional MRI sequences with very high sensitivity but moderate specificity.
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Affiliation(s)
- Vivek Agarwal
- Neuroradiology Division, Department of Radiodiagnosis and Imaging, Post Graduate institute of Medical Education and Research, Chandigarh, India.
| | - Paramjeet Singh
- Neuroradiology Division, Department of Radiodiagnosis and Imaging, Post Graduate institute of Medical Education and Research, Chandigarh, India
| | - Chirag K Ahuja
- Neuroradiology Division, Department of Radiodiagnosis and Imaging, Post Graduate institute of Medical Education and Research, Chandigarh, India
| | - Sunil Kumar Gupta
- Department of Neurosurgery, Post Graduate institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Post Graduate institute of Medical Education and Research, Chandigarh, India
| | - Rajashekhar Narayanan
- Department of Neurosurgery, Post Graduate institute of Medical Education and Research, Chandigarh, India
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