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

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Moyamoya 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.


This 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.


After 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.


ASL-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.

ABBREVIATIONS ACA = anterior cerebral artery; ASL = arterial spin labeling; CBF = cerebral blood flow; DSA = digital subtraction angiography; DSC = dynamic susceptibility contrast; MCA = middle cerebral artery; PCA = posterior cerebral artery; SNR = signal-to-noise ratio.

Article Information

Correspondence Kristen W. Yeom: Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, CA.

INCLUDE WHEN CITING Published online February 8, 2019; DOI: 10.3171/2018.11.PEDS18498.

J.L.Q. and L.H.K. share first authorship of this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



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    Case example of manually created regions of interest. A: High ACA (1 and 2) and high MCA (3 and 4) territories. B: Low ACA territory (1 and 2), putamen (3 and 4), thalamus (5 and 6), occipital (7 and 8), and low MCA territory (9 and 10).

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    Change in CBF from before to after surgery in the high MCA (A) and putamen (B). Solid horizontal lines indicate the mean.

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    Case 2. ASL and DSA studies obtained before (A) and after (B) revascularization surgery. A: Reduced right MCA territory cerebral perfusion is seen, as indicated by the dark ASL signal (arrows). On DSA, marked proliferation of collaterals is seen (arrow). B: After revascularization, improved flow signal is seen to the right MCA territory (arrows). The DSA shows pruning or regression of collaterals seen prior to revascularization.

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    Case 3. FLAIR and ASL sequences obtained before (A) and after (B) revascularization surgery. The preoperative ASL perfusion (A) shows markedly reduced perfusion to bilateral MCA territories, as indicated by dark ASL signal (arrows). The postoperative image (B) shows increased ASL signal in the bilateral MCA territories (arrows) compared with the preoperative image (A).





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