Preoperative computed tomography perfusion in pediatric moyamoya disease: a single-institution experience

Restricted access

OBJECTIVE

Moyamoya disease is a progressive occlusive arteriopathy for which surgical revascularization is indicated. In this retrospective study, the authors investigated the use of preoperative CT perfusion with the aim of establishing pathological data references.

METHODS

The authors reviewed the medical records of children with moyamoya disease treated surgically at one institution between 2016 and 2019. Preoperative CT perfusion studies were used to quantify mean transit time (MTT), cerebral blood volume (CBV), cerebral blood flow (CBF), and time to peak (TTP) for the anterior, middle, and posterior cerebral artery vascular territories for each patient. CT perfusion parameter ratios (diseased/healthy hemispheres) and absolute differences were compared between diseased and normal vascular territories (defined by catheter angiography studies). Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values for CT perfusion parameters for severe angiographic moyamoya were calculated.

RESULTS

Nine children (89% female) had preoperative CT perfusion data; 5 of them had evidence of unilateral hemispheric disease and 4 had bilateral disease. The mean age at revascularization was 77 months (range 40–144 months). The etiology of disease was neurofibromatosis type 1 (3 patients), Down syndrome (2), primary moyamoya disease (2), cerebral proliferative angiopathy (1), and sickle cell disease (1). Five patients had undergone unilateral revascularization. Among these patients, pathological vascular territories demonstrated increased MTT in 66% of samples, increased TTP in 66%, decreased CBF in 47%, and increased CBV in 87%. Severe moyamoya (Suzuki stage ≥ 4) had diseased/healthy ratios ≥ 1 for MTT in 78% of cases, for TTP in 89%, for CBF in 67%, and for CBV in 89%. The MTT and TTP region of interest ratio ≥ 1 demonstrated 89% sensitivity, 67% specificity, 80% PPV, and 80% NPV for the prediction of severe angiographic moyamoya disease.

CONCLUSIONS

Pathological hemispheres in these children with moyamoya disease demonstrated increased MTT, TTP, and CBV and decreased CBF. The authors’ results suggest that preoperative CT perfusion may, with high sensitivity, be useful in deciphering perfusion mismatch in brain tissue in children with moyamoya disease. More severe angiographic disease displays a more distinct correlation, allowing surgeons to recognize when to intervene in these patients.

ABBREVIATIONS ACA = anterior cerebral artery; CBF = cerebral blood flow; CBV = cerebral blood volume; CVRC = cerebrovascular reserve capacity; MCA = middle cerebral artery; MTT = mean transit time; NPV = negative predictive value; PCA = posterior cerebral artery; PPV = positive predictive value; ROI = region of interest; TTP = time to peak.
Article Information

Contributor Notes

Correspondence Sandi Lam: Northwestern University Feinberg School of Medicine, Chicago, IL. sandilam@luriechildrens.org.INCLUDE WHEN CITING Published online January 24, 2020; DOI: 10.3171/2019.10.PEDS19450.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Headings
References
  • 1

    Axel L: Tissue mean transit time from dynamic computed tomography by a simple deconvolution technique. Invest Radiol 18:94991983

  • 2

    Gadgil NLam SPyarali MPaldino MPan IWDauser RC: Indirect revascularization with the dural inversion technique for pediatric moyamoya disease: 20-year experience. J Neurosurg Pediatr 22:5415492018

    • Search Google Scholar
    • Export Citation
  • 3

    Gupta AChazen JLHartman MDelgado DAnumula NShao H: Cerebrovascular reserve and stroke risk in patients with carotid stenosis or occlusion: a systematic review and meta-analysis. Stroke 43:288428912012

    • Search Google Scholar
    • Export Citation
  • 4

    Guzman RLee MAchrol ABell-Stephens TKelly MDo HM: Clinical outcome after 450 revascularization procedures for moyamoya disease. Clinical article. J Neurosurg 111:9279352009

    • Search Google Scholar
    • Export Citation
  • 5

    Kang KHKim HSKim SY: Quantitative cerebrovascular reserve measured by acetazolamide-challenged dynamic CT perfusion in ischemic adult moyamoya disease: initial experience with angiographic correlation. AJNR Am J Neuroradiol 29:148714932008

    • Search Google Scholar
    • Export Citation
  • 6

    Lee MZaharchuk GGuzman RAchrol ABell-Stephens TSteinberg GK: Quantitative hemodynamic studies in moyamoya disease: a review. Neurosurg Focus 26(4):E52009

    • Search Google Scholar
    • Export Citation
  • 7

    Lee SRivkin MJKirton AdeVeber GElbers J: Moyamoya disease in children: results from the International Pediatric Stroke Study. J Child Neurol 32:9249292017

    • Search Google Scholar
    • Export Citation
  • 8

    Manninen ALIsokangas JMKarttunen ASiniluoto TNieminen MT: A comparison of radiation exposure between diagnostic CTA and DSA examinations of cerebral and cervicocerebral vessels. AJNR Am J Neuroradiol 33:203820422012

    • Search Google Scholar
    • Export Citation
  • 9

    Ravindra VMRiva-Cambrin JSivakumar WMetzger RRBollo RJ: Risk factors for traumatic blunt cerebrovascular injury diagnosed by computed tomography angiography in the pediatric population: a retrospective cohort study. J Neurosurg Pediatr 15:5996062015

    • Search Google Scholar
    • Export Citation
  • 10

    Rim NJKim HSShin YSKim SY: Which CT perfusion parameter best reflects cerebrovascular reserve?: correlation of acetazolamide-challenged CT perfusion with single-photon emission CT in moyamoya patients. AJNR Am J Neuroradiol 29:165816632008

    • Search Google Scholar
    • Export Citation
  • 11

    Sakamoto SOhba SShibukawa MKiura YArita KKurisu K: CT perfusion imaging for childhood moyamoya disease before and after surgical revascularization. Acta Neurochir (Wien) 148:77812006

    • Search Google Scholar
    • Export Citation
  • 12

    Schubert GACzabanka MSeiz MHorn PVajkoczy PThomé C: Perfusion characteristics of moyamoya disease: an anatomically and clinically oriented analysis and comparison. Stroke 45:1011062014

    • Search Google Scholar
    • Export Citation
  • 13

    Suzuki JTakaku A: Cerebrovascular "moyamoya" disease. Disease showing abnormal net-like vessels in base of brain. Arch Neurol 20:2882991969

    • Search Google Scholar
    • Export Citation
  • 14

    Veeravagu AGuzman RPatil CGHou LCLee MSteinberg GK: Moyamoya disease in pediatric patients: outcomes of neurosurgical interventions. Neurosurg Focus 24(2):E162008

    • Search Google Scholar
    • Export Citation
  • 15

    Wintermark MMaeder PVerdun FRThiran JPValley JFSchnyder P: Using 80 kVp versus 120 kVp in perfusion CT measurement of regional cerebral blood flow. AJNR Am J Neuroradiol 21:188118842000

    • Search Google Scholar
    • Export Citation
  • 16

    Xie ALuo LDing YLi G: Ischemic and hemorrhagic moyamoya disease in adults: CT findings. Int J Clin Exp Med 8:21351213572015

  • 17

    Yonas HSmith HADurham SRPentheny SLJohnson DW: Increased stroke risk predicted by compromised cerebral blood flow reactivity. J Neurosurg 79:4834891993

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 102 102 102
Full Text Views 34 34 34
PDF Downloads 21 21 21
EPUB Downloads 0 0 0
PubMed
Google Scholar