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Alaa S. Montaser, Harishchandra Lalgudi Srinivasan, Steven J. Staffa, David Zurakowski, Anna L. Slingerland, Darren B. Orbach, Moran Hausman-Kedem, Jonathan Roth, and Edward R. Smith

T he ivy sign is a radiographic finding consisting of a bright signal in the cortical sulci and subarachnoid space on specific MRI sequences, which was first described on T1-weighted postcontrast studies, then subsequently on FLAIR images. 1 – 4 Previously called leptomeningeal contrast enhancement or leptomeningeal high signal intensity, 5 , 6 it was initially recognized decades ago in a small series of 3 children with moyamoya disease in Japan. 1 While the presence of the ivy sign has since been identified in multiple conditions in which there is slow

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Armide Storey, R. Michael Scott, Richard Robertson, and Edward Smith

on axial FLAIR images (ivy sign) on MRI. 3 , 8 , 14 The Matsushima grade on postoperative digital subtraction angiography (DSA) and evidence of new postoperative infarct on MRI or CT (as compared with preoperative studies) were used to evaluate the outcome of this cohort. 16 Transdural collaterals were defined as blood supply to the cortex from branches of the ECA, as determined by formal neuroradiology review. (Ophthalmic collateral vessels were excluded from this study because they originate from branches of the ICA and, from a practical standpoint, are not

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Hime Suzuki, Takeshi Mikami, Tomoyoshi Kuribara, Kazuhisa Yoshifuji, Katsuya Komatsu, Yukinori Akiyama, Hirofumi Ohnishi, Kiyohiro Houkin, and Nobuhiro Mikuni

impairment. 4 , 13 Linear hyperintensity along the sulci on fluid-attenuated inversion recovery (FLAIR) imaging is referred to as the “leptomeningeal ivy sign,” is considered to indicate retrograde slow flow of the leptomeningeal anastomosis produced by the stenotic or occlusive change in the major vessels, 20 and is indicative of misery perfusion, which is hemodynamic compromise due to impaired cerebral blood flow. 15 , 24 , 36 In some pediatric cases, the linear hyperintensity on FLAIR imaging extends to the perivascular space of the deep white matter, 16 , 20 , 31

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Eika Hamano, Hiroharu Kataoka, Naomi Morita, Daisuke Maruyama, Tetsu Satow, Koji Iihara, and Jun C. Takahashi

) absence of acute infarction; and 3) absence of acute hemorrhage ( Fig. 1 left ). A high-intensity signal in the cortical sulci, commonly called the “ivy sign” ( Fig. 1 right ), 25 , 32 was strictly excluded from consideration as the CHB sign. FIG. 1. Differences in MR FLAIR images. Left: The CHB sign (circled) . Right: The ivy sign (arrows) . All slices of the axial FLAIR images were reviewed to determine the extent to which the CHB sign was present, according to a procedure adapted from a previous report. 30 The central sulcus represented the

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Alaa Montaser, Jessica Driscoll, Hudson Smith, Madeline B. Karsten, Emily Day, Tina Mounlavongsy, Darren B. Orbach, and Edward R. Smith

identified cohort was conducted, and the following data were collected and analyzed: age at presentation, sex, associated medical conditions, whether the patient received cranial irradiation for a tumor, clinical presentation, disease laterality, radiographic evidence of stroke, radiographic evidence of slow blood flow on axial FLAIR MR images (“ivy sign”), 1 presence of collaterals at the time of diagnosis, Suzuki stage of associated ICA disease, indications for surgery, type of surgical technique, intraoperative blood loss, intra- and postoperative complications

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Katie P. Fehnel, Craig D. McClain, and Edward R. Smith

ischemia and slow blood flow 30 ( Fig. 2 ). FIG. 1. Anteroposterior ( A ) and lateral ( B ) right carotid artery injection angiograms demonstrate near complete absence of flow at the right carotid artery terminus, with tortuous collaterals. Left carotid artery injection angiogram ( C ) demonstrates slow cross-filling from the left. FIG. 2. Axial T2 FLAIR MR image demonstrating a high-convexity ivy sign ( white arrow ) suggestive of slow flow. Preoperative Counseling Given the patient’s progressive symptoms and risk of peripartum ischemia, surgical revascularization was

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Subash Lohani, Joseph R. Madsen, Ann M. Bergin, and Edward R. Smith

demonstrating slow flow in the right temporoparietal region represented by bright signal in the sulci (ivy sign). E: Right internal carotid artery injection (anteroposterior view) arteriogram showing severe right-sided stenoocclusive changes particularly involving the right M 1 with corresponding perforating vessel proliferation consistent with moyamoya disease, Suzuki Stage III. Repeat video-EEG telemetry performed at the age of 5 years captured 18 seizures on EEG studies after anti-convulsant medication withdrawal. Seizures arose in the right midposterior temporal

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Ning Lin, Lissa Baird, McKenzie Koss, Kimberly E. Kopecky, Evelyne Gone, Nicole J. Ullrich, R. Michael Scott, and Edward R. Smith

narrowing of the anterior cerebral, middle cerebral, or internal carotid arteries on MR imaging or catheter angiogram (per the cited guidelines); 2) development of FLAIR hyperintensity in the sulci on MR imaging—the “ivy sign”—as a marker of slow cerebral blood flow; and 3) evidence of radiographic infarction, as determined by MR imaging and reported by neuroradiologists. 3 , 4 , 23 Although all patients were by definition asymptomatic at the time of the initial radiographic diagnosis of moyamoya, we collected data on the number of patients in whom clinical symptoms

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David S. Hersh, Kenneth Moore, Vincent Nguyen, Lucas Elijovich, Asim F. Choudhri, Jorge A. Lee-Diaz, Raja B. Khan, Brandy Vaughn, and Paul Klimo Jr.

contrast kinetics (TRICKS) dynamic MRA; and axially acquired 3D time-of-flight MRA sequences were obtained. 5 Particular attention was paid to any evidence of ischemia (old or new), as well as the “ivy sign,” defined as areas of hyperintensity following a cortical surface or sulcal pattern on fluid attenuated inversion recovery (FLAIR) sequences, which is suggestive of slow flow in the distal branches of the anterior, middle, and/or posterior cerebral arteries, as well as leptomeningeal collaterals. 12 , 20 Multidelay ASL perfusion imaging was qualitatively evaluated

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Vance T. Lehman, Petrice M. Cogswell, Lorenzo Rinaldo, Waleed Brinjikji, John Huston III, James P. Klaas, and Giuseppe Lanzino

arrowheads ), and hemosiderin within a lacunar infarct in the deep right periventricular white matter ( asterisk ). E and F: In contrast, the cortical vessels are not detected on axial 2D T2 FLAIR; associated areas of white matter T2 hyperintensity as well as the lacunar infarct ( asterisk ) within the right hemispheric white matter are seen. There is also mild volume loss in the right MCA territory with mildly increased prominence of the sulci. FIG. 2. Diffuse hypoperfusion, extensive collateral blood supply with ivy sign, and acute superimposed on chronic parenchymal