Cerebral circulation and oxygen metabolism in childhood moyamoya disease: a perioperative positron emission tomography study

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✓ Thirteen children with moyamoya disease who had no apparent cerebral infarction or hemorrhage were examined pre- and postoperatively by means of positron emission tomography (PET) to investigate the underlying cerebral circulation and metabolism and the effect of bypass surgery. The preoperative regional cerebral blood flow (rCBF) and mean transit time were significantly decreased and increased, respectively, in the cerebral cortex of these patients compared to control values. The regional cerebral blood volume (rCBV) and the regional oxygen extraction fraction (rOEF) had significantly increased to compensate for the reduced rCBF and perfusion pressure and also to maintain the regional cerebral metabolic rate of oxygen (rCMRO2). In the basal ganglia, rCBV elevation was more prominent than that in the cerebral cortex, although changes in rCBF, rOEF, and rCMRO2 were relatively minor.

Postoperative improvements were observed predominantly near the cortex where bypass surgery had been performed and in the basal ganglia. Direct and combined indirect bypass procedures improved cerebral circulation more effectively than single indirect bypass surgery. Although the angiographic findings were not always compatible with the clinical results, the postoperative improvements on PET scans correlated with the disappearance of transient ischemic attacks. In addition to the clinical courses and angiographic findings, PET analysis was indispensable in evaluating the cerebral circulation and metabolism in childhood moyamoya disease.

Article Information

Address reprint requests to: Kiyonobu Ikezaki, M.D., Department of Neurosurgery, Neurological Institute, Faculty of Medicine, Kyushu University, Fukuoka 812, Japan.

© AANS, except where prohibited by US copyright law.

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Figures

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    Magnetic resonance (MR) images obtained in Case 11, a patient whose main symptom was transient weakness in the right upper extremity. Left: A T2-weighted image showing abundant flow-void areas in the basal ganglia but not in the left middle cerebral artery branches in the sylvian fissure. No apparent cerebral infarction was noted. Right: Moyamoya vessels are visualized on this T1-weighted coronal image.

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    Pre- and postoperative angiograms obtained in Case 11. Left: Preoperative internal carotid angiogram revealing Stage III moyamoya disease. Right: Postoperative external carotid angiogram disclosing excellent collateral formation through a superficial temporal artery-middle cerebral artery anastomosis and encephalomyosynangiosis.

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    Preoperative (upper) and postoperative (lower) positron emission tomography scans obtained in Case 11. Upper: Reduced regional cerebral blood flow (rCBF) and increased regional oxygen extraction fraction (rOEF) and regional cerebral blood volume (r CBV) are seen preoperatively in the left frontotemporal lobe and basal ganglia. Lower: Significant postoperative improvement of these parameters is obtained, including increased rCBF (arrows) and decreased rOEF and rCBV (arrowheads). There are no significant changes in regional cerebral metabolic rate for oxygen between the preoperative and postoperative studies.

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    Bar graph showing postoperative improvement of mean transit time (rTT, in seconds) at various locations and the effect of operative procedures. Values are mean ± standard deviation. Pre = preoperative; indirect = indirect bypass; direct = direct bypass; Cont = control.

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