• Annick Kronenburg, Bulder Marcel M M MMM Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, Utrecht, the Netherlands; Department of Neurology, Bravis Hospital, Bergen op , Bokkers Reinoud P H RPH Department of Radiology, UMC Utrecht, Utrecht, the Netherlands; Department of Radiology, Medical Imaging Center, University Medical Center Groning, Nolan S Hartkamp, Jeroen Hendrikse, Evert-Jan Vonken, L Jaap Kappelle, Albert van der Zwan, Klijn Catharina J M CJM Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, Utrecht, the Netherlands; Department of Neurology, Donders Institute for Bra, and Braun Kees P J KPJ Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, Utrecht, the Netherlands..
• Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, Utrecht, the Netherlands. Electronic address: A.Kronenburg@umcutrecht.nl.
• World Neurosurg. 2019 May 1; 125: e639-e650.

BackgroundArterial spin labeling (ASL) perfusion magnetic resonance imaging (MRI) may be used to determine brain regions at risk for ischemia in patients with moyamoya vasculopathy and to identify patients who may benefit from surgical revascularization. We aimed to investigate whether 1) the severity of moyamoya is related to the presence of leptomeningeal collaterals and cerebrovascular reactivity (CVR), 2) the presence of collaterals and ivy sign reflects disturbed CVR, and 3) arterial transit artefacts (ATAs) and ivy sign reflect the presence of collaterals.MethodsWe determined severity of moyamoya on digital subtraction angiography (DSA) according to the modified Suzuki classification in 20 brain regions and scored regional tissue revascularization using a 4-point scale. Regional CVR and ATAs were assessed on ASL perfusion MRI, ivy sign on fluid attenuation inversion recovery MRI.ResultsIn 11 patients (median age 36 years; 91% female), we studied 203 regions. ATAs were associated with the presence of collaterals on DSA (P < 0.01). Of all regions with clearly visible collateral vessels on DSA, however, only 24% had ATAs. Ivy sign was not related to the presence or absence of collaterals nor to CVR. In 10% of regions with good vascularization on DSA, CVR was poor or showed steal.ConclusionsATAs were associated with the presence of collaterals on DSA. Although DSA vascularization scores correlated with CVR, 10% of regions with good vascularization on DSA had absent CVR or steal on ASL-MRI. DSA and ivy sign did not provide adequate information on the hemodynamic status of brain tissue in patients with moyamoya vasculopathy.Copyright © 2019 Elsevier Inc. All rights reserved.

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