Presurgical Magnetic Resonance Imaging Indicators of Revascularization Response in Adults With Moyamoya Vasculopathy

• Published in: Journal of magnetic resonance imaging Vol. 56; no. 4; pp. 983 - 994
• Main Authors: Waddle, Spencer, Garza, Maria, Davis, Larry T., Chitale, Rohan, Fusco, Matthew, Lee, Chelsea, Patel, Niral J., Kang, Hakmook, Jordan, Lori C., Donahue, Manus J.
• Format: Journal Article
• Language: English
• Published: Hoboken, USA John Wiley & Sons, Inc 01.10.2022; Wiley Subscription Services, Inc
• Subjects: Adult; Age; Angiogenesis; Angiography; Angiography, Digital Subtraction; Arteries; BOLD; Cerebral Revascularization - methods; Cerebrovascular Circulation - physiology; cerebrovascular reactivity; Clinical trials; Delay time; Diabetes mellitus; encephalo‐duro‐arterio‐synangiosis (EDAS); Evaluation; Female; Field strength; Health risks; Hemispheres; Humans; intracranial stenosis; Magnetic resonance imaging; Magnetic Resonance Imaging - methods; Mathematical analysis; Medical imaging; Middle Aged; Middle Cerebral Artery - diagnostic imaging; Middle Cerebral Artery - surgery; moyamoya; Moyamoya Disease - diagnostic imaging; Moyamoya Disease - surgery; Oxygenation; Prospective Studies; Race; Risk analysis; Risk factors; Statistical analysis; Statistical tests; Vascular diseases; Veins & arteries; intracranial stenosis; BOLD; cerebrovascular reactivity; moyamoya; encephalo-duro-arterio-synangiosis (EDAS); angiography
• ISSN: 1053-1807; 1522-2586; 1522-2586
• DOI: 10.1002/jmri.28156

Background Moyamoya is a progressive intracranial vasculopathy, primarily affecting distal segments of the internal carotid and middle cerebral arteries. Treatment may comprise angiogenesis‐inducing surgical revascularization; however, lack of randomized trials often results in subjective treatment decisions. Hypothesis Compensatory presurgical posterior vertebrobasilar artery (VBA) flow‐territory reactivity, including greater cerebrovascular reactivity (CVR) and reduced vascular delay time, portends greater neoangiogenic response verified on digital subtraction angiography (DSA) at 1‐year follow‐up. Study Type Prospective intervention cohort. Subjects Thirty‐one patients with moyamoya (26 females; age = 45 ± 13 years; 41 revascularized hemispheres). Methods Anatomical MRI, hypercapnic CVR MRI, and DSA acquired presurgically in adult moyamoya participants scheduled for clinically indicated surgical revascularization. One‐year postsurgery, DSA was repeated to evaluate collateralization. Field Strength 3 T. Sequence Hypercapnic T2*‐weighted gradient‐echo blood‐oxygenation‐level‐dependent, T2‐weighted turbo‐spin‐echo fluid‐attenuated‐inversion‐recovery, T1‐weighted magnetization‐prepared‐rapid‐gradient‐echo, and T2‐weighted diffusion‐weighted‐imaging. Assessment Presurgical maximum CVR and response times were evaluated in VBA flow‐territories. Revascularization success was determined using an ordinal scoring system of neoangiogenic collateralization from postsurgical DSA by two cerebrovascular neurosurgeons (R.V.C. with 8 years of experience; M.R.F. with 9 years of experience) and one neuroradiologist (L.T.D. with 8 years of experience). Stroke risk factors (age, sex, race, vasculopathy, and diabetes) were recorded. Statistical Tests Fisher's exact and Wilcoxon rank‐sum tests were applied to compare presurgical variables between cohorts with angiographically confirmed good (>1/3 middle cerebral artery [MCA] territory revascularized) vs. poor (<1/3 MCA territory revascularized) outcomes. Significance: two‐sided P < 0.05. Normalized odds ratios (ORs) were calculated. Results Criteria for good collateralization were met in 25 of the 41 revascularized hemispheres. Presurgical normalized VBA flow‐territory CVR was significantly higher in those with good (1.12 ± 0.13 unitless) vs. poor (1.04 ± 0.05 unitless) outcomes. Younger (OR = −0.60 ± 0.67) and White (OR = −1.81 ± 1.40) participants had highest revascularization success (good outcomes: age = 42 ± 14 years, race = 84% White; poor outcomes: age = 49 ± 11 years, race = 44% White). Data Conclusion Presurgical MRI‐measures of VBA flow‐territory CVR are highest in moyamoya participants with better angiographic responses to surgical revascularization. Level of Evidence 1 Technical Efficacy Stage 4