Comparison of CBF Measured with Combined Velocity-Selective Arterial Spin-Labeling and Pulsed Arterial Spin-Labeling to Blood Flow Patterns Assessed by Conventional Angiography in Pediatric Moyamoya

D.S. Bolar; B. Gagoski; D.B. Orbach; E. Smith; E. Adalsteinsson; B.R. Rosen; P.E. Grant; R.L. Robertson

doi:10.3174/ajnr.A6262

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Fig 1.
Representative ASPECTS regions used for scoring of both DSA (A) and ASL data (B); specifically, 2 ACA regions, 6 MCA regions, and 2 posterior cerebral artery regions per side were evaluated.
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Fig 2.
Representative DSA data (A), PASL CBF maps (B), and VSASL CBF maps (C) for a preoperative patient with left-sided moyamoya. A, Frontal DSA data from bilateral ICA injections at various postinjection times. The right side appears relatively normal, with early arterial filling and ACA/MCA parenchymal blush at 2.0 seconds. In contrast, the left side demonstrates delayed anterograde filling through a proximal M1 MCA stenosis (red arrowhead), retrograde filling via ACA-MCA collaterals, and delayed parenchymal perfusion of the MCA territory. Parenchymal perfusion of the left MCA territory is finally reached by 4.0 seconds. PASL maps (B) reflect the DSA appearance at 2.0 seconds bilaterally, including areas of curvilinear hyperintensity corresponding to macrovascular flow and perfusion deficit, while VSASL maps (C) reflect parenchymal DSA phases, despite these occurring at different times (2.0 seconds on the right, 4.0 seconds on the left). RICA indicates right ICA injection; LICA, left ICA injection.
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Fig 3.
Average PASL and VSASL-CBF CV (a marker of perfusion variability) calculated for patient vascular territories demonstrating delayed-but-complete parenchymal perfusion by DSA, with normal sibling values provided for comparison. Patient VSASL values are similar to those of healthy siblings, consistent with the DSA appearance, but PASL values are markedly different. Error bars denote 95% CI.
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Fig 4.
Standard ASL label propagation with patent proximal vessels (A) and steno-occlusive disease with secondary collateralization (B). A, The ASL label travels from the labeling band to the distant microvasculature during the standard PLD, resulting in symmetric, homogeneous gray matter perfusion (C). B, The label is delayed due to slow flow through the stenosis and circuitous collateral pathways. Consequently, the label does not fully reach the distal microvasculture during PLD and remains caught in the macrovasculature, resulting in areas of apparent perfusion deficit and hyperintense arterial transit artifacts (D).

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Table 1:

Patient demographics

Pt.	Moyamoya Etiology	Age (yr)	Sex	Laterality	Operative Status	Suzuki³⁷ (R/L), Preoperative	Treatment	Matsushima³⁸ (R/L)
1	Idiopathic	11	F	Left	Pre	IV
		12			Post		Left synangiosis	C
2	NF1	6	M	Right	Post	IV–V	Right synangiosis	A
3	SCD	13	F	Bilateral	Post	NA	Bil synangiosis	A
4	Idiopathic	14	F	Bilateral	Post	III–IV/III–IV	Bil synangiosis	A/A
5	Idiopathic	19	F	Bilateral	Post	V–VI/III–IV	Bil synangiosis	A/C
6	NF1	17	F	Bilateral	Pre	I/III–IV
7	SCD	11	M	Bilateral	Post	II/II	Bil synangiosis	A/B
8	Idiopathic	14	M	Bilateral	Post	IV/IV	Bil synangiosis	A/A
9	Idiopathic	13	F	Bilateral	Post	II/III	Bil synangiosis	B/C
10	Idiopathic	16	F	Bilateral	Pre	I/I
11	Idiopathic	7	F	Bilateral	Pre	II/II
12	NF1^{^a}	5	F	Right	Pre	I
13	SCD	11	F	Right	Pre	II
14	NF1	8	M	Left	Post	III	Left synangiosis	A
15	Idiopathic	7	F	Right	Post	III	Right synangiosis	A
16	Idiopathic	13	F	Left	Post	NA	Left synangiosis	B
17	Idiopathic	19	F	Bilateral	Pre	III/I–II
18	Idiopathic	3	M	Bilateral	Post	II–III/II–III	Bil synangiosis	B/A–B
19	NF1	15	M	Left	Post	V	Left synangiosis	B
20	Idiopathic	12	M	Right	Post	III–IV	Right synangiosis	B–C
21	Idiopathic	15	M	Bilateral	Post	III/III	Bil synangiosis	B/B
22	Idiopathic	2	M	Bilateral	Post	IV/II	Bil synangiosis	A/A–B

Note:—NF1 indicates neurofibromatosis type 1; SCD, sickle cell disease; Pre, before; Post, after; R, right; L, left; NA, not applicable; Bil, bilateral.
↵a Patient with NF1 with radiated right masticator space tumor; arteriopathy possibly related to radiation.

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Table 2:
Contingency table of ASPECTS-based scoring for ASL and DSA data^{^a}
DSA Score ASL Score Totals
0 1 2 3
0 0 1 0 0 1 (<1%)
1 0 6 17 1 24 (5%)
2 0 7 192 21 220 (46%)
3 0 0 13 222 235 (49%)
Totals 0 (0%) 14 (3%) 222 (46%) 244 (51%) 480
↵a Agreement = 88%, Cohen κ = 0.77, P < .0001.