Magnetic Resonance Imaging (MRI) and Digital Subtraction Angiography Investigation of Childhood Moyamoya Disease

Abstract

Because digital subtraction angiography (DSA) is not an ideal angiographic examination for moyamoya disease in the pediatric population, magnetic resonance angiography (MRA) provides a noninvasive contrast-free angiographic examination; whereas magnetic resonance imaging (MRI) provides superior spatial resolution and soft-tissue contrast for lesion assessment. Ninety patients with moyamoya disease were examined by MRI and DSA to assess the distribution of lesions and their diagnostic agreement between modalities. MRI examination revealed 439 lesions. Punctate lesions were the most abundant, followed by patchy lesions. These lesions generally covered a smaller area than the abnormal-vascular corresponding brain parenchyma. Steno-occlusive changes at bilateral anterior, medial, and posterior cerebral arteries were identified by MRA and DSA. MRI showed moderate agreement in identifying lesions after steno-occlusive changes in anterior and medial cerebral arteries, and good agreement in posterior cerebral arteries; 6% to 11% of cases were misdiagnosed by MRA.

Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association

“…MRI sequences that are particularly useful in moyamoya include fluid-attenuated inversion recovery images to assess chronic infarct burden and areas of slow flow (as evidenced by the so-called ivy sign, or serpentine sulcal hyperintensity, present in ≈80% of cases) and MRA to visualize the circle of Willis. 177,179,200,201,[258][259][260][261][262] Advances in vessel wall imaging can help to distinguish between vasculitis and moyamoya. 263 DSA is important for surgical planning to avoid disruption of natural collaterals from the external carotid circulation.…”

Pathophysiology of Vascular Stenosis and Remodeling in Moyamoya Disease

“…MRI demonstrated good diagnostic coherence regarding stenotic and/or occlusive changes in the bilateral PCA. However, it is important to note that in 6 to 11% of patients, an MRA evaluation may lead to misdiagnosis of moyamoya (162).…”

Magnetic Resonance Imaging/Angiography Versus Catheter Angiography for Annual Follow-up of Pediatric Moyamoya Patients: A Cost Outcomes Analysis

“…12 This is also the case for moyamoya in the pediatric population, where DSA is frequently used to assess patients in the postoperative period. 11,[13][14][15][16][17][18][19][20] However, MRI/A has shown similar efficacy in diagnostic performance compared with DSA when following other cerebral vascular lesions, including aneurysms 21 and arteriovenous malformations. 22 Given recent evidence that Matsushima grade does not correlate with clinical outcome or hypovascular territories 8 and that the ivy sign scoring system provides useful and prognostic clinical data, 9 MRI/A could potentially halve the number of DSA studies for many moyamoya patients.…”

“…The additional information rendered by DSA is unlikely to justify the added invasiveness, cost, and time required because new hypovascular territories were detected equivalently by MRI/A in our study. Although MRI/A has been compared with DSA before for the initial diagnosis of moyamoya, 19,20,23 data comparing these 2 modalities for the purposes of postoperative follow-up are limited. DSA is likely superior to MRI/A in detailed characterization of steno-occlusive disease, 20 but postoperatively, this is less relevant than the detection of new hypovascular territories, which MRI/A can also provide.…”