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Infarct Pattern and Collateral Status in Adult Moyamoya Disease: A Multimodal Magnetic Resonance Imaging Study
Dong Yeop Kim1, Jeong Pyo Son1, Je Young Yeon1
1From the Departments of Neurology (D.Y.K., G.-M.K., O.Y.B.) and Neurosurgery (J.Y.Y., J.-S.K., S.-C.H.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea (J.P.S., O.Y.B.).
Background And Purpose:
Moyamoya disease (MMD) is a unique cerebrovascular disease characterized by the progressive stenosis of large intracranial arteries and a hazy network of basal collaterals, called moyamoya vessels. Although hemodynamic studies have been applied in MMD patients, the mechanisms of stroke in MMD are still unclear. The present study evaluated the infarct pattern and collateral status using multimodal magnetic resonance imaging in MMD patients.
Methods:
Adult MMD patients with acute ischemic stroke were prospectively recruited, and infarct pattern on diffusion-weighted imaging was evaluated. A collateral flow map, derived from magnetic resonance perfusion-weighted imaging data, was generated through automatic postprocessing, and collateral status was assigned into 3 grades. Transcranial Doppler monitoring was performed to detect microembolic signals in selected patients.
Results:
A total of 67 hemispheres (31 patients with bilateral and 5 patients with unilateral MMD) were analyzed. Most patients (83.7%) showed embolic pattern and rarely deep (9.3%) or hemodynamic infarct pattern (7.0%) on diffusion-weighted imaging. Most cases (86%) showed good collateral status, and few patients with acute infarcts of embolic pattern showed poor collateral status (n=7). One third (31.6%) of patients who underwent transcranial Doppler monitoring showed microembolic signals.
Conclusions:
In the studied population of adult MMD patients, embolic phenomenon played an important role in ischemic stroke. Therapeutic strategies against thromboembolism, as well as collateral enhancing strategies targeting improvement of hemodynamic status or increased washout of emboli, are warranted.
Insights
Embolic strokes are common in adult Moyamoya disease (MMD) patients, despite good collateral status. Further research into anti-thromboembolism and collateral enhancement strategies is needed for MMD stroke management.
Area of Science:
- Neurology
- Cerebrovascular Diseases
- Radiology
Background:
- Moyamoya disease (MMD) is a cerebrovascular disorder with progressive intracranial artery stenosis and moyamoya vessel formation.
- The precise mechanisms of stroke in MMD remain incompletely understood despite hemodynamic studies.
- Multimodal magnetic resonance imaging (MRI) is utilized to investigate infarct patterns and collateral status in MMD.
Purpose of the Study:
- To evaluate the infarct patterns and collateral status in adult Moyamoya disease patients with acute ischemic stroke.
- To elucidate the underlying mechanisms contributing to stroke in Moyamoya disease.
- To inform potential therapeutic strategies for managing stroke in MMD.
Main Methods:
- Prospective recruitment of adult MMD patients experiencing acute ischemic stroke.
- Assessment of infarct patterns using diffusion-weighted imaging (DWI).
- Generation of collateral flow maps from perfusion-weighted imaging (PWI) for collateral status grading and transcranial Doppler (TCD) monitoring for microembolic signals.
Main Results:
- Analysis of 67 hemispheres from 36 MMD patients revealed an embolic infarct pattern in 83.7% of cases.
- The majority of patients (86%) exhibited good collateral status, with few embolic infarcts associated with poor collateral status (n=7).
- Microembolic signals were detected in 31.6% of patients undergoing TCD monitoring.
Conclusions:
- Embolic phenomena are a significant contributor to ischemic stroke in adult Moyamoya disease patients.
- Therapeutic strategies should address both thromboembolism and the enhancement of collateral circulation.
- Improving hemodynamic status and emboli washout are potential targets for future MMD treatments.
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