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Assessment of cerebrovascular reserve using acetazolamide brain perfusion SPECT in Moyamoya disease
Harish Goyal1, Dhritiman Chakraborty2, Srinivas Ananth Kumar1
1Department of Nuclear Medicine, Jawaharlal Institute of Postgraduate Medical Education Research, Puducherry, India.
Objectives:
Moyamoya disease (MMD) is a rare, progressive steno-occlusive cerebrovascular disorder characterized by impaired cerebral perfusion and an elevated risk of ischemic events. Accurate cerebrovascular reserve (CVR) assessment is crucial for guiding surgical decision-making. This study evaluated the clinical utility of acetazolamide (ACZ)-challenged brain perfusion single-photon emission computed tomography (SPECT) in assessing CVR in patients with MMD.
Methods:
We retrospectively analyzed 10 patients (6 males, four females; aged 5-65 years) with angiographically confirmed MMD who underwent baseline and post-ACZ 99mTc-ECD SPECT. Regional perfusion across 12 brain regions per patient was visually graded and classified using Rogg's criteria (Type I-III) to assess CVR.
Results:
At baseline, 78/120 regions showed normal perfusion; post-ACZ, this decreased to 72 regions, with an increase in severe hypoperfusion (from 16 to 26 regions). A total of 44 regions demonstrated improved perfusion following ACZ, indicating preserved reserve. According to Rogg's classification, 63 regions showed Type I, 13 showed Type II, and 39 showed Type III responses. Three patients had infarcts, with two exhibiting crossed cerebellar diaschisis. In a patient who underwent revascularization, new postoperative perfusion defects developed in regions that corresponded to preoperative Type III responses.
Conclusion:
ACZ-challenged SPECT effectively characterizes regional CVR in MMD. Identifying Type II and III responses is a valuable predictor for ischemic vulnerability and guides the selection of surgical candidates.
Insights
Acetazolamide-challenged SPECT effectively assesses cerebrovascular reserve in Moyamoya disease, identifying patients at high risk for stroke. This imaging technique aids in selecting appropriate surgical candidates for improved outcomes.
Area of Science:
- Neurology
- Radiology
- Vascular Medicine
Background:
- Moyamoya disease (MMD) is a rare cerebrovascular disorder causing progressive stenosis.
- Impaired cerebral perfusion in MMD increases the risk of ischemic events.
- Accurate assessment of cerebrovascular reserve (CVR) is vital for surgical planning.
Purpose of the Study:
- To evaluate the clinical utility of acetazolamide (ACZ)-challenged brain perfusion SPECT in assessing CVR in MMD patients.
- To determine if ACZ-challenged SPECT can predict ischemic vulnerability and guide surgical decisions.
Main Methods:
- Retrospective analysis of 10 MMD patients (ages 5-65).
- 99mTc-ECD SPECT performed at baseline and after ACZ challenge.
- Regional CVR assessed visually and classified using Rogg's criteria (Type I-III).
Main Results:
- ACZ challenge revealed increased hypoperfusion and identified 44 regions with preserved CVR.
- Rogg's classification showed 63 Type I, 13 Type II, and 39 Type III responses.
- Type III responses correlated with infarcts and postoperative perfusion defects.
Conclusions:
- ACZ-challenged SPECT is effective in characterizing regional CVR in MMD.
- Identifying Type II and III responses predicts ischemic vulnerability.
- This method aids in selecting surgical candidates for MMD.
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