PMC6305662_01
Cerebral angiography with sequential preoperative lateral views of internal left internal carotid artery show narrowing beyond ICA terminus and minimal filling of what should be middle and anterior cerebral artery territories.
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Imaging with both cerebral angiography and MRI demonstrated bilateral moyamoya disease (Fig. 1, Fig. 2), with classic flow compromise beginning at the terminus of bilateral internal carotid arteries.
Axial T2 MRI shows an absence of ischemic deficits (A). Representative images from parametric mapping of Tmax (transit time) perfusion imaging results before (B) and after (C) reperfusion, showing interval decrease in hypoperfused brain parenchyma. Automated quantification of perfusion imaging (RAPID) gives a reduction in tissue meeting threshold for hypoperfusion (Tmax > 6 s) from 150.7 cm3 to 14 cm3 (whole brain). Y-axis color units displayed are perfusion times in seconds.
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Over an 18 month period, serial MR perfusion studies utilizing Tmax (the time to maximum of the residue function) as a surrogate marker of cerebral hypoperfusion were obtained and showed increasing perfusion delays over the bilateral middle and anterior cerebral artery territories, concomitant with worsening seizure control (Fig. 2). Nine-month post-operative MRI scan shows marked improvements in bilateral CNS perfusion (Fig. 2).