PMC10010568_01
Clinical and imaging findings. Brain MRI and MR angiography of the subject performed before revascularization at 8 years of age (A-D) and at last follow-up, after eleven months (E-H). A) Axial T2-weighted image shows a chronic arterial ischemic infarct in the right cerebral hemisphere (empty arrows) with relative sparing of the mesial frontal and insular regions. (B,C) Brain MR angiography with 3D reconstruction, frontal view (B) and axial MinIP reconstruction (C) demonstrate bilateral stenosis of the right supraclinoid portions of the internal carotid arteries with absent flow signal in the middle cerebral arteries (thick arrows) and anterior cerebral arteries, and multiple moyamoya collaterals (arrowheads). Note the initial distal stenosis of the left posterior cerebral artery. (D) Brain arterial spin labeling MR perfusion reveals reduced signal in the right cerebral hemisphere and in the left anterior frontal and parietal lobes (thin arrows) with bilateral arterial transit artifacts (arrowheads). (E) Follow-up axial T2-weighted image performed 11 months after the revascularization procedure shows no other ischemic infarcts. (F,G) Corresponding MR angiography images reveal reduction of flow signal in the superficial temporal arteries (arrowheads), absence of collateral formation at surgical site on the right, and a limited region of revascularization in the left fronto-basal region (thick arrow). (H) Arterial spin labeling MR perfusion demonstrated increased CBF only in the left fronto-basal region (arrowhead).
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Brain MRI at 8 years of age showed a large chronic infarct in the right middle and posterior cerebral arteries territories (Figure 1A) while MR angiography demonstrated marked stenosis of both supra-clinoid portions of the internal carotid arteries, with absent flow signal in the middle cerebral arteries and anterior cerebral arteries and extensive moyamoya collaterals (Figures 1B,C). Brain perfusion MR studies revealed areas of reduced perfusion in both the right and left hemispheres (Figure 1D). However, follow-up brain MRI studies performed 4 and 11 months after the procedures, respectively, showed an extremely limited neovascularization, only involving a small portion of the left frontal basal cortex (Figures 1E-H).