J Korean Neurosurg Soc.  2024 Jul;67(4):442-450. 10.3340/jkns.2023.0183.

Early Detection of hyperemia with Magnetic Resonance Fluid Attenuation Inversion Recovery Imaging after Superficial Temporal Artery to Middle Cerebral Artery Anastomosis

• Eun J
• Park IS

• KMID: 2556741
• DOI: http://doi.org/10.3340/jkns.2023.0183

Abstract

Objective
: Cerebral hyperperfusion syndrome (CHS) manifests as a collection of symptoms brought on by heightened focal cerebral blood flow (CBF), afflicting nearly 30% of patients who have undergone superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis. The aim of this study was to investigate whether the amalgamation of magnetic resonance imaging (MRI) fluid-attenuated inversion recovery (FLAIR) and apparent diffusion coefficient (ADC) imaging via MRI can discern cerebral hyperemia after STA-MCA anastomosis surgery.
Methods
: A retrospective study was performed of patients who underwent STA-MCA anastomosis due to Moyamoya disease or atherosclerotic steno-occlusive disease. A protocol aimed at preventing CHS was instituted, leveraging the use of MRI FLAIR. Patients underwent MRI diffusion with FLAIR imaging 24 hours after STA-MCA anastomosis. A high signal on FLAIR images signified the presence of hyperemia at the bypass site, triggering a protocol of hyperemia care. All patients underwent hemodynamic evaluations, including perfusion MRI, single-photon emission computed tomography (SPECT), and digital subtraction angiography, both before and after the surgery. If a high signal intensity is observed on MRI FLAIR within 24 hours of the surgery, a repeat MRI is performed to confirm the presence of hyperemia. Patients with confirmed hyperemia are managed according to a protocol aimed at preventing further progression.
Results
: Out of a total of 162 patients, 24 individuals (comprising 16 women and 8 men) exhibited hyperemia on their MRI FLAIR scans following the procedure. SPECT was conducted on 23 patients, and 11 of them yielded positive results. All 24 patients underwent perfusion MRI, but nine of them showed no significant findings. Among the patients, 10 displayed elevations in both CBF and cerebral blood volume (CBV), three only showed elevation in CBF, and two only showed elevation in CBV. Follow-up MRI FLAIR scans conducted 6 months later on these patients revealed complete normalization of the previously observed high signal intensity, with no evidence of ischemic injury.
Conclusion
: The study determined that the use of MRI FLAIR and ADC mapping is a competent means of early detection of hyperemia after STA-MCA anastomosis surgery. The protocol established can be adopted by other neurosurgical institutions to enhance patient outcomes and mitigate the hazard of permanent cerebral injury caused by cerebral hyperemia.

Keyword

Cerebral revascularization; Cerebrovascular circulation; Hyperemia

Figure

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  Fig. 1. Protocol. STA : superficial temporal artery, MCA : middle cerebral artery, CT : computed tomography, MRI : magnetic resonance imaging, FLAIR : fluid-attenuated inversion recovery, POD : post operative day.

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  Fig. 2. Postoperative MRI FLAIR (A) and ADC (B) images. At postoperative day 1, a high signal intensity area was observed on the right frontal lobe (arrow in A) indicating vasogenic edema on FLAIR. A high signal intensity area was observed on the ADC image (arrow in B) in the same area indicating interstitial edema not cerebral infarction. MRI : magnetic resonance imaging, FLAIR : fluid-attenuated inversion recovery, ADC : apparent diffusion coefficient.

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  Fig. 3. A case illustrations of postoperative MRI FLAIR, perfusion MRI, and SPECT image. A : A high signal intensity area was observed on the left frontal lobe (arrows) indicating vasogenic edema on FLAIR. B : A perfusion MRI of the same patients revealed a slight decrease in cerebral blood volume and postoperative SPECT showed a decrease in blood flow at the bypass site. C : A follow up MRI taken 6 months later showed complete recovery of hyperemia in FLAIR image (arrow), indicating that the vasogenic edema had resolved. FLAIR : fluid-attenuated inversion recovery, ADC : apparent diffusion coefficient, DWI : diffusion weighted imaging, CBF : cerebral blood flow, TTP : time-to-peak, SPECT : single-photon emission computed tomography, MRI : magnetic resonance imaging.

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  Fig. 4. A case illustration of MRI FLAIR, SPECT, and perfusion MRI. A : An MRI FLAIR image showed a high signal intensity area in the right frontal lobe (arrows), indicating vasogenic edema. The same perfusion MRI showed increased cerebral blood flow at the site of the operation. B : SPECT showed increased flow on operation site (arrows). C : The postoperative MRI FLAIR taken 2 months after surgery showed that the previously observed lesion had normalized (arrow). FLAIR : fluid-attenuated inversion recovery, CBF : cerebral blood flow, TTP : time-to-peak, SPECT : single-photon emission computed tomography, f/u : follow-up, MRI : magnetic resonance imaging.

Reference

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