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Research ArticlePediatric Neuroimaging

Quantitative Assessment of Neovascularization after Indirect Bypass Surgery: Color-Coded Digital Subtraction Angiography in Pediatric Moyamoya Disease

H.-H. Cho, J.-E. Cheon, S.-K. Kim, Y.H. Choi, I.-O. Kim, W.S. Kim, S.-M. Lee, S.K. You and S.-M. Shin
American Journal of Neuroradiology May 2016, 37 (5) 932-938; DOI: https://doi.org/10.3174/ajnr.A4614
H.-H. Cho
aFrom the Department of Radiology (H.-H.C., J.-E.C., Y.H.C., I.-O.K., W.S.K., S.-M.L., S.K.Y.), Seoul National University Hospital, Seoul, Korea
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J.-E. Cheon
aFrom the Department of Radiology (H.-H.C., J.-E.C., Y.H.C., I.-O.K., W.S.K., S.-M.L., S.K.Y.), Seoul National University Hospital, Seoul, Korea
bDepartment of Radiology (J.-E.C., Y.H.C., I.-O.K., W.S.K.), Seoul National University College of Medicine, Seoul, Korea
cInstitute of Radiation Medicine (J.-E.C., I.-O.K., W.S.K.), Seoul National University Medical Research Center, Seoul, Korea
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S.-K. Kim
dDivision of Pediatric Neurosurgery (S.-K.K.), Seoul National University Children's Hospital, Seoul, Korea
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Y.H. Choi
aFrom the Department of Radiology (H.-H.C., J.-E.C., Y.H.C., I.-O.K., W.S.K., S.-M.L., S.K.Y.), Seoul National University Hospital, Seoul, Korea
bDepartment of Radiology (J.-E.C., Y.H.C., I.-O.K., W.S.K.), Seoul National University College of Medicine, Seoul, Korea
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I.-O. Kim
aFrom the Department of Radiology (H.-H.C., J.-E.C., Y.H.C., I.-O.K., W.S.K., S.-M.L., S.K.Y.), Seoul National University Hospital, Seoul, Korea
bDepartment of Radiology (J.-E.C., Y.H.C., I.-O.K., W.S.K.), Seoul National University College of Medicine, Seoul, Korea
cInstitute of Radiation Medicine (J.-E.C., I.-O.K., W.S.K.), Seoul National University Medical Research Center, Seoul, Korea
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W.S. Kim
aFrom the Department of Radiology (H.-H.C., J.-E.C., Y.H.C., I.-O.K., W.S.K., S.-M.L., S.K.Y.), Seoul National University Hospital, Seoul, Korea
bDepartment of Radiology (J.-E.C., Y.H.C., I.-O.K., W.S.K.), Seoul National University College of Medicine, Seoul, Korea
cInstitute of Radiation Medicine (J.-E.C., I.-O.K., W.S.K.), Seoul National University Medical Research Center, Seoul, Korea
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S.-M. Lee
aFrom the Department of Radiology (H.-H.C., J.-E.C., Y.H.C., I.-O.K., W.S.K., S.-M.L., S.K.Y.), Seoul National University Hospital, Seoul, Korea
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S.K. You
aFrom the Department of Radiology (H.-H.C., J.-E.C., Y.H.C., I.-O.K., W.S.K., S.-M.L., S.K.Y.), Seoul National University Hospital, Seoul, Korea
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S.-M. Shin
eDepartment of Radiology (S.-M.S.), Seoul Metropolitan Government–Seoul National University, Boramae Medical Center, Seoul, Korea.
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    Fig 1.

    Postprocessing cascade of the DSA image. A, A color-coded single image is obtained from DSA images of CCA angiography; then, we draw selected ROIs along the estimated EDAS flap site. A reference ROI is drawn within the proximal input artery. B, The time-attenuation intensity curve is obtained automatically. The superior green line represents the time-attenuation intensity curve within the selected ROI, and the inferior red line represents that of the reference ROI. C, Using the time-attenuation intensity curve, we calculated the TTP and AUC within the selected ROI, adjusted by the reference ROI.

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    Fig 2.

    A 4-year-old boy with excellent clinical outcome after EDAS neovascularization. Comparing pre- (A) and post- (E) operative ECA angiograms shows good neovascularization after EDAS. Postprocessed pre- (B) and post- (F) operative CCA angiograms show shortening of TTP of approximately 2.3 seconds and an increase of the percentage of AUC difference of about 51.0% after the operation. Approximately a 1080.5% increment of the percentage of AUC difference after surgery is noted when comparing pre- (C) and post- (G) operative ECA angiograms, and an approximate 44.0% of AUC difference decrease is noted when comparing pre- (D) and post- (H) operative ICA angiograms.

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    Fig 3.

    A 5-year-old boy with poor clinical outcome after EDAS neovascularization. Comparing pre- (A) and post- (E) operative ECA angiograms shows poor neovascularization after EDAS. Postprocessed pre- (B) and post- (F) operative CCA angiograms show no definite shortening of the TTP (0.0 seconds), with a decrease of the percentage of AUC difference of approximately 2.0% after the operation. About a 41.2% increase of the percentage of AUC difference after the operation is noted when comparing pre- (C) and post- (G) operative ECA angiograms, and about a 13.7% of AUC difference increase is noted when comparing pre- (D) and post- (H) operative ICA angiograms.

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    Table 1:

    Relationships between DSA parameters and clinical outcomes

    GroupExcellent (n = 16)Good (n = 4)Fair (n = 8)Poor (n = 4)P Value
    ΔTTP in CCA (sec)2.021.00.80−0.13.003
    ΔAUC ratio in CCA (%)68.131.59.1−11.3.000
    ΔAUC ratio in ECA (%)1119.8768.2279.5248.7.000
    ΔAUC ratio in ICA (%)−41.0−35.6−44.2−22.3.418
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    Table 2:

    Relationships between DSA parameters and angiographic outcomes

    GroupGood (n = 16)Fair (n = 7)Poor (n = 9)P Value
    ΔTTP in CCA (sec)2.010.970.49.005
    ΔAUC ratio in CCA (%)64.529.80.4.000
    ΔAUC ratio in ECA (%)1065.9753.1210.5.000
    ΔAUC ratio in ICA (%)−41.0−42.4−32.2.424
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    Table 3:

    Cutoff values between favorable and unfavorable groups

    ParameterCriterionSensitivity (%)Specificity (%)
    ΔTTP in CCA (sec)>1.2781.491.7
    ΔAUC ratio in CCA (%)>33.581100
    ΔAUC ratio in ECA (%)>50485.392
    ΔAUC ratio in ICA (%)≤20.285.933.4
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American Journal of Neuroradiology: 37 (5)
American Journal of Neuroradiology
Vol. 37, Issue 5
1 May 2016
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H.-H. Cho, J.-E. Cheon, S.-K. Kim, Y.H. Choi, I.-O. Kim, W.S. Kim, S.-M. Lee, S.K. You, S.-M. Shin
Quantitative Assessment of Neovascularization after Indirect Bypass Surgery: Color-Coded Digital Subtraction Angiography in Pediatric Moyamoya Disease
American Journal of Neuroradiology May 2016, 37 (5) 932-938; DOI: 10.3174/ajnr.A4614

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Quantitative Assessment of Neovascularization after Indirect Bypass Surgery: Color-Coded Digital Subtraction Angiography in Pediatric Moyamoya Disease
H.-H. Cho, J.-E. Cheon, S.-K. Kim, Y.H. Choi, I.-O. Kim, W.S. Kim, S.-M. Lee, S.K. You, S.-M. Shin
American Journal of Neuroradiology May 2016, 37 (5) 932-938; DOI: 10.3174/ajnr.A4614
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