The Ivy Sign on Fluid Attenuated Inversion Recovery Images Related to Single-Photon Emission Computed Tomography Cerebral Blood Flow in Moyamoya Disease: A Case Report

Özet

Moyamoya disease is an idiopathic progressive cerebrovascular steno-occlusive disorder characterized by the formation ofnumerous collaterals called Moyamoya vessels. Accurate evaluation of vascular status and cerebral blood flow (CBF) is needed forprompt treatment to prevent ischemic and/or hemorrhagic events. The pathogenesis of the ivy sign on fluid attenuated inversionrecovery (FLAIR) images of Moyamoya disease patients is unclear. We report a Moyamoya disease case wherein the ivy signchanged in relation to single-photon emission computed tomography (SPECT)-measured CBF during progression and followingtreatment. A 49-year-old female presented with slight aphasia and right hemiparesis. Magnetic resonance imaging (MRI) diffusionweighted image revealed cerebral infarction in the left frontal lobe. Cerebral angiography images showed bilateral distal internalcarotid artery stenosis and Moyamoya vessels. FLAIR images exhibited the ivy sign. We performed superficial temporal artery–middle cerebral artery (STA-MCA) bypass surgery with encephalogaleosynangiosis (EGS) and encephalomyosynangiosis (EMS) onthe left side 6 months after first presentation. After operation, left-side resting CBF gradually improved on SPECT and the ivy signdecreased. On the other hand, right-side CBF gradually deteriorated at rest, and the ivy sign increased. Therefore, we performedSTA−MCA bypass with EGS and EMS on the right side 4 years after first presentation. After the operation, the resting CBF increasedand the ivy sign decreased. The FLAIR ivy sign may be a useful indicator of both deterioration and improvement of CBF statuswithout the need for CBF imaging using contrast material.