The role of quantitative hemodynamic magnetic resonance imaging in the surgical revascularization of cerebral tissue
DOI:
https://doi.org/10.18690/Keywords:
steno-occlusive disease, STA-MCA bypass, MRI, BOLD-CVR, hemodynamicsAbstract
The goal of surgical revascularization of brain tissue is to improve cerebral perfusion in patients with cerebrovascular stenotic-occlusive disease, where certain regions of the brain are hypoperfused. The most commonly performed procedure, anastomosis between the superficial temporal artery and middle cerebral artery (STA–MCA bypass), is indicated in moyamoya vasculopathy, in selected cases of chronic stenotic-occlusive disease, and in acute ischemic stroke with hemodynamic impairment. Quantitative hemodynamic assessment plays a key role in selecting candidates for the procedure. Among modern non-invasive methods for assessing cerebral hemodynamics, blood oxygenation-level dependent cerebrovascular reactivity (BOLD-CVR) stands out. This special form of magnetic resonance imaging allows detection of regions with reduced vasodilatory capacity, thereby identifying hemodynamically endangered brain tissue. This article presents the current indications and decision-making processes in selecting patients for surgical revascularization of the brain, as well as institutional experiences in patient selection based on BOLD-CVR. The critical importance of this method for successful planning and execution of revascularization is emphasized, as it significantly contributes to optimizing surgical and clinical outcomes.
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1. Sebök M, Höbner LM, Grob A, Fierstra J, Schubert T, Wegener S, et al. Flow capacity of a superficial temporal artery as a donor in a consecutive series of 100 patients with superficial temporal artery-middle cerebral artery bypass. J Neurosurg. 2025;142(1):62-9.
2. Esposito G, Sebök M, Fierstra J, Regli L. Flow-Augmentation Bypass Surgery: Indications and Decision-Making. Acta Neurochir Suppl. 2025;136:113-8.
3. Esposito G, Sebök M, Amin-Hanjani S, Regli L. Cerebral Bypass Surgery: Level of Evidence and Grade of Recommendation. Acta Neurochir Suppl. 2018;129:73-7.
4. Sebök M, Höbner LM, Fierstra J, Schubert T, Wegener S, Kulcsár Z, et al. Flow-augmentation STA-MCA bypass for acute and subacute ischemic stroke due to internal carotid artery occlusion and the role of advanced neuroimaging with hemodynamic and flow-measurement in the decision-making: preliminary data. Quant Imaging Med Surg. 2024;14(1):777-88.
5. Esposito G, Amin-Hanjani S, Regli L. Role of and Indications for Bypass Surgery After Carotid Occlusion Surgery Study (COSS)? Stroke. 2016;47(1):282-90.
6. Sebök M, Esposito G, Niftrik C, Fierstra J, Schubert T, Wegener S, et al. Flow augmentation STA-MCA bypass evaluation for patients with acute stroke and unilateral large vessel occlusion: a proposal for an urgent bypass flowchart. J Neurosurg. 2022;137(4):1047-55.
7. Sebök M, van der Wouden F, Mader C, Pangalu A, Treyer V, Fisher JA, et al. Hemodynamic Failure Staging With Blood Oxygenation Level-Dependent Cerebrovascular Reactivity and Acetazolamide-Challenged ((15)O-)H(2)O-Positron Emission Tomography Across Individual Cerebrovascular Territories. J Am Heart Assoc. 2023;12(24):e029491.
8. Esposito G, Kronenburg A, Fierstra J, Braun KP, Klijn CJ, van der Zwan A, et al. "STA-MCA bypass with encephalo-duro-myo-synangiosis combined with bifrontal encephalo-duro-periosteal-synangiosis" as a one-staged revascularization strategy for pediatric moyamoya vasculopathy. Childs Nerv Syst. 2015;31(5):765-72.
9. Kronenburg A, Braun KP, van der Zwan A, Klijn CJ. Recent advances in moyamoya disease: pathophysiology and treatment. Curr Neurol Neurosci Rep. 2014;14(1):423.
10. Smith ER, Scott RM. Spontaneous occlusion of the circle of Willis in children: pediatric moyamoya summary with proposed evidence-based practice guidelines. A review. J Neurosurg Pediatr. 2012;9(4):353-60.
11. Miyamoto S, Yoshimoto T, Hashimoto N, Okada Y, Tsuji I, Tominaga T, et al. Effects of extracranial-intracranial bypass for patients with hemorrhagic moyamoya disease: results of the Japan Adult Moyamoya Trial. Stroke. 2014;45(5):1415-21.
12. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med. 1985;313(19):1191-200.
13. Powers WJ, Clarke WR, Grubb RL, Jr., Videen TO, Adams HP, Jr., Derdeyn CP. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial. Jama. 2011;306(18):1983-92.
14. Ma Y, Wang T, Wang H, Amin-Hanjani S, Tong X, Wang J, et al. Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion: The CMOSS Randomized Clinical Trial. Jama. 2023;330(8):704-14.
15. Reynolds MR, Derdeyn CP, Grubb RL, Jr., Powers WJ, Zipfel GJ. Extracranial-intracranial bypass for ischemic cerebrovascular disease: what have we learned from the Carotid Occlusion Surgery Study? Neurosurg Focus. 2014;36(1):E9.
16. Guida L, Sebök M, Wegener S, Fierstra J, van Niftrik B, Luft AR, et al. Flow-augmentation bypass in the treatment of acute ischemic stroke. J Neurosurg Sci. 2021;65(3):269-76.
17. van Niftrik CHB, Piccirelli M, Bozinov O, Pangalu A, Fisher JA, Valavanis A, et al. Iterative analysis of cerebrovascular reactivity dynamic response by temporal decomposition. Brain Behav. 2017;7(9):e00705.
18. Sebök M, van Niftrik CHB, Piccirelli M, Bozinov O, Wegener S, Esposito G, et al. BOLD cerebrovascular reactivity as a novel marker for crossed cerebellar diaschisis. Neurology. 2018;91(14):e1328-e37.
19. Ladner TR, Donahue MJ, Arteaga DF, Faraco CC, Roach BA, Davis LT, et al. Prior Infarcts, Reactivity, and Angiography in Moyamoya Disease (PIRAMD): a scoring system for moyamoya severity based on multimodal hemodynamic imaging. J Neurosurg. 2017;126(2):495-503.
20. Sebök M, Stumpo V, Bellomo J, Esposito G, van Niftrik CHB, Kulcsár Z, et al. Preoperative BOLD cerebrovascular reactivity correlates with intraoperative STA-MCA bypass flow and influences postoperative CVR improvement. Eur Stroke J. 2025:23969873251337234.
21. Garbani Nerini L, Bellomo J, Höbner LM, Stumpo V, Colombo E, van Niftrik CHB, et al. BOLD Cerebrovascular Reactivity and NOVA Quantitative MR Angiography in Adult Patients with Moyamoya Vasculopathy Undergoing Cerebral Bypass Surgery. Brain Sci. 2024;14(8).
22. Han JS, Abou-Hamden A, Mandell DM, Poublanc J, Crawley AP, Fisher JA, et al. Impact of extracranial-intracranial bypass on cerebrovascular reactivity and clinical outcome in patients with symptomatic moyamoya vasculopathy. Stroke. 2011;42(11):3047-54.
23. Conklin J, Fierstra J, Crawley AP, Han JS, Poublanc J, Mandell DM, et al. Impaired cerebrovascular reactivity with steal phenomenon is associated with increased diffusion in white matter of patients with Moyamoya disease. Stroke. 2010;41(8):1610-6.
24. Mesiwala AH, Sviri G, Fatemi N, Britz GW, Newell DW. Long-term outcome of superficial temporal artery-middle cerebral artery bypass for patients with moyamoya disease in the US. Neurosurg Focus. 2008;24(2):E15.
25. van Niftrik CHB, Sebök M, Germans MR, Halter M, Pokorny T, Stumpo V, et al. Increased Risk of Recurrent Stroke in Symptomatic Large Vessel Disease With Impaired BOLD Cerebrovascular Reactivity. Stroke. 2024;55(3):613-21.
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