Assessment of Cerebral Hemodynamic Changes in Pediatric Patients with Moyamoya Disease Using Probabilistic Maps on Analysis of Basal/Acetazolamide Stress Brain Perfusion SPECT

소아 모야모야병에서 뇌확률지도를 이용한 수술전후 혈역학적 변화 분석

  • Lee, Ho-Young (Departments of Nuclear Medicine, Seoul National University College of Medicine) ;
  • Lee, Jae-Sung (Departments of Nuclear Medicine, Seoul National University College of Medicine) ;
  • Kim, Seung-Ki (Departments of Pediatric Neurosurgery, Seoul National University College of Medicine) ;
  • Wang, Kyu-Chang (Departments of Pediatric Neurosurgery, Seoul National University College of Medicine) ;
  • Cho, Byung-Kyu (Departments of Pediatric Neurosurgery, Seoul National University College of Medicine) ;
  • Chung, June-Key (Departments of Nuclear Medicine, Seoul National University College of Medicine) ;
  • Lee, Myung-Chul (Departments of Nuclear Medicine, Seoul National University College of Medicine) ;
  • Lee, Dong-Soo (Departments of Nuclear Medicine, Seoul National University College of Medicine)
  • 이호영 (서울대학교 의과대학 핵의학교실) ;
  • 이재성 (서울대학교 의과대학 핵의학교실) ;
  • 김승기 (서울대학교 의과대학 소아신경외과교실) ;
  • 왕규창 (서울대학교 의과대학 소아신경외과교실) ;
  • 조병규 (서울대학교 의과대학 소아신경외과교실) ;
  • 정준기 (서울대학교 의과대학 핵의학교실) ;
  • 이명철 (서울대학교 의과대학 핵의학교실) ;
  • 이동수 (서울대학교 의과대학 핵의학교실)
  • Published : 2008.06.30

Abstract

To evaluate the hemodynamic changes and the predictive factors of the clinical outcome in pediatric patients with moyamoya disease, we analyzed pre/post basal/acetazolamide stress brain perfusion SPECT with automated volume of interest (VOIs) method. Methods: Total fifty six (M:F = 33:24, age $6.7{\pm}3.2$ years) pediatric patients with moyamoya disease, who underwent basal/acetazolamide stress brain perfusion SPECT within 6 before and after revascularization surgery (encephalo-duro-arterio-synangiosis (EDAS) with frontal encephalo-galeo-synangiosis (EGS) and EDAS only followed on contralateral hemisphere), and followed-up more than 6 months after post-operative SPECT, were included. A mean follow-up period after post-operative SPECT was $33{\pm}21$ months. Each patient's SPECT image was spatially normalized to Korean template with the SPM2. For the regional count normalization, the count of pons was used as a reference region. The basal/acetazolamide-stressed cerebral blood flow (CBF), the cerebral vascular reserve index (CVRI), and the extent of area with significantly decreased basal/acetazolamide- stressed rCBF than age-matched normal control were evaluated on both medial frontal, frontal, parietal, occipital lobes, and whole brain in each patient's images. The post-operative clinical outcome was assigned as good, poor according to the presence of transient ischemic attacks and/or fixed neurological deficits by pediatric neurosurgeon. Results: In a paired t-test, basal/acetazolamide-stressed rCBF and the CVRI were significantly improved after revascularization (p<0.05). The significant difference in the pre-operative basal/acetazolamide-stressed rCBF and the CVRI between the hemispheres where EDAS with frontal EGS was performed and their contralateral counterparts where EDAS only was done disappeared after operation (p<0.05). In an independent student t-test, the pre-operative basal rCBF in the medial frontal gyrus, the post-operative CVRI in the frontal lobe and the parietal lobe of the hemispheres with EDAS and frontal EGS, the post-operative CVRI, and ${\Delta}CVRI$ showed a significant difference between patients with a good and poor clinical outcome (p<0.05). In a multivariate logistic regression analysis, the ${\Delta}CVRI$ and the post-operative CVRI of medial frontal gyrus on the hemispheres where EDAS with frontal EGS was performed were the significant predictive factors for the clinical outcome (p =0.002, p =0.015), Conclusion: With probabilistic map, we could objectively evaluate pre/post-operative hemodynamic changes of pediatric patients with moyamoya disease. Specifically the post-operative CVRI and the post-operative CVRI of medial frontal gyrus where EDAS with frontal EGS was done were the significant predictive factors for further clinical outcomes.

목적: 본 연구의 목적은 소아 모야모야병 환자에 있어서, 수술 전후 기저/아세타졸아미드 부하 뇌혈류 단일광자방출 단층촬영(SPECT) 분석에 확률뇌지도를 이용하여 수술로 인한 뇌혈역학적 변화 및 예후 예측인자 분석을 하여 뇌확률지도의 유용성을 평가하는 것이다. 대상 및 방법: 연구대상으로 서울대어린이 병원에서 소아 모야모야병으로 진단받고, 수술받은 56명(남:여=32:24, 나이 $6.7{\pm}3.2$세)이 포함되었다. 각각의 환자는 기저/아세타졸아미드 부하 뇌혈류 SPECT를 수술 전후 6-12개월 사이에 시행하였다. 각각의 환자는 한 측 반구에 encephalo-duro-arterio-synangiosis (EDAS)와 encephalo-galeo-synangiosis (EGS)를 우선적으로 시행받았고, 그 후 순차적으로 반대측 반구에 EDAS를 시행하였다. 환자들은 수술 후 $33{\pm}21$개월 추적 관찰하였다. 환자들의 SPECT 영상을 SPM에서 공간정규화 하고 뇌교의 계수를 기준으로 계수정규화한 후 한국표준확률뇌지도 (Koreans Statistical Probabilistic Map, K-SPAM)를 이용하여 부위별 혈류를 정량화 하였다. 각각 정류화된 혈류를 수술 전후, 대뇌반구간, 그리고 임상결과에 따라 비교하였다. 또한 임상결과가 좋은 군과 나쁜 군 사이에 차이가 있는 요소를 이용하여 회귀분석을 시행하였다. 결과: 수술 후 양측 내측 전두엽이랑, 전두엽, 두정엽, 측두엽, 내측경동맥 영역, 전뇌의 기저/아세타졸아미드 부하 뇌혈류가 유의하게 호전되었다(p<0.05). 대뇌반구간 비교에서는 수술전 기저/아세타졸아미드 부하 뇌혈류 및 혈류예비능지표에 차이가 있었으나, 수술 후 이 차이는 사라졌다(p<0.05). 임상결과가 좋은 환자군의 수술 전 EDAS와 EGS를 시행한 내측 전두엽 뇌이랑의 기저 뇌혈류, 동측 전두엽, 측두엽, 그리고 전뇌의 수술 후 혈류예비능지표 및 수술전후 혈류예비능지표차가 더 우수하였다(p<0.05). 회귀분석결과에 의하면, EDAS와 EGS를 시행한 내측 전두엽 뇌이랑의 수술 전 혈류예비능지표와 전뇌의 수술 전후 혈류예비능지표차가 수술 후 임상결과를 예측할 수 있는 유의한 인자이다(p=0.002, p=0.015). Conclusion: 뇌확률지도를 이용하여 소아 모야모야병 환자의 기저/아세타졸아미드 부하 뇌혈류 SPECT를 정량화하여 분석할 수 있었다. 이 방법으로 수술에 의한 뇌혈류역학적 변화를 객관적으로 평가할 수 있었으며, 모야모야병환자의 수술 결과의 예측인자를 평가할 수 있었다.

Keywords

References

  1. Takeuchi K, Shimizu K. Hypoplasia of the bilateral internal carotid arteries (in Japanese). No To Shinke1957;9:37-43
  2. Suzuki J. A study on disease showing singular cerebroangiographicalfindings which seem to be new collateral circulation. In: Proceedings of the 22nd meeting of Japan Neurosurgical Society 1963
  3. Kudo T. Spontaneous occlusion of the circle of Wilis: A disease apparently confined to Japanese. Neurology 1968;18:485-96 https://doi.org/10.1212/WNL.18.5.485
  4. Suzuki J, Takaku A. Cerebrovascular moyamoya disease: A disease showing abnormal net-like vessels in base of brain. Arch Neurol 1969;20:288-99 https://doi.org/10.1001/archneur.1969.00480090076012
  5. Fukumi M. Current state of study on moyamoya disease in Japan. Surg Neurol 1997;47:138-43 https://doi.org/10.1016/S0090-3019(96)00358-8
  6. Kurokawa T, Tomita S, Ueda K, et al. Prognosis of occlusive disease of the circle of Willis (moyamoya disease) in children. Pediatr Neurol 1985;5:274-7
  7. Suzuki J, Kodama N. Moyamoya disease - a review. Stroke 1983; 14:104-9 https://doi.org/10.1161/01.STR.14.1.104
  8. Fukui M, Members of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) of the Ministry of Health and Welfare, Japan. Guidelines for the diagnosis and treatment of spontaneous occlusion of the circle of Willis ('Moyamoya' disease). Clin Neurol Neurosurg 1997;99(suppl): S238-S40
  9. Hoshi H, Ohnishi T, Jinnouchi S, et al. Cerebral blood flow study in patients with moyamoya disease evaluated by IMP SPECT. J Nucl Med 1994;35:44-50
  10. Touho H, Karasawa J, Ohnishi H. Preoperative and postoperative evaluation of cerebal perfusion and vasodilatory capacity with $^{99m}Tc$-HMPAO SPECT and acetazolamide in childhood moyamoya disease. Stroke 1996;27:282-9 https://doi.org/10.1161/01.STR.27.2.282
  11. Yamada I, Murata Y, Umehara I, Suzuki S, Matsushima Y. SPECT and MRI evaluations of the posterior circulation in moyamoya disease. J Nucl Med 1996;37:1613-7
  12. Lee DS, Hyun IY, Wang KC, Cho BK, Chung J-K, Lee MC. Evaluation of surgical outcome with pre and postoperative rest/acetazolamide $^{99m}Tc$ HMPAO SPECT in children with moyamoya disease. Korean J Nucl Med 1998;32:314-24
  13. Kim S-K, Wang K-C, Kim I-O, Lee DS, Cho B-K. Combined encephaloduroarteriosynangiosis and bifrontal encephalogaleo(periosteal) synangiosis in pediatric moyamoya disease. Neurosurgery 2002;50:88-96 https://doi.org/10.1097/00006123-200201000-00016
  14. Houkin K, Kamiyama H, Takahashi A, Kuroda S, Abe H. Combined revascularization surgery for childhood moyamoya disease: STA-MCA and encephalo-duro-arterio-myo-synangiosis. Childs Nerv Syst 13:24-9 https://doi.org/10.1007/s003810050034
  15. So Y, Lee HY, Kim SK, Lee JS, Wang KC, Cho BK, et al. Prediction of the clinical outcome of pediatric moyamoya disease with postoperative basal/acetazolamide stress brain perfusion SPECT after revascularization surgery. Stroke 2005;36:1485-9 https://doi.org/10.1161/01.STR.0000170709.95185.b1
  16. Koo BB, Lee JM, Kim JS, Lee JS, Kim IY, Kim JJ, et al. Developing a Korean Standard Brain Atlas on the basis of Statistical and Probabilistic Approach and Visualization tool for Functional image analysis. Korean J Nucl Med 2003;37:162-70
  17. Lee HY, Paeng JC, Lee DS, et al. Efficacy assessment of cerebral arterial bypass surgery using statistical parametric mapping and probabilistic brain atlas on basal/acetazolamide brain perfusion SPECT. J Nucl Med 2004;45:202-6
  18. Kim SK, Seol HJ, Cho BK, Hwang YS, Lee DS, Wang KC. Moyamoya disease among young patients: its aggressive clinical course and the role of active surgical treatment. Neurosurgery 2004;54:840-6 https://doi.org/10.1227/01.NEU.0000114140.41509.14
  19. Fukuyama Y, Umezu R. Clinical and cerebral angiographic evolutions of idiopathic progressive occlusive disease of the circle of Willis (moyamoya" disease) in children. Brain Dev 1985;7: 21-37 https://doi.org/10.1016/S0387-7604(85)80055-3
  20. Karasawa J, Touho H, Ohnishi H, Miyamoto S, Kikuchi H. Long-term follow-up study after extracranial-intracranial bypass surgery for anterior circulation ischemia in childhood moyamoya disease. J Neurosurg 1992;77:84-9 https://doi.org/10.3171/jns.1992.77.1.0084
  21. Nakashima H, Meguro T, Kawada S, Hirotsune N, Ohmoto T. Long-term results of surgically treated Moyamoya disease. Clin Neurol Neurosurg 1997;99(suppl):S156-S61
  22. Kinugasa K, Mandai S, Tokunaga K, et al. Ribbon encephaloduro- myo-synangiosis for moyamoya disease. Surg Neurol 1994;41: 455-1 https://doi.org/10.1016/0090-3019(94)90007-8
  23. Burt RW, Witt RM, Cikrit DF, Reddy RV. Carotid artery disease: evaluation with acetazolamide-enhanced Tc-99m HMPAO SPECT. Radiology 1992;182:461-6 https://doi.org/10.1148/radiology.182.2.1732965
  24. Lee JS, Lee DS, Kim YK, et al. Probabilistic map of blood flow in the brain from the internal carotid artery. Neuroimag 2004;23: 1422-31 https://doi.org/10.1016/j.neuroimage.2004.07.057
  25. Matsushima Y, Fukai N, Tanaka K, et al. A new surgical treatment of moyamoya disease in children: a preliminary report. Surg Neuro 1981;15:313-20 https://doi.org/10.1016/S0090-3019(81)80017-1
  26. Matsushima Y, Inaba Y. Moyamoya disease in children and its surgical treatment. Introduction of a new surgical procedure and its follow-up angiograms. Childs Brain 1984;11:155-70
  27. Houkin K, Kuroda S, Nakayama N. Cerebral revascularization for moyamoya disease in children. Neurosurg Clin N Am 2001;36: 575-84
  28. Kinugasa K, Mandai S, Kamata I, Sugiu K, Ohmoto T. Surgical treatment of moyamoya disease: operative technique for encephaloduro- arterio-myo-synangiosis, its follow-up, clinical results, and angiograms. Neurosurgery 1993;32:527-31 https://doi.org/10.1227/00006123-199304000-00006
  29. Houkin K, Kamiyama H, Abe H, Takahashi A, Kuroda S. Surgical therapy for adult moyamoya disease. Can surgical revascularization prevent the recurrence of intracerebal hemorrhage? Stroke 1996;27: 1342-6 https://doi.org/10.1161/01.STR.27.8.1342
  30. Suzuki R, Matsushima Y, Takada Y, Nariai T, Wakabayashi S, Tone O. Changes in cerebral hemodynamics following encephaloduro- arterio-synangiosis in young patients with moyamoya disease. Surg Neurol 1989;31:343-9 https://doi.org/10.1016/0090-3019(89)90065-7
  31. Houkin K, Aoki T, Takahashi A, Abe H. Diagnosis of moyamoya disease with magnetic resonance angiogrphy. Stroke 1994;25: 2159-64 https://doi.org/10.1161/01.STR.25.11.2159
  32. Lagrese HL, Levine RL, Sunderland JS, Nickles RJ. Pitfalls of regional cerebral blood flow analysis in cerebrovascular disease. Clin Nucl Med 1988;13:197-201 https://doi.org/10.1097/00003072-198803000-00016
  33. Juni JE, Waxman AD, Devous MD, et al. Procedure guideline for brain perfusion SPECT using 99mTc radiopharmaceuticals. Society of Nuclear Medicine. J Nucl Med 1998;39:923-6
  34. Isaka Y., Furukawa S., Etani H., Nakanishi E., Ooe Y., Imaizumi M. Noninvasive measurement of serebral blood flow with 99mTc-Hexamethylpropyleneamine oxime SPECT and 1-point venous blood sampling. Stroke 2000;31:2203-7 https://doi.org/10.1161/01.STR.31.9.2203