title: Impaired cerebrovascular reactivity with steal phenomenon is associated with increased diffusion in white matter of patients with Moyamoya disease.
abstract: OBJECTIVE
  Reduced cerebrovascular reactivity (CVR) with steal phenomenon is an independent predictor for stroke and may indicate tissue exposed to episodic low-grade ischemia. The apparent diffusion coefficient (ADC) calculated using diffusion-weighted MRI is effective in characterizing focal brain ischemia and subtle structural changes in normal-appearing white matter (WM). We hypothesized that regions of steal phenomenon are associated with increased ADC in normal-appearing WM of patients with Moyamoya disease.
  
  
  METHODS
  Twenty-two patients with unilateral CVR impairment secondary to Moyamoya disease and 12 healthy control subjects underwent diffusion-weighted MRI and functional MRI mapping of the cerebrovascular response to hypercapnia. Parametric maps of ADC and CVR were calculated, coregistered, and segmented using automated image processing methods. ADC of normal-appearing WM was compared between hemispheres, and between WM with negative CVR (ie, steal phenomenon) and WM with positive CVR.
  
  
  RESULTS
  In patients, ADC of normal-appearing WM was elevated in the hemisphere ipsilateral to the CVR impairment compared with the contralateral hemisphere (P<0.005) and in WM with negative CVR compared with WM with positive CVR (P<0.001). WM in regions of steal phenomenon within the affected hemisphere had higher ADC than homologous contralateral WM (P<0.005). In control subjects, negative CVR in WM was not associated with elevated ADC.
  
  
  CONCLUSIONS
  Regions of steal phenomenon are spatially correlated with elevated ADC in normal-appearing WM of patients with Moyamoya disease. This structural abnormality may reflect low-grade ischemic injury after exhaustion of the cerebrovascular reserve capacity.
authors.affiliation: Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Conklin
authors.forename: Jorn
authors.initials: J
authors.lastname: Fierstra
authors.forename: Adrian P
authors.initials: AP
authors.lastname: Crawley
authors.forename: Jay S
authors.initials: JS
authors.lastname: Han
authors.forename: Julien
authors.initials: J
authors.lastname: Poublanc
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Mandell
authors.forename: Frank L
authors.initials: FL
authors.lastname: Silver
authors.forename: Michael
authors.initials: M
authors.lastname: Tymianski
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Fisher
authors.forename: David J
authors.initials: DJ
authors.lastname: Mikulis
mesh_terms: D000293:Adolescent; D000328:Adult; D001921:Brain / Q000503:physiopathology*; D001931:Brain Mapping; D002560:Cerebrovascular Circulation; D038524:Diffusion Magnetic Resonance Imaging; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008875:Middle Aged; D009072:Moyamoya Disease / Q000503:physiopathology*; D018579:Patient Selection; D013349:Subclavian Steal Syndrome / Q000503:physiopathology*