Acetazolamide-challenged ASL-derived perfusion metrics demonstrated moderate predictive performance for angiographic features in moyamoya angiopathy, with discriminatory performance comparable to that of CTP.
ASL-based models demonstrated moderate to good discrimination for angiographic outcomes in moyamoya angiopathy.
CTP-based models showed comparable discrimination to ASL-based models for shared endpoints.
The study evaluated territory-specific CBF and CVR derived from pCASL MRI at baseline and after acetazolamide challenge.
ASL with acetazolamide challenge was evaluated as a noninvasive alternative to CTP and PET for cerebrovascular reserve assessment in moyamoya angiopathy.
Logistic regression models using ROC analysis were applied to predict dichotomized angiographic outcomes from perfusion metrics.
The clinical implications of ASL-based perfusion metrics for moyamoya angiopathy management remain to be established.
This research suggests that MRI-based blood flow measurements, taken before and after a drug called acetazolamide that stresses the brain's blood vessels, can moderately predict the severity of moyamoya angiopathy — a rare disease that causes progressive narrowing of arteries in the brain. The technique, called arterial spin labeling (ASL), was able to predict outcomes like how severe the disease appeared on invasive imaging and how well surgical bypass procedures worked, with accuracy scores (AUC) ranging from 0.71 to 0.85, where higher scores indicate better prediction. Importantly, this noninvasive MRI approach performed similarly to CT perfusion imaging, which requires radiation and an injected contrast agent. The study enrolled 39 patients who underwent both MRI with ASL and conventional catheter-based brain imaging (digital subtraction angiography). Researchers measured blood flow in different brain regions and calculated how much blood flow changed after acetazolamide, a measure called cerebrovascular reserve (CVR). These measurements were used in statistical models to predict disease severity and surgical outcomes. No significant differences in predictive accuracy were found between the MRI-based and CT-based approaches. This research suggests that ASL MRI with an acetazolamide challenge could serve as a radiation-free and contrast-free alternative to CT perfusion for evaluating moyamoya angiopathy, which may be particularly valuable since PET imaging — another option — is not widely available. However, the authors caution that the study was small, retrospective, and conducted at a single center, so the practical clinical usefulness of this approach still needs to be confirmed in larger, prospective studies.
Serdyuk V, Filimonova E, Ovsyannikov K, Parshin D, Rzaev J. (2026). Acetazolamide-challenged ASL shows comparable performance to CT perfusion for angiographic outcomes in moyamoya angiopathy.. Clinical neurology and neurosurgery. https://doi.org/10.1016/j.clineuro.2026.109517