Ivy signs on FLAIR images before and after STA-MCA anastomosis in patients with Moyamoya disease

Acta Radiol. 2011 Apr 1;52(3):291-6. doi: 10.1258/ar.2011.100367. Epub 2011 Mar 3.


Background: Leptomeningeal high signal intensity (ivy sign) on fluid-attenuated inversion-recovery (FLAIR) MR imaging is one of the features of Moyamoya disease. However, the correlation between ivy sign and cerebral perfusion status has not been fully evaluated.

Purpose: To characterize ivy sign on FLAIR images in Moyamoya disease and compare this finding with hemodynamic alterations on perfusion single-photon emission CT (SPECT) obtained before and after bypass surgery.

Material and methods: Sixteen patients with angiographically confirmed Moyamoya disease who underwent superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis were included in the study. The presence of ivy sign on FLAIR images was classified as 'negative', 'minimal' and 'positive'. We evaluated the relationship between ivy sign and findings of SPECT, including cerebral vascular reserve (CVR) before and after surgery.

Results: Minimal or positive ivy sign was seen in 13 (81%) of 16 patients, and 21 (66%) of 32 hemispheres. CVR in the areas with positive or minimal ivy sign was lower than that in the areas with negative ivy sign. After STA-MCA anastomosis, ivy sign disappeared or decreased in all 21 hemispheres demonstrating ivy sign. SPECT demonstrated apparent hemodynamic improvement in areas demonstrating disappearance or decrease of ivy sign.

Conclusion: Ivy sign on FLAIR image is seen in areas with decreased cerebral perfusion. The sign is useful for non-invasive assessment of cerebral hemodynamic status before and after surgery.

Publication types

  • Comparative Study

MeSH terms

  • Acetazolamide
  • Adolescent
  • Adult
  • Anastomosis, Surgical
  • Anticonvulsants
  • Cerebral Angiography
  • Child
  • Child, Preschool
  • Contrast Media
  • Female
  • Hemodynamics
  • Humans
  • Image Interpretation, Computer-Assisted
  • Infant
  • Magnetic Resonance Imaging / methods*
  • Male
  • Middle Aged
  • Moyamoya Disease / diagnostic imaging
  • Moyamoya Disease / pathology*
  • Moyamoya Disease / surgery*
  • Radiopharmaceuticals
  • Statistics, Nonparametric
  • Tomography, Emission-Computed, Single-Photon
  • Tomography, X-Ray Computed
  • Treatment Outcome


  • Anticonvulsants
  • Contrast Media
  • Radiopharmaceuticals
  • Acetazolamide