Introduction: Digital subtraction angiography (DSA) is commonly performed post pial synangiosis to establish the degree of neovascularization. However, angiography is invasive, and the risk of ionizing radiation is a concern in children. Our study aimed to identify whether arterial spin labelling (ASL) can predict post-operative angiogram grading. In addition, we aimed to identify whether patients who underwent ASL imaging without DSA had similar postoperative outcomes when compared to patients who received ASL imaging and post-operative DSA. Methods: The medical records of patients undergoing pial synangiosis at a single institution were reviewed during a 10-year period. Results: Twenty-two patients were identified. Twenty-one hemispheres of 13 patients with "ASL only" and 14 hemispheres of 9 patients with "ASL + DSA" were analyzed. Both groups had similar rates of MRI evidence of acute or chronic stroke preoperatively; 61.9% in the ASL only group and 64.3% in the ASL + DSA group. All symptoms improved in frequency after intervention except categories of hemorrhage and non-chronic headaches. We found a significant correlation between revascularization observed on the DSA and the ASL graded by 3 neuroradiologists. The ASL grades in patients with a postoperative Matsushima grade indicating robust neovascularization were significantly higher than the ASL grades of patients with a poor postoperative Matsushima grade. Conclusions: Non-invasive ASL perfusion imaging had an association with post-operative DSA neoangiogenesis following pial synangiosis surgery. There were no significant stroke-risk differences between ASL and ASL + DSA cohorts. Both cohorts show significant improvement in pre-operative symptoms after surgery. Providers may consider obtaining a postoperative ASL MRI imaging in lieu of a catheter angiogram.

Phillip Storm

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