Sulcal Hyperintense Vessel Sign (Vessel Wall Magnetic Resonance Ivy Sign) in Adult Moyamoya Disease: A High-Resolution Vessel Wall Imaging Study

BACKGROUND: Hyperintense vessel signs in the cerebral sulci have recently been identified on vessel wall magnetic resonance imaging in moyamoya disease, referred to as the vessel wall magnetic resonance ivy sign (VIS). This study aimed to establish a novel scoring system for the VIS score and elucidate its clinical implications. METHODS: This retrospective analysis included 125 patients with moyamoya disease (nonstroke group, n=27; ischemic group, n=61; and hemorrhagic group, n=37), and VIS was examined in the superior frontal sulcus, inferior frontal sulcus, precentral sulcus, central sulcus, postcentral sulcus, and intraparietal sulcus. The total VIS score (TVIS) ranged from 0 to 6. A multinomial logistic regression analysis was performed to explore the association of TVIS with hemorrhagic and ischemic stroke. A receiver operating characteristic curve analysis was used to assess the ability of TVIS in discriminating between hemorrhagic and ischemic strokes. TVIS also correlated with the hemodynamic stage on single-photon emission computed tomography. RESULTS: Among the 125 patients, VIS score was present in 43.2%, 66.4%, 67.2%, 75.2%, 70.4%, and 48.8% in the superior frontal, inferior frontal, precentral sulcus, central sulcus, postcentral sulcus, and intraparietal sulcus, respectively. Multinomial logistic regression model indicated that choroidal anastomosis (odds ratio, 3.60 [95% CI, 1.06–12.17]; P =0.039) and TVIS (per 1-score increase: odds ratio, 1.51 [95% CI, 1.10–2.05]; P =0.009) were independently associated with the hemorrhagic group. Furthermore, TVIS (per 1-score increase: odds ratio, 1.78 [95% CI, 1.33–2.36]; P <0.001) was identified as an independent factor for the ischemic group. The area under the curve for TVIS in distinguishing between hemorrhagic and ischemic strokes were 0.776 and 0.812, respectively. TVIS demonstrated a strong correlation with single-photon emission computed tomography–identified hemodynamic stages (Spearman ρ =0.646, P <0.001). CONCLUSIONS: We developed a TVIS system that demonstrates strong correlations with stroke subtypes and hemodynamic status in moyamoya disease. A higher TVIS was independently and commonly associated with higher risks of hemorrhagic and ischemic strokes, highlighting its potential as a predictive imaging biomarker. Asymptomatic patients with a higher TVIS may represent a subgroup at particularly high risk for subsequent stroke.