In the present study, we demonstrated the clinical utility of 4D-MR angiography with pCASL combined with CENTRA-keyhole (4D-PACK) in Moyamoya disease by comparing with a well-established pulsed ASL-based 4D-MRA called contrast inherent inflow enhanced multi-phase angiography (CINEMA). 4D-PACK provided higher CNRs than CINEMA in distal MCA branches in later phases indicating that 4D-PACK enables better visualizations of distal cerebral arteries supplied by collaterals vessels during a long transit time. This could be due to higher flow signal obtained with pCASL and less saturation effect after labeling. 4D-PACK can be a non-invasive clinical tool in assessing hemodynamics in Moyamoya disease.
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