High-resolution cone-beam CT (DynaCT Micro) enhances preoperative and intraoperative visualization of intracranial...

Preservation of perforator arteries during cerebrovascular interventions remains challenging due to their submillimeter caliber and variable anatomy. High-resolution cone-beam computed tomography (HR-CBCT) offers improved resolution compared with conventional CT angiography (CTA), yet its utility for perforator assessment has not been systematically evaluated. This study assessed HR-CBCT for visualization of intracranial perforators in both preoperative and intraoperative contexts.

Imaging from 20 patients who underwent aneurysm clipping, arteriovenous malformation resection, or dural arteriovenous fistula treatment between July 2022 and November 2024 was reviewed. Three imaging modalities were evaluated: preoperative CTA, preoperative HR-CBCT, and intraoperative HR-CBCT. Five perforator arteries-the recurrent artery of Heubner, anterior choroidal artery, lateral lenticulostriate arteries, basilar artery perforators, and posterior cerebral artery perforators-were independently scored by four neuroradiologists using a three-point visibility scale (3 = visible, 2 = not visible due to limited field of view, 1 = not visible due to resolution). Reader confidence was recorded, and statistical analysis was performed using R.

Perforator visualization was significantly higher with both preoperative and intraoperative HR-CBCT compared with CTA. On preoperative imaging, confidence was significantly higher for anterior choroidal and lateral lenticulostriate arteries (p < 0.001), but not for the recurrent artery of Heubner (p = 0.102). Intraoperative scans showed no significant reduction in visibility. Effective dose did not differ between CTA and HR-CBCT (p = 0.700).

Preoperative and intraoperative HR-CBCT provide superior perforator visualization compared with CTA, with intraoperative imaging closely matching preoperative performance.