Pre-operative visualization of cerebral vasculature using photon-counting CT ultra-high resolution pure lumen imaging

Preoperative neuronavigation relies on multimodal imaging to delineate lesion anatomy and surrounding neurovascular structures. Ultra-high-resolution photon-counting CT (UHR PCCT) provides submillimeter vascular and osseous detail and may improve surgical planning compared with conventional CT and MRI.

To evaluate the potential added value of UHR PCCT for preoperative neuronavigation in selected complex intracranial lesions.

We performed a selected retrospective observational pilot study of patients who underwent preoperative PCCT angiography and/or venography for neuronavigation between 2023 and 2026 at a tertiary neurosurgical center. Of 45 examinations, twenty patients were selected based on lesion complexity, vascular involvement, and size. PCCT findings were compared with conventional CT and MRI. Operative reports were retrospectively reviewed for intraoperative use of PCCT-derived findings.

The cohort comprised twelve meningiomas, two aneurysms, one arteriovenous malformation, and five other intracranial lesions. Median age was 53 years (IQR 46-63), and 80% were female. PCCT demonstrated additional arterial anatomical information in eleven patients (55%), including perforators in two (10%), and additional tumor vascular supply in seven patients (35%). Additional venous anatomical information was identified in six and skull base, orbital, or osseous findings in eight (40%) patients. The additional PCCTA findings were used intraoperatively in all patients.

UHR PCCT demonstrates substantial potential as a comprehensive imaging modality for neurosurgical navigation and provides additional neurovascular and osseous anatomical information in this selected cohort. The definitive intraoperative use of these findings merits prospective comparative validation of PCCT as a complementary preoperative imaging modality.