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

BACKGROUND AND PURPOSE: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: Preoperative and intraoperative HR-CBCT provide superior perforator visualization compared with CTA, with intraoperative imaging closely matching preoperative performance.