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Intra-Arterial Intraoperative Computed Tomography Angiography Guided Navigation: A New Technique for Localization of Vascular Pathology

Raza, Shaan M. MD*,‡; Papadimitriou, Kyriakos MD*,‡; Gandhi, Dheeraj MBBS, MD§; Radvany, Martin MD§; Olivi, Alessandro MD; Huang, Judy MD

doi: 10.1227/NEU.0b013e3182647a73
Technique Assessment

BACKGROUND: Precise intraoperative surgical localization of small distal aneurysms, arteriovenous malformations (AVMs), and cranial base dural arteriovenous fistulae may be challenging. Current neuronavigational techniques are based on imaging techniques with limited sensitivity to detect vascular lesions that are small. We introduce the technique of intraoperative computed tomography angiography (iCTA) with an intra-arterial injection for surgical navigation.

OBJECTIVE: To determine whether iCTA integrated with a navigation platform is accurate and useful for precise localization of small vascular lesions that are challenging to treat.

METHODS: This study included 8 patients: 2 with aneurysms, 3 with small cortical AVMs, and 3 with cranial base dural arteriovenous fistulae. iCTA with intra-arterial contrast injection was performed in all patients for precise localization of the small vascular lesion to facilitate craniotomy planning and microsurgical approach. All operative reports, inpatient and outpatient records, and radiographic studies available were reviewed retrospectively.

RESULTS: The iCTA was used to target 2 aneurysms, 3 small subcortical AVMs, and 3 dural arteriovenous fistulae. This technique was most helpful to localize the 3 AVMs and the distal M4 aneurysm precisely. Craniotomy planning was accurate in all instances; no complications related to the technique were noted, and all patients had uneventful postoperative recoveries.

CONCLUSION: iCTA is an effective and accurate novel technique that can enhance the safety of surgical treatment for small intra-axial vascular pathology.

ABBREVIATIONS: AVM, arteriovenous malformation

CTA, computed tomography angiography

DAVF, dural arteriovenous fistula

DSA, digital subtraction angiography

iCTA, intraoperative computed tomography angiography

MCA, middle cerebral artery

MSCT, multislice computed tomography

MRA, magnetic resonance angiography

Departments of Neurosurgery

§Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland

Correspondence: Judy Huang, MD, Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 8-181c, Baltimore, MD 21287. E-mail:

* These authors contributed equally to this work.

Received October 14, 2011

Accepted May 30, 2012

Copyright © by the Congress of Neurological Surgeons