Intraoperative angiography using a mobile cone-beam CT device for neurovascular lesions: A technical note and feasibility study

The surgical management of neurovascular lesions, including aneurysms, arteriovenous malformations (AVMs) and dural arteriovenous fistulas (dAVFs), often requires intraoperative or postoperative imaging to confirm successful occlusion or complete resection. While intraoperative cone-beam CT (CBCT) imaging has been widely used in spinal surgery, its application in intracranial neurovascular procedures remains limited. This technical note evaluates the feasibility and workflow of intraoperative CBCT-Angiography utilizing a mobile device as a complementary tool for visualizing neurovascular structures during surgery. A retrospective analysis was conducted on four patients who underwent surgical treatment for neurovascular lesions (two dural arteriovenous fistulas and two aneurysms) between 2022 and 2024. These patients received intraoperative CBCT-Angiography utilizing a mobile CBCT device. Scans were acquired before and/or after lesion treatment. Native scan subtraction was utilized to improve vascular structure visualization. In addition, all patients also underwent intraoperative indocyanine green (ICG) angiography and postoperative digital subtraction angiography (DSA) for comparison. CBCT-Angiography was successfully utilized in three intracranial cases: one dAVF and two aneurysms. In these cases, the technology visualized lesion morphology pre-treatment and/or confirmed lesion obliteration and parent artery patency post-treatment. This approach resulted in valuable three-dimensional vascular information, extending diagnostic insight beyond the microscopic operative field. In contrast, for one spinal dAVF case, severe beam hardening artifacts from surrounding bony structures significantly compromised angiographic image quality, thereby limiting its diagnostic use. Intraoperative CBCT-Angiography using a mobile CBCT device is technically feasible for intraoperative imaging of selected intracranial neurovascular lesions. It shows potential as a valuable complementary imaging tool.