• Xiaolin Hou, Tao Wu, Dingjun Li, and Ruxiang Xu.
• The Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China. Electronic address: hxlhxf@126.com.
• World Neurosurg. 2024 Oct 1; 190: e302e309e302-e309.

ObjectiveSome patients with intracranial aneurysms (IAs) cannot undergo three-dimensional computed tomography angiography (3D-CTA) or digital subtraction angiography due to contraindications to contrast agents or radiation. Time-of-flight magnetic resonance angiography (TOF-MRA) offers a contrast-free alternative but lacks cranial bone detail critical for surgical planning. This study evaluates the feasibility of using 3D Slicer to fuse TOF-MRA with thin-section CT images to generate synthetic images resembling CTA for surgical clipping planning.MethodsThis prospective study included 22 patients with unruptured IAs and 8 with ruptured IAs undergoing aneurysm clipping surgery (≥3 mm). TOF-MRA and CT/3D-CTA scans were fused using 3D Slicer. Neuroradiologists and neurosurgeons independently assessed 3D-CTA and synthetic TOF-MRA-CT images for aneurysm detection rates, morphology, and dimensions. Evaluation metrics included dice similarity coefficient and 95% Hausdorff distance.ResultsEvaluation of aneurysm detection rates, morphology, and dimensions showed no significant differences between synthetic TOF-MRA-CT fusion images and 3D-CTA (all P > 0.05). Neuroradiologist assessments revealed strong concordance in aneurysm morphology between synthetic TOF-MRA-CT fusion images and 3D-CTA (κ = 0.867, P < 0.001). The dice similarity coefficient (0.937 ± 0.012) and Hausdorff distance (4.54 ± 0.26) indicated a high degree of image overlap between synthetic TOF-MRA-CT fusion images and 3D-CTA. Surgeons rated the consistency of aneurysm morphology between synthetic TOF-MRA-CT fusion images and intraoperative findings as strongly concordant (κ = 0.873, P < 0.001).ConclusionsSynthetic TOF-MRA-CT fusion images closely match 3D-CTA for ≥3 mm aneurysms, demonstrating comparable diagnostic and surgical clipping planning effectiveness. They represent a promising alternative for personalized preoperative planning, particularly when contrast agents are contraindicated.Copyright © 2024 Elsevier Inc. All rights reserved.

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