Three-dimensional rotational angiography-based multimodal fusion imaging for preoperative neurovascular assessment in intracranial meningiomas: a retrospective technical feasibility study of 72 cases.

BACKGROUND AND OBJECTIVE: Surgical management of anatomically complex intracranial meningiomas requires accurate assessment of tumor vascular supply, venous sinus involvement, cortical venous relationships, and skull base anatomy. Although multimodal fusion imaging and angiographic assessment are established, the incremental role and appropriate use of arterial- and venous-phase three-dimensional rotational angiography (3DRA)-based multimodal fusion imaging (MFI) remain uncertain. We evaluated the technical feasibility, anatomical information yield, and potential decision-support utility of this workflow. METHODS: We retrospectively reviewed 72 consecutive patients with pathologically confirmed intracranial meningiomas who underwent microsurgical resection with preoperative 3DRA-based MFI between May 2023 and March 2026. Preoperative imaging datasets included contrast-enhanced three-dimensional T1-weighted magnetic resonance imaging (MRI), thin-section computed tomography (CT), and arterial- and venous-phase 3DRA. These datasets were fused to generate patient-specific three-dimensional models for surgical planning, neurovascular mapping, early intraoperative anatomical orientation, and postoperative assessment. Simpson grade I-II resection, perioperative complications, and digital subtraction angiography (DSA)-related complications were recorded. RESULTS: Among the 72 patients, 35 tumors were located at the skull base and 37 were non-skull base meningiomas. Venous sinus involvement was identified in 24 patients, pial arterial supply in 14 patients, and meningeal arterial supply in 54 patients. Abnormal vascular findings were detected in 10 patients, including 9 aneurysms and 1 arterial occlusion. Simpson grade I-II resection was achieved in 67 patients (93.1%), and perioperative complications occurred in 5 patients (6.9%). No DSA-related complications were observed. In exploratory subgroup analyses, no statistically significant differences in resection or complication rates were observed according to angiographically defined vascular involvement or tumor location. CONCLUSION: 3DRA-based MFI is a feasible adjunct for patient-specific neurovascular and skull base assessment in selected patients with anatomically complex intracranial meningiomas. Its potential value may be greatest in skull base, hypervascular, vessel-adjacent, and venous sinus-related tumors when detailed vascular information may influence surgical or embolization planning. Because this retrospective study lacked a control group and did not prospectively assess management changes, operative efficiency, functional outcomes, or cost-effectiveness, it does not establish superiority over noninvasive imaging or support routine use in all meningioma patients. Future prospective comparative studies should include an appropriate conventional-imaging control group, prospectively document management plans before and after review of the fusion images, and assess predefined operative, functional, safety, and cost-effectiveness outcomes to determine the incremental clinical value of this approach.