Preoperative Evaluation of Perforating Arteries in Amygdala Glioblastoma Using UHR-IA-CTA and MR Tractography

Overview

This case study demonstrates the use of ultra-high-resolution intra-arterial CT angiography combined with MR tractography to visualize critical perforating arteries supplying the pyramidal tract in a patient with left amygdala glioblastoma. The imaging allowed precise assessment of tumor-vessel relationships, facilitating safe maximal tumor resection while preserving neurological function.

Background

Gliomas in the medial temporal region, including the amygdala, pose surgical challenges due to proximity to vital neuronal and vascular structures such as the pyramidal tract and its supplying perforating arteries. The anterior choroidal artery and lenticulostriate arteries provide critical blood supply to these regions, but their small caliber complicates visualization with conventional imaging. Recent advances in ultra-high-resolution CT angiography combined with diffusion tensor imaging enable detailed mapping of these vessels and their spatial relationship to tumors, aiding surgical planning.

Data Highlights

Digital subtraction angiography identified tumor supply from a branch of the anterior choroidal artery (AchoA). MR angiography showed a hypoplastic left posterior communicating artery and a well-developed left P1 segment. 3D maximum intensity projection images from UHR-IA-CTA clearly visualized the pyramidal tract-supplying lenticulostriate arteries (PT-LSAs) and AchoA perforators (PT-AchoAs). Fusion imaging confirmed these vessels were displaced but not encased by the tumor, supporting feasibility of maximal safe resection.

Key Findings

• UHR-IA-CTA combined with MR tractography enabled clear visualization of PT-LSAs and PT-AchoAs despite their small diameter.
• The tumor was supplied solely by a branch of the anterior choroidal artery, with no involvement of the internal carotid or middle cerebral arteries.
• 3D fusion images showed the PT-LSAs and PT-AchoAs were displaced anteriorly and medially but not encased by the tumor.
• Preoperative imaging findings guided surgical planning, allowing maximal safe resection with preservation of critical vascular structures.
• Postoperative imaging confirmed total tumor resection with a small ischemic focus; the patient’s sensory aphasia improved, though right lower quadrant hemianopsia developed.

Clinical Implications

The integration of UHR-IA-CTA with MR tractography provides a powerful tool for preoperative assessment of tumors near critical perforating arteries, enabling surgeons to delineate vascular anatomy and tumor boundaries precisely. This approach can inform surgical decision-making to maximize tumor resection while minimizing neurological deficits. Continuous intraoperative monitoring remains essential to detect and prevent ischemic complications.

Conclusion

This case illustrates that advanced imaging modalities combining ultra-high-resolution intra-arterial CT angiography and diffusion tensor tractography can effectively visualize small perforating arteries around medial temporal glioblastomas. Such detailed vascular mapping facilitates safe maximal tumor resection and may improve surgical outcomes.

References

1. Author/Source/Year -- Evaluation of Perforating Arteries Surrounding Amygdala Glioblastoma Prior to Surgery Utilizing Intra-Arterial CT Angiography and High-Resolution CT with MR Tractography: A Case Study