Imaging Modalities to Visualize Deep Cerebral Perforating Arteries: A Systematic Review and Meta-Analysis

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Abstract
The reliable visualization of deep cerebral perforating arteries is a challenge. Despite the advancements in high resolution imaging, the optimal modality to depict deep cerebral perforating arteries remains unclear. The purpose of this systematic review was to provide an overview of the imaging modalities used to visualize perforating arteries and to evaluate their diagnostic performance. EMBASE, Ovid Medline, the Web of Science Core Collection, Google Scholar, and Cochrane Central Register of Controlled Trials were searched from database inception to April 15th, 2025. Original studies using imaging modalities to depict perforating arteries in human subjects were included. The search strategy yielded 3,857 articles of which 1,725 remained after removing duplicates. After the initial sift phase, 215 articles remained to be assessed for eligibility based on full-text sifting. Finally, 106 studies (6,785 participants;14,041 hemispheres) were included. As a performance measure, detection rate was defined as the percentage of participants in which at least one perforating artery in one arterial territory could be detected. Pooled estimate (%) of detection rate per imaging modality was calculated using a random-effects model with a 95% confidence interval (CI). Studies used 7T MRA/MRI (n=56), 3T MRA/MRI (n=32), 1.5T MRA/MRI (n=6), CTA (n=4), CT (n=1), DSA (n=14), and transcranial ultrasound (n=3). Pooled estimates found a detection rate of 94% (95% CI 0.90-0.97; I2=64%) for 7T MRA/MRI and 85% (95% CI 0.63-0.95; I2=84%) for 3T MRA/MRI. One 3T MRA study performed an in-vivo diagnostic validation study by direct intraoperative evaluation. Our findings have not been validated in-vivo. Multiple imaging modalities including 7T, 3T, and 1.5T MRA/MRI, CTA, and DSA, have been used to visualize deep cerebral perforating arteries. High-resolution MRI, particularly 7T MRA, shows the highest detection rates (up to 94%), although most studies were performed in healthy volunteers and lacked anatomical validation. Consequently, reported detection rates may overestimate true vessel visualization. Future research should prioritize rigorous in-vivo validation of these techniques to establish their clinical reliability.

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