Background Since its introduction, digital subtraction angiography has been considered the gold standard in diagnostic imaging for neurovascular disease. Modern post-processing techniques have made angiography even more informative to the cerebrovascular neurosurgeon or neurointerventionalist. Open neurosurgical procedures such as aneurysm clipping, extirpation of arteriovenous malformations, and extracranial–intracranial bypass remain important techniques in the armamentarium of a comprehensive cerebrovascular neurosurgeon. In-depth study of the anatomy of vascular pathology prior to and after surgery, often via selective cerebral angiography, is a critical component of surgical planning. However, when a vascular lesion or relevant anatomical region is perfused by two or more vascular territories, each selective angiographic imaging volume may provide an incomplete anatomical picture.

Methods An institutional database was searched for cases in which the syngo Inspace 3D–3D fusion software was used and assisted in diagnosis and surgical management.

Results In the six cases reviewed, the 3D–3D fusion imaging was crucial in understanding the anatomy of the vascular lesion and aided in surgical decision-making. The cases included two unique anterior communicating artery aneurysms, an arteriovenous malformation, an extracranial–intracranial bypass, and an angiographically negative subarachnoid hemorrhage.

Conclusions This is a novel strategy of combining two independently acquired selective cerebral angiography volumes to create a more accurate representation of the vascular anatomy. Given the increasing availability of the relevant image acquisition and processing technologies, we propose this strategy as a valuable adjunct in cerebrovascular procedures.