Stereotactic Brain Biopsy Procedures Research Articles

Diagnostic Yield and Complication of Frameless Stereotactic Brain Biopsy.

Background:With the advancement of neuronavigation technologies, frameless stereotactic brain biopsy has been developed. Previous studies proved that frameless stereotactic brain biopsy was as effective and safe as frame-based stereotactic brain biopsy. The authors aimed to find the factors associated with diagnostic yield and complication rate of frameless intracranial biopsy.Materials and Methods:Frameless stereotactic brain biopsy procedures, between March 2009 and April 2017, were retrospectively reviewed from medical records including imaging studies. Using logistic regression analysis, various factors were analyzed for association with diagnostic yield and postoperative complications.Results:Eighty-nine frameless stereotactic brain biopsy procedures were performed on 85 patients. The most common pathology was primary central nervous system lymphoma (43.8%), followed by low-grade glioma (15.7%), and high-grade glioma (15%), respectively. The diagnostic yield was 87.6%. Postoperative intracerebral hematoma occurred in 19% of cases; however, it was symptomatic in only one case. The size of the lesion was associated with both diagnostic yield and postoperative intracerebral hematoma complication. Lesions, larger than 3 cm in diameter, were associated with a higher rate of positive biopsy result (P = 0.01). Lesion 3 cm or smaller than 3 cm in diameter, and intraoperative bleeding associated with a higher percentage of postoperative intracerebral hematoma complications (P = 0.01).Conclusions:For frameless stereotactic brain biopsy, the size of the lesion is the essential factor determining diagnostic yield and postoperative intracerebral hematoma complication.

Application of a Thrombin-Gelatin Matrix in the Management of Intractable Hemorrhage During Stereotactic Biopsy

Few studies have been published about percutaneous techniques for management of surgical bed hemorrhage during a stereotactic biopsy, a serious complication that may affect patient outcome. We describe the injection of a thrombin-gelatin matrix through the biopsy cannula as an effective method to arrest surgical bed bleeding that does not respond to conventional methods of hemostasis. We prospectively documented image-guided stereotactic brain biopsy procedures in 30 awake patients between July 2014 and July 2017 at our center. Among patients presenting with intractable surgical bed bleeding, a thrombin-gelatin matrix injection through the biopsy cannula was performed. Details of the injection technique, surgical outcome, and complications were recorded. Among 30 documented stereotactic brain biopsies, 3 (10%) had intractable surgical bed bleeding during the procedure. In all 3 cases, thrombin-gelatin matrix was injected, and an immediate arrest of hemorrhage was achieved. None of the patients required a craniotomy or further invasive measure to achieve hemostasis. No postoperative complications were recorded. Our preliminary results suggest that thrombin-gelatin matrix injection is a simple, safe, and effective stereotactic practice to manage persistent surgical bed bleeding that cannot be arrested by standard, conventional hemostatic methods.

How is stereotactic brain biopsy evolving? A multicentric analysis of a series of 421 cases treated in Rome over the last sixteen years

ObjectiveIn recent decades, frame-based (FBB) and frame-less stereotactic brain biopsy (FLB) have played a crucial role in defining the diagnosis and management of expanding intracranial lesions in critical areas. During the same period, there have been significant advances in diagnostic imaging, a shift in surgical strategies towards extensive resection in gliomas and new molecular classification of brain tumors. Taking these advances into account, we have evaluated whether significant changes have occurred over the last sixteen years of our clinical practice in terms of frequency, indications, target selection, and the histologic results of stereotactic brain biopsy (SBB) procedures. Patients and MethodsWe analyzed a series of 421 SBB cases treated between January 2002 and June 2017 in three major neurosurgical institutes in Rome, serving a total of 1.5 million people. Within this series, 94.8% of patients underwent FBB, while, more recently, FLB was performed in 5.2% of cases. The entire period under consideration, running from 2002 to 2017, has been further stratified into four-year time-frames (2002–2005, 2006–2009, 2010–2013, 2014–2017) for the purpose of analysis. ResultsThe diagnostic yield was 97%. Final diagnoses revealed tumors in 90% of cases and non-neoplastic masses in 7%, while 3% of cases were not conclusive.The morbidity rate was 3% (12 cases) and mortality was 0.7% (3 cases). Intra-operative frozen sections were made in 78% of biopsies.In our three institutes, the number of SBBs decreased steadily throughout the time-frames under consideration. We have also observed a statistically significant reduction in biopsy procedures in lobar lesions, while those performed on the basal ganglia increased and the number of SBBs of multiple masses and lesions of the corpus callosum remained stable. Primary central nervous system diagnosis of lymphomas (PCNSL) was the sole diagnosis whose incidence increased significantly. ConclusionsOver the last sixteen years, we have witnessed a significant decrease in SBB procedures and a modification in target selection and histologic results. Despite the significant evolution of neuroimaging, an accurate non-invasive diagnosis of intracranial expanding lesions has not yet been achieved. Furthermore, the most recent WHO classification of brain tumors (2016), which incorporates molecular and morphological features, has boosted the need for molecular processing of tissue samples in all expanding brain lesions. For these reasons, it is likely that SBBs will continue to be performed in specific cases, playing a significant role in diagnostic confirmation by providing tissue samples, so as to better assess the biology and the prognosis of cerebral lesions, as well as their sensitivity to standard radio-chemotherapy or to new molecular target therapies.

5-ALA fluorescence and laser Doppler flowmetry for guidance in a stereotactic brain tumor biopsy.

A fiber optic probe was developed for guidance during stereotactic brain biopsy procedures to target tumor tissue and reduce the risk of hemorrhage. The probe was connected to a setup for the measurement of 5-aminolevulinic acid (5-ALA) induced fluorescence and microvascular blood flow. Along three stereotactic trajectories, fluorescence (n = 109) and laser Doppler flowmetry (LDF) (n = 144) measurements were done in millimeter increments. The recorded signals were compared to histopathology and radiology images. The median ratio of protoporphyrin IX (PpIX) fluorescence and autofluorescence (AF) in the tumor was considerably higher than the marginal zone (17.3 vs 0.9). The blood flow showed two high spots (3%) in total. The proposed setup allows simultaneous and real-time detection of tumor tissue and microvascular blood flow for tracking the vessels.

Frameless image-guided stereotactic brain biopsies: emphasis on diagnostic yield.

Studies regarding frameless stereotactic brain biopsy mainly report high diagnostic yield (DY) as opposed to relatively low diagnostic accuracy. This discrepancy raises the question of the certainty and precision of obtained diagnoses. This article proposes a DY definition encompassing diagnostic certainty and precision according to the World Health Organization (WHO) central nervous system (CNS) tumour classification system. Furthermore, our eight-year experience with this procedure is reviewed and evaluated. A consecutive series of 235 frameless biopsy procedures was reviewed. Criteria were set up for categorising obtained diagnoses. All cases were included in a predictive factor analysis of inconclusive biopsy and postoperative complications. According to our predefined DY criteria, the DY was 72.8 %. The inconclusive biopsy outcome measured 21.7 %; the non-diagnostic biopsy outcome was 5.5 %. The only predictive factor found for inconclusive biopsy procedures was age under 30. Predictive factors for postoperative complications, which were found statistically significant after multivariable analysis, were glucose level and intra-operative haemorrhage. The total morbidity rate was 8.5 %, including a mortality rate of 0.9 %. Although frameless stereotactic brain biopsy procedures are considered to be relatively safe, the true DY is significantly less than previously reported, most probably due to the lack of standardised DY criteria. Based on our DY definition and subsequent DY findings, standardisation of DY criteria and definition is paramount for biopsy diagnosis interpretation.

Towards improving the safety and diagnostic yield of stereotactic biopsy in a single centre

BackgroundPreviously, we reported on our single centre results regarding the diagnostic yield of stereotactic needle biopsies of brain lesions. The yield then (1996–2006) was 89.4%. In the present study, we review and evaluate our experience with intraoperative frozen-section histopathologic diagnosis on-demand in order to improve the diagnostic yield.MethodsOne hundred sixty-four consecutive frameless biopsy procedures in 160 patients (group 1, 2006–2010) were compared with the historic control group (group 2, n = 164 frameless biopsy procedures). Diagnostic yield, as well as demographics, morbidity and mortality, was compared. Statistical analysis was performed by Student's t, Mann–Whitney U, Chi-square test and backward logistic regression when appropriate.ResultsDemographics were comparable. In group 1, a non-diagnostic tissue specimen was obtained in 1.8%, compared to 11.0% in group 2 (p = 0.001). Also, both the operating time and the number of biopsies needed were decreased significantly. Procedure-related mortality decreased from 3.7% to 0.6% (p = 0.121). Multivariate analysis only proved operating time (odds ratio (OR), 1.012; 95% confidence interval (CI), 1.000–1.025; p = 0.043), a right-sided lesion (OR, 3.183; 95% CI, 1.217–8.322; p = 0.018) and on-demand intraoperative histology (OR, 0.175; 95% CI, 0.050–0.618; p = 0.007) important factors predicting non-diagnostic biopsies.ConclusionsThe importance of a reliable pathological diagnosis as obtained by biopsy must not be underestimated. We believe that when performing stereotactic biopsy for intracranial lesions, next to minimising morbidity, one should strive for as high a positive yield as possible. In the present single centre retrospective series, we have shown that using a standardised procedure and careful on-demand intraoperative frozen-section analysis can improve the diagnostic yield of stereotactic brain biopsy procedures as compared to a historical series.

Balloon Compression Technique in the Management of Persistent Intraoperative Intratumoral Hemorrhage Resulting From Stereotactic Biopsy

Despite its proven safety, intraoperative intratumoral hemorrhage is an uncommon but serious complication of stereotactic brain biopsy. We describe the "balloon compression technique" that was used in the management of persistent intraoperative bleeding that could not be arrested by conventional methods of hemostasis. Between January 2001 and March 2009, of 184 image-guided stereotactic brain biopsy procedures, intraoperative intratumoral bleeding occurred in 12 cases (6.5%). In 3 of these 12 cases (1.6%), intraoperative hemorrhage was persistent. In these cases, after adjustment of the optimum length, a balloon catheter (Fogarty) was inserted through the cannula and inflated with a contrast agent. We observed the patient for 10 minutes by checking the position of the balloon with regular intervals, using a frozen C-arm fluoroscope to determine any significant changes in its initial position due to possible enlargement of the hematoma. The patient was also closely observed during this time. Hemostasis was obtained immediately after the inflation of the balloon in all 3 cases. The patients tolerated the procedure well. During and after the procedure no complications related to the technique were observed. None of the cases required craniotomy for evacuation of the hematoma and to secure hemostasis. Our preliminary results indicate that the balloon compression technique seems to be a safe, rapid, and effective stereotactic practice in the management of the persistent intraoperative intratumoral bleeding that could not be arrested by standard, conventional hemostatic methods.

Frameless stereotactic brain biopsy procedures using the Stealth Station: indications, accuracy and results.

This study presents the results of 57 stereotactic brain biopsies using a frameless neuronavigation system, the Stealth Station. The supratentorial lesions had a mean diameter of 33 mm and a mean distance of 32 mm from the entry point at brain surface. In all cases the stereotactic procedure was planned in the preoperative 3-D magnetic resonance data set. In seven cases additional data for identification of eloquent brain areas was integrated from magnetoencephalography or functional magnetic resonance imaging. During surgery the samples were sent to neuropathological examination and the operation completed after the confirmation of pathological tissue. Using this method, in 56 cases a pathological tissue was obtained and a diagnostic yield of 98% was achieved. In two cases (3.5%) a new neurological deficit remained (hemiparesis and visual field deficit). The mean operation time was 92 minutes including examination of frozen sections. The results of our series demonstrate, that frameless stereotactic systems can also be reliably applied for biopsy of supratentorial lesions larger than 15 mm. Frameless stereotaxy in combination with intraoperative pathological confirmation is a safe and reliable method for stereotactic brain biopsy with a diagnostic yield comparable to frame-based stereotaxy.

Histological yield, complications, and technological considerations in 114 consecutive frameless stereotactic biopsy procedures aided by open intraoperative magnetic resonance imaging.

The authors undertook a prospective study of frameless, magnetic resonance (MR)-guided stereotactic brain biopsy procedures performed with the aid of an open MR system. Morbidity and mortality rates, frequency of postoperative hemorrhage, and histological yield were evaluated, as well as the size and location of the lesions under investigation. During a period of 51 months (July 1996-November 2000), 114 consecutive frameless stereotactic biopsy procedures were performed with the aid of an open intraoperative MR system to investigate supratentorial lesions in 113 patients. The median volume of the lesions was 33.5 cm3, and 31.9% were deep seated. All biopsy samples comprised pathological tissue and in 111 (97.4%) of 114 a specific neuropathological diagnosis was made. A follow-up computerized tomography (CT) scan was obtained on the 1st postoperative day in all patients to evaluate postoperative complications. In two cases (1.8%), a hemorrhage was found on postoperative CT scans, with no neurological worsening of the patients. Morbidity with neurological worsening was seen in three patients; it was transient in two of them (1.8%), and in one (0.9%) subsequent emergency craniotomy was necessary because of increased edema. There were no infections, but there was one death (0.9%) Open intraoperative MR imaging transforms a blind conventional stereotactic procedure into a visually controlled procedure that is adaptable to dynamic anatomical changes. Routine postprocedural MR imaging makes follow-up CT scanning obsolete. This largest reported series of intraoperative MR-guided biopsy procedures shows results that are at least comparable with those in reports of larger series of conventional stereotactic biopsy sampling. The mean procedure time was 60 minutes including planning, and this method produced low morbidity and complication rates and a high histological yield.

Computed Imaging-Assisted Stereotactic Brain Biopsy: A Risk Analysis of 225 Consecutive Cases

Background Treatment strategies for intracranial mass lesions are most effective when based upon histopathological diagnoses. Image-guided stereotaxy has provided the means to sample tissue from small or deeply seated intraparenchymal lesions with a relatively high degree of safety and accuracy. Although procedural complications are infrequent, devastating neurological sequelae may result from hemorrhage or direct trauma. This study was undertaken to identify factors that may confer an increased risk of morbidity from stereotactic brain biopsy. Methods Two hundred twenty-five consecutive computer-assisted stereotactic brain biopsy procedures were reviewed. Patient age averaged 47.4 years (range, 3–84 years); gender ratio was approximately 2:1 (male:female). Pre-existing medical conditions were identified in nearly half of the cohort. 61.3% of biopsied lesions were lobar; the remainder (38.7%) were “deep-seated” (thalamus, basal ganglia, pineal, hypothalamus, cerebellum, brainstem). Glial tumors accounted for the majority (44.4%) of biopsied lesions; metastases (12.9%) and lymphoma (11.6%) were also relatively common. Demographical, anatomical, surgical, and histological data were compiled and putative risk factors for morbidity identified. These variables were then subjected to univariate and logistic regression analyses to determine their significance as independent predictors of operative risk. Results Twelve patients suffered complications as a consequence of the biopsy procedure (eight from hemorrhage, four from direct trauma). Major morbidity (hemiparesis, aphasia, obtundation) occurred in eight patients (3.6%). Three patients (1.3%) suffered minor morbidity (transient, mild neurological deficits). One operative fatality occurred (0.4%). An increased risk of morbidity was associated with the preoperative use of antiplatelet agents, chronic corticosteroids, deep-seated lesions, malignant gliomas, and a greater number of biopsy attempts ( p < 0.05). Factors not conferring increased morbidity included gender, age, pre-existing illness, extracranial malignancy, cardiac disease, hypertension, diabetes, HIV status, and instrument used to procure the specimen. Conclusions Complications arising from stereotactic brain biopsy are infrequent but can be disastrous. Operative risk is a function of several independent variables, including lesion properties (location, histology), preoperative pharmacological therapy (corticosteroids, antiplatelet agents), and operative technique. This analysis suggests that the morbidity of stereotactic brain biopsy may be minimized by risk factor modification.