Frame-based stereotaxy in a frameless era: current capabilities, relative role, and the positive- and negative predictive values of blood through the needle

Abstract

Introduction In the modern era of frameless stereotaxis (FL), the role of frame-based (FB) stereotactic needle biopsy is evolving. Methods Retrospective review of prospective database of 106 lesions in 91 consecutive patients undergoing FB stereotactic needle biopsy with a systematic ''geologic core'' technique by a single surgeon. Diagnostic accuracy was calculated comparing biopsy diagnosis with final pathology in 11 patients who underwent subsequent surgical resection. All instances of intra-operative bleeding through the needle were prospectively noted and compared with post-biopsy CT scan. Lesions were classified as risky for FL technique if they were (1) infratentorial or pineal, (2) within 10 mm of the circle of Willis or root of the Sylvian fissure, or (3) within 10 mm of deep cerebral veins. Results Diagnostic yield was 94%. Diagnostic accuracy was 91%. Of 18 lesions involving the corpus callosum, 13 (72.2%) were GBM 2 were anaplastic astrocytoma, and 1 each were found to be anaplastic oligodendroglioma, primary central nervous system lymphoma (PCNSL) and tumescent MS. Of 25 multifocal lesions, malignant primary brain tumor was diagnosed in 17 (68%) (11 GBM, 3 PCNSL, 2 anaplastic ologodendroglioma, and 1 anaplastic astrocytoma). Mortality was 0%. Three patients developed temporary neurologic deficits and one had permanent deficit. Absence of persistent blood through the biopsy needle had a negative predicative value of 98.8% for subsequent neuroimaging blood [5 mm diameter. According to our criteria, 80% of patients would have been candidates for FL biopsy. Conclusions Stereotactic biopsy is an effective, safe and important technique for histologic diagnosis of brain lesions, particularly for multifocal and corpus callosum lesions. Postbiopsy CT can be safely reserved for patients who demonstrate persistent bleeding through the biopsy needle. FB stereotaxy remains an important technique for the 20% with small or deep seated lesions or when it is advantageous to avoid an incision, a burr hole or general anesthesia.

Robot-assisted procedures in pediatric neurosurgery

“…In general, frameless biopsy offers more ergonomic properties and an easier surgical workflow, 21,25,71 especially in cases of supratentorial tumors and lesions larger than 15 mm. 3,49,57 On the other hand, frame-based biopsy envisages a more complex surgical workflow, 23,51,57 and it is still preferred in many centers for the deepest and smallest lesions, or for lesions located close to highly vascular areas, such as the pineal region. 39 So far, robot-assisted biopsies have been routinely performed at only a few centers in a limited number of patients.…”

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

“…The radiology images are not always reliable in terms of defining the right target point. In an analysis of the safety of stereotactic biopsy procedures in 300 patients, the histological diagnosis was reported to have been different from the preoperative clinical diagnosis in 49% of the cases [1]. Moreover, during a biopsy procedure the location of the targets may vary relative to the precalculated coordinates due to a brain shift usually caused by the cerebrospinal fluid loss after skull bone and dura opening [2].…”

“…Some patients can have a higher risk for hemorrhage due to different diseases, location of the tumor and radiological factors [4,7,9]. Observation of persistent blood in the biopsy needle has been suggested as a method for detection of hemorrhage intraoperatively, however, a reliable detection requires postoperative imaging [1]. To avoid the complications, it is of benefit to use an intraoperative guidance system to safely reach and identify the target and reduce the risk of hemorrhage due to vessel rupture during the needle insertion and more importantly during the biopsy removal as the tumors have a higher affinity for bleeding.…”

405 nm versus 633 nm for protoporphyrin IX excitation in fluorescence‐guided stereotactic biopsy of brain tumors

“…[12] Actually, the reported diagnostic yield (percentage of biopsy procedures leading to conclusive histopathological diagnosis) of stereotactic biopsy ranges from 76% to 99%. [13][14][15][16][17][18][19][20] These numbers indicate that in many cases additional support for the neurosurgeon beyond the conventional imaging techniques would be desirable. This is all the more true as usually several biopsy samples are taken to permit a diagnosis with acceptable reliability [7,13].…”