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Frame placement
The patient should have adequate intravenous sedation but remain alert
enough to participate and maintain an upright seated posture, which
greatly facilitates frame placement. If sedation is performed without
monitored anesthesia care, then pulse oximetry and oxygen delivered
by nasal cannula should be used. The authors do not routinely perform
any head shave for frame placement, although this is preferred by some
surgeons. An approximate entry point should be anticipated to avoid
placement of a pin-site or frame post too close to the desired incision.
The frame should be assembled without pins in place, and placed on
the patients head in the approximate position. The posts can be rotated
into a position that optimizes fixation by avoiding excessively medial or
lateral location. The pins should be located at or below the greatest
circumference of the calvaria. This aids with fixation and places the
localizing carbon fiber rods appropriately. Ensuring that the frame is not
positioned too close to the bridge of the nose is also important.
The anticipated pin sites can then be wiped with an alcohol or Betadine
wipe and injected with local anesthetic. The pins are then placed in the
frame posts, with attention to use the appropriate length pins. With the
CRW frame, generally the shorter pair of pins are placed in the posterior
posts, while the longer pair of pins are placed in the anterior posts.
Antibiotic ointment is applied to the pins, and the pins are advanced
through the posts to each be flush with the skin surface.
The authors generally prefer to secure one anterior pin and a
contralateral posterior pin first, which then allows the frame to be
balanced relative to the horizon as desired. Once in satisfactory
position, the remaining 2 pins are advanced until each is rigidly secured.
As the pins are advanced, giving more local anesthetic as needed may
be necessary. Ensuring that the posts exert no pressure on the scalp is
important while advancing the pins. Placing 1 or 2 radio-opaque fiducial
markers on the scalp near the planned incision can be useful. This can
help tailor the incision, and, before the sterile stereotactic frame is
attached to the base, it can help with approximating the skin incision
and a smaller area of hair can be shaved if desired.
Trajectory planning
With the frame satisfactorily placed, the patient can then be taken for a
localizing CT scan or MRI. Generally, a contrast-enhanced head CT
scan is sufficient for identifying a target. With high-grade intrinsic brain
tumors, the area of thickest enhancement is conventionally targeted.[7] A
target can also be selected such that slightly deeper or shallower
samples could be obtained along the same trajectory. With low-grade
gliomas, a T2-weighted MRI may allow for better targeting. The
localizing CT scan is fused with the preoperative MRI, which provides
adequate accuracy. Advanced planning of an MRI-based trajectory with
subsequent fusion to a localizing CT scan reduces overall operative
time.[8]
The entry point should be planned to avoid entry into a dural blood
vessel, cortical blood vessel, or sulcus. Depending on whether or not
future attempts are resection are anticipated, the entry point could be
planned to be incorporated into the craniotomy incision. The trajectory
should then be reviewed to ensure that the biopsy cannula will avoid
unnecessarily traversing pial or ependymal surfaces. Generally, the
shortest distance that takes these structures into consideration and
avoids eloquent cortex is preferred.
Separate specimens can be obtained from a single trajectory by altering
the depth of the biopsy cannula and also by rotating the aperture of the
side-cutting biopsy cannula. Although even further sampling
heterogeneity may be afforded by planning multiple trajectories, this is
reported to increase the risk of postoperative deficits in deeper lesions.[9]
Biopsy
Once a trajectory is planned, the stereotactic coordinates should be
confirmed and transferred from the planning station into the operating
room. Once the patient arrives in the operating room, he or she can be
positioned on the operating table and intravenous sedation resumed.
The stereotactic frame should be assembled by a skilled operating room
nurse or the surgeon. The stereotactic coordinates should be registered
onto the frame and verified.
With the planned scalp entry site, a small area of hair can be shaved if
desired. The patient can be prepped with caution to avoid the eyes. A
custom drape, the Apuzzo Stereotactic Drape (Integra LifeSciences,
Plainsboro, NJ) can be useful when using the CRW frame because it
has 3 perforations in the drape that exist where the sterile stereotactic
ring attaches to the nonsterile patient frame. Once the ring is placed,
the trajectory should be verified, and any minor adjustments to the scalp
incision can be made. Local anesthetic is injected into the scalp for
patient comfort and hemostasis.
The 2 methods of trephination are twist-drill or bur hole. Twist-drill offers
the advantage of a small punctate skin incision that can be made with a
#11 or #15 scalpel and need measure no larger than a standard 2.7-mm
diameter twist-drill. This allows for less scalp bleeding, quicker closure,
improved cosmesis, and can also facilitate incorporation into a
craniotomy if staged tumor resection is anticipated.
In contrast, a bur hole can be made with a high-speed cranial perforator
or fluted matchstick bur. The theoretical advantage of making a bur hole
is that any dural or cortical blood vessels can be directly cauterized with
bipolar cautery. A bur hole requires a larger linear or curvilinear incision.
If a twist-drill is made, the drill bit should be guided through the guide
tube and reducer in the exact planned trajectory of the biopsy needle. If
a bur hole is made, the ring of the stereotactic arc can be temporarily
rotated out of the way to improve access.
Once the bur hole is made, the biopsy needle should be advanced
down the guide tube to confirm that no bony edges deflect its trajectory.
Once the dura is sharply opened, this should again be confirmed. The
biopsy needle should be measured to the appropriate depth. The
standard distance to the target should be borne in mind depending on
the exact configuration of reducers and guide tubes. The authors use a
disposable Nashold Biopsy Needle (Integra Radionics, Burlington, MA)
and measure the distance from the mid position of the side-cutting port
to the depth stop. The biopsy needle has a Luer lock attachment in
which a saline-filled syringe can be attached in order to apply slight
negative pressure.
The system is flushed with saline, and the side-cutting port is closed.
When the hub of the inner cannula of the needle is rotated 180, the
side-cutting port is opened. The port should be flushed and closed and
then gradually advanced to the planned depth, with attention to notice
any change in resistance as the needle is advanced, which can be an
indication that tumor is entered. Once at the planned depth, the sidecutting port is opened by rotating the inner hub 180, and slight negative
pressure is applied by withdrawing on the saline-filled syringe to pull
tissue into the needle. The side-cutting port is then closed and the
needle withdrawn.
The specimen can be retrieved in a similar manner, by opening the port
and flushing saline through to eject the specimen. Additional specimens
can be obtained by rotating the aperture in different directions, or
alternatively by varying the depth slightly. The authors generally avoid
taking more than 4 specimens. Once specimens are obtained, they can
be sent to pathology, where frozen sections are obtained at the
discretion of the surgeon. The scalp can be closed with a single figureof-8 absorbable suture in the case of twist drill. With a bur hole, the
scalp is closed in layers with buried suture in the galea and a running
suture or staples in the skin. The frame is removed, and any bleeding
encountered from the pin sites can generally be controlled with
tamponade or antibiotic ointment.
FramelessStereotacticBrainBiopsy
Frameless biopsy occurs without a stereotactic frame but typically is
performed with the patient in pin-fixation. Generally, pin-fixation is better
tolerated under general anesthesia, which is more common for
frameless procedures. Because a stereotactic frame is not used, a
coregistration process must be performed. Several methods for this
include fiducial markers, anatomic landmarks, and surface matching.
Fiducial marks can be placed on the patients scalp prior to acquisition
of CT scan or MR imaging. When placing fiducial markers on the scalp,
shaving a patch of hair so the adhesive backing can adhere to the scalp
may be necessary. The authors outline the fiducial with a marker in the
event that it is removed. A minimum of 4 fiducial marks are typically
Pearls
Having a clear conceptualization of framed stereotactic biopsy makes
surgery safer and simpler. In essence, the target is defined as a single
point within 3 axes, x,y, and z. The frame can translate in these 3 axes
to position the center of a sphere over that target. Termed the center-ofarc principle, this can be conceived as a sphere in space that is
centered at the target. Following a trajectory from any point along the
surface of that sphere still leads to the center of the sphere when the
trajectory remains perpendicular.
Thus, as long as the x, y, and z coordinates define the target, the arc
and ring angles can be used to vary the entry point. Although this will
alter the skin incision, the bur hole, the exact trajectory, and the
structures traversed, it will lead to the same target. Thus, modification of
the arc and ring angles can be used intraoperatively without
recalculating a target. Drastic alterations in these angles should be
reviewed on the planning station to confirm that no unexpected
Complications
Hemorrhage
In a consecutive series of 500 patients at a single institution undergoing
framed stereotactic brain biopsy between 1990 and 1999, the reported
rate of hemorrhage identified on routine postoperative CT scan was 8%,
whereas the rate of neurologically symptomatic hemorrhage was 1.2%
and the rate of fatal hemorrhage was 0.2%.[7] The authors identified a
platelet count below 150,000/mm3 and pineal region lesions as
predictors of hemorrhage. The method of biopsy described by the
authors is a small 4-mm twist-drill craniotomy as opposed to a standard
bur hole, which is also worth emphasizing. This small trephination does
not appear to confer any increased risk of extra-axial hemorrhage.
Another series reports no additional risk of an even smaller trephination
using a 2-mm twist-drill.[11]
Some have argued that the number of specimens obtained may confer
increased risk of hemorrhage,[12] although this was not borne out in a
large series, where the median number of specimens was 3, and over
10% of patients had more than 5 specimens sent.[7]
Nondiagnostic sample
The goal of performing a stereotactic brain biopsy is to obtain tissue
diagnosis. Thus, a nondiagnostic sample enables no therapeutic
decision-making and potentially commits the patient to an additional
procedure. Technical reasons for nondiagnostic tissue are minimized
with the use of stereotaxy, and diagnostic yields are consistently
reported to approach 100% in many series.[7, 13, 14]
Visual inspection of the specimens can help determine whether or not
diagnostic tissue is obtained. One consideration is to send a sample for
immediate frozen section pathology, while the patient remains on the
operating table such that further specimens can be obtained if
necessary. Some have argued that diagnostic tissue can be consistently
obtained without intraoperative pathology.[13] In a single series of 134
patients treated between 2005 and 2007, a diagnostic yield of 99.3%
was reported without the guidance of frozen section pathology to
Follow-up
The neurosurgeon, generally in consultation with colleagues
from radiation oncology and medical oncology, will set up
follow-up care and treatment based on the results of the
biopsy. If an infectioun is suspected, consultation with
infectious disease specialists is forthcoming.
tereotacticBrainBiopsy
AboutStereotacticBrainBiopsy
Stereotactic neurosurgery involves mapping the brain in a three
dimensional coordinate system. With the help of MRI and CT scans and
3D computer workstations, neurosurgeons are able to accurately target
any area of the brain in stereotactic space (3D coordinate system).
Stereotactic brain biopsy is a minimally invasive procedure that uses this
technology to obtain samples of brain tissue for diagnostic purposes.
Indications
Technique
Risks
Three types of biopsy are often performed in patients with brain tumors:
Needle Biopsy: A small cut is made and a small hole, called a
burr hole, is drilled in the skull. A narrow, hollow needle is inserted
through the hole, and tumor tissue is removed from the core of the
needle. The surgeon then sends the tumor tissue to a pathologist for
study and review.
Stereotactic Biopsy: The same procedure as a needle biopsy,
but performed with a computer-assisted guidance system that aids in
the location and diagnosis of the tumor. The computer, using
information from a CT or MRI scan, provides precise information about
a tumors location and its position relative to the many structures in the
brain. Stereotactically guided equipment might be moved into the burr
hole to remove a sample of the tumor. The surgeon then sends the
tumor sample to a pathologist for study and review. This is also called a
closed biopsy.
Open Biopsy: The tissue sample is taken during an operation
while the tumor is exposed. The surgeon then sends the sample to a
pathologist for study and review.
If the results of your biopsy are not normal, you will be sent back to the
doctor for further tests and advice.
It is important to note that the information provided here is basic and
does not take the place of an in-person assessment by a physician. If
you have any questions about how brain tumors are diagnosed, please
contact your doctor.
Brain Biopsy
Definition
H
H
A brain biopsy is a surgery that removes a small piece of brain tissue for
testing. The tissue may be removed by one of the following ways:
Stereotactic biopsyA computer is used to help locate where the biopsy will
be taken, so only a small hole will be needed
Burr holeA small hole is made in the skull over the biopsy area
CraniotomyA piece of skull is cut out and then put back in after the biopsy is
taken
Brain biopsies are used to make a diagnosis so that treatment can be started.
Some conditions that are diagnosed with this surgery include:
Brain cancer
Brain tumors or growths
Infection
Inflammation
Creutzfeldt Jakob disease
Possible Complications
Complications are rare, but no procedure is completely free of risk. If you are
planning to have a brain biopsy, your doctor will review a list of possible
complications, which may include:
Bleeding
Infection
Brain swelling
Damage to brain which may cause:
Changes in memory, behavior, thinking, or speech
Vision problems
Problems with balance
Bowel and bladder problems
Seizures
Paralysis or weakness
Reaction to the anesthesia
Heart attack
Blood clots
Smoking may increase the risk of complications.
Be sure to discuss these risks with your doctor before your biopsy.
What to Expect
Prior to Procedure
Anesthesia
You may receive:
Local anesthesia and light sedation for stereotactic biopsiesblocks just the
area where surgery is taking place; light sedation makes you sleepy during
surgery
General anesthesia for craniotomies or burr holesblocks pain and keeps
you asleep during surgery; given through an IV
Post-procedure Care
At the Hospital
Your brain function will be checked frequently. This will include:
Pupil reactions
Mental status
Responsiveness
You may receive:
Medication to prevent seizures
Antibiotics to prevent bacterial infection
The dressing will be removed in 24-48 hours. A lighter dressing will be place
on your head.
While in the hospital, you may be asked to:
Try not to strain or hold your breath. This can increase pressure on your brain.
Get out of bed and walk. This will help to prevent problems, like blood clots
and pneumonia.
At Home
When you are at home, do the following for a smooth recovery:
Get plenty of rest.
Follow your doctor's instructions.
After you leave the hospital, contact your doctor if any of the following occurs:
Any changes in physical abilitybalance, strength, or movement
Any changes in mental statuslevel of consciousness, memory, thinking, or
responsiveness
Redness, swelling, increasing pain, a lot of bleeding, or any discharge from
the incision site
Headache that does not go away
Changes in vision
Fainting
Signs of infection, including fever and chills
Nausea and/or vomiting that you cannot control with the medications you
were given, or that continue for more than 2 days after leaving the hospital
Pain that you cannot control with the medications you have been given
Trouble controlling your bladder and/or bowels
If any of the following occurs, someone should call for medical help for you:
New seizures
Shortness of breath, or chest pain
Loss of consciousness
In case of an emergency, call for emergency medical services right away.
RESOURCES
American Brain Tumor Association
http://www.abta.org
National Brain Tumor Society
http://www.braintumor.org
CANADIAN RESOURCES
Brain Tumor Foundation of Canada
http://www.braintumour.ca
Canadian Cancer Society
http://www.cancer.ca
References
About stereotactic brain biopsy. University of Florida Department of
Neurosurgery website. Available at:
http://www.http://neurosurgery.ufl.edu/residency/about-us/clinicalspecialties/stereotactic-brain-biopsy/. Accessed November 12, 2015.
Your surgery guide: Information about your craniotomy or biopsy for a brain
tumor. Cedars Sinai Medical Center website. Available at:
http://www.braintumortreatment.com/What-to-Expect/The-Treatment-
Revision Information