Endoscopic versus stereotactic biopsies of intracranial lesions involving the ventricles.

Stereotactic biopsies of ventricular lesions may be less safe and less accurate than biopsies of superficial lesions. Accordingly, endoscopic biopsies have been increasingly used for these lesions. Except for pineal tumors, the literature lacks clear, reliable comparisons of these two methods. All 1581 adults undergoing brain tumor biopsy from 2007 to 2018 were retrospectively assessed. We selected 119 patients with intraventricular or paraventricular lesions considered suitable for both stereotactic and endoscopic biopsies. A total of 85 stereotactic and 38 endoscopic biopsies were performed. Extra procedures, including endoscopic third ventriculostomy and tumor cyst aspiration, were performed simultaneously in 5 stereotactic and 35 endoscopic cases. In 9 cases (5 stereotactic, 4 endoscopic), the biopsies were nondiagnostic (samples were nondiagnostic or the results differed from those obtained from the resected lesions). Three people died: 2 (1 stereotactic, 1 endoscopic) from delayed intraventricular bleeding and 1 (stereotactic) from brain edema. No permanent morbidity occurred. In 6 cases (all stereotactic), additional surgery was required for hydrocephalus within the first month postbiopsy. Rates of nondiagnostic biopsies, serious complications, and additional operations were not significantly different between groups. Mortality was higher after biopsy of lesions involving the ventricles, compared with intracranial lesions in any location (2.4% vs 0.3%, p = 0.016). Rates of nondiagnostic biopsies and complications were similar after endoscopic or stereotactic biopsies. Ventricular area biopsies were associated with higher mortality than biopsies in any brain area.

Complications after frame-based stereotactic brain biopsy: a systematic review.

Stereotactic frame-based brain biopsy is one of the most used procedures to obtain brain tissue. This procedure is usually considered as mini-invasive, quick, efficient, and safe even if results of the different studies are widely heterogenous. The objective of this review of the literature is to describe and analyze the complications of stereotactic frame-based brain biopsy. About 132 articles were found after a research in the Medline database. We only considered English references published between 1994 and June 2019. Additional studies were found by using the references from articles identified in the original search. This systematic review was conducted according to PRISMA guidelines. After applying exclusion criteria, we eventually considered 25 relevant studies. The mortality rate varies from 0.7 to 4%. Overall morbidity ranges from 3 to 13%. Most of the complications are revealed by the following symptoms: neurological impairment (transient or permanent), seizure, and unconsciousness. Symptomatic hemorrhage range varies from 0.9 to 8.6%, whereas considering asymptomatic bleeding, the range may be up to 59.8%. Complications were clinically evident within minutes to a few hours after the biopsy. Corrective surgeries are very rare (< 1%). Complications occurring after a frame-based stereotactic brain biopsy are rare but with serious side effects. It rarely leads to death or to permanent neurological impairment. Description and classification of complications are often heterogeneous in the literature. The use of a grading scale could help comparisons between series from around the world. Future studies should establish a score that allows neurosurgeon to predict post-biopsy complications.

Complications of stereotactic biopsy of lesions in the sellar region, pineal gland, and brainstem: A retrospective, single-center study.

Stereotactic biopsy (STB) is commonly used in the pathological diagnosis of intracranial lesions. The associated complication and mortality rates are low, but few reports with large sample sizes have assessed the complications of STB for lesions in the brain midline.To evaluate the complications of STB of lesions in the sellar region, pineal region, and brainstem.This was a retrospective analysis of patients who underwent STB of lesions in the sellar region, pineal region, and brainstem at the Neurosurgery Department, Sixth Medical Center, PLA General Hospital, China, between January 2015 and December 2017. The rates of and possible reasons for surgical complications (including bleeding) and mortality were analyzed.A total of 145 patients underwent STB of midline brain lesions, including 16 (11.0%) in the sellar region, 18 (12.4%) in the pineal region, and 111 (76.6%) in the brainstem. Successful biopsy of the sellar region, pineal region, and brainstem was achieved in 16/16 (100%), 18/18 (100%), and 107/111 (96.4%) patients, respectively. There were no complications following STB of lesion in the sellar or pineal regions. Complications occurred in 17/111 patients (15.3%) during/after brainstem biopsy, three of whom died (2.7%). The main clinical manifestations were facioplegia, facial pain, changes in blood pressure and heart rate, and difficulty breathing.STB of lesions in the sellar region, pineal region, and brainstem had a high success rate, but mortality was 2.7%. The occurrence of complications (15.3%) was closely related to the anatomical and functional characteristics of the region biopsied.

Comparison of endoscopic evacuation, stereotactic aspiration, and craniotomy for treatment of basal ganglia hemorrhage.

BACKGROUND: The main surgical techniques for spontaneous basal ganglia hemorrhage include stereotactic aspiration, endoscopic aspiration, and craniotomy. However, credible evidence is still needed to validate the effect of these techniques. OBJECTIVE: To explore the long-term outcomes of the three surgical techniques in the treatment of spontaneous basal ganglia hemorrhage. METHODS: Five hundred and sixteen patients with spontaneous basal ganglia hemorrhage who received stereotactic aspiration, endoscopic aspiration, or craniotomy were reviewed retrospectively. Six-month mortality and the modified Rankin Scale score were the primary and secondary outcomes, respectively. A multivariate logistic regression model was used to assess the effects of different surgical techniques on patient outcomes. RESULTS: For the entire cohort, the 6-month mortality in the endoscopic aspiration group was significantly lower than that in the stereotactic aspiration group (odds ratio (OR) 4.280, 95% CI 2.186 to 8.380); the 6-month mortality in the endoscopic aspiration group was lower than that in the craniotomy group, but the difference was not significant (OR=1.930, 95% CI 0.835 to 4.465). A further subgroup analysis was stratified by hematoma volume. The mortality in the endoscopic aspiration group was significantly lower than in the stereotactic aspiration group in the medium (≥40-<80 mL) (OR=2.438, 95% CI 1.101 to 5.402) and large hematoma subgroup (≥80 mL) (OR=66.532, 95% CI 6.345 to 697.675). Compared with the endoscopic aspiration group, a trend towards increased mortality was observed in the large hematoma subgroup of the craniotomy group (OR=8.721, 95% CI 0.933 to 81.551). CONCLUSION: Endoscopic aspiration can decrease the 6-month mortality of spontaneous basal ganglia hemorrhage, especially in patients with a hematoma volume ≥40 mL.

Stereotactic aspiration for hypertensive intracerebral haemorrhage in a Chinese population: a retrospective cohort study.

Objective: We aimed to compare the therapeutic effects of stereotactic aspiration and best medical management in patients who developed supratentorial hypertensive intracerebral haemorrhage (HICH) with a volume of haemorrhage between 20 and 40 mL. Methods: The clinical data of 220 patients with supratentorial HICH with a volume between 20 and 40 mL were retrospectively analysed. Among them, 142 received stereotactic aspiration surgery (stereotactic aspiration group) and 78 received best medical management (conservative group). All were followed up for 6 months. Multivariate logistic regression and Kaplan-Meier survival curves were used to compare the outcome between the two groups. Results: The rebleeding rate was lower in the group that had stereotactic aspiration when compared with the group with medical treatment (6 [4.2%] vs 9 [11.5%], χ2=4.364, p=0.037). After 6 months, although the mortality rate did not differ significantly between the two groups (8 cases [5.6%] vs 10 cases [12.8%], χ2=3.461, p=0.063), the rate of a favourable outcome was higher in the group who received stereotactic aspiration (χ2=15.870, p=0.000). Logistic regression identified that medical treatment (OR=1.64, p=0.000) was an independent risk factor for an unfavourable outcome. The Kaplan-Meier curves indicated that the median favourable outcome time in the stereotactic aspiration group was 59.5 days compared with that in the medically treated group (87.0 days). The log-rank test indicated that the prognosis at 6 months was better for those treated with stereotactic haematoma aspiration (χ2=29.866, p=0.000). However, the 6-month survival rate was similar between the two groups (χ2=3.253, p=0.068). Conclusions: Stereotactic haematoma aspiration significantly improved the quality of life, although did not effectively reduce the rate of mortality. When selected appropriately, patients with HICH may benefit from this type of surgical intervention.

Complications Following Stereotactic Needle Biopsy of Intracranial Tumors.

BACKGROUND: Data from single-institution studies suggest that perioperative complication rates after stereotactic needle brain biopsies range from 6% to 12%, with permanent morbidity and mortality ranging from 3.1% to 6.4% and 0% to 1.7%, respectively. However, no population-level data are available. We conducted a population-based analysis to study complications after needle brain biopsy. METHODS: We analyzed patients recorded in the Nationwide Inpatient Sample who underwent stereotactic needle brain biopsy for neoplastic lesions between 2006 and 2012. A multivariate logistic model was used to identify factors associated with complications. RESULTS: We identified 7514 patients who underwent biopsy for various intracranial pathologies, including primary malignant neoplasm (52.3%), unspecified neoplasm (17.9%), metastasis (9.7%), meningioma (1.5%), radiation necrosis (0.8%), lymphoma (0.5%), and pineal region neoplasm (0.3%). Intracranial hemorrhage was the most frequent complication (5.8%). Other complications, including operative infection (0.1%) and wound breakdown (0.2%), were rare. Multivariate logistic regression analysis revealed that hemorrhage is associated with older age (reference <40 years; 40-59 years, odds ratio [OR] 2.26, 95% confidence interval [CI] 1.51-3.38; ≥60 years, OR 1.90, 95% CI 1.22-2.97), hydrocephalus (OR 3.02, 95% CI 2.20-4.14), and cerebral edema (OR 2.16, 95% CI 1.72-2.72). Hemorrhage is less likely when taking a biopsy from a primary malignant neoplasm (OR 0.73, 95% CI 0.59-0.90). Overall inpatient mortality after biopsy was 2.8%. Patients with intracranial hemorrhage were significantly more likely than patients without hemorrhage to die in the hospital (12.8% vs. 2.2%, P < 0.001) or be discharged to a rehabilitation/nursing facility (45.2% vs. 23.1%, P < 0.001). CONCLUSIONS: Intracranial hemorrhage is the most frequent complication associated with needle brain biopsy and is associated with inpatient mortality and hospital disposition. Other complications are rare.

Complications of MRI-guided stereotactic biopsy of brain lymphoma.

OBJECTIVES: Stereotactic biopsy is a suitable method for sampling intrinsic brain lesions. Although this method is considered to be a safe procedure, some risk of complications still exists. The aim of the study was to retrospectively assess the morbidity and mortality of MRI-guided stereotactic biopsy of lesions which were histologically proven to be brain lymphoma. METHODS: We retrospectively studied all accessible medical records for patients who had undergone MRI-guided stereotactic biopsy of brain lesions with histologically proven brain lymphoma from January 2007 to December 2012. Our cohort included 45 patients, 27 males and 18 females, aged 23-84 (63±14) years. RESULTS: Forty-nine biopsies were carried out on 45 patients; the average number of tissue specimens was 3±1. The diagnostic yield of the stereotactic biopsy was 92%. Overall major morbidity directly related to stereotactic biopsy of brain lymphoma was 6.1% (3 cases) including 4.1% mortality (2 cases). Both deaths after the stereotactic procedure were due to intracranial hemorrhage and subsequent complications and both these patients had a history of treatment of systemic lymphomas. In one patient the stereotactic biopsy was complicated by a brain abscess which was successfully treated. CONCLUSION: Stereotactic biopsy is still a mandatory diagnostic procedure for primary brain lymphomas, with an acceptable risk of complications. However, according to our results, the risk of complications can be higher in patients who have previously been treated for secondary lymphomas.

Percutaneous stereotactic radiofrequency ablation of colorectal liver metastases.

OBJECTIVES: To evaluate the outcome of patients with colorectal liver metastasis (CRLM) treated with stereotactic radiofrequency ablation (SRFA). METHODS: Following IRB approval, a retrospective evaluation of 98 SRFA treatment sessions of 189 CRLMs in 63 consecutive patients was performed. Local recurrence rate (LR), overall survival (OS) and disease-free survival (DFS) were analysed. RESULTS: LR was identified in 16% of the tumours (31/189), with no significant differences (P = 0.635) when comparing tumour sizes <3 cm (17.7%), 3-5 cm (11.1%) and >5 cm (17.4%). The median OS from SRFA treatment was 33.2 months after a mean follow-up of 25 months (range 2-66); the corresponding 1-, 3- and 5- year survival rates were 87%, 44% and 27%. The median OS was significantly different when comparing unresectable and resectable patients (27 vs. 58 months, P = 0.002) with OS rates of 92%, 66% and 48% at 1, 3 and 5 years in resectable patients. Tumour size did not affect OS and DFS. CONCLUSION: Due to the favourable outcome, SRFA challenges resection as first-line local treatment of patients with CRLM. As long as randomised studies are pending, we recommend entering an individual decision-making process with every patient. KEY POINTS: Large colorectal liver metastases can be effectively treated by stereotactic radiofrequency ablation (SRFA). Using SRFA the overall survival is not affected by tumour size. SRFA achieves similar overall and disease-free survival rates as surgical resection. SRFA challenges surgical resection as the first-line treatment for colorectal liver metastases.

Are stereotactic sample biopsies still of value in the modern management of pineal region tumours? Lessons from a single-department, retrospective series.

OBJECTIVE: Recent improvements in imaging-based diagnosis, the broader application of neuroendoscopic techniques and advances in open surgery techniques mean that the need for stereotactic biopsies in the management of pineal region tumours must be reevaluated. The primary aim of this retrospective study was to establish whether stereotactic biopsy is still of value in the modern management of pineal region tumours. METHODS: From 1985 to 2009, 88 consecutive patients underwent a stereotactic biopsy in our institution (51 males and 37 females; median age at presentation 30; range 2-74). RESULTS: Accurate tissue diagnoses were obtained in all but one case (i.e. 99%). In one case (1%), three distinct stereotactic procedures were necessary to obtain a tissue diagnosis. There was no mortality or permanent morbidity associated with stereotactic biopsy. One patient (1%) presented an intra-parenchymal hematoma but no related clinical symptoms. Five patients (6%) presented transient morbidity, which lasted for between 2 days and 3 weeks after the biopsy. CONCLUSIONS: To guide subsequent treatment, we believe that histological diagnosis is paramount. Stereotactic biopsies are currently the safest and the most efficient way of obtaining this essential information. Recent improvements in stereotactic technology (particularly robotic techniques) appear to be very valuable, with almost no permanent morbidity or mortality risk and no decrease in the accuracy rate. In our opinion, other available neurosurgical techniques (such as endoscopic neurosurgery, stereotactic neurosurgery and open microsurgery) are complementary and not competitive.

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

BACKGROUND: Previously, 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. METHODS: One 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. RESULTS: Demographics 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. CONCLUSIONS: The 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.

Stereotactic biopsies of brain lesions.

OBJECTIVE: In the majority of cases, the correct treatment of brain lesions is possible only when the histopathological diagnosis is made. Several deep-seated lesions near eloquent areas are not safely approached by the classical neurosurgical procedures. These patients can get benefit by a minimally invasive procedure. METHOD: We present a series of 176 consecutive patients submitted to stereotactic biopsies due to a great variety of brain lesions. RESULTS: Histological diagnosis found in this series: glioma in 40.1% of the patients, other neoplasms in 12.2% and infectious or inflammatory diseases in 29.1 %. The result was inconclusive in 5.2% of the procedures. One patient died (0.6%) and two (1.2%) presented operative complications. The criteria, advantages and risks of the stereotactic biopsies are discussed. CONCLUSION: The efficacy of the method is adequate and morbid-mortality rates were low.

Stereotactic biopsies of brain lesions / Biópsia estereotáxica de lesões encefálicas

OBJECTIVE: In the majority of cases, the correct treatment of brain lesions is possible only when the histopathological diagnosis is made. Several deep-seated lesions near eloquent areas are not safely approached by the classical neurosurgical procedures. These patients can get benefit by a minimally invasive procedure. METHOD: We present a series of 176 consecutive patients submitted to stereotactic biopsies due to a great variety of brain lesions. RESULTS: Histological diagnosis found in this series: glioma in 40.1 percent of the patients, other neoplasms in 12.2 percent and infectious or inflammatory diseases in 29.1 percent. The result was inconclusive in 5.2 percent of the procedures. One patient died (0.6 percent) and two (1.2 percent) presented operative complications. The criteria, advantages and risks of the stereotactic biopsies are discussed. CONCLUSION: The efficacy of the method is adequate and morbid-mortality rates were low.

OBJETIVO: O diagnóstico anatomopatológico das lesões encefálicas é muitas vezes necessário para a instituição do tratamento adequado. Entretanto, muitas lesões localizadas profundamente no encéfalo ou em centros nervosos de grande importância funcional não podem ser acessadas sem riscos, com a aplicação dos procedimentos neurocirúrgicos habituais. MÉTODO: Apresentamos uma série de 176 doentes submetidos a biópsias estereotáxicas de lesões encefálicas. RESULTADOS: Em 40,1 por cento dos casos, o diagnóstico foi de glioma, em 12,2 por cento de outras neoplasias e em 29,1 por cento, de doenças infecciosas ou inflamatórias. O resultado foi inconclusivo em 5,2 por cento dos doentes. Um (0,6 por cento) doente faleceu e dois (1,2 por cento) apresentaram graves complicações operatórias. Os critérios de seleção, as vantagens e os riscos da biópsia estereotáxica são discutidos. CONCLUSÃO: A eficácia do método é boa e a morbimortalidade das biópsias estereotáxicas é baixa.

[Stereotactic brain biopsy in the diagnosis of focal brain lesions in AIDS]. / La biopsia estereotáctica en el diagnóstico de las lesiones cerebrales focales en sida.

Focal brain lesions are frequent complications among HIV/AIDS patients. Between January 1999 and May 2007, 83 procedures of stereotactic brain biopsies in HIV/AIDS patients with focal cerebral lesions were carried out. The inclusion criteria were lack of response to current diagnostic and therapeutic guidelines for brain lesions. All the samples underwent microscopic evaluation during surgery to assert valid material and delayed histopathological and microbiological examination. Forty one patient images demonstrated multiple brain lesions. Sixty two cases had supratentorial localization, 4 lesions were located beneath the tentorium and 17 showed both settings. Fifty one lesions presented peripheral enhancement after contrast computed tomography (CT) or magnetic resonance imaging (MRI). A 100% of useful samples recovery was achieved. Progressive multifocal leucoencephalopathy (PML) was the most frequent diagnosis (29%), followed by primary central nervous system lymphoma (PCNSL) (23%), and toxoplasmosis (15.7%). Statistically significant association was observed between histopathological diagnosis and lesion location and between those and peripheral ring enhancement images. The positive diagnostic rate of the invasive procedure was 90.3%. The morbidity/mortality rate was 2.4% in this series. In conclusion, the stereotactic brain biopsy ordered early during the patient's evolution showed a good performance in order to achieve a prompt and accurate diagnosis and to guide the therapeutic scheme in these AIDS patients with focal brain lesions.

La biopsia estereotáctica en el diagnóstico de las lesiones cerebrales focales en sida / Stereotactic brain biopsy in the diagnosis of focal brain lesions in AIDS

Las lesiones cerebrales focales constituyen una complicación frecuente en los pacientes con infección por el virus de la inmunodeficiencia humana (HIV) y síndrome de inmunodeficiencia adquirida (sida). Durante el período comprendido entre enero de 1999 y mayo de 2007 se realizaron un total de 83 biopsias en pacientes con sida y lesiones cerebrales. Se incluyeron aquellos pacientes que no hubiesen respondido al algoritmo habitual de enfoque diagnóstico-terapéutico de estas lesiones. Todas las muestras obtenidas fueron sometidas a evaluación intraoperatoria para asegurar la obtención de material patológico y posterior análisis histopatológico y exámenes microbiológicos. De los 41 pacientes con lesiones cerebrales múltiples, 62 tenían localización supratentorial, en 4 eran infratentoriales y 17 mostraron ambas localizaciones. Cincuenta y un lesiones seleccionadas como blanco estereotáctico tuvieron refuerzo periférico del contraste. Se obtuvo material histopatológico en el 100% de los procedimientos. El diagnóstico más frecuente fue el de leucoencefalopatía multifocal progresiva (LEMP) con 24 casos (29%), seguido del linfoma primario del sistema nervioso central (LPSNC) con 19 diagnósticos (23%) y de toxoplasmosis en 13 pacientes (15.7%). Se comprobó una relación significativa entre los diagnósticos histopatológicos y la localización de las lesiones y entre los diagnósticos histopatológicos y el comportamiento de las imágenes luego de la administración de la sustancia de contraste. El rédito diagnóstico alcanzó el 90.3% (75 biopsias). La morbiletalidad en esta serie fue de 2.4%. La biopsia cerebral estereotáctica permitió alcanzar el diagnóstico etiológico y adecuar el enfoque terapéutico en la mayoría de los pacientes de esta serie.

Focal brain lesions are frequent complications among HIV/AIDS patients. Between January 1999 and May 2007, 83 procedures of stereotactic brain biopsies in HIV/AIDS patients with focal cerebral lesions were carried out. The inclusion criteria were lack of response to current diagnostic and therapeutic guidelines for brain lesions. All the samples underwent microscopic evaluation during surgery to assert valid material and delayed histopathological and microbiological examination. Forty one patient images demonstrated multiple brain lesions. Sixty two cases had supratentorial localization, 4 lesions were located beneath the tentorium and 17 showed both settings. Fifty one lesions presented peripheral enhancement after contrast computed tomography (CT) or magnetic resonance imaging (MRI). A 100% of useful samples recovery was achieved. Progressive multifocal leucoencephalopathy (PML) was the most frequent diagnosis (29%), followed by primary central nervous system lymphoma (PCNSL) (23%), and toxoplasmosis (15.7%). Statistically significant association was observed between histopathological diagnosis and lesion location and between those and peripheral ring enhancement images. The positive diagnostic rate of the invasive procedure was 90.3%. The morbidity/mortality rate was 2.4% in this series. In conclusion, the stereotactic brain biopsy ordered early during the patient’s evolution showed a good performance in order to achieve a prompt and accurate diagnosis and to guide the therapeutic scheme in these AIDS patients with focal brain lesions.

Establishing a benchmark for complications using frame-based stereotactic surgery.

We sought to establish a benchmark for complications using frame-based stereotactic surgery for both deep and lobar brain surgery. During a 28-year interval, we performed frame-based stereotactic surgery in 2,651 patients. Our database was retrospectively used to assess the risks of complications after frame-based stereotactic surgery. Routine immediate intraoperative imaging detected new blood products after diagnostic biopsy in 43 cases (2.6%); only 6 patients (0.36%) required craniotomy for hematoma evacuation. Perioperative seizures occurred in 6 patients (0.36%), and 2 patients developed burr hole site infections. One patient (1%) developed an intra-abscess hemorrhage after biopsy and catheter drainage. Two deaths (0.08%) related to surgery occurred. Some centers are currently migrating to frameless, even pinless, neuronavigation-guided needle procedures for both lobar and deep brain targets. Although experimental accuracy under optimal conditions is reported to be similar to that of frame-based systems, the complication rates from a significant number of cases have yet to be reported. This report establishes the safety profile of frame-based stereotactic surgery based on a 28-year period. These results may serve as a benchmark against which free-hand or guided neuronavigation approaches may be measured, as both the advantages and risks of such procedures are assessed.

Complications in 622 cases of frame-based stereotactic biopsy, a decreasing procedure.

BACKGROUND: Frame-based stereotactic brain biopsy has played an important role in the management of patients with suspected neoplastic intracranial lesions over the last three decades. We reviewed the surgical experience of one surgeon to determine the nature and frequency of complications associated with this procedure. METHODS: Records were reviewed for 858 patients undergoing frame-based stereotactic procedures from January 1986 to May 2006. Data on each case were prospectively collected by the senior author. Procedures for Ommaya reservoir placement, brachytherapy, stereotactic craniotomy flap localization, shunt placement, or treatment of previously-diagnosed intracranial cystic lesions were excluded, leaving 614 patients in whom a total of 622 procedures were performed for purely diagnostic purposes. Complication rates and their association with clinical variables were sought. RESULTS: Morbidity and mortality rates were 6.9% (43/622) and 1.3% (8/622), respectively. The risk of symptomatic hemorrhage (intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], intraventricular hemorrhage [IVH]) was 4.8%. The risks of transient or permanent neurological deficits were 2.9% (18/622) and 1.5% (9/622), respectively. Biopsy of deep-seated lesions was associated with increased overall complication rate, while biopsy of Glioblastoma Multiforme (GBM) was associated with perioperative mortality. CONCLUSIONS: Overall, complication rates were comparable with those in previous reports. The subgroup of patients with deep-seated lesions or a histologic diagnosis of GBM may possess an elevated risk of overall complications or mortality, respectively, compared to other patients undergoing frame-based stereotactic brain biopsy.

Haemorrhagic complications and the incidence of asymptomatic bleeding associated with stereotactic brain biopsies.

OBJECT: Stereotactic brain biopsy is a routinely used technique for the diagnosis of brain lesions. Due to its minimally invasive nature, the potential risks associated with this procedure are sometimes underestimated. We have retrospectively analyzed the incidence of symptomatic and asymptomatic haemorrhagic complications associated with stereotactic biopsies. Various variables that may contribute to such complications have been retrospectively analyzed. METHODS: Medical and radiological records of 355 consecutive patients who underwent a diagnostic stereotactic brain biopsy were reviewed. The incidence of haemorrhage was derived from a routine post-operative CT scan done within 90-120 minutes of the biopsy. Demographic, radiographic, pathological, and clinical data were also extracted and evaluated for their possible association with haemorrhagic complications. RESULTS: Twenty-five patients (7%) experienced haemorrhagic complications associated with stereotactic biopsy, about half of whom (3.4%) were asymptomatic with no impact on the clinical course. Thirteen (3.6%) complications were symptomatic and two patients (0.6%) died. Lesions located in the brainstem were found to have a significantly higher rate of complications compared to other locations. No other variables, such as location, edema, number of biopsy specimens, or pre-existing neurological deficit showed a statistically significant impact on the incidence or severity of haemorrhage. Seven of the symptomatic complications occurred immediately post biopsy, but in six patients they developed within several hours and even days. The overall diagnostic yield of the biopsies was 93.8%, but was somewhat lower in patients experiencing a haemorrhagic complication. CONCLUSIONS: Stereotactic brain biopsy was associated with a low incidence of symptomatic haemorrhagic complications, morbidity and mortality, and a high diagnostic yield. About half of the haemorrhagic complications were asymptomatic. Lesions located in the brainstem had a higher rate of complications. No other clinical, radiographic, or pathological variables were found as predictors of increased risk for haemorrhage.

Morbidity and mortality following pallidotomy in Parkinson's disease: a systematic review.

OBJECTIVE: To study the frequency of morbidity and mortality associated with pallidotomy. METHOD: The authors searched the MEDLINE electronic database for pallidotomy articles reported between January 1992 and December 2000. They selected studies by the following criteria: original clinical data, unequivocal description of morbidity and mortality, and unselected consecutive cases. The authors extracted the following data: number of patients, unilateral or bilateral procedures, age, localization technique, follow-up time, number of patients with adverse effects, number of patients with permanent adverse effects (>3 months), types of adverse effects, and mortality. RESULTS: For unilateral pallidotomy, 12 prospective studies included 334 patients. Of these patients, 30.2% (95% CI, 25.3 to 35.2) had adverse effects, and 13.8% (95% CI, 10.1 to 17.5) had permanent adverse effects. A symptomatic infarction or hemorrhage occurred in 3.9% (95% CI, 2.1 to 6.6). The mortality rate was 1.2% (95% CI, 0.3 to 3.0). In the series with microelectrode recording, the frequency of adverse effects was 14.4% (95% CI, 4.7 to 24.1) higher and the frequency of stroke was 4.9% (95% CI, 1.4 to 8.4) higher. The most frequent adverse effects were problems with speech (11.1%) and facial paresis (8.4%). For bilateral pallidotomy, five historical cohort studies including 20 patients were available for review. Fourteen patients had an adverse effect, and the most frequent adverse effects were impairments of speech and cognition. CONCLUSIONS: The risk of permanent adverse effects associated with unilateral pallidotomy was 13.8%. A symptomatic infarction or hemorrhage occurred in 3.9% of patients, and the associated mortality rate was 1.2%.

Frameless stereotaxy with scalp-applied fiducial markers for brain biopsy procedures: experience in 218 cases.

OBJECT: The goal of this study was to develop and assess the use and limitations of performing brain biopsy procedures by using image-guided surgical navigation systems (SNSs; that is, frameless stereotactic systems) with scalp-applied fiducial markers. METHODS: Two hundred eighteen percutaneous brain biopsies were performed in 213 patients by using a frameless stereotactic SNS that operated with either sonic or optical digitizer technology and scalp-applied fiducial markers for the purpose of registering image space with operating room space. Common neurosurgical and stereotactic instrumentation was adapted for use with a localizing wand, and recently developed target and trajectory guidance software was used. Eight (3.7%) of the 218 biopsy specimens were nondiagnostic; five of these (2.4%) were obtained during procedures in 208 supratentorial lesions and three were obtained during procedures in 10 infratentorial lesions (30%; p < 0.001). Complications related to the biopsy procedure occurred in eight patients (seven of whom had supratentorial lesions and one of whom had an infratentorial lesion, p > 0.25). Five complications were intracerebral hemorrhages (two of which required craniotomy), two were infections, and one was wound breakdown after instillation of intratumoral carmustine following biopsy. There were only three cases of sustained morbidity, and there were two deaths and one delayed deterioration due to disease progression. Two surgeons performed the majority of the procedures (193 cases). The three surgeons who performed more than 10 biopsies had complication rates lower than 5%, whereas two of the remaining four surgeons had complication rates greater than 10% (p = 0.15). Twenty-three additional procedures were performed in conjunction with the biopsies: nine brachytherapies; five computer-assisted endoscopies; four cyst aspirations; two instillations of carmustine; two placements of Ommaya reservoirs; and one craniotomy. CONCLUSIONS: Brain biopsy procedures in which guidance is provided by a frameless stereotactic SNS with scalp-applied fiducial markers represents a safe and effective alternative to frame-based stereotactic procedures for supratentorial lesions. There were comparable low rates of morbidity and a high degree of diagnostic success. Strategies for performing posterior fossa biopsies are suggested.

Diffuse brain stem glioma. A review of stereotactic biopsies.

The diagnosis and management of diffuse brain stem gliomas (DBSGs) remain a challenging problem for the neurosurgeon and neuro-oncologist. Opposing views on the necessity for biopsy have emerged over the last decade. Open biopsy, with its prohibitive morbidity and mortality, has been replaced by stereotactically guided biopsy, with markedly reduced risk. This has been paralleled by improvements in imaging techniques and diagnostic accuracy, which has created reluctance to endorse diagnostic biopsies coupled with the potential of nonrepresentative samples from a heterogeneous tumour mass. For typical DBSGs biopsy is now accepted as unnecessary. We performed a retrospective analysis of radiologically and histologically proven DBSGs in 18 children to assess both morbidity and reliability of our stereotactically guided biopsy procedure.