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.

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 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.

[Stereotactic brain biopsy in the diagnosis of focal brain lesions in AIDS]

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.

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.

[Image guided stereotactic approach of central nervous system lesions: accuracy, morbidity, mortality]

We studied seventy-five patients with brain lesions biopsied by stereotaxis from March 1993 to December 1998 at Universidade Federal de São Paulo-Escola Paulista de Medicina. The three most frequent lesions were: metastasis, low grade astrocytomas and glioblastoma multiforme. The morbidity rate was 2.66% due to: one case of scalp infection in a patient with thalamic cyst; and a partial seizure during surgery in a patient with lymphoma. The mortality rate was 1.33% due to increasing of cerebral edema after biopsy and the patient died after one week. The diagnostic accuracy was 89.33%.

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.

Endoscopic stereotaxy--an eight year's experience

During the 10th meeting of the WSSFN in Maebashi in 1989, we discussed 'endoscopic stereotaxy', and presented our preliminary results. This technique was first designed to optimize stereotactic biopsy, but it proved to be effective for other neurosurgical indications as well, including endoscopic stereotactic evacuation of intraparenchymal and intraventricular space-occupying cysts, endoscopic stereotactic cystoventriculostomy, third ventriculostomy, evacuation of brain abscess and intracerebral hematoma, and retrieval of adherent or free-floating ventricular catheters. Our results with endoscopic stereotaxy in different indications are encouraging, compared to conventional microsurgical techniques and pure stereotactic techniques. From 1989 to 1997 we have performed more than 400 stereotactic endoscopic procedures. The mortality rate is below 1%, the operative morbidity is below 3%.

[The stereotaxic biopsy of tumors in the pineal area]

The outcomes of stereotactic biopsy (STB) of pineal tumors are presented. This diagnostic approach was applied in 51 patients aged 7 to 59 years (mean 23 years) and its main indication is to develop an adequate treatment policy by specifying the histological structure of a tumor. Informative morphological samples were taken in 42 (82%) cases. One patient died, another developed a persistent neurological defect after STB. A third of all cases was diagnosed as having germinomas and other 5 patients were found to have germinative cellular tumors of mixed structure, which reflects the views on the policy of examination and treatment of patients with pineal tumors and indications for the biopsy, which have been established at the N. N. Burdenko Institute of Neurosurgery, Russian Academy of Medical Sciences. In 14 cases, STB diagnosis was verified from 1 to 46 weeks of postbioptic surgery connected with tumor removal or autopsy. There was 100% coincidence in histological diagnosis. Indications for STB in patients with pineal tumors, the significance of its findings, methodological and technical aspects, as well as the clinical value of this diagnostic procedure are dealt with in the paper.

Stereotactic procedures for lesions of the pineal region

During the 7-year period between June 1985 and May 1992, 34 patients with pineal lesions underwent 66 stereotactic procedures (37 biopsies, 19 third ventriculostomies, 6 cyst aspirations, 3 instillations of 32P into cysts, and 1 insertion of an Ommaya reservoir into a cyst) at the Mayo Clinic. Nine patients subsequently also underwent 10 open resections of lesions of the pineal region. In the 34 study patients, the pathologic entities were 9 gliomas (5 astrocytomas, 2 ependymomas, and 2 oligodendrogliomas), 9 germ cell tumors (7 germinomas, 1 entodermal sinus tumor, and 1 malignant teratoma), 8 pineal parenchymal tumors (3 pinealomas, 3 pinealoblastomas, 1 mixed pinealoma-pinealoblastoma, and 1 intermediate differentiation pineal tumor), 4 other malignant tumors (2 undifferentiated carcinomas, 1 malignant melanoma, and 1 non-Hodgkin's lymphoma), 2 meningiomas, and 2 nonneoplastic lesions (1 glial cyst and 1 inflammatory lesion). No mortality or permanent morbidity was associated with the 66 stereotactic procedures; 2 patients had temporary complications--1 neurologic (transient diplopia) and 1 nonneurologic (pulmonary embolism). Diagnostic tissue was obtained in 33 of the 34 patients. An algorithm for the diagnosis and management of patients with lesions of the pineal region is presented. We conclude that stereotactic biopsy of pineal lesions can be performed safely, has a high diagnostic yield, and facilitates rational planning of treatment.

Treatment of craniopharyngiomas--the stereotactic approach in a ten to twenty-three years' perspective. I. Surgical, radiological and ophthalmological aspects

A multi-modality treatment programme, where stereotactic methods were used preferentially, gave results in a consecutive series of craniopharyngiomas, not inferior to those reported after microsurgical removal. Fourty-two patients with a follow-up range of 10-23 years are reported.

Volumetric stereotactic surgical resection of intra-axial brain mass lesions

From August 1984 to August 1987 at the Mayo Clinic, 226 computer-assisted stereotactic resections based on computed tomography or magnetic resonance imaging (or both) were performed on 203 supratentorial and 23 infratentorial lesions in various deep-seated or essential brain locations. Histologic examination revealed 112 glial neoplasms, 70 nonglial tumors, and 44 nonneoplastic lesions. The overall morbidity was 9.3% (21 of 226 patients were worse after the procedure), and the 30-day operative mortality was 1% (2 patients). The procedure provides maximal cytoreduction in high-grade glial neoplasms but is most beneficial to patients who have histologically circumscribed tumors, such as pilocytic astrocytomas, metastatic neoplasms, and miscellaneous nonglial and nonneoplastic lesions.