Efficacy and Safety of Local Versus General Anesthesia in Stereotactic Biopsies: A Matched-pairs Cohort Study

High intratumoral susceptibility signal grade on susceptibility-weighted imaging: a risk factor for hemorrhage after stereotactic biopsy

OBJECTIVE

This study aimed to examine the association of preoperative intratumoral susceptibility signal (ITSS) grade with hemorrhage after stereotactic biopsy (STB).

METHODS

The authors retrospectively reviewed 66 patients who underwent STB in their institution. Preoperative factors including age, sex, platelet count, prothrombin time-international normalized ratio, activated thromboplastin time, antiplatelet agent use, history of diabetes mellitus and hypertension, target location, anesthesia type, and ITSS data were recorded. ITSS was defined as a dot-like or fine linear low signal within a tumor on susceptibility-weighted imaging (SWI) and was graded using a 3-point scale: grade 1, no ITSS within the lesion; grade 2, 1-10 ITSSs; and grade 3, ≥ 11 ITSSs. Postoperative final tumor pathology was also reviewed. The association between preoperative variables and the size of postoperative hemorrhage was examined.

RESULTS

Thirty-four patients were men and 32 were women. The mean age was 66.6 years. The most common tumor location was the frontal lobe (27.3%, n = 18). The diagnostic yield of STB was 93.9%. The most common pathology was lymphoma (36.4%, n = 24). The ITSS was grade 1 in 37 patients (56.1%), grade 2 in 14 patients (21.2%), and grade 3 in 15 patients (22.7%). Interobserver agreement for ITSS was almost perfect (weighted kappa = 0.87; 95% CI 0.77-0.98). Age was significantly associated with ITSS (p = 0.0075). Postoperative hemorrhage occurred in 17 patients (25.8%). Maximum hemorrhage diameter (mean ± SD) was 1.78 ± 1.35 mm in grade 1 lesions, 2.98 ± 2.2 mm in grade 2 lesions, and 9.51 ± 2.11 mm in grade 3 lesions (p = 0.01). Hemorrhage > 10 mm in diameter occurred in 10 patients (15.2%), being symptomatic in 3 of them. Four of 6 patients with grade 3 ITSS glioblastomas (66.7%) had postoperative hemorrhages > 10 mm in diameter. After adjusting for age, ITSS grade was the only factor significantly associated with hemorrhage > 10 mm (p = 0.029). Compared with patients with grade 1 ITSS, the odds of postoperative hemorrhage > 10 mm in diameter were 2.57 times higher in patients with grade 2 ITSS (95% CI 0.31-21.1) and 9.73 times higher in patients with grade 3 ITSS (95% CI 1.57-60.5).

CONCLUSIONS

ITSS grade on SWI is associated with size of postoperative hemorrhage after STB.

Pushing the boundaries of accuracy and reliability during stereotactic procedures: A prospective study on 526 biopsies comparing the frameless robotic and Image-Guided Surgery systems

INTRODUCTION

A 12-year long, prospective, single center study was conducted, comparing two frameless systems for brain biopsies: ROSA robotic-assisted stereotaxy and BrainLab Varioguide image-guided stereotaxy (Image Guided Surgery, IGS).

METHOD

All consecutive adult and pediatric patients undergoing frameless brain biopsies were included. Successfully achieving diagnosis was the primary endpoint, analysis of all periprocedural complications was the secondary endpoint, and the tertiary endpoint was the length of the procedure, with the aim of assessing of the learning curve for each operator over time. The results for the ROSA robot and the Varioguide system were compared and benchmarked to data from the literature.

RESULTS

We performed 526 on 516 patients, 314 with the ROSA robot (Group A) and 212 with the IGS Varioguide (Group B). Histological diagnosis was achieved in 97.4% of cases in Group A, versus 93.3% in Group B (p < 0.05). No statistically significant difference was found for secondary and tertiary endpoints. The complication rate appeared similar between the 2 frameless systems, with a hemorrhagic complications rate of 3.5% in Group A and 4.7% in Group B. Permanent neurological deterioration was only recorded in 0.8% of cases from Group B. Mortality was recorded in 0.3% in Group A and 0.4% in Group B.

CONCLUSION

This study provides evidence to confirm that robotic surgery lives up to its promises of increased safety, accuracy, and reliability.

Related factors with diagnostic yield and intracranial hemorrhagic complications in frame-based stereotactic biopsy. Review

The frame-based stereotactic biopsy is a minimally invasive technique that allows us to obtain a sample of brain tissue for subsequent diagnosis and treatment. The scope of this article is to review the published data related to the factors that could condition its diagnostic yield, and the appearance of post-biopsy hemorrhagic complications. PubMed search, last updated June 2020, was conducted using the terms "stereotactic biopsy", "diagnostic yield" and "intracranial post-biopsy hemorrhage". A total of 38 studies, that showed descriptive or analytical results, were included, and reviewed. Our literature review show that some characteristics of the lesion and surgical procedure peculiarities are significantly related with the effectiveness and safety of the technique. In this way, they must be taken into account in order to optimize its results.

Severity, timeline, and management of complications after stereotactic brain biopsy

OBJECTIVE

The literature shows discrepancies in stereotactic brain biopsy complication rates, severities, and outcomes. Little is known about the timeline of postbiopsy complications. This study aimed to analyze 1) complications following brain biopsies, using a graded severity scale, and 2) a timeline of complication occurrence. The secondary objectives were to determine factors associated with an increased risk of complications and to assess complication-related management and extra costs.

METHODS

The authors retrospectively examined 1500 consecutive stereotactic brain biopsies performed in adult patients at their tertiary medical center between April 2009 and April 2019.

RESULTS

Three hundred eighty-one biopsies (25.4%) were followed by a complication, including 88.2% of asymptomatic hemorrhages. Symptomatic complications involved 3.0% of the biopsies, and 0.8% of the biopsies were fatal. The severity grading scale had a 97.6% interobserver reproducibility. Twenty-three (51.1%) of the 45 symptomatic complications occurred within the 1st hour following the biopsy, while 75.6% occurred within the first 6 hours. Age ≥ 65 years, second biopsy procedures, gadolinium-enhanced lesions, glioblastomas, and lymphomas were predictors of biopsy-related complications. Brainstem biopsy-targeted lesions and cerebral toxoplasmosis were predictive of mortality. Asymptomatic hemorrhage was associated with delayed (> 6 hours) symptomatic complications. Symptomatic complications led to extended hospitalization in 86.7% of patients. The average extra cost for management of a patient with postbiopsy symptomatic complication was $35,702.

CONCLUSIONS

Symptomatic complications from brain biopsies are infrequent but associated with substantial adverse effects and cost implications for the healthcare system. The use of a severity grading scale, as the authors propose in this article, helps to classify complications according to the therapeutic consequences and the patient's outcome. Because this study indicates that most complications occur within the first few hours following the biopsy, postbiopsy monitoring can be tailored accordingly. The authors therefore recommend systematic monitoring for 2 hours in the recovery unit and a CT scan 2 hours after the end of the biopsy procedure. In addition, they propose a modern algorithm for optimal postoperative management of patients undergoing stereotactic biopsy.

Related factors with diagnostic yield and intracranial hemorrhagic complications in frame-based stereotactic biopsy. Review

The frame-based stereotactic biopsy is a minimally invasive technique that allows us to obtain a sample of brain tissue for subsequent diagnosis and treatment. The scope of this article is to review the published data related to the factors that could condition its diagnostic yield, and the appearance of post-biopsy hemorrhagic complications. PubMed search, last updated June 2020, was conducted using the terms "stereotactic biopsy", "diagnostic yield" and "intracranial post-biopsy hemorrhage". A total of 38 studies, that showed descriptive or analytical results, were included, and reviewed. Our literature review show that some characteristics of the lesion and surgical procedure peculiarities are significantly related with the effectiveness and safety of the technique. In this way, they must be taken into account in order to optimize its results.

Neurological diseases of unknown etiology: Brain-biopsy diagnostic yields and safety

BACKGROUND

For nonneoplastic neurological diseases, no recommendation exists regarding the place or appropriate timing of brain biopsy. The aim of this study was to evaluate the diagnostic yield and safety of brain biopsies from patients with neurological diseases of unknown etiology.

METHODS

We performed a retrospective cohort study from January 1, 2008 to December 31, 2018. We analyzed 1847 brain-biopsied patients, including 178 biopsies indicated for neurological diseases of unknown etiology. Specific histological and final diagnosis rates, positive diagnosis-associated factors, complication rate and complication-associated factors were assessed.

RESULTS

Specific histological diagnosis and final diagnosis rates were 71.3% and 83.1%, respectively, leading to therapeutic management change(s) for 75.3% of patients. Brain- biopsy-related mortality and permanent neurological morbidity occurred in 1.1% and 0.6% of the patients, respectively. The multivariable logistic-regression model retained (odds ratio [95% CI] only immunodepression (2.2 [1.1-4.7]; P=.04) as being independently associated with specific histological diagnosis, while supratentorial biopsy-targeted lesions (4.1 [1.1-15.2]; P=.04) were independently associated with a final diagnosis. Biopsies obtained from comatose patients were less contributive to the diagnosis (0.2 [0.05-0.7]; P=.01). Prebiopsy platelet count <100 G/L (28.5 [1.8-447]; P=.02), hydrocephalus (6.3 [1.2-15.3]; P=.02) and targeted lesions <1 cm (4.3 [1.2-15.3]; P=.03) were independently associated with brain biopsy-related complications.

CONCLUSION

For highly selected patients with neurological diseases of unknown etiology, brain biopsy has a high diagnostic yield and low frequency of severe complications. We advocate that this procedure be considered early in the diagnosis algorithm of these patients.

Symptomatic intracranial hemorrhages and frame-based stereotactic brain biopsy

BACKGROUND

Stereotactic biopsy is a well-established procedure in neurosurgery. Our objective is to define the clinical, radiological, and technical factors that can condition the emergence of postbiopsy symptomatic intracranial hemorrhage. Based on our findings, we suggest recommendations to improve its usual clinical practice.

METHODS

We made a retrospective study of 429 cases with stereotactic biopsies performed in the past 37 years. The surgical procedure-was adapted in terms of the stereotactic frames (Todd-Wells, CRW, Leksell), neuroimaging tests, and planning programs available in the hospital. Fifty-three variables were analyzed for each patient (SPSS.23).

RESULTS

The diagnostic yield was 90.7%. Forty-one patients (9.5%) suffered a symptomatic postbiopsy hemorrhage; only 17 (3.9%) had permanent morbidity. The mortality was 0.93% (n = 4). A postsurgical CT scan was requested only in 99 patients (23%) of our series. Lesion mass effect, cystic component, contrast enhancement, histological nature, or number of targets were not associated with a greater risk of symptomatic postbiopsy hemorrhage (P > 0.05). On the other hand, the biopsies made by nonexpert neurosurgeons (P = 0.01) or under general anesthesia (P = 0.02) resulted in a greater risk of symptomatic postbiopsy hemorrhage. Anesthetic type was the clearest predictive factor of bleeding with this technique (OR: 0.24).

CONCLUSION

Stereotactic biopsy is a very valuable tool. To optimize its safety and minimize the risk of intracranial bleeding, it requires both a knowledge of stereotactic techniques and very careful surgical planning. While the patient's stay in intensive vigilance units after the procedure is a useful strategy, the request for control CT scans should be conditioned by the clinical evolution of each patient.

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.

WITHDRAWN: Frame-Based Stereotactic Brain Biopsy and Symptomatic Intracranial Hemorrhages: Associated Factors in a Series of 407 Patients

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Assessment of molecular markers demonstrates concordance between samples acquired via stereotactic biopsy and open craniotomy in both anaplastic astrocytomas and glioblastomas

The classification, treatment and prognosis of high-grade gliomas has been shown to correlate with the expression of molecular markers (e.g. MGMT promotor methylation and IDH1 mutations). Acquisition of tumor samples may be obtained via stereotactic biopsy or open craniotomy. Between the years 2009 and 2013, 22 patients initially diagnosed with HGGs via stereotactic biopsy, that ultimately underwent open craniotomy for resection of their tumor were prospectively included in an institutional glioma database. MGMT promotor analysis was performed using methylation-specific (MS)-PCR and IDH1R132H mutation analysis was performed using immunohistochemistry. Three patients (13.7%) exhibited IDH1R132H mutations in samples obtained via stereotactic biopsy. Tissue derived from stereotaxic biopsy was demonstrated to have MGMT promotor methylation in ten patients (45.5%), while a non-methylated MGMT promotor was demonstrated in ten patients (45.5%); inconclusive results were obtained for the remaining two patients (9%) within our cohort. The initial histologic grading, IDH1R132H mutation and MGMT promotor methylation results were confirmed using samples obtained during open craniotomy in all but one patient; here inconclusive MGMT promotor analysis was obtained in contrast to that which was obtained via stereotactic biopsy. Tumor samples acquired via stereotactic biopsy provide accurate information with regard to clinically relevant molecular markers that have been shown to impact patient care decisions. The profile of markers analyzed in our cohort was nearly concordant between those samples obtained via stereotactic biopsy or open craniotomy thereby suggesting that clinical decisions may be based on the molecular profile of the tumor samples obtained via stereotactic biopsy.

Benefit and Complications of Frame-Based Stereotactic Biopsy in Old and Very Old Patients

OBJECTIVE

Stereotactic biopsy is an everyday procedure implemented in numerous neurosurgical departments. The procedure is performed to obtain tumor tissue of unclear diagnosis. Going in hand with low complication rates and high diagnostic yield, stereotactic biopsies can be performed in adults and children likewise for histopathologic evaluation of lesions in eloquent localizations. However, little is known about whether aged patients do benefit from stereotactic biopsy or rather the therapy that is derived from histopathologic results. In this study, we therefore focused on old (80-84 years) and very old patients (85 years and older) to evaluate whether stereotactic biopsy should be performed leading to further therapy. We also assessed the complication rates of the procedure in this aged population.

METHODS

We performed a retrospective analysis of our database and included all patients older than 80 years who underwent stereotactic biopsy at our department from October 2005 until May 2016. Forty-seven patients were included in this study. These patients were divided into 2 subgroups: group 1 consisted of patients from 80 to 84 years old and group 2 of patients aged 85 years and older. All patients underwent stereotactic biopsy to establish histopathologic diagnosis. We excluded patients who underwent cyst puncture or puncture of a hemorrhage because the procedure was not performed for diagnostic purposes. We assessed gender, neuroradiologic diagnosis, Karnofsky Performance Score (KPS), number of tissue samples taken, histopathologic diagnosis, localization, postoperative hemorrhage, modality of anesthesia anticoagulation, and further therapy.

RESULTS

Group 1 consisted of 34 patients and group 2 of 13 patients. KPS was 80 and 70, respectively. A histopathologic diagnosis was possible in all but 1 patient. In group 1, 61.8% of the patients agreed to further postoperative therapy (radiation, 35.3%; chemotherapy, 11.8%; combined radiochemotherapy, 11.8%; complication that prevented therapy, 2.9%), as did 53.8% of the patients in group 2 (resection, 7.7%; radiation, 15.4%; combined radiochemotherapy, 30.7%). In group 1, 38.2% declined further therapy, as did 64.1% in group 2.

CONCLUSIONS

Also in old and very old patients, a final histopathologic diagnosis should be established to provide adequate therapy. Our data show that most of these aged patients want to be treated.

The Utility of Peripheral Nerve Blocks in Interventional Radiology

OBJECTIVE

The aim of this article is to provide an overview of peripheral nerve blocks, the use of peripheral nerve block within and outside interventional radiology, and the complications of peripheral nerve block.

CONCLUSION

Interventional radiologists are often responsible for sedation and pain management in the majority of interventional radiology procedures. Peripheral nerve block is increasingly being used in interventional radiology.

Stereotactic biopsy of brainstem lesions: 21 years experiences of a single center

Stereotactic biopsies are procedures performed to obtain tumor tissue for diagnostic examinations. Cerebral lesions of unknown entities can safely be accessed and tissue can be examined, resulting in correct diagnosis and according treatment. Stereotactic procedures of lesions in highly eloquent regions such as the brainstem have been performed for more than two decades in our department. In this retrospective study we focus on results, approaches, modalities of anesthesia, and complications. We performed a retrospective analysis of our prospective database, including 26 patients who underwent stereotactic biopsy of the brainstem between April 1994 and June 2015. All of the patients underwent preoperative MRI. Riechert-Mundinger-frame was used before 2000, thereafter the Leksell stereotactic frame was used. After 2000 entry and target points were calculated by using BrainLab stereotactic system. We evaluated histopathological results as well as further treatment; additionally we compared complications of local versus general anesthesia and complications of a frontal versus a trans-cerebellar approach. Median age of all patients was 33 years, and median number of tissue samples taken was 12. In all patients a final histopathological diagnosis could be established. 5 patients underwent the procedure under local anesthesia, 21 patients in general anesthesia. In 19 patients a frontal approach was performed, while in 7 patients a trans-cerebellar approach was used. Complications occurred in five patients. Thereby no significant difference was found with regard to approach (frontal versus trans-cerebellar) or anesthesia (local versus general). Stereotactic biopsies even of lesions in the brainstem are a save way to obtain tumor tissue for final diagnosis, resulting in adequate treatment. Approach can be trans-cerebellar or frontal and procedure can be performed either under local or general anesthesia without significant differences concerning complication rate.

Neuroanesthesiology update

We review topics pertinent to the perioperative care of patients with neurological disorders. Our review addresses topics not only in the anesthesiology literature, but also in basic neurosciences, critical care medicine, neurology, neurosurgery, radiology, and internal medicine literature. We include literature published or available online up through December 8, 2013. As our review is not able to include all manuscripts, we focus on recurring themes and unique and pivotal investigations. We address the broad topics of general neuroanesthesia, stroke, traumatic brain injury, anesthetic neurotoxicity, neuroprotection, pharmacology, physiology, and nervous system monitoring.