Image-guided frameless stereotactic needle biopsy in awake patients without the use of rigid head fixation

Comparative Analysis of Efficacy and Safety of Frame-Based, Frameless, and Robot-Assisted Stereotactic Brain Biopsies: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

For 50 years, frame-based stereotactic brain biopsy has been the "gold standard" for its high diagnostic yield and safety, especially for complex or deep-seated lesions. Over the past decade, frameless and robotic alternatives have emerged. This report evaluates and compares the outcomes, diagnostic yield, and safety of these methods.

METHODS

Major databases were screened for studies reporting data on diagnostic yield, postoperative hemorrhage, neurological deficits, and mortality after frame-based, robot-assisted or neuronavigation-assisted frameless biopsies. Meta-analysis with random-effect modeling was performed to compare diagnostic yield, operative duration, length of stay, complications, and mortality.

RESULTS

A total of 92 studies were included with 9801 patients in the frame-based group, 2665 in the robot-assisted group, and 1862 in the frameless group. Pooled diagnostic yield rates were 97% (96%-98%, I 2 = 49%) in robot-assisted, 95% (94%-96%, I 2 = 74%) in frame-based, and 94% (91%-96%, I 2 = 55%) frameless groups with a statistically significant difference ( P < .01, I 2 = 71%). The mean total operative duration including anesthesia, system setup, patient registration, trajectory planning, and skin incision to closure was significantly shorter in the robot-assisted group (76.6 vs 132.7 vs 97.3 minutes, P < .01). The duration from skin incision to closure was comparable between the groups (robot-assisted: 37.8 mins, frame-based: 42.6 minutes, frameless: 58.2 minutes; P = .23). Pooled rates of symptomatic hemorrhage (0.005% vs 0.009% vs 0.007, P = .71, I 2 = 34%), asymptomatic hemorrhage (4% vs 3% vs 3%, P = .64, I 2 = 93%), transient neurological deficit (3% vs 2% vs 2%, P = .5, I 2 = 72%), permanent neurological deficit (0.001% vs 0.001% vs 0.0002, P = .78, I 2 = 47%), and mortality (0% vs 0.001% vs 0.006%, P < .01, I 2 = 10%) were similar between groups. Deaths were mainly due to postprocedural hemorrhage (robotic: 46%, frame-based: 48%, frameless: 72%).

CONCLUSION

Robot-assisted biopsy is not inferior in diagnostic yield and safety to the gold standard frame-based and neuronavigation-assisted frameless biopsy methods.

Three-Dimensional Structure Light Robot-Assisted Frameless Stereotactic Brain Biopsy

BACKGROUND AND OBJECTIVES

To assess the feasibility, accuracy, and safety of 3-dimensional (3D) structure light robot-assisted frameless stereotactic brain biopsy.

METHODS

Five consecutive patients (3 males, 2 females) were included in this study. The patients' clinical, imaging, and histological data were analyzed, and all patients received a 3D structure light robot-assisted frameless stereotactic brain biopsy. The raw and/or analyzed data of the study are available from the corresponding author.

RESULTS

The statistical results showed a mean age of 59.6 years (range 40-70 years), a mean target depth of 60.9 mm (range 53.5-65.8 mm), a mean radial error of 1.2 ± 0.7 mm (mean ± SD), a mean depth error of 0.7 ± 0.3 mm, and a mean absolute tip error of 1.5 ± 0.6 mm. The calculated Pearson product-moment correlation coefficient ( r = 0.23) revealed no correlation between target depth and absolute tip error. All biopsy needles were placed in line with the planned trajectory successfully, and diagnostic specimens were harvested in all cases. Histopathological analysis revealed lymphoma (2 cases), lung adenocarcinoma (1 case), glioblastoma multiforme (1 case), and oligodendroglioma (1 case).

CONCLUSION

Surface registration using the 3D structure light technique is fast and precise because of the achievable million-scale point cloud data of the head and face. 3D structure light robot-assisted frameless stereotactic brain biopsy is feasible, accurate, and safe.

Application of multimodal MRI and radiologic features for stereotactic brain biopsy: insights from a series of 208 patients

OBJECTIVES

We reviewed our institutional experience during a 10-year period for improvement of safety and efficacy of stereotactic biopsy procedures.

METHODS

We performed a retrospective review of inpatient summaries, stereotactic worksheets and radiologic investigations of 208 consecutive patients, who underwent MRI-guided stereotactic biopsies between March 2010 and March 2020.

RESULTS

The overall diagnostic yield was 96.2%. CT-confirmed intracranial hemorrhage occurred in 17 patients (8.2%), and the overall mortality rate was 0.5%. Combined MRS and PWI helped target selection in 27 cases (13.0%), the diagnostic yield was 100%. The results of the regression analysis revealed that non-diagnostic biopsy specimen significantly correlated with the cystic trait (p<.01) and edema of lesions (p<.05). Enhancement (p<.01) is shown to be an important factor for obtaining a diagnostic biopsy. Furthermore, the edema trait of lesions (p<.01) showed the important factors of hemorrhage.

CONCLUSIONS

The radiological features of lesions and use of the most suitable MRI sequences during biopsy planning are recommended ways to improve the diagnostic yield and safety of this technique.

Safety and accuracy of frameless electromagnetic-navigated (AXIEMTM)-guided brain lesion biopsies: a large single-unit study

BACKGROUND

Brain biopsies are required to establish a definitive histological diagnosis for brain lesions that have been identified on imaging in order to guide further treatment for patients.

OBJECTIVE

Various navigation systems are in use but little up to date evidence is available regarding the safety and accuracy of a frameless, electromagnetic technique to target brain lesions.

METHODS

Data was collected retrospectively on all patients that had brain biopsies at our institution from 01/01/2010 to 31/12/2017. Operation notes, neuropathology reports, and clinical notes on electronic patient record were used to determine whether biopsy of adequate identifiable abnormal tissue was achieved, whether a definitive diagnosis was established, any adverse events occurred, and if a repeat biopsy was carried out.

RESULTS

Three hundred seventy-one AxiEM (Medtronic, Minneapolis, USA)-guided brain tumor biopsies were performed in this 8-year period. Three hundred forty-nine (94.07%) procedures provided definitive tissue diagnosis, 22 (5.93%) were non diagnostic; in 6 cases (1.62%), repeat biopsy was performed and adverse events which caused clinical compromise were observed in 4 patients (1.08%).

CONCLUSIONS

The AxiEM is a fast, effective, and safe frameless and pinless neuronavigational system. It offers a high degree of accuracy required for the establishment of a definitive diagnosis, permitting optimal further treatment, and thus improving patient outcomes.

Frameless stereotactic biopsy for precision neurosurgery: diagnostic value, safety, and accuracy

BACKGROUND

Stereotactic biopsy is consistently employed to characterize cerebral lesions in patients who are not suitable for microsurgical resection. In the past years, technical improvement and neuroimaging advancements contributed to increase the diagnostic yield, the safety, and the application of this procedure. Currently, in addition to histological diagnosis, the molecular analysis is considered essential in the diagnostic process to properly select therapeutic and prognostic algorithms in a personalized approach. The present study reports our experience with frameless stereotactic brain biopsy in this molecular era.

METHODS

One hundred forty consecutive patients treated from January 2013 to September 2018 were analyzed. Biopsies were performed using the Brainlab Varioguide® frameless stereotactic system. Patients' clinical and demographic data, the time of occupation of the operating room, the surgical time, the morbidity, and the diagnostic yield in providing a histological and molecular diagnosis were recorded and evaluated.

RESULTS

The overall diagnostic yield was 93.6% with nine procedures resulting non-diagnostic. Among 110 patients with glioma, the IDH-1 mutational status was characterized in 108 cases (98.2%), resulting wild-type in all subjects but 3; MGMT methylation was characterized in 96 cases (87.3%), resulting present in 60 patients, and 1p/19q codeletion was founded in 6 of the 20 cases of grade II-III gliomas analyzed. All the specimens were apt for molecular analysis when performed. Bleeding requiring surgical drainage occurred in 2.1% of the cases; 8 (5.7%) asymptomatic hemorrhages requiring no treatment were observed. No biopsy-related mortality was recorded. Median length of hospital stay was 5 days (IQR 4-8) with mean surgical time of 60.77 min (± 23.12) and 137.44 ± 24.1 min of total occupation time of the operative room.

CONCLUSIONS

Stereotactic frameless biopsy is a safe, feasible, and fast procedure to obtain a histological and molecular diagnosis.

Image-Guided Biopsy of Intracranial Lesions with a Small Robotic Device (iSYS1): A Prospective, Exploratory Pilot Study

BACKGROUND

Robotic technologies have been used in the neurosurgical operating rooms for the last 30 yr. They have been adopted for several stereotactic applications and, particularly, image-guided biopsy of intracranial lesions which are not amenable for open surgical resection.

OBJECTIVE

To assess feasibility, safety, accuracy, and diagnostic yield of robot-assisted frameless stereotactic brain biopsy with a recently introduced miniaturized device (iSYS1; Interventional Systems Medizintechnik GmbH, Kitzbühel, Austria), fixed to the Mayfield headholder by a jointed arm.

METHODS

Clinical and surgical data of all patients undergoing frameless stereotactic biopsies using the iSYS1 robotized system from October 2016 to December 2017 have been prospectively collected and analyzed. Facial surface registration has been adopted for optical neuronavigation.

RESULTS

Thirty-nine patients were included in the study. Neither mortality nor morbidity related to the surgical procedure performed with the robot was recorded. Diagnostic tissue samples were obtained in 38 out of 39 procedures (diagnostic yield per procedure was 97.4%). All patients received a definitive histological diagnosis. Mean target error was 1.06 mm (median 1 mm, range 0.1-4 mm).

CONCLUSION

The frameless robotic iSYS1-assisted biopsy technique was determined to be feasible, safe, and accurate procedure; moreover, the diagnostic yield was high. The surface matching registration method with computed tomography as the reference image set did not negatively affect the accuracy of the procedure.

Navigation accuracy after automatic- and hybrid-surface registration in sinus and skull base surgery

Objective

Computer-aided-surgery in ENT surgery is mainly used for sinus surgery but navigation accuracy still reaches its limits for skull base procedures. Knowledge of navigation accuracy in distinct anatomical regions is therefore mandatory. This study examined whether navigation accuracy can be improved in specific anatomical localizations by using hybrid registration technique.

Study design

Experimental phantom study.

Setting

Operating room.

Subjects and methods

The gold standard of screw registration was compared with automatic LED-mask-registration alone, and in combination with additional surface matching. 3D-printer-based skull models with individual fabricated silicone skin were used for the experiments. Overall navigation accuracy considering 26 target fiducials distributed over each skull was measured as well as the accuracy on selected anatomic localizations.

Results

Overall navigation accuracy was <1.0 mm in all cases, showing the significantly lowest values after screw registration (0.66 ± 0.08 mm), followed by hybrid registration (0.83± 0.08 mm), and sole mask registration (0.92 ± 0.13 mm).On selected anatomic localizations screw registration was significantly superior on the sphenoid sinus and on the internal auditory canal. However, mask registration showed significantly better accuracy results on the midface. Navigation accuracy on skull base localizations could be significantly improved by the combination of mask registration and additional surface matching.

Conclusion

Overall navigation accuracy gives no sufficient information regarding navigation accuracy in a distinct anatomic area. The non-invasive LED-mask-registration proved to be an alternative in clinical routine showing best accuracy results on the midface. For challenging skull base procedures a hybrid registration technique is recommendable which improves navigation accuracy significantly in this operating field. Invasive registration procedures are reserved for selected challenging skull base operations where the required high precision warrants the invasiveness.

Accuracy of VarioGuide Frameless Stereotactic System Against Frame-Based Stereotaxy: Prospective, Randomized, Single-Center Study

INTRODUCTION

Frameless stereotactic brain biopsy systems are widely used today. VarioGuide (VG) is a relatively novel frameless system. Its accuracy was studied in a laboratory setting but has not yet been studied in the clinical setting. The purpose of this study was to determine its accuracy and diagnostic yield and to compare this with frame-based (FB) stereotaxy.

MATERIAL AND METHODS

Overall, 53 patients (33 males and 20 females, 60 ± 15 years old) were enrolled into this prospective, randomized, single-center study. Twenty-six patients were randomized into the FB group and 27 patients into the VG group. Real trajectory was pointed on intraoperative magnetic resonance. The distance of the targets and angle deviation between the planned and real trajectories were computed. The overall discomfort of the patient was subjectively assessed by the visual analog scale score.

RESULTS

The median lesion volume was 5 mL (interquartile range [IQR]: 2-16 mL) (FB) and 16 mL (IQR: 2-27 mL) (VG), P = 0.133. The mean distance of the targets was 2.7 ± 1.1 mm (FB) and 2.9 ± 1.3 mm (VG), P = 0.456. Mean angle deviation was 2.6 ± 1.3 deg (FB) and 3.5 ± 2.1 deg (VG), P = 0.074. Diagnostic yield was 93% (25/27) in VG and 96% (25/26) in FB, P = 1.000. Mean operating time was 47 ± 26 minutes (FB) and 59 ± 31 minutes (VG), P = 0.140. One minor bleeding was encountered in the VG group. Overall patient discomfort was significantly higher in the FB group (visual analog scale score 2.5 ± 2.1 vs. 1.2 ± 0.6, P = 0,004).

CONCLUSIONS

The VG system proved to be comparable in terms of the trajectory accuracy, rate of complications and diagnostic yield compared with the "gold standard" represented by the traditional FB stereotaxy for patients undergoing brain biopsy. VG is also better accepted by patients.

The role of biopsy in the management of patients with presumed diffuse low grade glioma: A systematic review and evidence-based clinical practice guideline

QUESTION

What is the optimal role of biopsy in the initial management of presumptive low-grade glioma in adults?

TARGET POPULATION

Adult patients with imaging suggestive of a low-grade glioma.

RECOMMENDATIONS

LEVEL III

Stereotactic biopsy is recommended when definitive surgical resection is limited by lesions that are deep-seated, not resectable, and/or located within eloquent cortex, or in patients unable to undergo craniotomy due to medical co-morbidities to obtain the critical tissue diagnosis needed for targeted treatment planning for patients with low-grade gliomas.

QUESTION

What is the best technique for brain biopsy?

TARGET POPULATION

Adult patients with imaging suggestive of a low-grade glioma.

RECOMMENDATIONS

LEVEL III

Frameless and frame-based stereotactic brain biopsy for low-grade gliomas are recommended based on clinical circumstances as they provide similar diagnostic yield, diagnostic accuracy, morbidity, and mortality. It is recommended the surgeon consider advanced imaging techniques (e.g., perfusion, spectroscopy, metabolic studies) to target specific regions of interest to potentially improve diagnostic accuracy.

Real-time magnetic resonance imaging-guided frameless stereotactic brain biopsy: technical note

OBJECTIVE

The object of this study was to assess the feasibility, accuracy, and safety of real-time MRI-compatible frameless stereotactic brain biopsy.

METHODS

Clinical, imaging, and histological data in consecutive patients who underwent stereotactic brain biopsy using a frameless real-time MRI system were analyzed.

RESULTS

Five consecutive patients (4 males, 1 female) were included in this study. The mean age at biopsy was 45.8 years (range 29-60 years). Real-time MRI permitted concurrent display of the biopsy cannula trajectory and tip during placement at the target. The mean target depth of biopsied lesions was 71.3 mm (range 60.4-80.4 mm). Targeting accuracy analysis revealed a mean radial error of 1.3 ± 1.1 mm (mean ± standard deviation), mean depth error of 0.7 ± 0.3 mm, and a mean absolute tip error of 1.5 ± 1.1 mm. There was no correlation between target depth and absolute tip error (Pearson product-moment correlation coefficient, r = 0.22). All biopsy cannulae were placed at the target with a single penetration and resulted in a diagnostic specimen in all cases. Histopathological evaluation of biopsy samples revealed dysembryoplastic neuroepithelial tumor (1 case), breast carcinoma (1 case), and glioblastoma multiforme (3 cases).

CONCLUSIONS

The ability to place a biopsy cannula under real-time imaging guidance permits on-the-fly alterations in the cannula trajectory and/or tip placement. Real-time imaging during MRI-guided brain biopsy provides precise safe targeting of brain lesions.

Blurring the boundaries between frame-based and frameless stereotaxy: feasibility study for brain biopsies performed with the use of a head-mounted robot

OBJECT

Frame-based stereotactic interventions are considered the gold standard for brain biopsies, but they have limitations with regard to flexibility and patient comfort because of the bulky head ring attached to the patient. Frameless image guidance systems that use scalp fiducial markers offer more flexibility and patient comfort but provide less stability and accuracy during drilling and biopsy needle positioning. Head-mounted robot-guided biopsies could provide the advantages of these 2 techniques without the downsides. The goal of this study was to evaluate the feasibility and safety of a robotic guidance device, affixed to the patient's skull through a small mounting platform, for use in brain biopsy procedures.

METHODS

This was a retrospective study of 37 consecutive patients who presented with supratentorial lesions and underwent brain biopsy procedures in which a surgical guidance robot was used to determine clinical outcomes and technical procedural operability.

RESULTS

The portable head-mounted device was well tolerated by the patients and enabled stable drilling and needle positioning during surgery. Flexible adjustments of predefined paths and selection of new trajectories were successfully performed intraoperatively without the need for manual settings and fixations. The patients experienced no permanent deficits or infections after surgery.

CONCLUSIONS

The head-mounted robot-guided approach presented here combines the stability of a bone-mounted set-up with the flexibility and tolerability of frameless systems. By reducing human interference (i.e., manual parameter settings, calibrations, and adjustments), this technology might be particularly useful in neurosurgical interventions that necessitate multiple trajectories.

Comparative effectiveness of frame-based, frameless, and intraoperative magnetic resonance imaging-guided brain biopsy techniques

OBJECTIVE

To compare the diagnostic yield and safety profiles of intraoperative magnetic resonance imaging (MRI)-guided needle brain biopsy with 2 traditional brain biopsy methods: frame-based and frameless stereotactic brain biopsy.

METHODS

A retrospective analysis was performed of 288 consecutive needle brain biopsies in 277 patients undergoing stereotactic brain biopsy with any of the 3 biopsy methods at Brigham and Women's Hospital from 2000-2008. Variables including age, sex, history of radiation and previous surgery, pathology results, complications, and postoperative length of hospital stay were analyzed.

RESULTS

Over the course of 8 years, 288 brain biopsies were performed. Of these, 253 (87.8%) biopsies yielded positive diagnostic tissue. Young age (<40 years old) and history of brain radiation or surgery were significant negative predictors for a positive biopsy diagnostic yield. Excluding patients with prior radiation or surgeries, no significant difference in diagnostic yield was detected among the 3 groups, with frame-based biopsies yielding 96.9%, frameless biopsies yielding 91.8%, and intraoperative MRI-guided needle biopsies yielding 89.9% positive diagnostic yield. Serious adverse events occurred 19 biopsies (6.6%). Intraoperative MRI-guided brain biopsies were associated with less serious adverse events and the shortest postoperative hospital stay.

CONCLUSIONS

Frame-based, frameless stereotactic, and intraoperative MRI-guided brain needle biopsy techniques have comparable diagnostic yield for patients with no prior treatments (either radiation or surgery). Intraoperative MRI-guided brain biopsy is associated with fewer serious adverse events and shorter hospital stay.

A miniature optical neuronavigation system for CT-guided stereotaxy

BACKGROUND AND OBJECTIVE

Neuronavigation devices have progressed over the past 2 decades, but logistical limitations remain for many stereotactic procedures. We describe our technique and accuracy for a novel miniature optical tracking system which overcomes these limitations.

METHOD

The minioptical tracking system uses a miniature video camera mounted on a rigid cannula to determine cannula location and orientation relative to a patient-attached sticker containing reference markers. A CT scan is used to register these markers to the anatomy and a user-selected target. A computer displays the cannula guidance information to the target. Bench testing was performed on 225 targets in a custom test phantom and additional testing was performed on 20 small targets in an anthropomorphic head phantom to determine the practical accuracy and workflow.

RESULTS

The phantom study demonstrated that 3-D navigation accuracy is 1.41 ± 0.53 mm. There was a 100% head phantom study success rate for the 20 small targets.

CONCLUSIONS

The resulting accuracy data demonstrated good correlation with the CT data, and the clinical simulation workflow indicated its potential usefulness for common neurosurgical applications. Furthermore, this small-footprint tracking technology does not experience the traditional environmentally induced issues or the requirement of pin-based head fixation, allowing for use in the neurointensive care unit and the emergency department.

An Experimental and Numerical Investigation of Phase Change Electrodes for Therapeutic Irreversible Electroporation

Irreversible electroporation (IRE) is a new technology for ablating aberrant tissue that utilizes pulsed electric fields (PEFs) to kill cells by destabilizing their plasma membrane. When treatments are planned correctly, the pulse parameters and location of the electrodes for delivering the pulses are selected to permit destruction of the target tissue without causing thermal damage to the surrounding structures. This allows for the treatment of surgically inoperable masses that are located near major blood vessels and nerves. In select cases of high-dose IRE, where a large ablation volume is desired without increasing the number of electrode insertions, it can become challenging to design a pulse protocol that is inherently nonthermal. To solve this problem we have developed a new electrosurgical device that requires no external equipment or protocol modifications. The design incorporates a phase change material (PCM) into the electrode core that melts during treatment and absorbs heat out of the surrounding tissue. Here, this idea is reduced to practice by testing hollow electrodes filled with gallium on tissue phantoms and monitoring temperature in real time. Additionally, the experimental data generated are used to validate a numerical model of the heat transfer problem, which is then applied to investigate the cooling performance of other classes of PCMs. The results indicate that metallic PCMs, such as gallium, are better suited than organics or salt hydrates for thermal management, because their comparatively higher thermal conductivity aids in heat dissipation. However, the melting point of the metallic PCM must be properly adjusted to ensure that the phase transition is not completed before the end of treatment. When translated clinically, phase change electrodes have the potential to continue to allow IRE to be performed safely near critical structures, even in high-dose cases.

Neuronavigation in the surgical management of brain tumors: current and future trends

Neuronavigation has become an ubiquitous tool in the surgical management of brain tumors. This review describes the use and limitations of current neuronavigational systems for brain tumor biopsy and resection. Methods for integrating intraoperative imaging into neuronavigational datasets developed to address the diminishing accuracy of positional information that occurs over the course of brain tumor resection are discussed. In addition, the process of integration of functional MRI and tractography into navigational models is reviewed. Finally, emerging concepts and future challenges relating to the development and implementation of experimental imaging technologies in the navigational environment are explored.

Navigation-guided endoscopic biopsy for intraparenchymal brain tumor

To evaluate the efficacy of intraparenchymal brain tumor biopsy using endoscopy and a navigation system (navigation-guided endoscopic biopsy) as a diagnostic tool, a case series of intraparenchymal tumor biopsies was reviewed. Navigation-guided endoscopic biopsy was applied in 9 cases, stereotactic needle biopsy in 16 cases, and open biopsy with or without navigation system in 34 cases. In all biopsy cases, 84.7% of biopsy points were sampled accurately, and 93.2% of diagnoses by biopsy were correct. Comparison of each type of biopsy showed that the resected volumes in navigation-guided endoscopic biopsy and open biopsy tended to be larger than those in stereotactic biopsy, and the mean operation time for the open biopsy procedure was the longest. To define the most applicable device or examination method to increase sampling accuracy, various factors were analyzed in 59 procedures. Navigation-guided endoscopic biopsy was the most accurate of the three types of biopsy, although the statistical difference was not significant. Older patients, histological diagnosis of high-grade glioma or malignant lymphoma, positive photodynamic diagnosis, and positive intraoperative pathology were significant factors in improving the sampling accuracy. Navigation-guided endoscopic biopsy could provide a larger sample volume within a relatively short operation time. The biopsy can be easily combined with both photodynamic diagnosis and intraoperative pathology, significantly improving the histological diagnostic yield.