- Email: [email protected]
An Experience with Frame-Based Stereotactic Biopsy of Posterior Fossa Lesions via Transcerebellar Route
Original Article
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An Experience with Frame-Based Stereotactic Biopsy of Posterior Fossa Lesions via Transcerebellar Route Q19 Q20 Q1 Q18
Eshagh Bahrami, Mansour Parvaresh, Mahsa Bahrami, Arash Fattahi
BACKGROUND: Tissue diagnosis for lesions in the posterior fossa, such as the brainstem, cerebellar peduncle, and cerebellum, is an important determinant of the next treatment option. Herein, we present our 10-year experience with magnetic resonance imaging (MRI)e guided Leksell frameebased stereotactic biopsy for 39 patients with posterior fossa lesions, the largest case series in this matter.
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METHODS: We performed a retrospective crosssectional study on all patients with posterior fossa lesion admitted to 2 referral centers between 2006 and 2016. We used Leksell Frame G for stereotactic biopsy of all patients. MRI systems of both hospitals were 1.5 T.
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RESULTS: We performed analysis on the 39 cases (21 men and 18 women). Age of the patients ranged between 9 and 73 years (mean, 35.4 15.7 years). Localization success rate was 100%. For 38 patients (97.4%), tissue sample size was enough for tissue diagnosis. For 1 case, it was insufficient and nondiagnostic. In this series, we had no surgery-related complications.
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CONCLUSIONS: We present the largest reported series of MRI-guided frame-based stereotactic biopsy of the posterior fossa lesions via a transcerebellar route. We prefer oblique positioning of the frame on the skull and use a transcerebellar route to reduce surgical complications and achieve a greater localization success rate.
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Key words Complication - Magnetic resonance imaging - Oblique - Posterior fossa - Stereotactic biopsy - Transcerebellar - Transfrontal
INTRODUCTION
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iverse histopathologic diagnoses can be found for lesions of the posterior fossa (e.g., primary and metastatic brain lesions, hematomas, demyelinating lesions, vasculitis, ischemic lesion, infections and granulomas, radiation-induced necrosis).1,2 Tissue diagnosis for lesions in the posterior fossa, Q 3 such as the brainstem, cerebellar peduncle, and cerebellum, is an important determinant of the next treatment option (e.g., medical therapy, cytoreductive surgery, chemotherapy, radiotherapy).2 For children, diffuse brainstem glioma could be Q 17 diagnosed solely by magnetic resonance imaging (MRI) without the need for tissue diagnosis.3 However, for all lesions in the posterior fossa in the adult population and unusual types in Q 2 children, histopathology is needed before deciding treatment options.4 Image-guided stereotactic biopsy of posterior fossa lesions is the accepted and precise approach that could be used to achieve tissue diagnosis, with a low complication rate.5 Herein, we present our 10-year experience with MRI-guided Leksell framebased stereotactic biopsy for 39 patients with posterior fossa Q 6 lesions. METHODS We performed a retrospective cross-sectional study on all patients with a posterior fossa lesion admitted to the Rasool Akram Hospital and Erfan Hospital, as referral centers, during a 10-year period between 2006 and 2016. We used Leksell Frame G for stereotactic biopsy of all patients. MRI systems of both hospitals were 1.5 T and were Siemens in one and Phillips Q 7 in another. We used some inclusion criteria for transcerebellar Q 8 stereotactic biopsy (TCSB), including any posterior fossa lesions, especially in the brainstem, that were not totally
TFSB: Transfrontal stereotactic biopsy
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Neurosurgery, Iran University of Medical Sciences, Tehran, Iran To whom correspondence should be addressed: Mansour Parvaresh, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2020). https://doi.org/10.1016/j.wneu.2020.01.003 Journal homepage: www.journals.elsevier.com/world-neurosurgery
Abbreviations and Acronyms MRI: Magnetic resonance imaging TCSB: Transcerebellar stereotactic biopsy TF: Transfrontal
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STEREOTACTIC BIOPSY OF POSTERIOR FOSSA LESIONS
Figure 1. For oblique fixation of the frame, we could see sites of stereotactic screw fixation on the skull and the site of entrance of the
resectable via surgery or had a deceptive imaging appearance. We treated all accessible lesions via open surgery, and for them, we did not use TCSB. Adult patients underwent awake TCSB in a semisitting position and were only sedated to cooperate in intraoperative neurologic examination. For children, we performed the procedure under general anesthesia. First, the locations of stereotactic screws in the scalp were infiltrated with 2% lidocaine. The stereotactic frame was put on all patients in the oblique view and was fixed to the skull with 4 screws (Figure 1A). Then, patients were transferred to the MRI center to perform nongap axial 1-mm-thickness MRI in T1 sequence with and without gadolinium. Stereotactic calculation of coordinates (x, y, and z) and trajectory (arc and ring) was calculated with stereotactic software (Stereonata and frame-link Medtronic 7S software). Then the patient was placed in the operating room and positioned semisitting, with the stereotactic frame and head of the patient fixed to the operating table. After preparation and drape, and under local anesthesia with 5 cc 2% lidocaine, a skin incision was made, and the skull burr hole was done. Then, with right orientation (Figure 1B) or anterior/ posterior orientation of the stereotactic arc (Figure 1C), a 2.5-mm biopsy needle was inserted and at least 1 or sometimes 2 specimens, based on volume size of the biopsy, were taken. After removing the needle biopsy, we irrigated the trajectory of the biopsy needle with normal saline. After confirming there was no bleeding, we put bone dust at the burr hole site and closed the anatomic structures. The frame was then removed and we performed a computed tomography scan of the posterior fossa. Usually, if there were no concomitant comorbidities, patients were discharged 1 or 2 days after surgery. We defined localization success rate as the percent of patients who had a site of biopsy on postoperative imaging that matched with the site of pathology on preoperative imaging. Also, we defined a nondiagnostic sample if the final report of histopathologic examination was insufficient tissue sample size.
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needle for biopsy (A and B), and the positioning of the arc and trajectory of the needle (B and C).
For ethical considerations, written consent was obtained from all patients or from first degree family for children. We guaranteed the confidentiality of all patients. All procedures were performed in a globally accepted standard manner. We analyzed all information about all patients. This research has been approved by the ethics committee of Iran University of Medical Sciences. Because of the small size of our series, a limitation of our study, we did not divide patients based on their age or other variants and report all of them in one group.
RESULTS In our survey over a 10-year period, a total of 265 patients underwent stereotactic surgery in our 2 centers. We performed stereotactic biopsy of the posterior fossa lesion in just 44 cases. Because of limitations in available information for 5 patients, we excluded them. Finally, we performed analyses on the remaining 39 cases (21 men and 18 women). All demographic and detailed information of the included patients is provided in Tables 1 and 2. One of the patients was a 28-year-old man referred from another center with nonconclusive biopsy of left middle cerebellar peduncle and brainstem mass. In that center, he underwent ipsilateral transfrontal stereotactic biopsy (TFSB) and because of hemorrhagic events, he had gait disturbance and a gaze problem. We performed a TCSB and the final histopathology was granuloma. The age of the patients ranged between 9 and 73 years (mean, 35.4 15.7 years). Because of causes other than surgically related and other comorbidity, the time for hospital stay in 3 of the patients was 60, 34, and 18 days. Overall, the mean time for hospital stay was 6.4 days, but without these 3 patients, it was 3.8 days. The localization success rate was 100%. For 38 patients (97.4%), the tissue sample size was enough for tissue diagnosis. For 1 case, it was insufficient and nondiagnostic. Histopathologic diversity of the cases is shown in Tables 1 and 2. The most prevalent histopathologic report was astrocytoma grade 2. After final histologic diagnoses, as shown in Table 2, we consulted with other specialists (e.g., infectious diseases specialist, radio-
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297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370
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STEREOTACTIC BIOPSY OF POSTERIOR FOSSA LESIONS
Table 1. Demographic Information and Histopathologic Findings of the Patients Variable
Value 35.4 15.7 (9e73)
Age, mean (range) (years) Sex, male/female
21 (53.8)/18 (46.2)
Length of hospital stay, mean (range) (days)
6.45 (1e60)
Successful localization
39 (100)
Intraoperative satisfaction about adequacy of specimen size
38 (97.4)
Success in histopathologic diagnosis achievement
38 (97.4)
Histopathologic report frequency Astrocytoma grade 2
14 (35.9)
Astrocytoma grade 3
5 (12.8)
Malignant lymphoma
5 (12.8)
Glioblastoma
2 (5.1)
Demyelinating lesion
2 (5.1)
Fungal infection
2 (5.1)
Encephalitis
2 (5.1)
Ganglioglioma
1 (2.5)
Hemorrhagic cyst
1 (2.5)
Astrogliosis
1 (2.5)
Encephalomalacia
1 (2.5)
Vasculitis
1 (2.5)
Granuloma
1 (2.5)
Nondiagnostic
1 (2.5)
Values are number of patients (%) or as otherwise indicated.
oncologist, neurologist) to choose the best next treatment option. None of our patients needed surgical treatment. In 1 patient with hemorrhagic cyst, we performed TCSB as curative treatment. In this series, we had no surgery-related complications (e.g., cranial nerve palsies, hemorrhage at the site of biopsy). For all cases, we could see bubble of pneumocephalus only at the site of biopsy (Figure 2).
DISCUSSION In 1889, Zernov was the first physician who applied a localizing device for approach to a deep-seated brain lesion.6 In 1980, after 91 years and the start of use of MRI for precise localization of brain lesions, the frame-based stereotactic system emerged in neurosurgery.7 Although stereotactic biopsy of the posterior fossa and brainstem started in 1975, computed tomography scan was the first imaging tool for localizing lesions.8 Today, MRI-guided frame-based stereotactic biopsy is a safe and low
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complication approach to achieve tissue samples for histopathologic diagnosis.2 To access posterior fossa lesions for biopsy, we could use 1 of 4 possible routes: transtentorial approach, suboccipital TCSB approach, ipsilateral TFSB approach, and contralateral extraventricular transfrontal (TF) approach.9 In 2012, Dellaretti et al.10 compared the TCSB approach and TF approach to access the brainstem and found some preference for the TF approach that was not statistically significant. Both approaches had similar complication rates. Chen et al.2 compared these approaches in 10 cases, and they concluded the selection of the approach must be case by case. Because of shorter trajectory to the brainstem and less possibility of hemorrhage in the posterior fossa, they preferred the TCSB approach via the middle cerebellar peduncle to access the brainstem.2 Considering frame-based or frameless approaches, Barnett et al.11 reported a tissue diagnosis rate of 97.6% for 208 cerebral lesions compared with 70% for 10 infratentorial lesions via a frameless approach. Based on these findings and other supporting information, it seems the frameless stereotactic biopsy has limitations in the posterior fossa.2 Herein, we present, to our knowledge, the largest reported case series for MRI-guided frame-based stereotactic biopsy of posterior fossa lesions via the transcerebellar route.1,2,12 Because of the shorter distance between the entrance to target point and fewer complications in comparing transtentorial and supratentorial approaches, in our center we selected the transcerebellar route for stereotactic biopsy of the lesions in the posterior fossa.2 In all patients, we fixed the frame on the skull in the oblique position. In 2017, Quick-Weller et al.12 reported their experiences with TCSB in Q 11 20 patients where they approached 12 patients with oblique frame fixation. They had 2 hemorrhagic complications of the Q 12 biopsy site, and both were in the group with a straight frame on the skull. Finally, they concluded the oblique positioning of the frame could be a safe route for TCSB. Also, now, we report an experience of 39 cases with no complications while used a frame obliquely on the skull. Aiming to reduce surgical complications, we think carefully following some important points could be helpful. First, using a frame obliquely on the skull could reduce complications.12 Second, we used nongap 1-mm-thickness axial MRI for localization that reduced mistakes in selecting true targets and fine trajectory and avoiding vasculature and vital structures. Finally, we think use of a TCSB approach has fewer surgeryrelated complications because it is straightforward and has a shorter trajectory to the brainstem in comparison with TFSB. Adhering to these points, we achieved a 100% localization success rate without any complications for TCSB in 39 cases. Some limitations of our study are that it was performed Q 13 retrospectively and had a small sample size. Also, we had not Q 14 controlled group with performing stereotactic biopsy via other routes and we were not blinded. In the future, we think a prospective case-control study is needed for revealing the best stereotactic approach to the lesions in the posterior fossa.
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371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444
ORIGINAL ARTICLE ESHAGH BAHRAMI ET AL.
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STEREOTACTIC BIOPSY OF POSTERIOR FOSSA LESIONS
Table 2. Detailed Information of Patients Case Number
Age (years) Sex
Site of Biopsy
Tissue Diagnosis
Next Treatment After Biopsy
Duration of Hospitalization (days)
1
23
F
Pons
Calcified astrocytoma grade 2
Radiotherapy
3
2
51
M
Rt. cerebellar hemisphere
Malignant lymphoma
Chemoradiotherapy
2
3
32
M
Brainstem
Ganglioglioma
Radiotherapy
1
4
43
F
Lt. middle cerebellar peduncle
Astrocytoma grade 3
Chemoradiotherapy
2
5
29
M Infiltrative mesencephalic and pontine
Astrocytoma grade 3
Chemoradiotherapy
1
6
62
F
Infiltrative Rt. pontocerebellar hemisphere
Astrocytoma grade 3
Chemoradiotherapy
1
7
44
F
Lt. brainstem
Hemorrhagic cyst
Therapeutic aspiration
1
8
30
M
Brainstem and Rt. middle cerebellar peduncle
Glioblastoma
Chemoradiotherapy
4
9
37
M
Brainstem
Fibrillary astrocytoma grade 2
Radiotherapy
2
10
62
F
Middle cerebellar peduncle
Lymphocytic vasculitis
Immunosuppression
2
11
37
F
Pons
Malignant lymphoma
Chemoradiotherapy
2
12
18
F
Multiple brainstem lesions
Astrocytoma grade 3
Chemoradiotherapy
2
13
42
F
Lt. midbrain and diencephalon lesions
Malignant lymphoma
Chemoradiotherapy
2
14
43
M
Brainstem and Rt. middle cerebellar peduncle
Malignant lymphoma
Chemoradiotherapy
1
15
28
F
Brainstem and Rt. thalamus
Astrocytoma grade 2
Radiotherapy
5
16
12
F
Lt. cerebellar hemisphere, pons, and midbrain with fourth ventricle compression
Astrocytoma grade 3
Chemoradiotherapy
12
17
52
M
Pons
Fungal infection
Antifungal therapy
7
18
11
F
Rt. thalamus and midbrain
Astrocytoma grade 2
Radiotherapy
11
19
48
M
Midbrain
Malignant (diffuse large B-cell) lymphoma
Chemoradiotherapy
9
20
32
M
Pons
Astrocytoma grade 2
Radiotherapy
7
21
28
M
Lt. middle cerebellar peduncle
Granuloma
Antituberculosis
5
22
70
M
Pineal and midbrain
Astrocytoma grade 2
Radiotherapy
34
23
24
F
Midbrain and basal ganglia
Pleomorphic xanthoastrocytoma (grade 2)
Radiotherapy
3
24
73
M
Pons and midbrain
Glioblastoma
Chemoradiotherapy
2
25
19
F
Brainstem
Astrocytoma grade 2
Radiotherapy
2
26
18
F
Midbrain
Demyelinating lesion
Immunosuppression
8
27
53
M
Pons
Astrogliosis
Close observation
3
28
22
M
Pons
Astrocytoma grade 2
Radiotherapy
4
29
37
M
Brainstem
Fibrillary astrocytoma grade 2
Radiotherapy
3
30
10
M
Brainstem and thalamus
Astrocytoma grade 2
Radiotherapy
4
31
37
F
Midbrain
Encephalitis
Antibiotic and antiviral therapy
5
32
9
M
Basal ganglia and midbrain
Astrocytoma grade 2
Radiotherapy
5
33
43
M
Brainstem
Fungal infection
Antifungal therapy
60 Continues
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STEREOTACTIC BIOPSY OF POSTERIOR FOSSA LESIONS
Table 2. Continued Case Number
Age (years) Sex
Site of Biopsy
Tissue Diagnosis
Next Treatment After Biopsy
Duration of Hospitalization (days)
Rt. cerebellopontine angle
Astrocytoma grade 2
Radiotherapy
18
34
47
M
35
33
F
Brainstem
Astrocytoma grade 2
Radiotherapy
3
36
34
F
Rt. cerebellopontine angle
Demyelinating lesion
Immunosuppression
6
37
22
M
Lt. middle cerebellar peduncle
Encephalomalacia
Follow-up
5
38
40
F
Brainstem
Encephalitis
Antibiotic and antiviral therapy
3
39
25
M
Brainstem and Rt. middle cerebellar peduncle
Blood clot (nondiagnostic)
Close observation
2
F, female; M, male; Rt., right; Lt., left.
CONCLUSIONS We present the largest reported series of MRI-guided frame-based stereotactic biopsy of posterior fossa lesions via a transcerebellar
Figure 2. Preoperative axial T1 sequence magnetic resonance imaging with gadolinium and early postoperative computed tomography scan of some cases in our series. (A and B) A 28-year-old man with granuloma of the left middle cerebellar peduncle. (C and D) A 43-year-old woman with anaplastic
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route. We preferred oblique positioning of the frame on the skull and used a transcerebellar route for reducing surgical complications and to achieve a greater localization success rate.
astrocytoma (astrocytoma grade 3) of the left middle cerebellar peduncle. (E and F) A 43-year-old man with malignant lymphoma. (G and H) A 44-year-old woman with hemorrhagic cyst of the left brainstem.
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STEREOTACTIC BIOPSY OF POSTERIOR FOSSA LESIONS
CRediT AUTHORSHIP CONTRIBUTION STATEMENT Q 21
Eshagh Bahrami: Conceptualization, Supervision, Validation. Mansour Parvaresh: Conceptualization, Writing - review &
REFERENCES 1. Samadani U, Judy KD. Stereotactic brainstem biopsy is indicated for the diagnosis of a vast array of brainstem pathology. Stereotact Funct Neurosurg. 2003;81:5-9. 2. Chen SY, Chen CH, Sun MH, Lee HT, Shen CC. Stereotactic biopsy for brainstem lesion: comparison of approaches and reports of 10 cases. J Chin Med Assoc. 2011;74:110-114. 3. Epstein F, McCleary EL. Intrinsic brain-stem tumors of childhood: surgical indications. J Neurosurg. 1986;64:11-15. 4. Sanai N, Wachhorst SP, Gupta NM, McDermott MW. Transcerebellar stereotactic biopsy for lesions of the brainstem and peduncles under local anesthesia. Neurosurgery. 2008;63: 460-466 [discussion: 466-468]. 5. Manoj N, Arivazhagan A, Bhat DI, et al. Stereotactic biopsy of brainstem lesions: techniques, efficacy, safety, and disease variation between adults and children: a single institutional series and review. J Neurosci Rural Pract. 2014;5:32.
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editing, Supervision. Mahsa Bahrami: Methodology. Arash Fattahi: Writing - original draft, Methodology.
6. Iijima K, Hirato M, Miyagishima T, et al. Microrecording and image-guided stereotactic biopsy of deep-seated brain tumors. J Neurosurg. 2015;123: 978-988. 7. Brown RA, Nelson JA. The origin and history of the N-localizer for stereotactic neurosurgery. Cureus. 2015;7:e323. 8. Mathisen JR, Giunta F, Marini G, Backlund EO. Transcerebellar biopsy in the posterior-fossa - 12 years experience. Surg Neurol. 1987;28:100-104. 9. Amundson EW, McGirt MJ, Olivi A. A contralateral, transfrontal, extraventricular approach to stereotactic brainstem biopsy procedures - technical note. J Neurosurg. 2005;102: 565-570. 10. Dellaretti M, Reyns N, Touzet G, et al. Stereotactic biopsy for brainstem tumors: comparison of transcerebellar with transfrontal approach. Stereotact Funct Neurosurg. 2012;90:79-83. 11. Barnett GH, Miller DW, Weisenberger J. Frameless stereotaxy with scalp-applied fiducial markers
for brain biopsy procedures: experience in 218 cases. J Neurosurg. 1999;91:569-576. 12. Quick-Weller J, Brawanski N, Dinc N, et al. Stereotactic biopsy of cerebellar lesions: straight versus oblique frame positioning. Br J Neurosurg. 2018;32:210-213.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 16 August 2019; accepted 2 January 2020 Citation: World Neurosurg. (2020). https://doi.org/10.1016/j.wneu.2020.01.003 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2020 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.01.003
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An Experience with Frame-Based Stereotactic Biopsy of Posterior Fossa Lesions via Transcerebellar Route Q19 Q20 Q1 Q18
Eshagh Bahrami, Mansour Parvaresh, Mahsa Bahrami, Arash Fattahi
BACKGROUND: Tissue diagnosis for lesions in the posterior fossa, such as the brainstem, cerebellar peduncle, and cerebellum, is an important determinant of the next treatment option. Herein, we present our 10-year experience with magnetic resonance imaging (MRI)e guided Leksell frameebased stereotactic biopsy for 39 patients with posterior fossa lesions, the largest case series in this matter.
-
Q4
METHODS: We performed a retrospective crosssectional study on all patients with posterior fossa lesion admitted to 2 referral centers between 2006 and 2016. We used Leksell Frame G for stereotactic biopsy of all patients. MRI systems of both hospitals were 1.5 T.
-
RESULTS: We performed analysis on the 39 cases (21 men and 18 women). Age of the patients ranged between 9 and 73 years (mean, 35.4 15.7 years). Localization success rate was 100%. For 38 patients (97.4%), tissue sample size was enough for tissue diagnosis. For 1 case, it was insufficient and nondiagnostic. In this series, we had no surgery-related complications.
-
CONCLUSIONS: We present the largest reported series of MRI-guided frame-based stereotactic biopsy of the posterior fossa lesions via a transcerebellar route. We prefer oblique positioning of the frame on the skull and use a transcerebellar route to reduce surgical complications and achieve a greater localization success rate.
-
Key words Complication - Magnetic resonance imaging - Oblique - Posterior fossa - Stereotactic biopsy - Transcerebellar - Transfrontal
INTRODUCTION
D
iverse histopathologic diagnoses can be found for lesions of the posterior fossa (e.g., primary and metastatic brain lesions, hematomas, demyelinating lesions, vasculitis, ischemic lesion, infections and granulomas, radiation-induced necrosis).1,2 Tissue diagnosis for lesions in the posterior fossa, Q 3 such as the brainstem, cerebellar peduncle, and cerebellum, is an important determinant of the next treatment option (e.g., medical therapy, cytoreductive surgery, chemotherapy, radiotherapy).2 For children, diffuse brainstem glioma could be Q 17 diagnosed solely by magnetic resonance imaging (MRI) without the need for tissue diagnosis.3 However, for all lesions in the posterior fossa in the adult population and unusual types in Q 2 children, histopathology is needed before deciding treatment options.4 Image-guided stereotactic biopsy of posterior fossa lesions is the accepted and precise approach that could be used to achieve tissue diagnosis, with a low complication rate.5 Herein, we present our 10-year experience with MRI-guided Leksell framebased stereotactic biopsy for 39 patients with posterior fossa Q 6 lesions. METHODS We performed a retrospective cross-sectional study on all patients with a posterior fossa lesion admitted to the Rasool Akram Hospital and Erfan Hospital, as referral centers, during a 10-year period between 2006 and 2016. We used Leksell Frame G for stereotactic biopsy of all patients. MRI systems of both hospitals were 1.5 T and were Siemens in one and Phillips Q 7 in another. We used some inclusion criteria for transcerebellar Q 8 stereotactic biopsy (TCSB), including any posterior fossa lesions, especially in the brainstem, that were not totally
TFSB: Transfrontal stereotactic biopsy
Q5
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Neurosurgery, Iran University of Medical Sciences, Tehran, Iran To whom correspondence should be addressed: Mansour Parvaresh, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2020). https://doi.org/10.1016/j.wneu.2020.01.003 Journal homepage: www.journals.elsevier.com/world-neurosurgery
Abbreviations and Acronyms MRI: Magnetic resonance imaging TCSB: Transcerebellar stereotactic biopsy TF: Transfrontal
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149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222
Q15
Q9
Q 10
STEREOTACTIC BIOPSY OF POSTERIOR FOSSA LESIONS
Figure 1. For oblique fixation of the frame, we could see sites of stereotactic screw fixation on the skull and the site of entrance of the
resectable via surgery or had a deceptive imaging appearance. We treated all accessible lesions via open surgery, and for them, we did not use TCSB. Adult patients underwent awake TCSB in a semisitting position and were only sedated to cooperate in intraoperative neurologic examination. For children, we performed the procedure under general anesthesia. First, the locations of stereotactic screws in the scalp were infiltrated with 2% lidocaine. The stereotactic frame was put on all patients in the oblique view and was fixed to the skull with 4 screws (Figure 1A). Then, patients were transferred to the MRI center to perform nongap axial 1-mm-thickness MRI in T1 sequence with and without gadolinium. Stereotactic calculation of coordinates (x, y, and z) and trajectory (arc and ring) was calculated with stereotactic software (Stereonata and frame-link Medtronic 7S software). Then the patient was placed in the operating room and positioned semisitting, with the stereotactic frame and head of the patient fixed to the operating table. After preparation and drape, and under local anesthesia with 5 cc 2% lidocaine, a skin incision was made, and the skull burr hole was done. Then, with right orientation (Figure 1B) or anterior/ posterior orientation of the stereotactic arc (Figure 1C), a 2.5-mm biopsy needle was inserted and at least 1 or sometimes 2 specimens, based on volume size of the biopsy, were taken. After removing the needle biopsy, we irrigated the trajectory of the biopsy needle with normal saline. After confirming there was no bleeding, we put bone dust at the burr hole site and closed the anatomic structures. The frame was then removed and we performed a computed tomography scan of the posterior fossa. Usually, if there were no concomitant comorbidities, patients were discharged 1 or 2 days after surgery. We defined localization success rate as the percent of patients who had a site of biopsy on postoperative imaging that matched with the site of pathology on preoperative imaging. Also, we defined a nondiagnostic sample if the final report of histopathologic examination was insufficient tissue sample size.
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needle for biopsy (A and B), and the positioning of the arc and trajectory of the needle (B and C).
For ethical considerations, written consent was obtained from all patients or from first degree family for children. We guaranteed the confidentiality of all patients. All procedures were performed in a globally accepted standard manner. We analyzed all information about all patients. This research has been approved by the ethics committee of Iran University of Medical Sciences. Because of the small size of our series, a limitation of our study, we did not divide patients based on their age or other variants and report all of them in one group.
RESULTS In our survey over a 10-year period, a total of 265 patients underwent stereotactic surgery in our 2 centers. We performed stereotactic biopsy of the posterior fossa lesion in just 44 cases. Because of limitations in available information for 5 patients, we excluded them. Finally, we performed analyses on the remaining 39 cases (21 men and 18 women). All demographic and detailed information of the included patients is provided in Tables 1 and 2. One of the patients was a 28-year-old man referred from another center with nonconclusive biopsy of left middle cerebellar peduncle and brainstem mass. In that center, he underwent ipsilateral transfrontal stereotactic biopsy (TFSB) and because of hemorrhagic events, he had gait disturbance and a gaze problem. We performed a TCSB and the final histopathology was granuloma. The age of the patients ranged between 9 and 73 years (mean, 35.4 15.7 years). Because of causes other than surgically related and other comorbidity, the time for hospital stay in 3 of the patients was 60, 34, and 18 days. Overall, the mean time for hospital stay was 6.4 days, but without these 3 patients, it was 3.8 days. The localization success rate was 100%. For 38 patients (97.4%), the tissue sample size was enough for tissue diagnosis. For 1 case, it was insufficient and nondiagnostic. Histopathologic diversity of the cases is shown in Tables 1 and 2. The most prevalent histopathologic report was astrocytoma grade 2. After final histologic diagnoses, as shown in Table 2, we consulted with other specialists (e.g., infectious diseases specialist, radio-
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ORIGINAL ARTICLE ESHAGH BAHRAMI ET AL.
297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370
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STEREOTACTIC BIOPSY OF POSTERIOR FOSSA LESIONS
Table 1. Demographic Information and Histopathologic Findings of the Patients Variable
Value 35.4 15.7 (9e73)
Age, mean (range) (years) Sex, male/female
21 (53.8)/18 (46.2)
Length of hospital stay, mean (range) (days)
6.45 (1e60)
Successful localization
39 (100)
Intraoperative satisfaction about adequacy of specimen size
38 (97.4)
Success in histopathologic diagnosis achievement
38 (97.4)
Histopathologic report frequency Astrocytoma grade 2
14 (35.9)
Astrocytoma grade 3
5 (12.8)
Malignant lymphoma
5 (12.8)
Glioblastoma
2 (5.1)
Demyelinating lesion
2 (5.1)
Fungal infection
2 (5.1)
Encephalitis
2 (5.1)
Ganglioglioma
1 (2.5)
Hemorrhagic cyst
1 (2.5)
Astrogliosis
1 (2.5)
Encephalomalacia
1 (2.5)
Vasculitis
1 (2.5)
Granuloma
1 (2.5)
Nondiagnostic
1 (2.5)
Values are number of patients (%) or as otherwise indicated.
oncologist, neurologist) to choose the best next treatment option. None of our patients needed surgical treatment. In 1 patient with hemorrhagic cyst, we performed TCSB as curative treatment. In this series, we had no surgery-related complications (e.g., cranial nerve palsies, hemorrhage at the site of biopsy). For all cases, we could see bubble of pneumocephalus only at the site of biopsy (Figure 2).
DISCUSSION In 1889, Zernov was the first physician who applied a localizing device for approach to a deep-seated brain lesion.6 In 1980, after 91 years and the start of use of MRI for precise localization of brain lesions, the frame-based stereotactic system emerged in neurosurgery.7 Although stereotactic biopsy of the posterior fossa and brainstem started in 1975, computed tomography scan was the first imaging tool for localizing lesions.8 Today, MRI-guided frame-based stereotactic biopsy is a safe and low
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complication approach to achieve tissue samples for histopathologic diagnosis.2 To access posterior fossa lesions for biopsy, we could use 1 of 4 possible routes: transtentorial approach, suboccipital TCSB approach, ipsilateral TFSB approach, and contralateral extraventricular transfrontal (TF) approach.9 In 2012, Dellaretti et al.10 compared the TCSB approach and TF approach to access the brainstem and found some preference for the TF approach that was not statistically significant. Both approaches had similar complication rates. Chen et al.2 compared these approaches in 10 cases, and they concluded the selection of the approach must be case by case. Because of shorter trajectory to the brainstem and less possibility of hemorrhage in the posterior fossa, they preferred the TCSB approach via the middle cerebellar peduncle to access the brainstem.2 Considering frame-based or frameless approaches, Barnett et al.11 reported a tissue diagnosis rate of 97.6% for 208 cerebral lesions compared with 70% for 10 infratentorial lesions via a frameless approach. Based on these findings and other supporting information, it seems the frameless stereotactic biopsy has limitations in the posterior fossa.2 Herein, we present, to our knowledge, the largest reported case series for MRI-guided frame-based stereotactic biopsy of posterior fossa lesions via the transcerebellar route.1,2,12 Because of the shorter distance between the entrance to target point and fewer complications in comparing transtentorial and supratentorial approaches, in our center we selected the transcerebellar route for stereotactic biopsy of the lesions in the posterior fossa.2 In all patients, we fixed the frame on the skull in the oblique position. In 2017, Quick-Weller et al.12 reported their experiences with TCSB in Q 11 20 patients where they approached 12 patients with oblique frame fixation. They had 2 hemorrhagic complications of the Q 12 biopsy site, and both were in the group with a straight frame on the skull. Finally, they concluded the oblique positioning of the frame could be a safe route for TCSB. Also, now, we report an experience of 39 cases with no complications while used a frame obliquely on the skull. Aiming to reduce surgical complications, we think carefully following some important points could be helpful. First, using a frame obliquely on the skull could reduce complications.12 Second, we used nongap 1-mm-thickness axial MRI for localization that reduced mistakes in selecting true targets and fine trajectory and avoiding vasculature and vital structures. Finally, we think use of a TCSB approach has fewer surgeryrelated complications because it is straightforward and has a shorter trajectory to the brainstem in comparison with TFSB. Adhering to these points, we achieved a 100% localization success rate without any complications for TCSB in 39 cases. Some limitations of our study are that it was performed Q 13 retrospectively and had a small sample size. Also, we had not Q 14 controlled group with performing stereotactic biopsy via other routes and we were not blinded. In the future, we think a prospective case-control study is needed for revealing the best stereotactic approach to the lesions in the posterior fossa.
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371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444
ORIGINAL ARTICLE ESHAGH BAHRAMI ET AL.
445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518
STEREOTACTIC BIOPSY OF POSTERIOR FOSSA LESIONS
Table 2. Detailed Information of Patients Case Number
Age (years) Sex
Site of Biopsy
Tissue Diagnosis
Next Treatment After Biopsy
Duration of Hospitalization (days)
1
23
F
Pons
Calcified astrocytoma grade 2
Radiotherapy
3
2
51
M
Rt. cerebellar hemisphere
Malignant lymphoma
Chemoradiotherapy
2
3
32
M
Brainstem
Ganglioglioma
Radiotherapy
1
4
43
F
Lt. middle cerebellar peduncle
Astrocytoma grade 3
Chemoradiotherapy
2
5
29
M Infiltrative mesencephalic and pontine
Astrocytoma grade 3
Chemoradiotherapy
1
6
62
F
Infiltrative Rt. pontocerebellar hemisphere
Astrocytoma grade 3
Chemoradiotherapy
1
7
44
F
Lt. brainstem
Hemorrhagic cyst
Therapeutic aspiration
1
8
30
M
Brainstem and Rt. middle cerebellar peduncle
Glioblastoma
Chemoradiotherapy
4
9
37
M
Brainstem
Fibrillary astrocytoma grade 2
Radiotherapy
2
10
62
F
Middle cerebellar peduncle
Lymphocytic vasculitis
Immunosuppression
2
11
37
F
Pons
Malignant lymphoma
Chemoradiotherapy
2
12
18
F
Multiple brainstem lesions
Astrocytoma grade 3
Chemoradiotherapy
2
13
42
F
Lt. midbrain and diencephalon lesions
Malignant lymphoma
Chemoradiotherapy
2
14
43
M
Brainstem and Rt. middle cerebellar peduncle
Malignant lymphoma
Chemoradiotherapy
1
15
28
F
Brainstem and Rt. thalamus
Astrocytoma grade 2
Radiotherapy
5
16
12
F
Lt. cerebellar hemisphere, pons, and midbrain with fourth ventricle compression
Astrocytoma grade 3
Chemoradiotherapy
12
17
52
M
Pons
Fungal infection
Antifungal therapy
7
18
11
F
Rt. thalamus and midbrain
Astrocytoma grade 2
Radiotherapy
11
19
48
M
Midbrain
Malignant (diffuse large B-cell) lymphoma
Chemoradiotherapy
9
20
32
M
Pons
Astrocytoma grade 2
Radiotherapy
7
21
28
M
Lt. middle cerebellar peduncle
Granuloma
Antituberculosis
5
22
70
M
Pineal and midbrain
Astrocytoma grade 2
Radiotherapy
34
23
24
F
Midbrain and basal ganglia
Pleomorphic xanthoastrocytoma (grade 2)
Radiotherapy
3
24
73
M
Pons and midbrain
Glioblastoma
Chemoradiotherapy
2
25
19
F
Brainstem
Astrocytoma grade 2
Radiotherapy
2
26
18
F
Midbrain
Demyelinating lesion
Immunosuppression
8
27
53
M
Pons
Astrogliosis
Close observation
3
28
22
M
Pons
Astrocytoma grade 2
Radiotherapy
4
29
37
M
Brainstem
Fibrillary astrocytoma grade 2
Radiotherapy
3
30
10
M
Brainstem and thalamus
Astrocytoma grade 2
Radiotherapy
4
31
37
F
Midbrain
Encephalitis
Antibiotic and antiviral therapy
5
32
9
M
Basal ganglia and midbrain
Astrocytoma grade 2
Radiotherapy
5
33
43
M
Brainstem
Fungal infection
Antifungal therapy
60 Continues
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593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666
STEREOTACTIC BIOPSY OF POSTERIOR FOSSA LESIONS
Table 2. Continued Case Number
Age (years) Sex
Site of Biopsy
Tissue Diagnosis
Next Treatment After Biopsy
Duration of Hospitalization (days)
Rt. cerebellopontine angle
Astrocytoma grade 2
Radiotherapy
18
34
47
M
35
33
F
Brainstem
Astrocytoma grade 2
Radiotherapy
3
36
34
F
Rt. cerebellopontine angle
Demyelinating lesion
Immunosuppression
6
37
22
M
Lt. middle cerebellar peduncle
Encephalomalacia
Follow-up
5
38
40
F
Brainstem
Encephalitis
Antibiotic and antiviral therapy
3
39
25
M
Brainstem and Rt. middle cerebellar peduncle
Blood clot (nondiagnostic)
Close observation
2
F, female; M, male; Rt., right; Lt., left.
CONCLUSIONS We present the largest reported series of MRI-guided frame-based stereotactic biopsy of posterior fossa lesions via a transcerebellar
Figure 2. Preoperative axial T1 sequence magnetic resonance imaging with gadolinium and early postoperative computed tomography scan of some cases in our series. (A and B) A 28-year-old man with granuloma of the left middle cerebellar peduncle. (C and D) A 43-year-old woman with anaplastic
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route. We preferred oblique positioning of the frame on the skull and used a transcerebellar route for reducing surgical complications and to achieve a greater localization success rate.
astrocytoma (astrocytoma grade 3) of the left middle cerebellar peduncle. (E and F) A 43-year-old man with malignant lymphoma. (G and H) A 44-year-old woman with hemorrhagic cyst of the left brainstem.
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667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740
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741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784 785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809 810 811 812 813 814
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CRediT AUTHORSHIP CONTRIBUTION STATEMENT Q 21
Eshagh Bahrami: Conceptualization, Supervision, Validation. Mansour Parvaresh: Conceptualization, Writing - review &
REFERENCES 1. Samadani U, Judy KD. Stereotactic brainstem biopsy is indicated for the diagnosis of a vast array of brainstem pathology. Stereotact Funct Neurosurg. 2003;81:5-9. 2. Chen SY, Chen CH, Sun MH, Lee HT, Shen CC. Stereotactic biopsy for brainstem lesion: comparison of approaches and reports of 10 cases. J Chin Med Assoc. 2011;74:110-114. 3. Epstein F, McCleary EL. Intrinsic brain-stem tumors of childhood: surgical indications. J Neurosurg. 1986;64:11-15. 4. Sanai N, Wachhorst SP, Gupta NM, McDermott MW. Transcerebellar stereotactic biopsy for lesions of the brainstem and peduncles under local anesthesia. Neurosurgery. 2008;63: 460-466 [discussion: 466-468]. 5. Manoj N, Arivazhagan A, Bhat DI, et al. Stereotactic biopsy of brainstem lesions: techniques, efficacy, safety, and disease variation between adults and children: a single institutional series and review. J Neurosci Rural Pract. 2014;5:32.
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editing, Supervision. Mahsa Bahrami: Methodology. Arash Fattahi: Writing - original draft, Methodology.
6. Iijima K, Hirato M, Miyagishima T, et al. Microrecording and image-guided stereotactic biopsy of deep-seated brain tumors. J Neurosurg. 2015;123: 978-988. 7. Brown RA, Nelson JA. The origin and history of the N-localizer for stereotactic neurosurgery. Cureus. 2015;7:e323. 8. Mathisen JR, Giunta F, Marini G, Backlund EO. Transcerebellar biopsy in the posterior-fossa - 12 years experience. Surg Neurol. 1987;28:100-104. 9. Amundson EW, McGirt MJ, Olivi A. A contralateral, transfrontal, extraventricular approach to stereotactic brainstem biopsy procedures - technical note. J Neurosurg. 2005;102: 565-570. 10. Dellaretti M, Reyns N, Touzet G, et al. Stereotactic biopsy for brainstem tumors: comparison of transcerebellar with transfrontal approach. Stereotact Funct Neurosurg. 2012;90:79-83. 11. Barnett GH, Miller DW, Weisenberger J. Frameless stereotaxy with scalp-applied fiducial markers
for brain biopsy procedures: experience in 218 cases. J Neurosurg. 1999;91:569-576. 12. Quick-Weller J, Brawanski N, Dinc N, et al. Stereotactic biopsy of cerebellar lesions: straight versus oblique frame positioning. Br J Neurosurg. 2018;32:210-213.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 16 August 2019; accepted 2 January 2020 Citation: World Neurosurg. (2020). https://doi.org/10.1016/j.wneu.2020.01.003 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2020 Elsevier Inc. All rights reserved.
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