Medscape is available in 5 Language Editions – Choose your Edition here.


Brain Biopsy

  • Author: Anand I Rughani, MD; Chief Editor: Jonathan P Miller, MD  more...
Updated: Mar 14, 2016


Tissue-based pathological diagnosis is the criterion standard in the diagnosis of brain tumors. In situations in which surgical resection is not necessarily indicated but diagnosis of a brain lesion is needed to determine optimal treatment, a stereotactic brain biopsy offers a relatively safe and reliable method of obtaining diagnostic tissue. For over half a century, frame-based stereotactic methods have proven their use, and, more recently, frameless stereotaxy has emerged as a valuable alternative to this. Both framed and frameless stereotactic biopsy are discussed in this topic.



Brain biopsy should be considered when a tissue diagnosis from a suspicious brain lesion is needed to guide treatment and less-invasive methods of diagnosis are exhausted or inappropriate. Generally, brain biopsy is performed in 2 different scenarios. First, and most commonly, it is performed to confirm a suspected brain tumor. A typical situation occurs when diagnostic imaging demonstrates the classic appearance of a primary brain tumor and resection is not felt appropriate, as when the treating team suspects a high-grade glial tumor on the basis of imaging characteristics and does not feel that an aggressive resection is achievable.[1] Tissue diagnosis can confirm the suspected pathology and guide further non-operative treatments.

The second and fortunately less-common scenario occurs when a wide-ranging differential diagnosis has been cast, and a diagnosis remains elusive despite less invasive work-up.



Practically speaking, absolute contraindications to brain biopsy are limited to those lesions felt to be too small to accurately and safely target and to those patients who are coagulopathic or otherwise unable to safely tolerate intravenous sedation or general anesthesia. In patients whose mental status would not permit stereotactic frame placement while under local anesthetic, a general anesthetic could be considered.

In any patient considered for stereotactic brain biopsy, weighing the relative merits of biopsy, namely the ability to obtain a tissue diagnosis, against the potential risks is important. In making this decision, all less-invasive opportunities to obtain a diagnosis should be considered. These could potentially include imaging adjuncts such as MR spectroscopy, sampling of spinal fluid by lumbar puncture, or identification of alternative systemic lesions to biopsy, such as an accessible lung lesion in the setting of multiple intracranial metastases. Exercising caution is important when considering biopsy of lesions that are suspicious for vascular malformations or with highly vascular tumors such as metastatic melanoma. With intraventricular tumors, an endoscopic biopsy can be entertained in favor of a stereotactic biopsy.

Contributor Information and Disclosures

Anand I Rughani, MD Neurosurgeon, Epilepsy and Functional Neurosurgery, Maine Medical Center

Anand I Rughani, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.


Jeffrey E Florman, MD Assistant Clinical Professor of Neurosurgery, Tufts University School of Medicine; Chairman, Division of Neurosurgery, Maine Medical Center; Adjunct Assistant Professor, Division of Neurosurgery, University of Vermont College of Medicine; Neurosurgical and Spine Surgery, Maine Medical Partners

Jeffrey E Florman, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery

Disclosure: Received consulting fee from Stryker Spine for consulting.

Chief Editor

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery Center, Associate Professor of Neurological Surgery, George R and Constance P Lincoln Endowed Chair, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine

Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Medical Association, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic Neuromodulation.

  1. Sanai N, Polley MY, McDermott MW, Parsa AT, Berger MS. An extent of resection threshold for newly diagnosed glioblastomas. J Neurosurg. 2011 Jul. 115(1):3-8. [Medline]. [Full Text].

  2. Watson R, Leslie K. Nerve blocks versus subcutaneous infiltration for stereotactic frame placement. Anesth Analg. 2001 Feb. 92(2):424-7. [Medline].

  3. Tetzlaff JE. The pharmacology of local anesthetics. Anesthesiology Clinical North America. 2000. 18(2):217-233.

  4. Warnick RE, Longmore LM, Paul CA, Bode LA. Postoperative management of patients after stereotactic biopsy: results of a survey of the AANS/CNS section on tumors and a single institution study. J Neurooncol. 2003 May. 62(3):289-96. [Medline].

  5. Boulton M, Bernstein M. Outpatient brain tumor surgery: innovation in surgical neurooncology. J Neurosurg. 2008 Apr. 108(4):649-54. [Medline].

  6. Kaakaji W, Barnett GH, Bernhard D, Warbel A, Valaitis K, Stamp S. Clinical and economic consequences of early discharge of patients following supratentorial stereotactic brain biopsy. J Neurosurg. 2001 Jun. 94(6):892-8. [Medline].

  7. Field M, Witham TF, Flickinger JC, Kondziolka D, Lunsford LD. Comprehensive assessment of hemorrhage risks and outcomes after stereotactic brain biopsy. J Neurosurg. 2001 Apr. 94(4):545-51. [Medline].

  8. Smith JS, Quiñones-Hinojosa A, Barbaro NM, McDermott MW. Frame-based stereotactic biopsy remains an important diagnostic tool with distinct advantages over frameless stereotactic biopsy. J Neurooncol. 2005 Jun. 73(2):173-9. [Medline].

  9. McGirt MJ, Woodworth GF, Coon AL, Frazier JM, Amundson E, Garonzik I. Independent predictors of morbidity after image-guided stereotactic brain biopsy: a risk assessment of 270 cases. J Neurosurg. 2005 May. 102(5):897-901. [Medline].

  10. Woodworth GF, McGirt MJ, Samdani A, Garonzik I, Olivi A, Weingart JD. Frameless image-guided stereotactic brain biopsy procedure: diagnostic yield, surgical morbidity, and comparison with the frame-based technique. J Neurosurg. 2006 Feb. 104(2):233-7. [Medline].

  11. Bot M, van den Munckhof P, Bakay R, Sierens D, Stebbins G, Verhagen Metman L. Analysis of Stereotactic Accuracy in Patients Undergoing Deep Brain Stimulation Using Nexframe and the Leksell Frame. Stereotact Funct Neurosurg. 2015. 93 (5):316-25. [Medline].

  12. Pfisterer WK, Papadopoulos S, Drumm DA, Smith K, Preul MC. Fiducial versus nonfiducial neuronavigation registration assessment and considerations of accuracy. Neurosurgery. 2008 Mar. 62(3 Suppl 1):201-7; discussion 207-8. [Medline].

  13. Rughani AI, Keen J, Tranmer BI, Florman JE. Intracranial Hemorrhage Patterns Associated with Stereotactic Tumor Biopsy. October 2010.

  14. Kondziolka D, Firlik AD, Lunsford LD. Complications of stereotactic brain surgery. Neurol Clin. 1998 Feb. 16(1):35-54. [Medline].

  15. Shooman D, Belli A, Grundy PL. Image-guided frameless stereotactic biopsy without intraoperative neuropathological examination. J Neurosurg. 2010 Aug. 113(2):170-8. [Medline].

  16. Frati A, Pichierri A, Bastianello S, Raco A, Santoro A, Esposito V. Frameless stereotactic cerebral biopsy: our experience in 296 cases. Stereotact Funct Neurosurg. 2011. 89(4):234-45. [Medline].

  17. Paleologos TS, Dorward NL, Wadley JP, Thomas DG. Clinical validation of true frameless stereotactic biopsy: analysis of the first 125 consecutive cases. Neurosurgery. 2001 Oct. 49(4):830-5; discussion 835-7. [Medline].

  18. Amin DV, Lozanne K, Parry PV, Engh JA, Seelman K, Mintz A. Image-guided frameless stereotactic needle biopsy in awake patients without the use of rigid head fixation. J Neurosurg. 2011 May. 114(5):1414-20. [Medline].

  19. Bernays RL, Kollias SS, Khan N, Brandner S, Meier S, Yonekawa Y. Histological yield, complications, and technological considerations in 114 consecutive frameless stereotactic biopsy procedures aided by open intraoperative magnetic resonance imaging. J Neurosurg. 2002 Aug. 97(2):354-62. [Medline].

  20. Bernays RL, Kollias SS, Khan N, Brandner S, Meier S, Yonekawa Y. Histological yield, complications, and technological considerations in 114 consecutive frameless stereotactic biopsy procedures aided by open intraoperative magnetic resonance imaging. J Neurosurg. 2002 Aug. 97(2):354-62. [Medline].

Upper left: The Cosman-Roberts-Wells (CRW) unit is affixed to the skull using 4-point fixation of the base ring. The CRW frame is attached to the base ring by way of 3 ball-in-socket joints. Upper right: With adequate low placement of the base ring, direct posterior fossa trajectories are practicable. Lower left: Demonstration of a direct lateral entry point approach is possible with the frame. Lower right: Lateral placement of the base ring is feasible with the use of specially designed partial arcs.
The Leksell head ring.
Preoperative contrast-enhanced coronal T1-weighted MRI demonstrating a multifocal enhancing left fronto-temporo-insular tumor, suggestive of a high-grade glioma.
This illustrates the planned target, cortical entry point, and trajectory of the stereotactic biopsy of the lesion seen in the previous image. The trajectory is planned with an effort to obtain the most accessible enhancing portion of the lesion. Of note, the planning software reverses the conventional left-right orientation.
This is the 3-dimensional representation of the biopsy plan seen in the previous images as generated by the planning software. In the absence of a phantom base, generating this image in the operating room to confirm that the actual trajectory is consistent with this representation can be useful.
This is the postoperative noncontrast coronal CT scan of the same patient in the previous images, which clearly demonstrates the trephination and the biopsy tract, with a punctate hemorrhage at the biopsy site and scant hemorrhage along the tract.
This image illustrates a typical configuration of the targeting device. Knowing the distances from each point in the configuration to the target is important. From the bottom of the blue reducer, the target is 160 mm. The blue reducer measures 10 mm and thus places the target at 170 mm. Generally, an additional reducer, measuring 5 mm, is placed within the blue reducer, which leads to a final distance of 175 mm to target. Thus, the biopsy cannula can be set to that depth.
The distance to the target can be calculated, but direct measurement with a phantom base should be considered to confirm the calculation.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.