Brain Biopsy

Updated: Oct 29, 2018
  • Author: Anand I Rughani, MD; Chief Editor: Jonathan P Miller, MD  more...
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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.