Brain Biopsy Periprocedural Care

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

Equipment

Several different stereotactic frames are widely used and available to surgeons. The 2 most commonly used are the Leksell frame (Elekta Instrument, Stockholm, Sweden) illustrated in the first image below and the Cosman-Roberts-Wells, or CRW frame (Radionics Inc, Burlington, MA), illustrated in the second image below. Commonly used surgical planning and navigation software is available from both proprietors, as well as from BrainLAB (BrainLAB, Heimstetten, Germany) and StealthStation (Medtronic, Fridley, MN).

The Leksell head ring. The Leksell head ring.
Upper left: The Cosman-Roberts-Wells (CRW) unit is 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.
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Patient Preparation

Anesthesia

Framed stereotactic biopsy is generally performed under local anesthetic with intravenous sedation, whereas frameless stereotactic biopsy is more commonly performed under general anesthetic. Stereotactic frame placement typically occurs in the preoperative holding area or on the inpatient ward. During frame placement, a combination of intravenous narcotic (such as fentanyl) and anxiolytic (such as midazolam) are both given as a single dose. Additionally, local anesthetic is injected at the 4 pin sites. The authors prefer to use 0.5% bupivacaine with epinephrine. Consideration can also be given to performing nerve blocks as well. [2] The injection of local anesthetic is better tolerated when buffered with sodium bicarbonate.

Once the frame is placed, the patient is taken to CT or MRI without additional sedation, which facilitates patient transfers onto the CT or MRI gurney and subsequently onto the operative table. When satisfactorily positioned on the operative table, additional intravenous sedation can resume and continue through the procedure. At this point, a continuous infusion, such as propofol, is frequently used as needed for patient comfort. Additional local anesthetic is injected at the planned surgical incision. Intravenous sedation, should be performed under monitored anesthesia care from the time of frame placement until frame removal. Maximum tolerated doses of local anesthetics should be borne in mind. With 0.5% bupivacaine and 1:1000 epinephrine, the maximum dose is 3 mg/kg. [3]

In those patients unable to tolerate frame placement under local anesthetic and sedation alone, general anesthesia can be performed. This generally requires frame placement in the operating room and requires more support staff to facilitate with patient positioning and transfers.

Positioning

For most lesions being biopsied, the patient can be positioned on the operating table in the supine position. This allows comfortable entry to most frontal, temporal, parietal, and subcortical structures. Lateral position can be used for a horizontal trajectory to approach temporal lesions, and prone position can be used for access to the posterior fossa. For patient comfort and access, the back of the table is raised to 30-45º, and the legs dropped. The frame is rigidly secured to the operating table with a Mayfield head holder. The patient can be firmly secured to the table with a padded safety belt. Arm boards can remain attached to the table for patient comfort. For a more detailed description of frame placement, see the Technique section.

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Monitoring & Follow-up

Routine postoperative imaging

In a survey of 629 practicing neurosurgeons, the slight majority (59%) routinely perform an automatic noncontrast head CT scan following biopsy, regardless of patient clinical condition. [4] Several advantages to obtaining a postoperative CT scan exist. First, the location of the biopsy can usually be appreciated by a scant amount of hemorrhage or air at the site. This can prove useful in the event that the pathology does not corroborate precisely, either nondiagnostically or with a discrepancy in tumor grading. Second, a CT scan that shows no appreciable or clinically relevant hemorrhage can help more appropriately select a postoperative setting for the patient.

Overnight observation

Among patients who are admitted for an elective biopsy, the postoperative care can range from discharge home to intensive care unit observation. In a recent survey, 6% of surgeons routinely discharge patients home following biopsy, and 47% admit them to a routine surgical ward. [4] Some data suggest that patients can be safely discharged home without risk of deterioration or readmission in the appropriately selected patients who undergo a routine postoperative head CT scan and 4 hours of observation without risk of deterioration or readmission. [5, 6, 6]

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