Stereotactic biopsy complications

Stereotactic biopsy complications

The most frequent complication after stereotactic biopsy is hemorrhage, although most are too small to have a clinical impact. The risk of a major complication (mostly due to hemorrhage) in nonimmunocompromised (NIC) patients ranges from 0–3% (with most < 1%), and 0–12% in AIDS 1)

Higher complication rates seen in AIDS patients in some series may be due to reduced platelet count or function, and to vessel fragility in primary CNS lymphoma. In NIC patients, multifocal high-grade gliomas had the highest complication rate. Infection is an infrequent complication with a needle biopsy.

About 132 articles were found after research in the Medline database. Riche et al. only considered English references published between 1994 and June 2019. Additional studies were found by using the references from articles identified in the original search. This systematic review was conducted according to PRISMA guidelines. After applying exclusion criteria, they eventually considered 25 relevant studies. The mortality rate varies from 0.7 to 4%. Overall morbidity ranges from 3 to 13%. Most of the complications are revealed by the following symptoms: neurological impairment (transient or permanent), seizure, and unconsciousness. Symptomatic hemorrhage range varies from 0.9 to 8.6%, whereas considering asymptomatic bleeding, the range may be up to 59.8%. Complications were clinically evident within minutes to a few hours after the biopsy. Corrective surgeries are very rare (< 1%). Complications occurring after a frame-based stereotactic brain biopsy are rare but with serious side effects. It rarely leads to death or to permanent neurological impairment. The description and classification of complications are often heterogeneous in the literature. The use of a grading scale could help comparisons between series from around the world. Future studies should establish a score that allows neurosurgeon to predict post-biopsy complications 2).

Negative biopsy

Insufficient yield in up to 5% as well as surgical complications in up to 6 to 12% has been reported 3) 4) 5) 6) 7)

Livermore et al., advocate intra-operative histopathological analysis to decrease negative biopsy rates and advise increased caution when undertaking biopsies of deep lesions or suspected lymphoma cases due to the potentially increased risk of hemorrhage 8).




Nicolato A, Gerosa M, Piovan E, et al. Computerized Tomography and Magnetic Resonance Guided Stereotactic Brain Biopsy in Nonimmunocom- promised and AIDS Patients. Surg Neurol. 1997; 48: 267–277

Riche M, Amelot A, Peyre M, Capelle L, Carpentier A, Mathon B. Complications after frame-based stereotactic brain biopsy: a systematic review. Neurosurg Rev. 2020 Jan 4. doi: 10.1007/s10143-019-01234-w. [Epub ahead of print] Review. PubMed PMID: 31900737.

Dammers R, Haitsma IK, Schouten JW, Kros JM, Avezaat CJ, Vincent AJ. Safety and efficacy of frameless and frame-based intracranial biopsy techniques. Acta Neurochir (Wien). 2008;150(1):23-29.

Hall WA. The safety and efficacy of stereotactic biopsy for intracranial lesions. Cancer. 1998;82(9):1749-1755.

Lu Y, Yeung C, Radmanesh A, Wiemann R, Black PM, Golby AJ. Comparative effectiveness of frame-based, frameless, and intraoperative magnetic resonance imaging-guided brain biopsy techniques. World Neurosurg. 2015;83(3):261-268.

Malone H, Yang J, Hershman DL, Wright JD, Bruce JN, Neugut AI. Complications following stereotactic needle biopsy of intracranial tumors. World Neurosurg. 2015;84(4):1084-1089.

Dammers R, Schouten JW, Haitsma IK, Vincent AJ, Kros JM, Dirven CM. Towards improving the safety and diagnostic yield of stereotactic biopsy in a single centre. Acta Neurochir. 2010;152(11):1915-1921.

Livermore LJ, Ma R, Bojanic S, Pereira EA. Yield and complications of frame-based and frameless stereotactic brain biopsy – The value of intra-operative histological analysis. Br J Neurosurg. 2014 Feb 25. [Epub ahead of print] PubMed PMID: 24568533.

Frame-based stereotactic biopsy

Frame-based stereotactic biopsy

Frame based stereotactic biopsy (FSB) remains the ‘gold standard’ for obtaining diagnostic samples of intracranial lesions to guide therapy. Nevertheless, diagnostic yield is highly variable.

The diagnostic yield from contemporary FSB is high and is dependent predominantly on lesion size. 1).


Case series

retrospective cohort study was conducted of all adult patients with imaging-documented lesions undergoing FSB at the Beth Israel Deaconess Medical Center between 20132018. Diagnostic accuracy, lesion characteristics associated with non-diagnostic biopsy, and surgical complications were evaluated. A biopsy was considered non-diagnostic if all frozen samples and the final pathology yielded normal brain tissue or non-specific reactive tissue unless the “reactive” pathology was consistent with radiation injury from prior therapy.

This search identified 198 FSB patients. Mean (SD) age was 62±17 years and 44.2% were female. The median procedure time was 32 minutes. A definitive histologic diagnosis was established in 187 cases (94.4% diagnostic yield). The mean lesion diameter was 31.9±16.8 mm. Multivariable logistic regression revealed only lesion diameter to be significantly associated with a diagnostic result (OR for the non-diagnostic result: 0.94 per mm diameter decrease, 95% CI 0.87-0.99, P=0.028). On univariable analysis, the diagnosis of CNS lymphoma appeared to increase the risk of a non-diagnostic biopsy (P=0.025), but this association disappeared when controlling for lesion size and steroid administration prior to biopsy. Eight patients (4.0%) developed postoperative hemorrhagic complications, three of whom required reoperation, and another expired.

This study demonstrates that diagnostic yield from contemporary FSB is high and is dependent predominantly on lesion size. 2).

Hamisch et al. evaluated the feasibility, safety, and diagnostic yield of frame-based stereotactic biopsies (SB) in lesions located in deep-seated and midline structures of the brain to analyze these parameters in comparison to other brain areas.

In a retrospective, tertiary care single-center analysis, they identified all patients who received SB for lesions localized in deep-seated and midline structures (corpus callosum, basal ganglia, pineal region, sella, thalamus, and brainstem) between January 1996 and June 2015. Study participants were between 1 and 82 years. We evaluated the feasibility, procedural complications (mortality, transient and permanent morbidity), and diagnostic yield. We further performed a risk analysis of factors influencing the latter parameters. Chi-square test, Student t test, and Mann-Whitney rank-sum test were used for statistical analysis.

Four hundred eighty-nine patients receiving 511 SB procedures (median age 48.5 years, range 1-82; median Karnofsky Performance Score 80%, range 50-100%, 43.8% female/56.2% male) were identified. Lesions were localized in the corpus callosum (29.5%), basal ganglia (17.0%), pineal region (11.5%), sella (7.8%), thalamus (4.3%), brainstem (28.8%), and others (1.1%). Procedure-related mortality was 0%, and permanent morbidity was 0.4%. Transient morbidity was 9.6%. Histological diagnosis was possible in 99.2% (low-grade gliomas 16.2%, high-grade gliomas 40.3%, other tumors in 27.8%, no neoplastic lesions 14.5%, no definitive histological diagnosis 0.8%). Only the pons location correlated significantly with transient morbidity (p < 0.001).

In experienced centers, frame-based stereotactic biopsy is a safe diagnostic tool with a high diagnostic yield also for deep-seated and midline lesions 3).

A report described the methodology, diagnostic yield, and adverse events (AE) associated with frame-based stereotactic brain biopsies (FBSB) obtained from 26 dogs with solitary forebrain lesions. Medical records were reviewed from dogs that underwent FBSB using two stereotactic headframes designed for use in small animals and compatible with computed tomographic (CT) and magnetic resonance (MR) imaging. Stereotactic plans were generated from MR and CT images using commercial software, and FBSB performed both with (14/26) and without intraoperative image guidance. Records were reviewed for diagnostic yield, defined as the proportion of biopsies producing a specific neuropathological diagnosis, AE associated with FBSB, and risk factors for the development of AE. Postprocedural AE were evaluated in 19/26 dogs that did not proceed to a therapeutic intervention immediately following biopsy. Biopsy targets included intra-axial telencephalic masses (24/26), one intra-axial diencephalic mass, and one extra-axial parasellar mass. The median target volume was 1.99 cm(3). No differences in patient, lesion, or outcome variables were observed between the two headframe systems used or between FBSB performed with or without intraoperative CT guidance. The diagnostic yield of FBSB was 94.6%. Needle placement error was a significant risk factor associated with procurement of non-diagnostic biopsy specimens. Gliomas were diagnosed in 24/26 dogs, and meningioma and granulomatous meningoencephalitis in 1 dog each. AE directly related to FBSB were observed in a total of 7/26 (27%) of dogs. Biopsy-associated clinical morbidity, manifesting as seizures and transient neurological deterioration, occurred in 3/19 (16%) of dogs. The case fatality rate was 5.2% (1/19 dogs), with death attributable to intracranial hemorrhage. FBSB using the described apparatus was relatively safe and effective at providing neuropathological diagnoses in dogs with focal forebrain lesions 4).

Grand Challenge Veterinary Neurology and Neurosurgery: Veterinary Neurology and Neurosurgery – Research for Animals and Translational Aspects 5).


1) , 2)

Maragkos GA, Penumaka A, Ahrendsen JT, Salem MM, Nelton EB, Alterman RL. Factors Affecting the Diagnostic Yield of Frame-Based Stereotactic Intracranial Biopsies. World Neurosurg. 2019 Dec 25. pii: S1878-8750(19)33134-1. doi: 10.1016/j.wneu.2019.12.102. [Epub ahead of print] PubMed PMID: 31883483.

Hamisch CA, Minartz J, Blau T, Hafkemeyer V, Rueß D, Hellerbach A, Grau SJ, Ruge MI. Frame-based stereotactic biopsy of deep-seated and midline structures in 511 procedures: feasibility, risk profile, and diagnostic yield. Acta Neurochir (Wien). 2019 Jul 29. doi: 10.1007/s00701-019-04020-1. [Epub ahead of print] PubMed PMID: 31359191.

Rossmeisl JH, Andriani RT, Cecere TE, Lahmers K, LeRoith T, Zimmerman KL, Gibo D, Debinski W. Frame-Based Stereotactic Biopsy of Canine Brain Masses: Technique and Clinical Results in 26 Cases. Front Vet Sci. 2015 Jul 27;2:20. eCollection 2015. PubMed PMID: 26664949.

Tipold A. Grand Challenge Veterinary Neurology and Neurosurgery: Veterinary Neurology and Neurosurgery – Research for Animals and Translational Aspects. Front Vet Sci. 2015 May 26;2:13. eCollection 2015. PubMed PMID: 26664942.
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