Complications in 622 Cases of Frame-Based Stereotactic Biopsy, a Decreasing Procedure

Background:Frame-based stereotactic brain biopsy has played an important role in the management of patients with suspected neoplastic intracranial lesions over the last three decades. We reviewed the surgical experience of one surgeon to determine the nature and frequency of complications associated with this procedure.Methods:Records were reviewed for 858 patients undergoing frame-based stereotactic procedures from January 1986 to May 2006. Data on each case were prospectively collected by the senior author. Procedures for Ommaya reservoir placement, brachytherapy, stereotactic craniotomy flap localization, shunt placement, or treatment of previously-diagnosed intracranial cystic lesions were excluded, leaving 614 patients in whom a total of 622 procedures were performed for purely diagnostic purposes. Complication rates and their association with clinical variables were sought.Results:Morbidity and mortality rates were 6.9% (43/622) and 1.3% (8/622), respectively. The risk of symptomatic hemorrhage (intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], intraventricular hemorrhage [IVH]) was 4.8%. The risks of transient or permanent neurological deficits were 2.9% (18/622) and 1.5% (9/622), respectively. Biopsy of deep-seated lesions was associated with increased overall complication rate, while biopsy of Glioblastoma Multiforme (GBM) was associated with perioperative mortality.Conclusions:Overall, complication rates were comparable with those in previous reports. The subgroup of patients with deep-seated lesions or a histologic diagnosis of GBM may possess an elevated risk of overall complications or mortality, respectively, compared to other patients undergoing frame-based stereotactic brain biopsy.

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IMPACT OF BRAIN BIOPSY ON THE MANAGEMENT OF PATIENTS WITH NONNEOPLASTIC UNDIAGNOSED NEUROLOGICAL DISORDERS

Neurosurgery ◽

10.1227/01.neu.0000318168.97966.17 ◽

2008 ◽

Vol 62 (4) ◽

pp. 833-838 ◽

Cited By ~ 20

Author(s):

Heinke Pulhorn ◽

D. Gavin Quigley ◽

Jark J.D. Bosma ◽

Ramez Kirollos ◽

Daniel G. du Plessis ◽

...

Keyword(s):

Neurological Disorders ◽

Stereotactic Biopsy ◽

Diagnostic Yield ◽

Diagnostic Category ◽

Brain Biopsy ◽

Clinical Impact ◽

Complication Rates ◽

Open Biopsy ◽

Retrospective Case ◽

Stereotactic Brain Biopsy

Abstract OBJECTIVE We sought to assess the diagnostic yield, complication rates, and therapeutic impact of open brain biopsy and serial stereotactic brain biopsy in the management of patients with nonneoplastic neurological conditions in which conventional investigations did not yield a definitive diagnosis. METHODS A retrospective case note analysis was undertaken in consecutive patients undergoing brain biopsy at The Walton Centre for Neurology and Neurosurgery during a 15-year period. The diagnostic yield, prebiopsy diagnostic category, biopsy technique (open versus stereotactic), complication rates, and impact on clinical management were assessed. Biopsies were grouped into one of five categories: diagnostic, suggestive, nonspecific, normal, or nondiagnostic. RESULTS Thirty-nine patients underwent biopsy. The diagnostic yield (combined diagnostic and suggestive) of targeted serial stereotactic biopsy was 64% (seven of 11 patients); in the open brain biopsy group, the diagnostic yield was 46% (13 of 28 patients). The prebiopsy diagnosis was confirmed in 100% (three of three patients) stereotactic biopsy patients and 75% (nine of 12 patients) of open biopsy patients. Two patients (7%) in the open biopsy group had short-term complications. The clinical impact was similar in both groups: nine of 28 (32%) open biopsy patients and four of 11 (36%) stereotactic biopsy patients. CONCLUSION Despite the low clinical impact, diagnostic brain biopsy should be considered in patients with nonneoplastic undiagnosed neurological disorders. Patients with neuroimaging abnormalities should preferentially undergo targeted biopsy.

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Histological yield, complications, and technological considerations in 114 consecutive frameless stereotactic biopsy procedures aided by open intraoperative magnetic resonance imaging

Journal of Neurosurgery ◽

10.3171/jns.2002.97.2.0354 ◽

2002 ◽

Vol 97 (2) ◽

pp. 354-362 ◽

Cited By ~ 54

Author(s):

René L. Bernays ◽

Spyros S. Kollias ◽

Nadia Khan ◽

Sebastian Brandner ◽

Sonja Meier ◽

...

Keyword(s):

Magnetic Resonance ◽

Mr Imaging ◽

Stereotactic Biopsy ◽

Brain Biopsy ◽

Ct Scanning ◽

Complication Rates ◽

Stereotactic Brain Biopsy ◽

Content Type ◽

Fine Print

Object. The authors undertook a prospective study of frameless, magnetic resonance (MR)—guided stereotactic brain biopsy procedures performed with the aid of an open MR system. Morbidity and mortality rates, frequency of postoperative hemorrhage, and histological yield were evaluated, as well as the size and location of the lesions under investigation. Methods. During a period of 51 months (July 1996–November 2000), 114 consecutive frameless stereotactic biopsy procedures were performed with the aid of an open intraoperative MR system to investigate supratentorial lesions in 113 patients. The median volume of the lesions was 33.5 cm3, and 31.9% were deep seated. All biopsy samples comprised pathological tissue and in 111 (97.4%) of 114 a specific neuropathological diagnosis was made. A follow-up computerized tomography (CT) scan was obtained on the 1st postoperative day in all patients to evaluate postoperative complications. In two cases (1.8%), a hemorrhage was found on postoperative CT scans, with no neurological worsening of the patients. Morbidity with neurological worsening was seen in three patients; it was transient in two of them (1.8%), and in one (0.9%) subsequent emergency craniotomy was necessary because of increased edema. There were no infections, but there was one death (0.9%) Conclusions. Open intraoperative MR imaging transforms a blind conventional stereotactic procedure into a visually controlled procedure that is adaptable to dynamic anatomical changes. Routine postprocedural MR imaging makes follow-up CT scanning obsolete. This largest reported series of intraoperative MR—guided biopsy procedures shows results that are at least comparable with those in reports of larger series of conventional stereotactic biopsy sampling. The mean procedure time was 60 minutes including planning, and this method produced low morbidity and complication rates and a high histological yield.

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Frameless image-guided stereotactic brain biopsy procedure: diagnostic yield, surgical morbidity, and comparison with the frame-based technique

Journal of Neurosurgery ◽

10.3171/jns.2006.104.2.233 ◽

2006 ◽

Vol 104 (2) ◽

pp. 233-237 ◽

Cited By ~ 132

Author(s):

Graeme F. Woodworth ◽

Matthew J. McGirt ◽

Amer Samdani ◽

Ira Garonzik ◽

Alessandro Olivi ◽

...

Keyword(s):

Stereotactic Biopsy ◽

Diagnostic Yield ◽

Brain Biopsy ◽

Morbidity Rate ◽

Frameless Stereotaxy ◽

Cortical Lesions ◽

Stereotactic Brain Biopsy ◽

Biopsy Procedure ◽

Image Guided ◽

Permanent Morbidity

Object The gold standard for stereotactic brain biopsy target localization has been frame-based stereotaxy. Recently, frameless stereotactic techniques have become increasingly utilized. Few authors have evaluated this procedure, analyzed preoperative predictors of diagnostic yield, or explored the differences in diagnostic yield and morbidity rate between the frameless and frame-based techniques. Methods A consecutive series of 110 frameless and 160 frame-based image-guided stereotactic biopsy procedures was reviewed. Associated variables for both techniques were reviewed and compared. All stereotactic biopsy procedures were included in a risk factor analysis of nondiagnostic biopsy sampling. Frameless stereotaxy led to a diagnostic yield of 89%, with a total permanent morbidity rate of 6% and a mortality rate of 1%. Larger lesions were fivefold more likely to yield diagnostic tissues. Deep-seated lesions were 2.7-fold less likely to yield diagnostic tissues compared with cortical lesions. Frameless compared with frame-based stereotactic biopsy procedures showed no significant differences in diagnostic yield or transient or permanent morbidity. For cortical lesions, more than one needle trajectory was required more frequently to obtain diagnostic tissues with frame-based as opposed to frameless stereotaxy, although this factor was not associated with morbidity. Conclusions With regard to diagnostic yield and complication rate, the frameless stereotactic biopsy procedure was found to be comparable to or better than the frame-based method. Smaller and deep-seated lesions together were risk factors for a nondiagnostic tissue yield. Frameless stereotaxy may represent a more efficient means of obtaining biopsy specimens of cortical lesions but is otherwise similar to the frame-based technique.

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Incidence of silent hemorrhage and delayed deterioration after stereotactic brain biopsy

Journal of Neurosurgery ◽

10.3171/jns.1998.89.1.0031 ◽

1998 ◽

Vol 89 (1) ◽

pp. 31-35 ◽

Cited By ~ 83

Author(s):

Abhaya V. Kulkarni ◽

Abhijit Guha ◽

Andres Lozano ◽

Mark Bernstein

Keyword(s):

Ct Scan ◽

Neurological Deficit ◽

Stereotactic Biopsy ◽

Brain Biopsy ◽

Ct Scanning ◽

Ct Scans ◽

Stereotactic Brain Biopsy ◽

Content Type ◽

Fine Print

Object. Many neurosurgeons routinely obtain computerized tomography (CT) scans to rule out hemorrhage in patients after stereotactic procedures. In the present prospective study, the authors investigated the rate of silent hemorrhage and delayed deterioration after stereotactic biopsy sampling and the role of postbiopsy CT scanning. Methods. A subset of patients (the last 102 of approximately 800 patients) who underwent stereotactic brain biopsies at the Toronto Hospital prospectively underwent routine postoperative CT scanning within hours of the biopsy procedure. Their medical charts and CT scans were then reviewed. A postoperative CT scan was obtained in 102 patients (aged 17–87 years) who underwent stereotactic biopsy between June 1994 and September 1996. Sixty-one patients (59.8%) exhibited hemorrhages, mostly intracerebral (54.9%), on the immediate postoperative scan. Only six of these patients were clinically suspected to have suffered a hemorrhage based on immediate postoperative neurological deficit; in the remaining 55 (53.9%) of 102 patients, the hemorrhage was clinically silent and unsuspected. Among the clinically silent intracerebral hemorrhages, 22 measured less than 5 mm, 20 between 5 and 10 mm, five between 10 and 30 mm, and four between 30 and 40 mm. Of the 55 patients with clinically silent hemorrhages, only three demonstrated a delayed neurological deficit (one case of seizure and two cases of progressive loss of consciousness) and these all occurred within the first 2 postoperative days. Of the neurologically well patients in whom no hemorrhage was demonstrated on initial postoperative CT scan, none experienced delayed deterioration. Conclusions. Clinically silent hemorrhage after stereotactic biopsy is very common. However, the authors did not find that knowledge of its existence ultimately affected individual patient management or outcome. The authors, therefore, suggest that the most important role of postoperative CT scanning is to screen for those neurologically well patients with no hemorrhage. These patients could safely be discharged on the same day they underwent biopsy.

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Stereotactic Brain Biopsy in Eloquent Areas Assisted by Navigated Transcranial Magnetic Stimulation: a Technical Case Report

Operative Neurosurgery ◽

10.1093/ons/opy321 ◽

2018 ◽

Vol 17 (3) ◽

pp. E124-E129 ◽

Cited By ~ 2

Author(s):

Jiri Bartek ◽

Gerald Cooray ◽

Mominul Islam ◽

Margret Jensdottir

Keyword(s):

Transcranial Magnetic Stimulation ◽

Magnetic Stimulation ◽

Stereotactic Biopsy ◽

Brain Biopsy ◽

Awake Surgery ◽

Histopathological Diagnosis ◽

Navigated Transcranial Magnetic Stimulation ◽

Stereotactic Brain Biopsy ◽

Eloquent Areas ◽

The Brain

Abstract BACKGROUND AND IMPORTANCE Stereotactic brain biopsy (SB) is an important part of the neurosurgical armamentarium, with the possibility of achieving histopathological diagnosis in otherwise inaccessible lesions of the brain. Nevertheless, the procedure is not without the risk of morbidity, which is especially true for lesions in eloquent parts of the brain, where even a minor adverse event can result in significant deficits. Navigated transcranial magnetic stimulation (nTMS) is widely used to chart lesions in eloquent areas, successfully guiding maximal safe resection, while its potential role in aiding with the planning of a stereotactic biopsy is so far unexplored. CLINICAL PRESENTATION Magnetic resonance imaging of a 67-yr-old woman presenting with dysphasia revealed a noncontrast enhancing left-sided lesion in the frontal and parietal pars opercularis. Due to the location of the lesion, nTMS was used to chart both primary motor and language cortex, utilizing this information to plan a safe SB trajectory and sampling area according to the initial work-up recommendations from the multidisciplinary neuro-oncology board. The SB was uneventful, with histology revealing a ganglioglioma, WHO I. The patient was discharged the following day, having declined to proceed with tumor resection (awake surgery) due to the non-negligible risk of morbidity. Upon 1- and 3-mo follow-up, she showed no signs of any procedure-related deficits. CONCLUSION nTMS can be implemented to aid with the planning of a stereotactic biopsy procedure in eloquent areas of the brain, and should be considered part of the neurosurgical armamentarium.

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Frame-based Stereotactic Biopsy: Description and Association of Anatomical, Radiologic, and Surgical Variables with Diagnostic Yield in a Series of 407 Cases

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0038-1676597 ◽

2019 ◽

Vol 80 (03) ◽

pp. 149-161 ◽

Cited By ~ 3

Author(s):

Monica Lara-Almunia ◽

Javier Hernandez-Vicente

Keyword(s):

Stereotactic Biopsy ◽

Diagnostic Yield ◽

Invasive Technique ◽

Histologic Diagnosis ◽

Stereotactic Techniques ◽

Cystic Component ◽

Intracranial Lesions ◽

Spss Software ◽

Improved Accuracy ◽

Extensive Necrosis

Background and Study Aims Stereotactic biopsy is a versatile, minimally invasive technique to obtain tissue safely from intracranial lesions for their histologic diagnosis and therapeutic management. Our objective was to determine the anatomical, radiologic, and technical factors that can affect the diagnostic yield of this technique. We suggest recommendations to improve its use in clinical practice. Methods This retrospective study evaluated 407 patients who underwent stereotactic biopsies in the past 34 years. The surgical methodology changed through time, distinguished by three distinct periods. Different stereotactic frames (Todd-Wells, CRW, Leksell), neuroimaging tests, and planning programs were used. Using SPSS software v.23, we analyzed a total of 50 variables for each case. Results The series included 265 men (65.1%) and 142 women (34.9%) (average age 53.8 years). The diagnostic yield was 90.4%, morbidity was 5.65% (n = 17), and mortality was 0.98% (n = 4). Intraoperative biopsy improved accuracy (p = 0.024). Biopsies of deep lesions (p = 0.043), without contrast enhancement (p = 0.004), edema (p = 0.036), extensive necrosis (p = 0.028), or a large cystic component (p = 0.023) resulted in a worse diagnostic yield. Neurosurgeons inexperienced in stereotactic techniques obtained more nondiagnostic biopsies (p = 0.043). Experience was the clearest predictive factor of diagnostic yield (odds ratio: 4.049). Conclusions Increased experience in stereotactic techniques, use of the most suitable magnetic resonance imaging sequences during biopsy planning, and intraoperative evaluation of the sample before finalizing the collection are recommended features and ways to improve the diagnostic yield of this technique.

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Stereotactic Biopsy in the Diagnosis of Brain Masses: Comparison of Results of Biopsy and Resected Surgical Specimen

Neurosurgery ◽

10.1227/00006123-198902000-00002 ◽

1989 ◽

Vol 24 (2) ◽

pp. 160-165 ◽

Cited By ~ 133

Author(s):

Parakrama T. Chandrasoma ◽

Maurice M. Smith ◽

Michael L. J. Apuzzo

Keyword(s):

Glioblastoma Multiforme ◽

Clinical Management ◽

Stereotactic Biopsy ◽

Granulomatous Inflammation ◽

Brain Biopsy ◽

Diagnostic Error ◽

Stereotactic Brain Biopsy ◽

Biopsy Material ◽

Surgical Specimen ◽

Oligodendroglial Component

Abstract We report the pathological accuracy of image-directed stereotactic brain biopsy in 30 patients who had mass lesions of the brain and subsequently underwent resection of the mass. The histological diagnosis at stereotactic biopsy was appropriate for direction of clinical management in 28 of 30 patients. Correlation between the stereotactic and resection diagnoses was exact in 19 of 30 cases. These included 11 of 12 nonastrocytic neoplasms and 8 of 13 astrocytic neoplasms. Correlation was imperfect in 9 of 30 cases, but not to the extent of having significant clinical impact. These included 2 cases of anaplastic astrocytoma that were upgraded to glioblastoma multiforme, 2 cases of astrocytoma that had a significant oligodendroglial component, and 5 non-neoplastic lesions that were reported on biopsy as showing nonspecific reactive changes. In 2 of 30 patients, the stereotactic biopsy was not accurate. This included one patient who had glioblastoma multiforme whose stereotactic biopsy showed only necrotic tissue. Serious diagnostic error that resulted in clinical mismanagement occurred in one patient who had a pineal germinoma that had large areas of granulomatous inflammation at which the stereotactic biopsy was directed. This study provides evidence that, with careful target placement, stereotactic biopsy can provide biopsy material that represents the entire lesion with an accuracy that is sufficient for clinical management.

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SURGERY FOR CONVEXITY MENINGIOMAS

Neurosurgery ◽

10.1227/01.neu.0000310692.80289.28 ◽

2008 ◽

Vol 63 (3) ◽

pp. 427-434 ◽

Cited By ~ 48

Author(s):

Andrew P. Morokoff ◽

Jacob Zauberman ◽

Peter M. Black

Keyword(s):

Recurrence Rate ◽

Malignant Tumors ◽

Surgical Techniques ◽

Senior Author ◽

Neurological Deficits ◽

Complication Rates ◽

Recurrence Rates ◽

Complete Excision ◽

Image Guided

ABSTRACT OBJECTIVE Meningiomas that occur over the convexity of the brain are the most common meningiomas, but little has been published about their contemporary management. We aimed to analyze a large series of convexity meningiomas with respect to surgical technique, complication rates, and pathological factors leading to recurrence. METHODS We retrospectively reviewed 163 cases of convexity meningiomas operated on in our institution by the senior author (PMB) between 1986 and 2005. The median follow-up time was 2.3 years (range, 1–13 yr). RESULTS Convexity tumors represented 22% of all meningiomas operated on. There was a female:male ratio of 2.7:1. Median age was 57 years (range, 20–89 yr). Image-guided surgery was used on all cases in the last 5 years. The 30-day mortality rate was 0%. The incidence of new neurological deficits was 1.7%, and the overall complication rate was 9.4%. The pathology of the tumors was benign in 144 (88.3%), atypical in 16 (9.8%), and anaplastic/malignant in 3 (1.8%). In six of the cases designated “benign,” there were borderline atypical features. The 5-year recurrence rate for benign meningiomas was 1.8%, atypical meningiomas 27.2%, and anaplastic meningiomas 50%. The two cases of benign tumor recurrences involved tumors with borderline atypia and high MIB-1 indices. The borderline atypical cases had a 5-year recurrence-free survival rate of only 55.9%, more closely approximating that of tumors designated “atypical.” CONCLUSION Convexity meningiomas can be safely removed using modern image-guided minimally invasive surgical techniques with a very low operative mortality. Benign convexity meningiomas having a Simpson Grade I complete excision have a very low recurrence rate. The recurrence rates of atypical and malignant tumors are significantly higher, and borderline atypical tumors should be considered to behave more like atypical rather than benign lesions. Longer-term follow-up data are needed to more accurately determine the recurrence rates of benign meningiomas.

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A prospective single-center analysis of the safety and efficacy of the HydroCoil embolization system for the treatment of intracranial aneurysms

Journal of Neurosurgery ◽

10.3171/jns.2007.106.2.226 ◽

2007 ◽

Vol 106 (2) ◽

pp. 226-233 ◽

Cited By ~ 48

Author(s):

Eric M. Deshaies ◽

Matthew A. Adamo ◽

Alan S. Boulos

Keyword(s):

Recurrence Rate ◽

Neurological Complication ◽

Contrast Material ◽

Senior Author ◽

Neurological Deficits ◽

Complication Rates ◽

Recurrence Rates ◽

Aneurysm Embolization ◽

Cranial Nerve Palsies ◽

Bare Platinum Coils

Object The HydroCoil embolization system is a helical platinum coil coated with a polymeric hydrogel that expands when it contacts aqueous solutions to increase filling volumes, improve mesh stability, and possibly elicit a healing response within the aneurysm. In this paper, the authors report the 1-year recurrence and complication rates of 67 aneurysms embolized with the HydroCoil system. Methods Sixty-four consecutive patients (67 total aneurysms) with small (≤ 7 mm), large (8–15 mm), very large (16–24 mm), and giant (≥ 25 mm) aneurysms in the anterior and posterior intracranial circulations were treated with HydroCoils between March 2003 and September 2004. All aneurysms were embolized by the senior author (A.S.B) with HydroCoils alone or in combination with bare platinum coils, until either there was no further angiographic contrast filling of the aneurysm or the microcatheter was pushed out of the dome by the coil mass. Balloon assistance was used in three cases and combined Neuroform stent–coil embolization in eight other cases. To evaluate the safety and 1-year efficacy of the HydroCoil system, periprocedural complications were recorded, and angiographic recurrences were categorized using the Raymond–Roy Occlusion Classification (RROC) system. The 1-year aneurysm recurrence rate independent of size was 15% in patients treated with HydroCoils. Seventy percent of the patients had stable occlusions. The recurrence rate for small aneurysms was 3.7%, and the combined recurrence rate for small and large aneurysms was 6%. Fifteen percent of the aneurysms initially categorized as RROC Type 2 or 3 with stasis of contrast material at the time of initial embolization improved in RROC type, allowing the authors to develop the aneurysm embolization grade to predict recurrence. The neurological complication rate was 14.9%, of which 4.5% represented permanent neurological deficits. Conclusions The HydroCoil embolization system is safe and provides excellent 1-year occlusion of small and large aneurysms with initial RROC Type 1, as well as those with RROC Types 2 and 3 with stasis of contrast material at the time of embolization. Very large and giant aneurysms were not as successfully occluded with this system. Treatment of large and giant internal carotid artery aneurysms was more likely to result in cranial nerve palsies and postembolization headaches than treatment in other locations. The aneurysm embolization grade the authors developed using the results of this study accurately predicted 1-year recurrence rates based on the immediate postembolization angiographic characteristics of the treated aneurysm.

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Balloon Compression Technique in the Management of Persistent Intraoperative Intratumoral Hemorrhage Resulting From Stereotactic Biopsy

Operative Neurosurgery ◽

10.1227/01.neu.0000369655.96692.c5 ◽

2010 ◽

Vol 66 (suppl_2) ◽

pp. onsE334-onsE335

Author(s):

Murat Kutlay ◽

Hakan Şimşek ◽

Ahmet Çolak ◽

Mehmet Nusret Demircan

Keyword(s):

Stereotactic Biopsy ◽

Balloon Catheter ◽

Brain Biopsy ◽

Initial Position ◽

Compression Technique ◽

Stereotactic Brain Biopsy ◽

Intraoperative Bleeding ◽

Intratumoral Hemorrhage ◽

Balloon Compression ◽

Intratumoral Bleeding

Abstract BACKGROUND Despite its proven safety, intraoperative intratumoral hemorrhage is an uncommon but serious complication of stereotactic brain biopsy. OBJECTIVE We describe the “balloon compression technique” that was used in the management of persistent intraoperative bleeding that could not be arrested by conventional methods of hemostasis. METHODS Between January 2001 and March 2009, of 184 image-guided stereotactic brain biopsy procedures, intraoperative intratumoral bleeding occurred in 12 cases (6.5%). In 3 of these 12 cases (1.6%), intraoperative hemorrhage was persistent. In these cases, after adjustment of the optimum length, a balloon catheter (Fogarty) was inserted through the cannula and inflated with a contrast agent. We observed the patient for 10 minutes by checking the position of the balloon with regular intervals, using a frozen C-arm fluoroscope to determine any significant changes in its initial position due to possible enlargement of the hematoma. The patient was also closely observed during this time. RESULTS Hemostasis was obtained immediately after the inflation of the balloon in all 3 cases. The patients tolerated the procedure well. During and after the procedure no complications related to the technique were observed. None of the cases required craniotomy for evacuation of the hematoma and to secure hemostasis. CONCLUSION Our preliminary results indicate that the balloon compression technique seems to be a safe, rapid, and effective stereotactic practice in the management of the persistent intraoperative intratumoral bleeding that could not be arrested by standard, conventional hemostatic methods.

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