Use of cytological preparations for the intraoperative diagnosis of stereotactically obtained brain biopsies: a 19-year experience and survey of neuropathologists

Object. The goals of this study were to analyze the accuracy of cytological techniques, consisting of touch and smear preparations, for the intraoperative diagnosis of stereotactically obtained brain biopsy samples, and to determine the prevalence of the use of these methods among neuropathologists.Methods. A survey regarding preferred methods for intraoperative diagnosis of stereotactically obtained brain biopsy samples was completed by 92 (62%) of 148 neuropathologists. Twenty-three percent of respondents chose frozen-section examination alone; 13% chose one or more cytological methods alone; and the remainder (64%) chose a combination of frozen-section examination and cytology.At the University of Pittsburgh, the neuropathology records for all stereotactic brain biopsies performed from May 1979 through May 1998 were retrospectively reviewed. Of the 946 stereotactic brain biopsies, 316 cases were excluded because the intraoperative neuropathological consultation was not recorded. Thirty-five cases were excluded because frozen-section examinations were performed. Therefore, a total of 595 cases were suitable for analysis.Intraoperative cytological investigation correlated with the final diagnosis in 90% of cases (52% complete correlation and 38% partial correlation). In 11% of cases there was no correlation between the intraoperative and final diagnoses. Intraoperative diagnoses were most accurate in cases of abscess, germinoma, lymphoma, metastasis, and malignant glioma.Overall, 91% of biopsy specimens were diagnostic when examined using the paraffin-embedded section technique. The sensitivity of cytological preparations in detecting a diagnostic specimen was 96% and the specificity in detecting a nondiagnostic specimen was 75%.Conclusions. Intraoperative cytological preparations correlated with the final diagnoses in 90% of stereotactic biopsies and had a 96% sensitivity in detecting diagnostic specimens. The highest rate of correlation was noted in cases of abscess, germinoma, lymphoma, metastasis, and malignant glial tumor.

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Brain biopsy sampling by using prospective stereotaxis and a trajectory guide

Journal of Neurosurgery ◽

10.3171/jns.2001.94.1.0067 ◽

2001 ◽

Vol 94 (1) ◽

pp. 67-71 ◽

Cited By ~ 36

Author(s):

Walter A. Hall ◽

Haiying Liu ◽

Alastair J. Martin ◽

Robert E. MAxwell ◽

Charles L. Truwit

Keyword(s):

Frozen Section ◽

Spin Echo ◽

Brain Biopsy ◽

Pathological Examination ◽

Single Shot ◽

Biopsy Needle ◽

Content Type ◽

Postoperative Myocardial Infarction ◽

Clinically Significant ◽

Fine Print

Object. The authors describe their initial results obtained using a skull-mounted trajectory guide for intraoperative magnetic resonance (MR) imaging—guided brain biopsy sampling. The device was used in conjunction with a new methodology known as prospective stereotaxis for surgical trajectory alignment. Methods. Between January 1999 and March 2000, 38 patients underwent 40 brain biopsy procedures in which prospective stereotaxis was performed with the trajectory guide in a short-bore 1.5-tesla MR imager. In most cases, orthogonal T2-weighted half-Fourier acquisition single-shot turbo spin—echo (HASTE) images were used to determine the desired trajectory and align the device. The surgical trajectory was defined as a line connecting three points: the target, pivot, and alignment stem points. In all cases, surgical specimens were submitted for frozen section and pathological examination. Postoperative turbofluid-attenuated inversion-recovery and gradient-echo images were obtained to exclude the presence of hemorrhage. Trajectory determination and alignment was simple and efficient, requiring less than 5 minutes. Confirmatory HASTE images were obtained along the biopsy needle as it was being advanced or after reaching the target. All biopsy procedures yielded diagnostic tissue. One patient with a lesion near the motor strip experienced a transient hemiparesis of the hand related to passage of the biopsy needle, and another sustained a fatal postoperative myocardial infarction. No patient suffered a clinically significant or radiologically visible hemorrhage. Conclusions. In combination with prospective stereotaxis, the trajectory guide provided a safe and accurate way to perform brain biopsy procedures.

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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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Radiation-induced intracranial malignant gliomas

Journal of Neurosurgery ◽

10.3171/jns.1989.71.1.0077 ◽

1989 ◽

Vol 71 (1) ◽

pp. 77-82 ◽

Cited By ~ 63

Author(s):

Scott Shapiro ◽

John Mealey ◽

Carl Sartorius

Keyword(s):

Central Nervous System ◽

Radiation Necrosis ◽

External Beam Radiotherapy ◽

Malignant Gliomas ◽

Interstitial Brachytherapy ◽

External Beam ◽

Glial Tumor ◽

Content Type ◽

Radiation Induced ◽

Fine Print

✓ The authors present seven cases of malignant gliomas that occurred after radiation therapy administered for diseases different from the subsequent glial tumor. Included among these seven are three patients who were treated with interstitial brachytherapy. Previously reported cases of radiation-induced glioma are reviewed and analyzed for common characteristics. Children receiving central nervous system irradiation appear particularly susceptible to induction of malignant gliomas by radiation. Interstitial brachytherapy may be used successfully instead of external beam radiotherapy in previously irradiated, tumor-free brain, and thus may reduce the risk of radiation necrosis.

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99mTc-hexamethylpropyleneamine oxime leukocyte scintigraphy and C-reactive protein levels in the differential diagnosis of brain abscesses

Journal of Neurosurgery ◽

10.3171/jns.1992.77.5.0732 ◽

1992 ◽

Vol 77 (5) ◽

pp. 732-736 ◽

Cited By ~ 25

Author(s):

Ivar Amund Grimstad ◽

Henry Hirschberg ◽

Kjell Rootwelt

Keyword(s):

Differential Diagnosis ◽

Brain Abscess ◽

Protein Level ◽

Final Diagnosis ◽

C Reactive Protein ◽

Content Type ◽

Reactive Protein ◽

Leukocyte Scintigraphy ◽

Mass Lesions ◽

Fine Print

✓ The demonstration and accurate localization of intracerebral mass lesions are commonly performed with computerized tomography (CT), which often cannot determine the nature of the lesion. As an aid in the differential diagnosis between brain abscess and neoplasm, the authors have evaluated both 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) leukocyte scintigraphy and the serum C-reactive protein level. Of 23 patients with intracranial mass lesions, 22 individuals showed ring-like contrast enhancement on CT scans; the one exception was a patient treated for a meningioma who had a negative CT scan despite clinical suspicion of intra- or extracranial abscess. The final diagnosis was invariably established by microscopic examination of tissue specimens. In 10 patients the final diagnosis was brain abscess; the other 13 patients harbored a brain neoplasm (glioma in nine, astrocytoma in one, and metastasis in three). The 99mTc-HMPAO leukocyte scintigraphy detected all cases of abscess. There were no false-positive results. An elevated C-reactive protein level (> 13 mg/liter) was found in all but one patient with abscess and in three patients with neoplasm; two of these three patients had dental root infections which could account for the elevation of C-reactive protein. It is concluded that 99mTc-HMPAO leukocyte scintigraphy should be performed when there is a possibility that a brain abscess may exist. Any steroid treatment should be discontinued for 48 hours prior to leukocyte scintigraphy. Also, C-reactive protein determination should be performed and is useful even when steroids are given.

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Independent predictors of morbidity after image-guided stereotactic brain biopsy: a risk assessment of 270 cases

Journal of Neurosurgery ◽

10.3171/jns.2005.102.5.0897 ◽

2005 ◽

Vol 102 (5) ◽

pp. 897-901 ◽

Cited By ~ 123

Author(s):

Matthew J. McGirt ◽

Graeme F. Woodworth ◽

Alex L. Coon ◽

James M. Frazier ◽

Eric Amundson ◽

...

Keyword(s):

Risk Factors ◽

Basal Ganglia ◽

Predictive Value ◽

Brain Biopsy ◽

Stereotactic Brain Biopsy ◽

Content Type ◽

Image Guided ◽

Independent Risk Factors ◽

Thalamic Lesions ◽

Fine Print

Object. Image-guided stereotactic brain biopsy is associated with transient and permanent incidences of morbidity in 9 and 4.5% of patients, respectively. The goal of this study was to perform a critical analysis of risk factors predictive of an enhanced operative risk in frame-based and frameless stereotactic brain biopsy. Methods. The authors reviewed the clinical and neuroimaging records of 270 patients who underwent consecutive frame-based and frameless image-guided stereotactic brain biopsies. The association between preoperative variables and biopsy-related morbidity was assessed by performing a multivariate logistic regression analysis. Transient and permanent stereotactic biopsy-related morbidity was observed in 23 (9%) and 13 (5%) patients, respectively. A hematoma occurred at the biopsy site in 25 patients (9%); 10 patients (4%) were symptomatic. Diabetes mellitus (odds ratio [OR] 3.73, 95% confidence interval [CI] 1.37–10.17, p = 0.01), thalamic lesions (OR 4.06, 95% CI 1.63–10.11, p = 0.002), and basal ganglia lesions (OR 3.29, 95% CI 1.05–10.25, p = 0.04) were independent risk factors for morbidity. In diabetic patients, a serum level of glucose that was greater than 200 mg/dl on the day of biopsy had a 100% positive predictive value and a glucose level lower than 200 mg/dl on the same day had a 95% negative predictive value for biopsy-related morbidity. Pontine biopsy was not a risk factor for morbidity. Only two (4%) of 45 patients who had epilepsy before the biopsy experienced seizures postoperatively. The creation of more than one needle trajectory increased the incidence of neurological deficits from 17 to 44% when associated with the treatment of deep lesions (those in the basal ganglia or thalamus; p = 0.05), but was not associated with morbidity when associated with the treatment of cortex lesions. Conclusions. Basal ganglia lesions, thalamic lesions, and patients with diabetes were independent risk factors for biopsy-associated morbidity. Hyperglycemia on the day of biopsy predicted morbidity in the diabetic population. Epilepsy did not predispose to biopsy-associated seizure. For deep-seated lesions, increasing the number of biopsy samples along an established track rather than performing a second trajectory may minimize the incidence of morbidity. Close perioperative observation of glucose levels may be warranted.

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Frameless stereotaxy with scalp-applied fiducial markers for brain biopsy procedures: experience in 218 cases

Journal of Neurosurgery ◽

10.3171/jns.1999.91.4.0569 ◽

1999 ◽

Vol 91 (4) ◽

pp. 569-576 ◽

Cited By ~ 109

Author(s):

Gene H. Barnett ◽

David W. Miller ◽

Joseph Weisenberger

Keyword(s):

Surgical Navigation ◽

Brain Biopsy ◽

Computer Assisted ◽

Frameless Stereotaxy ◽

Complication Rates ◽

Navigation Systems ◽

Fiducial Markers ◽

Content Type ◽

Wound Breakdown ◽

Fine Print

Object. The goal of this study was to develop and assess the use and limitations of performing brain biopsy procedures by using image-guided surgical navigation systems (SNSs; that is, frameless stereotactic systems) with scalp-applied fiducial markers.Methods. Two hundred eighteen percutaneous brain biopsies were performed in 213 patients by using a frameless stereotactic SNS that operated with either sonic or optical digitizer technology and scalp-applied fiducial markers for the purpose of registering image space with operating room space. Common neurosurgical and stereotactic instrumentation was adapted for use with a localizing wand, and recently developed target and trajectory guidance software was used.Eight (3.7%) of the 218 biopsy specimens were nondiagnostic; five of these (2.4%) were obtained during procedures in 208 supratentorial lesions and three were obtained during procedures in 10 infratentorial lesions (30%; p < 0.001). Complications related to the biopsy procedure occurred in eight patients (seven of whom had supratentorial lesions and one of whom had an infratentorial lesion, p > 0.25). Five complications were intracerebral hemorrhages (two of which required craniotomy), two were infections, and one was wound breakdown after instillation of intratumoral carmustine following biopsy. There were only three cases of sustained morbidity, and there were two deaths and one delayed deterioration due to disease progression.Two surgeons performed the majority of the procedures (193 cases). The three surgeons who performed more than 10 biopsies had complication rates lower than 5%, whereas two of the remaining four surgeons had complication rates greater than 10% (p = 0.15).Twenty-three additional procedures were performed in conjunction with the biopsies: nine brachytherapies; five computer-assisted endoscopies; four cyst aspirations; two instillations of carmustine; two placements of Ommaya reservoirs; and one craniotomy.Conclusions. Brain biopsy procedures in which guidance is provided by a frameless stereotactic SNS with scalp-applied fiducial markers represents a safe and effective alternative to frame-based stereotactic procedures for supratentorial lesions. There were comparable low rates of morbidity and a high degree of diagnostic success. Strategies for performing posterior fossa biopsies are suggested.

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The Centennial Anniversary of the Frozen Section Technique at the Mayo Clinic

Archives of Pathology & Laboratory Medicine ◽

10.5858/2005-129-1532-tcaotf ◽

2005 ◽

Vol 129 (12) ◽

pp. 1532-1535 ◽

Cited By ~ 1

Author(s):

Anthony A. Gal

Keyword(s):

20Th Century ◽

Mayo Clinic ◽

Frozen Section ◽

Historical Review ◽

New Era ◽

Intraoperative Diagnosis ◽

Section Technique ◽

Before And After ◽

Invaluable Tool ◽

Centennial Anniversary

Abstract The frozen section technique has become an invaluable tool to assist the surgeon with intraoperative diagnosis. Although there were various descriptions of frozen section technique before and after the turn of the 20th century, the publication by Louis B. Wilson, MD, at the Mayo Clinic in 1905 heralded the beginning of a new era in intraoperative diagnosis. This historical review traces the circumstances that led to this landmark publication 100 years ago.

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Experimental study of the magnetic stereotaxis system for catheter manipulation within the brain

Journal of Neurosurgery ◽

10.3171/jns.2000.93.2.0282 ◽

2000 ◽

Vol 93 (2) ◽

pp. 282-288 ◽

Cited By ~ 34

Author(s):

M. Sean Grady ◽

Matthew A. Howard ◽

Ralph G. Dacey ◽

Walter Blume ◽

Michael Lawson ◽

...

Keyword(s):

Mr Imaging ◽

Tissue Sample ◽

Brain Biopsy ◽

Content Type ◽

Minimum Path ◽

Fluoroscopic Imaging ◽

Surgical Preparation ◽

And Performance ◽

The Brain ◽

Fine Print

Object. The magnetic stereotaxis system (MSS) is a device designed to direct catheter tips through magnetic forces. In this study the authors tested the safety and performance of the MSS in directing catheters through a nonlinear path to obtain biopsy specimens in pig brains.Methods. Sixteen pigs underwent biopsy of the frontal brain region with the aid of an MSS (11 pigs) or a standard stereotactic biopsy tool (five pigs). Surgical preparation consisted of placement of six fiducial markers in the skull and the creation of a burr hole for attachment of a cranial bolt and passage of the biopsy catheter. The pigs underwent magnetic resonance (MR) imaging of the head to define a biopsy target and to plan a nonlinear path. Guided by the MSS, which used nearly real-time fluoroscopic imaging fused to the preoperative MR image, the authors advanced a catheter to the biopsy target. A biopsy tool was passed through the catheter and a tissue sample was obtained. The animals were observed for 3 to 5 days postoperatively, when they were assessed for neurological abnormalities or other signs of morbidity. Actual catheter placement was within 1.5 mm of the planned path to the biopsy site, using a minimum path radius of 30 mm. The registration error associated with the use of the MSS x-ray fluoroscopy and MR imaging averaged 1.7 mm. Tissue disruption caused by the MSS was similar to that of standard stereotactic procedures.Conclusions. The MSS affords accurate and safe guidance of brain catheters in animals. The application tested here, brain biopsy, is one of a number of potential catheter-guided procedures.

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Role of glial fibrillary acidic protein expression in the biology of human glioblastoma U-373MG cells

Journal of Neurosurgery ◽

10.3171/jns.1998.89.6.0997 ◽

1998 ◽

Vol 89 (6) ◽

pp. 997-1006 ◽

Cited By ~ 19

Author(s):

Katrina G. Murphy ◽

James D. Hatton ◽

Hoi Sang U

Keyword(s):

Population Doubling ◽

Cell Behavior ◽

Glial Tumor ◽

Invasive Potential ◽

Content Type ◽

Expression Clone ◽

Gfap Expression ◽

Tumor Cell Behavior ◽

The Relationship ◽

Fine Print

Object. The relationship between glial fibrillary acidic protein (GFAP) expression and glial tumor cell behavior has not been well defined. The goal of this study was to examine this relationship further. Methods. To investigate the relationship between GFAP expression and glial tumor cell behavior, the authors isolated clones from the human glioblastoma cell line, U-373MG, according to their level of GFAP expression. Immunochemical analysis demonstrated that one clone had consistently low GFAP expression (approximately 93% of cells were GFAP negative), whereas a second clone had consistently high GFAP expression (approximately 80% of the cells were GFAP positive). The structure, population doubling time, saturation density, anchorage-independent growth, migratory rate, and invasive potential of these two clones were determined in relation to their level of GFAP expression. Morphologically, both clones were composed of ameboid as well as stellate components. Although the population doubling times of the two clones were equally rapid, the clone with low GFAP expression demonstrated a slightly higher saturation density compared with the clone with high GFAP expression. In an anchorage-independent environment (soft agar), a greater difference in growth characteristics was noted between the two clones: the high-expression clone formed more colonies and these colonies were compact, well defined, and spherical, whereas the low-expression clone formed predominantly smaller, two-dimensional colonies with vague boundaries and isolated cells or groups of cells at the periphery. In contrast to these minor differences between the clones, the low-expression clone showed a markedly increased migratory rate and invasive potential compared with the high-expression clone. Therefore, the clone with reduced GFAP expression appeared more aggressive, demonstrating decreased contact inhibition, increased migratory rate, and increased invasive potential. Conclusions. These results suggest a direct correlation between GFAP expression and some measures of aggressive tumor growth and transformation properties.

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