Report Stereotactic Biopsy

Preoperative
Postoperative

Diagnosis:
Diagnosis:

Malignant
Malignant

primary
primary

astrocytoma
astrocytoma

(
(

Grade
Grade

IV
IV

)
)

Procedure Performed:
Left parietal bur hole and CT-guided biopsy of same with glioblastoma multiforme favored by
the
pathologist
postoperatively
on
frozen
section.
Anesthesia:.General.endotracheal.
Indication/Consent:
The patient is a 21-year-old gentleman with migraines and balance problems that have been
improved significantly with levetiracetam (Keppra). MRI was obtained and it showed an
approximately 2.3 -cm left parietal tumor that comes to the surface with a significant amount of
cerebral edema. I discussed the problem with the patient and discussed the consideration of
trying a gross total resection. The patient did not want to accept any significant risks and,
therefore, requested a biopsy be performed instead. In accordance with his wishes, the following
wasperformed.
Details of Procedure:
The patient was taken to the operating room, and after induction of general endotracheal
anesthesia, the patient was on the CT scanner table. The stereotactic frame ring was put into
place. The patient was turned left side up, right side down. He was placed into the ring and his
head was supported in the usual fashion. Pillows and normal bracing were placed around his
body to keep him in a somewhat lateral position and was just ever so slightly turned to the right
so the left side of the head was facing upward. The hair was shaved. Markers were placed on the
scalp, and the CT scan gave me the localization. I made a small needle cut in the skin at the site
for the biopsy (the patient had been given contrast material). The markers were removed, and the
skin scalp was further shaved, prepped and draped in the usual septic fashion.
The skin was infiltrated with 0.5% lidocaine with epinephrine, and a vertical incision was made
in the lower cerebra, centered about the point marked by CT, and small Weitlaner retractors were
placed. The temporalis muscle was cauterized and opened sharply and then the bur hole was
placed with a Black Max drill using an M1 tip. This was opened a little bit further with a 2-mm
punch. The bone was not bleeding. The dura was cut using bipolar electrocautery and opened
with an 11 blade and then the stereotatic apparatus was further placed and the biopsy probe was
evaluated; it was right at the surface, as was the tumor.
It was not possible to determine whether there was any nerve contact underneath the tumor.
Since it could generate a permanent damage to the brain and nervous system, it was not possible
to go ahead with the discussed procedure. We decided to take the biopsies and make the
necessary tractions in the patients cerebrum.

Using the biopsy probe, I went below the surface and took the first biopsy, which was sent to be
frozen. This came back consistent with high-grade primary tumor being favored versus
metastatic. I took another freehand sample, more anterior, since this was immediately below the
surface. There was a lot of good tissue that was also sent for permanent section. There was
minimal bleeding. The wound was irrigated with antibiotic, and the post biopsy CT scan showed
no evidence of any blood in the tumor, but there was some air in the tumor itself, as expected.
The wound was again irrigated with antibiotic solution. A thrombin gel was placed in the bur
hole site, and the scalp flap was closed in two layers using interrupted 3-0 Vicryl on the galea;
running 3-0 Prolene was used to close the skin. A sterile dressing was applied. Needle and
sponge counts were correct. Estimated blood loss was approximately 10 cc. Replacement was
that of crystalloid only. There were complications, but the patient was stablized. The patient was
extubated and taken to the recovery room in stable condition.
Prescripted Medications :

Phenytoin (Dilantin), or Carbamazepine (Tegretol)