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Report Stereotactic Biopsy

Preoperative Diagnosis: Malignant primary astrocytoma ( Grade IV )Postoperative Diagnosis: Malignant primary astrocytoma ( Grade 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)