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

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.