Hemorrhage after stereotactic brain biopsy [Neurosurgery Wiki]

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====== Hemorrhage after stereotactic brain biopsy ======

[[Hemorrhage]] of the surgical trajectory and surgical bed of a [[stereotactic brain biopsy]] (SBB) is clinically seen in 0.3%-8.6% of all cases, depending on the methodology chosen
((Apuzzo MLJ, Chandrasoma PT, Cohen D, Zee CS,
Zelman V. Computed imaging stereotaxy (experience
and perspective related to 500 procedures
applied to brain masses). Neurosurgery. 1987;20:
930-937.))
((Ben-Haim S, Asaad WF, Gale JT, Eskandar EN.
Risk factors for hemorrhage during
microelectrode-guided deep brain stimulation and
the introduction of an improved microelectrode
design. Neurosurgery. 2009;64:754-763.))
((Binder DK, Rau GM, Starr PA. Risk factors for
hemorrhage during microelectrode-guided deep
brain stimulator implantation for movement disorders.
Neurosurgery. 2005;56:722-732.))
((Kutlay M, Sims¸ek H, Colak A, Demircan MN.
Balloon compression technique in the
management of persistent intraoperative intratumoral
hemorrhage resulting from stereotactic
biopsy: technical note. Neurosurgery. 2010;66(6
Suppl Operative):334-335.)).

Achieving hemostasis requires an open craniotomy in 0.8%-2,7% of all patients
((Apuzzo MLJ, Chandrasoma PT, Cohen D, Zee CS,
Zelman V. Computed imaging stereotaxy (experience
and perspective related to 500 procedures
applied to brain masses). Neurosurgery. 1987;20:
930-937.))
((Ben-Haim S, Asaad WF, Gale JT, Eskandar EN.
Risk factors for hemorrhage during
microelectrode-guided deep brain stimulation and
the introduction of an improved microelectrode
design. Neurosurgery. 2009;64:754-763.))


In the case of SB in eloquent areas, minimizing the risk of complication is important, since even a minor hemorrhage can have devastating consequences for the patient
((Bartek J Jr, Cooray G, Islam M, Jensdottir M. Stereotactic Brain Biopsy in
Eloquent Areas Assisted by Navigated Transcranial Magnetic Stimulation: a
Technical Case Report. Oper Neurosurg (Hagerstown). 2018 Oct 26. doi:
10.1093/ons/opy321. [Epub ahead of print] PubMed PMID: 30371829.
)).


One of the most serious [[complication]]s of [[stereotactic biopsy]] is [[postoperative]] symptomatic [[hemorrhage]] due to [[injury]] to the basal [[perforating vessel]]s such as the [[lenticulostriate arteries]] neighboring the [[basal ganglia]] [[lesion]]s.

===== Treatment =====

There is no gold standard concerning its intraoperative management. Traditionally, treatment of intraoperative bleeding during SBB includes irrigation with temperate saline solution through the biopsy cannula, favorable positioning of the headrest of the surgical table, and controlled intraoperative systemic hypotension.

Intraoperative management of profuse arterial bleeding may be challenging during SBBs. The limited working
channel and absence of direct visualization of the bleeding vessel often lead many neurosurgeons to convert the procedure to open craniotomy and coagulate the vessel under microscopic visualization and/or evacuate the associated hematoma
((Field M, Witham TF, Flickinger JC, Kondziolka D,
Lunsford LD. Comprehensive assessment of
hemorrhage risks and outcomes after stereotactic
brain biopsy. J Neurosurg. 2001;94:545-551.)).


Some authors have described percutaneous techniques based on on-site
compression or the use of hemostatic agents with favorable results
((Kutlay M, Sims¸ek H, Colak A, Demircan MN.
Balloon compression technique in the
management of persistent intraoperative intratumoral
hemorrhage resulting from stereotactic
biopsy: technical note. Neurosurgery. 2010;66(6
Suppl Operative):334-335.))
((Chimowitz MI, Barnett GH, Palmer J. Treatment
of intractable arterial hemorrhage during stereotactic
brain biopsy with thrombin. Report of three
patients. J Neurosurg. 1991;74:301-303.))
((Zrinzo L, Foltynie T, Limousin P, Hariz MI.
Reducing hemorrhagic complications in functional
neurosurgery: a large case series and systematic
literature review. J Neurosurg. 2012;116:
84-94.)).

Preliminary results suggest that the thrombin-gelatin matrix injection is a simple, safe and effective stereotactic practice to manage persistent surgical bed bleeding that cannot be arrested by standard, conventional hemostatic methods
((de Quintana-Schmidt C, Leidinger A, Teixidó JM, Bertrán GC. Application of a
thrombin-gelatin matrix in the management of intractable hemorrhage during
stereotactic biopsy: a Technical Note. World Neurosurg. 2018 Oct 13. pii:
S1878-8750(18)32350-7. doi: 10.1016/j.wneu.2018.10.053. [Epub ahead of print]
PubMed PMID: 30326309.))


===== Prevention =====


A new target-planning method was proposed by Sato et al. from the Kitasato University School of Medicine, Sagamihara, University of Yamanashi Faculty of Medicine, Chuo, Japan, to reduce hemorrhagic complications by avoiding injury to the perforating arteries.

Three-dimensional 3-T [[Time-of-flight magnetic resonance angiography]] (3D 3-T TOF) imaging was applied to delineate the basal perforating arteries such as the lenticulostriate arteries. The incidence of [[postoperative hemorrhage]] in basal ganglia cases was compared between a new method using 3D 3-T TOF and a conventional target-planning method based on contrast-enhanced T1-weighted magnetic resonance images obtained by 1.5-T scanning.

3D 3-T TOF imaging could delineate the basal perforating arteries sufficiently in target planning. No postoperative hemorrhage occurred with the new method (n = 10), while 6 postoperative hemorrhages occurred with the conventional method (n = 14). The new method significantly reduced the occurrence of postoperative hemorrhages (p = 0.017).

3D 3-T TOF MR imaging with contrast medium administration provides useful information about the perforating arteries and allows safe stereotactic biopsy of basal ganglia lesions
((Sato S, Dan M, Hata H, Miyasaka K, Hanihara M, Shibahara I, Inoue Y, Kumabe T.
Safe Stereotactic Biopsy for Basal Ganglia Lesions: Avoiding Injury to the Basal 
Perforating Arteries. Stereotact Funct Neurosurg. 2018 Aug 28:1-5. doi:
10.1159/000492057. [Epub ahead of print] PubMed PMID: 30153687.
)).