Vol 44 # 4 December 2012 - Kma.org.kw

December 2012
KUWAIT MEDICAL JOURNAL 304
technique for diagnosis and abscess drainage. Lunsford
et al [9] reported good results with overall bacteriologic
identification of 97% and cure rates of 72% in patients
with brain abscesses. Stereotactic aspirations of
intracerebral hypertensive hemorrhages (acute or
subacute) have shown encouriging results [10] . Catheter
reservoirs may be implanted into the hematoma,
followed with streptokinase or tissue plasminogen
activator injections to lyse the clot [11] .
Although it is a minimally invasive technique, yet
complications have been reported. Sometimes, sample
of the brain tissue taken for biopsy may be nondiagnostic
and may warrant a repeat biopsy. Other
risks include intracranial hemorrhage, infection or
seizures.
Appuzo et al [12] reported 1% morbidity (intracranial
hemorrhage, infection, increased neurological deficit
and seizures) and 0.2 % mortality. Lunsford et al [13]
reported postoperative complications in 2.9% (77)
patients in a series of 2651 patients who underwent
different stereotactic procedures. Out of those,
intracranial hemorrhage occurred in 55 (2.07%)
patients; 11 (0.41%) had local infections at pin sites;
11 (0.41%) patients had post-procedural seizures.
Two (0.075%) patients died from the complications of
the procedure. Although some centers are currently
migrating to frameless stereotactic procedures, their
complication rates are yet to be reported [13] .
PATIENTS AND METHODS
Between 2005 and 2011, we have managed 40
patients with stereotactic surgery. The patients were
selected on the basis of following diagnostic and
therapeutic indications.
Diagnostic
1. Tumors not correlating with their natural history
2. Multiple brain lesions
3. Small and deeply located tumors
4. Patients in good clinical condition (Karnofsky score
> 70)
Therapeutic
5. Cystic lesions that need aspiration
6. Intracranial abscesses
The mean age of the patients was 47 years (range 9
- 70 years). There were 26 male and 14 female patients.
Most of the patients presented with occasional
headaches followed by nausea. Five patients
presented with focal seizures and 12 with neurological
deficits. Twenty patients had lesions, located in the
supratentorial region, 12 in the thalamic and basal
ganglia area, two in the suprasellar region and seven
had multiple intracranial lesions. Stereotactic surgery
was performed with computed tomography (CT)/
magnetic resonance imaging (MRI) - guided Leksell
stereotactic system® and Leksell SurgiPlan® software
v2.20. The procedure started with fixation of Leksell
frame to the head after conscious sedation and local
anesthesia (Fig. 1). All the patients underwent CT
scan with contrast after the attachment of the fiducial
box to the frame. All the brain images were exported
to the computer workstation through Dicom system.
Fig.1: Application of Leksell frame and the arc in a 45 years old
patient who underwent stereotactic biopsy for the suspected tumor
Coordinates (x, y, z) were calculated with the help
of Leksell surgiplan® software v2.20. Under general
anesthesia, the patient’s head was fixed onto the
Mayfield skull clamp. An arc of the stereotactic system
was attached to the base ring of Leksell frame and
positioned according to the calculated coordinates
so that its center coincides with the selected brain
target. The choice of entry point is free and can be
reached from any direction without the need of
computer calculation (Fig. 2). It depends upon the
location, size, and consistency and the intervening
neural and vascular structures. The entry point should
minimize the length of passage through the brain
and avoid eloquent areas. At the point of entry, a
small skin incision is given, a burr hole is made and
the dura opened to allow visualization of the cortex.
It provides complete freedom of choice of trajectory
and entry point selection. The specimen is taken from
the selected target with the help of biopsy needle and
stored in a bottle with formalin solution and sent for
histopathology. The frame is removed and the patient
is sent for CT scan of brain to rule out any postoperative
complication like hemorrhage and is then transferred
to the recovery room.
RESULTS
Stereotactic biopsy established brain tumors in
28 (70%) patients, brain abscesses in five (12.5%) and