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

December 2012
KUWAIT MEDICAL JOURNAL 306
Fig. 3: MRI of the patient with brain abscess, showing pre (3a) and
post-radiosurgery imaging (3b)
and were referred for chemotherapy and radiation
therapy. The patient with brain metastasis was further
investigated and his origin of the primary disease was
found to be in the lungs. The patient was referred to
radiation oncologist for further management.
Stereotactic drainage of the intracranial abscess
was performed in five patients. Pus was sent for
culture sensitivity and postoperatively, patients
were managed conservatively with antibiotics.
Post surgical imaging showed reduction in size of
the abscess cavities and clinically all the patients
improved.
Post-operative complication occurred in one
patient. This was asymptomatic hemorrhage after
tissue biopsy which was managed conservatively.
There was no other procedure-related morbidity or
mortality.
DISCUSSION
Stereotactic surgery has been recognized since
many decades after the use of freehand biopsy
techniques resulted in too many postoperative
complications [14-16] .
Stereotactic surgery either for diagnosis or
treatment provides us precision, accuracy and safety
to localize the target in the brain. Stereotactic biopsy
stresses the importance of histological diagnosis
with low morbidity and zero mortality. Many reports
are published in the literature on the safe use of this
technique and a tissue diagnosis is always required
prior to treatment for most cerebral lesions. In their
early experience, Lunsford et al [17] published results of
102 patients with brain disorders who were referred
to University of Pittsburgh for surgical exploration,
using CT-guided stereotactic system. All the patients
were referred because of critical size and location of
the lesions in brain. Diagnostic stereotactic biopsy
demonstrated diagnosis in 98 (96.1%) patients.
Direct therapeutic intervention using this technique
was possible in 26 (25.5%) patients. There was no
morbidity and mortality seen in this early series.
According to them, histological diagnosis must be
sought in all patients with symptomatic brain lesions
regardless of their size or location and “Empiric”
forms of therapy are no longer justified in the age
of CT scanning. Lunsford et al[ 18] reported another
series of 39 patients with craniopharyngiomas who
underwent multimodality stereotactic techniques.
Cystic craniopharyngiomas were treated successfully
with stereotactic implantation of radioactive P32 in
the cystic cavity of the tumor. The success rate was
96%. Kondziolka et al [9] reported a series of 29 patients
with brain abscess. Out of these, 22 (76%) patients had
stereotactic abscess drainage with purulent centers
and seven (24%) patients underwent lesion biopsy
for diagnosis. Twelve patients with large abscesses of
diameter > 3 cm, underwent stereotactic insertion of
drainage catheters. Long-term clinical and imaging
follow-up confirmed disease resolution in 21 patients
(72%) and eventual abscess resolution occurred
in an additional six patients (21%), who required
multiple procedures. Lakecivic et al [19] published an
article to differentiate the results of survival and
outcome of patients with malignant brain gliomas
who were treated by different modes. The control
group of 21 patients had undergone craniotomy and
surgical excision, followed by oncological protocol
while the case group of 11 patients underwent
stereotactic biopsy followed by oncological protocol.
The majority of patients diagnosed by a stereotactic
biopsy survived for more than two years. The
survival and outcome for the patients in whom a
stereotactic biopsy was performed were notably
better compared to the patients who were diagnosed
after surgical excision. Consequently, it appears
that a stereotactic biopsy is a better option for
primary treatment of patients with malignant brain
gliomas when the survival and quality of life are
concerned. Broggi et al [20] published their experience
in 35 patients who underwent stereotactic biopsy
for deeply located lesions. According to them, the
biopsies confirmed the diagnosis based on clinical
and imaging findings in 25 patients but in 10 patients
the histological diagnosis was different from the
presumptive one. The treatment option was changed
in these ten patients. Ostertag et al [4] reported their
experience with 302 cases of stereotactic biopsy and
advocated that exploratory craniotomies, risky freehand
punctures and aspirations deep in the brain
should not be done without prior diagnosis.
Our report emphasises the importance of
histological diagnosis to avoid the hazards of
treatments based on clinical and radiological
findings. Only one of 40 patients had complication,
which shows safety profile of frame based stereotactic
surgery.