Technique and planning software for stereotactic brainstem and
basal ganglia biopsies
István Valálik MD, PhD 1, Ferenc Pongrácz1, András Csókay MD, PhD2
1Department of Neurosurgery, St. John’s Hospital, Budapest, Hungary
2Department of Neurosurgery, BAZ County and Teaching Hospital, Miskolc, Hungary
With high resolution CT or MR techniques
stereotactic targeting provides a sample of
tissue even from a lesion with a size of 5 mm.
Basal ganglia and brainstem as eloquent
regions of the brain require special issues in
the technique. In order to avoid bleeding as
the most dangerous complication of the
intervention, the positions of serial biopsy and
tissue volume need to be carefully controlled.
Specially designed biopsy module of Vister-
3D stereotactic planning software with CT-MR
fusion is presented on the Fig. 2-5. The
procedures were performed with the Riechert-
Mundinger or with the MHT stereotactic
systems A micro-rongeour (biopsy forceps)
with a 1.2-mm size was used to obtain tissue.
The small sample size is a great challenge for
neuropathology in aspects of handling during
not only the block and slice preparation but
also the evaluation procedure.
Stereotactic biopsy in the region of basal ganglia and brainstem with
special technique can be performed safely in both adult and pediatric
cases and it appears to allow us to define further therapeutic strategies.
48 patients were operated on, including 6 pediatric cases. Asymptomatic bleeding was
observed in 3 cases (8%), and symptomatic bleeding was observed in 1 case (2%). The
proportion of negative results is 1 case (2%), where a repeated procedure was needed.
21th Congress of the ESSFN, 17-20 September, 2014, Maastricht
In order to minimise the interventional
invasiveness in patients with basal ganglia
and brainstem tumours, it is crucial to define
the histological type of the different cerebral
lesions. Although a better quality of MR
imaging with new sequences has allowed a
higher correlation with histological results, the
presence of bias is still high.
Fig. 2. CT-based planning of the
biopsy from the pineal region with the
Vister-3D software (Valálik-Pongrácz),
including serial biopsy module with
projected 4 sample locations.
Fig. 1. Contrast enhanced stereotactic CT-scanning.
Fig. 4. Biopsy of the right thalamo-peduncular region. CT-MR
planning with Vister-3D software (Valálik-Pongrácz).
Visualisation in coronal, axial, sagittal and 3-D plane modes.
Fig. 3. Pons biopsy,
crossing the midline.
The projected 5
on the axial
Fig. 7. A - The prepared entry point in the OR. B – The
canula was inserted into the brain via twist drilled hole with
diameter of 3.2 mm.
Fig. 8. Handling of the tissue sample.
Fig. 10. Postoperative CT-scanning. A - twist drilled entry on
the right frontal bone. B – axial scan after biopsy of the right
thalamo-peduncular region with a small region of blood-
Fig. 6. Biopsy instrument, a 1.2 mm micro-rongeur with
adjustable width of opening.
Fig. 9. Wound closure with strips or with 1 suture.
Fig. 5. The printed plan with visualisation of projected
sample locations, target and entry coordinates, arc settings
and sample locations on the trajectory to the main target.
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