Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Frame-Based Stereotactic Brain Biopsy (Leksell / CRW)

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with a [deep / eloquent / multifocal] [location] brain lesion of uncertain diagnosis planned for frame-based stereotactic needle biopsy ([Leksell / CRW]) for tissue diagnosis.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

Neurosurgical Atlas · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Frame-Based Stereotactic Brain Biopsy — Figure 1 Figure 1. Multimodal imaging findings of a patient with primary CNS lymphoma in the splenium of the corpus callosum: A: slightly higher CT plain scan density; B: hypointense in T1; C: hypointense… Source: Preliminary clinical application of multimodal imaging combined with frameless robotic stereotactic biopsy in the diagnosis of primary central nervous system lymphoma — Heliyon 2022; CC BY.

Frame-Based Stereotactic Brain Biopsy — Figure 2 Figure 2. The spectra showed an obvious increase in CHO, a decrease in NAA, and an increase in CHO/Cr and Cho/NAA ratios in the lesion (in the red boxes) compared with the normal brain (in the… Source: Preliminary clinical application of multimodal imaging combined with frameless robotic stereotactic biopsy in the diagnosis of primary central nervous system lymphoma — Heliyon 2022; CC BY.

Frame-Based Stereotactic Brain Biopsy — Figure 3 Figure 3. Procedure of frameless stereotactic robotic needle biopsy in the patient with PCNSL: A: the puncture trajectory was determined according to the puncture target; B: Four spherical… Source: Preliminary clinical application of multimodal imaging combined with frameless robotic stereotactic biopsy in the diagnosis of primary central nervous system lymphoma — Heliyon 2022; CC BY.

Frame-Based Stereotactic Brain Biopsy — Figure 1 Figure 1. All patients underwent robot-assisted stereotactic brain biopsy using one of three systems: a ROSA robotic system (Zimmer Biomet Robotics, Montpellier, France), the CAS-R-2 (Tianjin… Source: Novel application of robot-guided stereotactic technique on biopsy diagnosis of intracranial lesions — Frontiers in Neurology 2023; CC BY.

Frame-Based Stereotactic Brain Biopsy — Figure 2 Figure 2. (A,B) The REMEBOT and (C,D) the CAS-R-2 use scalp markers for registration. The patient’s head is prepared for skin adhesion to the scalp markers before surgery (E,F). The ROSA robot… Source: Novel application of robot-guided stereotactic technique on biopsy diagnosis of intracranial lesions — Frontiers in Neurology 2023; CC BY.

Frame-Based Stereotactic Brain Biopsy — Figure 3 Figure 3. Measurement of entry point and target point error based on preoperatively planned target and on the fusion of postoperative CT to the preoperative dataset. Source: Novel application of robot-guided stereotactic technique on biopsy diagnosis of intracranial lesions — Frontiers in Neurology 2023; CC BY.

History of Present Illness

Past Medical History

Imaging Review

MRI (T1±Gad, T2, FLAIR, DWI) ± CTA

Labs

Neurological Examination

Surgical Planning

Case Logistics, OR Needs & Orders

Workflow

  1. Apply stereotactic frame (Leksell/CRW) under local anesthesia ± sedation (4 pins to skull) — keep frame aligned to anatomy
  2. Stereotactic imaging (CT, or MRI) with frame/fiducial box
  3. Plan on workstation: select target (enhancing tissue), entry point, trajectory avoiding vessels/sulci/ventricles; compute frame coordinates (x, y, z) and arc/ring angles
  4. Transfer to OR

Position

Key Surgical Steps

  1. Set the frame coordinates and arc/ring angles per plan; mount the arc
  2. Confirm entry point on the scalp; small incision and twist-drill burr hole at the planned entry
  3. Coagulate and open the dura (and pia) at entry
  4. Advance the biopsy needle (Sedan side-cutting cannula) along the frame-defined trajectory to target depth
  5. Take serial biopsies: obtain specimens at staged depths through the lesion and from multiple radial orientations (rotate the side-cutting window)
  6. Frozen section / smear confirmation that diagnostic tissue is present before finishing (re-sample if non-diagnostic/necrotic)
  7. Hemostasis: observe the cannula for bleeding; if bleeding, leave cannula, irrigate, wait; persistent → manage/re-image
  8. Withdraw needle, closure of the small incision
  9. Remove frame

Critical Anatomy & Structures at Risk

  1. Vessels along the trajectory (sulcal/cortical, deep) — hemorrhage is the main risk
  2. Ventricles (CSF egress, deviation), eloquent cortex/tracts
  3. Deep structures (thalamus/brainstem targets — narrow margins)

Equipment

Anesthesia

Potential Complications

  1. Hemorrhage (~1-3% symptomatic — into tract/lesion) — deficit, rarely catastrophic
  2. Non-diagnostic sample (necrosis/sampling error) — frozen confirmation reduces; may need repeat
  3. Seizure, infection, neurological deficit (eloquent trajectory), transient worsening

Operative Note Template

Preoperative Diagnosis: [Location] brain lesion of uncertain diagnosis ([deep/eloquent/multifocal])

Postoperative Diagnosis: Same (pending pathology)

Procedure: Frame-based ([Leksell/CRW]) stereotactic biopsy of [location] lesion

Surgeon / Assistant: Anesthesia: [Local + sedation / general] EBL / Fluids: Minimal Adjuncts: Stereotactic frame + arc, planning workstation, stereotactic CT/MRI, Sedan side-cutting needle; intraoperative frozen section Specimens: Brain lesion (multiple cores) for permanent ± flow cytometry/microbiology Complications: None

Indications: [Age]yo [M/F] with a [deep/eloquent] [location] lesion where resection is not indicated and tissue diagnosis will guide management. [Steroids were withheld given lymphoma suspicion.] Coagulopathy corrected. Risks (hemorrhage, non-diagnostic sample) discussed.

Description of Procedure: After consent and time-out, the stereotactic frame was applied under local anesthesia, a stereotactic CT obtained and merged with the planning MRI, and the target (enhancing tissue), entry, and an avascular trajectory computed. In the OR, the arc was set to the calculated coordinates and a small incision and twist-drill burr hole made at the entry; the dura/pia were coagulated and opened.

The Sedan side-cutting biopsy needle was advanced along the frame-defined trajectory to the target, and serial specimens taken at staged depths and radial orientations. Frozen section confirmed diagnostic tissue. The tract was observed for bleeding and hemostasis confirmed, the needle withdrawn, the incision closed, and the frame removed.

A postoperative CT was obtained to exclude hemorrhage. The patient was transferred to the floor.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Frame-Based Stereotactic Brain Biopsy (Leksell / CRW):

Common Pimp Questions

Use these to pressure-test preparation for Frame-Based Stereotactic Brain Biopsy (Leksell / CRW):

  1. What target coordinate, trajectory, and no-fly-zone were chosen?
  2. What imaging confirms target accuracy and avoids vessel/ventricle/sulcus violation?
  3. What specimen, pathology, culture, or molecular study must be obtained?
  4. What hemorrhage, edema, seizure, or thermal-injury sign must be watched for tonight?
  5. What postop scan timing and steroid/antiepileptic plan is appropriate?

Attending Preference Variables

Items that commonly vary by surgeon or institution: