Image-guided frameless stereotactic needle biopsy in awake patients without the use of rigid head fixation

Clinical article

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Image-guided frameless stereotactic techniques provide an alternative to traditional head-frame fixation in the performance of fine-needle biopsies. However, these techniques still require rigid head fixation, usually in the form of a head holder. The authors report on a series of fine-needle biopsies and brain abscess aspirations in which a frameless technique was used with a patient's head supported on a horseshoe headholder. To validate this technique, they performed an in vitro accuracy study.


Forty-eight patients underwent fine-needle biopsy of intracranial lesions that ranged in size from 0.9 to more than 107.7 ml; a fiducial-less, frameless, image-guided technique was used without rigid head fixation. In 1 of the 48 patients a cerebral abscess was drained. The accuracy study was performed with a skull phantom that was imaged with a CT scanner and tracked with a registration mask containing light-emitting diodes. The objective was a skin fiducial marker with a 4-mm circular target to accommodate the 2.5-mm biopsy needle. A series of 50 trials was conducted.


Diagnostic tissue was obtained on the first attempt in 47 of 48 brain biopsy cases. In 2 cases small hemorrhages at the biopsy site were noted as a complication on the postoperative CT scan. One of these hemorrhages resulted in hand and arm weakness. The accuracy study demonstrated a 98% success rate of the biopsy needle passing through the 4-mm circular target using the registration mask as the registration and tracking device. This demonstrates a ± 0.75-mm tolerance on the targeting method.


The accuracy study demonstrated the ability of the mask to actively track the target and allow navigation to a 4-mm-diameter circular target with a 98% success rate. The frameless, pinless, fiducial-less technique described herein will likely be another safe, fast alternative to frame-based stereotactic techniques for fine-needle biopsy that avoids the potential morbidity of rigid head-pin fixation. Furthermore, it should lend itself to other image-guided applications such as the placement of ventricular catheters for shunting or Ommaya reservoirs.

Abbreviation used in this paper: LED = light-emitting diode.

Article Information

Address correspondence to: Arlan Mintz, M.D., Shadyside Hospital, Cancer Pavilion, 5150 Centre Avenue, Suite 430, Pittsburgh, Pennsylvania 15232. email:

Please include this information when citing this paper: published online August 20, 2010; DOI: 10.3171/2010.7.JNS091493.

© AANS, except where prohibited by US copyright law.



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    Auto-registration mask adhered to face.

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    Operative setup for frameless and pinless stereotactic biopsy.

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    The Stryker frameless guiding kit. The baseplate is secured to the skull with 8-mm screws.

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    Baseplate with the swiveling cannula attached.

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    Image guidance screen showing the target as the center of the virtual tip.

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    Biopsy needle with stopper set at calculated depth of insertion.

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    Skull phantom with tracking mask and frameless needle at targeted position within the skin fiducial marker.

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    Left: Axial T1-weighted contrast-enhanced MR image showing peripherally enhancing lesion and surrounding edema suggestive of cerebral abscess in a 54-year-old man presenting with new-onset seizure. Right: Axial T1-weighted contrast-enhanced MR image obtained following aspiration of the abscess using frameless, pinless stereotactic technique.


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