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.
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Contributor Notes

Address correspondence to: Arlan Mintz, M.D., Shadyside Hospital, Cancer Pavilion, 5150 Centre Avenue, Suite 430, Pittsburgh, Pennsylvania 15232. email: include this information when citing this paper: published online August 20, 2010; DOI: 10.3171/2010.7.JNS091493.
  • 1

    Barnett GHKormos DWSteiner CPWeisenberger J: Use of a frameless, armless stereotactic wand for brain tumor localization with two-dimensional and three-dimensional neuroimaging. Neurosurgery 33:6746781993

    • Search Google Scholar
    • Export Citation
  • 2

    Barnett GHMiller DWWeisenberger J: Frameless stereotaxy with scalp-applied fiducial markers for brain biopsy procedures: experience in 218 cases. J Neurosurg 91:5695761999

    • Search Google Scholar
    • Export Citation
  • 3

    Dorward NLAlberti OPalmer JDKitchen NDThomas DG: Accuracy of true frameless stereotaxy: in vivo measurement and laboratory phantom studies. Technical note. J Neurosurg 90:1601681999

    • Search Google Scholar
    • Export Citation
  • 4

    Germano IMQueenan JV: Clinical experience with intracranial brain needle biopsy using frameless surgical navigation. Comput Aided Surg 3:33391998

    • Search Google Scholar
    • Export Citation
  • 5

    Helm PAEckel TS: Accuracy of registration methods in frameless stereotaxis. Comput Aided Surg 3:51561998

  • 6

    Leuthardt ECFox DOjemann GADacey RGGrubb RLRich KM: Frameless stereotaxy without rigid pin fixation during awake craniotomies. Stereotact Funct Neurosurg 79:2562612002

    • Search Google Scholar
    • Export Citation
  • 7

    Mangano FTLimbrick DD JrLeonard JRPark TSSmyth MD: Simultaneous image-guided and endoscopic navigation without rigid cranial fixation: application in infants: technical case report. Neurosurgery 58:4 Suppl 2ONS-E3772006

    • Search Google Scholar
    • Export Citation
  • 8

    Paleologos TSDorward NLWadley JPThomas DG: Clinical validation of true frameless stereotactic biopsy: analysis of the first 125 consecutive cases. Neurosurgery 49:8308372001

    • Search Google Scholar
    • Export Citation
  • 9

    Reavey-Cantwell JFBova FJPincus DW: Frameless, pinless stereotactic neurosurgery in children. J Neurosurg 104:6 Suppl3923952006

    • Search Google Scholar
    • Export Citation
  • 10

    Reichter REPark HMHall D: Skull defects due to Mayfield head stabilizer. Clin Nucl Med 8:5531983

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