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Utility of Postoperative CT Scan Following Stereotactic Brain Biopsy

Friday, May 3, 2024

Presenting Author(s)

Christina Abi Faraj, MD (she/her/hers)

Postdoctoral research fellow.
Department of Neurosurgery, MD Anderson Cancer Center
Houston, TX, US

Co-Author(s)

SF

Sherise D. Ferguson, MD

Associate Professor
Department of Neurosurgery, MD Anderson Cancer Center
Houston, Texas, United States
MG

Maria Kristine Gule-Monroe, MD

Associate Professor
Department of Neuroradiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
AH

Amy Heimberger, MD

Neurosurgeon
Northwestern Memorial Hospital
Chicago, Illinois, United States
FL

Frederick F. Lang, MD

Professor
Department of Neurosurgery, MD Anderson Cancer Center, United States
CL

Cheuk Hong Leung, MS

Research Biostatistician
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, United States
Ian E. McCutcheon, MD

Professor
Department of Neurosurgery, MD Anderson Cancer Center
HOUSTON, TX, United States
Nelson Moss, MD

Neurosurgeon and Co-Director, Multidisciplinary Brain Metastasis Program
Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY
New York City, New York, United States
SP

Sujit S. Prabhu, MD

Professor
Department of Neurosurgery, MD Anderson Cancer Center
Houston, Texas, United States
GR

Ganesh Rao, MD

Attending
Baylor College of Medicine
Houston, Texas, United States
RS

Raymond Sawaya, MD

Raja N. Khuri Dean
Faculty of Medicine, American University of Beirut, United States
DS

Dima Suki, MS, PHD

Professor
Department of Neurosurgery, MD Anderson Cancer Center, United States
JW

Jeffrey S. Weinberg, MD

Professor
Department of Neurosurgery, MD Anderson Cancer Center, United States

Introduction: Stereotactic brain biopsy (SBB) has been established as an effective and safe procedure. The role of routine post-biopsy computed tomography (CT) in ruling out hemorrhage is controversial given that highly variable rates of post-biopsy hemorrhage have been reported (1–60%).

Methods: We retrospectively reviewed 757 patients who underwent 767 SBBs from 1993-2021. All patients had a CT within 48 hours postoperatively. We recorded subsequent bleeding on CT, new/worsening neurological symptoms within 30 days postoperatively, and clinical characteristics. Clinical factors and symptoms associated with bleeding were assessed using logistic regression and Chi-squared test.

Results: Blood was detected on postoperative CT in 202 (26%) biopsies. Biopsy trajectory/site constituted the most common bleed location (95%) (largest diameter 0.2-3.7 cm). A platelet count < 150,000 (p < 0.001) and detecting blood through the biopsy needle intraoperatively (p < 0.001) were associated with subsequent blood on CT. New/worsening neurological symptoms were detected in 162 (21%) patients. Patients with positive postoperative CT were more likely to develop new/worsening neurological symptoms (30% vs 18%, p< 0.001), specifically altered mental status (AMS) (11% vs 3%, p< 0.001). Seventeen (2%) patients developed symptoms attributed to hemorrhage (0-24 days post-biopsy). Of those, ten patients had AMS, six neurological deficit, two signs of increased intracranial pressure, and one a seizure. Of the 17 patients, 13 (76%) had a positive postoperative CT scan, while 4 (24%) had negative initial scans. Two (0.3%) patients underwent hemorrhage evacuation. The positive predictive value of postoperative CT in detecting new/expanding hemorrhage is 16%, and its negative predictive value is 95%. Findings of postoperative CT altered patient management in 5% of the cases.

Conclusion : The rate of clinically significant hemorrhage after SBB is low. Instead of routine postoperative CT scan, we recommend performing one on a case-by-case basis in patients with risk factors for bleeding, intraoperative bleeding, and/or new/worsening neurological symptoms postoperatively to exclude clinically significant hemorrhage requiring re-operation.