Indian J.

SHAH,
BHADE, Anaesth. 2002;
DAVE, 46 (2)
SHAH : 111-114
: STEREOTACTIC BRAIN BIOPSY AND ANAESTHESIA 111
RUKMINI PANDIT AWARD WINNING ARTICLE : ISACON - 2001

ANAESTHETIC ASPECTS OF
STEREOTACTIC BRAIN BIOPSY
Dr. M. A. Bhade 1 Dr. Bhavna Shah 2 Dr. C. R. Dave 3 Dr. R. A. Shah 4

SUMMARY
Stereotactic or ‘keyhole’ neurosurgery poses number of anaesthetic challenges. Stereotactic brain enables biopsy of deep seated brain
lesions with minimal brain tissue damage. Apart from inherent problems of neuroanaesthesia, there is an additional challenge due
to compromised airway arising out of application of stereotactic frame The study presents the various anaesthetic aspects right from
the application of frame outside OT, transport of sedated patient to radiology department for CT scan, computerised analysis of
radiological information to finally the actual neurosurgical procedure. Modern drugs like propofol and midazolam help in maintaining
conscious sedation analgesia during its various stages. Elective intubation before frame application is beneficial in paediatric patients
and in difficult intubation cases.With the applicability of stereotactic neurosurgery, anaesthesiologist needs to be familiar with its
various clinical and technical aspects.
Keywords : Stereotactic frame, Airway Maintenance, Sedation, Intubation.

Introduction brain lesions causing minimal iatrogenic brain trauma and

The term ‘Stereotactic is a composite of the Greek hence its importance.
word ‘Stereos’ which refers to the geometry of solid bodies Application of the frame gives extremely limited
and the Latin ‘Tactus’ which signifies the sense of touch. airway access creating problems during maintenance of
Progress in noninvasive imaging technologies like ‘conscious sedation analgesia’ or intubation; due to
CT scan, MRI, DSA and key concepts by Dr. Ruseel Brown restricted movement of head and neck apart from other
of university of Utah has enabled the transformation of two procedure related problems.
dimensional CT scan information into three dimensional Thus, the aim of our study was to observe the
stereotactic frame co-ordinates (Fig-1). The combined efforts difficulties encountered by anesthesiologist, find their
of Cosman, Roberts and Wells have resulted in the present solution and observe the related clinical and technical aspects.
popularly used CRW ARC SYSTEM1.
Material and Method
The study consists of 25 patients with age ranging
from 7yrs to 75yrs under either general anesthesia or
sedation with local anaesthesia. GA was given in children,
in patients with brain stem lesions (vital areas of brain),
unco-operative adults or for transnasal procedure. Stereotactic
biopsy can be done under sedation in cooperative adults.
Routine preanaesthetic checkup along with
neurological assessment was done one day prior and the
Aim procedure explained to adults to allay anxiety.
With the help of this extracranial reference system
Premedication in the form of Inj. Glycopyrrolate
the surgeon can guide instruments accurately to deep seated
2-4 mcg/kg-1 IV & Inj. Pentazocine 0.3-0.6 mg/kg-1 IV
1. M.D., Junior Lecturer was given. General anaesthesia was administered in five
2. M.D., Associate Professor patients taking all neuroanaesthetic precautions of smooth
3. M.D., Professor induction using IV Pentothal (2.5%) 5-7mg/kg-1, Inj.
4. M.D., Professor & Head Suxamethonium 1-2mg/kg-1 & maintained with Inj.
Department Of Anaesthesiology Vencuronium bromide + gas + O2 + trace of halothane.
Gujarat Cancer & Research Institute
B J Medical College, Admedabad - 380 016 For sedation, the patients were divided in two groups
Correspond to :
Dr. Madhuri A Bhade Group I : Inj. Pentazocine 0.3-0.6 mg/kg-1 IV with Inj.
16/B, Janvishram Society, B/H, Sahjanand College Midazolam 0.05-0.1 mg/kg-1 IV. Top up
Ambawadi, Ahmedabad - 380 015 supplements with Inj. Midazolam.
112 INDIAN JOURNAL OF ANAESTHESIA, APRIL 2002

Group II : Inj. Pentazocine 0.3-0.6 mg/kg-1 IV with inj. 3. CRW Arc:

Propofol 2mg/kg -1 IV bolus. Top up The base of CRW arc is a square structure fitted
supplements with Inj. Propofol. over the headring. The arc system has 3 translational
0.375% bupivacaine was used for local infiltration slides that move the centre of the arc to the anatomical
for application of frame prior to actual surgical procedure. target. These slides are designated by AP, lateral and
vertical coordinates and the mllimetre scales are engraved
The patients were well monitored, both clinically
on the arc for easy visibility by the surgeon during the
and by using pulse oximeter, ECG, NIBP & Capnography
surgery. (Photo-2).
Extension tubing was attached to IV access where necessary,
as patients get fully draped with very limited access.
Indications
Following were the indications for brain biopsy in
the study:
- Secondaries in brain from lung/breast/pancreas.
- Brainstem SOL.
- Tuberculoma.
- Pyogenic abscess.
- SOL with or without hydrocephalus.

ABOUT THE FRAME AND THE PROCEDURE

The CRW are system (Stereotactic frame) has 3 parts:
1. Basic CRW Intubation Headring Assembly
This ring has a rotatable intubation hoop in front
that helps anesthesiologist in maintaining airway access.
(Photo – 1)
The procedure of stereotactic brain biopsy involves
4 steps:-

* Application of base ring of stereotactic frame outside

OT.

* Transport of sedated/intubated patient to radiology

department for CT Scan.

* Transport back to OT and processing of CT Scan

data using laptop computer by surgeon to calculate
the cartesian coordinates.

2. CT Localiser
* Biopsy Surgical procedure.

It enables the stereotactic coordinates (X,Y,Z) to Average duration of the procedure ranges from 1hr
be determined relative to the headring independent of to 2hr 30min.
scanner position. (Fig. 2)
Observations
Applications of the base ring are done outside OT
in either supine or sitting position depending on the age
and neurological status of the patient. Head frame is applied
by local infiltration at four different sites on the scalp
over which head posts of the base ring are screwed.
Sedation helps to minimize the ring discomfort. Paediatric
patients were intubated electively before application of
frame for complete control of airway. Spontaneous
BHADE, SHAH, DAVE, SHAH : STEREOTACTIC BRAIN BIOPSY AND ANAESTHESIA 113

breathing was maintained & supplemented with oxygen with the help of portex endotracheal tube connector,
and titrated dose of sedatives. so that throughout the procedure spo2 caphograpy
and breathing movement could be observed over the bag
The patients were monitored with pulse oximetry (Photo – 3)
during transport to radiology department, along with all
the resuscitative measures kept ready. Most important is Anaesthesiologist has to be always aware of the
that the head wrench should be carried along with the possibility of convulsions with the frame in situ.
patient so that in case of an emergency, the frame can be Anticonvulsant medication Inj. Phenytoin sodium was gives
removed1 Placing a thin sand bag or rolled towel helped IV when procedure was converted from biopsy to craniotomy
to extend the head as frame limited its extension. Sedative or excision biopsy as the duration of surgery increases.
drugs need to be titrated carefully to avoid tongue fall While administering general anesthesia it was
and excessive respiratory depression with adverse effect difficult to achieve tight fitting of mask for ventilating the
on ICP. patient due to frame.
The CT localiser frame with N shaped carbon fibre Though the intubation hoop is rotated downward
rods is applied over the base ring in radiology dept. there is hinderance for mask fitting & laryngoscopy2
Radiocontrast dye is injected intravenously. Thus here Sniffing morning air’ position is not possible for intubation
the anesthetist faces the problems of outside OT due to limited extension, so ‘pseudo-anterior’ larynx is
anaesthesiologist and airway maintenance whilst being visualized. A well trained assistant proves helpful who
remoter from the patient apart from allergy to contrast can show the larynx by means of external pressure. Dr.
medium and radiation exposure. Neil Bradburn advocated the use of one smaller ID tube
to overcome this difficulty1. Again, this being a closed
After CT scanning the patient is transported back procedure, surgeon does not have access for cauterization.
to OT. Spontaneous breathing technique proves beneficial Therefore, excellent perioperative haemodynamic and ICP
as anesthetist may face problems like elevator failure control is essential. All neuroanesthetic precautions for
during transport. Processing of the CT data is done with smooth induction were taken and muscle relaxant was
the help of laptop computer. Thus, some time elapses used for maintenance.
before the procedure begins, as coordinates need to be
Positioning of the patient is done on OT table with
adjusted over the CRW arc. Localisation of the target is Mayfield skull clamp. It needs to be applied carefully in
checked by placing CRW arc on rectilinear phantom frame paediatric patient as skull is thin and it can increase ICP3
before applying head (Photo–2) In lateral position, the edge of the basering can forcefully
The patients head gets fully draped with extremely encroach on patient’s neck and shoulder, conceivably
limited access to airway after application of CRW arc. resulting in neuropraxia of the brachial plexus especially
in obese patients2 (Photograph-4).
In sedation group attaching right angle bar with
OT table helps as in other head & neck surgery, as it
gives some access below the drapes. Use of nasopharyngeal
airway was found to be extremely helpful for oxygenation
& airway maintenance. Breathing circuit with gas analyzer
cable and capnograph module should be attached to it

After the procedure, patients were observed in

NICU for 4-6 hrs and CT scan was done postoperatively
in cases where biopsy was taken from vital areas of brain
to rule out haematoma formation.
114 INDIAN JOURNAL OF ANAESTHESIA, APRIL 2002

Discussion Patient responded well to resuscitative measures (Ventilation

There are various anaesthetic options for the with 100% oxygen + Inj Atropine 0.5 mg IV fast + Inj.
procedure. The whole of it can be done under GA but that Xylocard 2%, 2 mg /kg-1 IV slowly) and there was no
increase the cost and adds problems of transporting the untoward complication.
anaesthetized patient, as radiology department and surgical This emphasizes the importance of central line in
theatre may not be on the same floor. In paediatric patients case of biopsy in sitting position2.
and in difficult intubation cases elective endotracheal
intubation help as it abolishes the problems of airway after Conclusion
head ring application. In paediatric patients and those with difficult airway,
In adult patients, stereotactic biopsy can be done elective intubation before frame application helps in
under sedation with local anaesthesia because the skull can maintaining complete control of airway. All precautions
be drilled with minimal discomfort. Unexpected pain may as for neuroanesthesia like smooth perioperative ICP and
occur when the tip of drill impinges on the dura. Scalp haemodynamic control and precautions while positioning
though being vascular does not give rise to systemic toxicity the patient including the aspects of sitting position need to
of local anaesthetic drugs compared to their subcutaneous be taken into account.
infiltration at other sites4. Modern drugs like propofol and midazolam with
Xylocaine 2% with adrenaline could not be used in favourable effect on ICP and rapid recovery help in
all the patients as most of them had associated problems maintaining Total Intravenous Anaesthesia (TIVA)
like HT/IHD. 0.375% bupivacaine was found to be throughout the procedure.
satisfactory as it provided longer analgesia.
Future Scope
Amongst the sedative drugs, propofol was found to The field of stereotactic surgery is very vast in the
offer advantages like ability to rapidly tirate level of form of functional stereotaxy for treatment of
anaesthesia, easy maintenance during patient transfer and extrapytamidal movement disorders, management of
at sites without anaesthetic machine, rapid recovery and neurogenic central pain syndromes and as stereotactic
antiemetic property5,6. radiosurgery for treatment of brain tumours and vascular
Midazolam was used due to rapid recovery over lesions.
diazepam and favourable effect on ICP. For GA, relaxant The study was a step towards understanding its
technique is ideal in neurosurgical patients for good various challenging anaesthetic aspects.
haemodynamic and ICP control in a closed procedure like
stereotactic brain biopsy. References
1. Malcolm F Pell, Eric R. Cosman, David Thomas : Handbook
Complications of stereotaxy using CRW apparatus.
Stereotactic brain biopsy is universally described as 2. Roy F. Cucchiara, Susan black, John D Michenfelder : Clinical
low risk procedure with complication rate of 0 to 4%1. Neuroanaesthesia, 1998, 2nd edition, 477 - 493.
Bleeding and haematoma formation is possible as 3. William DM, Baerts, JAAPJDE LANGE et al : Complications
of the Mayfield skull clamp, Anaesthesiology, 1984, 61, 460.
there is no direct access for cauterization of bleeding sites.
Patients were also observed for complications related to 4. Blood level of bupivacaine after injection into the scalp with
head frame application like haematoma/perforation. None and without adrenaline, Anaesthesiology, 1981, vol. 54, 81.
of these were observed. 5. K.C.Baker and P.R.I.Sert: Anesthetic considerations for childen
undergoing stereitactic radiosurgery, Anaesthesia and Intensive
In one of the patient there was air embolism in care 1997, Vol.25, 691-695.
whom biopsy was taken in sitting position. The ETCO2 6. Bone M.E., Bristow A : Total IV Anesthesia in stereotactic
had dropped from 28 to 13 along with multiple VPC’s and surgery-One years clinical experience. Eur.J.Anaesthesiol 1991,
hypotension (Systolic 60 mmHg). The surgical field was 8, 47-54.
immediately flooded with saline and patient turned supine.