J Neurol Surg A Cent Eur Neurosurg 2024; 85(01): 048-061
DOI: 10.1055/a-1994-8033
Original Article

Diagnostic Accuracy and Field for Improvement of Frameless Stereotactic Brain Biopsy: A Focus on Nondiagnostic Cases

1   Department of Surgery, Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
2   Department of Neurosurgery, Tuen Mun Hospital, Hong Kong, China
Cannon Xian Lun Zhu
1   Department of Surgery, Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
Danny Tat Ming Chan
1   Department of Surgery, Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
Tom Chi Yan Cheung
3   Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
Ho-Keung Ng
4   Department of Anatomical & Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
Vincent Chung Tong Mok
5   Department of Medicine and Therapeutics, Division of Neurology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
Wai Sang Poon
1   Department of Surgery, Division of Neurosurgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
› Author Affiliations
Funding None.


Background The diagnostic accuracy of frameless stereotactic brain biopsy has been reported, but there is limited literature focusing on the reasons for nondiagnostic cases. In this study, we evaluate the diagnostic accuracy of frameless stereotactic brain biopsy, compare it with the current international standard, and review the field for improvement.

Methods This is a retrospective analysis of consecutive, prospectively collected frameless stereotactic brain biopsies from 2007 to 2020. We evaluated the diagnostic accuracy of the frameless stereotactic brain biopsies using defined criteria. The biopsy result was classified as conclusive, inconclusive, or negative, based on the pathologic, radiologic, and clinical diagnosis concordance. For inconclusive or negative results, we further evaluated the preoperative planning and postoperative imaging to review the errors. A literature review for the diagnostic accuracy of frameless stereotactic biopsy was performed for the validity of our results.

Results There were 106 patients with 109 biopsies performed from 2007 to 2020. The conclusive diagnosis was reached in 103 (94.5%) procedures. An inconclusive diagnosis was noted in four (3.7%) procedures and the biopsy was negative in two (1.9%) procedures. Symptomatic hemorrhage occurred in one patient (0.9%). There was no mortality in our series. Registration error (RE) and inaccurate targeting occurred in three trigonal lesions (2.8%), sampling of the nonrepresentative part of the lesion occurred in two cases (1.8%), and one biopsy (0.9%) for lymphoma was negative due to steroid treatment. The literature review suggested that our diagnostic accuracy was comparable with the published literature.

Conclusion The frameless stereotactic biopsy is a safe procedure with high diagnostic accuracy only if meticulous preoperative planning and careful intraoperative registration is performed. The common pitfalls precluding a conclusive diagnosis are RE and biopsies at nonrepresentative sites.


The study result was presented in the oral format at the Annual Scientific Meeting of the Hong Kong Neurosurgical Society on December 18, 2020, by Dr. He Zhexi and in video format at the 7th World Federation of Neurosurgical Societies (WFNS) Foundation Asian Congress of Neurological Surgeons (ACNS) Winter Web Seminar on February 20, 2021, by Dr. He Zhexi.

A preprint version of the older version of this manuscript is available on Research Square with DOI:10.21203/rs.3.rs-854266/v1 and was cited in the manuscript as Reference 4. The current manuscript included the latest publications in the literature review and updated the discussion.

Availability of Data and Material

The data that support the findings of this study are available upon request from the corresponding author, under the regulations of the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee.

Ethical Approval

This research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. The study protocol was reviewed and approved by the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee (CREC Ref. No. 2021.354).

Consent to Participate

The study protocol is reviewed and approved by the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee (CREC Ref. No. 2021.354) with the patient consent waived as this research is based on secondary analysis of available data with no additional risk to patients. There is no patient-identifiable information contained in this manuscript.

Publication History

Received: 20 June 2022

Accepted: 05 December 2022

Accepted Manuscript online:
08 December 2022

Article published online:
11 May 2023

© 2023. Thieme. All rights reserved.

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Rüdigerstraße 14, 70469 Stuttgart, Germany

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