Open biopsy in patients with acute progressive neurologic decline and absence of mass lesion

Abstract

Objective: Patients with acute to subacute neurologic decline undergo a battery of imaging and laboratory tests to determine a diagnosis and treatment plan. Often, after an extensive evaluation, a brain biopsy is recommended as yet another tool to assist in determining the diagnosis. The goal of this retrospective cohort analysis is to measure the sensitivity of open brain biopsy in this patient population, compare these results with the preoperative presumed diagnosis, and evaluate if the biopsy result significantly alters treatment.

Methods: The authors reviewed the medical records of 135 consecutive patients who underwent open brain biopsies for acute to subacute progressive neurologic decline between January 1999 and September 2008 at a single institution. All patients with mass lesions, with HIV/AIDS, and who were younger than 20 years of age were excluded from the study. Fifty-one patients met these criteria and all preoperative tests, imaging, and treatment plans were examined and compared with postbiopsy interventions to determine the impact of the biopsy on patient outcome.

Results: The sensitivity of open brain biopsy at our institution was 35%. The most common preoperative presumed diagnosis was vasculitis and the most common postoperative finding was Creutzfeldt-Jakob disease, followed by amyloid angiopathy. Postbiopsy hemorrhage was a complication in 4% of patients. Treatment plans changed as a direct result of the biopsy in 8% of patients, and in only 4% did the biopsy findings make a difference in disease course.

Conclusion: In patients with progressive neurologic decline without a radiographic mass lesion or immunodeficiency, open brain biopsy often fails to provide a diagnosis and even more rarely does it significantly alter treatment.

Figure 1 Encephalomyelitis Axial fluid-attenuated inversion recovery image showing hyperintensities throughout the white matter in a patient diagnosed with acute disseminated encephalomyelitis by biopsy.

Figure 2 Creutzfeldt-Jakob disease MRI axial image demonstrating classic fluid-attenuated inversion recovery hyperintensities in the caudate and putamen in a patient with Creutzfeldt-Jakob disease.

Figure 3 Presumed vasculitis: Nondiagnostic Digital subtraction angiogram demonstrating multiple areas of alternating dilation and constriction in the bilateral posterior cerebral arteries read as suggestive of but not diagnostic of vasculitis. Open biopsy was nondiagnostic.