- Department of Neurosurgery, Hospital de Santa Maria, Av. Professor Egas Moniz, 649-035, Lisbon, Portugal
- Department of Neurology, Laboratory of Neuropathology, Hospital de Santa Maria, Instituto de Medicina Molecular, Lisbon, Portugal
Department of Neurosurgery, Hospital de Santa Maria, Av. Professor Egas Moniz, 649-035, Lisbon, Portugal
DOI:10.4103/2152-7806.148057Copyright: © 2014 Lorenzetti M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Lorenzetti M, Carvalho H, Cattoni M, Antonio Gonçalves-Ferreira, José Pimentel, Joao Antuñes. Cavernous sinus lesions biopsy with neuronavigation and tip-cut needle. Surg Neurol Int 30-Dec-2014;5:
How to cite this URL: Lorenzetti M, Carvalho H, Cattoni M, Antonio Gonçalves-Ferreira, José Pimentel, Joao Antuñes. Cavernous sinus lesions biopsy with neuronavigation and tip-cut needle. Surg Neurol Int 30-Dec-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/cavernous-sinus-lesions-biopsy-neuronavigation-tip%e2%80%91cut-needle/
Background:Transoval biopsy of cavernous sinus (CS) lesions is the last non-invasive diagnostic option in those 15% of patients in whom etiology remains unclear in spite of extensive neuroradiological imaging, clinical assessment, and laboratory evaluation. However, there are no guidelines defining indications and the most appropriate technique for this procedure.
Case Description:We present four patients in whom we performed X-ray and neuronavigation-assisted transoval CS biopsies using tip-cut needles.
Conclusion:The technique described allows the operator to determine the optimal angle for entering the CS, avoiding the complications due to distorted anatomy, and facilitating orientation once inside the CS. It reduces both radiation exposure as well as general anesthesia duration.
Keywords: Cavernous sinus lesions, foramen ovale biopsy, minimally invasive biopsy, tip-cut needle, transoval approach
The cavernous sinus (CS), described by Dwight Parkinson as an “anatomical jewel box,” can contain lesions of different pathological nature.[
Correct diagnosis is thus essential for safe and successful treatment.[
Since it was first performed by Stechison in 1989, minimally invasive biopsy through foramen ovale has become the gold standard non-invasive diagnostic procedure for the 15% of CS lesions in which clinical, laboratory, and imaging studies fail to identify the exact nature of the process.[
A number of biopsy techniques have been developed over the years, reflecting the advances in cerebral imaging and bioptic instruments.
The present paper describes a CS transoval lesion biopsy technique using a frameless image-guidance and a frontal tip-cut biopsy needle.
A 76-year-old woman with no previous history of cancer presented with intractable headache followed by diplopia and left hemifacial numbness lasting for 2 weeks.
Cerebral magnetic resonance imaging (MRI) showed a CS lesion extending to the Meckel's cave. The patient underwent a transoval biopsy of the lesion. Histopathology confirmed an adenocarcinoma metastasis of unknown origin. She was subsequently treated with stereotactic radiosurgery (SRS).
A 40-year-old, 16 weeks pregnant, HIV- and hepatitis C virus (HCV)-positive woman presented with a 6-day history of bilateral diplopia, frontal headaches, and left eye ptosis. Non-contrast enhanced cerebral MRI revealed a CS lesion extending to the Meckel's cave. In view of the patient's history, we were quite reluctant to rule out infectious etiology on the basis of neuroimaging studies alone. In spite of steroid treatment, both diplopia and ptosis worsened over the next few days. Following a discussion of intended benefits and potential risk of the procedure, an informed consent for transoval biopsy was obtained. Contrast MRI and computed tomography (CT) using abdominal protection was obtained. Histology implied a typical World Health Organziation (WHO) Grade I meningioma. Given the benign nature of the lesion and the patient's pregnancy, we refrained from urgent SRS.
A 60-year-old male with a 3-year history of CS syndrome consisting of left ptosis, diplopia, and ipsilateral exophthalmos presented with a sudden deterioration of his symptoms. Cerebral MRI showed a CS lesion with posterior extension to the Meckel's cave. He underwent transoval biopsy of the lesion. Histology revealed an atypical WHO grade II meningioma and SRS treatment was commenced.
A 37-year-old male with previous surgery for right eye convergent strabism at the age of 19 was admitted with sudden onset of complete right-sided ptosis, non-reactive mydriasis, and abducent palsy. Neurological examination showed right-sided hemifacial numbness and masticatory muscle atrophy. Cerebral MRI revealed a CS lesion with extension to the Meckel's cave. The patient underwent transoval percutaneous biopsy of the lesion which yielded a histopathological diagnosis of atypical WHO grade II meningioma. He was then treated with SRS.
The transoval biopsy as described was performed under neuronavigation and fluoroscopic real-time guidance [
Following sterile preparation of the skin, local anesthetic (lidocaine) was injected locally through an entry point located 2.5 cm laterally to the labial commissure and down to the foramen ovale. This entry point was identified with the aid of the neuronavigation system as per the classic approach to the foramen ovale described by Hartel.
The neuronavigation needle (Sure track system) [
Histological evaluation of a tumor specimen obtained through transoval biopsy describing: (a) rests of epithelial cells in a mesenchymal stroma, forming circular cavities (H and E, ×40); (b) strong CK7 cytokeratine immunoreactivity. The histological diagnosis was of metastasis of adenocarcinoma of unknown primary tumor
We encountered no intra- or post-operative complications.
A large variety of pathological lesions can occur in the CS.
However, benign and malignant tumors are the most frequently encountered lesions in this area, with meningioma being the most common.[
Differentiation of these deep lesions is essential for determining the most appropriate treatment option and, hence, reducing the complications of both surgical[
Transoval biopsy of CS lesions is the last non-invasive diagnostic option in those 15% of patients in whom etiology remains unclear in spite of extensive neuroradiological imaging, clinical assessment, and laboratory evaluation. It is particularly valuable in cases where inflammatory or malignant lesions with “meningioma-like” appearance on imaging could be mistaken for a true meningioma.[
The transoval foramen biopsy route was first described by Stechison (1989) in a case of breast cancer metastasis to the CS.[
Despite the low incidence of complications,[
This is why several biopsy techniques, using a variety of needles and intra-operative imaging methods, have been developed over the years.
Fluoroscopy and/or CT-guided techniques[
Use of obsolete biopsy needles has also been strongly criticized. In particular, Dolenc argued that using a large-bore 14 gauge Tuohy needle turns the procedure into an invasive one. The risk is further increased by the curette effect of a strong aspiration, as described by Sindou.[
Side-cutting aspiration type needles with a diameter ranging from 14 to 22 gauge were the only alternatives described in the literature. In spite of criticism, no other needle design has been employed until now.
We describe a novel X-ray and neuronavigator-assisted technique in which fused CT and angio-MRI images serve as a base for planning the ideal needle trajectory and guiding its advancement by 3D virtual intra-operative control. This allowed us to tailor the procedure to each patient's bony, vascular, and soft tissue anatomy. Unlike fluoroscopy, this technique proved useful even in the context of a pathologic CS in which the normal vascular anatomy is altered by a potentially highly vascularized lesion. Contrary to the case report by Frighetto,[
In the four cases presented, we chose a frontal cut needle, which gave us the advantage of reaching the lesion by advancing the needle 0.5 cm less than would have been necessary with a laterally fenestrated biopsy needle. Its tip opening reduced the risk of tearing the intracavernous segment of internal carotid artery.
Despite the low incidence of complications, biopsy of CS lesions should be considered a high-risk procedure. This is not only due to the complex peri- and intra-cavernous anatomy, but also due to the fact that the operator is “nibbling” blindly at very deep and potentially highly vascularized target.
In our opinion, the approach guided by neuronavigation and X-ray is both the easiest and most reliable of the transoval percutaneous biopsy techniques. The technique described safely allows the neurosurgeon to choose the best needle entrance angle, avoids the pitfalls associated with distorted anatomy due to small foramina, and keeps the operator well oriented once inside the CS. Finally, it avoids excessive dose of ionizing radiation and shortens the duration of general anesthesia to a mean of 40 min. In view of our satisfying results, we are optimistic that future experience shall confirm the superiority of the frontal cut needle for all the biopsy techniques.
We wish to thank Dr. Daniel Polakovič for his fundamental language revision of this article.
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