J Neurosurg 89:31–35, 1998

Incidence of silent hemorrhage and delayed deterioration

after stereotactic brain biopsy

ABHAYA V. KULKARNI, M.D., ABHIJIT GUHA, M.D., ANDRES LOZANO, M.D.,

AND MARK BERNSTEIN, M.D., F.R.C.S.(C)

Division of Neurosurgery, Toronto Hospital, Toronto, Ontario, Canada; Department of Surgery,

University of Toronto, Toronto, Ontario, Canada

Object. Many neurosurgeons routinely obtain computerized tomography (CT) scans to rule out hemorrhage in
patients after stereotactic procedures. In the present prospective study, the authors investigated the rate of silent
hemorrhage and delayed deterioration after stereotactic biopsy sampling and the role of postbiopsy CT scanning.
Methods. A subset of patients (the last 102 of approximately 800 patients) who underwent stereotactic brain biop-
sies at the Toronto Hospital prospectively underwent routine postoperative CT scanning within hours of the biopsy
procedure. Their medical charts and CT scans were then reviewed.
A postoperative CT scan was obtained in 102 patients (aged 17–87 years) who underwent stereotactic biopsy
between June 1994 and September 1996. Sixty-one patients (59.8%) exhibited hemorrhages, mostly intracerebral
(54.9%), on the immediate postoperative scan. Only six of these patients were clinically suspected to have suffered a
hemorrhage based on immediate postoperative neurological deficit; in the remaining 55 (53.9%) of 102 patients, the
hemorrhage was clinically silent and unsuspected. Among the clinically silent intracerebral hemorrhages, 22 measured
less than 5 mm, 20 between 5 and 10 mm, five between 10 and 30 mm, and four between 30 and 40 mm. Of the 55
patients with clinically silent hemorrhages, only three demonstrated a delayed neurological deficit (one case of seizure
and two cases of progressive loss of consciousness) and these all occurred within the first 2 postoperative days. Of the
neurologically well patients in whom no hemorrhage was demonstrated on initial postoperative CT scan, none experi-
enced delayed deterioration.
Conclusions. Clinically silent hemorrhage after stereotactic biopsy is very common. However, the authors did
not find that knowledge of its existence ultimately affected individual patient management or outcome. The authors,
therefore, suggest that the most important role of postoperative CT scanning is to screen for those neurologically
well patients with no hemorrhage. These patients could safely be discharged on the same day they underwent
biopsy.

KEY WORDS • intracranial hemorrhage • complications • stereotactic biopsy •

computerized tomography scanning

HE use of stereotactic biopsy sampling in the man-
T agement of intracranial lesions has been well estab-
lished. However, this relatively less invasive proce-
dure is associated with complication rates ranging from
1.2 to 7.2%.1,2,5,8,10,12–17 Given these significant numbers, it
is not an uncommon practice for many neurosurgeons to
obtain computerized tomography (CT) scans routinely
after uncomplicated stereotactic biopsies. However, there
is little in the literature to support this practice. To study
the diagnostic and, ultimately, the therapeutic yield of this
practice, we prospectively obtained CT scans immediate-
ly following all frame-based stereotactic biopsies in pa-
tients beginning in June 1994 and compiled our cumula-
tive results. We looked specifically at those patients who
initially had a clinically silent hemorrhage and whether
they went on to experience delayed deficit in any pre-
dictable fashion. This was not intended to serve as a
review of early symptomatic complications following
stereotactic biopsy, which has already been well docu-
mented in previous studies.1,2,5,8,10,12–17
Clinical Material and Methods
At the Division of Neurosurgery at the Toronto Hospital
between June 1994 and September 1996, 102 patients (51
men and 51 women) with a mean age of 56.8 years (range
17–87 years) in whom frame-based stereotactic biopsies
were obtained prospectively underwent CT scanning
within hours of their procedure. All biopsies were per-
formed by surgeons with special expertise and experience
in stereotactic technique and represented only the most
recent in a series totaling nearly 800 cases. The systems
used were the Brown-Roberts-Wells (Radionics, Burling-

J. Neurosurg. / Volume 89 / July, 1998 31

 A. V. Kulkarni, et al.

TABLE 1 TABLE 2
Pathological diagnosis of lesions in 102 patients who underwent Incidence of hemorrhage on routine postoperative CT scans in
stereotactic brain biopsy 102 patients who underwent stereotactic brain biopsy
Diagnosis No. of Patients No. of Patients (%)
Type of
neoplastic 90 Hemorrhage All Hemorrhages Silent Hemorrhages
high-grade astrocytoma 49
low-grade astrocytoma 17 intracerebral
metastasis 9 ,5 mm 23 (22.5) 22 (21.6)
lymphoma 9 5–10 mm 21 (20.6) 20 (19.6)
oligodendroglioma 4 10–30 mm 7 (6.9) 5 (4.9)
other 2 30–40 mm 5 (4.9) 4 (3.9)
infectious 4 subarachnoid 3 (2.9) 2 (2.0)
infarction 1 subdural 1 (1.0) 1 (1.0)
other 4 intraventricular 1 (1.0) 1 (1.0)
nondiagnostic 3 total 61 (59.8) 55 (53.9)

ton, MA), Cosman-Roberts-Wells (Radionics), or Leksell
(AB Elekta Instruments, Stockholm, Sweden) stereotactic
frame systems; all were used with CT guidance. The tech-
nique of skull penetration was by burr hole or twist drill,
based on the surgeon’s preference. A direct trajectory
through a single pial surface was chosen and almost never
involved transgression of an ependymal surface. All bi-
opsies were performed with a side-cutting needle. Pro-
cedures were performed after the patient had been admin-
istered a local anesthetic agent; this was occasionally
supplemented with intravenous sedation. Routine preop-
erative blood work included a platelet count in all cases,
but further coagulation screening was only performed
when clinically indicated.
We reviewed the CT scans and compared preoperative
and postoperative images. New hemorrhages were classi-
fied by location (intraparenchymal, intraventricular, sub-
arachnoid, subdural, or epidural) and by size (maximum
diameter for intraparenchymal and maximum thickness
for subdural or epidural). The clinical charts of all patients
were also reviewed to determine if there was any new
neurological deficit associated with the stereotactic pro-
cedure.
Patients in whom stereotaxy was performed for func-
tional procedures, Ommaya reservoir insertion, ventricu-
loperitoneal shunt placement, brachytherapy, or cranioto-
my planning were excluded from the study.
Results
All 102 patients underwent framed-based stereotactic
biopsies and postoperative CT scanning. Preoperative co-
agulation testing revealed only one abnormal result in a
patient with an International Normalized Ratio (INR) of
1.46 (normal 0.9–1.1). The technique of skull penetration
was by burr hole in 22 patients and by twist drill in 80 pa-
tients. The pathological characteristics of the lesions that
were obtained by biopsy sampling are listed in Table 1.
In 41 patients (40.2%) there was no new hemorrhage
seen on the initial postoperative CT scan. There were a
total of 61 patients (59.8%) in whom hemorrhage was
visualized on postoperative imaging. Of the 56 hemor-
rhages that were intraparenchymal, 23 (41.1%) were less
than 5 mm in maximum diameter, 21 (37.5%) between 5
and 10 mm, seven (12.5%) between 10 and 30 mm, and
five (8.9%) between 30 and 40 mm (Table 2). Associated
with these intracerebral hemorrhages were four intraven-
tricular hemorrhages, two subarachnoid hemorrhages, and
one subdural hematoma. In all such cases, the intracere-
bral component was the major hemorrhage and, therefore,
these seven are listed under intracerebral hemorrhage in
Table 2. There were also three patients with isolated sub-
arachnoid hemorrhage, one patient with isolated intraven-
tricular hemorrhage, and one patient with isolated subdu-
ral hematoma.
Among the more common pathological conditions as-
sociated with the hemorrhages, postoperative hemorrhage
was seen in 31 (63%) of 49 high-grade astrocytomas,
eight (47%) of 17 of low-grade astrocytomas, four (44%)
of nine metastases, and four (44%) of nine lymphomas.
The average number of needle biopsy samples taken
per case was 1.68 (range 1–8). In those cases with post-
operative hemorrhage, the mean was 1.82 and in those
with no hemorrhage the mean was 1.46. This difference
did not achieve statistical significance (p = 0.479 using the
Mann–Whitney rank-sum test).
Nine patients (8.8%) experienced an early postopera-
tive neurological deficit, which was defined as a deficit
that presented within hours of the procedure and was pres-
ent at the time of initial postoperative CT scanning. Three
of the nine patients had no hemorrhage on their post-
operative CT and their deficit was attributed to increased
tumor edema and mass effect. Six patients had a new neu-
rological deficit that was associated with postoperative
hemorrhage (Table 3). One of these patients, who initially
had left-sided hemiparesis associated with a 20-mm hem-
orrhage, went on to experience delayed decreased level of
consciousness on the 5th postoperative day. At that time
CT scanning revealed evidence of significant new he-
morrhage. That patient improved after a period of obser-
vation only.
Fifty-five patients who experienced postoperative hem-
orrhages were neurologically unchanged. This group in-
cluded nine patients with hemorrhages measuring be-
tween 10 and 40 mm (Table 2). The patient with an INR
of 1.46 experienced an asymptomatic 5- to 10-mm hem-
orrhage.
Of the 55 patients who experienced clinically silent
hemorrhages, three developed a delayed neurological
deficit, which was defined as the onset of a new neuro-

32 J. Neurosurg. / Volume 89 / July, 1998

Hemorrhage after biopsy

TABLE 3
Early new neurological deficit associated with hemorrhage in six
patients who underwent stereotactic brain biopsy*
Hemorrhage
Deficit Lesion Size & Location Treatment

increased dysphasia GBM 20 mm, lt temporal observed

decreased LOC MA 40 mm, rt frontal urgent craniotomy,
died
increased confusion MA 10 mm, para–third observed
ventricle
lt leg numbness MA ,5 mm, rt parietal observed
lt hemiparesis GBM 20 mm, rt frontal rebleeding on Day
5, observed FIG. 1. Case 1 from Table 4. Preoperative magnetic resonance
decreased LOC MA massive SAH observed images obtained in a 50-year-old man who presented with seizure
* GBM = glioblastoma multiforme; LOC = level of consciousness; MA = but had no gross neurological deficit. Coronal T1-weighted
malignant astrocytoma; SAH = subarachnoid hemorrhage. gadolinium-enhanced (left) and axial T2-weighted (right) images
showing right frontal oligodendroglioma.

logical deficit beginning after the day of surgery (Table 4).
Case 1 from Table 4 serves as an illustrative example. This
50-year-old man originally presented with a right frontal
mass (Fig. 1), but was neurologically intact. He underwent
biopsy sampling of what proved to be an oligodendro-
glioma. He was neurologically intact postoperatively;
however, a routine CT scan revealed a 35-mm right frontal
hemorrhage (Fig. 2). On the 1st postoperative day he de-
veloped a seizure, which was easily controlled. Repeated
CT scanning at that time revealed some increase in the
size of the hemorrhage (Fig. 3); the patient was observed
in the hospital for 6 uneventful days, after which he was
discharged home.
The patient in Case 2 from Table 4 also had evidence of
significant new hemorrhage that coincided with his dete-
rioration on postoperative Day 1. The patients in Cases 1
and 3 were successfully managed with observation alone,
whereas no aggressive therapy was given to the patient in
Case 2 because of his overall poor prognosis; that patient
died shortly thereafter.
There were a total of two biopsy-related deaths in this
group of patients for a mortality rate of 2%.
Overall, the rate of delayed deterioration after stereo-
tactic biopsy was found to be 3.9% (four of 102). The inci-
dence of delayed deterioration after an initially silent hem-
orrhage was 5.5% (three of 55). In neurologically well
patients with no hemorrhage on the initial postoperative
CT scan, there were no delayed deteriorations. Therefore,
of the population of patients who initially were well, with
no new neurological deficit (93 patients), the positive pre-
dictive value of the initial postoperative CT scan in fore-
casting delayed deterioration was only 5.5%. However,
the negative predictive value was 100%.
Discussion
Many neurosurgeons routinely obtain CT scans in pa-
tients in an attempt to detect occult hemorrhages after
uncomplicated stereotactic biopsy. The diagnostic yield in
detecting these occult bleeds is not well known. More
important, one must ask the question: does the finding of
an occult hemorrhage have any significant effect on pa-
tient management or outcome? There is little information
available in the literature regarding this practice.

TABLE 4
Delayed neurological deficit after silent hemorrhage in three
patients who underwent stereotactic brain biopsy*
Age Initial Hemor-
Case (yrs), Deficit & Pathological rhage Size Treatment
No. Sex Time Condition & Location & Outcome

1 50, M seizure, oligodendro- 35 mm, rt observed,

POD 1 glioma frontal recovered
2 66, M decreased glioblas- 5–10 mm, comfort mea-
LOC, toma rt parietal sures only,
POD 1 died
3 49, F decreased epidermoid 25 mm, lt observed,
LOC, cyst temporal recovered
FIG. 2. Case 1 from Table 4. Initial CT scan obtained hours after
POD 2
biopsy showing a 35-mm hemorrhage. At this time, the patient did
* LOC = level of consciousness; POD = postoperative day. not demonstrate any neurological deficit.

J. Neurosurg. / Volume 89 / July, 1998 33


FIG. 3. Case 1 from Table 4. A CT scan obtained on postopera-
tive Day 1, after the patient had suffered a seizure, showing evi-
dence of some new hemorrhage with intraventricular extension.
The patient was successfully managed conservatively and was dis-
charged on postoperative Day 6.
Incidence Rates in the Literature
The early reports on experience with CT-guided needle
biopsies presented some data on the incidence of hemor-
rhage following needle placement into the brain, with
asymptomatic hemorrhages ranging from 0% to 40% in a
few small series.6,7,11 These procedures, of course, are very
different from modern stereotaxy and the results cannot be
reliably extrapolated.
In modern larger series of stereotactic biopsies, compli-
cation rates range from 1.2 to 7.2%.1,2,5,8,10,12–17 However, in
all previous studies, only symptomatic complications and
hemorrhages were considered. The authors of very few
series even considered asymptomatic hemorrhage as a
reportable event. Voges and colleagues17 found eight post-
operative hemorrhages in a series of 338 patients; three
were asymptomatic. Levin9 reported three asymptomatic
hemorrhages in 87 stereotactic biopsies. However, al-
though not specified, it appears that postoperative CT
scans were obtained only in patients in whom there was
intraoperative suspicion of bleeding. Bullard, et al.,3 re-
ported finding five small (3–7 mm), asymptomatic hem-
orrhages on 11 postbiopsy CT scans from a series of 44
patients. In another series, Bullard and associates4 found
that, of four postoperative CT scans obtained because of
patient complaints of headache or to confirm biopsy loca-
tion, the majority showed evidence of hemorrhage. How-
ever, Niizuma, et al.,13 reported only four cases of asymp-
tomatic hemorrhage in a series of 121 biopsies. Clearly
there is no consensus in the literature regarding the fre-
quency of silent hemorrhage. The problem inherent in
almost all of these series is that the indications for obtain-
ing postoperative CT scans were not given and it is not
clear whether all asymptomatic hemorrhages were, in fact,
reported. In no previous study has the frequency of silent
hemorrhage been considered in the context of a rigid,
prospective study protocol.
34
A. V. Kulkarni, et al.
Uniqueness of the Present Study
The present report represents the first study in which
the true rate of asymptomatic hemorrhage following
stereotactic biopsy was specifically investigated. In this
prospective study of 102 patients, there was, indeed, a
very significant rate of occult, clinically silent hemorrhage
(53.9%), although the majority were very small. At first
glance, this result appears disturbingly high, especially in
the context of most previous studies of stereotactic biopsy
in which hemorrhage and complication rates have been
reported to be below 7 or 8%.1,2,5,8,10,12–17 In fact, in two pre-
vious large, retrospective reviews from this institution a
major morbidity rate of 3% and an overall complication
rate of 6.3% have been reported.2,16 However, the results of
the present study cannot be fairly compared on a purely
quantitative basis with prior results because no previous
study contained a report of every single small, asymp-
tomatic hemorrhage following biopsy. Also, we would not
use the term “complication,” as it has been traditionally
used, to describe a clinically insignificant hemorrhage.
Clinical Relevance of Silent Hemorrhage
Despite the high incidence of postoperative hemorrhage
in our patients, we found that the ultimate clinical impact
of this finding was virtually nil. In three patients with
initially clinically silent hemorrhage, there did develop
delayed clinical deterioration. However, in two of these
patients (Cases 1 and 2 from Table 4) neurological deteri-
oration occurred within the 1st postoperative day. Even if
postoperative CT scans had not been obtained in these
patients, their clinical deterioration would have alerted the
surgeon while the patients were still in the hospital, be-
cause it was routine practice to keep all patients in the hos-
pital for at least 1 day postoperatively. Also, both patients
underwent repeated CT scanning at the time of their dete-
rioration, and this certainly would have been performed
regardless of whether an initial postoperative CT scan had
been obtained. Of further interest is the fact that the CT
scan obtained at the time of deterioration in both cases
showed significant interval increase in hematoma size that
could not have been predicted based on the initial postop-
erative CT scan. Three additional patients had silent hem-
orrhages similar in size to the one found in the patient in
Case 1; 19 patients had silent hemorrhages similar in size
to the one found in the patient in Case 2; and four patients
had silent hemorrhages similar in size to the one found in
the patient in Case 3. None of these patients suffered any
delayed deterioration. In all such cases, the delayed deficit
was either minor and transient or was associated with a
hopeless prognosis, rendering all cases suitable for con-
servative management alone. This appears to be the hall-
mark characteristic of patients with delayed deterioration
after biopsy.
Only one patient in the entire series required a cra-
niotomy for an intracerebral hemorrhage that ultimately
proved to be fatal. In this case the patient’s clinical deteri-
oration was obvious immediately postoperatively, prior to
his undergoing routine postoperative CT scanning. This
likely echoes the experience of most neurosurgeons, in
that those cases in which craniotomy for postbiopsy hem-
orrhage is required declare themselves very early in the
J. Neurosurg. / Volume 89 / July, 1998
Hemorrhage after biopsy
postoperative course. Those cases in which the patients do
well initially, although subject to a small incidence of
delayed deterioration, usually require only conservative
management.
Pathological Conditions
Among the more common pathological conditions, it
appeared that high-grade astrocytomas had the greatest
tendency to bleed (63%). Low-grade astrocytomas, metas-
tases, and lymphoma had hemorrhage rates of approxi-
mately 45% each. Although the overall numbers are too
small to make any definite conclusions, it would appear
intuitive that high-grade astrocytomas, with the increased
presence of vascular proliferation, would have a greater
tendency to bleed after biopsy. In fact, all of the hemor-
rhages that produced an early neurological deficit were
associated with high-grade astrocytomas (Table 3). This is
consistent with previous experience at our institution.2
One such patient initially suffered from a mild hemipare-
sis as a result of a 20-mm postbiopsy hemorrhage; this
patient went on to experience additional deterioration in
level of consciousness on the 5th postoperative day as a
result of significant new hemorrhage. The causal implica-
tion of the biopsy procedure itself may be questioned,
given the delay of 5 days from biopsy to new hemorrhage.
In any case, this patient only required conservative man-
agement.
Role for Postbiopsy CT Scanning
A very important finding in our study was that, in
patients who had no new neurological deficit after biopsy
and whose initial CT scan showed no evidence of hemor-
rhage (38 patients in our study), there were no incidents
of delayed deterioration. The negative predictive value,
therefore, was 100%. This fact does, indeed, suggest a
possibly useful role for routine postoperative CT scan-
ning. If the CT scan shows no hemorrhage hours after
biopsy sampling in a neurologically well patient, the
patient may be safely discharged home that day rather
than be required to stay overnight in the hospital. This is
now the current practice at our institution. The financial
implications of this are obvious. The cost of routine CT
scanning is outweighed by the savings incurred through
the elimination of nearly 37% (38 of 102 patients) of
overnight admissions. For example, at our institution, the
cost of a routine overnight admission for a relatively
healthy stereotactic patient is approximately four to five
times the cost of an unenhanced CT study of the head.
Therefore, this practice would result in substantial sav-
ings. In these days of ever-tightening fiscal restraint and
an increasing trend toward outpatient-based medical care,
any investigation that can save a hospital admission while
maintaining a high degree of medical safety would be
greatly valued. It appears that postoperative CT scanning
after stereotactic biopsy, if required at all, may well meet
this criteria.
Conclusions
Based on our present experience, we believe that ob-
taining a CT scan after routine stereotactic biopsy sam-
J. Neurosurg. / Volume 89 / July, 1998
pling does not add significantly to patient management or
outcome and is not recommended if the results will not
affect earlier discharge policy. The role of early CT scan-
ning in selecting patients who are safe for same-day dis-
charge is attractive, both medically and financially, and
may be an important aspect of postbiopsy CT scanning in
the future.
References
1. Apuzzo MLJ, Chandrasoma PT, Cohen D, et al: Computed
imaging stereotaxy: experience and perspective related to
500 procedures applied to brain masses. Neurosurgery 20:
930–937, 1987
2. Bernstein M, Parrent AG: Complications of CT-guided stereo-
tactic biopsy of intra-axial brain lesions. J Neurosurg 81:
165–168, 1994
3. Bullard DE, Makachinas TT, Nashold BS Jr: The role of mono-
polar stimulation during computed-tomography-guided stereo-
tactic biopsies. Appl Neurophysiol 51:45–54, 1988
4. Bullard DE, Osborne D, Burger PC, et al: Further experience
utilizing the Gildenberg technique for computed tomography-
guided stereotactic biopsies. Neurosurgery 19:386–391, 1986
5. Cook RJ, Guthrie BL: Complications of stereotactic biopsy.
Perspect Neurol Surg 4:131–140, 1993
6. Hahn JF, Levy WJ, Weinstein MJ: Needle biopsy of intracranial
lesions guided by computerized tomography. Neurosurgery 5:
11–15, 1979
7. James HE, Wells M, Alksne JF, et al: Needle biopsy under com-
puterized tomographic control: a method for tissue diagnosis in
intracranial lesions. Neurosurgery 5:671–674, 1979
8. Kelly PJ: Tumor Stereotaxis. Philadelphia: WB Saunders,
1991, pp 183–223
9. Levin AB: Experience in the first 100 patients undergoing com-
puterized tomography-guided stereotactic procedures utilizing
the Brown-Roberts-Wells guidance system. Appl Neuro-
physiol 48:45–49, 1985
10. Lunsford LD, Martinez AJ: Stereotactic exploration of the brain
in the era of computed tomography. Surg Neurol 22:222–230,
1984
11. Moran CJ, Naidich TP, Gado MH, et al: Central nervous system
lesions biopsied or treated by CT-guided needle placement.
Radiology 131:681–686, 1979
12. Mundinger F: CT stereotactic biopsy for optimizing the therapy
of intracranial processes. Acta Neurochir Suppl 35:70–74,
1985
13. Niizuma H, Otsuki T, Yonemitsu T, et al: Experiences with
CT-guided stereotaxic biopsies in 121 cases. Acta Neurochir
Suppl 42:157–160, 1988
14. Ostertag CB, Mennel HD, Kiessling M: Stereotactic biopsy of
brain tumors. Surg Neurol 14:275–283, 1980
15. Sedan R, Peragut JC, Farnarier P, et al: Intra-encephalic stereo-
tactic biopsies (309 patients/318 biopsies). Acta Neurochir
Suppl 33:207–210, 1984
16. Soo TM, Bernstein M, Provias J, et al: Failed stereotactic biop-
sy in a series of 518 cases. Stereotact Funct Neurosurg 64:
183–196, 1995
17. Voges J, Schröder R, Treuer H, et al: CT-guided and computer
assisted stereotactic biopsy. Technique, results, indications.
Acta Neurochir 125:142–149, 1993
Manuscript received December 2, 1997.
Accepted in final form March 3, 1998.
Address reprint requests to: Mark Bernstein, M.D., F.R.C.S.(C),
Division of Neurosurgery, Toronto Hospital, Western Division, 399
Bathurst Street, Toronto, Ontario, M5T 2S8 Canada.
35