Open Biopsy With Acute Progressive Neurologic Decline and Absence of Mass Lesion - An Overview

Introduction:

Acute progressive neurological decline is when an individual's brain function deteriorates rapidly over a short period, such as within days or weeks. This deterioration can significantly impact cognitive behavior, sensory perception, consciousness, and motor function. One of the primary diagnostic challenges in this condition is the absence of identifiable mass lesions. Consequently, invasive procedures, such as open biopsy, may be performed. During an open biopsy, a tiny piece of brain tissue is removed and examined under a microscope for pathological analysis. This examination is crucial for comprehensively evaluating the condition, ultimately guiding appropriate management strategies.

What Is Acute Progressive Neurological Decline?

Acute progressive neurological decline is when a person's neurological function becomes impaired or deteriorates over time. Some characteristic features include:

• Rapid Onset: This condition is characterized by a sudden onset of neurological deficits within a short period, necessitating urgent medical attention.

• Progressive Nature: Symptoms associated with this condition worsen rapidly over time.

• Diverse Symptoms: Patients with this condition exhibit diverse symptoms, including cognitive changes, loss of coordination, headaches, seizures, sensory disturbances, and other psychiatric symptoms.

• Absence of Mass Lesion: One of the diagnostic challenges in this condition is the absence of structural abnormalities or lesions in the brain that can be visualized in diagnostic images such as CT (computed tomography) scans or MRI (magnetic resonance imaging) scans.

• Diagnostic Complexity: Despite extensive diagnostic evaluations, including CT, MRI, blood tests, CSF (cerebrospinal fluid) studies, and cerebral diagnostic subtraction angiography for visualizing brain blood vessels, accurate diagnoses remain elusive. Therefore, a brain biopsy is often necessary.

What Are the Clinical Features of Acute Progressive Neurologic Decline?

The clinical features of acute progressive neurological decline include:

• Cognitive Changes: These include memory loss, altered mental status, confusion, and difficulty concentrating.

• Motor Symptoms: These encompass weakness in limbs, muscle stiffness, tremors, difficulty in maintaining balance, loss of coordination, and involuntary movements.

• Sensory Disturbances: These involve sensations such as numbness or tingling in the limbs, altered perception of pain, or loss of sensation in certain areas.

• Seizures: Seizures result in changes in behavior, movements, or sensations due to uncontrolled activity in the brain.

• Speech Problems: This encompasses difficulty in articulating words or slurred speech.

• Psychiatric Symptoms: These encompass hallucinations, irritability, mood changes, and psychosis, which can lead to disrupted thoughts.

• Headaches: Severe headaches are common symptoms in many individuals.

• Autonomic Dysfunction: This includes changes in bladder control, blood pressure, or even heart rate.

• Others: Altered consciousness and vision changes.

What Is Open Biopsy for Acute Progressive Neurological Decline and Absence of Mass Lesion?

When a patient presents with a history of neurological decline deteriorating over a short period, evaluations such as CSF studies, blood tests, and diagnostic imaging such as MRI or CT are typically conducted. However, in cases where these tests fail to provide a definitive diagnosis, an open brain biopsy may be performed. According to studies, patients with cancer or immunodeficiencies have benefited from this procedure.

Stereotactic needle biopsies, involving the insertion of a thin needle into the brain to extract tissue are not recommended due to the risk of inadequate sampling. Instead, a procedure known as craniotomy is performed, which entails creating an opening in the skull to access and remove brain tissue. This approach ensures the retrieval of adequate brain tissue for comprehensive evaluation.

According to numerous studies, approximately 1 cubic centimeter-sized brain tissue is typically extracted, encompassing all layers of brain tissue, including the arachnoid (the layer surrounding the brain), cortex (the outermost layer of the brain), pia (the deep layer adhered to the brain surface), and the white matter (deep brain tissues). Consequently, the most common sampling site for evaluation includes the right frontal lobe of the brain, specifically the middle frontal gyrus.

What Are the Positive Outcomes of Open Brain Biopsy?

The positive outcomes of open brain biopsy include:

• Definitive Diagnosis: Open biopsy can aid in achieving an accurate diagnosis, especially in infections and autoimmune disorders, facilitating appropriate management.

• Treatment Planning: The definitive diagnosis obtained through open biopsy allows for a better understanding of the disease's aggressiveness, enabling the initiation of an appropriate treatment plan.

• Disease Staging: Pathological evaluation can assist in grading the disease and comprehending its progression, contributing to a more comprehensive understanding of the condition.

• Prognosis: This diagnostic method can offer valuable insights into the disease's prognosis, potentially improving survival rates and providing essential information about the patient's condition.

Therefore, biopsies can provide valuable information, even when no specific treatments are available.

What Are the Risks and Complications of Open Brain Biopsy?

The risks and complications of open biopsy include:

• Infection: Surgical procedures carry the potential risk of infection; therefore, preventive measures such as aseptic techniques should be rigorously followed.

• Bleeding: This can be a potential complication, as a hematoma may form at the surgical site due to increased intracranial pressure within the brain. Therefore, precautions should be taken to control bleeding from the surgical site.

• Seizures: During the removal of brain tissue, seizures can occur in some individuals during the operation or in the postoperative period.

• Neurological Deficits: Depending on the site of tissue removal, new deficits may arise, including sensory disturbances, weakness, or cognitive impairment.

• CSF Leakage: The biopsy can sometimes breach the protective brain layer, leading to cerebrospinal fluid leakage. This poses a risk of infection and may require additional surgical intervention.

• Pain and Discomfort: Pain and discomfort can be common complications in most patients but can be managed effectively with pain medications and adequate rest.

• Brain Herniation: This life-threatening condition can occur due to elevated pressure inside the brain.

• Scarring: Scalp scarring may occur, and the severity of scarring depends on the size of the incision.

• Others: Some can encounter allergic reactions to anesthesia or medications or damage to adjacent structures such as the cortex or deep layers of the brain.

Conclusion:

Therefore, weighing the potential benefits of the biopsy procedure, such as achieving a definitive diagnosis and facilitating appropriate management, is important against the associated complications and risks. The decision to proceed with an open biopsy varies for individuals, and healthcare providers should take necessary precautions to minimize risks and enhance patient safety. However, with new techniques such as neuroimaging and serological testing, the need for invasive procedures may decrease in some instances.