Introduction: Stereotactic needle biopsies provide a minimally invasive option for the diagnosis of intracranial lesions but are limited by inconclusive diagnoses on frozen pathology. Additional samples and prolonged procedure times increase risk of complications. 5-Aminovelunic acid (5-ALA) and sodium fluorescein have previously demonstrated potential as diagnostic adjuvants for rapid intraoperative pathology. Stereotactic biopsy with near-infrared (NIR) fluorescence has not been reported. We identified five representative cases utilizing the NIR-fluorescent dye Indocyanine-Green (ICG), administered in a high dose, delayed manner.

Methods: We identified five patients enrolled in an ongoing IRB-approved protocol who underwent Second Window ICG (SWIG)-guided stereotactic biopsy for diagnosis of suspected glioma or tumor recurrence. Up to 5 mg/kg ICG was administered approximately 24 hours prior to surgery. Stereotactic core needle biopsies were conducted in the standard fashion, targeting regions of suspected tumor using intraoperative frameless navigation. Core samples were examined under standard visible light and for fluorescence using conventional NIR imaging platforms intraoperatively. Findings were correlated with frozen and final tumor pathology for all cases.

Results: Ten biopsy specimens were obtained in five patients. Three (30%) did not fluoresce and did not demonstrate tumor on preliminary or final pathology, including a non-gadolinium-enhancing sample taken proximal to the final target. The remaining 7 (70%) samples fluoresced, of which 5 (71%) contained positively identifiable tumor. One sample (14%) contained necrosis; however, a separate fluorescent biopsy from this patient demonstrated glioblastoma. Fluorescence was also noted in a patient with radiation treatment effect. Overall fluorescence characteristics were highly concordant with both preliminary and final diagnoses.

Conclusions: SWIG provides rapid intraoperative confirmation of gadolinium-enhancing, pathologic brain tissue during stereotactic biopsy. Because the mechanism of ICG accumulation is similar to that of gadolinium in permeating neoplastic or inflammatory brain tissue, we believe SWIG-guided stereotactic biopsy can improve surgical efficiency by improving confidence in acquisition of target tissue.

Patient Care: The objective of stereotactic brain biopsy is to safely acquire diagnostic specimen. However, inconclusive intraoperative pathology and prolonged procedure times mean surgeons must decide whether additional trajectories and samples are required to render a diagnosis. SWIG and other fluorescence-guided surgical techniques are a promising means of reducing complications.

Learning Objectives: "By the conclusion of this session, participants should be able to: 1) Describe the utility of near-infrared imaging in stereotactic biopsy 2) Discuss, in small groups, the postulated relationship between biopsy fluorescence and regions of gadolinium-enhancement on MRI 3) Identify entities who would benefit from this adjunct intraoperative visualization technique."

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