Safety and diagnostic value of brain biopsy in HIV patients: a case series and meta-analysis of 1209 patients

Abstract

Early brain biopsy may be indicated in HIV patients with focal brain lesion. This study aimed to evaluate and compare the safety and diagnostic value of brain biopsy in HIV patients in the pre-highly active antiretroviral therapy (HAART) versus post-HAART era via meta-analysis. Appropriate studies were identified per search criteria. The local database was retrospectively reviewed to select a similar patient cohort. Patient demographics, brain biopsy technique, histopathology and patient outcomes were extracted from each study. Study-specific outcomes were combined per random-effects model. Outcomes were compared between the pre-HAART and post-HAART era. Correlations between outcomes and baseline characteristics were assessed via meta-regression analysis. The proportions of histopathological diagnosis were tabulated and compared between the pre- and post-HAART era. Survival analysis was performed for patients in the post-HAART era. A total of 26 studies (including the local database) with 1209 patients were included in this meta-analysis. The most common indications for brain biopsy were diagnosis unlikely to be toxoplasmosis (n=8, 42.1%), focal brain lesion (n=5, 26.3%) or both (n=3, 15.8%). The weighted proportions for diagnostic success were 92% (95% CI 90.0% to 93.8%), change in management 57.7% (45.9% to 69.1%) and clinical improvement 36.6% (26.3% to 47.5%). Morbidity and mortality were 5.7% (3.6% to 8.3%) and 0.9% (0.3% to 1.9%), respectively. Diagnostic success rate was significantly higher in the post-HAART than the pre-HAART era (97.5% vs 91.9%, p=0.047). The odds ratio (OR) for diagnostic success in patients with contrast-enhanced lesions was 2.54 ((1.25 to 5.15), p<0.01). The median survival for HIV patients who underwent biopsy in the post-HAART era was 225 days (90-2446). Brain biopsy in HIV patients is safe with high diagnostic yield. Early brain biopsy should be considered in patients without classic presentation of toxoplasmosis encephalitis.

The role of brain biopsy in the clinical management of HIV‐related focal brain lesions

“…[20,21] In our centre, the indication for early biopsy was, in 100% of cases, attributable to a low diagnostic presumption of CNS toxoplasmosis, which reflects the high negative predictive value of the combination of imaging studies and serology. [2,3,14,20] In agreement with previous studies on biopsies in HIVinfected patients, the morbidity and mortality of the procedure were low. In our study, the most frequent complication was infection of the surgical site, whereas in previous reports, bleeding was the most prevalent complication [2,7,10,14,17,21].…”

“…Gildenberg et al described the results of 250 biopsies between 1984 and 1998 with a diagnostic success rate of 94% [15]. In a recent meta-analysis that included 1209 patients from 26 studies, diagnostic success was reported as between 75 and 100%, with a change in therapeutic management based on biopsy results of 57.7% [3]. Although in our centre the percentage of diagnostic success for histology was lower, the procedure allowed us to obtain material in order to perform other complementary diagnostic methods in addition to histology.…”

“…The involvement of the central nervous system (CNS) in patients with HIV infection occurs in approximately 40-60% of individuals and, in 10-20% of cases, neurological compromise is the first manifestation of HIV infection [2]. The spectrum of neurological symptoms depends on the degree of immunosuppression, which is reflected in the CD4 cell count and the plasma viral load [3]. Focal brain lesions (FBLs) are a frequent reason for admission of patients with HIV infection and often represent a diagnostic dilemma [1,4,5].…”

Diagnostic accuracy of SPECT, PET, and MRS for primary central nervous system lymphoma in HIV patients

“…[41] Unfortunately, brain biopsy is invasive while conventional imaging modalities have limited diagnostic accuracy. [6,12] Functional nuclear imaging modalities such as SPECT and PET have become increasingly popular diagnostic tools, as they provide images with high spatiotemporal resolution to evaluate perfusion or metabolism. SPECT relies on gamma ray emission from uptake of radiotracers such as Tc-99m, while PET utilizes positron-emitting radiotracers such as 18 F-fluorodeoxyglucose.…”

“…Brain biopsy, despite being the current diagnostic gold standard, is invasive and has high morbidity. [12] Over the past few decades, noninvasive functional nuclear imaging modalities such as single-photon emission computed tomography (SPECT) and positron emission tomography (PET) have been used to detect PCNSL based on physiologic differences between lymphoma and infectious lesions. Several studies have shown high diagnostic accuracy of both SPECT [10,13–17] and PET, [18–23] but a few other studies have cast doubt on the utility of SPECT.…”