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Kumarasamy S, Garg K, Singh PK, Satyarthee GD, Agrawal D. Cisternostomy as an Adjuvant or Standalone Approach for Management of Traumatic Brain Injury: A Systematic Review and Network Meta-Analysis. World Neurosurg 2024:S1878-8750(24)01071-4. [PMID: 38925245 DOI: 10.1016/j.wneu.2024.06.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of morbidity in all age groups worldwide. Decompressive craniectomy (DC) is a salvage procedure in patients with TBI. The outcome and quality of life following DC is questionable. Basal cisternostomy (BC) has been proposed to reduce edema and lead to brain relaxation. It was initially used as an adjunct in TBI patients, thereby improving outcomes. With gaining popularity among neurosurgeons, BC was used as a standalone approach in TBI patients. This network meta-analysis aims to analyze the role of BC either as an adjunct or as a standalone approach in managing TBI patients. METHODS A comprehensive search of electronic databases (PubMed and SCOPUS) was performed using the search strategy using the field terms and medical subheading terms (MeSH Terms) to retrieve studies describing the role of BC in patients with TBI either as an adjunct with DC or standalone treatment and their outcome. RESULTS Thirty-one articles were selected for full-text review and 18 articles were selected for the final analysis. BC alone group was found to have minimum in-hospital mortality (odds ratio [OR], 0.348; 95% credible interval [CrI], 0.254 to 0.477) followed by DC combined with BC group (OR, 0.645; 95% CrI, 0.476 to 0.875). DC combined with the BC group was found to have a minimum duration of mechanical ventilation (OR, 0.114; 95% CrI, 0.005 to 2.451) followed by the BC alone group (OR, 0.604; 95% CrI, 0.024 to 15.346). DC combined with the BC group were found to have the maximum Glasgow Outcome Scale score (OR, 1.661; 95% CrI, 0.907 to 3.041) followed by the BC alone group (OR, 1.553; 95% CrI, 0.907 to 3.041). CONCLUSIONS Our analysis showed that BC alone was associated with lower in-hospital mortality rates in TBI patients. DC with BC had decreased the requirement of mechanical ventilation. However, larger multi-centric studies from other parts of the world are required to confirm these findings.
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Affiliation(s)
- Sivaraman Kumarasamy
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
| | - Pankaj Kumar Singh
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Guru Dutta Satyarthee
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
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Gao L, Yu K, Feng Y, Yan F, Qian C. Intraventricular haemorrhage treated by extra ventricular drainage with catheter mistakenly penetrating the cisterna ambiens: A case report. J Int Med Res 2024; 52:3000605241237680. [PMID: 38606755 PMCID: PMC11015790 DOI: 10.1177/03000605241237680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 02/20/2024] [Indexed: 04/13/2024] Open
Abstract
Intraventricular haemorrhage (IVH) is a severe and acute type of stroke with a complex pathophysiology and is a therapeutic challenge. This case report described a man in his early 50's diagnosed with IVH by computed tomography (CT). Although bilateral extraventricular drainage (EVD) was undertaken, a postoperative CT scan showed that while the left catheter was correctly positioned, the right catheter had been wrongly inserted into the cisterna ambiens. The procedure was equivalent to simultaneous EVD combined with cisternostomy. As a consequence, the haematoma was rapidly removed, the risk of infection and long-term hydrocephalus was reduced, and prognosis was improved. Large case-control studies or prospective studies are needed to evaluate the safety and effectiveness of this treatment modality.
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Affiliation(s)
- Liansheng Gao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Kaibo Yu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Yanfei Feng
- Department of Urology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feng Yan
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Cong Qian
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
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Vandenbulcke A, Messerer M, Garvayo Navarro M, Peters DR, Starnoni D, Giammattei L, Ben-Hamouda N, Puccinelli F, Saliou G, Cossu G, Daniel RT. Cisternal nicardipine for prevention of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a comparative retrospective cohort study. Acta Neurochir (Wien) 2024; 166:133. [PMID: 38472426 DOI: 10.1007/s00701-024-06023-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Intrathecal vasoactive drugs have been proposed in patients with aneurysmal subarachnoid hemorrhage (aSAH) to manage cerebral vasospasm (CV). We analyzed the efficacy of intracisternal nicardipine compared to intraventricular administration to a control group (CG) to determine its impact on delayed cerebral ischemia (DCI) and functional outcomes. Secondary outcomes included the need for intra-arterial angioplasties and the safety profile. METHODS We performed a retrospective analysis of prospectively collected data of all adult patients admitted for a high modified Fisher grade aSAH between January 2015 and April 2022. All patients with significant radiological CV were included. Three groups of patients were defined based on the CV management: cisternal nicardipine (CN), ventricular nicardipine (VN), and no intrathecal nicardipine (control group). RESULTS Seventy patients met the inclusion criteria. Eleven patients received intracisternal nicardipine, 18 intraventricular nicardipine, and 41 belonged to the control group. No cases of DCI were observed in the CN group (p = 0.02). Patients with intracisternal nicardipine had a reduced number of intra-arterial angioplasties when compared to the control group (p = 0.03). The safety profile analysis showed no difference in complications across the three groups. Intrathecal (ventricular or cisternal) nicardipine therapy improved functional outcomes at 6 months (p = 0.04) when compared to the control group. CONCLUSION Administration of intrathecal nicardipine for moderate to severe CV reduces the rate of DCI and improved long-term functional outcomes in patients with high modified Fisher grade aSAH. This study also showed a relative benefit of cisternal over intraventricular nicardipine, thereby reducing the number of angioplasties performed in the post-treatment phase. However, these preliminary results should be confirmed with future prospective studies.
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Affiliation(s)
- Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Marta Garvayo Navarro
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - David R Peters
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Lorenzo Giammattei
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Intensive Care, University Hospital of Lausanne (CHUV), University of Lausanne, Lausanne, Vaud, Switzerland
| | - Francesco Puccinelli
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Guillaume Saliou
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne (CHUV), Lausanne, Vaud, Switzerland
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne (CHUV), University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Vaud, Switzerland.
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Hossain I, Rostami E, Marklund N. The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies. Curr Opin Crit Care 2023; 29:650-658. [PMID: 37851061 PMCID: PMC10624411 DOI: 10.1097/mcc.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours. RECENT FINDINGS Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials. SUMMARY Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.
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Affiliation(s)
- Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala
- Department of Neuroscience, Karolinska institute, Stockholm
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
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Garvayo M, Messerer M, Starnoni D, Puccinelli F, Vandenbulcke A, Daniel RT, Cossu G. The positive impact of cisternostomy with cisternal drainage on delayed hydrocephalus after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:187-195. [PMID: 36504078 PMCID: PMC9840569 DOI: 10.1007/s00701-022-05445-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hydrocephalus is one of the major complications of aneurysmal subarachnoid haemorrhage (aSAH). In the acute setting, an external ventricular drain (EVD) is used for early management. A cisternal drain (CD) coupled with the micro-surgical opening of basal cisterns can be an alternative when the aneurysm is clipped. Chronic hydrocephalus after aSAH is managed with ventriculo-peritoneal (VP) shunt, a procedure associated with a wide range of complications. The aim of this study is to analyse the impact of micro-surgical opening of basal cisterns coupled with CD on the incidence of VP shunt, compared to patients treated with EVD. METHODS The authors conducted a retrospective review of 89 consecutive cases of patients with aSAH treated surgically and endovascularly with either EVD or CD between January 2009 and September 2021. Patients were stratified into two groups: Group 1 included patients with EVD, Group 2 included patients with CD. Subgroup analysis with only patients treated surgically was also performed. We compared their baseline characteristics, clinical outcomes and shunting rates. RESULTS There were no statistically significant differences between the two groups in terms of epidemiological characteristics, WFNS score, Fisher scale, presence of intraventricular hemorrhage (IVH), acute hydrocephalus, postoperative meningitis or of clinical outcomes at last follow-up. Cisternostomy with CD (Group 2) was associated with a statistically significant reduction in VP-shunt compared with the use of an EVD (Group 1) (9.09% vs 53.78%; p < 0.001). This finding was confirmed in our subgroup analysis, as among patients with a surgical clipping, the rate of VP shunt was 43.7% for the EVD group and 9.5% for the CD group (p = 0.02). CONCLUSIONS Cisternostomy with CD may reduce the rate of shunt-dependent hydrocephalus. Cisternostomy allows the removal of subarachnoid blood, thereby reducing arachnoid inflammation and fibrosis. CD may enhance this effect, thus resulting in lower rates of chronic hydrocephalus.
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Affiliation(s)
- Marta Garvayo
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Francesco Puccinelli
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland.
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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Atchley TJ. In Reply: Review of Cerebrospinal Fluid Physiology and Dynamics: A Call for Medical Education Reform. Neurosurgery 2022; 91:e150. [DOI: 10.1227/neu.0000000000002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 11/19/2022] Open
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Giammattei L, Starnoni D, Messerer M, Daniel RT. Letter: Review of Cerebrospinal Fluid Physiology and Dynamics: A Call for Medical Education Reform. Neurosurgery 2022; 91:e148-e149. [DOI: 10.1227/neu.0000000000002159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/08/2022] [Indexed: 11/19/2022] Open
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Giammattei L, Starnoni D, Messerer M, Daniel RT. Basal Cisternostomy for Severe TBI: Surgical Technique and Cadaveric Dissection. Front Surg 2022; 9:915818. [PMID: 35599786 PMCID: PMC9120838 DOI: 10.3389/fsurg.2022.915818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/19/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction Cisternostomy is emerging as a novel surgical technique in the setting of severe brain trauma. Different surgical techniques have been proposed with a variable degree of epidural bone work. We present here the surgical technique as it is currently performed in our Institution. Methods Anatomical dissection of one adult cadaveric head, injected and non-formalin fixed was perfomed. A large right fronto-temporo-parietal craniotomy was accomplished. Extradural sphenoidal drilling till opening of the superior orbital fissure was performed. The microsurgical anatomy of basal cisternostomy was then explored. Results A step by step description of the surgical technique, enriched with cadaveric and intraoperative images, was made. Conclusion Basal cisternostomy is a promising surgical technique that does not necessarily include complex surgical maneuvers. Trained neurosurgeon can safely implement it in their clinical practice.
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Affiliation(s)
- L. Giammattei
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Correspondence: Lorenzo Giammattei
| | - D. Starnoni
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
| | - M. Messerer
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - R. T. Daniel
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Singh RD, van Dijck JTJM, Maas AIR, Peul WC, van Essen TA. Challenges Encountered in Surgical Traumatic Brain Injury Research: A Need for Methodological Improvement of Future Studies. World Neurosurg 2022; 161:410-417. [PMID: 35505561 DOI: 10.1016/j.wneu.2021.11.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/22/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Investigating neurosurgical interventions for traumatic brain injury (TBI) involves complex methodological and practical challenges. In the present report, we have provided an overview of the current state of neurosurgical TBI research and discussed the key challenges and possible solutions. METHODS The content of our report was based on an extensive literature review and personal knowledge and expert opinions of senior neurosurgeon researchers and epidemiologists. RESULTS Current best practice research strategies include randomized controlled trials (RCTs) and comparative effectiveness research. The performance of RCTs has been complicated by the heterogeneity of TBI patient populations with the associated sample size requirements, the traditional eminence-based neurosurgical culture, inadequate research budgets, and the often acutely life-threatening setting of severe TBI. Statistical corrections can mitigate the effects of heterogeneity, and increasing awareness of clinical equipoise and informed consent alternatives can improve trial efficiency. The substantial confounding by indication, which limits the interpretability of observational research, can be circumvented by using an instrumental variable analysis. Traditional TBI outcome measures remain relevant but do not adequately capture the subtleties of well-being, suggesting a need for multidimensional approaches to outcome assessments. CONCLUSIONS In settings in which traditional RCTs are difficult to conduct and substantial confounding by indication can be present, observational studies using an instrumental variable analysis and "pragmatic" RCTs are promising alternatives. Embedding TBI research into standard clinical practice should be more frequently considered but will require fundamental modifications to the current health care system. Finally, multimodality outcome assessment will be key to improving future surgical and nonsurgical TBI research.
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Affiliation(s)
- Ranjit D Singh
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands.
| | - Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Thomas A van Essen
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
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Ramesh Chandra V, Bodapati Chandra mowliswara P, Banavath HN, Kalakoti CSR. “Cisternostomy Vs Decompressive Craniectomy for The Management of Traumatic Brain Injury: A Randomized Controlled Trial”. World Neurosurg 2022; 162:e58-e64. [DOI: 10.1016/j.wneu.2022.02.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
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Parthiban JKBC, Sundaramahalingam S, Rao JB, Nannaware VP, Rathwa VN, Nasre VY, Prahlad ST. Basal Cisternostomy - A Microsurgical Cerebro Spinal Fluid Let Out Procedure and Treatment Option in the Management of Traumatic Brain Injury. Analysis of 40 Consecutive Head Injury Patients Operated with and without Bone Flap Replacement Following Cisternostomy in a Tertiary Care Centre in India. Neurol India 2021; 69:328-333. [PMID: 33904445 DOI: 10.4103/0028-3886.314535] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Decompressive craniectomy (DC) is considered the gold standard blanket surgical procedure for all medically intractable cerebral oedema in Traumatic Brain Injury (TBI). It's only proven fact is that it reduces Intra Cerebral Pressure (ICP) by providing space for the oedematous brain. Attempts are being made to find additional or alternative procedures to improve outcomes in TBI. Basal Cisternostomy is one such technique proposed to bring such a change in world literature. Aim To analyse the validity of Basal Cisternostomy in TBI patients. Materials and Methods A total of 40 patients who underwent Basal Cisternostomy (BC) in TBI admitted in the senior author's unit between January 2016 and April 2019 were analysed retrospectively. All surgeries were performed by single surgeon with microsurgical expertise. Outcome was assessed according to Glasgow outcome scale (GOS). Results were analysed using SPSS software. Results In severe TBI, Basal Cisternostomy group showed 77.8% favourable outcome while Decompressive Craniectomy in addition to Basal Cisternostomy group showed 72.7% only. While favourable GOS was seen in 82% (33/40), the unfavourable outcome was noticed in 12.5% (5/40) and death in 5% (2/40) in this series. Hydrocephalus was seen in 12.5% (5/40). Patients operated earlier from the time of injury showed better results than those who got operated later irrespective of severity of neurological status. ICU stay and hospital stay duration and its validity could not be assessed. Conclusion Basal Cisternostomy is an effective procedure in Traumatic Brain Injury patients that not only improves outcome but also reduces the need for Decompressive Craniectomy as a blanket procedure and thus avoiding its associated complications.
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Affiliation(s)
- Jutty K B C Parthiban
- Senior Consultant and HOD, Department of Neurosurgery, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | | | - J Balaparameswara Rao
- Fellow in Neurosurgery, Department of Neurosurgery, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Vaishali Pralhad Nannaware
- Registrars PG students, Department of Neurosurgery, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Vishnu Najarubhai Rathwa
- Registrars PG students, Department of Neurosurgery, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Vaibhav Yogesh Nasre
- Registrars PG students, Department of Neurosurgery, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
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Affiliation(s)
- P Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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13
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Kanmounye US. The Rise of Inflow Cisternostomy in Resource-Limited Settings: Rationale, Limitations, and Future Challenges. Emerg Med Int 2021; 2021:6630050. [PMID: 33505727 PMCID: PMC7810553 DOI: 10.1155/2021/6630050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 11/18/2022] Open
Abstract
Low- and middle-income countries (LMICs) bear most of the global burden of traumatic brain injury (TBI), but they lack the resources to address this public health crisis. For TBI guidelines and innovations to be effective, they must consider the context in LMICs; keeping this in mind, this article will focus on the history, pathophysiology, practice, evidence, and implications of cisternostomy. In this narrative review, the author discusses the history, pathophysiology, practice, evidence, and implications of cisternostomy. Cisternostomy for the management of TBI is an innovation developed in LMICs, primarily for LMICs. Its practice is based on the cerebrospinal fluid shift edema theory that attributes injury to increased pressure within the subarachnoid space due to subarachnoid hemorrhage and subsequent dysfunction of glymphatic drainage. Early reports of the technique report significant improvements in the Glasgow Outcome Scale, lower mortality rates, and shorter intensive care unit durations. Most reports are single-center studies with small sample sizes, and the technique requires experience and skill. These limitations have led to criticisms and slow adoption of the technique. Further research is needed to establish the effect of cisternostomy on TBI outcomes.
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Servadei F, Kolias A, Kirollos R, Khan T, Hutchinson P. Cisternostomy for traumatic brain injury-rigorous evaluation is necessary. Acta Neurochir (Wien) 2020; 162:481-483. [PMID: 31965317 DOI: 10.1007/s00701-020-04224-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Box 167, Cambridge, CB2 0QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Ramez Kirollos
- National Neuroscience Institute and Duke-NUS Medical School, Singapore, Singapore
| | - Tariq Khan
- Department of Neurosurgery, Northwest General Hospital and Research Center, Peshawar, Pakistan
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Box 167, Cambridge, CB2 0QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
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Giammattei L, Starnoni D, Maduri R, Bernini A, Abed-Maillard S, Rocca A, Cossu G, Simonin A, Eckert P, Bloch J, Levivier M, Oddo M, Messerer M, Daniel RT. Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma. Acta Neurochir (Wien) 2020; 162:469-479. [PMID: 32016585 PMCID: PMC7046565 DOI: 10.1007/s00701-020-04222-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/10/2020] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI). METHODS A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, "primary procedure" and "secondary procedure", was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO2) values as well as the need for additional osmotherapy and CSF drainage. RESULTS Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average post-surgical ICP values, higher PbO2 values and required less osmotic treatments as compared with those treated with DC alone. CONCLUSION Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.
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Szczygielski J, Hubertus V, Kruchten E, Müller A, Albrecht LF, Mautes AE, Schwerdtfeger K, Oertel J. Brain Edema Formation and Functional Outcome After Surgical Decompression in Murine Closed Head Injury Are Modulated by Acetazolamide Administration. Front Neurol 2019; 10:273. [PMID: 30972006 PMCID: PMC6443632 DOI: 10.3389/fneur.2019.00273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/01/2019] [Indexed: 11/13/2022] Open
Abstract
Acetazolamide (ACZ), carbonic anhydrase inhibitor, has been successfully applied in several neurosurgical conditions for diagnostic or therapeutic purposes. Furthermore, neuroprotective and anti-edematous properties of ACZ have been postulated. However, its use in traumatic brain injury (TBI) is limited, since ACZ-caused vasodilatation according to the Monro-Kellie doctrine may lead to increased intracranial blood volume / raise of intracranial pressure. We hypothesized that these negative effects of ACZ will be reduced or prevented, if the drug is administered after already performed decompression. To test this hypothesis, we used a mouse model of closed head injury (CHI) and decompressive craniectomy (DC). Mice were assigned into following experimental groups: sham, DC, CHI, CHI+ACZ, CHI+DC, and CHI+DC+ACZ (n = 8 each group). 1d and 3d post injury, the neurological function was assessed according to Neurological Severity Score (NSS) and Beam Balance Score (BBS). At the same time points, brain edema was quantified by MRI investigations. Functional impairment and edema volume were compared between groups and over time. Among the animals without skull decompression, the group additionally treated with acetazolamide demonstrated the most severe functional impairment. This pattern was reversed among the mice with decompressive craniectomy: CHI+DC treated but not CHI+DC+ACZ treated animals showed a significant neurological deficit. Accordingly, radiological assessment revealed most severe edema formation in the CHI+DC group while in CHI+DC+ACZ animals, volume of brain edema did not differ from DC-only animals. In our CHI model, the response to acetazolamide treatment varies between animals with decompressive craniectomy and those without surgical treatment. Opening the cranial vault potentially creates an opportunity for acetazolamide to exert its beneficial effects while vasodilatation-related risks are attenuated. Therefore, we recommend further exploration of this potentially beneficial drug in translational research projects.
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Affiliation(s)
- Jacek Szczygielski
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.,Institute of Neuropathology, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.,Faculty of Medicine, University of Rzeszów, Rzeszów, Poland
| | - Vanessa Hubertus
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.,Department of Neurosurgery, Charité University Medicine, Berlin, Germany
| | - Eduard Kruchten
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.,Institute of Interventional and Diagnostic Radiology, Karlsruhe Municipal Hospital, Karlsruhe, Germany
| | - Andreas Müller
- Department of Radiology, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Lisa Franziska Albrecht
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Angelika E Mautes
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Karsten Schwerdtfeger
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
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Levi V, Vetrano IG. Exploring Cerebro-Spinal Fluid Dynamics as a Tool to Improve Clinical Outcomes in Traumatic Brain Injuries. World Neurosurg 2019; 121:290. [DOI: 10.1016/j.wneu.2018.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 11/16/2022]
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May Cisternostomy and Glymphatic System Be Considered the Deus ex Machina of Refractory Posttraumatic Intracranial Hypertension? World Neurosurg 2018; 117:471-472. [DOI: 10.1016/j.wneu.2018.05.231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 11/20/2022]
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Current Perspectives in the Surgical Treatment of Severe Traumatic Brain Injury. World Neurosurg 2018; 116:322-328. [DOI: 10.1016/j.wneu.2018.05.176] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/22/2018] [Accepted: 05/24/2018] [Indexed: 12/14/2022]
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Di Cristofori A, Gerosa A, Panzarasa G. Is Neurosurgery Ready for Cisternostomy in Traumatic Brain Injuries? World Neurosurg 2018; 111:427. [PMID: 29499598 DOI: 10.1016/j.wneu.2017.11.139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Andrea Di Cristofori
- Division of Neurosurgery, University Hospital-Maggiore Hospital of Charity of Novara, Novara, Italy.
| | - Andrea Gerosa
- Division of Neurosurgery, University Hospital-Maggiore Hospital of Charity of Novara, Novara, Italy
| | - Gabriele Panzarasa
- Division of Neurosurgery, University Hospital-Maggiore Hospital of Charity of Novara, Novara, Italy
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Giammattei L, Messerer M, Daniel RT. In Reply to "Is Neurosurgery Ready for Cisternostomy in Traumatic Brain Injuries?". World Neurosurg 2018; 111:428. [PMID: 29499599 DOI: 10.1016/j.wneu.2017.12.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Lorenzo Giammattei
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland.
| | - Mahmoud Messerer
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
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Letter to the Editor Regarding “Cisternostomy for Refractory Posttraumatic Intracranial Hypertension”. World Neurosurg 2018; 112:311-312. [DOI: 10.1016/j.wneu.2018.01.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 12/27/2022]
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Moscote-Salazar LR, Narvaez-Rojas AR, Pacheco-Hernandez A. Cisternostomy: Surgical Alternative for Patients with Refractory Posttraumatic Intracranial Hypertension. World Neurosurg 2018; 110:507. [DOI: 10.1016/j.wneu.2017.10.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 10/28/2017] [Indexed: 10/18/2022]
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Giammattei L, Messerer M, Daniel RT. In Reply to “Cisternostomy: Surgical Alternative for Patients with Refractory Posttraumatic Intracranial Hypertension”. World Neurosurg 2018; 110:508. [DOI: 10.1016/j.wneu.2017.11.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 10/18/2022]
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