Is basal cisternostomy in traumatic brain injury a need of hour or white elephant - A randomized trial to answer

Background

Basal cisternostomy (BC) recently emerged as an adjuvant/alternative procedure to decompressive craniectomy (DC) in traumatic brain injuries (TBIs) with its potential to effectively reduce both intracranial pressure (ICP) and brain edema. However, its role in TBI is not yet established in the true sense and with clarity. The objective of the present study was to evaluate the effect of adjuvant BC on ICP, mortality, and clinicoradiological outcome.

Methods

A single-center randomized control trial was conducted. Fifty patients were assigned to each DC-group and DC+BC-group. Randomization was done using the sealed envelope method. Both groups were followed in the postoperative period to compare the impact of surgery on ICP, radiological changes, and clinical outcome (mortality, days on ventilator/in intensive care unit (ICU), and Glasgow outcome scale-extended (GOS-E) at 12 weeks).

Results

Both groups were comparable in terms of preoperative clinicoradiological characteristics. On postoperative days 1, 2, and 3, mean ICP was significantly low in the DC+BC-group (P < 0.0001). The decline in ICP in the DC+BC-group was significant in both moderate and severe TBI patients. In comparison, DC+BC-group has a shorter duration of mechanical ventilation/ICU stay and significantly better GOS-E score at 12 weeks (P < 0.0001*). The mortality rate was less in the DC+BC-group (48%) as compared to the DC-group (64%). Among radiological features, mean midline shift and mean outward brain herniation were significantly less in the DC+BC group. Bone-flap replacement was possible in ten patients of DC+BC-group at the time of primary surgery.

Conclusion

Results of our study indicated that BC is beneficial in reducing both ICP and brain edema, which translates into favorable clinicoradiological outcomes.

Basal cisternostomy for traumatic brain injury: A case report of unexpected good recovery

In subarachnoid hemorrhage following traumatic brain injury (TBI), the high intracisternal pressure drives the cerebrospinal fluid into the brain parenchyma, causing cerebral edema. Basal cisternostomy involves opening the basal cisterns to atmospheric pressure and draining cerebrospinal fluid in an attempt to reverse the edema. We describe a case of basal cisternostomy combined with decompressive craniectomy. A 35-year-old man with severe TBI following a road vehicle accident presented with acute subdural hematoma, Glasgow coma scale score of 6, fixed pupils and no corneal response. Opening of the basal cisterns and placement of a temporary cisternal drain led to immediate relaxation of the brain. The patient had a Glasgow coma scale score of 15 on postoperative day 6 and was discharged on day 10. We think basal cisternostomy is a feasible and effective procedure that should be considered in the management of TBI.

Basal Cisternostomy in Head Injury: More Questions than Answers

Background

Cisternostomy has recently been reintroduced in the setting of severe TBI as an adjuvant surgical technique for decreasing brain edema and refractory intracranial hypertension. However, there is not much clarity regarding its role in head injury.

Objective

Study the effect of cisternostomy on intracranial pressure, morbidity, and mortality in head-injured patients.

Material and Methods

We conducted a single-center quasi-experimental study between November 2018 and November 2020. All candidates for decompressive hemicraniectomy (DHC) were divided into two groups: DHC-BC (undergoing basal cisternostomy with DHC) and DHC (undergoing DHC alone). We compared the impact of surgery on decreasing ICP and clinical outcomes in both groups.

Results

During the study duration, we admitted 659 head-injury patients. Forty patients were included in the study (9 in the DHC-BC group and 31 in the DHC group). Both the groups were comparable in terms of baseline clinical characteristics such as age, gender, preoperative GCS, head injury severity, radiological features, and opening ICP. Patients in both groups had a decline in ICP following surgery. The mean closing pressure in the DHC-BC group (11.3 ± 5.9) was significantly higher than that in the DHC group (5.3 ± 3.5) (P = 0.003). The mean drop in ICP in the DHC-BC group was 14.4 ± 11.5 while that in the DHC group was 18.9 ± 12.4 (P = 0.359). The average total number of hours of ICP >20 mm Hg and intracranial hypertension index were higher for the DHC-BC group. The average number of days of stay in the ICU and hospital were lower for the DHC-BC group (7.0 ± 6.1 and 15.0 ± 20.2, respectively) compared to the DHC group (10.6 ± 9.3 and 19.3 ± 13.9, respectively). The 30-day mortality rate was higher for the DHC-BC group (66.6%) than the DHC group (32.2%). The mean GCS at discharge was better in the DHC-BC group (11.7 ± 2.9) compared to 10.5 ± 3.7 in the DHC group, while 11.1% of patients in the DHC-BC group had a favorable outcome (1-month GOS-E) compared to 9.7% patients in the DHC group.

Conclusions

Our preliminary single-center study failed to show a clear benefit of adding basal cisternostomy to decompressive hemicraniectomy in patients with head injuries.

Analysis of 40 Consecutive Head Injury Patients Operated with and without Bone Flap Replacement Following Cisternostomy in a Tertiary Care Centre in India

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.

Putting 'CSF-Shift Edema' Hypothesis to Test: Comparing Cisternal and Parenchymal Pressures After Basal Cisternostomy for Head Injury

BACKGROUND

Increased brain edema in head injury is due to shift of cerebrospinal fluid (CSF) from cisterns at high pressure to brain parenchyma at low pressure. By opening basal cisterns and decreasing the increased cisternal pressure, basal cisternostomy (BC) results in reversal of CSF shift from parenchyma to cisterns, leading to decreased brain edema. Though the CSF-shift edema hypothesis is based on pressure difference between cisterns and brain parenchyma, the relationship of these pressures has not been studied.

METHODS

A prospective clinical study was conducted from November 2018 to March 2020 including adult patients with head injury who were candidates for standard decompressive hemicraniectomy (DHC). All patients had neurological assessment and head computed tomography preoperatively and postoperatively. All patients underwent BC with DHC. Postoperatively, parenchymal and cisternal pressures and neurological condition were monitored hourly for 72 hours.

RESULTS

Nine (5 men, 4 women) patients with head injury (mean age, 45.7 years; range, 25-72 years) underwent DHC-BC. Median Glasgow Coma Scale score of patients at admission was 8 (range, 4-14), and median midline shift on computed tomography was 8 mm (range, 7-12 mm). There was a significant difference between opening (25.70 ± 10.48 mm Hg) and closing (11.30 ± 5.95 mm Hg) parenchymal pressures (t₉ = 3.963, P = 0.003). Immediate postoperative cisternal pressure was 1-11 mm Hg and was lower than immediate postoperative parenchymal pressure in all except 1 patient. Postoperatively, if cisternal pressure remained low, parenchymal pressure also decreased, and patients showed clinical improvement. Patients showing increased cisternal pressure showed increased parenchymal pressure and clinical worsening.

CONCLUSIONS

Our study supports the CSF-shift edema hypothesis. Following DHC-BC, cisternal pressure is lowered to near-atmospheric pressure, and its relationship to parenchymal pressure predicts the future course of patients by reversal or re-reversal of CSF shift.