Cisternostomy: Replacing the age old decompressive hemicraniectomy?

Abstract

Backround: Practical scenario in trauma neurosurgery comes with multiple challenges and limitations. It accounts for the maximum mortality in neurosurgery and yet the developing countries are still ill-equipped even for an emergency set-up for primary management of traumatic brain injuries. The evolution of modern neurosurgical techniques in traumatic brain injury has been ongoing for the last two centuries. However, it has always been a challenge to obtain a satisfactory clinical outcome, especially those following severe traumatic brain injuries. Other than the well-established procedures such as decompressive hemicraniectomy and those for acute and or chronic subdural hematomas and depressed skull fractures, contusions etcetera newer avenues for development of surgical techniques where indicated have been minimal. We are advocating a replacement for decompressive hemicranictomy, which would have the same indications as decompressive hemicraniectomy. The results of this procedure has been compared with the results of decompressive hemicraniectomy done in our institution and elsewhere and has been proven beyond doubts to be superior to decompressive hemicraniectomy. This procedure is elegant and can replace decompressive hemicraniectomy because of low morbidity and mortality. However, there is a steep learning curve and the microscope has to be used.

Materials and methods: Based on the clinical experience and observation of acute neurosurgical service in tertiary medical centers in a developing country, the procedure of cisternostomy in the management of trauma neurosurgery have been elucidated in the current study. The study proposes to apply the principles of microvascular surgery and skull base surgery in selected cases of severe traumatic brain injuries, thus replacing decompressive hemicraniectomy as the primary modality of treatment for indicated cases.

Conclusion: Extensive opening of cisterns making use of skull base techniques to approach them in a swollen brain is a better option to decompressive hemicraniectomy for the same indications.

Keywords: Brain swelling; cisterns; decompressive hemicraniectomy; intra brain pressure; intra cisternal pressure.

Graph 1

A total of 284 patients underwent decompressive hemicraniectomy, 272 of them underwent decompressive hemicraniectomy with cisternostomy and 476 of them underwent cisternostomy alone

Graph 2

Among the cisternostomy group, 52 patients had mild head injury, 206 patients had moderate head injuries and 218 patients had severe head injury

Graph 3

For severe head injuries, the mortality for cisternostomy was 15.6%, for DHC was 34.8% and for DHC with cisternostomy it was 26.4%

Graph 4

The mean days on the ventilator for the three groups were 2.4, 3.2 and 6.3 respectively for cisternostomy, decompressive hemicraniectomy with cisternostomy and decompressive hemicraniectomy

Graph 5

Mean GOS at 6 weeks for DHC arm was 2.8, for DHC and cisternostomy arm it was 3.7 and for cisternostomy alone arm it was 3.9

Figure 1

Virchow Robin spaces type 2 and 3

Figure 2

Virchow Robin spaces type 1

Figure 3

Cerebrospinal fluid migration in trauma

Figure 4

The role of decompressive craniectomy

Figure 5

Cisternostomy causing the reverse shift of cerebrospinal fluid

Figure 6

The pre-operative computed tomography scan of a male patient brought to the emergency with a Glasgow Coma Scale of 8

Figure 7

The post-operative scan after 2 weeks patient had a Glasgow Coma Scale of 15 with moderate cognitive deficit

Figure 8

(a) Immediately after the dural opening and evacuation of the acute subdural hematoma. The surgeon gets a window period of 2-3 min of slightly lax brain before it starts swelling again. (b) In this “window” the surgeon should open the interoptic cistern. (c) The brain becomes lax sufficiently to expose and dissect the opticocarotid space and the lateral carotid space. (d) And through either of these spaces or both, the membrane of Lilliquist is sharply dissected to reach the interpeduncular and the prepontine cisterns