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. 2020 Mar;162(3):469-479.
doi: 10.1007/s00701-020-04222-y. Epub 2020 Feb 3.

Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

Lorenzo Giammattei  1 , Daniele Starnoni  1 , Rodolfo Maduri  1 , Adriano Bernini  2 , Samia Abed-Maillard  2 , Alda Rocca  1 , Giulia Cossu  1 , Alexandre Simonin  1 , Philippe Eckert  2   3 , Jocelyne Bloch  1   3 , Marc Levivier  1   3 , Mauro Oddo  2   3 , Mahmoud Messerer  1   3 , Roy Thomas Daniel  4   5
Affiliations

Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

Lorenzo Giammattei et al. Acta Neurochir (Wien). 2020 Mar.

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.

Keywords: Cisternostomy; Decompressive craniectomy; Intracranial hypertension; Traumatic brain injury.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Flow chart showing the treatment pathway for patients admitted to our center with sTBI
Fig. 2
Fig. 2
Comparative histograms showing the clinical outcome, dichotomized as favorable (GOS-E ≥ 5) and unfavorable (< 5) in the overall population and subgroups
Fig. 3
Fig. 3
Neuromonitoring curves (ICP and PbO2) showing the mean hourly values after surgery in the overall group
Fig. 4
Fig. 4
Neuromonitoring data (ICP and PbO2) showing the mean hourly values after surgery in the primary and secondary procedure subgroups
See this image and copyright information in PMC

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