Cisternostomy versus Decompressive Craniectomy for the Management of Traumatic Brain Injury: A Randomized Controlled Trial

Abstract

Background: The goal of treatment of traumatic brain injury (TBI) is to avoid secondary brain injury. Decompressive craniectomy has been shown to reduce intracranial pressure (ICP), but it actually provides an outlet for brain tissue to expand without reducing edema. Basal cisternostomy is an emerging microsurgical technique to manage cerebral edema in TBI. Cerebrospinal fluid is released from basal cisterns, which reduces cerebral edema. We compared outcomes of cisternostomy with decompressive craniectomy in a randomized controlled trial and studied the effectiveness of cisternostomy in decreasing cerebral edema.

Methods: All enrolled patients were randomly assigned to 2 groups and assessed clinically and radiologically. TBIs were categorized as mild, moderate, and severe injuries, and Marshall computed tomography-based score was assessed. Intraoperative ICP was measured in both groups. Outcomes were assessed based on postoperative intensive care unit stay, days on ventilator support, and Glasgow Outcome Scale score.

Results: There were 50 patients randomly assigned to 2 groups (25 patients in each group). Mortality rate was 32% (8 deaths) in the cisternostomy group and 44% (11 deaths) in the decompressive craniectomy group. Patients in the cisternostomy group had decreased mean days of ventilator support and intensive care unit stay. Cisternostomy resulted in significant decreases in ICP after craniotomy. Age, time from trauma to surgery, and Marshall score showed prognostic importance on outcomes.

Conclusions: Cisternostomy was effective in reducing ICP in patients with TBI. Good Glasgow Outcome Scale scores and low rates of complications were found in the postoperative period after cisternostomy. Age, presenting Glasgow Coma Scale score, Marshall score, other major injuries, and time from trauma to surgery had a significant prognostic impact on outcome in management of TBI.

Keywords: Cisternostomy; Decompressive hemicraniectomy; Head injury management; ICP; Recent trends in traumatic brain injury; TBI.