Microneurosurgical anatomy of the basal cisterns: A brief review for cisternostomy

Abstract

Background: Cisternostomy is a surgical technique thought of and developed as an option for severe brain trauma treatment. It demands a particular knowledge and skill to microsurgically approach basal cisterns and effectively manipulate their contents. To perform this procedure safely, the anatomy and pathophysiology must be clearly understood.

Methods: Detailed microscopic dissection and anatomical review were done, after a detailed reading of facts and recent publications about cisternostomy. Cisternal pathways and landmark planning are described and augmented using a new method to show de arachnoid borders. Finally, a brief discussion is written as a synopsis.

Results: Cisternostomy requires thorough microscopic knowledge and microsurgical skills. This paper intends to provide information to understand better the anatomy related, thus, easing the learning curve. The technique used to show arachnoid borders, complementing cadaveric and surgical images, was useful for this purpose.

Conclusion: To perform this procedure safely, it is mandatory to handle microscopic details of cistern anatomy. Reaching a core cistern is necessary to assure effectiveness. This procedure needs, as well, surgical step-by-step landmark planning and performing. Cisternostomy could be a life-saving procedure and a new powerful tool for severe brain trauma treatment. Evidence is being collected to support its indications.

Keywords: Basal cisterns anatomy; Cisternostomy; Microsurgical technique; Severe brain trauma.

Figure 1:

List of cranial cisterns.

Figure 2:

List of cranial cisterns.

Figure 3:

Intracranial fluids circulation. This figure represents a schematic drawing showing the implication of cisternostomy (light green box) in the common outflow of all brain fluids.

Figure 4:

Sylvian cistern figure. The superficial part (A and B) is represented using (A) cadaveric and (B) surgical pictures. The deep part (D-E) is represented with (D) cadaveric and (E) surgical pictures (C) microscopically colored images demark the arachnoidal borders in the lateral and basal surfaces of the brain.

Figure 5:

Tentorial cisterns figure. (A) Shows a cadaveric preparation with cisternal contents from a lateral view and a schematic explanation of them. (B) Surgical image from a pterional left-sided approach after full arachnoid dissection. Opto-carotid triangle, posterior communicating artery and the Third cranial nerve are shown. A schematic explanation of this image is placed just next to the surgical picture. (C) Basal view of a microscopically colored preparation where the same contents can be founded in relation to arachnoidal borders.