The Role of Cisternostomy and Cisternal Drainage in the Treatment of Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review

Abstract

Aneurysmal subarachnoid hemorrhage (aSAH) provokes a cascade reaction that is responsible for early and delayed brain injuries mediated by intracranial hypertension, hydrocephalus, cerebral vasospasm (CV), and delayed cerebral ischemia (DCI), which result in increased morbidity and mortality. During open microsurgical repair, cisternal access is achieved essentially to gain proximal vascular control and aneurysm exposition. Cisternostomy also allows brain relaxation, removal of cisternal clots, and restoration of the CSF dynamics through the communication between the anterior and posterior circulation cisterns and the ventricular system, with the opening of the Membrane of Liliequist and lamina terminalis, respectively. Continuous postoperative CSF drainage through a cisternal drain (CD) is a valuable option for treating acute hydrocephalus and intracranial hypertension. Moreover, it efficiently removes the blood and toxic degradation products, with a potential benefit on CV, DCI, and shunt-dependent hydrocephalus. Finally, the CD is an effective pathway to administer vasoactive, fibrinolytic, and anti-oxidant agents and shows promising results in decreasing CV and DCI rates while minimizing systemic effects. We performed a comprehensive review to establish the adjuvant role of cisternostomy and CD performed in cases of direct surgical repair for ruptured intracranial aneurysms and their role in the prevention and treatment of aSAH complications.

Keywords: aneurysmal subarachnoid hemorrhage; cerebral vasospasm; cisternal drain; cisternostomy; delayed cerebral ischemia; hydrocephalus; ruptured aneurysm; vascular neurosurgery.

Figure 1

Flow chart showing the search strategy for the narrative review.

Figure 2

Step-by-step illustration of a cisternostomy performed during microsurgical clipping of an aneurysm of the right middle cerebral artery bifurcation. (a) Subfrontal approach and identification of the optic nerve (ON) with (b) progressive opening of the optico-carotid cistern and exposure of the internal carotid artery (ICA). (c) The dissection continues medially and posteriorly following the ON until the exposure of the optic chiasma (OC) and the lamina terminalis (LT). (d) The opening of the lamina terminalis gives access to the third ventricle and allows CSF drainage from the ventricular system. Brain relaxation is generally obtained at this stage after blood clot evacuation from the basal cisterns, the opening of the optico-carotid cisterns, and the LT. Abbreviations: CSF: cerebrospinal fluid; ICA: internal carotid artery; LT: lamina terminalis; OC: optic chiasma; ON: optic nerve.

Figure 3

Step-by-step illustration of a cisternostomy performed during microsurgical clipping of an aneurysm of the right middle cerebral artery bifurcation. (a) The diencephalic leaf of the Membrane of Liliequist (white asterisk) is seen through the optico-carotid triangle and (b) progressively opened, (c) enabling the exposure of the mesencephalic leaf (black arrow) that is finally opened. (d) The basilar artery (black asterisk) is visible in the pre-pontine cistern. (e) The tip of the cisternal drain is positioned between the ICA and the ON in the pre-pontine cistern. Abbreviations: ICA: internal carotid artery; ON: optic nerve.