Severe traumatic brain injury (TBI) is one of the major cause of morbidity and mortality

1. Role of Cisternostomy in
(Severe) Head Injury
Dr Iype Cherian, Professor and Head, Department of
Neurosurgery, NMC, Nepal
Dr Amit Agrawal,
Department of Neurosurgery, NMC, AP (India)

2.  Severe traumatic brain injury (TBI) is one of the major cause
of morbidity and mortality*
Concepts
*Olivecrona et al. Effective ICP Reduction by Decompressive Craniectomy in Patients
with Severe Traumatic Brain Injury Treated by an ICP-Targeted Therapy Journal of
Neurotrauma Volume 24, Number 6, 2007 Pp. 927-935

3.  Time and space for the injured brain to expand and recover
 A large craniotomy or craniectomy (with or without duroplasty)
 CSF drainage (EVD)
 Evacuation of the mass lesions
 Supportive measures including anti-edema measures
Concepts: Management of Severe
TBI
**K. Kinoshita, A. Sakurai, A. Utagawa, T. Ebihara, M. Furukawa, T. Moriya, K. Okuno,
A. Yoshitake, E. Noda, and K. Tanjoh. Importance of cerebral perfusion pressure
management using cerebrospinal drainage in severe traumatic brain injury Acta
Neurochir (2006) [Suppl] 96: 37-39.

4. Cisternostomy
 Applying principals of microneurosurgery to access skull
base in selected cases of severe traumatic brain injury
 Opening the basal cisterns to atmospheric pressure
 Allowing egress of the CSF from ventricles and cisterns to
the subarachnoid space
 Helping to reduce ICP and cerebral edema

5.  Similar to those for decompressive hemicraniectomy
 Acute subdural hematomas (SDH) with mass effect and
midline shift more than 1 cm
 Multiple contusions in combination with SDH and mass
effect
 Pediatric brain injuries with severe brain swelling
Indications

6. What is different??
Standard Approach Cisternostomy
Standard large craniotomy + +
Skull base exposure +/- +
Dural opening Curvilinear Parallel to the supraorbital
ridge
CSF diversion via alternative
pathways
+/- (EVD) Internal CSF Diversion
(Opening of the
membrane of Liliequist
and basal cisterns with or
without placement of a
catheter)
Evacuation of clot and SAH clot + +
Copious irrigation (to clear the clot
and to achieve hemostasis)
+ +
Duroplasty +/- ??
Replacement of bone flap +/- +

8. Hemi-craniectomy technique

10.  External ventricular related complications
 ICP monitoring related problems
 Craniectomy related complications
Advantages

11.  Opening cisterns in a tight brain is a difficult procedure
 (However, the skull base approach)
 It has learning curve
 It may take time to complete the procedures
 Injury to the vital neurovascular structures
Limitations

12.  Cisternostomy can be an option for the management of
severe TBI
 Who should do it?
 When we should do it?
 When we should not do it?
Conclusion

13.  Masoudi MS, Rezaee E, Hakiminejad HA, Tavakoli M, Sadeghpoor T.
Cisternostomy for Management of Intracranial Hypertension in Severe
Traumatic Brain Injury; Case Report and Literature Review. BullEmerg
Trauma. 2016;4(3):161-164.
 Cherian I, Yi G, Munakomi S. Cisternostomy: Replacing the age old
decompressive hemicraniectomy? Asian J Neurosurg. 2013;8(3):132-8.
 Cherian I. Basal cisternostomy-is it a panacea for traumatic brain
swelling? Journal of College of Medical Sciences-Nepal. 2012;8(1): 1-6.
 Cherian I, Bernardo A, Grasso G. Cisternostomy for Traumatic Brain
Injury: Pathophysiologic Mechanisms and Surgical Technical Notes.
World Neurosurg. 2016;89:51-7.
 Cherian I, Grasso G, Bernardo A, Munakomi S. Anatomy and physiology
of cisternostomy. Chin J Traumatol. 2016;19(1):7-10.
 lype Cherian, Sunil Munakomi. Surgical technique for cisternostomy: A
review
References