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

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 (PbO 2) 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 postsurgical ICP values, higher PbO 2 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.

Outcomes and Predictors of Outcome with Cisternostomy in the Management of Traumatic Brain Injury—A Prospective Observational Study at a Tertiary Centre

“…15 Giammattei et al in a study of 40 cases showed that implementation of cisternostomy as adjuvant to decompressive craniectomy had lower ICP values and better outcomes when compared with craniectomy alone. 16 In our study, patients with average low ICP after cisternostomy (5.71 AE 1.60 mm Hg) had good outcome at 3 months follow-up. Patients with high average ICP after cisternostomy (7.25 AE 1.39 mm Hg) had poor outcome.…”

Cisternostomy in Traumatic Brain Injury for a Novel Approach to Treatment: Review of Current Status

“…Giammattei et al performed a retrospective study in severe TBI patients comparing DC ( n = 22) with DC + CS ( n = 18). 15 The groups were comparable with respect to age and GCS at presentation, but the DC + CS group had more patients with unilateral pupillary dilation (55 vs. 36%) and higher average Rotterdam CT score (4.7 vs. 3.8; p = 0.03). The decision to add CS to DC was based on the availability of surgeon skilled in vascular and skull base approaches, which can be a source of introducing selection bias.…”

Effect of Early Rehabilitation Nursing on Motor Function and Living Ability of Patients with Traumatic Brain Injury Based on Orem’s Self-Care Theory

“…However, as people often attach importance to life rescue while neglecting functional rehabilitation, the disability rate is greatly increased, and most of the surviving patients will leave behind varying degrees of disability. In addition to cognitive dysfunction, language dysfunction, and physical function accounted for a large part [ 20 ]. In the United States, some scholars published the meta-analysis report “early rehabilitation based on evidence: recommendations for Clinical practice” from 1999 to 2000.…”