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.

Prevention of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage – Expert Consensus and Summary of Existing Evidence

“…To address the limitations of EVDs, neurosurgeons have attempted drainage from more inferior locations to capitalize on the gravity dependent accumulation of blood. Some studies have had di culty displaying the bene ts of cisternal lavage placements [50,51]. However, some have found that cisternal basilar drainage placement can reduce the incidence of vasospasm [52,53].…”

Lumboperitoneal shunt and ventriculoperitoneal shunt for chronic hydrocephalus after aneurysmal subarachnoid hemorrhage: a comparison

“…However, it is challenging to completely remove subarachnoid hemorrhage. Continuous drainage of cerebrospinal fluid is an important factor in facilitating subarachnoid blood drainage ( 6 ). External ventricular drainage is the most commonly used method to promote blood drainage from the subarachnoid space or ventricular system.…”