Role of Cisternostomy in (Severe) Head Injury

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 +/- +

7. Hemi- craniectomy technique

8. External ventricular related complications ICP monitoring related problems Craniectomy related complications Advantages

9. 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

10. 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

11. 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

12. Thank You