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EDITORIAL
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 243--244

Basal Cisternostomy: Hype or Hope?

P Sarat Chandra 
 Editor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
P Sarat Chandra
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
India




How to cite this article:
Chandra P S. Basal Cisternostomy: Hype or Hope?.Neurol India 2021;69:243-244


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Chandra P S. Basal Cisternostomy: Hype or Hope?. Neurol India [serial online] 2021 [cited 2021 Oct 17 ];69:243-244
Available from: https://www.neurologyindia.com/text.asp?2021/69/2/243/314592


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Basal cisternosotomy (BS) was introduced by Cherian I, et al.[1],[2],[3] based of the concept of reversing “CSF-shift edema” by opening up the basal cisterns in moderate to severe head injuries. The pathophysiology of traumatic brain swelling is complex and mainly thought to be cytotoxic and vasogenic in origin, but yet not completely understood. The “build up” of pressure in basal cisterns in head injuries is based on an additional mechanism- hydrodynamic mechanism. An increase of pressure in sub arachnoid spaces may happen in head injuries due to subarachnoid hemorrhage. This may result in “reverse shift” of CSF from the cisternal spaces into brain parenchyma further contributing to brain edema and swelling. The Virchow Robin spaces are said to play an important role in creating the “CSF-shift” edema due to their “permeable” junctions1. This may lead to increased fluid in the interstitial spaces very similar to peri ventricular changes seen in severe hydrocephalus. Thus, opening cisterns can lead to a CSF “release” leading to reduction of brain swelling.

This concept was later further explored by Daniel, et al.[4] in a retrospective series of 40 patients who underwent either basal cisternostomy or decompressive craniotomy alone.[5] They concluded that the patients who underwent BS had shorter duration of mechanical ventilation, ICU stay and a better Glasgow coma score at discharge, even though the mortality was similar. The BS cases also has significantly lower intra cranial pressure values, higher PbO2 values and required less of osmotic treatments as compared to those who underwent decompressive craniotomy. The Glasgow outcomes scores (GOS) were also significantly better for BS patients at 6 months (61% for BS vs 35% for decompressive craniotomy).

Goyal N, et al.[6] published a cohort 9 patients who underwent both BS and decompressive craniotomy. They demonstrated a significant difference between opening and closing parenchymal pressures. Their study supported the CSF-shift edema and suggested that both BS and decompressive craniotomy should be provided for head injuries with severe edema.

The study by Partiban, et al.[7] supports performing BS alone rather combining both BS and decompressive craniotomy. In this study, BS alone had a favorable GOS as compared to BS combined with decompressive craniotomy (82% vs 62%). Another major shortcoming of all the above studies includes, them being performed by a single surgeon.

Basal cisternostomy seems like a promising procedure. It does require the surgeons to have a certain amount of expertise to perform the procedure e.g., gentle retraction, opening basal cisterns, letting out of CSF etc., However, this only is unlikely to become the single solution to treat moderate/severe head injuries. Introduction of any new or novel procedures have the potential danger of “having too much optimism” initially followed by an equally “low pessimism” if the procedure does not produce optimal results. Only time would reveal a “balanced view” of the procedure.

The only manner to settle this would be to organize multi centric randomized studies.

References

1Cherian I, Beltran M, Kasper EM, Bhattarai B, Munokami S, Grasso G. Exploring the Virchow-Robin spaces function: A unified theory of brain diseases. Surg Neurol Int 2016;7:S711-S714.
2Cherian I, Beltran M, Landi A, Alafaci C, Torregrossa F, Grasso G. Introducing the concept of “CSF-shift edema” in traumatic brain injury. J Neurosci Res 2018;96:744-52.
3Cherian I, Grasso G, Bernardo A, Munakomi S. Anatomy and physiology of cisternostomy. Chin J Traumatol 2016;19:7-10.
4Giammattei L, Messerer M, Oddo M, Borsotti F, Levivier M, Daniel RT. Cisternostomy for Refractory Posttraumatic Intracranial Hypertension. World Neurosurg 2018;109:460-63.
5Giammattei L, Starnoni D, Maduri R, et al. Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma. Acta Neurochir (Wien) 2020;162:469-79.
6Goyal N, Kumar P. Putting 'CSF-Shift Edema' Hypothesis to Test: Comparing Cisternal and Parenchymal Pressures After Basal Cisternostomy for Head Injury. World Neurosurg 2021;148:e252-e263.
7Parthiban JKBC, Sundaramahalingam S, Rao JB, Nannaware VP, Rathwa VN, Nasre VY, et al. Basal cisternostomy -A Microsurgical Cerebro Spinal Fluid Let Out Procedure and Treatment Option in the Management of Traumatic Brain Injury. Analysis of 40 Consecutive Head Injury Patients Operated with and Without Bone Flap Replacement Following Cisternostomy In A Tertiary Care Centre in India. Neurol India 2021;69:328-333.