12/28/2015

1

Cisternostomy –Breaking the webCisternostomy –Breaking the web

DECOMPRESSIVE CRANIECTOMY IN TBI

“If there is no CSF pressure but brain pressure exists, then

pressure relief must be achieved by opening the skull”

First described by Kocher 1901

Emil Theodor Kocher

Removal of portion of skull to create more space to the swollen brain and relieve IC pressure.

Building a case…

• What is the cause for edema in the post traumatic brain..?

• Where did the CSF (120 ml)  in the cisterns disappear?

•In Fracture skull with CSF leak, the chances of brain edema is perhaps lower than a similar population of head injuries..

#G Lymphatic pathway – Iliff and Nedergaard*Lactate Storm in acute head injury – Sutherland and Lama

A few observations…..

1) Trauma and acute SAH (WFNS grades 4 &5) looks similar

2) Opening cisterns for SAH relaxes the brain 

3) The new studies on #CSF pathways suggest that CSF travels into the brain FROM THE CISTERNS and maybe the cause for acute edema

4) Lactate storm* in acute trauma is damaging and lactate clearance from the brain via CSF is important

5) Microneurosurgery has always given better results compared to gross surgery, when done by specialists.

12/28/2015

2

3rd V

Lat. V

4th V

Cisterns

Arach. Gra

Sinus

Brain

VR spaces

thru Capillaries, veins

SAH P

BRAIN

CISTERN

DHC

DECREASED ICP

But

AXONAL STRETCH ANDSEVERE DAMAGE TO STRETCHED BRAIN

ATROPHY AFTER DHC !!!

12/28/2015

3

CISTERNOSTOMY

BRAIN

CISTERN

CISTERNOSTOMY

BRAIN

CISTERN

SAH 

Brain

cisterns

CRANIUM

ATMOSPHERE

Principles of Cisternostomy ‐ OPEN CISTERNS TO ATMOSPHERIC PRESSURE…

VR Spaces

SO, WHY DOES VENTRICULAR DRAINAGE NOT WORK…?

• VENTRICLES HAVE 20 ML OF CSF.. COMPRESSED IN TRAUMA

• CISTERNS HAVE 120 ML AND THEY 

COMMUNICATE WITH THE PARENCHYMA

12/28/2015

4

EVIDENCE..?G lymphatic pathway J. Iliff, M. Nedergaard

Courtesy – Nedergaard et alCourtesy – Nedergaard et al

VENTRICULAR INJECTION CISTERNAL INJECTION

Our Study

•AIM: To analyse the efficacy of cisternostomyas a treatment for severe head injury

•Stepwise evolution from DC to Cisternostomyfor the author.

•Started August 2007

•No randomized controlled trial wasperformed

Selection criteria

• The clinicoradiological picture was used to make the decision to operate ( the basis of soon to be published Nepal Calgary CT ‐ Clinical grading)

• ICP monitoring was not used in decision making 

• Proactive surgery was done• Skull base and microsurgical principles used.

• Relatives were informed of both surgical options and were free to choose 

12/28/2015

5

CT parameters Variables Score

1.SAH Convexity

Cisternal

1

2

2.Mass lesion MLS <5mm

MLS >5mm

Hematoma <30ml

Hematoma >30ml

1

2

1

2

3.Herniation Unilateral

Bilateral

3

4

4. Ischemia

( HYPODENSITY ON CT)

PCA

Brainstem

5

6

Motor score Grade

6 1

5 2

3‐4 3

2 4

Cumulative score of the CT and motor grades are taken to get the Nepal Calgary

Clinicoradiological score.

Score 5‐ 12 ‐Indication for cisternostomy as decided by the surgeon

Score 12‐ 15 Cisternostomy indicated in

Young, healthy patients, brought within 6 hours of trauma, sudden deterioration, still having

spontaneous respiration, preferably at least one pupil still reactive.

Cisternostomy (N) = (1221) till Jan 2015

792 severe head injuries

Comparison of outcome in severe head injury ‐ DHC, DHC+Cis and Cisternostomy alone

N 792 Severe

12/28/2015

6

Presenting GCS 8, Lt pupil dilated. Severe brain swelling pre op.

Came walking. 8 weeks later

Child, Presenting GCS 9 dropped to 4, Rt pupil dilated. Severe brain swelling per op, Cisternostomydone.

12/28/2015

7

With consent from the patient’s relatives. 6 weeks post discharge ….Talking, walking patient.

GCS of 6/15, Left pupil dilated and fixed

With consent from the patient and the relatives.

12/28/2015

8

Presenting GCS 7, with anisocoria. At discharge, GCS 15/15, residual right 3rd nerve paresis.

GCS 6/15, Left pupil dilated

Severe brain swelling, Tentorial herniation noted with contused 3rd nerve. Cisternostomy done, Brain lax and pulsatile

GCS 14/15 at discharge, mild Rt. Hemiparesis, residual 3rd paresis.

12/28/2015

9

GCS 4T/15, Both pupils dilated before surgery. Small PF EDH evacuated, cisternostomy done.

GCS 14 on the second post op day.

7th Post op dayIndira Gupta

GCS 4, both pupils dilated, sluggish

12/28/2015

10

GCS 4/15 Both pupils dilated, mild anisocoria, brought to the hospital within 3 hours of trauma.

12/28/2015

11

GCS – E4 M5 V2 .Discharged.

HOW DO I DO IT?• FOR BEGINNERS …SELECT CASES

• DO DHC flap and craniotomy , REPOSITION THE HEAD WITH SLIGHT EXTENSION AND TILT

• Remove the sphenoid ridge till the superior orbital fissure

• Open dura in the DHC way• In the “window of opportunity” go lateral subfrontaland JUST RETRACT GENTLY AND USE A SUCTION open the interoptic and opticocarotid …Keep a drain

• Evolve to where you are confident of putting the bone flap back

Operative technique to deal with severe Brain swelling • MODIFIED DOLENCS APPROACH

• Orbitomeningeal band

• Dural opening as close as to the suprasellar cistern

12/28/2015

12

Why ? • Interoptic, optico carotid and lateral carotid cistern

•Membrane of Liliequist division

(VERY IMPORTANT TO AVOID REBOUND SWELLING) 

•Basilar quad and prepontine cistern exposure and washing out blood

• Intradural posterior clinoid drilling (if needed)

•Hemostasis ….primarily by irrigation

OBSERVATION

•The venous bleeding which is severe during the brain swelling stops soon after the cisterns are open as the brain starts getting lax…

12/28/2015

13

Cisternostomy Video When is Cisternostomy not useful ?

Motor score of 1 and 2 (Some cases might improve) combined with radiological features of ischemia.

Relative contraindications

• Sinus bleed

• Severe bleeding disorders

• Ischemic brain

Complications

• Revert to DHC – 1.76 percent (out of the 14 who reverted, 9 died and 2 had bad GOS..3 survived with moderate GOS)

• Vascular injury –• I case with carotid injury, Repaired primarily. Patient expired 6 days later. No infarct seen on post op scan.

• 1 case with Pcom tear. Pcom Clipped . No additional deficits.

• Pseudomeningocoele – 19 percent

• Hydrocephalus – 8 percent (98 patients) – 23 required shunt.

12/28/2015

14

Chapters and papers…

12/28/2015

15

In Summary

• The biggest killer in neurosurgical scenario... Neurotrauma.

• Young neurosurgeons and residents need proper training.

• Trauma surgery deserves the same attention to details and skills as skull base and microvascular

• Decompressive hemicraniectomy was the only workhorse of Trauma Neurosurgery, until now...

IT IS TIME  TO HAND OVER  THE  BATON…