Dissection of basal cisterns for treatment of severe traumatic brain injury

Background. According to WHO, severe traumatic brain injury is among the top ten leading causes of death worldwide. Despite the centuries‑old history of development of the treatment methods to patients with traumatic brain injury their results according to large randomized studies remain unsatisfactory – mortality and severe disability are observed in more than 50 % of patients. Some experimental studies indicate that decompressive craniectomy can aggravate the severity of cerebral edema by creating conditions for traction of nerve fibers and can lead to hemorrhagic transformation of injury foci and ischemia. During the last decade, experimental studies and technological progress have significantly expanded the understanding of brain normal and pathological physiology and made it possible to develop new methods of surgical interventions. In particular, a number of publications have shown significant advantages of dissection of arachnoid spaces of brain base in case of severe traumatic brain injury as compared with classical decompressive craniectomy.

Aim. To analyze the literature data on pathophysiological justification, surgery technique and results of dissection of arachnoid spaces of the brain base in case of severe traumatic brain injury as well as the advantages and disadvantages of the method as compared with standard treatment methods of such patients.

Materials and methods. Literature search through in the main databases was carried out. The methods of opening of basal subarachnoid spaces in case of severe traumatic brain injury, pathophysiological justification and surgery techniques as well as results of clinical studies of the techniques employed are analyzed.

Results. Information on pathogenesis of cerebral edema and pathophysiological justification of effectiveness of opening of brain base cisterns for treatment of traumatic brain injury, data on cisternostomy surgery technique and results were revealed, systematized and analyzed. Publications of individual clinical cases and series of observations indicate acceptable results of cisternostomy in comparison with decompressive craniectomy for treatment of traumatic brain injury.

Conclusions. Dissection of arachnoid spaces of the brain base with perforation of the terminal plate and the Liliequist membrane is a promising method of surgical treatment of severe traumatic brain injury.

1. Clinical guidelines on traumatic brain injury: in 3 vol. Ed. by A.N. Konovalov, L.B. Likhterman, A.A. Potapov. Moscow, 1998–2001.

2. Giammattei L., Messerer M., Cherian I. et al. Current perspectives in the surgical treatment of severe traumatic brain injury. World Neurosurg 2018;116:322–8. DOI: 10.1016/j.wneu.2018.05.176

3. Kocher T. Hirnerschütterung, Hirndruck und chirurgische Eingriffe bei Hirnerkrankungen. In: Specielle Pathologie und Therapie. Ed. by H. Nothnagel. Wien: A Hölder, 1901. Pt. 3: 81e290. Pp. 325e367. (In Germ.).

4. Hutchinson P.J., Kolias A.G., Timofeev I.S. et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 2016;375(12):1119–30. DOI: 10.1056/NEJMoa1605215

5. von Holst H., Li X., Kleiven S. Increased strain levels and water content in brain tissue after decompressive craniotomy. Acta Neurochir (Wien) 2012;154:1583–93. DOI: 10.1007/s00701-012-1393-2

6. Szczygielski J., Mautes A.E., Muller A. et al. Decompressive craniectomy increases brain lesion volume and exacerbates functional impairment in closed head injury in mice. J Neurotrauma 2016;33(1):122–31. DOI: 10.1089/neu.2014.3835

7. Cooper D.J., Rosenfeld J.V., Murray L. et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011;364(16):1493–502. DOI: 10.1056/NEJMoa1102077

8. Barthelemy E.J., Melis M., Gordon E. et al. Decompressive craniectomy for severe traumatic brain injury: a systematic review. World Neurosurg 2016;88:411–20. DOI: 10.1016/j.wneu.2015.12.044

9. Iliff J.J., Wang M., Liao Y. et al. A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid β. Sci Transl Med 2012;4(147):147ra111. DOI: 10.1126/scitranslmed.3003748

10. Cherian I., Yi G., Munakomi S. Cisternostomy: replacing the age old decompressive hemicraniectomy? Asian J Neurosurg 2013;8(3):132–8. DOI: 10.4103/1793-5482.121684

11. Goyal 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:e252–63. DOI: 10.1016/j.wneu.2020.12.133

12. Iliff J.J., Chen M.J., Plog B.A. et al. Impairment of glymphatic pathway function promotes tau pathology after traumatic brain injury. J Neurosci 2014;34(49):16180–93. DOI: 10.1523/JNEUROSCI.3020-14.2014

13. Cherian I., Beltran M., Landi A. et al. Introducing the concept of ‘CSF-shift edema’ in traumatic brain injury. J Neurosci Res 2018;96(4):744–52. DOI: 10.1002/jnr.24145

14. Ren Z., Iliff J.J., Yang L. et al. ‘Hit & Run’ model of closed-skull traumatic brain injury (TBI) reveals complex patterns of post-traumatic AQP4 dysregulation. J Cereb Blood Flow Metab 2013;33(6):834–45. DOI: 10.1038/jcbfm.2013.30

15. Xie L., Kang H., Xu Q. et al. Sleep drives metabolite clearance from the adult brain. Science 2013;342(6156):373–7. DOI: 10.1126/science.1241224

16. Yang L., Kress B.T., Weber H.J. Evaluating glymphatic pathway function utilizing clinically relevant intrathecal infusion of CSF tracer. J Trans Med 2013;11:107. DOI: 10.1186/1479-5876-11-107

17. Cherian I., Grasso G., Bernardo A., Munakomi S. Anatomy and physiology of cisternostomy. Chin J Traumatol 2016;19(1):7–10. DOI: 10.1016/j.cjtee.2016.01.003

18. Oncel D., Demetriades D., Gruen P. et al. Brain lobectomy for severe head injuries is not a hopeless procedure. J Trauma 2007;63(5):1010–3. DOI: 10.1097/TA.0b013e318156ee64

19. Parthiban J.K.B.C., Sundaramahalingam S., Rao J.B. 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(2):328–33. DOI: 10.4103/0028-3886.314535

20. Giammattei L., Messerer M., Oddo M. et al. Cisternostomy for refractory posttraumatic intracranial hypertension. World Neurosurg 2018;109:460–3. DOI: 10.1016/j.wneu.2017.10.085

21. Masoudi M.S., Rezaee E., Hakiminejad H. et al. Cisternostomy for management of intracranial hypertension in severe traumatic brain injury; case report and literature review. Bull Emerg Trauma 2016;4(3):161–4.

22. Lebedev V.V., Saribekyan A.S. Ventricular drains in patients with severe traumatic brain injury. Zhurnal voprosy neirokhirurgii im. N.N. Burdenko = Burdenko’s Journal of Neurosurgery 1983;47(4):36–41.

23. Zotov Yu.V., Kondakov E.N., Lapshinov Yu.P. External drains of brain ventricular system in complex intensive therapy of severe traumatic brain injuries. Zhurnal voprosy neirokhirurgii im. N.N. Burdenko = Burdenko’s Journal of Neurosurgery 1985;6:27–31.

24. Carney N., Totten A.M., O’Reilly C. et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017;80(1):6–15. DOI: 10.1227/NEU.0000000000001432

25. Timofeev I., Dahyot-Fizelier C., Keong N. et al. Ventriculostomy for control of raised ICP in acute traumatic brain injury. Acta Neurochir Suppl 2008;102:99–104. DOI: 10.1007/978-3-211-85578-2_20

26. Taoka T., Naganawa S. Glymphatic imaging using MRI. J Magn Reson Imaging 2020;51(1):11–24. DOI: 10.1002/jmri.26892

27. Cho Y.J., Kang S.H. Review of cranioplasty after decompressive craniectomy. Korean J Neurotrauma 2017;13(1):9–14. DOI: 10.13004/kjnt.2017.13.1.9

28. Di Cristofori A., Gerosa A., Panzarasa G. Is neurosurgery ready for cisternostomy in traumatic brain injuries? World Neurosurg 2018;111:427. DOI: 10.1016/j.wneu.2017.11.139