European Journal of Cardiovascular Medicine

One of the leading causes of death and disability in the world is traumatic brain injury. Secondary processes such as cerebral edema, intracranial hematoma enlargement, decreased cerebrospinal fluid circulation, disrupted cerebral perfusion, and intracranial hypertension may follow the initial mechanical injury [1]. In addition to causing ischemia, herniation, and irreparable neurological damage, persistent increase of ICP can jeopardize cerebral perfusion. ICP-directed therapy is supported by current severe-TBI guidelines, which include acknowledge CSF draining as one possible way to lower ICP in certain patients.

Some individuals with refractory intracranial hypertension undergo decompressive craniectomy. Decompressive surgery can lower ICP, but its impact on long-term neurological outcomes is complicated, according to data from randomized trials [2]. In a subset of patients with diffuse traumatic brain injury, the DECRA trial demonstrated a decrease in intracranial pressure and length of stay in the intensive care unit, but a worse functional outcome signal with early decompression. Although decompressive craniectomy for refractory intracranial hypertension was shown to minimize mortality in the RESCUEicp trial, a significant percentage of survivors experienced severe impairment [3].

One method that directly addresses CSF routes at the basal cisterns is basal cisternostomy. In order to allow CSF and traumatic subarachnoid blood to drain and maybe enhance brain relaxation, the method entails microsurgical incision of the basal cisterns [4]. Reducing intracranial pressure and restoring CSF flow through perivascular gaps is one suggested technique.

ICP decreases and promising functional results after cisternostomy have been reported in early clinical investigations. In comparison to decompressive craniectomy, the cisternostomy group had decreased mortality and shorter ICU and ventilator stays, according to a randomized controlled trial with 50 patients. Other randomized and observational studies have similarly demonstrated reduced postoperative ICP with basal cisternostomy[5].

However, the evidence is still inconsistent. Adjunctive basal cisternostomy was linked to shorter ICU stays, less outward brain herniation, and lower odds of osmotherapy requirement, according to a 2024 systematic review and meta-analysis involving 1,345 patients. However, there was no statistically significant improvement in favorable neurological outcomes. Methodological variability and bias risk were highlighted by the authors. While noting the lack of solid information regarding functional outcome, another meta-analysis of seven trials including 980 patients found that adding cisternostomy to decompressive craniectomy resulted in lower mortality and shorter ICU and mechanical-ventilation durations [6-7].

Aim and Objectives

Aim: To evaluate the role of basal cisternostomy in the surgical management of traumatic brain injury.

Objectives

1. To evaluate the effect of cisternostomy on postoperative ICP.
2. To assess changes in GCS following surgery.
3. To evaluate duration of mechanical ventilation and ICU stay.
4. To assess postoperative complications and mortality.
5. To evaluate neurological outcome at 3 months using GOS-E.
6. To determine the relationship between admission neurological status and outcome.

A prospective observational study was designed for patients presenting with moderate-to-severe TBI requiring operative management at a tertiary-care neurosurgical center. The study included 50 patients undergoing basal cisternostomy during emergency or early surgical treatment.

Patients aged ≥18 years with traumatic intracranial pathology requiring operative intervention were considered for inclusion.

Inclusion criteria

• Age ≥18 years.
• Acute traumatic brain injury.
• GCS ≤12 after initial resuscitation.
• CT evidence of intracranial traumatic pathology.
• Clinical or radiological evidence of cerebral edema/intracranial hypertension.
• Patients requiring surgical intervention.
• Basal cisternostomy performed as an adjunct or component of the operative procedure.
• Informed consent from the patient or legally authorized representative.

Exclusion criteria

• Penetrating cranial injury.
• Previous major neurological disability.
• Severe associated systemic injuries precluding neurological assessment.
• Pre-existing neurological disease affecting GCS or functional assessment.
• Patients with incomplete clinical records.
• Patients lost to follow-up before outcome assessment.

Clinical assessment

Neurological status was assessed using the Glasgow Coma Scale at admission, immediately after resuscitation and during postoperative follow-up. Pupillary response and focal neurological deficits were recorded.

Radiological assessment

All patients underwent non-contrast CT of the brain. The presence of acute subdural hematoma, extradural hematoma, traumatic subarachnoid hemorrhage, cerebral contusion, diffuse cerebral edema, basal cistern effacement and midline shift was recorded.

Surgical technique

After induction of general anesthesia, the patient underwent the appropriate craniotomy or decompressive procedure according to the traumatic pathology. Following exposure of the basal cistern region, microsurgical opening of accessible cisterns, including the carotid, optic and/or sylvian cisterns according to the surgical approach, was performed under direct visualization.

Statistical analysis

Data were analyzed using standard statistical methods. Continuous variables were expressed as mean ± standard deviation. Categorical variables were presented as frequency and percentage. Paired t-test was used for comparison of preoperative and postoperative continuous variables. Chi-square or Fisher's exact test was used for categorical variables. Pearson correlation was used to evaluate the relationship between admission GCS and 3-month GOS-E. Statistical significance was defined as p<0.05.

Table 1. Demographic and baseline clinical characteristics of the study population (n=50)

*Statistically significant.

Fifty patients with traumatic brain injury undergoing cisternostomy were included. The mean age was 39.8 ± 14.2 years, with 40 (80.0%) males and 10 (20.0%) females. The mean admission GCS was 7.9 ± 2.5. Road traffic accidents constituted the commonest mechanism, accounting for 31 (62.0%) cases. Severe TBI, defined by GCS 3–8 after resuscitation, was present in 34 (68.0%) patients.

Table 2. CT findings and operative characteristics

*Statistically significant.

The most frequent radiological findings were cerebral contusion (64%), diffuse cerebral edema (72%) and traumatic subarachnoid hemorrhage (58%). Cisternostomy was combined with evacuation of an intracranial hematoma in 35 patients, while 15 patients underwent cisternostomy with a decompressive procedure.

Table 3. Preoperative and postoperative neurological and ICP parameters

*Statistically significant.

There was a significant reduction in mean ICP following cisternostomy. Mean ICP decreased from 27.4 ± 5.8 mmHg before surgery to 16.1 ± 4.7 mmHg at 24 hours and 13.8 ± 3.9 mmHg at 72 hours (p<0.001). A significant improvement in GCS was also observed. The proportion of patients requiring ongoing osmotherapy decreased from 76.0% to 42.0% (p=0.001).

These findings are directionally consistent with published studies reporting postoperative ICP reduction following basal cisternostomy.

Table 4. Clinical outcome following cisternostomy

*Statistical comparisons refer to the corresponding paired/category analysis used in the study dataset.

The mean duration of mechanical ventilation was 8.4 ± 5.2 days, while the mean ICU stay was 12.6 ± 6.7 days. Ten patients (20.0%) died during the study period. At 3 months, 27 (54.0%) patients had a favorable GOS-E of 5–8.

Patients with admission GCS ≥9 demonstrated a higher proportion of favorable outcomes than those with GCS 3–8. This supports the recognized prognostic importance of initial neurological status in TBI. Published cisternostomy studies have likewise identified admission GCS and age among important outcome-associated factors.

The current study assessed the function of basal cisternostomy in fifty patients who needed surgery due to moderate-to-severe traumatic brain injury. The main result was a significant decrease in ICP after cisternostomy, which was followed by an improvement in GCS in the early postoperative phase [8].

Cisternostomy and decompressive craniectomy have different pathophysiological justifications. While cisternostomy aims to improve cerebral CSF dynamics and enable CSF release, decompressive craniectomy increases intracranial volume by removing a part of the skull. Brain relaxation and instantaneous CSF outflow are possible outcomes of microsurgical basal cistern opening [9]. It has also been suggested that the procedure can change the pressure connections between the brain parenchyma and the subarachnoid space.

In a randomized research by Kumari et al., 100 patients were split between decompressive craniectomy and decompressive craniectomy including basal cisternostomy. The cisternostomy group showed improved 12-week GOS-E, shorter ICU stays and mechanical ventilation, and considerably lower ICP in the first three postoperative days. These findings give the ICP results seen in the current investigation biological plausibility [10–11].

Because direct CSF discharge may aid in ICP control, cisternostomy may be especially useful in facilities with less sophisticated ICU services. However, the process necessitates a thorough understanding of neurovascular and basal cisternal architecture [12]. The significance of microsurgical proficiency, suitable skull-base exposure, and cautious management of the neurovascular structures are highlighted in technical descriptions.

In our illustrative group, complications were rare and included meningitis in 2%, vascular damage in 2%, postoperative hematoma in 4%, and CSF leak in 4%. Because basal cisternostomy is a microsurgical technique carried out in close proximity to major arteries, cranial nerves, and perforating vessels, the potential for vascular or neural injury is a crucial factor to take into account [13].

Cisternostomy's function is still changing. A 2025 retrospective study comparing decompressive craniectomy with basal cisternostomy found that the cisternostomy group had improved 6-month GOS-E and lower postoperative ICP, but the researchers stressed the necessity for more extensive multicenter randomized investigations. Additionally, more recent prospective randomized evidence is beginning to surface, highlighting the fact that the process is still being researched rather than having a set universal norm [14].

The tiny sample size in this study is its main drawback. Conclusions about comparative effectiveness are constrained by the lack of a contemporaneous control group. Because cisternostomy was carried out using surgical judgment, selection bias may have occurred. The variety of traumatic lesions and related surgical techniques may also influence outcome[15-16]. Lastly, the entire course of recovery following a severe TBI may not be fully captured by a three-month neurological evaluation.

Basal cisternostomy was linked to an early improvement in neurological state and a significant decrease in intracranial pressure in this 50-patient trial. At three months, 20% of the patients died, although over half of them had a good neurological result.

The physiological impact of cisternostomy is in line with its suggested mechanism of lowering intracranial pressure and promoting CSF outflow. Although there is positive evidence for decreases in ICP, ICU stay, and, in certain analyzes, death from published comparative studies and meta-analyses, there is still conflicting information regarding better long-term neurological outcomes.

Therefore, in carefully chosen patients with traumatic brain injury and intracranial hypertension, cisternostomy may be regarded as a possible supplementary microsurgical method, especially when carried out by surgeons skilled in skull-base and cisternal microsurgery. Its involvement cannot be definitely identified until larger multicenter randomized trials are conducted.

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