Innovation in Neurosurgery Special Section
Cisternostomy: A Timely Intervention in Moderate to Severe Traumatic Brain Injuries:
Rationale, Indications, and Prospects
Iype Cherian1, Hira Burhan1, Gleb Dashevskiy1, Shugar Jhamil Hinojosa Motta1, Jutty Parthiban2, Yonghong Wang3,
Haibo Tong3, Fabio Torregrossa4, Giovanni Grasso4
Traumatic brain injury (TBI) represents a major public
health concern worldwide, with no significant change in
its epidemiology over the last 30 years. After TBI, the pri-
mary injury induces irreversible brain damage, which is
untreatable. The subsequent secondary injury plays a
critical role in the clinical prognosis because without
effective treatment it will provide additional tissue dam-
age. The resulting scenario is the rise in intracranial
pressure (ICP) with the development of progressive
neurological deficits. Current optimal management is
based on a progressive, target-driven approach combining
both medical and surgical treatment strategies among
which is decompressive hemicraniectomy. With the advent
of technology, research in the glymphatic pathways, and
advances in microscopic surgery, a novel surgical tech-
nique—the cisternostomy—has emerged that holds prom-
ise in managing rising ICP in TBI-affected patients. In this
article we describe the rationale for cisternostomy, an
emerging microneurosurgical approach for the manage-
ment of moderate to severe TBI.
INTRODUCTION
T raumatic brain injury (TBI) may manifest in a spectrum of
presentations ranging from small contusions to intra-
parenchymal hemorrhages, subarachnoid hemorrhage,
and diffuse axonal injury. The mechanism of TBI consists of 2
main parts: primary damage due to impact or acceleration-
Key words
- Cisternostomy
- Decompressive hemicraniectomy
- Traumatic brain injury
Abbreviations and Acronyms
CSF: Cerebrospinal fluid
DHC: Decompressive hemicraniectomy
ICP: Intracranial pressure
LMIC: Low-to middle-income country
TBI: Traumatic brain injury
WORLD NEUROSURGERY 131: 385-390, NOVEMBER 2019
deceleration and secondary brain injury. The key feature in all
these presentations is the rise in intracranial pressure (ICP)
because of the increased volume occupied by the lesion. The
subsequent effects of raised ICP lead to the development of
neurological deficits as seen clinically and radiologically in post-
traumatic patients. Accordingly, strategies for minimizing the
negative effects of all the cascades that lead to secondary brain
injury can decrease mortality and achieve a positive neurological
outcome. To overcome these effects, several medical1,2 and sur-
gical methods3 have been proposed, among which is
decompressive hemicraniectomy (DHC). Despite the odds of an
unsatisfactory prognosis, DHC has been regarded as the most
widely accepted and practiced surgical management for
moderate to severe TBI.3
Devised by Kocher in the 20th century, DHC relies on the
Monro-Kellie doctrine and Boyles law (pressure is inversely pro-
portional to volume for a single compartment) to decrease ICP in a
swollen brain.3 By removing a large portion of the skull, the
expanding brain is allowed to swell, regardless of cortical
stretch and topographic distortion of the tracts, thereby
increasing the volume to combat the rising pressure.
With the advent of technology, research in the glymphatic
pathways, and advances in microscopic surgery, a completely
novel hypothesis has emerged that holds promise in managing
rising ICP in traumatic brain injuries with minimal morbidity.4 In
this article we describe the rationale of cisternostomy as an
advanced, yet more sophisticated microneurosurgical approach
in the management of moderate to severe TBI.
TBI: EPIDEMIOLOGY AND CURRENT GLOBAL SCENARIO
The statistics on TBI epidemiology provide a vague global image.
One recent study concludes that 69 million (95% confidence
From the 1Department of Neurosurgery, Institute of Neurosciences, Nobel Medical College
and Teaching Hospital, Biratnagar, Nepal; 2Department of Neurosurgery, Kovai Medical
Center and Hospital, Tamil Nadu, India; 3Department of Neurosurgery, Shanxi Dayi Hospital,
Taiyuan, China; and 4Department of Biomedicine, Neurosciences and Advanced Diagnostics,
University of Palermo, Palermo, Italy
To whom correspondence should be addressed: Yonghong Wang, M.D.
[E-mail: wyh200533@126.com]
Citation: World Neurosurg. (2019) 131:385-390.
https://doi.org/10.1016/j.wneu.2019.07.082
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IYPE CHERIAN ET AL.
interval: 64e74 million) individuals are estimated to suffer TBI
from all causes each year, with the Southeast Asian and Western
Pacific regions experiencing the greatest overall burden of
disease.5
Head injury after road traffic collision is more common in low-
to middle-income countries (LMICs), and the proportion of TBIs
secondary to road traffic collision is likewise greatest in these
countries. Meanwhile, despite the fact that the LMICs experience
nearly 3 times more cases of TBI proportionally than high-income
countries, the estimated incidence of TBI ranks highest in regions
with higher-quality data, specifically in North America and
Europe, where healthcare management is up-to-date and
centralized.5 It is because of this dilemma that the largest global
trials in health care are carried out in high-income countries,
which most often fail to recruit majority of the patient population
from LMICs.
Over the years, various studies and clinical trials have failed to
evaluate the prognostic value of DHC. To date, the largest clinical
trials, DECRA6 and RESCUEicp,7 have proven DHC to be superior
to medical therapy, but the rates of mortality remain a concern.
The DECRA trial enrolled 155 patients from 3 countries
(Australia, New Zealand, and Saudi Arabia) and showed that
neuroprotective bifrontal decompression is not helpful and
mortality rates are similar with or without surgical treatment.6
Later, the RESCUEicp trial, with a much larger patient
population (408 individuals from 20 countries), concluded that
decompression for refractory intracranial hypertension and
severe TBI reduce the mortality rate (26.9 vs. 48.9% in medical
therapy) but is associated with higher rate of disability and
vegetative state, particularly in severe head injury patients.7
Moreover, the rising cost of health care, rehabilitation, and
psycho-socio-economic instability calls for improvement in cur-
rent standards of TBI management.8 In this context, we propose a
novel technique, cisternostomy,4,9-11 which has rapidly gained
popularity in the neurosurgical community and has been regarded
as one of the surgical options for ICP reduction in moderate to
severe brain injury by the Global Neurotrauma Outcome Study,
funded by the US National Institutes of Health.12 The introduction
of microsurgery into trauma is a much-needed practice consid-
ering the beneficial outcomes in all other neurosurgical practices.
CEREBROSPINAL FLUID SHIFT EDEMA AND THE RATIONALE FOR
CISTERNOSTOMY
Brain matter is bathed by cerebrospinal fluid (CSF), which is
produced at the rate of 500 mL per day by the choroid plexus. The
conventional concept of CSF function is to provide buoyancy to the
brain and act as a mechanical cushion. Considering the 3- to
4-fold turnover rate of CSF production and absorption in arach-
noid granulations, the highly dynamic CSF circulation cannot
simply serve as a cushion, but also plays a significant role in
metabolic buffering of the cerebral environment. Extensive studies
on the glymphatic system in the early 2010s13-15 have established
grounds to support the communication of the CSF in the supra-
sellar cisterns with the brain parenchyma. This communication
helps in the “cleaning” of neural cells from tau proteins and
metabolic wastes such as lactate.14,16,17 This cleaning is aquaporin
channeledependent, and, in physiological states, the expression
386 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.07.082
INNOVATION IN NEUROSURGERY SPECIAL SECTION
CISTERNOSTOMY FOR TRAUMATIC BRAIN INJURY
of aquaporin-4 is highest during sleep.18 Hence, brain cleaning is
an active CSF-dependent process occurring during phases of
sleep, which explains why sleep is essential for the brain to
function. “Cooling”, on the other hand, is a passive process,
occurring around the clock, and is not aquaporin chan-
neledependent. Instead, it is a continuous process that relies on
the wet mucosal lining of the paranasal sinuses in the vicinity of
the suprasellar cisterns. The inhaled air, upon coming into contact
with the wet mucosal lining, causes evaporation, which, in turn,
cools the sinuses and the adjoining basal cisterns. The CSF in the
cisterns is driven into the Virchow-Robin spaces via the pulsatility
of vessels, which move from the cisterns into the brain. The CSF
in the Virchow-Robin spaces is in direct communication with the
brain interstitial fluid. This mechanism allows for the CSF to cool
the brain. The overall effect of this cycle is the removal of heat
from the brain, cooling it to maintain a steady thermal environ-
ment for normal functioning.19 It is worth noting that any
interruption or fault in this process leads to accumulation of
metabolic wastes and heat, thereby creating or perhaps
accelerating the development of neurodegenerative disorders.
For example, the expanded paravascular spaces in the elderly
decrease the rapid exchange of wastes, which increases
vulnerability of developing age-related disorders like dementia.20
The TBI cascade and the development of brain edema is closely
related to an altered gradient in the CSF circulation due to mass ef-
fects. For instance, accumulation of blood in the basal cisterns
following subarachnoid hemorrhage increases the cisternal pressures
and open pathways for CSF to “escape” the cisterns into the brain
through the Virchow-Robin spaces, compensating for the volume
occupied by the blood in the cisterns. This escaped CSF leaves the
paravascular spaces to enter into the brain parenchyma, increasing
the brain-fluid content, and increasing the interneuronal spaces, as
suggested by experimental evidence.21 This so-called CSF shift forms
the basis of CSF shift edema seen in traumatic brain injuries and
supports the role of cisternostomy in this scenario.22
Strategies to decrease ICP in a traumatic brain aim to provide
volume to counter the rising pressure. Cisternostomy aims to do
the same—although, instead of providing volume to the expand-
ing brain, this microneurosurgical procedure provides a way to
reverse the CSF shift edema that caused the brain expansion in the
first place.4,15
The use of cisternal drainage as a primary method to decrease
ICP is a revolutionary concept in neurotrauma management.22,23
Earlier studies on uncusectomy, tentorial cuts, and lumbar
puncture to remove CSF in head injuries have been in vogue for
some time.24 In this regard, cisternostomy uses the same
principles to take advantage of the anatomical relationship of
the brain with the extensive paravascular structure. Furthermore,
the experimental evidence, using photon tracers via ventricular
and cisternal injection, also validated the hypothesis of CSF
communication with the brain via cisterns rather than
ventricles—suggesting the efficacy of using cisternal drainage in
contrast to ventricular drainage for decreasing brain edema,
hence relieving ICP.25
Given the fact that even after DHC a large portion of bone is
removed, the edematous brain only expands to around 110 to
120 mL, thus corresponding to the same volume of CSF
residing in the cisternal system.26 It should not be surprising,

IYPE CHERIAN ET AL.
Figure 1. Artist illustration showing the main steps for
unlocking the brain. (A) Normal brain aspect, axial basal
view. (B) Axial unlocking step where the temporal lobe
is mobilized in an extradural fashion to obtain access to
the posterior suprasellar cistern. Blue arrow indicates
extradural mobilization of temporal lobe from frontal
therefore, to correlate the signs of obliterated cisterns with
severe brain swelling and its herniation through DHC in
severe head injury computed tomography scans. One open
question is, where does that 110e120 mL of CSF go if the
cisterns are obliterated and even ventricles appear “slit-like”?
The law of hydraulics states that no volume of fluid can be
compressed without significant pressure and this applies to
the CSF as well, which is not actually compressed even after
cisternal obliteration, but leaks out into the brain parenchyma
through the Virchow-Robin spaces, thereby increasing the
intraparenchymal pressures and contributing to a harmful
cascade of events.21
Another interesting finding is the positive therapeutic effect of
auto-cisternostomy in moderate to severe TBI. Fractures of the
skull base, petrous bone, and the cribriform plate result in CSF
otorrhea and rhinorrhea, which itself is a form of cisternostomy by
its nature that provides an alternative leakage to the CSF that
WORLD NEUROSURGERY 131: 385-390, NOVEMBER 2019
INNOVATION IN NEUROSURGERY SPECIAL SECTION
CISTERNOSTOMY FOR TRAUMATIC BRAIN INJURY
lobe. (C) Normal brain aspect, sagittal view. (D) Sagittal
unlocking step where the sphenoid ridge and the
anterior clinoid is removed to provide space to access
the anterior suprasellar cistern. Red arrow indicates
opening of the dural folds in sagittal plane to allow for a
wider surgical corridor.
would have otherwise shifted into the brain parenchyma as per the
above stated hypothesis.27,28
These mechanisms, coupled with outcomes from various centers
practicing cisternostomy, support cisternostomy as an effective sur-
gical procedure for relieving ICP in patients when it can be indicated.
Furthermore, continued CSF drainage from the basal cisterns for the
next few postoperative days can be useful to remove the accumulated
metabolic wastes and free radicals that are produced during the event
of injury, thus reducing chances of secondary brain injury. Cis-
ternostomy therefore plays a dual role in relieving the ICP by reversing
the CSF shift edema and counteracting the secondary brain injury that
soon follows the trauma cascade.4,29
SURGICAL TECHNIQUE
Cisternostomy is a microneurosurgical procedure requiring
considerable knowledge of the skull base anatomy and the skills
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IYPE CHERIAN ET AL.
Table 1. Cisternostomy Indication Score
GCS Motor Score (M) Pupil Status
M2/M1 0 Bilateral dilated and non-reactive
M3 1 Unilateral dilated and non-reactive
M4 2 Unilaterally dilative and reactive
M5 3 Normal
M6 4
TOTAL SCORE (MþPþC)
GCS, Glascow Coma Score; PCA, posterior cerebral artery; CPA, Cerebellopontine angle.
for fine microsurgical maneuvers and instrument handling.10 The
precise nature of the technique and the sophisticated environment
needed to perform this technique make it a questionable task in
most centers, which are not fully equipped for day-to-day
trauma surgeries. Nevertheless, attempts to improve trauma care
need to be taken in order to achieve the best line of management
for a better patient outcome. The concept of brain unlocking is
crucial for such a microsurgical procedure. The brain is like a tube
that is folded in 3 dimensions: sagittal, axial, and oblique planes.
A pterional approach with sylvian dissection helps in unfolding
the brain to a certain extent, in an oblique fashion, however, this
manoeuver limits the surgeon to only 1 surgical window. Man-
oeuvers to unlock the brain in the sagittal and axial plane provide
excellent exposure to the skull base. To unlock the brain in a
sagittal fashion, one needs to remove as much of sphenoid ridge.
To unlock the temporal lobe in an axial fashion, one needs to
detach the temporal lobe from the cavernous sinus in an extra-
dural fashion, thus opening the curve. Adding a sylvian dissection
to the above-mentioned manoeuvers greatly improves the basal
exposure by opening the brain in a lateral oblique fashion.
However, the sylvian dissection in a tight traumatic brain is
impractical although the axial and the sagittal unlocking tech-
niques maybe used to get to the base of the brain.
Complete unlocking of the frontal lobe from the temporal lobe
is achieved after removal of the anterior clinoid process. This step,
after the orbitomeningeal band dissection and sphenoid ridge
removal aids in gaining a much wider and better access to the
Table 2. Interpretation of the Total Cisternostomy Indication
Score
9e10 Conservative treatment and close neurological follow-up
recommended
8 Depending on the clinical progression and the clinical scenario,
either a close watch or cisternostomy
3e7 Cisternostomy is indicated if injury is no diffuse axonal injury seen
0e2 Cisternostomy is not useful
Performing cisternostomy in patients with a CIS of 8 or 0e2 is subject to clinical
assessment.
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INNOVATION IN NEUROSURGERY SPECIAL SECTION
CISTERNOSTOMY FOR TRAUMATIC BRAIN INJURY
(P) Cisterns on Computed Tomography (C)
0 Complete herniation with brainstem torsion and/or PCA infarction 0
1 Cerebellopontine angle obliterated 1
2 Suprasellar cisterns obliterated and CPA cistern widened 2
3 All cisterns open 3
/10
optic-carotid window. Figure 1 illustrates the main features of the
unlocking procedure.
Such a procedure should be reserved for complex cases, how-
ever, and needs surgical expertise. In most of the cases, a lateral
subfrontal approach combined with as much sphenoidal removal
as possible may be enough.
Indications and Contraindications
TBI is a dynamic disease with a cascade of deteriorating events as
time progresses, hence there is a fine timeline in deciding the best
choice for a patient according to the clinical and radiological
correlations. Accordingly, once the clinical status deteriorates and
the Glasgow Coma Scale motor score drops from 5 to 4, with
associated sign of ipsilateral cerebello-pontine angle cistern
widening, a cisternostomy is warranted to prevent ongoing
herniation.
In other cases of moderate to severe brain injury cisternostomy
is indicated as follows:
- Oculomotor nerve palsy
- Unilateral acute subdural hematoma with mass effect
- Sub-arachnoid hemorrhage with brain swelling
- Unilateral single contusion with mild to moderate mass effect
(with/without subdural hematoma)
- Unilateral multiple contusion with brain swelling (with/without
subdural hematoma)
- Bilateral contusions and bilateral subdural hematomas with
brain swelling
- Pediatric brain injury with brain swelling and without evident
lesion
Contraindications to cisternostomy are the following:
- Increased age (>80 years)
- Hemorrhage diathesis (International Normalized Ratio >3)
- Isolated diffuse axonal injury
- Systemic complications
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IYPE CHERIAN ET AL.
Table 3. An Observation in the Different Groups of Patients
Undergoing Decompression, Hybrid Cisternostomy with
Decompression, and Cisternostomy at the College of Medical
Sciences, Bharatpur, Nepal Between 2007 and 2012
Parameter DC Alone (Before 2007) DC D C
Number of cases 284 272
Mean GOS @ 6weeks 2.8 3.7
Mortality 34.8% 26.4%
Average intensive care 6 3
unit stay, days
GOS, Glasgow Outcome Scale.
Data courtesy of Cherian et al.29 with permission of Asian Journal of Neurosurgery.
- Polytrauma
- Prolonged severe hypotension preoperatively
- Prolonged hypoxia preoperatively
Cisternostomy has no role in improving outcomes after an
ischemic stroke or in patients with terminal coma, and hence is
absolutely contraindicated in such patients.
In order to provide a simple and useful tool, we propose a 10-
point Cisternostomy Indication Score that uses clinical and
radiological indications for cisternostomy (Tables 1 and 2).
Performing cisternostomy in patients with a Cisternostomy
Indication Score of 8 or 0e2 is subject to clinical assessment.
Overall, the timing for cisternostomy must be better established.
The comparable results from past (Table 3) and current studies
as well as the ongoing Global Neurotrauma Outcome Study will
provide more information about this critical issue.
CISTERNOSTOMY: THE ROAD TO PROGRESS
The introduction of microsurgical techniques and their contin-
uous refinement have strongly improved the outcome of patients
affected by vascular, tumor, and spinal pathologies. Nevertheless,
despite contributing the most to the overall burden of neurosur-
gical cases, to date surgical techniques for traumatic brain injury
have received less impetus than expected. In this scenario, the
choice of cisternostomy as a damage-control surgery might be
beneficial.9 In particular, draining the cisterns in a brain with a
burst lobe, large midline shift, and widened cerebello-pontine
angle cistern is a clear indication to perform cisternostomy in
order to prevent progression to a complete herniation and brain-
stem compression.
With the better knowledge of identification of patients in which
cisternostomy may act as a damage-control surgery, and keeping
decompression as a last tier for ischemic presentations, a number
of centers in the world have started to adopt the strategic man-
agement plans for trauma. The frontier center for cisternostomy,
located in Nepal, performed its first case 2007. The results of the
initial phase of transformation from performing decompression to
WORLD NEUROSURGERY 131: 385-390, NOVEMBER 2019
INNOVATION IN NEUROSURGERY SPECIAL SECTION
CISTERNOSTOMY FOR TRAUMATIC BRAIN INJURY
a combined cisternostomy with decompression, and, later, cis-
ternostomy only with bone flap placement, could yield significant
differences in the overall prognosis in TBI-affected patients.
The spontaneous relaxation of the brain after cisternal draining
allows replacement of the bone flap back, without letting the brain
C Alone expand and distort topographically. This modification not only
decreases ICP but also prevents further damage and brings about a
476 favorable prognosis. Over the course of time, centers in China,
3.9 India, parts of South Asia, and Europe have been adopting cis-
ternostomy with promising results and some clinical trials are still
15.6%
ongoing.30-32 For instance, the Global Neurotrauma Outcomes
2 Study has recently entered cisternostomy in its study protocol
(https://globalneurotrauma.com/wpcontent/uploads/2018/10/
protocol.pdf) for the management and outcomes of patients
undergoing emergency surgery for TBI.
In some scenarios, a hybrid cisternostomy with decompression
can also be effective where either the surgeon is not confident
enough of the outcomes, or where the brain does not achieve
complete relaxation after cisternal drainage. This is not uncom-
mon as a starting strategy to understand the efficacy of cisternal
drainage in TBI, and once the results are authenticated, cis-
ternostomy can be a routine protocol for moderate to severe brain
injuries.
It is important to understand the limitations and complication
in performing cisternostomy. This is a technique that requires a
round-the-clock microneurosurgical set-up, with technically skil-
led neurosurgeons. Considering the fact that most neurotrauma
occurs in developing parts of the world, it is unfortunate that the
microscopic facilities are “reserved” for rare, elective cases, which
makes it difficult to implement cisternostomy in such centers. A
few techniques, such as the hinged craniotomy,33 have been
identified to have comparable outcomes as cisternostomy,
although it is vital to understand the basic concept of the CSF-
shift edema to know the worth of implementing cisternostomy
in less-equipped centers.
CONCLUSIONS
To date, studies comparing the efficacy of cisternostomy with
decompressive hemicraniectomy are lacking. However, a perfect
comparison between the surgeries could not be possible because
both are performed with different timing and setting. The first is
following a certain protocol to operate a set of patients who have
high chances of deterioration in a scenario where close multi-
modality monitoring is impractical. This is true for most of the
head injuries, as they come from the low-income countries.
Decompressive hemicraniectomy is done as a last-ditch measure
where medical management fails. Furthermore, cisternostomy
needs advanced knowledge of skull-base anatomy and microsur-
gical technique. Decompressive hemicraniectomy is easier to
perform and does not demand substantial surgical skills or
infrastructure.
The last decade has seen a revolution in management of TBI
with cisternostomy. Results from incoming studies will provide
more evidence for this debated surgical solution.
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IYPE CHERIAN ET AL.
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 29 May 2019; accepted 8 July 2019
Citation: World Neurosurg. (2019) 131:385-390.
https://doi.org/10.1016/j.wneu.2019.07.082
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
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