Microsurgical Cisternostomy for Treating Critical Patients with Traumatic Brain Injury - An alternative Therapeutic Approach

Abstract

Introduction Traumatic brain injury (TBI) is a major cause of mortality around the world. Few advances regarding surgical approaches have been made in the past few years to improve its outcomes. Microsurgical cisternostomy is a well-established technique used in vascular and skull base surgery and recently emerges as a suitable procedure with lesser costs and morbidity when compared with decompressive craniectomy in patients with diffuse TBI. This study aims to describe the technique, indications, and limitations of cisternostomy and to compare it with decompressive craniectomy (DC).

Methods A prospective study is being conducted after obtaining approval of the local human ethics research committee. Once the inclusion and exclusion criteria are applied, the patients are submitted to microsurgical cisternostomy, pre and postoperative neurological status and brain computed tomography (CT) evaluation. A detailed review was also performed, which discusses diffuse TBI, DC, and cisternostomy for the treatment of TBI.

Results Two patients were submitted to cisternostomy after TBI and the presence of acute subdural hematoma and huge midline shift at admission computed tomography. The surgery was authorized by the family (the informed consent form was signed). Both patients evolved with a good recovery after the procedure, and had a satisfactory control brain CT. No further surgeries were required after the initial cisternostomy.

Conclusions Cisternostomy is an adequate technique for the treatment of selected patients affected by diffuse TBI, and it is a proper alternative to DC with lesser costs and morbidity, since a single neurosurgical procedure is performed. A prospective study is being conducted for a better evaluation and these were the initial cases of this new protocol.

Resumo

Introdução O traumatismo crânio-encefálico (TCE) é causa importante de mortalidade em todo mundo. Poucos avanços em relação a abordagens cirúrgicas foram feitos nos últimos anos com o objetivo de melhorar seus desfechos. A cisternostomia microcirúrgica é uma técnica bem estabelecida usada nas cirurgias vasculares e de base de crânio e que recentemente surgiu como um procedimento com menos custos e menor morbidade quando comparada a craniectomia descompressiva (CD) para pacientes vítimas de TCE. O presente estudo objetiva descrever a técnica, as indicações e as limitações da cisternostomia e compará-la com a CD.

Métodos Um estudo prospectivo está sendo conduzido após obtenção de autorização do comitê local de ética em pesquisa. Após aplicados os critérios de inclusão e exclusão, os pacientes são submetidos à cisternostomia microcirúrgica, sendo avaliados o status neurológico e as tomografias computadorizadas (TCs) de crânio pré e pós-operatórias. Alem disso, uma revisão detalhada foi realizada considerando a discussão sobre TCE difuso, CD, e cisternostomia para o tratamento do TCE.

Resultados Dois pacientes foram submetidos a cisternostomia após TCE com presença de lesão difusa incluindo hematoma subdural agudo e desvio de linha média. A cirurgia foi autorizada pelas famílias (o termo de consentimento informado foi assinado). Os pacientes evoluíram com boa recuperação após o procedimento, e a TC pós-operatória satisfatória. Não foram necessárias outras cirurgias após a cisternostomia.

Conclusões A cisternostomia é uma técnica adequada para o tratamento de pacientes selecionados vítimas de TCE com lesão difusa, e representa uma alternativa à CD, com menos custos e menor morbidade. Um estudo prospectivo está sendo conduzido para melhor avaliação, e esses foram os resultados iniciais deste novo protocolo.

Keywords

cisternostomy - traumatic brain injury - decompressive craniectomy - hydrodynamics

Palavras-chave

cisternostomia - traumatismo cranioencefalico - craniectomia descompressiva - hidrodinâmica

Publication History

Received: 25 June 2019

Accepted: 02 December 2019

Article published online:
23 June 2020

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