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Cisternostomy is not beneficial to reduce the occurrence of post-traumatic hydrocephalus in Traumatic Brain Injury

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Abstract

Background

The Cisternostomy is a novel surgical concept in the treatment of Traumatic Brain Injury (TBI), which can effectively drain the bloody cerebrospinal fluid from the skull base cistern, reduce the intracranial pressure, and improve the return of bone flap, but its preventive role in post-traumatic hydrocephalus (PTH) is unknow. The purpose of this paper is to investigate whether Cisternostomy prevents the occurrence of PTH in patients with moderate and severe TBI.

Methods

A retrospective analysis of clinical data of 86 patients with moderate and severe TBI from May 2019 to October 2021 was carried out in the Brain Trauma Center of Tianjin Huanhu Hospital. Univariate analysis was performed to examine the gender, age, preoperative Glasgow Coma Scale (GCS) score, preoperative Rotterdam CT score, decompressive craniectomy rate, intracranial infection rate, the incidence of subdural fluid, and incidence of hydrocephalus in patients between the Cisternostomy group and the non-Cisternostomy surgery group. we also analyzed the clinical outcome indicators like GCS at discharge,6 month GOS-E and GOS-E ≥ 5 in two groups.Additionaly, the preoperative GCS score, decompressive craniectomy rate, age, and gender of patients with PTH and non hydrocephalus were compared. Further multifactorial logistic binary regression was performed to explore the risk factors for PTH. Finally, we conducted ROC curve analysis on the statistically significant results from the univariate regression analysis to predict the ability of each risk factor to cause PTH.

Results

The Cisternostomy group had a lower bone flap removal rate(48.39% and 72.73%, p = 0.024)., higer GCS at discharge(11.13 ± 2.42 and 8.93 ± 3.31,p = 0.000) and better 6 month GOS-E(4.55 ± 1.26 and 3.95 ± 1.18, p = 0.029)than the non-Cisternostomy group However, there was no statistical difference in the incidence of hydrocephalus between the two groups (25.81% and 30.91%, p = 0.617). Moreover, between the hydrocephalus group and no hydrocephalus group,there were no significant differences in the incidence of gender, age, intracranial infection, and subdural fluid. While there were statistical differences in peroperative GCS score, Rotterdam CT score, decompressive craniectomy rate, intracranial infection rate, and the incidence of subdural fluid in the two groups, there was no statistical difference in the percentage of cerebral cisterns open drainage between the hydrocephalus group and no hydrocephalus group (32.00% and 37.70%, p = 0.617). Multifactorial logistic binary regression analysis results revealed that the independent risk factors for PTH were intracranial infection (OR = 18.460, 95% CI: 1.864–182.847 p = 0.013) and subdural effusion (OR = 10.557, 95% CI: 2.425–35.275 p = 0.001). Further, The ROC curve analysis showed that peroperative GCS score, Rotterdam CT score and subdural effusion had good ACU(0.785,0.730,and 0.749), with high sensitivity and specificity to predict the occurrence of PTH.

Conclusions

Cisternostomy may decrease morbidities associated with removal of the bone flap and improve the clinical outcome, despite it cannot reduce the disability rate in TBI patients.Intracranial infection and subdural fluid were found to be the independent risk factors for PTH in patients with TBI,and the peroperative GCS score, Rotterdam CT score and subdural effusion had higher sensitivity and specificity to predict the occurrence of PTH. And more importantly, no correlation was observed between open drainage of the cerebral cisterns and the occurrence of PTH, indicating that Cisternostomy may not be beneficial in preventing the occurrence of PTH in patients with moderate and severe TBI.

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Data availability

All data generated or analysed during this study are included in this published article.

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Funding

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Authors and Affiliations

  1. Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 300052, China

    Jun Liu & Rongcai Jiang

  2. Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, 300350, China

    Jun Liu, Shusheng Zhang, Yueda Chen, Xiaoxiong Jia, Zhongzhen Li, Ailin Li & Guobin Zhang

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Contributions

Study conception and design: Guobin Zhang, Rongcai Jiang. Surgical implementation:Jun Liu, Shusheng Zhang, Yueda Chen, Zhongzhen Li, Ailin Li, Guobin Zhang; Clinical data collection and analysis: Jun Liu; Drafting of the manuscript: Jun Liu; Statistic analysis:Jun Liu and Xiaoxiong Jia.All authors read and approved the final manuscript. Guobin Zhang and Rongcai Jiang supervised the project.

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Correspondence to Guobin Zhang or Rongcai Jiang.

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Ethics approval

The study protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of Tianjin Huanhu Hospital (JH 2020–71, JH 2020–75). Written informed consent was obtained from individual or guardian participants.

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Comments

The authors present an interesting study on the treatment of traumatic brain injury with cisternostomies and investigated the extent to which they could avoid the occurrence of post-traumatic hydrocephalus. Although the underlying pathophysiological concept seems plausible and the surgical procedure is manageable, the hitherto clinical results are rather disappointing, and the therapeutic effect in particular to restore and maintain cerebrospinal fluid circulation appears to be limited. However, the study has some relevant drawbacks, which is why the results should be interpreted with some caution. Whether and to what extent cisternostomies can influence other clinical aspects and the general outcome of patients after traumatic brain injury was not the prevalent question and remains to be elucidated by upcoming studies. I congratulate the authors on this relevant contribution to the field of neurotraumatology and on evaluating the novel therapeutic concept of cisternostomy. Future studies will hopefully shed additional light on the possibilities and limitations of this method and help to finally clarify its role and importance in the treatment of brain-injured patients.

Markus Florian Oertel

Zurich, Switzerland

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Liu, J., Zhang, S., Chen, Y. et al. Cisternostomy is not beneficial to reduce the occurrence of post-traumatic hydrocephalus in Traumatic Brain Injury. Acta Neurochir 166, 200 (2024). https://doi.org/10.1007/s00701-024-06084-0

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