Cisternostomy for Severe Traumatic Brain Injury: Illustrative Case and Cadaveric Study of the Neurovascular Anatomy of the Basal Cisterns: 2-Dimensional Operative Video

Management of intracranial pressure (ICP) remains the cornerstone for the treatment of severe traumatic brain injury (sTBI).(1,2) The latest guidelines recommend a stepwise algorithm that advances from less invasive measures to more invasive measures, if necessary, for the treatment of elevated ICP.(1,2) Decompressive craniectomy (DC) should be considered for patients with refractory intracranial hypertension despite adequate medical management.(2) Cisternostomy is an emerging surgical technique that can be performed as an adjunct to DC.(3,4) It involves opening of the basal cisterns and lamina terminalis with the placement of a cisternal drain, followed by cisternal drainage for 5-7 days postoperatively.(4,5) Recent studies with cisternal drainage have shown promising results with improved outcomes; decreased intensive care unit stay; and marked reduction in the use of osmotherapy, hypothermia, and barbiturates because of improved ICP control.(3,4,6-8) Large, multicenter, prospective clinical trials are needed to better establish and validate the role of cisternostomy in the management of sTBI. In this video, cisternal anatomy is identified and labeled during a cadaveric dissection, without pauses, from the same viewing angle that is seen during a real operation. This simulates intraoperative identification of neuroanatomic structures in a way that is more realistic than photographic atlases. Anatomic dissection is followed by a case illustration and intraoperative video of a patient with sTBI successfully treated with cisternostomy plus DC. This video provides educational content in a unique format that improves anatomic understanding and provides insights into the emerging surgical technique of cisternostomy. Emergent consent was obtained from the patient's family for the procedure.