Cisternostomy as a Surgical Treatment for Traumatic Brain Injury-Related Prolonged and Delayed Intracranial Pressure Elevation: A Case Report

Traumatic brain injury (TBI) can be classified into primary, due to the effect of the initial trauma, or secondary, due to increased intracranial pressure (ICP). Increased ICP may cause brain herniation and also decreases cerebral blood perfusion leading to ischemia. Recently, a few studies showed that cisternostomy with decompressive craniectomy (DC) has better outcomes than DC alone in patients with TBI. This can be explained by the recent advances indicating that cisternal cerebrospinal fluid (CSF) communicates with cerebral interstitial fluid (IF) through Virchow-Robin spaces. Theoretically, opening cisterns to atmospheric pressure may induce IF drainage and subsequently decrease ICP. A 55-year-old man presented to the emergency department with subdural hematomas, hemorrhagic contusions, and subarachnoid hemorrhage after falling off a moving truck. ICP elevation was refractory despite increased sedation, initiation of paralysis with Cisatracurium, esophageal cooling, multiple doses of 23.4 % saline and mannitol, and DC. Lumbar drain (LD) placement was performed with beneficial results. Unfortunately, the LD stopped functioning multiple times and each time this occurred, he developed increased ventricular size with elevated ICP. The patient underwent cisternostomy and lamina terminalis fenestration. No further increased ICPs were observed after cisternostomy at a one-month follow-up. Cisternostomy is a potential surgical treatment for patients with TBI-related prolonged ICP elevation.