Nicolas K Khattar, Fitri Sumardi, Ajmal Zemmar, Quinghua Liang, Haiyang Li, Yazhou Xing, Hugo Andrade, Jack L Fleming, Iype Cherian, Juha Hernesniemi, Joseph S Neimat, Robert James, Sunil Munakomi and Dale Ding.
Published 2019

Prakash Kafle, Babita Khanal, Iype Cherian, Dipak Kumar Yadav and Deepak Poudel
Published 2019

ABSTRACT: Background: Spinal cord injury causes serious disability among patients. More than 40 million people worldwide suffer from Spinal cord injury every year. Most of them are young men. More than10% of trauma victims sustain spine injury and have higher mortality than other injuries. Materials and Methods: This is a prospective observational hospital based study of traumatic spine injury cases admitted at Nobel Medical College Teaching Hospital, Biratanagr, Nepal from November 2017 to October2018. Results: Total of 352 cases were observed and 36 cases who meet the inclusion criteria for surgical intervention were analyzed. Most common affected age group was between 31-40 years with mean age of 40 years. Out of total cases, 81% were male. Most common cause for spine injury was road traffic accident. Cervical spine was the most common injury (66.7%) and C5- C6subluxation being common radiological diagnosis. ASIA-C neurology status (41.7%) on presentation being most common neurological status. Head injury was the most common associated injury. Anterior cervical discectomy and fusion was the most common surgical procedure performed. Superficial surgical site infections were observed in two cases and hardware failure was seen in one case. Conclusion: The epidemiology of traumatic spine injuries in eastern region of Nepal is similar with other developing countries. In present study, most common cause of spine injury was motor vehicle accidents followed by fall injuries and seen in male. Prevention of road traffic accident might decrease the incidence of spine injury there by reducing the national burden.

Sharanya Jayashankar, Sunil Munakomi, Vignesh Sayeerajan, Prakash Kafle, Pramod Chaudhary.

Ajmal Zemmar, Ahmed Al-Jradi, Vincent Ye, Ismail Al-Kebsi, Hugo Andrade, Emal Zemmar, Iype Cherian, Josue Avecillas-Chasin, AndreiV Krassioukov and Juha Hernesniemi
Published 2019

Iype Cherian, Salona Amatya and Hira Burhan
Published 2018

Lorenzo Giammattei, Mahmoud Messerer, Iype Cherian, Daniele Starnoni, Rodolfo Maduri, Ekkehard Kasper and Roy Thomas Daniel
Published 2018

Iype Cherian, Hira Burhan, Harshpreet Kaur and Rupesh Kumar Shreewastav
Published 2018

Sunil Munakomi, Binod Bhattarai and Iype Cherian
Published 2017

Yoko Kato, Yasuhiro Yamada, Akiyo Sadato, Mohsen Nouri, Iype Cherian, Teppei Tanaka and Joji Inamasu
Published 2017

Iype Cherian, Margarita Beltran, Alessandro Landi, Concetta Alafaci, Fabio Torregrossa and Giovanni Grasso
Published 2017

Trichy N. Janakiram, Shilpee B. Sharma, Ekkehard Kasper, Onkar Deshmukh and Iype Cherian
Published 2017

ABSTRACT:Background Juvenile nasal angiofibromas (JNA) is a benign lesion with high vascularity and propensity of bone erosion leading to skull base invasion and intracranial extension. It is known to involve multiple compartments, which are often surgically difficult to access. With evolution in surgical expertise and technical innovations, endoscopic and endoscopic-assisted management has become the preferred choice of surgical management. Over the last four decades, various staging systems have been proposed, which are largely based on the extent of nasal angiofibroma. However, no clear guidelines exist for the stage-appropriate surgical management. In this study, we aim to formulate a novel staging system based on the analysis of high quality preoperative imaging and propose detailed surgical guidelines related to disease stages as observed in 242 primary cases of JNA. Methods A retrospective analysis of the case records of 242 primary JNA cases was performed at our center. Patients were staged according to various existing staging systems as well as our own new staging system, and outcome variables were compared with respect to intraoperative blood loss, multiple staged operations, and tumor recurrences. Operative records were studied and precise endoscopic surgical guidelines were formulated for each stage. Results Comparing the intraoperative blood loss seen in stages of various classifications, it was found that intraoperative blood loss correlated best and statistically significantly with stages in the newly proposed Janakiram staging system when compared to the existing staging systems. Staged operations were performed in a total of 7/242 patients, and there was a significant association between the requirement of a staged operation and tumor extent (Fischer’s exact test, P < 0.001). Tumor recurrence was seen in 22 cases and the pterygoid wedge was found to be the most frequent site of recurrence initially. As the extent of resection improved with better surgical technique over time, recurrences were only found in superior orbital fissure, around the internal carotid artery, and in the middle cranial fossa. Conclusion This new Janakiram staging system is based on preoperative imaging data from one of the largest JNA case series reported thus far. Respective guidelines reliably stratify patients into treatment groups with definite surgical approaches and predicts outcome. Improved surgical approaches in the modern endoscopic era have redefined JNA management with improved outcome. This study shows the importance of precise presurgical imaging and the choice of the most suitable surgical approach in reducing morbidity and mortality in JNA surgery.Read Article

Iype Cherian, Margarita Beltran, Ekkehard Kasper, Binod Bhattarai, Sunil Munokami and Giovanni Grasso
Published 2016

ABSTRACT:Background: Cerebrospinal fluid (CSF) transport across the central nervous system (CNS) is no longer believed to be on the conventional lines. The Virchow-Robin space (VRS) that facilitates CSF transport from the basal cisterns into the brain interstitial fluid (ISF) has gained interest in a whole new array of studies. Moreover, new line of evidence suggests that VRS may be involved in different pathological mechanisms of brain diseases. Methods: Here, we review emerging studies proving the feasible role of VRS in sleep, Alzheimer′s disease, chronic traumatic encephalopathy, and traumatic brain injury (TBI). Results: In this study, we have outlined the possible role of VRS in different pathological conditions. Conclusion: The new insights into the physiology of the CSF circulation may have important clinical relevance for understanding the mechanisms underlying brain pathologies and their cure.
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Iype Cherian, Antonio Bernardo and Giovanni Grasso
Published 2016

ABSTRACT:Objective: Traumatic brain injury (TBI) is one of the major challenges in health care, representing the third most frequent cause of death. Current optimal management is based on a progressive, target-driven approach combining both medical and surgical treatment strategies. Here we describe cisternostomy, an emerging surgical treatment for TBI treatment. Methods: Cisternostomy is a novel technique that incorporates knowledge of skull base and microvascular surgery. By opening the brain cisterns to atmospheric pressure, the technique could decrease the intracranial pressure due to a backshift of the cerebrospinal fluid (CSF)from the swollen brain to the cisterns through the Virchow-Robin spaces. Results: An increasing number of evidence has demonstrated a paravascular pathway that facilitates CSF flow from the subarachnoid space through the brain parenchyma. This network of paravascular channels, termed as “glymphatic” pathway, reduces considerably its activity following TBI thus participating in the development of brain edema formation. Cisternostomy, by opening the brain cisterns to atmospheric pressure could decrease the intracerebral pressure due to a backshift of CSF through the Virchow-Robin spaces.results CONCLUSIONS: In the current common practice, the surgical measures for TBI include external ventricular drainage insertion and decompressive craniectomy. There is evidence that both of these measures reduce intracranial pressure but the effect on the outcome, particularly in the long term, is equivocal. A new line of evidence supports cisternostomy as an emerging surgical treatment for TBI.
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Sunil Munakomi, Binod Bhattarai, Balaji Srinivas and Iype Cherian
Published 2016

ABSTRACT:Background: Glasgow Coma Scale has been a long sought model to classify patients with head injury. However, the major limitation of the score is its assessment in the patients who are either sedated or under the influence of drugs or intubated for airway protection. The rational approach for prognostication of such patients is the utility of scoring system based on the morphological criteria based on radiological imaging. Among the current armamentarium, a scoring system based on computed tomography (CT) imaging holds the greatest promise in conquering our conquest for the same. Methods: We included a total of 634 consecutive neurosurgical trauma patients in this series, who presented with mild-to-severe traumatic brain injury (TBI) from January 2013 to April 2014 at a tertiary care center in rural Nepal. All pertinent medical records (including all available imaging studies) were reviewed by the neurosurgical consultant and the radiologist on call. Patients’ worst CT image scores and their outcome at 30 days were assessed and recorded. We then assessed their independent performance in predicting the mortality and also tried to seek the individual variables that had significant interplay for determining the same. Results: Both imaging score (Marshall) and clinical score (Rotterdam) can be used to reliably predict mortality in patients with acute TBI with high prognostic accuracy. Other specific CT characteristics that can be used to predict early mortality are traumatic subarachnoid hemorrhage, midline shift, and status of the peri-mesencephalic cisterns. Conclusion: We demonstrated in this cohort that though the Marshall score has the high predictive power to determine the mortality, better discrimination could be sought through the application of the Rotterdam score that encompasses various individual CT parameters. We thereby recommend the use of such comprehensive prognostic model so as to augment our predictive power for properly dichotomizing the prognosis of the patients with TBI. In the future, it will therefore be important to develop prognostic models that are applicable for the majority of patients in the world they live in, and not just a privileged few who can use resources not necessarily representative of their societal environment.
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Iype Cherian, Antonio Bernardo, Giovanni Grasso and Sunil Munakomi
Published 2016

ABSTRACT:Cisternostomy is defined as opening the basal cisterns to atmospheric pressure. This technique helps to reduce the intracranial pressure in severe head trauma as well as other conditions when the so-called sudden “brain swelling” troubles the surgeon. We elaborated the surgical anatomy of this procedure as well as the proposed physiology of how cisternostomy works. This novel technique may change the current trends in neurosurgery.
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Sunil Munakomi, Binod Bhattarai and Iype Cherian
Published 2015

ABSTRACT:In this case report, we discuss the microsurgical management of a Spetzler-Martin grade 5 arteriovenous malformation (AVM) in a young boy who presented with a hemorrhagic episode and had a high calculated risk of rebleeding. We also outline the rationale for choosing the management option.
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Niran Maharjan, Sangeeta Shrestha, Binod Bhattarai and Iype Cherian
Published 2015

ABSTRACT: JCMSBackground and Objectives: Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support. The risk of transporting, the increasing associated cost and operative room schedule are some of the obstacles for wider acceptance of this procedure. The use of rigid selection criteria exclude many patients who would benefit of this approach. The present study was designed to determine the safety of open bedside tracheostomy (OBT) as a routine intensive care units (ICU) procedure without any selection criteria, considering its peri and postoperative complications.Materials & Methods: Retrospective medical chart review of all patients that underwent elective tracheostomy between June 2014 and January 2015.Results: The study group comprised 52 patients with a mean age of 40.4±15.1 years. The incidence of intra-procedure complications was 5.7% and post-procedure complications was 3.8%.Conclusions: Open bedside tracheostomy seems to be a safe and simple procedure, even when performed by a trained resident under controlled circumstances, and should be considered as an option for ICU patients.JCMS Nepal. 2015;11(1): 9-11
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Sunil Munakomi, Binod Bhattarai and Iype Cherian
Published 2015

ABSTRACT:This is a case report of a neurologically intact patient following posttraumatic cervical spondyloptosis. We discuss the disease, management protocol and some surgical nuances to prevent any damage to the cord during different stages of its treatment.
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Sunil Munakomi, Balaji Srinivas and Iype Cherian
Published 2015

ABSTRACT:Here we present a very rare case of a woman with a bone fragment in the third ventricle of the brain following compound-depressed skull fractures due to a road traffic accident. There are only few case reports of bullets and textiloma being removed from the third ventricle. Following operative removal of the fragment, the patient was started on cortisol, mineralocorticoid and thyroid hormone replacement. However, the patient eventually died of the severe traumatic hypothalamic insult.
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Sunil Munakomi, Binod Bhattarai, Balaji Srinivas and Iype Cherian
Published 2015

ABSTRACT: Primary dural lymphoma is a subentity of primary leptomeningeal lymphoma which represents 0.1% of all non-Hodgkin’s lymphomas. Only five cases have been reported so far. We report a very rare case of primary dural-based lymphoma in a 14 year-old boy presenting with mass effect. The patient was managed with excision of the lesion and removal of the involved bone. Post-operatively, the patient showed good recovery. He was then referred to the oncology unit for further chemo-and radiation therapy. A high index of suspicion should therefore be kept in order to diagnose the condition in a timely fashion and then plan for appropriate management since diffuse large cell lymphoma has a relatively benign clinical prognosis.
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Sunil Munakomi, Binod Bhattarai, Iype Cherian and Balaji Srinivas
Published 2014

ABSTRACT:Critical illness-related cortisol insufficiency is a known entity. However, there are instances where there is a normal serum cortisol level in an unresponsive patient with low Glasgow Coma Scale (GCS), even after thorough investigations to rule out other correctable entities. In patients with lesions in the vicinity of hypothalamus, especially basifrontal contusion and vascular lesions affecting anterior communicating artery (ACOM) territory, we propose to see the efficacy of fludrocortisone replacement on such patients.
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Hirotoshi Sano, Akira Satoh, Yuichi Murayama, Yoko Kato, Hideki Origasa, Joji Inamasu, Mohsen Nouri, Nobuto Saito and Iype Cherian
Published 2014

ABSTRACT:Object: A modified World Federation of Neurosurgical Societies scale (m-WFNS scale) for aneurysmal subarachnoid hemorrhage (SAH) recently has been proposed, in which patients with Glasgow Coma Scale (GCS) scores of 14 are assigned to grade II and those with GCS scores of 13 are assigned to grade III regardless of the presence of neurologic deficits. The study objective was to evaluate outcome predictability of the m-WFNS scale in a large cohort. Methods: This was a multicenter prospective observational study conducted in Japan. A total of 1656 patients with SAH were registered during the 2.5-year study period, and the outcome predictability, using the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores at discharge and at 90 days after onset, was evaluated by comparing the m-WFNS with the original WFNS scale. We focused on whether significant differences in these scores were present between the neighboring grades. Results: In the m-WFNS scale, significant difference between any neighboring grades was observed both in the mean GOS and mRS scores at 90 days except between grades III/IV. However, differences were not significant between grades II/III and between grades III/IV in the original WFNS scale. Conclusions: SAH-induced brain injury may be substantially severer in patients with GCS 13 than those with GCS 14, which may explain why grade III patients faired significantly worse than grade II patients by the modified WFNS scale. Although further validation is necessary, the m-WFNS scale has a potential of providing neurosurgeons with simpler and more reliable prognostication of patients with SAH.
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Sunil Munakomi, Iype Cherian, Binod Bhattarai and Tamrakar Karuna
Published 2014

ABSTRACT: Arteriovenous malformation (AVM) of the scalp is an uncommon entity. Its management is difficult because of its high shunt flow, complex vascular anatomy, and possible cosmetic complications. The etiology of scalp AVMs that is, cirsoid aneurysm may be spontaneous or traumatic. Clinical symptoms frequently include pulsatile mass, headache, local pain, tinnitus; and less frequently, hemorrhage and necrosis. Selective angiography is the most common diagnosis method. Surgical excision is especially effective in AVMs and the most frequently used treatment method. Here, we present one such case where staged embolization, excision, and subsequent grafting was done.
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Iype Cherian, Ghuo Yi and Sunil Munakomi
Published 2013

ABSTRACT: Practical scenario in trauma neurosurgery comes with multiple challenges and limitations. It accounts for the maximum mortality in neurosurgery and yet the developing countries are still ill-equipped even for an emergency set-up for primary management of traumatic brain injuries. The evolution of modern neurosurgical techniques in traumatic brain injury has been ongoing for the last two centuries. However, it has always been a challenge to obtain a satisfactory clinical outcome, especially those following severe traumatic brain injuries. Other than the well-established procedures such as decompressive hemicraniectomy and those for acute and or chronic subdural hematomas and depressed skull fractures, contusions etcetera newer avenues for development of surgical techniques where indicated have been minimal. We are advocating a replacement for decompressive hemicranictomy, which would have the same indications as decompressive hemicraniectomy. The results of this procedure has been compared with the results of decompressive hemicraniectomy done in our institution and elsewhere and has been proven beyond doubts to be superior to decompressive hemicraniectomy. This procedure is elegant and can replace decompressive hemicraniectomy because of low morbidity and mortality. However, there is a steep learning curve and the microscope has to be used. Based on the clinical experience and observation of acute neurosurgical service in tertiary medical centers in a developing country, the procedure of cisternostomy in the management of trauma neurosurgery have been elucidated in the current study. The study proposes to apply the principles of microvascular surgery and skull base surgery in selected cases of severe traumatic brain injuries, thus replacing decompressive hemicraniectomy as the primary modality of treatment for indicated cases. Extensive opening of cisterns making use of skull base techniques to approach them in a swollen brain is a better option to decompressive hemicraniectomy for the same indications.
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Iype Cherian
Published 2012

ABSTRACT: The evolution of modern neurosurgical techniques in traumatic brain injury has been ongoing for the last two centuries. However it has always been a challenge to obtain an effective clinical outcome, especially those following severe traumatic brain injuries. Other than the well established procedures for acute and/ or chronic subdural hematomas and depressed skull fractures, newer avenues for development of surgical techniques where indicted have been minimal. Practical scenario in trauma neurosurgery comes with multiple challenges and limitations. In an emergency setup, primary management of traumatic brain injuries fall upon the on-duty resident or medical officer in training. Due to the emergent nature of the condition and time being an important variable, the experience of the operating surgeon as well as the severity of the injury become an important contributing factor in the disease prognosis. Based on clinical experience and observation of acute neurosurgical service in tertiary medical center in a developing country, a novel technique in the management of trauma neurosurgery have been elucidated in the current study. The study proposes to apply the principles of microvascular surgery and skull base surgery in selected cases of severe traumatic brain injuries. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-1, 1-6 DOI Read Article

Iype Cherian, Sachet Shrestha, Moti Lal Panhani and Om Parkash Talwar
Published 2010

ABSTRACT: A 48-year-old man presented with proptosis of the left eye, which on excisional biopsy proved to be primary adenosquamous carcinoma of the lacrimal gland. The lesion was excised radically by a limited frontotemporo-orbitozygomatic approach and any further surgeries, such as exenteration, were avoided in view of the patient’s wish to preserve the eye and vision. Long-term follow-up is planned to look for any metastasis or recurrence of the tumour. Primary adenosquamous carcinoma of the lacrimal gland is a very rare entity and, following a thorough literature review, only two cases of lacrimal gland adenosquamous carcinoma have been reported so far.Read Article

Cecilia Fernandes, Ayushi Agrawal, Binod Bade Shreshtha, Nikunj Yogi and Iype Cherian
Published 2010

ABSTRACT: A 12-year-old girl presented to Manipal Teaching Hospital with quadriparesis of 8 months’ duration. Examination revealed a hyperpigmented patch over the chest wall with overlying hypertrichosis, musculoskeletal anomalies, upper limb asymmetry and ipsilateral breast hypoplasia. MRI scan revealed cranio-vertebral junction anomaly and spina bifida occulta at the cervical spine level. Histopathological examination of the skin revealed findings consistent with Becker’s nevus. Based on the patient’s clinical presentation and investigations, a diagnosis of Becker’s nevus syndrome was made. However, she was managed conservatively as surgical intervention was not suitable in her case. The authors review Becker’s nevus syndrome and its clinical manifestations below.
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Iype Cherian
Published 2010

ABSTRACT: The health scenario of western Nepal is bleak and especially the Neurosurgical facilities are poor. We started the Department of Neurosurgery in April 2008 and has been improvising to do various cases with good success rate. Although not very well equipped, we have tried to do our best and the results have been encouraging.
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Iype Cherian and Sunil Munakomi
Published 2013

ABSTRACT: The evolution of modern neurosurgical techniques in traumatic brain injury has been ongoing for the last two centuries. However, it has always been a challenge to obtain an effective clinical outcome, especially in those following severe traumatic brain injuries. Other than the well-established procedures for acute and/or chronic subdural hematomas and depressed skull fractures, newer avenues for the development of surgical techniques, where indicated, have been minimal. The study proposes to apply the principles of microvascular surgery and skull base surgery in selected cases of severe traumatic brain injuries.
Read Article

ABSTRACT
Background: Goal of treatment in the management of traumatic brain injury (TBI) is to avoid the secondary brain injury. Though decompressive craniectomy has shown to reduce ICP but in reality, it provides an outlet for brain tissue to expand only without reducing the oedema. Basal Cisternostomy (BC) is an emerging microsurgical technique in the management of cerebral oedema in TBI. By this technique, CSF is let out from basal cisterns which reduces cerebral oedema. In this study we compared the outcomes of Cisternostomy with decompressive craniectomy and studied the effectiveness of Cisternostomy in decreasing cerebral oedema. This is the first Randomized controlled trial on comparing the Cisternostomy with decompressive craniectomy Methods: All the enrolled patients were randomised into 2 groups. They were assessed clinically and radiologically. Categorised into mild, moderate and severe head injury groups and Marshall CT score was given. Intraoperative ICP was measured in both the groups. Outcomes were assessed with the factors like post-operative ICU care, days on ventilator support and GOS score. Results: 50 patients were randomized into 2 groups with 25 patients each. Mortality rate in this study was 32% (8) in Cisternostomy group whereas it was 44% (11) in decompressive craniectomy group. There was decreased mean days of ventilator support and ICU care requirement in Cisternostomy group. Cisternostomy causes significant decreases in ICP after craniotomy. Age, time interval from trauma to surgery and Marshall CT score showed prognostic importance on outcomes. Conclusion: Cisternostomy was effective in reducing the ICP in the traumatic brain injury patients. With Cisternostomy there is good GOS and low rate of complications in the postoperative period. Age, presenting GCS, Marshall CT score, association with other major injuries and time interval from trauma to surgery had a significant prognostic impact on the outcome in the management of traumatic brain injury.

Introduction:
Goal of treatment in the management of traumatic brain injury (TBI) was mainly focused in avoiding the secondary brain injury.                                                                                                                                  1 This can be achieved with the meticulous control of intracranial pressure (ICP). 2 Decompressive craniectomy is the time tested and most commonly used neurosurgical procedure available to decrease the ICP in TBI. Though decompressive craniectomy has shown to reduce ICP but in reality, it provides an outlet for brain tissue to expand only without reducing the oedema. 3 Decompressive craniectomy itself associated with many complications and needs second surgery in the form of cranioplasty. So, search for effective alternative procedure which can replace the decompressive craniectomy is going on.4-7 Recently, cerebrospinal fluid (CSF) circulation model has been reconsidered and stated that CSF can be produced and absorbed throughout the entire CSF system. Pericapillary Virchow robin spaces (VRS) plays a critical role in the CSF system.8 Glymphatic system has proven that cerebrospinal fluid from the cisterns (and not from the ventricles) does communicate with the parenchyma through Virchow Robin spaces.9,10 It was suggested that in the TBI, there was a decrease in glymphatic removal of solutes from interstitial fluid. this leads to allowing CSF to be shifted from the cerebral cisterns to the brain following TBI.11 Cisternostomy is defined as opening the basal cisterns to atmospheric pressure. Iype Cherian et al. in 2009, described Cisternostomy for the control of ICP in TBI.12 By this technique, CSF is let out from basal cisterns which reduces cerebral oedema and relaxes the brain in acute and subacute settings thus allowing replacement of bone flap in otherwise irreplaceable settings. This technique has gained popularity in the Journal Pre-proof last decade and many neurosurgeons are now performing this technique of CSF let out in TBI. 13‑ 15 But till now, as per our knowledge, no randomised controlled trials were conducted on Cisternostomy. As everyone knows, any new procedure has the potential danger of “having too much optimism” initially. Randomized studies are the possible ways of testing the effectiveness of these procedures. So, we conducted this study to know the effectiveness of Cisternostomy. It is a first randomized controlled trial comparing effectiveness of Cisternostomy with decompressive craniectomy.

Materials and Methods:
Patient selection: All the patients presenting to the Department of Neurosurgery at Sri Venkateshwara Institute of Medical Sciences (SVIMS), Tirupati with traumatic brain injury who needs surgical management and fulfilled the inclusion criteria from April 2019 to December 2020 were enrolled in this study with consent.

Inclusion Criteria:
1. Age >18years and < 65years
2. GCS ≥ 4
3. Brain parenchymal contusions with mass effect and midline shift
4. Acute SDH with mass effect and midline shift
5. Traumatic SAH with mass effect and midline shift
6. Post traumatic diffuse oedema with mass effect and midline shift
Exclusion Criteria:
1. Age < 18years and age >65years
2. GCS = 3
3. Extra Dural Haemorrhage
4. Non-traumatic SAH
5. Non-traumatic intraparenchymal bleed
6. Acute infarcts with mass effect

Methodology: All the enrolled patients who given consent to participate in the study were categorized into 2 groups and randomized as Decompressive craniectomy group and Cisternostomy group Randomization sequence was generated before the start of study by a computer-generated (Random allocation software 1.0) set of random numbers. Treatment allocation was done by opaque sealed envelope method. After giving consent to participate in the study, envelop of allocation of surgical procedure was opened by the corresponding author in presence of the patient’s attendants who given consent for the surgery and to participate in the surgery Patients not willing to participate in the study, have been excluded from the study.

Randomization Flow Chart :

Computer Tomography (CT) of the Skull was done for every patient, as per the institute protocol, to determine the type of injury, hematomas or contusions of brain, volume of hematomas, mass effect, midline shift and Marshal’s CT scoring was done. All these patients were classified into mild, moderate and severe injury groups based on the clinical findings, Glasgow coma scale and based on CT findings Marshall CT score was given. Intraoperative ICP (intraparenchymal) monitoring was done in all these patients. As Cisternostomy was mainly based on the concept of CSF-shift edema, we mainly considered measuring the parenchymal pressure instead of intraventricular pressures Post operatively they were monitored for number of days of ventilator support needed, number of days of ICU care with ICP monitoring, any new neurological deficits in the form of cognitive, motor or sensory impairment post operatively, number of days of hospital stay, post operative complications, mortality and morbidity in follow up after 3months with Glasgow outcome scale.

Surgery methods:
1. Decompressive craniectomy
In the decompressive craniectomy group, standard decompressive craniectomy with large flap was done with placement of bone flap in anterior abdominal wall was done.
2. Cisternostomy
In Cisternostomy group, after craniotomy and Dural opening, basal Cisternostomy was done which includes opening of the interoptic, opticocarotid, lateral carotid cisterns, lamina terminalis and Lilliquist’s membrane. Cisternal drain was placed which was kept for 3 – 5 days in the post operative period. Duroplasty was done primarily or with peri cranial graft. Bone flap was replaced and fixed with miniplates and screws Journal Pre-proof All the surgeries in both the groups were done by single surgeon i.e first author of this study who had an experience of 13 years in performing skull base and aneurysm surgeries.

Regulatory approvals:

The study was conducted after approval by the institutional ‘Thesis Protocol Approval Committee’ and ‘Institutional Ethical Committee’. Written informed consent from each patient or his/her attendants was obtained before the study.

Sample size:

Since as we assuming Cisternostomy method was hypothetically better than the conventional decompressive craniectomy, we used one tailed hypothesis with power = 80% and with moderate impact, we studied minimum of 25 (n) patients from each group 1 as per Cohen’s – d method (www.danielsoper.com/statcalc/calculator).

Statistical analysis:

All the data was tabulated in Microsoft Excel 2007 data sheet with proper headings. For continuous variables, data was expressed as Mean and Standard deviation (SD). For categorical variables, the data was represented as count and percentage. Comparison of means between the two groups was done by using Student’s ‘t’ test provided the data is normally distributed; otherwise, Mann-Whitney ‘U’ test was used. Comparison of categorical variables was done using Chi square test. p <0.05 is considered significant. Statistical analysis was done using IBM SPSS20.0.

Results:

Total 58 patients were met with inclusion and exclusion criteria. But 8 patient’s attendants were not given consent to participate in the study. They were managed with decompressive craniectomy as it is the standard method of surgical method followed at our institute for the management of traumatic brain injury. Remaining 50 patients who given consent to participate in the study were randomized into 2 groups with 25 patients each. Average age of the patients in our study was 44.48 ± 12.48 years in Cisternostomy and 42.84 ± 13.90 in decompressive craniectomy group. 64% (16) from Cisternostomy group and 60% (15) from decompressive craniectomy group were above 40 years.

Average preoperative GCS was 6.88 ± 1.87 in Cisternostomy group and 7.80 ± 2.10 in decompressive craniectomy group.   72% (18) from Cisternostomy group and 56%

(14) from decompressive craniectomy group were with severe head injury with GCS

<9 at the time of presentation.

Average preoperative MARSHALL CT score was 4.16 ± 1.34 in Cisternostomy group and 4.44 ± 1.32 in decompressive craniectomy group.

In this study average time interval from trauma to surgery was 13.56 ± 9.15 hours in Cisternostomy group and it was 13.48 ± 8.90 hours decompressive craniectomy group. (As our institute was a tertiary care centre in our region, many cases were referred to here from peripheral centres. so, transportation of the patients took some time to reach here. So, mean time from trauma to surgery was long in our study when compared to previous studies)

They were categorized into 4 groups. 80% from Cisternostomy group and 48% from decompressive group were present between 6 to 24 hours interval group (including 7-12 hours group and 13 -24 hours group).

Average duration of surgery in Cisternostomy group was 3.28 ± 0.52 hours and it was

2.90 ± 0.38 hours in decompressive craniectomy group. It was statistically significant (p 0.005)

Average intraoperative blood loss in Cisternostomy group was 334.00 ± 87.46 ml and it was 322.00 ± 45.82 ml in decompressive craniectomy group

Average Intraoperative ICP measured after 1st burr hole was 27.92 ± 2.13 mmHg in Cisternostomy group with 27.16 ± 1.59 mmHg in decompressive craniectomy group. (P 0.159)

Average ICP after craniotomy in Cisternostomy group was 15.32 ± 3.17 mmHg and

16.28 ± 3.06 mmHg in decompressive craniectomy group. (P 0.281)

Average decrease in ICP from 1st burr hole to craniotomy was 12.60 ± 3.20 mmHg in Cisternostomy group and it was 10.88 ± 2.99 mmHg in decompressive craniectomy group.

Average duration of MV support was 5.68 ± 3.80 days in Cisternostomy group and 7.60 ± 4.93 days in decompressive craniectomy group.

Average duration of ICU care was 5.48 ± 4.85 days in Cisternostomy group and 7.12 ± 3.93 days in decompressive craniectomy group.

Average duration of hospital stay was 9.76 ± 5.17 days in Cisternostomy group and 10.04 ± 5.32 days in decompressive craniectomy group. (Patient’s demographic data was shown in table 1.)

Mortality rate in this study was 32% (8) in Cisternostomy group whereas it was 44 (11) in decompressive craniectomy group. They were given score of 1 as per Glasgow outcome scale.

In this study 50% mortality from Cisternostomy group and 82% (9 patients) mortality from decompressive craniectomy group was in patients with age more than 40 years.

Mean GOS in patients with moderate head injury was 4.57 in Cisternostomy group and 4.25 in decompressive craniectomy group.

Mean GOS in patients with severe head injury was 2.56 in Cisternostomy group and 1.40 in decompressive craniectomy group.

Average GOS in patients with MARSHALL CT score of 4 was 2.45 ± 1.75 in Cisternostomy group and 2.18 ± 1.47 in decompressive craniectomy group.

(Table 2: Relation of MARSHALL CT score with presenting GCS and ICP)

Average GOS was 1 in patients who presented after 24 hours of trauma in both the groups and was good in patients presented within 6 hours of trauma with 5 in Cisternostomy group and 3.89 ± 1.36 in decompressive craniectomy group.

(Table 3: Relation of ICP with GOS and Table 4: Relation of prognostic factors with GOS)

Discussion:

Severe traumatic brain injury (sTBI) is a life-threatening condition, which continues to cause substantial morbidity and mortality. In the setting of TBI, the development of an uncontrolled intracranial pressure (ICP) is associated with a poor prognosis. Management of traumatic brain injury is mainly focused on controlling the damage caused by secondary brain injury which occurs mainly by the raised ICP. DC proved to be effective in reducing ICP and mortality, but its effects on outcome are still under debate. In the traumatic brain injury, CSF rapidly shifts to the brain parenchyma. It is supported by the non-visualisation of cisterns and compressed ventricles. So external ventricular drainage is very much difficult and it doesn’t drain the CSF from brain parenchyma effectively.

Cisternostomy has been recently proposed in the setting of severe TBI as an adjuvant surgical technique that may have a potential for effectively improving ICP control and outcomes. In this study we randomized 50 patients into 2 groups as decompressive craniectomy group and Cisternostomy group, each group had 25 patients. we these groups studied in view of their outcome and effect of prognostic factors on them. Both these groups were comparable in view of Age, presenting GCS, Marshall CT score, time interval from trauma to surgery, duration of surgery, intraoperative blood loss and ICP after placement of first burr hole. (Demographic data shown in table 1).

Intra-operative and Post-operative Period:

According to Cherian et al, the average time for Cisternostomy from Dural opening is approximately 20 minutes with extra time needed in case of posterior clinoid drilling or any other additional unforeseen circumstances severe head injuries. In our study average duration of surgery was 3.28 ± 0.52 hours for Cisternostomy group and it was 2.90 ± 0.38 hours in the decompressive craniectomy group. This result was similar to their study but this extra time for Cisternostomy was statistically significant. (P 0.005) In a study by Cherian et al., the mortality rate for Cisternostomy was 13.8%, for DHC was 34.8%, and in our study mortality rate was 32% in Cisternostomy group and 44% in DHC group. Even though, mortality rate was high in our study, it was less in the Cisternostomy group. Mean duration on ventilator support and ICU care in this study was more when compared to a study done by Iype Cherian et al. in 2013, but it was lower Cisternostomy group when compared to decompressive craniectomy group.

GOS:

According to Cherian, Mean Glasgow Outcome Scale (GOS) was 2.8 for DHC-treated patients and 3.9 for Cisternostomy. In our study almost comparable with their results with mean GOS in DHC group was 2.68 and in Cisternostomy group it was 3.12. These results were also supported by Daniel, et al., in a retrospective series of 40 patients who underwent either basal Cisternostomy or decompressive craniotomy alone. The Glasgow outcomes scores (GOS) were also significantly better for BS patients at 6 months (61% for BS vs 35% for decompressive craniotomy). In a study done by Partiban et.al., BS alone had a favourable GOS as compared to BS combined with decompressive craniotomy (82% vs 62%). Goyal N, et al., published a cohort 9 patients who underwent both Basal Cisternostomy and decompressive craniotomy. They demonstrated a significant difference between opening and closing parenchymal pressures. Their study supported the CSF‑ shift oedema and suggested that both BS and decompressive craniotomy should be provided for head injuries with severe oedema.

Intraoperative ICP:

In this study we measured ICP intraoperatively. There is a significant decrease in ICP in both the groups from 1st burr hole to craniotomy. But when compared in both the groups, this decrease in ICP doesn’t have any statistical significance. In Cisternostomy group, the ICP further decreases significantly after Cisternostomy. In our study mortality rate was proportionally increasing with the delay in surgery in both the group. As patients who presented within 6 hours’ time interval from trauma to surgery had good out come and all patients who presented after 24 hours had worst outcome in both the groups.

In our study patients with poor prognosis had high ICP after craniotomy when compared to patients who showed good prognosis in both the groups. But Cisternostomy group patients showed significantly lower ICP (P 0.001) after craniotomy even in patients with poor prognosis when compared to decompressive craniectomy group. (Table 3)

Relation with Prognostic factors:

 In our Marshall CT score does not show any significant difference in the ICP at presentation. But patients poor Marshall CT score like 4 and 6 had poor GCS at presentation and poor GOS in both the groups. In our study patients with showed poor outcome with the increase of age in both the groups but it was better in Cisternostomy group when compared to decompressive craniectomy group. In our study patients with severe head injury (presenting GCS < 9) showed poor outcome in both the groups but it was better in Cisternostomy group which has statistical significance compared to decompressive craniectomy group. (P 0.002) (Table 4) Association with other major injuries like long bone and rib fractures showed worst outcome in both the groups.

Conclusion:

Cisternostomy was effective in reducing the ICP in the traumatic brain injury patients as there was significant decrease in ICP after the Cisternostomy. With Cisternostomy there is good GOS and low rate of complications in the post-operative period. Cisternostomy decreases the days of requirement of ventilator support and ICU care Cisternostomy avoids the need for second surgery in the form of cranioplasty and its associated morbidity. Marshall CT score does not show any significant difference in the ICP at presentation but patients with poor Marshall CT score like 4 and 6 have poor GCS at presentation and poor GOS age, presenting GCS, Marshall CT score, association with other major injuries and time interval from trauma to surgery had a significant prognostic impact on the outcome in the management of traumatic brain injury but outcome was better in Cisternostomy group. Even though, Basal Cisternostomy seems like a promising procedure. But performing Cisternostomy in TBI is challenging which requires expertise of surgeon in skull base surgeries and availability of microscope. With this single RCT we can’t say it is the alternative procedure for decompressive craniectomy to treat traumatic brain injury patients. More large multicentric randomized trials to be needed to establish the effectiveness of Cisternostomy in the management of TBI.

Limitations:

1. Only single center study

2. Small no. of patients as there are a smaller number of trauma cases in view of restrictions due to COVID19.

REFERENCES

1. Ghajar J. Traumatic brain injury. Lancet. 2000;356(9233):923-9.

2. Rahmanian A, Haghnegahdar A, Ghaffarpasand F. Effects of Intracranial Pressure Monitoring on Outcome of Patients with Severe Traumatic Brain Injury; Results of a Historical Cohort Study. Bull Emerg Trauma. 2014;2(4):151-5.
3. Cooper JD, Rosenfeld VJ, Murray L, Arabi MY, Davis AR, D’Urso P, et al.

Decompressive craniectomy in diffuse traumatic brain injury. N Eng J Med 2011; 364:1493‑ 502

4. Zanaty M, Chalouhi N, Starke RM, Clark SW, Bovenzi CD, Saigh M, et al.

Complications following cranioplasty: incidence and predictors in 348 cases.

5. Masoudi MS, Rezaee E, Hakiminejad HA, Tavakoli M, Sadeghpoor T. Cisternostomy for Management of Intracranial Hypertension in Severe Traumatic Brain Injury; Case Report and Literature Review. Bull Emerg Trauma. 2016;4(3):161-164.
6. Yang L, Kress BT, Weber HJ, et al. Evaluating glymphatic pathway function utilizing clinically relevant intrathecal infusion of CSF tracer. J Transl Med. 2013; 11:107.
7. Iliff JJ, Wang M, Liao Y, et al. A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid b. Sci Transl Med. 2012;4: 147ra111
8. Oreskovic D, Klarica M. The formation of cerebrospinal fluid: Nearly a hundred years of interpretations and misinterpretations. Brain Res Rev 2010; 64:241‑ 62
9. Yang L, Kress BT, Weber HJ, et al. Evaluating glymphatic pathway function utilizing clinically relevant intrathecal infusion of CSF tracer. J Transl Med. 2013; 11:107.
10. Iliff JJ, Wang M, Liao Y, et al. A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including amyloid b. SciTransl Med. 2012;4: 147ra111
11. Iliff JJ, Chen MJ, Plog BA, Zeppenfeld DM, Soltero M, Yang L, et al.

Impairment of glymphatic pathway function promotes tau pathology after traumatic brain injury. J Neurosci 2014; 34:16180‑ 93

12. Iype Cherian, Hira Burhan. Outcomes of severe head injury patients undergoing cisternostomy at tertiary care hospital in Nepal. Indonesian Journal of Neurosurgery (IJN) 2019; Vol 2, 3: 55-59

13. Giammattei L, Messerer M, Oddo M, Borsotti F, Levivier M, Daniel RT. Cisternostomy for refractory post traumatic intra‑ cranial hypertension. World Neurosurg 2018; 109:460-3.
14. Masoudi MS, Rezaee E, Hakiminejad H, Tavakoli M, Sadeghpoor T. Cisternostomy for management of intracranial hypertension in severe traumatic brain injury; case report and literature review. Bull Emerg Trauma 2016; 4:161-4.
15. Cherian I, Burhan H, Dashevskiy G, Motta SJH, Parthiban J, Wang Y, et al.

Cisternostomy: A timely intervention in moderate to severe traumatic brain injuries: Rationale, indications, and prospects. World Neurosurg 2019; 131:385-90
16. PeetersW, van den Brande R, Polinder S, Brazinova A, Steyerberg EW, Lingsma HF,Maas AI (2015) Epidemiology of traumatic brain injury in Europe. Acta Neurochir 157:1683–1696
17. Li LM, Timofeev I, Czosnyka M, Hutchinson PJ (2010) Review article: the surgical approach to the management of increased intracranial pressure after traumatic brain injury.Anesth Analg 111:736 – 748.
18. Cherian I, Grasso G, BernardoA, Munakomi S. Anatomy and physiology of cisternostomy. Chin J Traumatol. 2016;19(1):7-10
19. Cherian I, Yi G, Munakomi S (2013) Cisternostomy: replacing the age old decompressive hemicraniectomy? Asian J Neurosurg 8: 132–138. https://doi.org/10.4103/1793-5482.121684

20. Giammattei L, Messerer M, Cherian I, Starnoni D, Maduri R, Kasper EM, Daniel RT (2018) Current perspectives in the surgical treatment of severe traumatic brain injury. World Neurosurg 116: 322–328. https://doi.org/10.1016/j.wneu.2018.05.176
21. Giammattei L, Messerer M, Oddo M, Borsotti F, Levivier M, Daniel RT. Cisternostomy for Refractory Posttraumatic Intracranial Hypertension. World Neurosurg 2018; 109:460‑ 63
22. Parthiban JKBC, Sundaramahalingam S, Rao JB, Nannaware VP, Rathwa VN, Nasre VY, et al. Basal cisternostomy ‑ A Microsurgical Cerebro Spinal Fluid Let Out Procedure and Treatment Option in the Management of Traumatic Brain Injury. Analysis of 40 Consecutive Head Injury Patients Operated with and Without Bone Flap Replacement Following Cisternostomy in A Tertiary Care Centre in India. Neurol India 2021; 69:328-333.
23. Goyal N, Kumar P. Putting ‘CSF‑ Shift Edema’ Hypothesis to Test: Comparing Cisternal and Parenchymal Pressures After Basal Cisternostomy for Head Injury. World Neurosurg 2021;148: e252‑ e263.

Table 1: Demographic data in this study

Table 2: Relation of MARSHALL CT score with presenting GCS and ICP

Table 3: Relation of ICP with GOS

Table 4: Relation of prognostic factors with GOS