Het Shah, Santanu Kumar Bora, Kushagra Pandey, Surya Krishna Gaur, Deepak Aggarwal, Deepak Gupta, Shashank Sharad Kale
ABC is feasible and safe when performed by supervised trainees in a controlled neurosurgical training environment and reproducibly lowers ICP at the moment of cisternal opening. However, this physiological advantage conferred no significant functional benefit up to six months and came at a cost of increased operative duration and blood loss. Future multicentre trials are warranted to establish ABC's definitive role in the TBI management algorithm, if any.
OBJECTIVES: Basal cisternostomy has emerged as a promising adjunct to decompressive craniectomy (DC) for traumatic brain injury (TBI), with the potential to improve cerebrospinal fluid dynamics and intracranial pressure (ICP) control. However, prospective randomized evidence evaluating its effectiveness under routine clinical conditions remains limited. We compared the clinical and physiological effects of adjuvant basal cisternostomy (ABC) with standard DC in patients undergoing surgery for TBI, with follow-up until 6 months.
METHODS: This pragmatic, single-centre, parallel-group randomised controlled trial enrolled 50 patients undergoing emergency surgery for TBI between September 2023 and July 2026 (25 ABC, 25 DC). Neurosurgical residents in training performed the surgeries under consultant supervision. The primary outcome was Glasgow Outcome Scale-Extended (GOS-E) at discharge; GOS-E at three and six months, serial intracranial pressure (ICP), complications and mortality were secondary outcomes.
RESULTS: Baseline characteristics were comparable. Cisternal opening lowered ICP by a further 4.1 ± 2.8 mmHg beyond bony and dural decompression (p < 0.001), but ICP at the end of the operation was identical between arms (10.24 ± 2.93 (ABC) vs 9.35 ± 2.94 (DC) mmHg; p = 0.387). Mean GOS-E at discharge was 3.40 ± 2.16 after ABC and 2.84 ± 1.70 after DC (p = 0.31); by six months the arms had converged (4.08 ± 2.95 (ABC) vs 4.20 ± 2.65 (DC); p = 0.774), with favourable outcomes in 50.0% (ABC) and 52.0% (DC). ABC required 78 min more operating time (p < 0.001) and 276 mL more blood loss (p = 0.029). Hydrocephalus requiring diversion occurred in 8% versus 24% and CSF leak in 0% versus 12%, both favouring ABC; unplanned reoperation was more frequent after ABC (24% vs 12%).
CONCLUSIONS: ABC is feasible and safe when performed by supervised trainees in a controlled neurosurgical training environment and reproducibly lowers ICP at the moment of cisternal opening. However, this physiological advantage conferred no significant functional benefit up to six months and came at a cost of increased operative duration and blood loss. Future multicentre trials are warranted to establish ABC's definitive role in the TBI management algorithm, if any.