Clinical effects of adjuvant basal cisternostomy in traumatic brain injury: a pragmatic single-centre randomised controlled trial.
Het Shah, Santanu Kumar Bora, Kushagra Pandey et al.
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In 30 seconds
This pragmatic, single-centre randomised controlled trial compared adjuvant basal cisternostomy (ABC) with standard decompressive craniectomy (DC) in 50 patients undergoing emergency surgery for traumatic brain injury, with outcomes followed to six months. Cisternal opening produced an additional 4.1 ± 2.8 mmHg reduction in intracranial pressure (p < 0.001), but functional outcomes did not differ significantly: at six months, favourable outcomes occurred in 50.0% after ABC and 52.0% after DC. ABC also increased operating time and blood loss, indicating that the measured physiological effect did not translate into demonstrated functional benefit in this trial.
Key findings
- Cisternal opening lowered intracranial pressure by a further 4.1 ± 2.8 mmHg beyond bony and dural decompression (p < 0.001).
- At six months, favourable outcomes were reported in 50.0% (ABC) and 52.0% (DC); mean GOS-E was 4.08 ± 2.95 and 4.20 ± 2.65, respectively (p = 0.774).
- 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%, CSF leak in 0% versus 12%, and unplanned reoperation in 24% versus 12% (ABC vs DC).
Why it matters
The trial distinguishes an immediate physiological effect from patient-centred benefit: additional ICP reduction at cisternal opening was not accompanied by better functional outcomes through six months. The longer operation and greater blood loss are relevant trade-offs when considering an adjunctive procedure. These findings help frame the uncertainty around ABC while larger studies assess whether any patient groups benefit.
What to keep in mind
This was a single-centre trial with 50 patients, limiting the precision and generalisability of its findings.