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Traumatic brain injury (TBI) remains a major public health problem globally [14]. Indications for neurosurgical intervention following TBI can be broadly categorised as (1) evacuation of haematoma, (2) control of intracranial pressure (with or without haematoma evacuation), (3) elevation of depressed skull fractures, (4) repair of skull base fractures with or without CSF fistula, (5) treatment of hydrocephalus, and (6) cranial reconstruction [17]. Cisternal opening is a well-embedded microsurgical technique in neurosurgical practice for vascular and skull base pathologies. Its application in the context of TBI, in combination with insertion of an external cisternal drain which stays in place for a few days post-operatively, has been termed cisternostomy. The first publication of cisternostomy dates back to 2013 [2]. That paper reported the rationale around cisternal opening in TBI and also presented the results of a single-surgeon series of patients treated with decompressive craniectomy (DC) plus cisternostomy (272 patients) and cisternostomy alone (476 patients). Details about the research protocol are sparse but the authors reported that the mean GOS at 6 weeks was 3.7 and 3.9 respectively. The lack of details about (1) the research protocol, (2) the clinical TBI algorithm followed, and (3) the occurrence of complications mean that no firm conclusions can be drawn on the basis of that paper. Since then, we identified another 13 papers (PubMed search with the term “cisternostomy” or “cisternotomy” in the title). Only 2 of these 13 papers include patient data and both were single-patient case reports [6, 15]. The majority of the remaining papers are narrative reviews or letters and have mostly discussed the proposed physiological rationale of this operation, namely, reversal of cerebrospinal fluid shift oedema of the brain [3]. At this juncture, it has to be stated that the ability of this operation to reverse this type of oedema is an entirely theoretical concept with no direct evidence proving this hypothesis. The accompanying paper by Giammattei et al. presents the results of 40 patients with severe TBI (sTBI) treated at Centre Hospitalier Universitaire Vaudois in Lausanne between 2013 and 2018. This was a retrospective study. Of the 40 patients, 22 had a decompressive craniectomy (DC), while 18 had a DC with a cisternostomy. The decision as to whether a cisternostomy would be performed was only dependent on the availability of a neurosurgeon with vascular surgery expertise, rather than any clinical characteristics. This raises questions around the statement that “waiver of consent was granted because the procedure was part of our written algorithm for the management of sTBI”, given that the treatment algorithm would be different depending on who was the on-call neurosurgeon. This issue along with the fact that the published data on cisternostomy for TBI are very sparse indicates that the study should have happened prospectively in the context of a research protocol approved by an ethics committee [8]. The very limited sample size and the retrospective nature are major sources of bias. With the “subgroup analysis” (primary vs secondary procedure), the sample size becomes even more limited. On this basis, all outcome data should be treated cautiously and, at best, as evidence that in the hands of experienced vascular neurosurgeons the addition of cisternostomy to DC does not seem to lead to worse outcomes. This article is part of the Topical Collection on Brain trauma

Cisternostomy for traumatic brain injury—rigorous evaluation is necessary