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Table of Contents    
COMMENTARY
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 334-335

CSF Shift Edema - Role of “Fluid Shift” in Adopting a Microsurgical Technique for Moderate to Severe Head Injuries


Department of Neuroscience, Krishna Institute of Medical Sciences, Karad, Maharashtra, India

Date of Submission13-Feb-2020
Date of Decision18-Aug-2020
Date of Acceptance18-Sep-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
Iype Cherian
Department of Neuroscience, Krishna Institute of Medical Sciences, Karad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.314534

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How to cite this article:
Burhan H, Cherian I. CSF Shift Edema - Role of “Fluid Shift” in Adopting a Microsurgical Technique for Moderate to Severe Head Injuries. Neurol India 2021;69:334-5

How to cite this URL:
Burhan H, Cherian I. CSF Shift Edema - Role of “Fluid Shift” in Adopting a Microsurgical Technique for Moderate to Severe Head Injuries. Neurol India [serial online] 2021 [cited 2021 May 13];69:334-5. Available from: https://www.neurologyindia.com/text.asp?2021/69/2/334/314534




We read with great interest the article by Parthiban et al.[1] describing basal Cisternostomy as a cerebrospinal fluid (CSF) “let out” procedure in the surgical management of moderate to severe traumatic brain injury (TBI). It is important to understand the pathophysiology behind the cascade of events in the setting of moderate to severe TBI which supports CSF drainage as a surgical option with a favourable prognosis as observed in this study.

Here, the concept of CSF shift edema is the fundamental principle behind letting out CSF from an edematous and tight brain in traumatic head injuries. We have described this concept in detail in our previous publications[2] and its implications in maintaining the physiological brain cooling and cleaning.[3]

The CSF in the cisterns is fundamental to the cooling and cleaning of the brain. The cisternal CSF goes into the brain through the paravascular Virchow Robin Spaces (VRS) and reach almost everywhere in the brain. When there is traumatic subarachnoid hemorrhage (tSAH), the Cisternal pressure rises due to influx of blood and the CSF shifts into the VRS from the cisterns, thereby increasing the intra-parenchymal pressure. Cisternostomy addresses this principle by 'reversing' the shift and allowing the drainage of the cisterns to achieve brain relaxation.

The surgical procedure is complex - involving difficult maneuvers - hence requiring expertise of the performing surgeon in vascular and skull base surgeries. To make his way through narrow corridors of the optico-carotid and lateral carotid windows in a tight, angry brain is a challenge and time is of the essence in this procedure, as depicted by this study. In addition to the sub-frontal retraction, a better surgical corridor can be achieved by axial and sagittal brain unlocking maneuvers in an extradural fashion.[4] These involve drilling the sphenoid ridge and sharply dissecting the Orbito-meningeal band that would unlock the frontal and temporal lobes, flattening the curve and thus providing a wider surgical field. In more complex anatomical variants, the role of anterior clinoidectomy is commendable as an added maneuver to achieve further corridors.

The complexity of the procedure and the excellent prognosis over decompression alone, as seen from the recent studies in multiple centers, warrants consideration to implement Cisternostomy as primary surgical management of moderate to severe TBI, especially in centers where trauma constitutes major morbidity and mortality. It is no surprise that decompression, although achieving a decrease in intracranial pressures, has failed to show a prognosis comparable to Cisternostomy.[5]

The reason being that; decompression addresses the compliance of the entire intracranial system rather than the underlying pathology, which leads to secondary brain damage. By removing the bone flap and not bringing the cisternal pressures down, decompression only provides a route for the brain to herniate to the point that the axonal topography is compromised and leads to irreversible long-term complications in patients undergoing the procedure.

Cisternostomy, in contrast, not only achieves a decrease in intra-parenchymal pressure by reversing the CSF shift edema but also prevents the secondary brain damage by restoring the normal metabolic buffer system of the brain, allowing for rigorous removal of the metabolic wastes and misfolded proteins that would otherwise accumulate and block the Aquaporin channels that are crucial for this exchange of substance under normal circumstances.

Considering the fact that TBI has been an economic and social burden considering its dreadful outcomes as seen in patients undergoing decompression, there is an absolute need to give trauma surgery the attention and modification it demands. The use of microscopic surgery for trauma surgery as in Cisternostomy is a fair price to pay to alleviate the current economic and social burdens of TBI in developing nations where rehabilitation is beyond the reach of many. It is time to train the new generation of neurosurgeons with the expertise needed for draining cisterns in a tight traumatic brain under the microscope and improve the state of global neurotrauma care with better innovations based on scientific grounds.



 
  References Top

1.
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.  Back to cited text no. 1
  [Full text]  
2.
Cherian I, Beltran M, Landi A, Alafaci C, Torregrossa F, Grasso G. Introducing the concept of “CSF-shift edema” in traumatic brain injury. J Neurosci Res 2018;96:744-52. doi: 10.1002/jnr. 24145.  Back to cited text no. 2
    
3.
Hira Burhan and Iype Cherian (February 21st 2020). Brain Cooling and Cleaning: A New Perspective in Cerebrospinal Fluid (CSF) Dynamics, New Insight into Cerebrovascular Diseases-An Updated Comprehensive Review, Patricia Bozzetto Ambrosi, Rufai Ahmad, Auwal Abdullahi and Amit Agrawal, IntechOpen, DOI: 10.5772/intechopen. 90484. Available from: https://www.intechopen.com/books/new-insight-into-cerebrovascular-diseases-an-updated-comprehensive-review/brain-cooling-and-cleaning-a-new-perspective-in-cerebrospinal-fluid-csf-dynamics. [Last accessed on 2021 Feb 09].  Back to cited text no. 3
    
4.
Cherian I, Burhan H. “Unlocking the brain”-key concepts to accessing the anterolateral skull base made simple. Indonesian Journal of Neurosurgery 2020; 3. DOI: 10.15562/ijn.v3i3.103.  Back to cited text no. 4
    
5.
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;131:385-390. doi: 10.1016/j.wneu. 2019.07.082.  Back to cited text no. 5
    




 

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