Recommendations for ventriculostomy and cisternostomy in TBI management: Results of the WFNS-Neurotraumatology committee “Cusco consensus”

Rubiano A.M.; Gonzalez-Tobar W.D.; Loaiza-Cardona L.M.; Salazar A.F.; Cardona-Collazos S.; Hermosa D.; Hinojosa S.; Alvarez A.; Tsai E.; Zapata A.; Canitrot M.; Amorin R.; Acurio P.; Berra L.; El Fiki A.; Zapata L.; Wagner M.; Ganau M.; Paiva W.; Reisner A.; Alves O. · Brain and Spine (2026) · DOI: 10.1016/j.bas.2026.106142

Resumen

Introduction: Intracranial hypertension is a life-threatening complication of traumatic brain injury (TBI) and a major target in neurocritical care. While ventriculostomy for cerebrospinal fluid diversion and the emerging technique of cisternostomy are used on a regular basis in different areas of the world, their application is heterogeneous on indications, timing, and technical aspects in the surgical procedures. This variability highlights a critical lack of standardized protocols, particularly in resource-constrained environments where optimized recommendations are most needed. Research question: What are the specific, expert-consensus recommendations to standardize the use of ventriculostomy and cisternostomy within a protocol for TBI management? Material and methods: The Neurotrauma Committee of the World Federation of Neurosurgical Societies develop an international consensus, including a methodological group and a panel of 16 expert neurosurgeons following a Delphi process, involving systematic literature review, statement formulation, and iterative blinded voting using a 5-point Likert scale. Consensus was predefined as ≥75% agreement. Results: The panel ratified 69 consensus statements. Core recommendations advocate for ventriculostomy as an early therapeutic intervention for TBI requiring fluid drainage and define cisternostomy as an adjunctive procedure for selected patients with TBI and significant traumatic subarachnoid hemorrhage. Protocols with algorithms were proposed for both procedures. Discussion and conclusion: This consensus provides a practical framework to guide surgical management of TBI using ventriculostomy and or cisternostomy as techniques. It promotes a strategic shift towards prior heterogeneous concepts on ventriculostomy and defines a specific, consensus-guided role for cisternostomy. The statements aim to harmonize global practice and direct future research.