Traumatic brain injury (TBI) is a major public health issue and is a leading cause of death in North America. After a primary TBI, secondary brain insults can predispose patients to a worse outcome. One of the earliest secondary insults encountered during the perioperative period is hypotension, which has been directly linked to both mortality and poor disposition after TBI. Despite this, it has been shown that hypotension commonly occurs during surgery for TBI. We present a case of intraoperative hypotension during surgery for TBI, where the use of transthoracic echocardiography had significant diagnostic and therapeutic implications for the management of our patient. We then discuss the issue of cardiac dysfunction after brain injury and the implications that echocardiography may have in the management of this vulnerable patient population. 1. Introduction Traumatic brain injury (TBI) is a major public health issue and is a leading cause of death in North America . After a primary TBI, the burden of secondary brain insults can predispose patients to a worse outcome than if secondary insults did not occur [2, 3]. One of the earliest secondary insults encountered during the perioperative period is hypotension, which has been directly linked to both mortality and poor disposition after TBI [4, 5]. While recommendations of the 2007 Brain Trauma Foundation recommend maintaining systolic blood pressure (SBP) >90？mmHg , it has recently been shown that reduction in SBP to values below 90？mmHg commonly occurs during surgery for TBI. Risk factors for intraoperative hypotension include large lesions and the presence of multiple lesions on CT . Therapy for intraoperative hypotension has traditionally consisted of the administration of intravenous fluids and vasopressors, and vasopressor choice in this setting is often empiric. There are no guidelines specific for treatment of hypotension during the intraoperative period; thus, knowledge of a patient’s preexisting cardiac status may impact anesthesiologists’ choice of vasopressor for treatment of intraoperative hypotension. In this report, we present the clinical course of a patient with a traumatic holohemispheric subdural hematoma (SDH), where echocardiographic changes consistent with myocardial dysfunction were observed upon admission to the operating room. The echocardiographic abnormalities were rapidly reversed after craniotomy and surgical decompression. In this case, the use of point of care (POC) intraoperative transthoracic echocardiography (TTE) allowed for timely identification of a cardiac
W. Rutland-Brown, J. A. Langlois, K. E. Thomas, and Y. L. Xi, “Incidence of traumatic brain injury in the United States, 2003,” Journal of Head Trauma Rehabilitation, vol. 21, no. 6, pp. 544–548, 2006.
E. Jeremitsky, L. Omert, C. M. Dunham, J. Protetch, and A. Rodriguez, “Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion,” The Journal of Trauma, vol. 54, no. 2, pp. 312–319, 2003.
J. A. Pietropaoli, F. B. Rogers, S. R. Shackford, S. L. Wald, J. D. Schmoker, and J. Zhuang, “The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries,” The Journal of Trauma, vol. 33, no. 3, pp. 403–407, 1992.
S. L. Bratton, R. M. Chestnut, J. Ghajar, et al., “Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation,” Journal of Neurotrauma, vol. 24, supplement 1, pp. S7–S13, 2007.
D. Sharma, M. J. Brown, P. Curry, S. Noda, R. M. Chesnut, and M. S. Vavilala, “Prevalence and risk factors for intraoperative hypotension during craniotomy for traumatic brain injury,” Journal of Neurosurgical Anesthesiology, vol. 24, no. 3, pp. 178–184, 2012.
M. Filipovic, J. Wang, I. Michaux, P. Hunziker, K. Skarvan, and M. D. Seeberger, “Effects of halothane, sevoflurane and propofol on left ventricular diastolic function in humans during spontaneous and mechanical ventilation,” British Journal of Anaesthesia, vol. 94, no. 2, pp. 186–192, 2005.
D. Bolliger, M. D. Seeberger, J. Kasper et al., “Different effects of sevoflurane, desflurane, and isoflurane on early and late left ventricular diastolic function in young healthy adults,” British Journal of Anaesthesia, vol. 104, no. 5, pp. 547–554, 2010.
D. Pfister, S. P. Strebel, and L. A. Steiner, “Effects of catecholamines on cerebral blood vessels in patients with traumatic brain injury,” European Journal of Anaesthesiology, vol. 25, no. 42, pp. 98–103, 2008.
H. Bhagat, R. Narang, D. Sharma, H. H. Dash, and H. Chauhan, “ST elevation—an indication of reversible neurogenic myocardial dysfunction in patients with head injury,” Annals of Cardiac Anaesthesia, vol. 12, no. 2, pp. 149–151, 2009.
P. James, C. J. Ellis, R. M. L. Whitlock, A. R. McNeil, J. Henley, and N. E. Anderson, “Relation between troponin T concentration and mortality in patients presenting with an acute stroke: observational study,” British Medical Journal, vol. 320, no. 7248, pp. 1502–1504, 2000.
T. Kono, H. Morita, T. Kuroiwa, H. Onaka, H. Takatsuka, and A. Fujiwara, “Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium,” Journal of the American College of Cardiology, vol. 24, no. 3, pp. 636–640, 1994.
I. S. Wittstein, D. R. Thiemann, J. A. C. Lima et al., “Neurohumoral features of myocardial stunning due to sudden emotional stress,” The New England Journal of Medicine, vol. 352, no. 6, pp. 539–548, 2005.
J. Ako, K. Sudhir, H. M. O. Farouque, Y. Honda, and P. J. Fitzgerald, “Transient left ventricular dysfunction under severe stress: brain-heart relationship revisited,” American Journal of Medicine, vol. 119, no. 1, pp. 10–17, 2006.
H. A. Mashaly and J. J. Provencio, “Inflammation as a link between brain injury and heart damage: the model of subarachnoid hemorrhage,” Cleveland Clinic Journal of Medicine, vol. 75, pp. S26–30, 2008.
M. Berman, A. Ali, E. Ashley et al., “Is stress cardiomyopathy the underlying cause of ventricular dysfunction associated with brain death?” The Journal of Heart and Lung Transplantation, vol. 29, no. 9, pp. 957–965, 2010.
G. S. McHugh, D. C. Engel, I. Butcher et al., “Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study,” Journal of Neurotrauma, vol. 24, no. 2, pp. 287–293, 2007.