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 [1]. 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 [6], 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 [7]. 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
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