in today 's world with high speed collision , number of patients with complex trauma injuries has increased .
these patients present with unique challenges as several injuries may require contrasting physiological management . patients with traumatic brain injury ( tbi ) require maintenance of vital parameters within strict limits to prevent secondary brain insult .
it is well - recognized that low mean arterial pressure ( map ) reduces cerebral perfusion resulting in poor outcome in patients with severe tbi .
blunt aortic injury ( bai ) with pseudoaneurysm <3 cm have been managed conservatively in our center .
they can be managed by maintaining permissive hypotension ( map of 40 - 50 mmhg or a systolic blood pressure [ sbp ] 80 ) and serial imaging .
here , we report a case of tbi with bai ( pseudoaneurysm > 4 cm ) , where an urgent decompressive craniectomy was warranted .
bai was managed conservatively both in intra - operative and postoperative period with permissive hypotension without causing neurological deficit in long - term .
a 27-year - old male patient presented in our emergency department with a history of road traffic injury . on admission , his glasgow coma score ( gcs ) was e1v1m3 , heart rate ( hr ) was 85 beats / min and blood pressure ( bp ) was 135/82 mmhg .
his computed tomography ( ct ) scan showed right temporoparietal subdural hematoma ( sdh ) with multiple underlying contusions [ figure 1 ] .
he was immediately intubated with the help of injection propofol 60 mg intravenous ( iv ) and cricoid pressure , with manual in - line stabilization and cervical collar in situ .
patient also had left sided chest trauma and an intercostal drain ( icd ) was inserted , that drained around 200 ml of blood .
ct scan and angiography of the chest revealed a pseudoaneurysm of the aortic arch , proximal to the origin of subclavian artery , measuring 4 cm in diameter [ figures 2 and 3 ] .
the low gcs caused the evacuation of sdh to take precedence over bai and an immediate evacuation was planned .
non - contrast computed tomography head of the patient showing fronto - temporal subdural hematoma ( white arrow ) three - dimensional reconstruction of the computed tomography scan showing heart and the great vessels ( white arrow shows the aortic arch aneurysm ) computed tomography angiograph of the patient showing a small aneurysm proximal to the origin of the left subclavian artery ( white arrow ) the patient was taken to the operating room after obtaining high - risk consent .
anesthesia was induced with propofol 80 mg and fentanyl 100 g and muscle relaxation achieved with vecuronium 4 mg iv .
a central venous catheter ( central venous pressure [ cvp ] ) was placed in the right internal jugular vein and right radial artery was cannulated for invasive bp and serial arterial blood gas monitoring .
anesthesia was maintained with isoflurane in a mixture of air and oxygen ( 2:1 ) along with intermittent boluses of vecuronium and fentanyl .
iv fluid therapy was guided by cvp , urine output and blood loss , and hemodynamics were meticulously maintained .
our aim was to maintain sbp around 100 and map of 60 mmhg to maintain cerebral blood flow and also to prevent the aortic aneurysm from rupture .
surgery lasted for 4 h , at the end of which the patient was shifted to the intensive care unit ( icu ) for elective ventilation .
controlled ventilation was established with a tidal volume of 400 ml , respiratory rate of 15 breaths / min , positive end - expiratory pressure of 6 cm h2o and a fio2 of 0.5 .
he was sedated using continuous infusion of midazolam ( 2 mg / h ) and fentanyl ( 50 g / h ) .
esmolol infusion ( 50 - 100 g / kg / min ) required for a period of 22 h on the first postoperative day to control unexplained tachycardia , following which the map and hr remained stable .
intracranial pressure ( icp ) monitoring was carried out and a microdialysis catheter was also inserted to measure the lactate / pyruvate ( l / p ) ratio on day 2 of icu .
both icp and the l / p ratio remained within acceptable limits throughout the icu stay ( < 20 cmh2o and < 25 , respectively ) . mean cerebral perfusion pressure was maintained around 70 mmhg .
the icd was removed on day 5 and icp monitoring and microdialysis catheter were removed on day 7 of icu .
the patient was tracheostomized and discharged with a gcs of e4vtm6 and a resolving aneurysm on postoperative day 10 .
with extensive modernization and an exponential growth in motor vehicles , polytrauma has become increasingly common .
polytrauma patients form a special cohort since the management of one injury may interfere with the optimal treatment of the other , creating a dilemma for the treating physician .
such a situation arises , as in our patient , where tbi and bai coexist , which poses a challenge to the anesthesiologist during surgical management of either of the injuries .
secondary injury in tbi is described as the consequence of physiological insults such as ischemia , reperfusion and hypoxia to areas of  at risk  brain in the period after the initial injury .
it has been widely studied and reported that hypotension and hypoxia have deleterious effects on the outcomes of tbi patients .
the impact study suggested that hypotension and hypoxia were significantly associated with unfavorable 6-month outcome .
moreover , the duration of intra - operative hypotension was also inversely associated with functional outcome .
bai have a higher mortality rate with the majority of the patients succumbing at the site of trauma .
with improvement in pre hospital care the number of patients with bai reaching hospital has increased .
the patients may be managed by early surgery or nonoperative therapy depending on the severity of injury .
the principle of nonoperative management revolves around differentiating bai into minimal aortic injury ( mai ) and severe aortic injury ( sai ) .
patients with mai ( usually lesions <3 cm ) have a low risk of progression and aortic rupture and are better managed conservatively with aggressive negative inotropic and antihypertensive therapy , routine serial imaging and close clinical observation .
sai mandates surgical or endovascular repair in most of the cases if the risk - benefit ratio is favorable .
surgeons at our institution follow similar guidelines for management of aortic aneurysms . in our patient
the management of tbi took precedence over bai , therefore we decided to manage the bai conservatively and operate the sdh .
the pseudoaneurysm , although large ( > 4 cm ) , was managed conservatively in our patient . according to the recent retrospective analysis of bai by caffarelli et al .
, aortic injuries , especially pseudoaneurysms are different from nontraumatic atherosclerotic aneurysms , because in the majority of the trauma patients , the underlying pathology does not exist .
this stanford philosophy implies that nonoperative management may be more successful in traumatic aortic aneurysms as compared to pathological ones .
however , application of permissive hypotension in patients with neurological involvement must always be carried out in the presence of monitoring of cerebral function , such as cerebral oximetry . at our institution ,
intra - operative cerebral oximetry is not used , but the use of icp monitors and cerebral microdialysis catheters in the postoperative period are frequent . our patient , however , presented with the unique situation of tbi with bai ( pseudoaneurysm measuring 4 cm ) .
although according to the aneurysmal size the patient required surgery , the surgical management of tbi was more urgent .
the management of the intra - operative period required meticulous monitoring of bp so that we could maintain cerebral perfusion without rupturing pseudoaneurysm .
patients with bai with large size pseudoaneurysm may be managed intra - operatively with permissive hypotension in the presence of appropriate monitoring of cerebral function such as cerebral oximetry .
however , more cases are required to be studied for validation of this hypothesis and formulation of guidelines .
 with an ever - increasing incidence of high impact collisions , polytrauma is becoming increasingly common . 
 patients with traumatic brain injury ( tbi ) may require urgent surgical intervention along with maintenance of an adequate mean arterial pressure ( map ) to maintain cerebral perfusion . 
 on the other hand , patients who sustain blunt aortic injuries ( bai ) have a high mortality rate , many of them succumbing to their injury at the site of trauma . 
 surgery has been the mainstay of the management strategy for the remaining survivors . 
 however , in recent years , the paradigm has shifted from early operative management to conservative treatment with aggressive blood pressure and heart rate control , serial imaging , and close clinical monitoring . when tbi and bai coexist in a patient 
 , it becomes crucial to maintain the map within a narrow range to prevent secondary insult to the brain as well as to prevent aortic rupture . 
 we present the management of a case of tbi with traumatic aortic pseudoaneurysm , which required stringent monitoring and maintenance of hemodynamics during decompressive craniectomy . 
Introduction
Case Report
Discussion
Conclusion