Permissive hypotension in traumatic brain injury with blunt aortic injury: How low can we go?

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.