Intracranial Hypertension following Acute Mesenteric Ischemia: A Case Study on the Multiple Compartment Syndrome

Abstract

In this case study, we describe a 25-year-old male who was admitted due to a severe traumatic brain injury, requiring invasive intracranial pressure monitoring. At 48 hours posttrauma, he developed intracranial hypertension refractory to medical treatment without tomographic changes in the brain. Subsequently, intra-abdominal hypertension and tomographic signs of abdominal surgical pathology were observed. An exploratory laparotomy was performed with an intraoperative diagnosis of acute mesenteric ischemia. After surgical intervention for the abdominal pathology, intracranial pressure was restored to physiological values with a favorable recovery of the patient. In this report, the relationship between intracranial pressure and intra-abdominal pressure is discussed, highlighting the delicate association between the brain, abdomen, and thorax. Measures should be taken to avoid increases in intra-abdominal pressure in neurocritical patients. When treating intracranial hypertension refractory to conventional measures, abdominal causes and multiple compartment syndrome must be considered. The cranial compartment has physiological interdependence with other body compartments, where one can be modified by variations from another, giving rise to the concept of multiple compartment syndrome. Understanding this relationship is fundamental for a comprehensive approach of the neurocritical patient. To the best of our knowledge, this is the first report of a comatose patient post-traumatic brain injury, who developed medically unresponsive intracranial hypertension secondary to acute mesenteric ischemia, in which surgical resolution of intra-abdominal pathology resulted in intracranial pressure normalization and restitutio ad integrum of neurological status.

Keywords

intracranial hypertension - acute mesenteric ischemia - multiple compartment syndrome - traumatic brain injury

• References

• 1 Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. J Cereb Blood Flow Metab 2016; 36 (08) 1338-1350
• 2 Josephs LG, Este-McDonald JR, Birkett DH, Hirsch EF. Diagnostic laparoscopy increases intracranial pressure. J Trauma 1994; 36 (06) 815-818 , discussion 818–819
• 3 Scalea TM, Bochicchio GV, Habashi N. et al. Increased intra-abdominal, intrathoracic, and intracranial pressure after severe brain injury: multiple compartment syndrome. J Trauma 2007; 62 (03) 647-656 , discussion 656
• 4 Rubiano AM, Carney N, Chesnut R, Puyana JC. Global neurotrauma research challenges and opportunities. Nature 2015; 527 (7578): S193-S197
• 5 Coronado VG, Xu L, Basavaraju SV. et al; Centers for Disease Control and Prevention (CDC). Surveillance for traumatic brain injury-related deaths--United States, 1997-2007. MMWR Surveill Summ 2011; 60 (05) 1-32
• 6 Thurman DJ, Alverson C, Dunn KA, Guerrero J, Sniezek JE. Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehabil 1999; 14 (06) 602-615
• 7 Shen L, Wang Z, Su Z. et al. Effects of intracranial pressure monitoring on mortality in patients with severe traumatic brain injury: A meta-analysis. PLoS One 2016; 11 (12) e0168901
• 8 Marmarou A, Anderson RL, Ward JD. et al. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 1991; 75 suppl S59-S66
• 9 Kukreti V, Mohseni-Bod H, Drake J. Management of raised intracranial pressure in children with traumatic brain injury. J Pediatr Neurosci 2014; 9 (03) 207-215
• 10 Gragossian A, Shaydakov ME, Dacquel P. Mesenteric Artery Ischemia. In: StatPearls [Internet]. Treasure Island, FL:: StatPearls Publishing; 2022
• 11 Bala M, Kashuk J, Moore EE. et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2017; 12 (01) 38
• 12 Kirkpatrick AW, Roberts DJ, De Waele J. et al; Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013; 39 (07) 1190-1206
• 13 Depauw PRAM, Groen RJM, Van Loon J, Peul WC, Malbrain MLNG, De Waele JJ. The significance of intra-abdominal pressure in neurosurgery and neurological diseases: a narrative review and a conceptual proposal. Acta Neurochir (Wien) 2019; 161 (05) 855-864
• 14 Santa-Teresa P, Muñoz J, Montero I. et al. Incidence and prognosis of intra-abdominal hypertension in critically ill medical patients: a prospective epidemiological study. Ann Intensive Care 2012; 2 (Suppl (01) S3
• 15 Citerio G, Vascotto E, Villa F, Celotti S, Pesenti A. Induced abdominal compartment syndrome increases intracranial pressure in neurotrauma patients: a prospective study. Crit Care Med 2001; 29 (07) 1466-1471
• 16 Lauerman MH, Stein DM. Multicompartment management of patients with severe traumatic brain injury. Curr Opin Anaesthesiol 2014; 27 (02) 219-224
• 17 Rosenthal RJ, Friedman RL, Philips EH. Intra-abdominal pressure, intracranial pressure, and hemodynamics: a central nervous system-regulated response In: Rosenthal RJ, Friedman RL, Philips EH, eds. The Pathophysiology of Pneumoperitoneum. 1st ed.Berlin: Springer-Verlag; 1998 85–98
• 18 Rosenthal RJ, Friedman RL, Kahn AM. et al. Reasons for intracranial hypertension and hemodynamic instability during acute elevations of intra-abdominal pressure: observations in a large animal model. J Gastrointest Surg 1998; 2 (05) 415-425
• 19 Westlake EK, Kaye M. Raised intracranial pressure in emphysema. BMJ 1954; 1 (4857): 302-304