title: Increased intra-abdominal, intrathoracic, and intracranial pressure after severe brain injury: multiple compartment syndrome.
abstract: OBJECTIVE
  Fluid therapy and/or acute lung injury may increase intra-abdominal pressure (IAP) and intrathoracic pressure, thereby increasing intracranial pressure (ICP) after traumatic brain injury (TBI). Further fluid administration to support cerebral perfusion or increasing ventilatory support to treat acute lung injury further increases ICP. This can create a cycle that ultimately produces multiple compartment syndrome (MCS). Both decompressive craniectomy (DC) and decompressive laparotomy (DL) decrease ICP. DL can also decrease IAP and ICP. We evaluated the serial application of DC and DL to treat MCS.
  
  
  METHODS
  Data were analyzed for 102 consecutive patients with severe TBI who underwent DC alone to decrease ICP or in combination with DL to treat MCS.
  
  
  RESULTS
  All 102 patients sustained blunt injury. Seventy percent were men with a mean age of 29.5 years, an Injury Severity Score of 34.4, and admission Glasgow Coma Scale score of 7.1. Fifty-one patients had diffuse brain injury and 51 had mass lesions. Seventy-eight patients (76%) underwent DC alone. Twenty-four (22%) had both therapies for MCS. Fifteen patients had DC before DL and nine had DL before DC. Mean time between DC and DL was 3.4 +/- 6 days. The mean IAP before DL was 28 +/- 5 mm Hg. Twenty-four-hour cumulative mean intrathoracic pressure decreased significantly after DL in the MCS group (p = 0.01). Mean ICP decreased significantly after both DC and DL (p < 0.05).
  
  
  CONCLUSIONS
  Increased ICP may be from primary TBI or MCS. Patients with MCS have a higher Injury Severity Score, ICP, and fluid requirements, but no increase in mortality. Both DC and DL reduce ICP and can be used in sequence. MCS should be considered in multiply injured patients with increased ICP that does not respond to therapy.
authors.affiliation: R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, MD 21201, USA. tscalea@umm.edu
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Scalea
authors.forename: Grant V
authors.initials: GV
authors.lastname: Bochicchio
authors.forename: Nader
authors.initials: N
authors.lastname: Habashi
authors.forename: Maureen
authors.initials: M
authors.lastname: McCunn
authors.forename: Diane
authors.initials: D
authors.lastname: Shih
authors.forename: Karen
authors.initials: K
authors.lastname: McQuillan
authors.forename: Bizhan
authors.initials: B
authors.lastname: Aarabi
mesh_terms: D000005:Abdomen; D000328:Adult; D001930:Brain Injuries / Q000150:complications* / Q000628:therapy; D003161:Compartment Syndromes / Q000209:etiology* / Q000628:therapy; D003399:Craniotomy; D019299:Decompression, Surgical; D005260:Female; D005440:Fluid Therapy / Q000009:adverse effects; D015600:Glasgow Coma Scale; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000628:therapy; D007427:Intracranial Pressure; D007813:Laparotomy; D008297:Male; D013909:Thorax