Rare Event Captured with Intracranial Pressure Monitor: Malignant Spike in Intracranial Pressure During Delayed Chest Closure in Heart-Transplant Patient with Ischemic Stroke

Abstract

Background: Patients with open chest wounds, either related to trauma or cardiothoracic procedures, are subjected to significant physiologic alterations when undergoing chest wound closure. Sudden increased intrathoracic pressure at closure decreases venous return from the brain to the heart; consequently the total blood volume in the ridged skull increases, resulting in increased intracranial pressure (ICP). Patients with intact cerebrovascular autoregulation can compensate for these sudden changes by adjusting cerebral blood flow to maintain physiologic ICP. In cases where the autoregulatory mechanisms are compromised, such as stroke or trauma, the ICP can become pathologically elevated. If the patient does not have an ICP monitor, the spike in ICP can go unrecognized, compromising cerebral perfusion pressure and resulting in increased morbidity and mortality.

Case description: Herein we describe a case of pathologic elevations in ICP captured with an ICP monitor at the time of chest wound closure in a patient with delayed chest wound closure after orthotopic heart transplant and comorbid embolic stroke.

Conclusions: This case report demonstrates the potential utility of ICP monitoring in patients with impaired cerebrovascular autoregulation with open and manipulated chest wounds from transplant or trauma.

Keywords: Chest wound closure; Heart transplant; ICP monitor; Intracranial pressure; Malignant cerebral edema; Sternal closure ischemic stroke.