Rupture traumatique de l'isthme aortique chez un traumatisé crânien grave

Abstract

A 32-year-old man sustained a severe head injury in a road traffic accident. On admission, he was in deep coma (6 on the Glasgow coma scale). The aortic knuckle was difficult to identify on a plain chest film. Twenty hours after admission, the aortic knuckle had completely disappeared and the mediastinal shadow had become enlarged. The diagnosis of a ruptured aortic isthmus was confirmed by angiography. Surgical repair of this lesion may be carried out either with simple aortic cross-clamping, or by using cardiopulmonary bypass (CPB). Either technique may worsen other injuries, especially head injury, by initiating severe arterial hypertension or coagulation disturbances. In this patient, the technique chosen was aortic cross-clamping with permanent monitoring of the intracranial and cerebral perfusion pressures. Anaesthesia was obtained with 5 mg · kg −1 of thiopentone, 30 mg · kg −1 · h −1 of sodium gamma hydroxybutyrate and 8 μg · kg −1 of fentanyl. Surgery lasted for 90 min, with 33 min of aortic clamping. The increase in arterial blood pressure was controlled with 0.25 mg · kg −1 · h −1 of thiopentone and nicardipine which was stopped 8 min before unclamping. The postoperative course was uneventful. Sedation was stopped after 8 days, and the patient regained consciousness two days later. There remained a paraplegia with no sensory deficit, which had totally receded 15 months later. Carrying out this emergency surgery without CPB means that the intracranial pressure must imperatively be monitored during surgery. Any intracranial hypertension should delay the surgery.