Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3734_Библиотеки_им_академика_М_И_Перельмана

Intraoperative neuroprotection strategy begins with mitigation of antecedent neuro­logical injury followed by the prompt correction of central nervous system ischemia, or “neuromalperfusion.” For patients presenting with stroke symptoms or spinal mal­perfusion, the injury must be deemed to benet from an operation. In most situations, the patient will be better served by an operation than medical management. The excep­tions may be dense coma, the extremes of age, extensive malperfusion of the gut, or loss of hemodynamics prior to arriving in the operating room, among others. Once surgical intervention is decided upon, the initial objective is to improve blood ow to the ischemic territory by optimizing cerebral and spinal perfusion and minimizing systemic hypotension. In the preoperative period, management revolves around medi­cal therapy to balance perfusion and risk of dissection propagation or rupture. In almost all cases, the patient should undergo impulse control therapy, to reduce the blood pressure and heart rate resulting in a lesser pulse pressure. Careful coordination with the anesthesia team is necessary, in particular during anesthetic induction to pre­vent hemodynamic collapse. Signicant aortic insufciency or the presence of a peri­cardial effusion should prompt complete readiness of the surgical team at the time of induction. While this statement may seem obvious to the experienced team, subse­quent intraoperative neuroprotection strategies may be nullied by the cumulative effects of multiple episodes of neuromalperfusion in the perioperative period.