Ischemic injury is a main cause of neurological death during neurosurgery. An understanding of pathophysiology of ischemia is needed in order to manage ischemia and its complications. In this article, ischemic pathophysiology is discussed in the context of cerebral blood flow thresholds, metabolic derangements during ischemia, and mechanisms of irreversible cell damage. The therapeutic treatments that have been evaluated for cerebral protection are divided into two groups: those that increase substrate delivery to the ischemic region, and those that increase the resistance of the tissue to ischemic injury. The authors discuss the rationale and evidence for or against these techniques. Finally, the application of these techniques in two clinical situations, temporary vascular occlusion and carotid endarterectomy, is described.
Address correspondence and reprint requests to Dr. W. R. Selman at Department of Neurological Surgery, Case Western Reserve University, 2074 Abington Road, Cleveland, OH 44106, U.S.A.
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