Raabe and Seidel, discuss imaging and neurophysiological tools that may help the surgeon to detect intraoperative ischemia. The strength of intraoperative digital subtraction angiography (DSA) is the full view of the arterial and venous vessel. DSA is the gold standard in complex and giant aneurysms, but due to certain disadvantages, it cannot be considered standard of care.
Intraoperative microvascular Doppler sonography is probably the fastest diagnostic tool and can quickly aid diagnosis of large vessel occlusions.
Intraoperative indocyanine green videoangiography is the best tool to assess flow in perforating and larger arteries, as well as occlusion of the aneurysm sac.
Intraoperative neurophysiological monitoring with somatosensory evoked potentials and motor evoked potentials indirectly measures blood flow by recording neuronal function. It covers all causes of intraoperative ischemia, provided that ischemia occurs in the brain areas under surveillance. However, every method has advantages and disadvantages. No single method is superior to the others in every aspect. Therefore, it is very important for the neurosurgeon to know the strengths and weaknesses of each tool in order to have them available, to know how to use them for each individual situation, and to be ready to apply them within the time window for reversible cerebral ischemia 1).
During cerebral ischemia induced by severe hemorrhagic shock, intravascular microdialysis of the draining venous blood will exhibit changes of the Lactate to Pyruvate Ratio (LP ratio) revealing the deterioration of global cerebral oxidative energy metabolism. In neurocritical care, this technique might be used to give information regarding global cerebral energy metabolism in addition to the regional information obtained from intracerebral microdialysis catheters. The technique might also be used to evaluate cerebral energy state in various critical care conditions when insertion of an intracerebral microdialysis catheter may be contraindicated, e.g., resuscitation after cardiac standstill, open-heart surgery, and multi-trauma 2).
see ischemic stroke