Perioperative hemostasis in neurosurgery

Hemorrhage is probably the most serious complication arising in neurosurgical procedures; it is associated with significant morbidity and mortality. Neurosurgical patients may face several risk factors of bleeding: past medical comorbidities, particular neurosurgical techniques and medication, intraoperative hemodynamic disturbances, and specific neurochemical mechanisms can all lead to hemostatic disorders. These hemostatic abnormalities can lead to either hemorrhagic or thrombotic complications. Neurosurgical patients are known to be particularly exposed to thromboembolic events and there are many reasons why.Modern techniques can help the clinician detect hemostatic problems, both peri- and intraoperatively. Point-of-care tests, such as thromboelastometry and whole-blood impedance aggregometry, have become popular tools for the early detection of hemostatic perturbations and can guide the clinician in dealing with them.Managing hemostasis in neurosurgery implies dealing with specific anatomical conditions: the brain is the only organ locked in a non-expandable box; thus, any volume of bleeding will increase intracranial pressure with potentially devastating consequences for the surrounding tissue. The clinician responsible for neurosurgical patients faces multiple challenges in protecting neurological tissue since controlling bleeding and avoiding thrombotic side effects are contradictory objectives