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Ischemic tolerance (preconditioning) is taken to mean a short ischemic episode subfatal to cells that activates the protective endogenous mechanisms that ensure tolerance of further longer and more severe episodes of ischemia by the organ (tissue). The present review attempts to analyze information on ischemic preconditioning in the light of the possible use for brain protection. Experimental models, temporal aspects, crossed tolerance, genomic reaction, and mechanisms are considered. There is evidence for human ischemic preconditioning.

The present study was undertaken to evaluate the effects of sevoflurane on spontaneous brain bioelectrical activity in neurosurgical patients. Forty patients treated at the Research Institute of Neurosurgery underwent a neurophysiological examination. No epileptic syndrome was revealed in the clinical picture in 10 patients (a control group), the remaining 30 patients had a history of varying epileptic seizures of different degrees and frequency. Sevoflurane causes a relative acceleration of epileptiform activity synchronization, as evidenced by EEG, which is not a contraindication to the use of this drug in patients with cerebral organic lesion of various genesis with a history of epileptic syndrome and fails to induce clinically significant EEG epileptiform manifestations in patients without epilepsy. In patients with cerebrovascular abnormalities (arteriovenous malformation, cavernous angiomas) who have a history of paroxysmal conditions, inhalational sevoflurane anesthesia can be performed in combination with anticonvulsants (benzodiazepines) during an operation.

The paper analyzes the efficiency of multimodal neuromonitoring (transcranial ultrasound Doppler study, cerebral oximetry, and electroencephalography) for the early intraoperative diagnosis of cerebral ischemia in patients during carotid reparative interventions. On the basis of the findings, the authors have developed a diagnostic algorithm of cerebral ischemia in this group of patients at surgery. Its basis is Doppler monitoring; the data of cerebral oximetry and EEG are taken into account with the borderline values of linear blood flow velocity. The diagnosis of cerebral ischemia during operation on the carotids is a direct indication for the usage of a temporary intraluminal shunt. During carotid reconstructive interventions made under general anesthesia, the application of multimodal neuromonitoring is a valid approach and it should make the most use.

The paper gives the results of a study conducted in 3 groups of neurosurgical patients in the analysis of autoptic material over 15 years in order to detect pulmonary arterial thromboembolism (PATE) as a cause of postoperative death in neurosurgical patients. In the latter, the incidence of PATE was ascertained to be 5.4%, as evidenced by autopsy and the distribution of the onset of a fatal outcome was biphasic. The informative value of determination of the blood level of fibrin D-dimer was analyzed in neurosurgical patients as a screening method for diagnosing prethrombosis. The method has shown to be of high informative value (about 90% sensitivity) and may be used in clinical practice. The effectiveness and safety of the combined procedure of preventing venous thromboembolic events (mechanical method with a subsequent switching over to pharmacological methods on days 3) were evaluated. The method has proven to be effective and safe.

The results of treatment were analyzed in 40 patients aged 5 to 43 years who had been operated on for symptomatic temporal lobe epilepsy, among them there were 29 patients with low-grade intracerebral tumors. Local and regional lesions were observed in 27 and 13 cases, respectively. Thirteen patients with local lesions had also a local type of epileptiform activity; the remaining had a regional type. The involved area was removed in 10 patients; in 15 cases that was removed, with the areas wherein epileptform activity persisted; 15 patients underwent temporal lobectomy adapted to the data of neurophysiological study made before resection. Magnetic resonance imaging indicated that the involved area was completely removed; in 18 patients the resection borders exceeded the involved area. In local lesions accompanied by local epileptic activity, there were no significant differences between the removal in the borders of a lesion and that in a greater extent (p0.05). In patients with regional epileptiform activity, the results of treatment with removal in the greater extent were significantly better (por = 0.01). In these patients, an association was found between the significant disturbances of normal cortical rhythm outside the visualized involved area and the severe impairments in the cortical cytoarchitectonics in these areas. Persistent epileptic activity along with cortical rhythm disturbances on an electrocorticogram may be as a sign of lesion spread outside the visible borders and an indication for additional resections.

The paper analyzes the advantages and disadvantages of using locoregional anesthesia (LRA) modes (a combination of local anesthesia and regional blockade) in neurosurgical patients with intracranial, spine, and spinal cord occlusive cerebrovascular disease and lesions during transnasosphenoidal interventions. LRA is now an effective and frequently indispensable component of anesthetic management during neurosurgical interventions.

This paper provides the practical part of a procedure for endoscopic endonasal transsphenoidal resection of pituitary tumors. The authors have presently gained experience with about 400 endoscopic endonasal transsphenoidal operations. The advantages of endoscopic surgery include the wide vision field of an operative site under good illumination. The endoscopic intervention provides a possibility of extracting not only endo-, but also paracellular portions of a tumor under direct visual control, which can be rarely done during a standard microscopic transnasal operation. The paper gives recommendations on the equipment of an operating suite and anesthetic maintenance. It also describes surgical stages and postoperative management of patients.

The paper presents the results of clinical evaluation of combined prevention of leg deep vein thrombosis and pulmonary thromboembolism in 130 neurosurgical patients undergoing intracranial interventions for brain tumors. Combined prevention comprises mechanical (compression knitted wear + periodic pneumatic leg compression by a special device) and pharmacological (subcutaneous injection of low molecular-weight heparins on postoperative day 2, followed by the daily administration of acetylsalicylic acid from the moment of a patient's activation) treatments. The study has indicated that this preventive procedure is effective and at the same time safe against the development of intracranial hemorrhagic complications.

The paper presents the results of clinical evaluation of the informative value of determination of blood fibrinogen D-dimer in 177 neurosurgical patients undergoing intracranial interventions for brain tumors. Screening detection of patients at high risk for thromboembolic complications is based on the determination of the blood levels of D-dimer on the first day after admission. To verify the diagnostic informative value of D-dimer determination, the patients with higher values (0.5+/-0.03 ng/l) underwent ultrasound scanning of lower extremity veins within the following 1-2 days. Despite its preliminary nature, the study showed the predictive value of determination of blood D-dimer levels in neurosurgical patients in the preoperative period and in the screening of prethrombotic events.

The study was conducted at the Academician N. N. Burdenko Institute of Neurosurgery, Moscow, in 1999 to 2006. The paper presents the results of stepwise surgical treatment in 84 patients with chronic cerebral ischemia, caused by multiple stenotic and occlusive lesions of the brachiocephalic arteries, who underwent 183 reparative operations. Six major groups of patients with various combinations of lesions of major cerebral arteries were identified. An attempt was made to create an algorithm of the optimum stepwise surgical treatment policy in the identified groups of patients on the basis of the site, degree, and nature of stenotic lesions, by taking into account the cerebral hemodynamics and collateral circulation at all stages of surgical treatment. At the same time, changes in the degree of neurological deficit as one of the major determinants of the results of surgical treatment could be evaluated. The study has demonstrated that the chosen tactics of employing series arterial reconstructions in multiple stenotic and occlusive lesions of major cerebral arteries is an effective treatment option in patients with chronic cerebral ischemia.

A Gamma-Knife unit that is currently the gold standard in radiosurgery was first used in clinical practice in 1968. The essence of the radiosurgical treatment is to apply the stereotactic technique to high-precision irradiation of small intracranial targets by narrow beams of ionizing radiation from external sources. Three hundred and six patients with various intracranial diseases (137 with malignant tumors, 136 with benign tumors, and 33 patients with vascular diseases) underwent radiosurgery on a Gamma-Knife unit for over 1.5 years, from May 2005 to October 2006. A total of 329 irradiation sessions were performed. By summing up the first results, it can be noted that stereotactic radiosurgery using a Gamma-Knife unit is an effective and rather safe technique in the treatment of patients with various types of intracranial pathology, which maintains the high quality of life, reduces the likelihood of development of different neurological disorders after treatment and avoids the risk of operative complications. The possibility of performing outpatient treatment for a diversity of diseases without mandatory anesthesiological, ICU, and rehabilitative maintenance, determines the potential economic efficiency of this treatment.

Central neurocytoma (CN) is a rare brain neoplasm which is characterized by certain clinical, radiological, and morphological characteristics. This tumor was first described in 1982 by J. Hassoun et al. who found neurosecretory granules and microtubules while microscopically studying 2 patients with oligodendrogliomas of lateral ventricles and concluded that these neoplasms were of neuronal origin. Materials and methods. In 1992 to 2004, a total of 84 patients diagnosed as having CN were treated at the Academician N. N. Burdenko Research Institute of Neurosurgery, Russian Academy of Medical Sciences. In most cases, the tumor showed a clinical picture as elevated intracranial pressure that was detected in 80 (more than 90%) cases. In this series, all neurocytomas were located in the ventricles, mainly in the pellucid septal region; tumor infiltration of the lateral ventricular ependyma and medullary substance invasion into the region of the thalamus and corpus callosum. Computed tomographic scans displayed central neurocytomas as space-occupying lesions of mixed (heterogeneous) density, which frequently contained single and multiple petrificates and cysts. TI-weighted magnetic resonance imaging (MRI) indicated that in most cases (n=56, 66%), the intensity of a signal from the tumor was mixed and similar to that of the white matter of the brain. These masses were characterized by the presence of tumor structural cysts that were better visualized on T2-weighted tomograms. The tumor was removed in 83 cases; 2 out of them had previously undergone stereotactic biopsy (STB). STB was performed alone in one case. Transcallous, transcortical-through-premotor-area, combined, and transcallous-transcortical approaches were applied when the neurocytomas were removed. Results. Total removal of a tumor (when its remains were not visualized by postoperative MRI) was achieved in 11 (13%) patients. Its subtotal removal was accomplished in 48 (58%) patients. Partial removal was done in 24 (29%) patients. In the early postoperative period after tumor removal, there was a worse health status along with a transient progression of cerebral and focal symptoms in most patients with CN. The magnitude, pattern, and duration of these changes differed. Conclusion. The long (from several months to several years) history of the disease and young age (14 to 59 years) are typical of patients with CN. The tumors are located intraventricularly, more commonly along the midline, and they have well-defined X-ray signs: these are well-circumscribed tumors of heterogeneous density, which frequently contain single and/or multiple cysts and petrificates; there is a moderate contrast enhancement. The basic way of improving the results of treatment in patients with CN is the latter's early diagnosis and surgery when the tumor is locally advanced within the ventricular system.

The results of treatment were analyzed in 37 patients with drug-resistant symptomatic temporal lobe epilepsy among whom there were 22 patients with low-grade intracellular tumors, 2 with cavernomas; 6 with cortical malformations, and 9 with residual organic lesions. Double pathology was noted in 4 patients. Mono- and multiregional lesions were observed in 30 cases. Removal of the site of lesion, extended medial resections, and temporal lobectomy were performed in 7, 5, and 25 cases, respectively. There was an association of the quality of outcomes with the scope of an intervention: the best results were achieved when the affected area with adjacent cortical portions was completely removed within the eliptogenic area. Resections for multiregional lesions are low effective.

A clinical case of successful use of 4% modified liquid gelatin (Helofusin, B. Braun, Germany) at a single-stage infusion volume of 4.5 liters (!) is described in a neurosurgical patient with the single during removal of a giant parietooccipal tumor complicated by rapid massive operative blood loss. The paper discusses the side effects of artificial colloidal infusion solutions, namely their effects on hemostasis and the status of viscera.

This review permits assessment of whether sevoflurane complies with the requirements for an ideal inhalational anesthetic in neuroanesthesiology. It considers the pharmacokinetic characteristics of sevoflurane. The data of studies on animal and man are used to evaluate the effects of sevoflurane on the intracranial parameters of the central nervous system and on cerebral hemodynamics. Where possible, sevoflurane is compared with isoflurane that is currently regarded as the drug of choice in neuroanesthesia.

The paper describes a relatively rare clinical case of stepwise surgical treatment in a patient with concomitant cerebrovascular pathology: thrombosis of the left internal carotid artery + critical stenosis of the right internal carotid artery + arteriovenous malformation of the right occipital lobe. The patient underwent open right carotid endarterectomy left extra-intracranial microvascular anastomotic application, and histoacryl endovascular embolization of the major afferents and arteriovenous malformation stroma in the stepwise fashion. Management policy, possible complications, and ways of their prevention in these patients are discussed.

The paper describes a case of dislocation and impaction of the brain in a child with a large brain tumor, which developed after purgetive enema. It also discusses the management of patients with this complication and possible ways of its prevention.

The paper gives a clinical example of embolization of the vascular network of carotid paraganglioma with subsequent en-block tumor removal with bifurcation of the common carotid artery and with recovery of great blood flow along the internal carotid artery through alloprosthesis of the latter. The positive effects of a combination of endovascular embolization of the vascular network of the tumor with its subsequent removal are noted. Indications for endovascular embolization and its procedure, intraoperative evaluation of cerebral collateral circulation are discussed. Those for carotid repair during en-block removal of carotid paraganglioma with bifurcation of the common carotid artery are considered.

The present study involves the analysis of the results of surgical treatment in 35 patients with drug-resistant epilepsy caused by local temporal lobar lesions: glioma without growth (n = 31), gliosis (n = 1), and cavernoma (n = 3). The medial location of neoplasms involving the hippocampus was noted in 25 cases, their extrahippocampal location was observed in 10 cases. The history of seizures was 2 to 18 years; the duration of a postoperative follow-up was 1 to 6 years. Electrocorticographic and EEG findings indicated that in all cases the eliptogenic zone was located in the medial portions of the temporal lobes at the site of lesion. The first stage of surgery was to remove a neoplasm; the adjacent portions of an epileptogenic zone were resected only with preserved convulsive activity in the surrounding areas. Good results (Classes I-II) were observed in cases of the medial location of a lesion in both total removal of a neoplasm and additional resections; in the group of patients the results were better than in routine removal (seizures ceasing in 4 of 5 and in 3 of 12 patients, respectively). Bad results (Classes III-V) were noted with partial removal of a neoplasm from the medial portions (n = 4), there were much better results (Classes I-II) with its total removal from the medial portions and with its partial removal from other areas. With total removal of extrahippocampal neoplasms, seizures were retained (Classes III-IV); additional resections of neocortical zones (n = 2) failed to improve the results of treatment. With resections in the entorial cortical area, the results were better (Class II). Our findings confirm that hippocampal removal plays an important role in symptomatic temporal epilepsy for an adequate monitoring of seizures.

The paper describes a clinical case of successful transsphenoidal removal of sphenoidal sinus tumor in a patient with severe thrombocytopenia. It also discusses the problems of infusion-transfusion therapy policy in such patients during surgery.

A clinical observation of an extremely rare but highly severe complication, i.e. anaphylatic/anaphylactoid reaction to the infusion of a synthetic colloid plasma-expander (Gelofusion) is described in the paper. Dropping arterial pressure concurrent with tachycardia and a negative dynamics of ST segment in ECGS were the main reaction signs. Besides, mechanisms of allergic reactions developing during the anesthesia implementation as well as the related measures of prevention and therapy are also elucidated.

The structure and main annual indices of the waking-up anesthesiology ward, Anesthesiology Department, Burdenko's Research Institute of Neurosurgery, Russian Academy of Medical Sciences, are addressed in the paper. Outfit, personal structure and the spectrum of the prevailing neurosurgery pathology related with the above ward functioning as well as the reasons due to which the patients are transferred to intensive care are under discussion.

The paper describes a clinical case of the severe potentially fatal postoperative complication--massive pulmonary thromboembolism--in a patient after uncomplicated removal of meningioma of the wing of os basilare. It also describes the problems in the diagnosis, treatment, prevention of perioperative deep venous thrombosis of the shin and subsequent pulmonary thromboembolism in neurosurgery patients.

The paper outlines a rare clinical case of cavernous angioma of the brain stem in a female who was operated on in the sitting position and who intraoperatively developed 6 episodes of massive venous air embolism in tandem from the transverse sinus defect undetectable by the cervical vein compression test. Why it is difficult to diagnose this complication in this case is considered. Preventive and therapeutical measures are given.

Automated reinfusion of autoerythrocytes prepared from blood lost during removal of tumors was the main component of transfusion therapy in 49 patients (52 operations) with brain tumors. All patients developed massive blood loss of 0.5-5 TCB during the intervention, reinfusion device cell saver C.A.T.S 2-02 (Fresenius, Germany) was used. Various aspects of clinical application of this method are discussed, its efficiency and factors affecting it are analyzed. Special attention is paid to time course of hemostasis values during automated reinfusion and the problem of tumor contamination of reinfused suspension. This latter problem was solved by using the last-generation leukocyte filter RC-400 Klev (Pall, Germany). Automated reinfusion of autoerythromass effectively compensated for massive intraoperative blood loss, on condition of correction of hemostasis disorders by fresh frozen plasma and purification of reinfused suspension from tumor cells by filtering through leukocytic filters. Moreover, our results indicate that utilization of cell saver is obligatory for some patients with supermassive hemorrhages.

A method of anesthesia allowing patient's awakening to the level of verbal contact after trephination and opening of the dura mater was used in 37 patients with bulky formations (33 patients with tumors and 4 with arteriovenous malformations) in the speech zones of speech-dominant hemisphere. Speech mapping of the brain, carried out in alert patients, helped eliminate permanent speech deficiency during the postoperative period in all patients. The protocol of anesthesia was as follows: locoregional anesthesia of soft tissues of the head with a mixture of 2% xylocaine and 0.5% marcaine with epinephrine intravenous diprivan at stages requiring no patient's alertness, clopheline, fractionated midazolam (after identification of speech zones). The study showed that this protocol helps solve the problem and adequately protects the organism from surgical stress, provides good conditions for manipulations on the brain, involves no unpleasant sensations for the patient, and in 70% patients helps attain complete amnesia of the perioperative period. The most severe complication is an epileptic attack. Respiratory monitoring (pulse oximetry and capnography in the lateral duct) is obligatory for preventing respiratory disorders in patients on spontaneous respiration who were not intubated.

A young patient without history of epilepsy developed a pronounced motor reaction simulating an epileptic attack in response to diprivan. Possible causes of motor excitation in response to diprivan and probability of their prediction are discussed.

The study was carried out in 22 patients operated on for vertebral disk hernias and spinal tumors at lumbosacral level. The patients were divided in 2 groups depending on the type of anesthesia (epidural or neuroleptanalgesia-EA and NLA). In the test group all patients were operated under EA with local anesthetics combined with intravenous sedative drugs (diprivan + relanium) under conditions of spontaneous respiration and O2 inhalation through a mask. In the control group combined total intravenous anesthesia by myorelaxants and tracheal intubation were carried out (relanium + diprivan: induction dose 1.95 +/- 0.5 mg/kg, maintenance dose 5.3 +/- 0.4 mg/kg/h, and phentanyl). The purpose of the study was to compare the efficiency of anesthesiological protection under EA and traditional NLA in interventions on the spine, when surgical injury is inflicted in the immediate vicinity to the central structures responsible for pain impulsation. Only EA ensured adequate protection of the patients from surgical stress, as was seen from hemodynamic (arterial pressure and heart rate) and endocrine metabolic parameters (glucose, epinephrine, norepinephrine, hydrocortisone, and prolactin levels). Hence, EA fully demonstrated its protective properties during operations on the spine, and therefore can be regarded as a method of choice in this patient population.

A total of 144 neurosurgical interventions were performed in 138 patients with cerebrovascular diseases (arterial aneurysms in the acute and cold periods after a subarachnoidal hemorrhage, arteriovenous malformations, and carotid-cavernous anastomoses). Intraoperative monitoring of regional saturation of hemoglobin with oxygen in the blood flowing in brain vessels was carried out by a cerebral oximeter INVOS 3100 for early intraoperative diagnosis of cerebral ischemia. This paper analyzes factors affecting changes in rSO2 parameter during surgery and discusses the prognostic significance of the detected shifts. Various factors affected the time course of rSO2: decrease in AP within the framework of controlled arterial hypotone and other causes, insertion of autosupported retractor spatulae, temporary clipping and embolism of cerebral arteries, vasospasm, aneurysm rupture, dissection of arteriovenous malformation, etc. Any intraoperative shift of rSO2 surpassing 5%, no matter of what direction (decrease or increase), deserves special attention of anesthesiologist, as it indicates development of cerebral ischemia with a high degree of probability.

Effects of epidural anesthesia (EA) on early components of somatosensory evoked potentials (SSEP) were studied and the objectiveness and efficiency of SSEP monitoring during interventions on the spine under EA were evaluated. Evoked potentials were studied in 21 patients operated on for vertebral disk hernias and extra-intradural tumors of the spine (lower thoracic and lumbar levels) under bupivacaine EA. Cortical SSEP were recorded and analyzed on a Viking IV neuroaverager (Nicolet, USA) stimulating n. tibialis posterior for obtaining a greater amplitude of evoked potentials. The following SSEP characteristics were measured: latency of PI (P37), NI (N45), and PII (P60) peaks, amplitude of PINI peak, and inter-peak latency of PI-NI and PI-PII. The major changes in cortical SSEP caused by EA (local anesthetic 0.5% bupivacaine) involve only PI and NI components which reflect the entry of information on an external stimulus into the cortex and objective physical parameters of this stimulus; this helps predict the onset of full-value epidural block and its duration. General anesthetic (propofol) affect mainly a later component of response, PII peak, which is responsible for processing of primary information about an external stimulus and reflects the activation of associative areas of the brain. Hence, SSEP regulation can be used together with traditional methods (pin prick test and Bromage scale) for evaluating epidural block in patients with spinal diseases.

Simultaneous monitoring by cerebral oximetry and electrophysiological methods (electroencephalography and electrocorticography) was performed in 21 patients with arterial cerebral aneurysms during direct intracranial interventions, endovascular interventions, and Matas' test. Electrophysiological methods are sufficiently accurate indicators of cerebral ischemia even at a functionally reversible level. The results of simultaneous monitoring were similar in 80% cases, indicating cerebral ischemia even at functionally reversible level, which was detected by both electrophysiological methods and cerebral oximetry. Variously directed shifts were detected in 4 cases; the causes are discussed. Cerebral oximetry detects cerebral ischemia with a sensitivity similar to that of electrophysiological methods. The method does not depend on temperature or anesthetics. Limitations of the method are due to its local application.

The paper presents two cases of high-surgical-risk deep arteriovenous malformations (AVM) concurrent with aneurysms of the middle portion of the anterior ciliary artery (a male aged 35 years and a female aged 24 years). In the former case, aneurysm and large AVM in the left visual tuber were causes of 4 hemorrhages. In the latter, AVM of subcortical nodes and internal capsule were responsible for single hemorrhage. The patients underwent intraoperative embolization of the anterior ciliary artery followed by its clipping. This allowed the authors to exclude aneurysm and to achieve obliteration of the bulk of AVM. Operation were performed under intraoperative guidance of motor and speech functions. Residual AVM were exposed to proton beam radiation. The outcomes of treatment were good. After 4 months of surgery, the male had no neurological disorders; in the female motor and speech disorders were associated with prior hemorrhage.

The paper presents a clinical case of severe excess cerebrospinal spinal fluid drain syndrome with hematomas of the cerebral hemispheres being formed in a 18-year-old young man undergone ventriculoatriostomy with mean-pressure pump implantation. A complication occurred 6 months after surgery and ran progressively. Closed external drainage of hematomas greatly reduced their volumes, but deteriorated the patient's condition due to the development of excess drain syndrome. Replacement of the mean-pressure pump by a high-pressure one rapidly normalized the patient's status.

The paper describes a rare combination of atypical meningioma of the base of the skull, which was greatly extended, with a life-time unrecognized small vascular malformation of the brain stem at the level of the pons. Intraoperative hemorrhage into the stem from the micromalformation was a cause of the female patient's death. A detailed account of the operation and the postoperative period and a review of literature on the main aspects of the problem in the diagnosis of cerebral micromalformations are given.

An extremely rare case is described: massive gas (oxygen) embolism resultant from erroneous intraventricular administration of 3% hydrogen peroxide solution, which manifested by total systems hemodynamic and respiratory disorders. Hydrogen peroxide, which is still widely used in surgery, is a serious risk factor as regards gas embolism.

The paper describes a clinical case of the cerebral hyperperfusion syndrome, a rare complication of carotid endarterectomy. The syndrome appeared as the generalized convulsive syndrome in the patient in the early postoperative period. In the context of clinical observation, the results of analysis of the literature are presented and the pathogenesis, diagnosis, therapy, and prevention of the cerebral hyperperfusion syndrome considered.

Clinical study of the effect of propofol (diprivan) on intracranial and cerebral perfusion pressure (ICP and CPP, respectively) in 30 patients with neurosurgical diseases of the brain showed that propofol without narcotic analgesics did not block ICP increase in response to tracheal intubation. If it was combined with narcotic analgesics, the optimal combination was with pyritramide in a dose of 0.4 mg/kg, because this combination blocked ICP increase in response to laryngoscopy and tracheal intubation and did not appreciably decrease CPP. Propofol for decreasing acute intracranial hypertension (like bolus injection of thiopental) during surgery is unjustified, because during anesthesia, bolus injection of propofol just negligibly decreases ICP.

Bullard laryngoscope was for the first time used for intubation of the trachea in 232 neurosurgical patients. The advantages of the new laryngoscope and specific problems associated with its use are discussed. The principal advantage is no need in direct laryngoscopy, which permits using this instrument in patients with short and rigid neck, in those with ankylosis of the temporomandibular joint, with injuries to, or unstable spine. The problems are mainly related to obturation of the optic system of the laryngoscope by secretion and to selection of an adequate diameter of the intubation tube.