covid

COVID-19 for neurosurgeons

COVID-19 for neurosurgeons

In every country, all surgical plans have been modified. In Wuhan, the staff was enrolled in COVID-units. In New York, the Mount Sinai Hospital Health System was in lockdown mode. In South Korea, sterilizing chambers have been placed. In Italy, some Departments were reorganized in a Hub and Spoke fashion. In the Latin American region, they adopted special measures for every case. In the UK a conference center has been used to accommodate intensive care unit (ICU) beds. The third part was about neurosurgical practice during the COVID-19 pandemic. In Wuhan, the main hospital was used for urgent non-COVID patients. In New York, the neurosurgeon staff works in ICU as an advanced practitioner (APP). In South Korea, every patient is screened. In Italy, the on-duty Hub neurosurgeons have been doubled. In the Latin American region recommendations have been developed by some neurosurgical societies. In the UK local non-specialists and rheumatologists, neurosurgical experts are collaborating in terms of best practice. The final part touched upon how to perform safe surgery and re-start after the pandemic. In China, elective surgical procedures are performed very carefully. In New York, surgery planning will be based on the patient’s viral load. In South Korea and in Italy disinfection plans and negative-pressure O.R. were created. In the Latin American region, the aim is to have a rapid testing system. In the UK they have developed flowcharts to guide trauma patient management.

In general, the pandemic scenario was presented as a thought-provoking challenge in all countries which requires tireless efforts for both maintaining emergency and elective neurosurgical procedures 1).

Impact of COVID-19 on the Neurosurgical Resident Training Program

Impact of COVID-19 on the Neurosurgical Resident Training Program

Clinical pathway

One of the challenges neurosurgeons are facing in the global public health crisis caused by the COVID-19 pandemic is to balance COVID-19 screening with timely surgery. Lee et al. described a clinical pathway for patients who needed emergency brain surgery and determined whether differences in the surgery preparation process caused by COVID-19 screening affected clinical outcomes.

During the COVID-19 period, patients in need of emergency brain surgery were managed using a novel standardized pathway designed for COVID-19 screening. They conducted a retrospective review of patients who were hospitalized through the emergency room and underwent emergency brain surgery. A total of 32 patients who underwent emergency brain surgery from February 1 to June 30, 2020 were included in the COVID-19 group, and 65 patients who underwent surgery from February 1 to June 30, 2019 were included in the pre-COVID-19 group. The baseline characteristics, disease severity indicators, time intervals of emergency processes, and clinical outcomes of the two groups were compared. Subgroup analysis was performed between the immediate surgery group and the semi-elective surgery group during the COVID-19 period.

There were no significant differences in baseline characteristics and severity indicators between the pre-COVID-19 group and COVID-19 group. The time interval to skin incision was significantly increased in the COVID-19 group (P = 0.027). However, there were no significant differences in the clinical outcomes between the two groups. In subgroup comparison, the time interval to skin incision was shorter in the immediate surgery group during the COVID-19 period compared with the pre-COVID-19 group (P = 0.040). The screening process did not significantly increase the time interval to classification and admission for immediate surgery. The time interval to surgery initiation was longer in the COVID-19 period due to the increased time interval in the semi-elective surgery group (P < 0.001).

They proposed a clinical pathway for the preoperative screening of COVID-19 in patients requiring emergency brain surgery. No significant differences were observed in the clinical outcomes before and after the COVID-19 pandemic. The protocol they described showed acceptable results during this pandemic 2).

Role

see Role of Neurosurgeons in the COVID-19 Pandemic.

While neurosurgeons are not on the frontline of COVID-19 management and treatment, they commonly care for critically ill patients who will continue to present with subarachnoid hemorrhages, subdural hematomas, brain tumors, traumatic brain injuries, spinal cord injuries, and compressive myelopathies while the pandemic occurs. While public health measures such as quarantine and social distancing are proving effective at slowing the spread, 3) 4) surgeons remain in direct contact with their patients throughout their operations. Protecting the surgical team from contracting COVID-19 is of utmost importance as they are both a potential vector for patient contamination and a scarce resource that cannot be easily replaced.

COVID-19 appears to be principally spread, either directly or via fomites, through droplets from respiratory epithelium— especially the upper respiratory tract. Blood is not at this point a recognized vehicle; if the significant virus were present in the blood, we would be able to do a blood test for the disease. Similarly, it does not seem to concentrate on the cerebrospinal fluid. Thus, most neurosurgical procedures to the spine and head should be safe with routine face and eye protection if Personal protection equipment is unavailable.

Recommendations

COVID-19 recommendations for neurosurgeons.

COVID-19 in chronic subdural hematoma

COVID-19 in chronic subdural hematoma.

Subarachnoid hemorrhage and COVID-19

see Subarachnoid hemorrhage and COVID-19.

Pituitary Surgery During Covid-19

Pituitary Surgery During Covid-19

New York City

In an Invited Commentary, Ammar et al. describe their experiences and share lessons learned regarding triage of patients, staff safety, workforce management, and the psychological impact as they have adapted to a new reality in the Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hotspot in New York City. Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hotspot in New York City 5).

Italy

see COVID-19 in Italy.

Switzerland

Switzerland neurosurgery is doing, where urgent or elective cases are performed in a separate location, and providers and patients require negative COVID-19 tests and chest radiographs prior to entry. Furthermore, there would be greater demand for rapid data analysis and iterative systems research to ensure the best neurosurgical practices 6).

COVID-19 and central nervous system

COVID-19 and central nervous system.

Emotional impact

The emotional impact of COVID-19: from medical staff to common people was published by Montemurro from the Department of Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa, Italy 7).

Neurosurgery in an infant with COVID-19

Administering general aneasthesia to infants with respiratory infections is a challenge because aneasthetic drugs suppress immunity and can thus contribute to intubation-related mechanical stress and inflammation. Neurosurgery in infants with coronavirus disease 2019 (COVID-19) therefore poses a dilemma because the infection is associated with relative immune suppression and a dysregulated inflammatory response, which act as drivers of the disease 8).

From Milan, Italy, we report the case of an 8-month-old male patient with a complex hydrocephalus who had a shunt malfunction during the COVID-19 pandemic. The infant presented with a mild temperature, a dry cough, and an occipital cerebrospinal fluid collection, suggestive for shunt malfunctioning. Neurological examination was negative, but the infant deteriorated and vomited repeatedly. The head CT scan indicated a shunt disconnection. A chest x-ray was negative for overt interstitial pneumonia and the nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 9)

While the baby showed upper respiratory symptoms due to COVID-19, concerns emerged regarding the need for general anaesthesia for shunt revision. To our knowledge, no reports exist regarding the risk of general anaesthesia in infants with COVID-19. Nevertheless, considering the certainty of progressive neurological deterioration if no intervention was taken, the neurosurgical intervention was arranged.

According to the available protocols for patients with COVID-19, 10)

a negative pressure operating room was set up. The staff were provided with full-head hoods, eye protection, filtering facepiece 3 masks, fluid-resistant gowns, double long-sleeved gloves, and impermeable disposable shoe covers. Surgeons and scrubbing nurses had additional sterile surgical suits and an additional pair of long-sleeved gloves. The patient was transferred from a ward dedicated to patients with COVID-19 to the surgical theatre through an isolated and restricted area by trained personnel wearing protective gear 11) Surgery lasted approximately 1 h, and the infant recovered from general anaesthesia promptly. 4 days after surgery, vomiting had worsened and a second neurosurgical revision of the shunt was done. Again, the baby underwent surgery under general anaesthesia without respiratory complications. The baby was promptly extubated, and the neurosurgical course was favourable. To the best of our knowledge, this is the first reported case of an infant with COVID-19 undergoing neurosurgical operations under general anaesthesia. This case might reflect a general observation of relative resistance of babies and children to COVID-19, 12) suggesting the possibility that paucisymptomatic infants with COVID-19 can undergo major surgical procedures without additional morbidity. This early case report needs confirmation and extension and might have broader implications for other surgical procedures addressing potentially life-threatening conditions in infants 13).

References

1)

Fontanella MM, Saraceno G, Lei T, Bederson JB, You N, Rubiano AM, Hutchinson P, Wiemeijer-Timmer F, Servadei F. Neurosurgical activity during COVID-19 pandemic: an expert opinion from China, South Korea, Italy, United Stated of America, Colombia and United Kingdom. J Neurosurg Sci. 2020 Apr 29. doi: 10.23736/S0390-5616.20.04994-2. [Epub ahead of print] PubMed PMID: 32347685.
2)

Lee SH, Jang JS, Chung JW, Kwon JT, Park YS. Clinical Pathway for Emergency Brain Surgery during COVID-19 Pandemic and Its Impact on Clinical Outcomes. J Korean Med Sci. 2021 Jan 11;36(2):e16. doi: 10.3346/jkms.2021.36.e16. PMID: 33429475.
3)

Chinazzi M, Davis JT, Ajelli M, et al. The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak. Science. published online: March 6, 2020 (doi:10.1126/science.aba9757).
4)

Wilder-Smith A, Chiew CJ, Lee VJ. Can we contain the COVID-19 outbreak with the same measures as for SARS? Lancet Infect Dis. published online: March 5, 2020 (doi:10.1016/S1473-3099(20)30129-8).
5)

Ammar A, Stock AD, Holland R, Gelfand Y, Altschul D. Managing a Specialty Service During the COVID-19 Crisis: Lessons From a New York City Health System. Acad Med. 2020 Apr 17. doi: 10.1097/ACM.0000000000003440. [Epub ahead of print] PubMed PMID: 32304386.
6)

Robertson FC, Lippa L, Broekman MLD. Editorial. Task shifting and task sharing for neurosurgeons amidst the COVID-19 pandemic. J Neurosurg. 2020 Apr 17:1-3. doi: 10.3171/2020.4.JNS201056. [Epub ahead of print] PubMed PMID: 32302998; PubMed Central PMCID: PMC7164328.
7)

Montemurro N. The emotional impact of COVID-19: from medical staff to common people. Brain Behav Immun. 2020 Mar 30. pii: S0889-1591(20)30411-6. doi: 10.1016/j.bbi.2020.03.032. [Epub ahead of print] PubMed PMID: 32240766.
8)

Lu X Zhang L Du H et al. SARS-CoV-2 infection in children. N Engl J Med. 2020; (published online March 18.) DOI:10.1056/NEJMc2005073
9) , 10)

Wax RS Christian MD Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anesth. 2020; (published online February 12.) DOI:10.1007/s12630-020-01591-x
11)

Tien HC Chughtai T Jogeklar A Cooper AB Brenneman F Elective and emergency surgery in patients with severe acute respiratory syndrome (SARS). Can J Surg. 2005; 48: 71-74
12)

Li G Fan Y Lai Y et al. Coronavirus infections and immune responses. J Med Virol. 2020; 92: 424-432
13)

Carrabba G, Tariciotti L, Guez S, Calderini E, Locatelli M. Neurosurgery in an infant with COVID-19. Lancet. 2020 Apr 22. pii: S0140-6736(20)30927-2. doi: 10.1016/S0140-6736(20)30927-2. [Epub ahead of print] PubMed PMID: 32333840.

COVID-19 for neurologists

COVID-19 for neurologists

Coronaviruses interfere with target cells by membrane-bound spike proteins. Angiotensin-converting enzyme 2 was identified as an input receptor for SARS-CoV-2. Due to its wide pattern of expression, COVID-19 was shown to affect several organs, including the central nervous system, where the receptor is mainly expressed as neurons.

In the current pandemic, there is a rising number of global infections, the aim of this case to increase the awareness about SARS-CoV-2 possible complications, even if there are possible further mutations for the virus, especially in the central nervous system 1).

Several neurological complications of the central and peripheral nervous systems following SARS-CoV-2 infection have gained clinicians’ attention. Encephalopathy, stroke, encephalitis/meningitis, Guillain-Barré syndrome, andmultiple sclerosis are considered probable neurological signs of COVID-19. The virus may invade the nervous system directly or induce a massive immune-inflammatory response via a “cytokine storm.” Specific antiviral drugs are still under study. To date, immunomodulatory therapies and supportive treatment are the predominant strategies. In order to improve the management of COVID-19 patients, it is crucial to monitor the onset of new neurological complications and to explore drugs/vaccines targeted against SARS-CoV-2 infection 2).

A cross-sectional exploratory prospective biomarker cohort study of 21 patients with COVID-19 neurological syndromes (Guillain Barre Syndrome [GBS], encephalitis, encephalopathy, acute disseminated encephalomyelitis [ADEM], intracranial hypertension and central pain syndrome) and 23 healthy COVID-19 negative controls. Ziff et al. measured cerebrospinal fluid (CSF) and serum biomarkers of amyloid processing, neuronal injury (neurofilament light), astrocyte activation (GFAp) and neuroinflammation (tissue necrosis factor [TNF] ɑ, interleukin [IL]-6, IL-1β, IL-8). Patients with COVID-19 neurological syndromes had significantly reduced CSF soluble amyloid precursor protein (sAPP)-ɑ (p = 0.004) and sAPPβ (p = 0.03) as well as amyloid β (Aβ) 40 (p = 5.2×10-8 ), Aβ42 (p = 3.5×10-7 ) and Aβ42/Aβ40 ratio (p = 0.005) compared to controls. Patients with COVID-19 neurological syndromes showed significantly increased neurofilament light (NfL, p = 0.001), and this negatively correlated with sAPPɑ and sAPPβ. Conversely, GFAp was significantly reduced in COVID-19 neurological syndromes (p = 0.0001) and this positively correlated with sAPPɑ and sAPPβ. COVID-19 neurological patients also displayed significantly increased CSF proinflammatory cytokines and these negatively correlated with sAPPɑ and sAPPβ. A sensitivity analysis of COVID-19 associated GBS revealed a non-significant trend towards greater impairment of amyloid processing in COVID-19 central than peripheral neurological syndromes. This pilot study raises the possibility that patients with COVID-19 associated neurological syndromes exhibit impaired amyloid processing. Altered amyloid processing was linked to neuronal injury and neuroinflammation but reduced astrocyte activation 3).

Dolatshahi et al. provided evidence to critically discuss the claim that the survived patients could possibly be at increased risk for neurodegenerative diseases via various mechanisms. This virus can directly invade the brain through the olfactory bulb, retrograde axonal transport from peripheral nerve endings, or via hematogenous or lymphatic routes. Infection of the neurons along with peripheral leukocyte activation results in pro-inflammatory cytokine increment, rendering the brain to neurodegenerative changes. Also, occupation of the Angiotensin-converting enzyme 2 (ACE2) with the virus may lead to a decline in ACE-2 activity, which acts as a neuroprotective factor. Furthermore, acute respiratory distress syndrome (ARDS) and septicemia induce hypoxemia and hypoperfusion, which is locally exacerbated due to the hypercoagulable state and micro-thrombosis in brain vessels, leading to oxidative stress and neurodegeneration. Common risk factors for COVID-19 and neurodegenerative diseases, such as metabolic risk factors, genetic predispositions, and even gut microbiota dysbiosis, can contribute to a higher occurrence of neurodegenerative diseases in COVID-19 survivors. However, it should be considered that the severity of the infection, the extent of neurologic symptoms, and the persistence of viral infection consequences are major determinants of this association. Importantly, whether this pandemic will increase the overall incidence of neurodegeneration is not clear, as a high percentage of patients with a severe form of COVID-19 might probably not survive enough to develop neurodegenerative diseases 4).

COVID-19 and Guillain-Barré Syndrome

see COVID-19 and Guillain-Barré Syndrome.

Acute ischemic stroke in COVID-19 pandemic

Acute ischemic stroke in COVID-19 pandemic.

International MG/COVID-19 Working Group, Jacob S, Muppidi S, Guidon A, Guptill J, Hehir M, Howard JF Jr, Illa I, Mantegazza R, Murai H, Utsugisawa K, Vissing J, Wiendl H, Nowak RJ. Guidance for the management of myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) during the COVID-19 pandemic. J Neurol Sci. 2020 Mar 25;412:116803. doi: 10.1016/j.jns.2020.116803. [Epub ahead of print] PubMed PMID: 32247193.

SARS-CoV-2 associated viral encephalitis

SARS-CoV-2 associated viral encephalitis

1)

Azab MA, Azzam AY. SARS-CoV-2 associated viral encephalitis with mortality outcome. Interdiscip Neurosurg. 2021 Sep;25:101132. doi: 10.1016/j.inat.2021.101132. Epub 2021 Feb 25. PMID: 33654659; PMCID: PMC7906535.
2)

Yu S, Yu M. Severe Acute Respiratory Syndrome Coronavirus 2-Induced Neurological Complications. Front Cell Dev Biol. 2020 Dec 10;8:605972. doi: 10.3389/fcell.2020.605972. PMID: 33363165; PMCID: PMC7758195.
3)

Ziff OJ, Ashton NJ, Mehta PR, Brown R, Athauda D, Heaney J, Heslegrave AJ, Benedet AL, Blennow K, Checkley AM, Houlihan CF, Gauthier S, Rosa-Neto P, Fox NC, Schott JM, Zetterberg H, Benjamin LA, Paterson RW. Amyloid processing in COVID-19 associated neurological syndromes. J Neurochem. 2022 Feb 8. doi: 10.1111/jnc.15585. Epub ahead of print. PMID: 35137414.
4)

Dolatshahi M, Sabahi M, Aarabi MH. Pathophysiological Clues to How the Emergent SARS-CoV-2 Can Potentially Increase the Susceptibility to Neurodegeneration. Mol Neurobiol. 2021 Jan 8:1–16. doi: 10.1007/s12035-020-02236-2. Epub ahead of print. Erratum in: Mol Neurobiol. 2021 Jan 27;: PMID: 33417221; PMCID: PMC7791539.

Covid-19 and pituitary apoplexy

Covid-19 and pituitary apoplexy

Kamel et al. reported a case of pituitary apoplexy associated with COVID-19 infection. Based on a patient’s clinical findings, review of the other reported cases, as well as the available literature, they put forth a multitude of pathophysiological mechanisms induced by COVID-19 that can possibly lead to the development of pituitary apoplexy. In their opinion, the association between both conditions is not just a mere coincidence. Although the histopathological features of pituitary apoplexy associated with COVID-19 are similar to pituitary apoplexy induced by other etiologies, future research may disclose unique pathological fingerprints of COVID-19 virus that explains its capability of inducing pituitary apoplexy 1).

A 75-year-old man who presented with a headache and was later diagnosed with hypopituitarism secondary to pituitary apoplexy. This occurred 1 month following a mild-to-moderate COVID-19 infection with no other risk factors commonly associated with pituitary apoplexy. This case, therefore, supplements an emerging evidence base supporting a link between COVID-19 and pituitary apoplexy 2).

Martinez-Perez et al. identified 3 consecutive cases of PA and concomitant COVID-19 infection. The most common symptoms at presentation were headache and vision changes. The included patients were successfully treated with surgical decompression and medical management of the associated endocrinopathy, ultimately experiencing improvement in their visual symptoms at the latest follow-up examination. COVID-19 infection in the perioperative period was corroborated by polymerase chain reaction test results in all the patients.

With the addition of our series to the literature, 10 cases of PA in the setting of COVID-19 infection have been confirmed. The present series was limited in its ability to draw conclusions about the relationship between these 2 entities. However, COVID-19 infection might represent a risk factor for the development of PA. Further studies are required. 3).

A review underlines that there could be a specific involvement of the pituitary gland which fits into a progressively shaping endocrine phenotype of COVID-19. Moreover, the care for pituitary diseases need to continue despite the restrictions due to the emergency. Several pituitary diseases, such as hypopituitarism and Cushing disease, or due to frequent comorbidities such as diabetes may be a risk factor for severe COVID-19 in affected patients. There is the urgent need to collect in international multicentric efforts data on all these aspects of the pituitary involvement in the pandemic in order to issue evidence driven recommendations for the management of pituitary patients in the persistent COVID-19 emergency. 4).

Pituitary apoplexy attributed solely to COVID-19 in the absence of other identifiable causes. While much remains to be discovered and understood regarding COVID-19, they discuss the potential pathophysiology of COVID-19-associated pituitary apoplexy and raise awareness of this clinical complication 5)

A neuro-ophthalmic presentation of pituitary apoplexy under the setting of COVID-19 infection in a middle-aged man who presented to ophthalmic emergency with sudden bilateral loss of vision along with a history of fever past 10 days. There was sluggishly reacting pupils and RT-PCR for COVID was positive. Imaging pointed the diagnosis as pituitary macroadenoma with apopexy. In view of pandemic situation, patient was given symptomatic treatment as per the protocols and stabilized. Vision also showed improvement to some extent and the patient is awaiting neurosurgery 6).

A case of a previously healthy woman with severe acute respiratory syndrome coronavirus 2 infection associated with pituitary apoplexy. The plausible pathophysiological mechanisms of pituitary apoplexy in infectious coronavirus disease 2019 are discussed. 7).

A 27-year-old male patient case with progressive decrease in visual acuity, associated with respiratory symptoms and intense headache. Multilobar infiltrate with a reticulonodular pattern is evident on chest CT scan. Brain CT scan with pituitary macroadenoma apoplexy was shown. SARS-Cov2 was confirmed, and respiratory support initiated. However, the patient died shortly afterward, secondary to pulmonary complications.

The angiotensin-converting enzyme (ACE) II receptor is expressed in circumventricular organs and in cerebrovascular endothelial cells, which play a role in vascular autoregulation and cerebral blood flow. For this reason, is rational the hypothesize that brain ACE II could be involved in COVID-19 infection. Underlying mechanisms require further elucidation in the future 8).

A 28-year-old G5P1 38w1d female presented with 4 days of blurry vision, left dilated pupil, and headache. She tested positive for SARS-CoV-2 on routine nasal swab testing but denied cough or fever. Endocrine testing demonstrated an elevated serum prolactin level, and central hypothyroidism. MRI showed a cystic-solid lesion with a fluid level in the pituitary fossa and expansion of the sella consistent with pituitary apoplexy. Her visual symptoms improved with corticosteroid administration and surgery was delayed to two weeks after her initial COVID-19 infection and to allow for safe delivery of the child. A vaginal delivery under epidural anesthetic occurred at 39 weeks. Two days later, transsphenoidal resection of the mass was performed under strict COVID-19 precautions including use of Powered Air Purifying Respirators (PAPRs) and limited OR personnel given high risk of infection during endonasal procedures. Pathology demonstrated a liquefied hemorrhagic mass suggestive of pituitary apoplexy. She made a full recovery and was discharged home two days after surgery.

They demonstrate the first known case of successful elective induction of vaginal delivery and transsphenoidal intervention in a near full term gravid patient presenting with pituitary apoplexy and acute SARS-CoV-2 infection. Further reports may help determine if there is a causal relationship or if these events are unrelated. Close adherence to guidelines for caregivers can greatly reduce risk of infection. 9).

A 25 year old male presented with dyspnoea, cough and high fevers for 4 days. He was commenced on broad-spectrum antimicrobials and oxygen therapy. His respiratory function deteriorated in spite of these measures and he required mechanical ventilation. CT showed left upper lobe consolidation as well as multifocal ground-glass opacification. Case 2: A 43 year-old male presented with headache and was found incidentally to have pneumonia. He was recently diagnosed with pituitary apoplexy secondary to an adenoma with resultant pituitary insufficiency but MRI brain was stable. His respiratory function deteriorated in spite of antibiotics and he required mechanical ventilation. CT showed likely atypical infection with resultant ARDS. Outcome Both underwent nasopharyngeal RT-PCR testing for SARS-CoV-2. Patient 2 was positive. Patient 1 was extubated and made a good recovery. Patient 2 was transferred to another centre for ECMO therapy. He died 27 days after transfer. Conclusion Given the atypical presentations in generally otherwise young and healthy individuals, the decision was made outside of national guidance to perform testing for SARS-CoV-2. This diagnosis had far-reaching implications for the SARS-CoV-2 pandemic within Ireland 10).

1)

Kamel WA, Najibullah M, Saleh MS, Azab WA. Coronavirus disease 2019 infection and pituitary apoplexy: A causal relation or just a coincidence? A case report and review of the literature. Surg Neurol Int. 2021 Jun 28;12:317. doi: 10.25259/SNI_401_2021. PMID: 34345458; PMCID: PMC8326077.
2)

Liew SY, Seese R, Shames A, Majumdar K. Apoplexy in a previously undiagnosed pituitary macroadenoma in the setting of recent COVID-19 infection. BMJ Case Rep. 2021 Jul 28;14(7):e243607. doi: 10.1136/bcr-2021-243607. PMID: 34321266; PMCID: PMC8319972.
3)

Martinez-Perez R, Kortz MW, Carroll BW, Duran D, Neill JS, Luzardo GD, Zachariah MA. Coronavirus Disease 2019 and Pituitary Apoplexy: A Single-Center Case Series and Review of the Literature. World Neurosurg. 2021 Aug;152:e678-e687. doi: 10.1016/j.wneu.2021.06.004. Epub 2021 Jun 12. PMID: 34129968; PMCID: PMC8196470.
4)

Frara S, Allora A, Castellino L, di Filippo L, Loli P, Giustina A. COVID-19 and the pituitary. Pituitary. 2021 Jun;24(3):465-481. doi: 10.1007/s11102-021-01148-1. Epub 2021 May 3. PMID: 33939057; PMCID: PMC8089131.
5)

Bordes SJ, Phang-Lyn S, Najera E, Borghei-Razavi H, Adada B. Pituitary Apoplexy Attributed to COVID-19 Infection in the Absence of an Underlying Macroadenoma or Other Identifiable Cause. Cureus. 2021 Feb 12;13(2):e13315. doi: 10.7759/cureus.13315. PMID: 33732566; PMCID: PMC7956048.
6)

Katti V, Ramamurthy LB, Kanakpur S, Shet SD, Dhoot M. Neuro-ophthalmic presentation of COVID-19 disease: A case report. Indian J Ophthalmol. 2021 Apr;69(4):992-994. doi: 10.4103/ijo.IJO_3321_20. PMID: 33727476; PMCID: PMC8012961.
7)

Ghosh R, Roy D, Roy D, Mandal A, Dutta A, Naga D, Benito-León J. A Rare Case of SARS-CoV-2 Infection Associated With Pituitary Apoplexy Without Comorbidities. J Endocr Soc. 2021 Jan 2;5(3):bvaa203. doi: 10.1210/jendso/bvaa203. PMID: 33501401; PMCID: PMC7798947.
8)

Solorio-Pineda S, Almendárez-Sánchez CA, Tafur-Grandett AA, Ramos-Martínez GA, Huato-Reyes R, Ruiz-Flores MI, Sosa-Najera A. Pituitary macroadenoma apoplexy in a severe acute respiratory syndrome-coronavirus-2-positive testing: Causal or casual? Surg Neurol Int. 2020 Sep 25;11:304. doi: 10.25259/SNI_305_2020. PMID: 33093981; PMCID: PMC7568102.
9)

Chan JL, Gregory KD, Smithson SS, Naqvi M, Mamelak AN. Pituitary apoplexy associated with acute COVID-19 infection and pregnancy. Pituitary. 2020 Dec;23(6):716-720. doi: 10.1007/s11102-020-01080-w. Epub 2020 Sep 11. PMID: 32915365; PMCID: PMC7484495.
10)

Faller E, Lapthorne S, Barry R, Shamile F, Salleh F, Doyle D, O’Halloran D, Prentice M, Sadlier C. The Presentation and Diagnosis of the First Known Community-Transmitted Case of SARS-CoV-2 in the Republic of Ireland. Ir Med J. 2020 May 7;113(5):78. PMID: 32603572.

Acute ischemic stroke in COVID-19 pandemic

Acute ischemic stroke in COVID-19 pandemic

Patients infected with SARS-CoV-2 develop arterial thrombosis including stroke, myocardial infarction and peripheral arterial thrombosis, all of which result in poor outcomes despite maximal medical, endovascular, and microsurgical treatment compared with non-COVID-19-infected patients 1).

Evidence now suggests that 1-6% of hospitalized COVID-19 patients develop stroke. According to some reports, stroke risk is more than sevenfold greater in patients with COVID-19 than influenza. Concerningly, outcomes of COVID-19-related stroke are often worse than in stroke patients without COVID-19 from the same cohorts. In a review, Stein et al. highlight the emerging association between COVID-19 and stroke and discuss putative pathogenetic mechanisms. The etiology of stroke in COVID-19 patients is likely multifactorial, related to coagulopathy, inflammation, platelet activation, and alterations to the vascular endothelium. Significant work remains to be done to better understand the pathogenesis of COVID-19-related stroke and for designing optimal primary and secondary prevention strategies 2).

The risk of discharge to destination other than home or death increased 2-fold with occurrence of acute ischemic stroke in patients with COVID-19 3).

Large Vessel Occlusion was predominant in patients with acute ischemic stroke and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA 4).

The goal of a study of Shahjouei et al. was to better depict the short-term risk of stroke and its associated factors among SARS-CoV-2 hospitalized patients.

This multicentre, multinational observational study includes hospitalized SARS-CoV-2 patients from North and South America (United States, Canada, and Brazil), Europe (Greece, Italy, Finland, and Turkey), Asia (Lebanon, Iran, and India), and Oceania (New Zealand). The outcome was the risk of subsequent stroke. Centres were included by non-probability sampling. The counts and clinical characteristics including laboratory findings and imaging of the patients with and without a subsequent stroke were recorded according to a predefined protocol. Quality, risk of bias, and heterogeneity assessments were conducted according to ROBINS-E and Cochrane Q-test. The risk of subsequent stroke was estimated through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines.

Shahjouei et al. received data from 26,175 hospitalized SARS-CoV-2 patients from 99 tertiary centres in 65 regions of 11 countries until May 1st, 2020. A total of 17,799 patients were included in meta-analyses. Among them, 156(0.9%) patients had a stroke-123(79%) ischaemic stroke, 27(17%) intracerebral/subarachnoid hemorrhage, and 6(4%) cerebral sinus thrombosis. Subsequent stroke risks calculated with meta-analyses, under low to moderate heterogeneity, were 0.5% among all centres in all countries, and 0.7% among countries with higher health expenditures. The need for mechanical ventilation (OR: 1.9, 95% CI:1.1-3.5, p = 0.03) and the presence of ischaemic heart disease (OR: 2.5, 95% CI:1.4-4.7, p = 0.006) were predictive of stroke.

Interpretation: The results of this multi-national study on hospitalized patients with SARS-CoV-2 infection indicated an overall stroke risk of 0.5%(pooled risk: 0.9%). The need for mechanical ventilation and the history of ischaemic heart disease are the independent predictors of stroke among SARS-CoV-2 patients 5).

Consensus recommendations

Based on a literature review, a series of consensus recommendations were established by the Madrid Stroke multidisciplinary group and its neurology committee.

These recommendations address 5 main objectives: 1) coordination of action protocols to ensure access to hospital care for stroke patients; 2) recognition of potentially COVID-19-positive stroke patients; 3) organisation of patient management to prevent SARS-CoV-2 infection among healthcare professionals; 4) avoidance of unnecessary neuroimaging studies and other procedures that may increase the risk of infection; and 5) safe, early discharge and follow-up to ensure bed availability. This management protocol has been called CORONA (Coordinate, Recognise, Organise, Neuroimaging, At home).

The recommendations presented may assist in the organisation of acute stroke care and the optimisation of healthcare resources, while ensuring the safety of healthcare professionals 6).

Case series

A series of 10 ischemic stroke patients with concomitant COVID-19 disease. Out of 10, 8 had large infarcts (3 massive middle cerebral artery, 2 basilar artery, 2 posterior cerebral artery, and 1 internal carotid artery infarct territory). Two had cardiogenic embolic stroke due to atrial fibrillation. Almost half of our patients did not have a vascular risk factor. Nine did not have fever and were diagnosed with COVID-19 upon admission for stroke. Stroke occurred in the first week of respiratory symptoms with moderate pulmonary involvement. Most Patients did not have hypoxia and did not establish respiratory failure or acute respiratory distress syndrome. The blood pressures were low and hemorrhagic transformation did not occur even after antiplatelet or anticoagulant therapy. Patients had markedly increased levels of lactate dehydrogenase, C-reactive protein, and D-dimer. Three patients died. It seems that ischemic strokes in COVID-19 patients tend to occur as large infarct and can be seen in patients with mild to moderate pulmonary involvement 7).

References

1)

Zakeri A, Jadhav AP, Sullenger BA, Nimjee SM. Ischemic stroke in COVID-19-positive patients: an overview of SARS-CoV-2 and thrombotic mechanisms for the neurointerventionalist. J Neurointerv Surg. 2021 Mar;13(3):202-206. doi: 10.1136/neurintsurg-2020-016794. Epub 2020 Dec 9. PMID: 33298508.
2)

Stein LK, Mayman NA, Dhamoon MS, Fifi JT. The emerging association between COVID-19 and acute stroke. Trends Neurosci. 2021 Apr 8:S0166-2236(21)00071-0. doi: 10.1016/j.tins.2021.03.005. Epub ahead of print. PMID: 33879319.
3)

Qureshi AI, Baskett WI, Huang W, Shyu D, Myers D, Raju M, Lobanova I, Suri MFK, Naqvi SH, French BR, Siddiq F, Gomez CR, Shyu CR. Acute Ischemic Stroke and COVID-19: An Analysis of 27 676 Patients. Stroke. 2021 Mar;52(3):905-912. doi: 10.1161/STROKEAHA.120.031786. Epub 2021 Feb 4. PMID: 33535779; PMCID: PMC7903982.
4)

Khandelwal P, Al-Mufti F, Tiwari A, Singla A, Dmytriw AA, Piano M, Quilici L, Pero G, Renieri L, Limbucci N, Martínez-Galdámez M, Schüller-Arteaga M, Galván J, Arenillas-Lara JF, Hashim Z, Nayak S, Desousa K, Sun H, Agarwalla PK, Nanda A, Roychowdhury JS, Nourollahzadeh E, Prakash T, Gandhi CD, Xavier AR, Lozano JD, Gupta G, Yavagal DR. Incidence, Characteristics and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study. Neurosurgery. 2021 Mar 18:nyab111. doi: 10.1093/neuros/nyab111. Epub ahead of print. PMID: 33734404.
5)

Shahjouei S, Naderi S, Li J, et al. Risk of stroke in hospitalized SARS-CoV-2 infected patients: A multinational study [published online ahead of print, 2020 Aug 17]. EBioMedicine. 2020;59:102939. doi:10.1016/j.ebiom.2020.102939
6)

Rodríguez-Pardo J, Fuentes B, Alonso de Leciñana M, Campollo J, Calleja Castaño P, Carneado Ruiz J, Egido Herrero J, García Leal R, Gil Núñez A, Gómez Cerezo JF, Martín Martínez A, Masjuán Vallejo J, Palomino Aguado B, Riera López N, Simón de Las Heras R, Vivancos Mora J, Díez Tejedor E; en nombre del Grupo Multidisciplinar del Plan Ictus Madrid. Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. Neurologia. 2020 May;35(4):258-263. English, Spanish. doi: 10.1016/j.nrl.2020.04.008. Epub 2020 Apr 24. PMID: 32364127; PMCID: PMC7180371.
7)

Ahmadi Karvigh S, Vahabizad F, Banihashemi G, Sahraian MA, Gheini MR, Eslami M, Marhamati H, Mirhadi MS. Ischemic Stroke in Patients with COVID-19 Disease: A Report of 10 Cases from Iran. Cerebrovasc Dis. 2020 Dec 15:1-6. doi: 10.1159/000513279. Epub ahead of print. PMID: 33321492; PMCID: PMC7801957.

Pituitary Surgery During Covid-19

Pituitary Surgery During Covid-19

see Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic

During the Covid-19 pandemic, every hospital has had to change its internal organization. The nature of the transsphenoidal corridor exposes the pituitary surgery team to an increased risk of virus exposure 1).

It was reported that the aerosolization and mucosal involvement increase the risk of viral transmission during operation. Therefore, transcranial is a safer surgical approach during the COVID-19 pandemic.

Case series

Nine cases of pituitary adenomas have presented with urgent manifestations. The endoscopic endonasal approach was performed in eight patients, while a craniotomy was selected for a recurrent pituitary adenoma. Pre- and postoperative thorough clinical evaluations with chest CT scans were performed. Other strict infection control measures have been applied.

In 8 weeks duration starting from the past days of February 2020, we have operated on four females and five males of pituitary adenomas. Visual deterioration was the main presenting symptom. The driving factor for surgery was saving vision in eight patients. Fortunately, the postoperative course was uneventful for all patients. No suspected COVID-19 infection has been reported in any patient or health-care team except one patient. In our city, PCR test was routinely not available 2).

A retrospective cohort study was conducted of all patients who underwent high-priority endoscopic nasal surgery or anterior skull base surgery between 23rd March and 15th June 2020 at University Hospitals Birmingham NHS Trust.

Twenty-four patients underwent endonasal surgery during the study period, 12 were males and 12 were females. There was no coronavirus-related morbidity in any patient.

This observational study found that it is possible to safely undertake urgent endonasal surgery; the nosocomial risk of coronavirus disease 2019 can be mitigated with appropriate peri-operative precautions 3).

Case reports

A 21-year old male, who required urgent surgery because of progressive visual disturbance due to giant pituitary adenoma. On brain MRI with contrast, it was revealed an extra-axial tumor extending anteriorly over planum sphenoidal with the greatest diameter was 5.34 cm. A transcranial approach was chosen to resect the tumor. Near-total removal of the tumor was achieved without damaging the vital neurovascular structure. The visual acuity was improved and no significant postoperative complication. Pathology examination revealed pituitary adenoma.

Transcranial surgery for pituitary adenoma is still an armamentarium in neurosurgical practice, especially in the COVID-19 pandemic to provide a safer surgical approach 4).

The goal of a paper of Penner et al. is to illustrate the feasibility of pituitary region surgery during the SARS-CoV-2 pandemic.

After two negative COVID tests were obtained, three patients with macro GH-secreting tumors, and two patients with micro ACTH-secreting tumors resistant to medical treatment underwent surgery during the pandemic. During the surgery, every patient was treated as if they were positive.

Neither operator nor patient has developed COVID symptoms. The two neurosurgeons performing the operations underwent two COVID swabs, which resulted in negative.

Pituitary surgery is high-risk non-urgent surgery. However, the method described has so far been effective and is safe for both patients and healthcare providers 5).

The impact of COVID-19 on pituitary surgery. ANZ J Surg. 2020 Apr 25. doi: 10.1111/ans.15959. [Epub ahead of print] PubMed PMID: 32336017 6).

A 47-year-old male COVID-19 positive patient presented to the Emergency Department with a left frontal headache that culminated with diplopia, left eye ptosis, and left visual acuity loss after 5 days. Transsphenoidal hypophysectomy was uneventfully performed, and the patient was discharged from the hospital on postoperative day four. It additionally describes in detail the University of Mississippi Medical Center airway management algorithm for patients infected with the novel coronavirus who need emergent surgical attention 7).

A 72-year-old woman who required urgent endonasal transsphenoidal surgery (eTSS) because of progressive visual field disturbance due to pituitary adenoma, in whom we conducted reverse-transcriptase-polymerase-chain-reaction (RT-PCR) for COVID-19 and chest CT before eTSS. We took care of her by following the rule for suspected infection patient and safely completed her treatment without medical staff infection. Under COVID-19 pandemic state, essentially careful management including RT-PCR test and chest CT should be taken for the high infection risk surgeries to avoid the outbreak through the hospital. And the cost of the RT-PCR test for the patients should be covered by the government budget 8).

References

1)

Quillin JW, Oyesiku NM. Status of Pituitary Surgery During the COVID-19 Pandemic. Neurol India. 2020 May-Jun;68(Supplement):S134-S136. doi: 10.4103/0028-3886.287685. PMID: 32611904.
2)

Arnaout MM, Bessar AA, Elnashar I, Abaza H, Makia M. Pituitary adenoma surgeries in COVID-19 era: Early local experience from Egypt. Surg Neurol Int. 2020 Oct 29;11:363. doi: 10.25259/SNI_472_2020. PMID: 33194296; PMCID: PMC7655998.
3)

Naik PP, Tsermoulas G, Paluzzi A, McClelland L, Ahmed SK. Endonasal surgery in the coronavirus era – Birmingham experience. J Laryngol Otol. 2020 Nov 4:1-4. doi: 10.1017/S0022215120002364. Epub ahead of print. PMID: 33143753; PMCID: PMC7729149.
4)

Golden N, Niryana W, Awyono S, Eka Mardhika P, Bhuwana Putra M, Stefanus Biondi M. Transcranial approach as surgical treatment for giant pituitary adenoma during COVID 19 pandemic – What can we learn?: A case report. Interdiscip Neurosurg. 2021 Feb 25:101153. doi: 10.1016/j.inat.2021.101153. Epub ahead of print. PMID: 33654658; PMCID: PMC7906516.
5)

Penner F, Grottoli S, Lanotte MMR, Garbossa D, Zenga F. Pituitary surgery during Covid-19: a first-hand experience and evaluation [published online ahead of print, 2020 Jul 10]. J Endocrinol Invest. 2020;10.1007/s40618-020-01354-x. doi:10.1007/s40618-020-01354-x
6)

Mitchell RA, King JA, Goldschlager T, Wang YY. The impact of COVID-19 on pituitary surgery. ANZ J Surg. 2020 Apr 25. doi: 10.1111/ans.15959. [Epub ahead of print] PubMed PMID: 32336017.
7)

Santos CDSE, Filho LMDCL, Santos CAT, Neill JS, Vale HF, Kurnutala LN. Pituitary tumor resection in a patient with SARS-CoV-2 (COVID-19) infection. A case report and suggested airway management guidelines. Braz J Anesthesiol. 2020 Mar-Apr;70(2):165-170. doi: 10.1016/j.bjane.2020.05.003. Epub 2020 Jun 10. PMID: 32834194; PMCID: PMC7283047.
8)

Akai T, Maruyama K, Takakura H, Yamamoto Y, Morinaga Y, Kuroda S. Safety management in urgent endonasal trans-sphenoidal surgery for pituitary adenoma during the COVID-19 pandemic in Japan – A case report. Interdiscip Neurosurg. 2020 Dec;22:100820. doi: 10.1016/j.inat.2020.100820. Epub 2020 Jul 10. PMID: 32835016; PMCID: PMC7347482.

COVID-19 Outcome

COVID-19 Outcome

The possible risk factors that lead to death in critical inpatients with coronavirus disease 2019 (COVID-19) are not yet fully understood.

Old age (>70 years), neutrophilia, C-reactive protein greater than 100 mg/L and lactate dehydrogenase over 300 U/L are high-risk factors for mortality in critical patients with COVID-19. Sinus tachycardia and ventricular arrhythmia are independent ECG risk factors for mortality from COVID-19 1).

While the disease itself is often mild, approximately 11% of cases require acute medical care, and this cohort quickly overwhelmed healthcare systems around the world 2).

In anticipation of such a demand, hospitals in many countries quickly stopped all nonurgent visits, procedures, and surgeries, freeing up beds, equipment, and workforce 3)

The mortality rate for COVID-19 is not as high (approximately 2-3%), but its rapid propagation has resulted in the activation of protocols to stop its spread. 4).

Diabetes is a risk factor for the progression and prognosis of COVID-19

A total of 174 consecutive patients confirmed with COVID-19 were studied. Demographic data, medical history, symptoms and signs, laboratory findings, chest computed tomography (CT) as well we treatment measures were collected and analyzed.

Guo et al. found that COVID-19 patients without other comorbidities but with diabetes (n=24) were at higher risk of severe pneumonia, the release of tissue injury-related enzymes, excessive uncontrolled inflammation responses and hypercoagulable state associated with dysregulation of glucose metabolism. Furthermore, serum levels of inflammation-related biomarkers such as IL-6, C-reactive protein, serum ferritin, and coagulation index, D-dimer, were significantly higher (p< 0.01) in diabetic patients compared with those without, suggesting that patients with diabetes are more susceptible to an inflammatory storm eventually leading to rapid deterioration of COVID-19.

Data support the notion that diabetes should be considered as a risk factor for a rapid progression and bad prognosis of COVID-19. More intensive attention should be paid to patients with diabetes, in case of rapid deterioration 5).

see Racism and discrimination in COVID-19 responses 6).

References

1)

Li L, Zhang S, He B, Chen X, Wang S, Zhao Q. Risk factors and electrocardiogram characteristics for mortality in critical inpatients with COVID-19. Clin Cardiol. 2020 Oct 22. doi: 10.1002/clc.23492. Epub ahead of print. PMID: 33094522.
2)

Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395(10231):P1225-P1228.
3)

Wong J, Goh QY, Tan Z, et al. Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anaesth. 2020;395:497.
4)

Palacios Cruz M, Santos E, Velázquez Cervantes MA, León Juárez M. COVID-19, a worldwide public health emergency. Rev Clin Esp. 2020 Mar 20. pii: S0014-2565(20)30092-8. doi: 10.1016/j.rce.2020.03.001. [Epub ahead of print] Review. English, Spanish. PubMed PMID: 32204922.
5)

Guo W, Li M, Dong Y, Zhou H, Zhang Z, Tian C, Qin R, Wang H, Shen Y, Du K, Zhao L, Fan H, Luo S, Hu D. Diabetes is a risk factor for the progression and prognosis of COVID-19. Diabetes Metab Res Rev. 2020 Mar 31:e3319. doi: 10.1002/dmrr.3319. [Epub ahead of print] PubMed PMID: 32233013.
6)

Devakumar D, Shannon G, Bhopal SS, Abubakar I. Racism and discrimination in COVID-19 responses. Lancet. 2020 Apr 1. pii: S0140-6736(20)30792-3. doi: 10.1016/S0140-6736(20)30792-3. [Epub ahead of print] PubMed PMID: 32246915.

COVID-19 Pandemic

COVID-19 Pandemic

On 30 December 2019, a report of a cluster of pneumonia of unknown etiology was published on ProMED-mail, possibly related to contact with a seafood market in Wuhan, China 1).

Hospitals in the region held an emergency symposium, and support from federal agencies is reportedly helping to determine the source of infection and causative organism. The seafood market has since been closed, but purportedly sold a variety of live animal species. On 5 January 2019, the World Health Organization (WHO) published a document outlining their request for more information from Chinese public health authorities and detailed 44 patients had ‘pneumonia of unknown etiology’, with 121 close contacts under surveillance (www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/). The WHO reported that 11 patients were severely ill, and many affected individuals had contact with the Huanan Seafood market. Some patients were reported to have fever, dyspnea and pulmonary infiltrates on chest radiography 2).

It was declared a public health emergency of international concern on Jan 30, 2020, by WHO 3).

By early January, terms like “the new coronavirus” and “Wuhan coronavirus” were in common use. On February 11, 2020, a taxonomic designation “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2) became the official means to refer to the virus strain, that was previously termed as 2019-nCoV and Wuhan coronavirus. Within a few hours on the same day, the WHO officially renamed the disease as COVID-19.

The infection spread quickly and was declared a pandemic by the World Health Organization (WHO) on March 11, 2019 4).

By March 30, more than 782 365 confirmed cases were reported and a third of the world population were living in confinement to try to contain the virus 5).

Epidemiology

COVID-19 Epidemiology

Etiology

COVID-19 has high homology to other pathogenic coronaviruses, such as those originating from bat-related zoonosis (SARS-CoV), which caused approximately 646 deaths in China at the start of the decade.

The COVID-19 generally had a high reproductive number, a long incubation period, a short serial interval and a low case fatality rate (much higher in patients with comorbidities) than SARS and MERS. Clinical presentation and pathology of COVID-19 greatly resembled SARS and MERS, with less upper respiratory and gastrointestinal symptoms, and more exudative lesions in post-mortems. Potential treatments included remdesivir, chloroquine, tocilizumab, convalescent plasma and vaccine immunization (when possible) 6).

Transmission

COVID-19 Transmission.

COVID-19 virus genome

The complete genome of SARS-CoV-2 from Wuhan, China was submitted on January 17, 2020 in the National Center for Biotechnology 7) (NCBI) database, with ID NC_045512. The genome of SARS-CoV-2 is a 29,903 bp single-stranded RNA (ss-RNA) coronavirus. It has now been shown that the virus causing COVID-19 is a SARS-like coronavirus that had previously been reported in bats in China.

COVID-19 and central nervous system

COVID-19 and central nervous system.

Essential care of critical illness

Essential care of critical illness must not be forgotten in the COVID-19 pandemic 8).

COVID-19 for neurologists

COVID-19 for neurologists.

COVID-19 for Neurosurgeons

see COVID-19 for neurosurgeons.

COVID-19 in Spinal Disorders

Effects of the COVID-19 Pandemic on the Management of Spinal Disorders.

COVID-19 for Vascular surgeons

see COVID-19 for Vascular surgeons.

COVID-19 for Dermatologists

COVID-19 for Dermatologists.

COVID-19 for Gastroenterologists

COVID-19 for Gastroenterologists

COVID-19 for Pediatricians

COVID-19 for Pediatricians

COVID-19 for Psychiatrists

COVID-19 for Psychiatrists.

COVID-19 for Oncologists

COVID-19 for Oncologists.

COVID-19 for Otolaryngologists

COVID-19 for Otolaryngologists.

COVID-19 for Cardiologists

COVID-19 for Cardiologists.

COVID-19 for Gynecologists

COVID-19 for Gynecologists.

Diagnosis

COVID-19 Diagnosis.

Treatment

COVID-19 Treatment.

Palliative Care

COVID-19 Palliative Care.

Prevention

COVID-19 Prevention.

Operating room preparation for COVID-19

see Operating room preparation for COVID-19.

Telemedicine in the COVID-19 era

see Telemedicine in the COVID-19 era.

Outcome

COVID-19 Outcome.

Case reports

2019 novel coronavirus infection in a three-month-old baby 9).

3 cases of SARS-CoV-2 infected children diagnosed from February 3 to February 17, 2020 in Tianjin, China. All of these three cases experienced mild illness and recovered soon after treatment, with the nucleic acid of throat swab turning negative within 14, 11, 7 days after diagnosis respectively. However, after been discharged, all the three cases were tested SARS-CoV-2 positive in the stool samples within 10 days, in spite of their remained negative nucleic acid in throat swab specimens. Therefore, it is necessary to be aware of the possibility of fecal-oral transmission of SARS-CoV-2 infection, especially for children cases 10).

Lv et al. reported the dynamic change process of target genes by RT-PCR testing of SARS-Cov-2 during the course of a COVID-19 patient: from successive negative results to successive single positive nucleocapsid gene, to two positive target genes (orf1ab and nucleocapsid) by RT-PCR testing of SARS-Cov-2, and describe the diagnosis, clinical course, and management of the case. In this case, negative results of RT-PCR testing was not excluded to diagnose a suspected COVID-19 patient, clinical signs and symptoms, other laboratory findings, and chest CT images should be taken into account for the absence of enough positive evidence. This case highlights the importance of successive sampling and testing SARS-Cov-2 by RT-PCR as well as the increased value of single positive target gene from pending to positive in two specimens to diagnose laboratory-confirmed COVID-19 11).

Literature

see COVID-19 Literature

References

1)

Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020;382(8):727-733.
2)

Bogoch II, Watts A, Thomas-Bachli A, Huber C, Kraemer MUG, Khan K. Pneumonia of unknown aetiology in Wuhan, China: potential for international spread via commercial air travel. J Travel Med. 2020 Mar 13;27(2). pii: taaa008. doi: 10.1093/jtm/taaa008. PubMed PMID: 31943059; PubMed Central PMCID: PMC7107534.
3)

WHO. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). Jan 30, 2020. https://www.who.int/newsroom/detail/30-01-2020-statement-on-thesecond-meeting-of-the-international-healthregulations-(2005)-emergency-committeeregarding-the-outbreak-of-novel-coronavirus- (2019-ncov) (accessed Feb 1, 2020).
4)

World Health Organization. WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19—11 March 2020. World Health Organization. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarksat-the-media-briefing– on-covid-19–11-march-2020. Accessed March 30, 2020
5)

Center for Systems Science and Engineering, Johns Hopkins Coronavirus Resource Center. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University, March 2020. https://coronavirus.jhu.edu/map.html. Accessed March 30, 2020
6)

Xie M, Chen Q. Insight into 2019 novel coronavirus – an updated intrim review and lessons from SARS-CoV and MERS-CoV. Int J Infect Dis. 2020 Apr 1. pii: S1201-9712(20)30204-6. doi: 10.1016/j.ijid.2020.03.071. [Epub ahead of print] Review. PubMed PMID: 32247050.
7)

Wuhan seafood market pneumonia virus isolate Wuhan-Hu-1, complete genome. Nucleotide, National Center for Biotechnology Information (NCBI), National Library of Medicine (US), National Center for Biotechnology Information, Bethesda, MD, https://www. ncbi.nlm.nih.gov/nuccore/1798174254 (accessed on 2020-02-28).
8)

Baker T, Schell CO, Petersen DB, Sawe H, Khalid K, Mndolo S, Rylance J, McAuley DF, Roy N, Marshall J, Wallis L, Molyneux E. Essential care of critical illness must not be forgotten in the COVID-19 pandemic. Lancet. 2020 Apr 1. pii: S0140-6736(20)30793-5. doi: 10.1016/S0140-6736(20)30793-5. [Epub ahead of print] PubMed PMID: 32246914.
9)

Zhang YH, Lin DJ, Xiao MF, Wang JC, Wei Y, Lei ZX, Zeng ZQ, Li L, Li HA, Xiang W. [2019 novel coronavirus infection in a three-month-old baby]. Zhonghua Er Ke Za Zhi. 2020 Mar 2;58(3):182-184. doi: 10.3760/cma.j.issn.0578-1310.2020.03.004. Chinese. PubMed PMID: 32135587.
10)

Zhang T, Cui X, Zhao X, Wang J, Zheng J, Zheng G, Guo W, Cai C, He S, Xu Y. Detectable SARS-CoV-2 Viral RNA in Feces of Three Children during Recovery Period of COVID-19 Pneumonia. J Med Virol. 2020 Mar 29. doi: 10.1002/jmv.25795. [Epub ahead of print] PubMed PMID: 32222992.
11)

Lv DF, Ying QM, Weng YS, Shen CB, Chu JG, Kong JP, Sun DH, Gao X, Weng XB, Chen XQ. Dynamic change process of target genes by RT-PCR testing of SARS-Cov-2 during the course of a Coronavirus Disease 2019 patient. Clin Chim Acta. 2020 Mar 27. pii: S0009-8981(20)30134-0. doi: 10.1016/j.cca.2020.03.032. [Epub ahead of print] PubMed PMID: 32229107.

COVID-19 recommendations for neurosurgeons

COVID-19 recommendations for neurosurgeons

On April 4, 2020, at 13.30 CET, a webinar was broadcasted, organized by Global Neuro and supported by WFNS. Expert neurosurgeons from 6 different countries (China, Italy, South Korea, USA, Colombia and United Kingdom) reported on the impact of the COVID-19 pandemic on their health care systems and neurosurgical activity.

RESULTS: The first part focused on the epidemiology until that date. The USA were the most affected State with 450.000 cases, followed by Italy (140.000 cases and 19.000 casualties), China (83.305 cases and 3.345 had died), South Korea (10.156 cases with 177 casualties), the UK (38.168 cases and 3.605 deaths) and Colombia (1.267 cases and 25 deaths). The second part concerned Institution and staff reorganization. In every country all surgical plans have been modified. In Wuhan the staff was enrolled in COVID-units. In New York, the Mount Sinai Health System was in lockdown mode. In South Korea, sterilizing chambers have been placed. In Italy some Departments were reorganized in a Hub and Spoke fashion. In the Latin American region, they adopted special measures for every case. In the UK a conference center has been used to accommodate intensive care unit (ICU) beds. The third part was about neurosurgical practice during the COVID-19 pandemic. In Wuhan the main hospital was used for urgent non-COVID patients. In New York the neurosurgeon staff work in ICU as advanced practitioner (APP). In South Korea every patient is screened. In Italy the on-duty Hub neurosurgeons have been doubled. In the Latin American region recommendations have been developed by some neurosurgical societies. In the UK local non-specialists and traumatologists neurosurgical experts are collaborating in terms of best practice. The final part touched upon how to perform safe surgery and re-start after the pandemic. In China elective surgical procedures are performed very carefully. In New York, surgery planning will be based on patient’s viral load. In South Korea and in Italy disinfection plans and negative-pressure O.R. were created. In the Latin American region, the aim is to have a rapid testing system. In the UK they have developed flowcharts to guide trauma patient management.

In general, the pandemic scenario was presented as a thought-provoking challenge in all countries which requires tireless efforts for both maintaining emergency and elective neurosurgical procedures 1).

Recommendations

• Operate on as few patients as possible:

◦ Only perform surgeries that cannot be delayed

◦ When an alternative to surgery exists and is equally valid, favor the alternative

◦ If the healthcare system becomes overwhelmed, only offer surgery to patients who have a reasonable prognosis

• Involve as few people as possible in the surgical procedures:

◦ Keep the number of individuals in the OR to the minimum required for safe completion of the surgery

◦ Do not involve observers, students, and even residents who do not have an indispensable role

◦ Minimize personnel turnover by extending shifts and minimizing breaks

◦ Segregate surgeons in specific hospitals to minimize nosocomial transmission from one hospital to another

◦ If possible, assign all COVID-19 patients to a single team that will minimize contacts with other surgeons

◦ Once immune status testing becomes available and reliable, consider assigning contamination-prone tasks and COVID-19 patients to staff with proven immunity.

• Depending on local epidemiology and resources, consider testing all surgical patients for SARS-CoV-2 or treating all patients (even asymptomatic) as potentially infected 2).

Tan et al. focused on the surgical practice in the Neurosurgery Department, Tongji Hospital, Wuhan, and drafted several recommendations based on the latest relevant guidelines and experience.

As the largest neurosurgical center in Wuhan, Neurosurgery Department of Tongji Hospital performed surgical treatments for patients in the epidemic situation. They carried out some management proposals of the patients on the basis of conventional treatment guidelines and clinical experiences. These recommendations have helped them until now to achieve ‘zero infection’ of doctors and nurses in this department. 3).

Preoperative evaluation and management

All patients have first applied to the special fever clinics in the out-patient department. After temperature test, a careful history query (especially the fever and cough manifestations in the last 2 weeks) and physical examination were performed by doctors from both outpatient and neurosurgery departments under strict third level protection (surgical masks, protective goggles and suit). Surgical indications should be rigorously evaluated and surgical treatment should be preserved for patients with an emergency condition, such as ruptured aneurysm and intracranial hemorrhage. Operations for patients with relatively stable conditions should be postponed, for example, patients with benign brain tumors. These patients were documented and followed up through phone calls. A pulmonary computed tomography (CT) scan and nucleic acid sequencing of throat swab were recommended for preliminary diagnosis of COVID-19 infection before hospitalization. Patients with positive results were identified to be confirmed cases and patients with preliminary negative results were considered to be suspected cases. However, these examinations should be canceled and direct emergency surgery should be performed for patients under life-threating conditions. Patients without immediate life-threating were transferred to the neurosurgery ward through a special lane to avoid cross-infection. The neurosurgery ward was divided into several areas: patient rooms were regarded as an infected area, while the nurse station and doctor office were considered to be a clean area. Patient rooms were further divided into two partitions for suspected cases and confirmed cases. Individual accommodation was recommended for all patients and rigorous quarantine should be applied to the confirmed cases. Daily sterilization was performed for every single room. Doctors and nurses must take strict third level protection before entering patient rooms. Regular preoperative neuroimaging and laboratory examinations were performed after hospitalization. We must emphasize that consultation from anesthesiologists and perioperative nurses was necessary to decide the date of operation and the intraoperative cooperation strategies.

Intraoperative management

Covid-19 intraoperative management recommendations for neurosurgeons

Postoperative management

All postoperative patients should be assumed to be suspected cases and quarantined for at least 2 weeks. Pulmonary CT scan and nucleic acid sequencing of throat swab should be repeated at least 3 times (in 2 weeks) after operation. The conditions of most postoperative patients of neurosurgery were critical. The monitoring and ventilator were necessary equipment for postoperative supportive care. The air ducts of ventilator should be daily replaced. Nutrition support was important for maintaining immunological function and reducing the possibility of virus and bacterial infection. If the pulmonary CT scan and nucleic acid sequencing of throat swab were negative for COVID-19 after 2 weeks, the quarantine could be terminated and patients were transferred to patient rooms of suspected cases. The recovery patients without COVID-19 would be transferred to neurosurgery recovery ward located on another floor.

Precautions for endoscopic transnasal skull base surgery

The impact of COVID-19 on pituitary surgery 4).

Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic.

Operating room preparation for COVID-19

see Operating room preparation for COVID-19.

Emergency consideration

In the Lombardy region in Italy, the following clinical situations have been defined as neurosurgical emergencies:

Cerebral hemorrhages (subarachnoid and intraparenchymal)

Acute hydrocephalus

Tumors at risk of intracranial hypertension

Spinal cord compressions with neurological deficit or at risk of

Traumatic cranial and spinal trauma emergencies 5).

Recommendations for Deep Brain Stimulation Device Management

Most medical centers are postponing elective procedures and deferring non-urgent clinic visits to conserve hospital resources and prevent spread of COVID-19. The pandemic crisis presents some unique challenges for patients currently being treated with deep brain stimulation (DBS). Movement disorder (Parkinson’s disease, essential tremor, dystonia), neuropsychiatric disorder (obsessive compulsive disorder, Tourette syndrome, depression), and epilepsy patients can develop varying degrees of symptom worsening from interruption of therapy due to neurostimulator battery reaching end of life, device malfunction or infection. Urgent intervention to maintain or restore stimulation may be required for patients with Parkinson’s disease who can develop a rare but potentially life-threatening complication known as DBS-withdrawal syndrome. Similarly, patients with generalized dystonia can develop status dystonicus, patients with obsessive compulsive disorder can become suicidal, and epilepsy patients can experience potentially life-threatening worsening of seizures as a result of therapy cessation. DBS system infection can require urgent, and rarely emergent surgery. Elective interventions including new implantations and initial programming should be postponed. For patients with existing DBS systems, the battery status and electrical integrity interrogation can now be performed using patient programmers, and employed through telemedicine visits or by phone consultations. The decision for replacement of the implantable pulse generator to prevent interruption of DBS therapy should be made on a case-by-case basis taking into consideration battery status and a patient’s tolerance to potential therapy disruption. Scheduling of the procedures, however, depends heavily on the hospital system regulations and on triage procedures with respect to safety and resource utilization during the health crisis 6).

References

1)

Fontanella MM, Saraceno G, Lei T, Bederson JB, You N, Rubiano AM, Hutchinson P, Wiemeijer-Timmer F, Servadei F. Neurosurgical activity during COVID-19 pandemic: an expert opinion from China, South Korea, Italy, United Stated of America, Colombia and United Kingdom. J Neurosurg Sci. 2020 Apr 29. doi: 10.23736/S0390-5616.20.04994-2. [Epub ahead of print] PubMed PMID: 32347685.
2)

Iorio-Morin C, Hodaie M, Sarica C, Dea N, Westwick HJ, Christie SD, McDonald PJ, Labidi M, Farmer JP, Brisebois S, D’Aragon F, Carignan A, Fortin D. Letter: The Risk of COVID-19 Infection During Neurosurgical Procedures: A Review of Severe Acute Respiratory Distress Syndrome Coronavirus 2 (SARS-CoV-2) Modes of Transmission and Proposed Neurosurgery-Specific Measures for Mitigation. Neurosurgery. 2020 Apr 26. pii: nyaa157. doi: 10.1093/neuros/nyaa157. [Epub ahead of print] PubMed PMID: 32335684.
3)

Tan YT, Wang JW, Zhao K, Han L, Zhang HQ, Niu HQ, Shu K, Lei T. Preliminary Recommendations for Surgical Practice of Neurosurgery Department in the Central Epidemic Area of 2019 Coronavirus Infection. Curr Med Sci. 2020 Mar 26. doi: 10.1007/s11596-020-2173-5. [Epub ahead of print] PubMed PMID: 32219625.
4)

Mitchell RA, King JA, Goldschlager T, Wang YY. The impact of COVID-19 on pituitary surgery. ANZ J Surg. 2020 Apr 25. doi: 10.1111/ans.15959. [Epub ahead of print] PubMed PMID: 32336017.
5)

Zoia C, Bongetta D, Veiceschi P, Cenzato M, Di Meco F, Locatelli D, Boeris D, Fontanella MM. Neurosurgery during the COVID-19 pandemic: update from Lombardy, northern Italy. Acta Neurochir (Wien). 2020 Mar 28. doi: 10.1007/s00701-020-04305-w. [Epub ahead of print] PubMed PMID: 32222820.
6)

Miocinovic S, Ostrem JL, Okun MS, Bullinger KL, Riva-Posse P, Gross RE, Buetefisch CM. Recommendations for Deep Brain Stimulation Device Management During a Pandemic. J Parkinsons Dis. 2020 Apr 24. doi: 10.3233/JPD-202072. [Epub ahead of print] PubMed PMID: 32333552.

COVID-19 in chronic subdural hematoma

COVID-19 in chronic subdural hematoma

see also chronic subdural hematoma outcome.

Panciani et al. compared a cohort of COVID-19 chronic subdural hematoma (CSDH) patients with historical series. Between May 2018 and September 2019, they operated 142 patients for CSDH and observed 5 deaths.

The mortality rate was 3.7% according to the literature 1).

They observed 4 death in 5 COVID-19 patients suffering from CSDH. Therefore, they observed a mortality rate of 80% about 21,6 times greater than the control data 2).

References

1)

Camel M, Grubb RL. Treatment of chronic subdural hematoma by twistdrill craniostomy with continuous catheter drainage. J Neurosurg. 1986;65(2): 183-187
2)

Panciani PP, Saraceno G, Zanin L, Renisi G, Signorini L, Fontanella MM. Letter: COVID-19 Infection Affects Surgical Outcome of Chronic Subdural Hematoma. Neurosurgery. 2020 Apr 18. pii: nyaa140. doi: 10.1093/neuros/nyaa140. [Epub ahead of print] PubMed PMID: 32304213.