Neurosurgical activity during COVID-19 pandemic: an experts' opinion from China, South Korea, Italy, the USA, Colombia, and the UK.

BACKGROUND: More than a million and a half people are infected worldwide with more than 90,000 casualties. The ongoing COVID-19 pandemic is radically altering both socio-economic and health care scenarios. METHODS: On April 4th, 2020, at 13:30 CET, a webinar was broadcasted, organized by Global Neuro and supported by WFNS. Expert neurosurgeons from six different countries (China, Italy, South Korea, the USA, Colombia, and the UK) 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 3345 have died), South Korea (10,156 cases with 177 casualties), the UK (38,168 cases and 3605 deaths) and Colombia (1267 cases and 25 deaths). The second part concerned Institution and staff reorganization. In every country all surgical plans have been modified. The third part was about neurosurgical practice during the COVID-19 pandemic. The fourth and last part touched upon how to perform safe surgery and re-start after the pandemic. CONCLUSIONS: 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.

By the Numbers Analysis of Effect of COVID-19 on a Neurosurgical Residency at the Epicenter.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 pandemic has created challenges to neurosurgical patient care. Despite editorials evaluating neurosurgery responses to 2019 novel coronavirus disease (COVID-19), data reporting effects of COVID-19 on neurosurgical case volume, census, and resident illness are lacking. The aim of this study was to present a real-world analysis of neurosurgical volumes, resident deployment, and unique challenges encountered during the severe acute respiratory syndrome coronavirus 2 outbreak peak in New York City. METHODS: Daily census and case volume data were prospectively collected throughout the severe acute respiratory syndrome coronavirus 2 outbreak in spring 2020. Neurosurgical census was compared against COVID-19 system-wide data. Neurosurgical cases during the crisis were analyzed and compared with 7-week periods from 2019 and early 2020. Resident deployment and illness were reviewed. RESULTS: From March 16, 2020, to May 5, 2020, residents participated in 72 operations and 69 endovascular procedures compared with 448 operations and 253 endovascular procedures from January 2020 to February 2020 and 530 operations and 340 endovascular procedures from March 2019 to May 2019. There was a 59% reduction in neurosurgical census during the outbreak (median 24 patients, 2.75 average total cases daily). COVID-19 neurosurgical admissions peaked in concert with the system-wide pandemic. Three residents demonstrated COVID-19 symptoms (no hospitalizations occurred) for a total 24 workdays lost (median 7 workdays). CONCLUSIONS: These data provide real-world guidance on neurosurgical infrastructure needs during a COVID-19 outbreak. While redeployment to support the COVID-19 response was required, a significant need remained to continue to provide critical neurosurgical service.

"Staying Home"-Early Changes in Patterns of Neurotrauma in New York City During the COVID-19 Pandemic.

OBJECTIVE: New York City is the epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic in the United States. Traumatic brain injury accounts for a significant proportion of admissions to our trauma center. We sought to characterize the effect of the pandemic on neurotraumas, given the cancellation of nonessential activities during the crisis. METHODS: Retrospective and prospective reviews were performed from November 2019 to April 2020. General demographics, clinical status, mechanism of trauma, diagnosis, and treatment instituted were recorded. We dichotomized the data between pre-COVID-19 (before 1 March) and COVID-19 periods and compared the differences between the 2 groups. We present the timeline of events since the beginning of the crisis in relation to the number of neurotraumas. RESULTS: A total of 150 patients composed our cohort with a mean age of 66.2 years (standard deviation ±18.9), and 66% were male. More males sustained neurotrauma in the COVID-19 period compared with the pre-COVID-19 (60.4% vs. 77.6%, P = 0.03). The most common mechanism of trauma was mechanical fall, but it was observed less frequently compared with the pre-COVID-19 period (61.4% vs. 40.8; P = 0.03). Subdural hematoma, traumatic subarachnoid hemorrhage, and intracerebral contusion accounted for the most common pathologies in both periods. Nonoperative management was selected for most patients (79.2 vs. 87.8%, P = 0.201) in both periods. CONCLUSIONS: A decrease in the frequency of neurotraumas was observed during the COVID-19 crisis concomitant with the increase in COVID-19 patients in the city. This trend began after the cancellation of nonessential activities and implementation of social distancing recommendations.

COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.

Endoscopic Skull Base Surgery Protocol From the Frontlines: Transnasal Surgery During the COVID-19 Pandemic.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic disrupted the standard management paradigms for care of patients with sinus and skull base presentations due to concern for patient and health care provider safety, given the high aerosol-generating potential of endonasal procedures. DATA SOURCES: We reviewed the relevant literature complied from available sources, including PubMed, Google Scholar, and otolaryngology journals providing electronic manuscripts ahead of indexing or publication. REVIEW METHODS: Incorporating available evidence and the projected infection control and resource limitations at our institution, we collectively authored a dynamic set of protocols guiding (1) case stratification, (2) preoperative assessment, (3) operative setup, and (4) postoperative care of patients with sinus or skull base presentations. Due to the rapidly evolving nature of COVID-19 publications, lack of rigorous data, and urgent necessity of standardized protocols, strict inclusion and exclusion criteria were not employed. CONCLUSIONS: As scarce hospital resources are diverted to COVID-19 care and staff are redeployed to forward-facing roles, endonasal procedures have largely ceased, leaving patients with ongoing sinonasal and skull base complaints untreated. Skull base teams now weigh the urgency of surgery in this population with the regional availability of resources. IMPLICATIONS FOR PRACTICE: The COVID-19 pandemic will have an enduring and unpredictable impact on hospital operations and surgical skull base practices and will require a dynamic set of management protocols responsive to new evidence and changing resources. In the current resource-limited environment, clinicians may utilize these protocols to assist with stratifying patients by acuity, performing preoperative assessment, and guiding peri- and postoperative care.

Neurosurgical management of brain and spine tumors in the COVID-19 era: an institutional experience from the epicenter of the pandemic.

The challenges of neurosurgical patient management and surgical decision-making during the 2019-2020 COVID-19 worldwide pandemic are immense and never-before-seen in our generation of neurosurgeons. In this case-based formatted report, we present the Mount Sinai Hospital (New York, NY) Department of Neurosurgery institutional experience in the epicenter of the pandemic and the guiding principles for our current management of intracranial, skull base, and spine tumors. The detailed explanations of our surgical reasoning for each tumor case is tailored to assist neurosurgeons across the United States as they face these complex operative decisions put forth by the realities of the pandemic.