Surgical treatment of patients with neurosurgical pathology combined with COVID-19

The objective is to present first-hand experience of microsurgical operations in patients with neuro-oncological diseases, vascular pathology and COVID-19 in the absence of unified standards of work during the pandemic, as well as summarize literature data on this problem. Clinical cases. Five cases of surgical interventions in patients with moderate COVID-19 pneumonia are presented: 1) microsurgical clipping of a saccular aneurysm of the posterior communicating artery which caused massive basal subarachnoid hemorrhage with bleeding into the IV ventricle;2) microsurgical resection of glioblastoma of the right temporal lobe;3) resection of an intracerebral hematoma in the right temporal, occipital and parietal lobes with total volume of 100 cm3 which caused transverse brain dislocation up to 10 mm to the left;4) microcoil embolization of a ruptured aneurysm of the posterior communicating artery;5) microcoil embolization of a ruptured aneurysm of the right middle cerebral artery. All surgeries were performed in personal protective gear and FFP3 masks. In 3 patients, positive pneumonia dynamics were observed;in 2 patients (with glioblastoma and subarachnoid hemorrhage from an aneurysm of the right middle cerebral artery), dynamics were negative. Among 5 patients, 4 were discharged in stable condition, 1 case ended in death (despite the absence of coagulopathy, massive brain ischemia with hemorrhagic transformation developed, probably due to endothelial cell dysfunction, high vascular permeability of cerebral arteries in conjunction with coronavirus effect on angiotensin transforming enzyme receptors). Literature analysis. Summarizing experiences of other researchers, the following changes in organization of neurosurgical practice during the pandemic can be recommended: 1) all patients should be considered potentially infected;2) emergency surgeries should be performed under local anesthesia and/or in separate operating rooms;3) in emergency cases of vascular pathology of the brain, endovascular interventions are the preferred approach;4) surgeries should be performed in FFP2/FFP3 masks, protective goggles, two pairs of gloves, protective suits and shoe covers;5) the number of personnel in the operating room should be minimized;6) manipulations that can potentially lead to increased formation of aerosol (craniotomies, coagulations) should be performed with special care, craniotome rotation speed should be decreased to minimize formation of bone particles, opening of paranasal sinuses and mastoid cells should be avoided if possible;7) negative pressure (–5 Pa) should be maintained in the operative room, frequency of interruption of the artificial lung ventilation machine circuit should be minimized, patients' nose and mouth should be covered with wet wipes;8) the personnel should be divided into several teams working in turns;9) personnel older than 65 years should be isolated;10) planned surgeries should be postponed indefinitely and patients should be consulted by phone, hospitalized only if their condition worsens;11) during admission, patients should be placed in observation rooms, where thermometry, computed tomography of the lungs and pharyngeal swab for SARS-CoV-2 should be performed;12) regardless of the SARS-CoV-2 analysis result, patients after surgery should be quarantined for 14 days. Conclusion. Our experience shows that patients with concomitant COVID-19 infection can receive neurosurgical help. Compliance with the guidelines leads to low risk of infection for the personnel and sufficient quality of medical care. © 2020 Authors. All rights reserved.

PROPERTIES OF RBD SPECIFIC IGG FROM COVID-19 PATIENTS AND SPUTNIK V VACCINATED INDIVIDUALS

SARS-CoV-2 specific antibody response is a generally accepted measure of postinfection and vaccination-induced immunity assessment. The dynamics of avidity maturation and neutralizing activity of virus-specific immunoglobulins G during the SARS-CoV-2–associated coronavirus infection was studied in cohorts of vaccinated volunteers and COVID-19 patients. 4–6 months after vaccination, neutralization activity was low compared to hospitalized patients (medians 57.4% vs 86.4%). On the opposite, the avidity indices in vaccinated volunteers were significantly higher (median 76.7%) than among hospitalized patients (median 61.4%). During the acute phase of the disease (14–16 days PI), post-vaccination patients have also higher avidity indices than primary patients (medians 43.5% vs 20.4%). Our results suggest that in long-term perspective antibody affinity maturation rate is higher after vaccination than after a natural infection. We demonstrated that Sputnik V vaccination leads to formation of high-avidity IgG, which persists for at least 6 months of observation. These results also indicate the presence of protective efficacy markers for at least 4–6 months after the vaccination or a previous illness and gives grounds for the half-year time period chosen for booster immunization with Sputnik V in Russia. © 2022 Pirogov Russian National Research Medical University. All rights reserved.

Surgical treatment of patients with neurosurgical pathology combined with COVID-19

The objective is to present first-hand experience of microsurgical operations in patients with neuro-oncological diseases, vascular pathology and COVID-19 in the absence of unified standards of work during the pandemic, as well as summarize literature data on this problem.Clinical cases. Five cases of surgical interventions in patients with moderate COVID-19 pneumonia are presented: 1) microsurgical clipping of a saccular aneurysm of the posterior communicating artery which caused massive basal subarachnoid hemorrhage with bleeding into the IV ventricle;2) microsurgical resection of glioblastoma of the right temporal lobe;3) resection of an intracerebral hematoma in the right temporal, occipital and parietal lobes with total volume of 100 cm3 which caused transverse brain dislocation up to 10 mm to the left;4) micro coil embolization of a ruptured aneurysm of the posterior communicating artery;5) microcoil embolization of a ruptured aneurysm of the right middle cerebral artery. All surgeries were performed in personal protective gear and FFP3 masks.In 3 patients, positive pneumonia dynamics were observed;in 2 patients (with glioblastoma and subarachnoid hemorrhage from an aneurysm of the right middle cerebral artery), dynamics were negative. Among 5 patients, 4 were discharged in stable condition, 1 case ended in death (despite the absence of coagulopathy, massive brain ischemia with hemorrhagic transformation developed, probably due to endothelial cell dysfunction, high vascular permeability of cerebral arteries in conjunction with coronavirus effect on angiotensin transforming enzyme receptors).Literature analysis. Summarizing experiences of other researchers, the following changes in organization of neurosurgical practice during the pandemic can be recommended: 1) all patients should be considered potentially infected;2) emergency surgeries should be performed under local anesthesia and/or in separate operating rooms;3) in emergency cases of vascular pathology of the brain, endovascular interventions are the preferred approach;4) surgeries should be performed in FFP2/FFP3 masks, protective goggles, two pairs of gloves, protective suits and shoe covers;5) the number of personnel in the operating room should be minimized;6) manipulations that can potentially lead to increased formation of aerosol (craniotomies, coagulations) should be performed with special care, craniotome rotation speed should be decreased to minimize formation of bone particles, opening of paranasal sinuses and mastoid cells should be avoided if possible;7) negative pressure (-5 Pa) should be maintained in the operative room, frequency of interruption of the artificial lung ventilation machine circuit should be minimized, patients’ nose and mouth should be covered with wet wipes;8) the personnel should be divided into several teams working in turns;9) personnel older than 65 years should be isolated;10) planned surgeries should be postponed indefinitely and patients should be consulted by phone, hospitalized only if their condition worsens;11) during admission, patients should be placed in observation rooms, where thermometry, computed tomography of the lungs and pharyngeal swab for SARS-CoV-2 should be performed;12) regardless of the SARS-CoV-2 analysis result, patients after surgery should be quarantined for 14 days.Conclusion. Our experience shows that patients with concomitant COVID-19 infection can receive neurosurgical help. Compliance with the guidelines leads to low risk of infection for the personnel and sufficient quality of medical care. Цель статьи - представить собственный опыт проведения микрохирургических операций у пациентов с нейроонкологическими заболеваниями или сосудистой патологией в сочетании с COVID-19 в условиях отсутствия единых стандартов работы в период пандемии, а также обобщить данные научной литературы по этой проблеме.Клинические случаи. Описано 5 случаев проведения операций у пациентов с пневмонией средней тяжести, вызванной SARS-CoV-2: 1) микрохирургическое клипирование мешотчатой аневризмы передней соединительной артерии, ставшей причиной массивного базального субарахноидального кровоизлияния с прорывом крови в IV желудочек;2) микрохирургическое удаление глиобластомы правой височной доли;3) удаление гематомы объемом 100 см3, располагавшейся в правых височной, затылочной и теменной долях головного мозга и обусловившей поперечную дислокацию мозга до 10 мм влево;4) эмболизация микроспиралями разорвавшейся аневризмы передней соединительной артерии;5) эмболизация микроспиралями разорвавшейся аневризмы правой средней мозговой артерии. Все операции проведены в средствах индивидуальной защиты и респираторах III класса защиты (FFP3).У 3 пациентов наблюдалась положительная динамика пневмонии, у 2 пациентов (с глиобластомой и субарахноидальным кровоизлиянием из аневризмы правой средней мозговой артерии) - отрицательная динамика. Из 5пациентов 4 выписаны в стабильном состоянии, в 1 случае произошел летальный исход (несмотря на отсутствие коагулопатии, развилась массивная ишемия головного мозга с геморрагической трансформацией, что, вероятно, связано с дисфункцией эндотелиальных клеток, высокой сосудистой проницаемостью артерий головного мозга на фоне влияния SARS-CoV-2 на рецепторы ангиотензинпревращающего фермента).Анализ научной литературы. Обобщая опыт исследователей, можно рекомендовать следующие изменения организации работы нейрохирургических отделений в условиях пандемии: 1) рассматривать всех пациентов как потенциально инфицированных;2) проводить экстренные операции под местной анестезией и/или в отдельных операционных;3) в экстренных случаях при сосудистой патологии мозга отдавать предпочтение эндоваскулярным вмешательствам;4) оперировать в респираторах класса FFP2/FFP3, защитных очках, двух парах перчаток, изоляционных костюмах и бахилах;5) минимизировать количество персонала в операционной;6) соблюдать особую осторожность при выполнении манипуляций, приводящих к повышенному образованию аэрозоля (краниотомия, коагулирование), снизить скорость вращения краниотома с целью сокращения выброса костной пыли, по возможности отказаться от вскрытия придаточных пазух носа и ячеек сосцевидного отростка;7) поддерживать отрицательное давление (-5 Па) в операционной, минимизировать частоту размыкания дыхательного контура аппарата искусственной вентиляции легких, укрывать нос и рот пациента влажными салфетками;8) разделить персонал на несколько бригад, работающих посменно;9) изолировать персонал старше 65 лет;10) отложить плановые операции на неопределенный срок и консультировать пациентов по телефону, госпитализировать лишь при ухудшении состояния;11) при поступлении помещать пациентов в обсервационные палаты, где проводить термометрию, компьютерную томографию легких и исследование мазка из зева на наличие SARS-CoV-2;12) вне зависимости от результата анализа на SARS-CoV-2 после операции помещать всех пациентов на карантин сроком на 14 сут.Заключение. Наш опыт свидетельствует о возможности оказания нейрохирургической помощи пациентам с сопутствующейинфекцией COVID-19. При соблюдении рекомендаций риск заражения медицинского персонала остается низким, а качество медицинской помощи - достаточно высоким.