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1.
World Neurosurg ; 163: e83-e88, 2022 Jul.
Article in English | MEDLINE | ID: covidwho-1900271

ABSTRACT

BACKGROUND: Telemedicine use skyrocketed in March 2020 on implementation of shelter-in-place measures owing to the coronavirus disease 2019 (COVID-19) pandemic. Within the past year, shelter-in-place measures were lifted and the COVID-19 vaccine was released, resulting in many neurosurgeons returning to in-person outpatient clinics. This study aimed to determine the extent of usage of telemedicine in neurosurgery 1 year into the COVID-19 pandemic. METHODS: A retrospective cohort study of patients who received neurosurgical care at a single institution from February 1 to April 18 of the years 2020 and 2021 was performed. The inclusion criteria were met by 11,592 patients. During the 2 study periods, 1465 patients underwent surgery, 7083 were seen in clinic via an in-person meeting, and 3044 were assessed via telemedicine. RESULTS: At 1 year after the COVID-19 outbreak, telemedicine usage was at 81.3% of the initial volume on implementation of shelter-in-place measures. In-person outpatient visits increased 40.2% from the early pandemic volume. Among the 4 neurosurgery divisions, telemedicine usage remained high in tumor and functional neurosurgery, significantly increased in vascular neurosurgery, and decreased in spine neurosurgery. CONCLUSIONS: Telemedicine use in neurosurgery clinics continues 1 year after the COVID-19 outbreak. Even after the lifting of shelter-in-place measures, many neurosurgeons still use telemedicine, while the operative volume remains stable. Owing to the limited physical examination that can be performed via current telemedicine platforms, telemedicine use in spine neurosurgery is lower than peak use during the early pandemic, while use has remained high among tumor, vascular, and functional neurosurgery.


Subject(s)
COVID-19 , Neurosurgery , Telemedicine , COVID-19 Vaccines , Disease Outbreaks , Humans , Neurosurgery/methods , Pandemics , Retrospective Studies , Telemedicine/methods
2.
J Clin Neurosci ; 99: 204-211, 2022 May.
Article in English | MEDLINE | ID: covidwho-1804600

ABSTRACT

OBJECTIVE: COVID-19 has caused a massive surge in telemedicine utilization as patients and physicians tried to minimize in-person contact to avoid the spread and impact of the pandemic. This study aims to expand on the knowledge of telemedicine during and beyond the COVID-19 era as it pertains to its use, efficacy, and patient and provider satisfaction through surveys. METHODS: This is a retrospective study involving 93 patients and 33 Neurosurgery physicians who anonymously participated in the survey about their experience with telemedicine visits. RESULTS: Most respondents indicated extreme satisfaction with their telemedicine encounters during the pandemic (77%). As for how comfortable physicians are in providing a diagnosis via telemedicine compared to clinic visits, 7 (21.9%) physicians felt extremely comfortable, 13 (40.6%) felt somewhat comfortable, 2 (6.4%) were neutral, 9 (28.1%) felt somewhat uncomfortable and 1 (3.1%) felt extremely uncomfortable. Physical examination was the main tool that telemedicine didn't provide (n = 21, 100%). CONCLUSION: Telemedicine has become a major force in the health care system under the circumstances the world is witnessing. Physicians and patients have displayed high levels of satisfaction with telemedicine which could be pivotal to improving healthcare access to underprivileged areas beyond the pandemic.


Subject(s)
COVID-19 , Neurosurgery , Physicians , Telemedicine , Humans , Patient Satisfaction , Retrospective Studies , SARS-CoV-2
4.
Oper Neurosurg (Hagerstown) ; 20(2): 174-182, 2021 01 13.
Article in English | MEDLINE | ID: covidwho-1455340

ABSTRACT

BACKGROUND: Carotid-cavernous fistulas (CCFs) are acquired pathological shunting lesions between the carotid artery and the cavernous sinus leading to elevated intraocular pressure (IOP). CCFs are commonly treated via endovascular embolization, which theoretically restores physiological pressure differentials. OBJECTIVE: To present our institutional data with CCF treated with embolization and discuss endovascular routes, recurrence rates, and dynamic IOP changes. METHODS: Retrospective analysis of 42 CCF patients who underwent Onyx (Covidien, Irvine, California) embolization and pre- and postoperative IOP measurement at a single institution. RESULTS: CCFs were 19.0% direct (type A) and 81.0% indirect (types B, C, or D). Onyx-18 liquid embolisate was used during all embolizations. Overall rate of total occlusion was 83.3% and was statistically similar between direct and indirect fistulas. Preoperative IOP was elevated in 37.5%, 100.0%, 75.0%, and 50% in type A, B, C, and D fistulas, respectively. Average ΔIOP was -7.3 ± 8.5 mmHg (range: -33 to +8). Follow-up time was 4.64 ± 7.62 mo. Full angiographic occlusion was a predictor of symptom resolution at 1 mo (P = .026) and 6 mo (P = .021). Partial occlusion was associated with persistent symptoms postoperatively at 1 mo (P = .038) and 6 mo follow-up (P = .012). Beyond 6 mo, negative ΔIOP was associated with continued symptom improvement. Recurrence occurred in 9.5% of patients, all of which were indirect CCFs. CONCLUSION: Onyx embolization of CCF is an effective treatment for CCF and often results in the reversal of IOP elevation. Full occlusion predicts favorable clinical outcomes up to 6 mo. Postoperative IOP reduction may indicate favorable long-term clinical outcomes.


Subject(s)
Carotid-Cavernous Sinus Fistula , Cavernous Sinus , Embolization, Therapeutic , Carotid-Cavernous Sinus Fistula/diagnostic imaging , Carotid-Cavernous Sinus Fistula/therapy , Humans , Intraocular Pressure , Retrospective Studies
5.
World Neurosurg ; 154: e473-e480, 2021 10.
Article in English | MEDLINE | ID: covidwho-1376112

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in nonconventional dire consequences. We sought to describe the characteristics of patients with intracranial hemorrhage who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and intracranial hemorrhage and propose possible pathophysiological mechanisms connecting the two. METHODS: We retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from 4 tertiary-care cerebrovascular centers. RESULTS: We identified a total of 19 patients consisting of 11 males (58%) and 8 females (42%). Mean age was 52.2, with 95% younger than 75 years of age. With respect to COVID-19 illness, 50% had mild-to-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the 19 cases, 12 patients had intraparenchymal hemorrhage (63%), 6 had subarachnoid hemorrhage (32%), and 1 patient had a subdural hematoma (5%). A total of 43% had an intracerebral hemorrhage score of 0-2 and 57% a score of 3-6. Modified Rankin Scale cores at discharge were 0-2 in 23% and 3-6 in 77%. The mortality rate was 59%. CONCLUSIONS: Our series sheds light on a distinct pattern of intracerebral hemorrhage in COVID-19-positive cases compared with typical non-COVID-19 cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage.


Subject(s)
COVID-19/complications , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/etiology , Adult , Age Factors , Aged , Aged, 80 and over , COVID-19/mortality , COVID-19/physiopathology , Female , Hematoma, Subdural/epidemiology , Hematoma, Subdural/etiology , Humans , Intracranial Hemorrhages/mortality , Intubation, Intratracheal , Male , Middle Aged , Retrospective Studies , Subarachnoid Hemorrhage/epidemiology , Subarachnoid Hemorrhage/etiology , Treatment Outcome , Young Adult
6.
J Neurosurg ; : 1-4, 2020 Sep 04.
Article in English | MEDLINE | ID: covidwho-1304575

ABSTRACT

Herein, the authors present the case of a 54-year-old male diagnosed with coronavirus disease 2019 (COVID-19) during a screening test. The patient was asked to self-isolate at home and report with any exacerbations of symptoms. He presented later with pneumonia complicated by encephalopathy at days 14 and 15 from initial diagnosis, respectively. MRI of the brain showed bithalamic and gangliocapsular FLAIR signal abnormality with mild right-sided thalamic and periventricular diffusion restriction. A CT venogram was obtained given the distribution of edema and demonstrated deep venous thrombosis involving the bilateral internal cerebral veins and the vein of Galen. CSF workup was negative for encephalitis, as the COVID-19 polymerase chain reaction (PCR) test and bacterial cultures were negative. A complete hypercoagulable workup was negative, and the venous thrombosis was attributed to a hypercoagulable state induced by COVID-19. The mental decline was attributed to bithalamic and gangliocapsular venous infarction secondary to deep venous thrombosis. Unfortunately, the patient's condition continued to decline, and care was withdrawn.

7.
Clin Neurol Neurosurg ; 206: 106677, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1230410

ABSTRACT

Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.


Subject(s)
COVID-19/complications , Carotid Artery Thrombosis/surgery , Endovascular Procedures , Infarction, Middle Cerebral Artery/surgery , Stroke/etiology , Thrombectomy , Aged , Carotid Artery Thrombosis/diagnosis , Carotid Artery Thrombosis/etiology , Female , Humans , Infarction, Middle Cerebral Artery/diagnosis , Infarction, Middle Cerebral Artery/etiology
10.
World Neurosurg ; 146: 20-25, 2021 02.
Article in English | MEDLINE | ID: covidwho-894259

ABSTRACT

The COVID-19 outbreak has led to fundamental disruptions of health care and its delivery with sweeping implications for patients and physicians of all specialties, including neurosurgery. In an effort to conserve hospital resources, neurosurgical procedures were classified into tiers to determine which procedures have to be performed in a timely fashion and which ones can be temporarily suspended to aid in the hospital's reallocation of resources when equipment is scarce. These guidelines were created quickly based on little existing evidence, and thus were initially variable and required refinement. As the early wave can now be assessed in retrospect, the authors describe the lessons learned and the protocols established based on published global evidence to continue to practice neurosurgery sensibly and minimize disruptions. These operational protocols can be applied in a surge of COVID-19 or another airborne pandemic.


Subject(s)
COVID-19/epidemiology , COVID-19/prevention & control , Neurosurgical Procedures/standards , Practice Guidelines as Topic/standards , Humans , Neurosurgery/standards , Neurosurgery/trends , Neurosurgical Procedures/trends , Pandemics/prevention & control , Personal Protective Equipment/standards , Personal Protective Equipment/trends
11.
Telemed J E Health ; 27(2): 227-230, 2021 02.
Article in English | MEDLINE | ID: covidwho-671545

ABSTRACT

Background and Purpose: As coronavirus disease 2019 (COVID-19) continues to be a global pandemic, there is a growing body of evidence suggesting that incidence of diseases that require emergent care, particularly myocardial infarction and ischemic stroke, has declined rapidly. The objective of this study is to quantify our experience of telestroke (TS) consults at a large tertiary comprehensive stroke center during the COVID-19 pandemic. Methods: We retrospectively reviewed TS consults of patients presenting to our neuroscience network. Those with a confirmed diagnosis of acute ischemic stroke or transient ischemia attack were included. Data were compared from April 1, 2019, to June 30, 2020, which include consults prepandemic and during the crisis. Results: A total of 1,982 TS consults were provided in 1 year. Prepandemic, the mean monthly consults were 148. In April 2020, only 59 patients were seen (49% decline). Mobile stroke unit consults decreased by 72% in the same month. The 30-day moving average of patients seen per day was between five and six prepandemic declined to between two and three in April, and then began to uptrend during May. The mean percentage of patients receiving intravenous tissue plasminogen activator was 16% from April 2019 to March 2020 and increased to 31% in April 2020. The mean percentage of patients receiving endovascular therapy was 10% from April 2019 to March 2020 and increased to 19% in April 2020. Conclusions: At our large tertiary comprehensive stroke center, we observed a significant and rapid decline in TS consults during the COVID-19 pandemic. We cannot be certain of the reasons for the decline, but a fear of contracting coronavirus, social distancing, and isolation likely played a major role. Further research must be done to elucidate the etiology of this decline.


Subject(s)
Brain Ischemia , COVID-19 , Stroke , Telemedicine/trends , Brain Ischemia/epidemiology , Brain Ischemia/therapy , Humans , Pandemics , Retrospective Studies , Stroke/epidemiology , Stroke/therapy , Tissue Plasminogen Activator/therapeutic use
12.
Int J Stroke ; 15(7): 733-742, 2020 10.
Article in English | MEDLINE | ID: covidwho-636180

ABSTRACT

BACKGROUND: The coronavirus disease 2019 is associated with neurological manifestations including stroke. OBJECTIVES: We present a case series of coronavirus disease 2019 patients from two institutions with acute cerebrovascular pathologies. In addition, we present a pooled analysis of published data on large vessel occlusion in the setting of coronavirus disease 2019 and a concise summary of the pathophysiology of acute cerebrovascular disease in the setting of coronavirus disease 2019. METHODS: A retrospective study across two institutions was conducted between 20 March 2020 and 20 May 2020, for patients developing acute cerebrovascular disease and diagnosed with coronavirus disease 2019. We performed a literature review using the PubMed search engine. RESULTS: The total sample size was 22 patients. The mean age was 59.5 years, and 12 patients were female. The cerebrovascular pathologies were 17 cases of acute ischemic stroke, 3 cases of aneurysm rupture, and 2 cases of sinus thrombosis. Of the stroke and sinus thrombosis patients, the mean National Institute of Health Stroke Scale was 13.8 ± 8.0, and 16 (84.2%) patients underwent a mechanical thrombectomy procedure. A favorable thrombolysis in cerebral infarction score was achieved in all patients. Of the 16 patients that underwent a mechanical thrombectomy, the mortality incidence was five (31.3%). Of all patients (22), three (13.6%) patients developed hemorrhagic conversion requiring decompressive surgery. Eleven (50%) patients had a poor functional status (modified Rankin Score 3-6) at discharge, and the total mortality incidence was eight (36.4%). CONCLUSIONS: Despite timely intervention and favorable reperfusion, the mortality rate in coronavirus disease 2019 patients with large vessel occlusion was high in our series and in the pooled analysis. Notable features were younger age group, involvement of both the arterial and venous vasculature, multivessel involvement, and complicated procedures due to the clot consistency and burden.


Subject(s)
Betacoronavirus , Brain Ischemia/epidemiology , Brain Ischemia/virology , Coronavirus Infections/complications , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/virology , Pneumonia, Viral/complications , Acute Disease , Adult , Aged , Brain Ischemia/diagnosis , COVID-19 , Coronavirus Infections/diagnosis , Coronavirus Infections/epidemiology , Female , Humans , Intracranial Hemorrhages/diagnosis , Male , Middle Aged , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/epidemiology , Retrospective Studies , SARS-CoV-2 , Survival Rate
13.
World Neurosurg ; 140: e387-e394, 2020 08.
Article in English | MEDLINE | ID: covidwho-548030

ABSTRACT

BACKGROUND: Before the COVID-19 pandemic, telemedicine utilization was mostly used for postoperative visits only in neurosurgery. Shelter-in-place measures led the rapid expansion of telemedicine to address the needs of the neurosurgical patient population. Our goal is to determine the extent of adoption of telemedicine across tumor, vascular, spine, and function neurosurgery and utilization for new patient visits. METHODS: A single-center retrospective cohort study of patients who received neurosurgical care at a tertiary academic center from February to April 2020 was conducted. Patients evaluated from March to April 2019 were included for comparison. A total of 10,746 patients were included: 1247 patients underwent surgery, 8742 were seen in clinic via an in-person outpatient visit, and 757 were assessed via telemedicine during the study period. RESULTS: A 40-fold increase in the use of telemedicine was noted after the shelter-in-place measures were initiated with a significant increase in the mean number of patients evaluated via telemedicine per week across all divisions of neurosurgery (4.5 ± 0.9 to 180.4 ± 13.9, P < 0.001). The majority of telemedicine appointments were established patient visits (61.2%), but the proportion of new patient visits also significantly increased to an average of 8.2 ± 5.3 per week across all divisions. CONCLUSIONS: Use of telemedicine drastically increased across all 4 divisions within neurosurgery with a significant increase in online-first encounters in order to meet the needs of our patients once the shelter-in-place measures were implemented. We provide a detailed account of the lessons learned and discuss the anticipated role of telemedicine in surgical practices once the shelter-in-place measures are lifted.


Subject(s)
Betacoronavirus/pathogenicity , Coronavirus Infections , Neurosurgical Procedures , Pandemics , Pneumonia, Viral , Telemedicine , Appointments and Schedules , COVID-19 , Humans , Retrospective Studies , SARS-CoV-2
14.
J Neurol Neurosurg Psychiatry ; 91(8): 846-848, 2020 08.
Article in English | MEDLINE | ID: covidwho-154812

ABSTRACT

BACKGROUND: Emergence of the novel corona virus (severe acute respiratory syndrome (SARS)-CoV-2) in December 2019 has led to the COVID-19 pandemic. The extent of COVID-19 involvement in the central nervous system is not well established, and the presence or the absence of SARS-CoV-2 particles in the cerebrospinal fluid (CSF) is a topic of debate. CASE DESCRIPTION: We present two patients with COVID-19 and concurrent neurological symptoms. Our first patient is a 31-year-old man who had flu-like symptoms due to COVID-19 and later developed an acute-onset severe headache and loss of consciousness and was diagnosed with a Hunt and Hess grade 3 subarachnoid haemorrhage from a ruptured aneurysm. Our second patient is a 62-year-old woman who had an ischaemic stroke with massive haemorrhagic conversion requiring a decompressive hemicraniectomy. Both patients' CSF was repeatedly negative on real-time PCR analysis despite concurrent neurological disease. CONCLUSION: Our report shows that patients' CSF may be devoid of viral particles even when they test positive for COVID-19 on a nasal swab. Whether SARS-CoV-2 is present in CSF may depend on the systemic disease severity and the degree of the virus' nervous tissue tropism and should be examined in future studies.


Subject(s)
Betacoronavirus/isolation & purification , Coronavirus Infections/cerebrospinal fluid , Coronavirus Infections/complications , Pneumonia, Viral/cerebrospinal fluid , Pneumonia, Viral/complications , Stroke/complications , Stroke/virology , Adult , COVID-19 , Female , Humans , Male , Middle Aged , Pandemics , SARS-CoV-2 , Stroke/cerebrospinal fluid
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