Necessity of mandatory postoperative intensive care unit management after clipping surgery for unruptured intracranial aneurysms.

OBJECTIVE: Many neurosurgeons routinely perform postoperative intensive care unit (ICU) management after clipping of unruptured intracranial aneurysms (UIAs). However, whether routine postoperative ICU care is necessary remains a clinical question. Therefore, we investigated which factors acted as risk factors that actually required ICU care after microsurgical clipping of unruptured aneurysms. METHODS: We included a total of 532 patients who underwent clipping surgery for UIA between January 2020 and December 2020. The patients were divided into two groups: those who really required ICU care (41 patients, 7.7%) and those who did not (491 patients, 92.3%). A backward stepwise logistic regression model was used to identify factors that were independently associated with ICU care requirement. RESULTS: The mean hospital stay duration and the operation time were significantly longer in the ICU requirement group than in the no ICU requirement group (9.9 ± 10.7 vs. 6.3 ± 3.7 days, p = 0.041), (259.9 ± 128.4 vs. 210.5 ± 46.1 min, p = 0.019). The transfusion rate was significantly higher (p = 0.024) in the ICU requirement group. Multivariable logistic regression analysis identified male sex (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.15-4.76; p = 0.0195), operation time (OR, 1.01; 95% CI, 1.00-1.01; p = 0.0022), and transfusion (OR, 2.35; 95% CI, 1.00-5.51; p = 0.0500) as independent risk factors for requiring ICU care after clipping. CONCLUSIONS: Postoperative ICU management may not be mandatory after clipping surgery for UIAs. Our results suggest that postoperative ICU management may be more required in the male sex, patients with longer operation times, and those who received a transfusion.

NeuroVerse: neurosurgery in the era of Metaverse and other technological breakthroughs.

The tremendous evolution in modern technology has led to a paradigm shift in neurosurgery. The latest advancements such as augmented reality, virtual reality, and mobile applications have been incorporated into neurosurgical practice. NeuroVerse, representing the application of the metaverse in neurosurgery, brings enormous potential to neurology and neurosurgery. Implementation of NeuroVerse could potentially elevate neurosurgical and interventional procedures, enhance medical visits and patient care, and reshape neurosurgical training. However, it is also vital to consider the challenges that may be associated with its implementation, such as privacy issues, cybersecurity breaches, ethical concerns, and widening of existing healthcare inequalities. NeuroVerse adds phenomenal dimensions to the neurosurgical environment for patients, doctors, and trainees, and represents an incomparable advancement in the delivery of medicine. Therefore, more research is needed to encourage widespread use of the metaverse in healthcare, particularly focusing on the areas of morality and credibility. Although the metaverse is expected to expand rapidly during and after the COVID-19 pandemic, it remains to be seen whether it represents an emerging technology that will revolutionize our society and healthcare or simply an immature condition of the future.

A tropical tertiary neurosurgical centre response to COVID-19 pandemic and its effect on neurosurgical practices.

Background: COVID-19 pandemic may decrease the quantum of care for patients with neurosurgical conditions. Objectives: To determine outpatient clinic (OPC) patient load, neurosurgical procedures volume and disease spectrum following the institution of a new care protocol during the ongoing COVID-19 pandemic and compare with previous practice data in our institution. Methods: A monocentric retrospective analysis of all patients requiring neurosurgical care over a 2-year period. Results: There was a 42.4% reduction in OPC attendance and 41.8% reduction in surgical procedures in 2020 compared to 2019. There was >60 percent reduction in the volume of surgery that was done at the onset and peak of the pandemic but this has normalized in November 2020 despite the resurgence of COVID-19, after the institution of a new care protocol. Neurotrauma procedures (29.6%) were the most common neurosurgical operation in 2020 while congenital malformation surgery (37.3%) was the most common procedure performed in 2019. Conclusions: The ongoing COVID-19 pandemic initially led to significant decrease in quantum and spectra of patients who presented at the OPC and for neurosurgical procedures. Instituted local protocol and Teleclinics, if added to clinical care armamentarium, may help to improve on the low patient attendance during pandemics.

360° 3D virtual reality operative video for the training of residents in neurosurgery.

OBJECTIVE: Training of residents is an essential but time-consuming and costly task in the surgical disciplines. During the coronavirus disease 2019 pandemic, surgical education became even more challenging because of the reduced caseload due to the increased shift to corona care. In this context, augmented 360° 3D virtual reality (VR) videos of surgical procedures enable effective off-site training through virtual participation in the surgery. The goal of this study was to establish and evaluate 360° 3D VR operative videos for neurosurgical training. METHODS: Using a 360° camera, the authors recorded three standard neurosurgical procedures: a lumbar discectomy, brain metastasis resection, and clipping of an aneurysm. Combined with the stereoscopic view of the surgical microscope, 7- to 10-minute 360° 3D VR videos augmented with annotations, overlays, and commentary were created. These videos were then presented to the neurosurgical residents at the authors' institution using a head-mounted display. Before viewing the videos, the residents were asked to fill out a questionnaire indicating their VR experience and self-assessment of surgical skills regarding the specific procedure. After watching the videos, the residents completed another questionnaire to evaluate their quality and usefulness. The parameters were scaled with a 5-point Likert scale. RESULTS: Twenty-two residents participated in this study. The mean years of experience of the participants in neurosurgery was 3.2 years, ranging from the 1st through the 7th year of training. Most participants (86.4%) had no or less than 15 minutes of VR experience. The overall quality of the videos was rated good to very good. Immersion, the feeling of being in the operating room, was high, and almost all participants (91%) stated that 360° VR videos provide a useful addition to the neurosurgical training. VR sickness was negligible in the cohort. CONCLUSIONS: In this study, the authors demonstrated the feasibility and high acceptance of augmented 360° 3D VR videos in neurosurgical training. Augmentation of 360° videos with complementary and interactive content has the potential to effectively support trainees in acquiring conceptual knowledge. Further studies are necessary to investigate the effectiveness of their use in improving surgical skills.

Current Attitudes Toward Neuroanatomy: A Comparative Cross-Sectional Survey of Neurosurgeons from the United Kingdom and Worldwide.

OBJECTIVE: How attitudes toward neuroanatomy and preferences of studying resources vary among neurosurgeons is unknown. The impact of the coronavirus disease 2019 (COVID-19) pandemic on anatomy learning habits is also yet to be elucidated. In this study, we explore these objectives, to guide the development of future neurosurgeon-tailored anatomy education and resources. METHODS: This was a 2-stage, cross-sectional study design comprising a local pilot survey followed by a structured 17-item questionnaire, distributed to both neurosurgical trainees and consultants. Grade and nationality differences in sentiment agreement were statistically compared. RESULTS: A total of 365 responses were received from 32 countries (overall response rate, 23.2%). Neuroanatomy is highly regarded among most neurosurgeons and takes a central role in their professional identity. Yet, 69% of neurosurgeons wanted to spend more time learning. Common study prompts included perceived operative complexity, lack of familiarity and teaching. Financial barriers and motivation were obstacles limiting neuroanatomy learning, more so among trainee neurosurgeons, with personal commitment barriers significantly varying with geographic location. Surgical relevance, accessibility, and image quality were important factors when selecting anatomy resources, with cost and up-to-datedness being important for juniors. The COVID-19 pandemic saw a shift toward virtual resources, particularly affecting United Kingdom-based trainees. CONCLUSIONS: Although neuroanatomy is well regarded, barriers exist that impede further neuroanatomy learning. Neurosurgical training programs should tailor anatomy education according to the seniority and background of their residents. Furthermore, resources that are surgically relevant and accessible and are of high image quality are more likely to be better used.

Neurosurgery Subspecialty Practice During a Pandemic: A Multicenter Analysis of Operative Practice in 7 U.S. Neurosurgery Departments During Coronavirus Disease 2019.

OBJECTIVE: Changes to neurosurgical practices during the coronavirus disease 2019 (COVID-19) pandemic have not been thoroughly analyzed. We report the effects of operative restrictions imposed under variable local COVID-19 infection rates and health care policies using a retrospective multicenter cohort study and highlight shifts in operative volumes and subspecialty practice. METHODS: Seven academic neurosurgery departments' neurosurgical case logs were collected; procedures in April 2020 (COVID-19 surge) and April 2019 (historical control) were analyzed overall and by 6 subspecialties. Patient acuity, surgical scheduling policies, and local surge levels were assessed. RESULTS: Operative volume during the COVID-19 surge decreased 58.5% from the previous year (602 vs. 1449, P = 0.001). COVID-19 infection rates within departments' counties correlated with decreased operative volume (r = 0.695, P = 0.04) and increased patient categorical acuity (P = 0.001). Spine procedure volume decreased by 63.9% (220 vs. 609, P = 0.002), for a significantly smaller proportion of overall practice during the COVID-19 surge (36.5%) versus the control period (42.0%) (P = 0.02). Vascular volume decreased by 39.5% (72 vs. 119, P = 0.01) but increased as a percentage of caseload (8.2% in 2019 vs. 12.0% in 2020, P = 0.04). Neuro-oncology procedure volume decreased by 45.5% (174 vs. 318, P = 0.04) but maintained a consistent proportion of all neurosurgeries (28.9% in 2020 vs. 21.9% in 2019, P = 0.09). Functional neurosurgery volume, which declined by 81.4% (41 vs. 220, P = 0.008), represented only 6.8% of cases during the pandemic versus 15.2% in 2019 (P = 0.02). CONCLUSIONS: Operative restrictions during the COVID-19 surge led to distinct shifts in neurosurgical practice, and local infective burden played a significant role in operative volume and patient acuity.

Impact of COVID-19 on the Neurosurgical Resident Training Program: An Early Experience.

BACKGROUND: The present study evaluates the impact of COVID-19 pandemic restrictions during the first lockdown period in spring 2020 on the neurosurgical resident training program, and provides constructive approaches to deal with such situations. METHODS: A concurrent embedded mixed methods design was used. Qualitative data were collected through in-depth interviews from all neurosurgical residents at three university hospitals in Germany. Concurrently, quantitative data of the number of performed surgeries, outpatient visits, and the usage of telemedicine in the period from October 2019 to July 2020 were collected and analyzed accordingly. RESULTS: During the period of COVID-19 pandemic restrictions in spring 2020, there was a marked reduction in the number of surgeries performed by neurosurgical residents, from an average of 41.26 (median 41) surgeries per month to 25.66 (median 24) per month, representing a decrease of 37.80%. The decrease in the operations was concerning mainly spinal and functional surgery. Outpatient visits were reduced significantly, with a concurrent fivefold increase in the usage of telemedicine. General and pediatric neurosurgery outpatient clinics were the most affected. However, although surgical exposure was reduced during the lockdown phase, neurosurgical residents focused on conducting research and improving theoretical knowledge. Nevertheless, the global uncertainties caused by COVID-19 generated notable psychological stress among some residents. CONCLUSIONS: The COVID-19 pandemic restrictions significantly affected the neurosurgical training program. Innovative solutions need to be developed to increase teaching and research capacities of neurosurgical residents as well as to improve surgical skills by installing surgical skill laboratories or similar constructs.

Properties and Characteristics of Three-Dimensional Printed Head Models Used in Simulation of Neurosurgical Procedures: A Scoping Review.

BACKGROUND: Intracranial surgery can be complex and high risk. Safety, ethical and financial factors make training in the area challenging. Head model 3-dimensional (3D) printing is a realistic training alternative to patient and traditional means of cadaver and animal model simulation. OBJECTIVE: To describe important factors relating to the 3D printing of human head models and how such models perform as simulators. METHODS: Searches were performed in PubMed, the Cochrane Library, Scopus, and Web of Science. Articles were screened independently by 3 reviewers using Covidence software. Data items were collected under 5 categories: study information; printers and processes; head model specifics; simulation and evaluations; and costs and production times. RESULTS: Forty articles published over the last 10 years were included in the review. A range of printers, printing methods, and substrates were used to create head models and tissue types. Complexity of the models ranged from sections of single tissue type (e.g., bone) to high-fidelity integration of multiple tissue types. Some models incorporated disease (e.g., tumors and aneurysms) and artificial physiology (e.g., pulsatile circulation). Aneurysm clipping, bone drilling, craniotomy, endonasal surgery, and tumor resection were the most commonly practiced procedures. Evaluations completed by those using the models were generally favorable. CONCLUSIONS: The findings of this review indicate that those who practice surgery and surgical techniques on 3D-printed head models deem them to be valuable assets in cranial surgery training. Understanding how surgical simulation on such models affects surgical performance and patient outcomes, and considering cost-effectiveness, are important future research endeavors.

Characteristics of Global Neurosurgery Sessions: A Retrospective Analysis of Major International Neurosurgical Conferences.

BACKGROUND: The global burden of neurosurgical disease is substantial, particularly in low- and middle-income countries (LMICs). Medical conferences are important in connecting those from LMICs to those from high-income countries for support and serve as an educational and networking tool. In this study, we sought to quantitatively assess the incorporation of global neurosurgery topics in international conferences related to the neurosurgical specialty. METHODS: A database of major international neurosurgical conferences, from the conference of a group of 9 major neurosurgical societies, that had global neurosurgery featured from 2015 to 2020 was created. We then did a retrospective analysis to study the characteristics of these conferences ranging from geographic location to number to different components of the conferences. RESULTS: There was an increase in the number of conferences with global neurosurgery since 2015. This, in addition to the occurrence of 3 wholly global neurosurgery-related conferences in recent years, is promising and suggests growth in the field. However, 52.6% of conferences took place in North American or European countries, the majority of which were high-income countries. Furthermore, a majority of the presence of global neurosurgery was in the form of individual talks (54.5%) as opposed to plenaries or sessions. CONCLUSIONS: The preponderance of conferences in North America and Europe can pose barriers for those from LMICs including travel time, expenses, and visa problems. As global neurosurgery becomes an increasing part of the global health movement, we hope that these barriers are addressed. Conferences may become an even stronger tool to promote equity in neurosurgical education and practice.

Outcomes and Surgical Considerations for Neurosurgical Patients Hospitalized with COVID-19-A Multicenter Case Series.

OBJECTIVE: Neurosurgical patients are at a higher risk of having a severe course of coronavirus disease 2019 (COVID-19). The objective of this study was to determine morbidity, hospital course, and mortality of neurosurgical patients during the coronavirus disease 2019 (COVID-19) pandemic in a multicenter health care system. METHODS: A retrospective observational study was conducted to identify all hospitalized neurosurgical patients positive for COVID-19 from March 11, 2020 to November 2, 2020 at Mayo Clinic and the Mayo Clinic Health System. RESULTS: Eleven hospitalized neurosurgical patients (0.68%) were positive for COVID-19. Four patients (36.6%) were men and 7 (63.3%) were women. The mean age was 65.7 years (range, 35-81 years). All patients had comorbidities. The mean length of stay was 13.4 days (range, 4-30 days). Seven patients had a central nervous system malignancy (4 metastases, 1 meningioma, 1 glioblastoma, and 1 schwannoma). Three patients presented with cerebrovascular complications, comprising 2 spontaneous intraparenchymal hemorrhages and 1 ischemic large-vessel stroke. One patient presented with an unstable traumatic spinal burst fracture. Four patients underwent neurosurgical/neuroendovascular interventions. Discharge disposition was to home in 5 patients, rehabilitation facility in 3, and hospice in 3. Five patients had died at follow-up, 3 within 30 days from COVID-19 complications and 2 from progression of their metastatic cancer. CONCLUSIONS: COVID-19 is rare among the inpatient neurosurgical population. In all cases, patients had multiple comorbidities. All symptomatic patients from the respiratory standpoint had complications during their hospitalization. Deaths of 3 patients who died within 30 days of hospitalization were all related to COVID-19 complications. Neurosurgical procedures were performed only if deemed emergent.

Neurosurgical Outcomes, Protocols, and Resource Management During Lockdown: Early Institutional Experience from One of the World's Largest COVID 19 Hotspots.

BACKGROUND: As the COVID-19 pandemic surpasses 1 year, it is prudent to reflect on the challenges faced and the management strategies employed to tackle this overwhelming health care crisis. We undertook this study to validate our institutional protocols, which were formulated to cater to the change in volume and pattern of neurosurgical cases during the raging pandemic. METHODS: All admitted patients scheduled to undergo major neurosurgical intervention during the lockdown period (15 March 2020 to 15 September 2020) were included in the study. The data involving surgery outcomes, disease pattern, anesthesia techniques, patient demographics, as well as COVID-19 status, were analyzed and compared with similar retrospective data of neurosurgical patients operated during the same time period in the previous year (15 March 2019 to 15 September 2019). RESULTS: Barring significant increase in surgery for stroke (P = 0.008) and hydrocephalus (P <0.001), the overall case load of neurosurgery during the study period in 2020 was 42.75% of that in 2019 (P < 0.001), attributable to a significant reduction in elective spine surgeries (P < 0.001). However, no significant difference was observed in the overall incidence of emergency and essential surgeries undertaken during the 2 time periods (P = 0.482). There was an increased incidence in the use of monitored anesthesia care techniques during emergency and essential neurosurgical procedures by the anesthesia team in 2020 (P < 0.001). COVID-19 patients had overall poor outcomes (P = 0.003), with significant increase in mortality among those subjected to general anesthesia vis-a-vis monitored anesthesia care (P = 0.014). CONCLUSIONS: Despite a significant decrease in neurosurgical workload during the COVID-19 lockdown period in 2020, the volume of emergency and essential surgeries did not change much compared with the previous year. Surgery in COVID-19 patients is best avoided, unless critical, as the outcome in these patients is not favorable. The employment of monitored anesthesia care techniques like awake craniotomy and regional anesthesia facilitate a better outcome in the ongoing COVID-19 era.

COVID-19 Testing in the Era of Modern Neurosurgery: Mitigating Risk in Our Vulnerable Patient Populations.

BACKGROUND: The respiratory illness identified as coronavirus disease 2019 (COVID-19) has resulted in a pandemic illness that has changed the face of healthcare. As the COVID-19 pandemic continues, patients have continued to require neurosurgical interventions, and the endoscopic endonasal approach for surgery has continued to be a mainstay treatment of pituitary tumors and anterior skull base lesions. METHODS: We sought to highlight the current lack of recommendations regarding testing protocols for neurosurgical patients. RESULTS: We implemented a novel testing protocol for our patient populations at increased risk and have proposed a model that can be used at other institutions to mitigate the risk of complications associated with some forms of COVID-19 testing. CONCLUSION: Patients with anterior skull base defects may be at risk with current COVID-19 testing protocols, and may benefit from alternative specimen collection strategies.

[Endoscopic endonasal surgery during COVID-19 pandemic: Management guideline]. / Cirugía endoscópica endonasal durante la pandemia COVID-19: protocolo de actuación.

Current SARS-CoV-2 coronavirus pandemic is challenging medical and surgical activities. Specifically, within neurosurgery, endoscopic endonasal approaches pose a high risk of contagion for healthcare personnel involved in it. Initially, the recommendation was to avoid such surgeries. However, the pandemic has dragged on and new solutions must be proposed to continue carrying out these approaches safely. Given the lack of established protocols, we propose the following one, which concisely establishes the measures to be taken in both urgent and scheduled surgery. In addition, a new protection-aspiration device (Maskpirator) is described.

Effects of the COVID-19 Pandemic on Operative Volume and Residency Training at Two Academic Neurosurgery Centers in New Orleans.

BACKGROUND: Medical subspecialties including neurosurgery have seen a dramatic shift in operative volume in the wake of the coronavirus disease 2019 (COVID-19) pandemic. The goal of this study was to quantify the effects of the COVID-19 pandemic on operative volume at 2 academic neurosurgery centers in New Orleans, Louisiana, USA from equivalent periods before and during the COVID-19 pandemic. METHODS: A retrospective review was conducted analyzing neurosurgical case records for 2 tertiary academic centers from March to June 2020 and March to June 2019. The records were reviewed for variables including institution and physician coverage, operative volume by month and year, cases per subspecialty, patient demographics, mortality, and morbidity. RESULTS: Comparison of groups showed a 34% reduction in monthly neurosurgical volume per institution during the pandemic compared with earlier time points, including a 77% decrease during April 2020. There was no change in mortality and morbidity across institutions during the pandemic. CONCLUSIONS: The COVID-19 pandemic has had a significant impact on neurosurgical practice and will likely continue to have long-term effects on patients at a time when global gross domestic products decrease and relative health expenditures increase. Clinicians must anticipate and actively prepare for these impacts in the future.

CSF Rhinorrhea After Endonasal Intervention to the Skull Base (CRANIAL) - Part 2: Impact of COVID-19.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised regarding the increased risk of perioperative mortality for patients with COVID-19, and the transmission risk to healthcare workers, especially during endonasal neurosurgical operations. The Pituitary Society has produced recommendations to guide management during this era. We sought to assess contemporary neurosurgical practice and the effects of COVID-19. METHODS: A multicenter prospective observational cohort study was conducted at 12 tertiary neurosurgical units (United Kingdom and Ireland). Data were collected from March 23 to July 31, 2020, inclusive. The data points collected included patient demographics, preoperative COVID-19 test results, operative modifications, and 30-day COVID-19 infection rates. RESULTS: A total of 124 patients were included. Of the 124 patients, 116 (94%) had undergone COVID-19 testing preoperatively (transsphenoidal approach, 97 of 105 [92%]; expanded endoscopic endonasal approach, 19 of 19 [100%]). One patient (1 of 116 [0.9%]) had tested positive for COVID-19 preoperatively, requiring a delay in surgery until the infection had been confirmed as resolved. Other than transient diabetes insipidus, no other complications were reported for this patient. All operating room staff had worn at least level 2 personal protective equipment. Adaptations to surgical techniques included minimizing drilling, draping modifications, and the use of a nasal iodine wash. At 30 days postoperatively, no evidence of COVID-19 infection (symptoms or positive formal testing results) were found in our cohort and no mortality had occurred. CONCLUSIONS: Preoperative screening protocols and operative modifications have facilitated endonasal neurosurgery during the COVID-19 pandemic, with the Pituitary Society guidelines followed for most of these operations. We found no evidence of COVID-19 infection in our cohort and no mortality, supporting the use of risk mitigation strategies to continue endonasal neurosurgery in subsequent pandemic waves.

Transnasal endoscopic skull base surgery in the COVID-19 era: Recommendations for increasing the safety of the method.

Transnasal endoscopic skull base surgery (eSBS) has been adopted in recent years, in great part to replace the extended procedures required by external approaches. Though sometimes perceived as "minimally invasive", eSBS still necessitates extensive manipulations within the nose/paranasal sinuses. Furthermore, exposure of susceptible cerebral structures to light and heat emanated by the telescope should be considered to comprehensively evaluate the safety of the method. While the number of studies specifically targeting eSBS safety still remains scarce, the problem has recently expanded with the SARS-CoV-2 pandemic, which also has implications for the safety of the surgical personnel. It must be stressed that eSBS may directly expose the surgeon to potentially high volumes of virus-contaminated aerosol. Thus, the anxiety of both the patient and the surgeon must be taken into account. Consequently, safety requirements must follow the highest standards. This paper summarizes current knowledge on SARS-CoV-2 biology and the peculiarities of human immunology in respect of the host-virus relationship, taking into account the latest information concerning the SARS-CoV-2 worrisome affinity for the nervous system. Based on this information, a workflow proposal is offered for consideration. This could be useful not only for the duration of the pandemic, but also during the unpredictable timeline involving our coexistence with the virus. Recommendations include technical modifications to the operating theatre, personal protective equipment, standards of testing for SARS-CoV-2 infection, prophylactic pretreatment with interferon, anti-IL6 treatment and, last but not least, psychological support for the patient.

Perioperative Coronavirus Disease 2019 (COVID-19) Incidence and Outcomes in Neurosurgical Patients at Two Tertiary Care Centers in Washington, DC, During a Pandemic: A 6-Month Follow-up.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) continues to affect all aspects of health care delivery, and neurosurgical practices are not immune to its impact. We aimed to evaluate neurosurgical practice patterns as well as the perioperative incidence of COVID-19 in neurosurgical patients and their outcomes. METHODS: A retrospective review of neurosurgical and neurointerventional cases at 2 tertiary centers during the first 3 months of the first peak of COVID-19 pandemic (March 8 to June 8) as well as following 3 months (post-peak pandemic; June 9 to September 9) was performed. Baseline characteristics, perioperative COVID-19 test results, modified Medically Necessary, Time-Sensitive (mMeNTS) score, and outcome measures were compared between COVID-19-positive and-negative patients through bivariate and multivariate analysis. RESULTS: In total, 652 neurosurgical and 217 neurointerventional cases were performed during post-peak pandemic period. Cervical spine, lumbar spine, functional/pain, cranioplasty, and cerebral angiogram cases were significantly increased in the postpandemic period. There was a 2.9% (35/1197) positivity rate for COVID-19 testing overall and 3.6% (13/363) positivity rate postoperatively. Age, mMeNTS score, complications, length of stay, case acuity, American Society of Anesthesiologists status, and disposition were significantly different between COVID-19-positive and-negative patients. CONCLUSIONS: A significant increase in elective case volume during the post-peak pandemic period is feasible with low and acceptable incidence of COVID-19 in neurosurgical patients. COVID-19-positive patients were younger, less likely to undergo elective procedures, had increased length of stay, had more complications, and were discharged to a location other than home. The mMeNTS score plays a role in decision-making for scheduling elective cases.

Clinical Pathway for Emergency Brain Surgery during COVID-19 Pandemic and Its Impact on Clinical Outcomes.

BACKGROUND: One of the challenges neurosurgeons are facing in the global public health crisis caused by the coronavirus disease 2019 (COVID-19) pandemic is to balance COVID-19 screening with timely surgery. We 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. METHODS: During the COVID-19 period, patients in need of emergency brain surgery in our institution were managed using a novel standardized pathway designed for COVID-19 screening. We 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. RESULTS: 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). CONCLUSION: We 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 we described showed acceptable results during this pandemic.

The Use of Acute Normovolemic Hemodilution in Clipping Surgery for Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: The occurrence of coronavirus disease 2019 (COVID-19) has overwhelmed the blood supply chain worldwide and severely influenced clinical procedures with potential massive blood loss, such as clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH). Whether acute normovolemic hemodilution (ANH) is safe and effective in aneurysm clipping remains largely unknown. METHODS: Patients with aSAH who underwent clipping surgery within 72 hours from bleeding were included. The patients in the ANH group received 400 mL autologous blood collection, and the blood was returned as needed during surgery. The relationships between ANH and perioperative allogeneic blood transfusion, postoperative outcome, and complications were analyzed. RESULTS: Sixty-two patients with aSAH were included between December 2019 and June 2020 (20 in the ANH group and 42 in the non-ANH group). ANH did not reduce the need of perioperative blood transfusion (3 [15%] vs. 5 [11.9%]; P = 0.734). However, ANH significantly increased serum hemoglobin levels on postoperative day 1 (11.5 ± 2.5 g/dL vs. 10.3 ± 2.0 g/dL; P = 0.045) and day 3 (12.1 ± 2.0 g/dL vs. 10.7 ± 1.3 g/dL; P = 0.002). Multivariable analysis indicated that serum hemoglobin level on postoperative day 1 (odds ratio, 0.895; 95% confidence interval, 0.822-0.973; P = 0.010) was an independent risk factor for unfavorable outcome, and receiver operating characteristic curve analysis showed that it had a comparable predictive power to World Federation of Neurosurgical Societies grade (Z = 0.275; P > 0.05). CONCLUSIONS: ANH significantly increased postoperative hemoglobin levels, and it may hold the potential to improve patients' outcomes. Routine use of ANH should be considered in aneurysm clipping surgery.

The Impact of COVID-19 on Neurosurgical Services in Africa.

INTRODUCTION: COVID-19 has affected the global provision of neurosurgical services. We sought to review the impact of COVID-19 on the neurosurgical services in Africa. METHODS: A cross-sectional survey was distributed to African neurosurgeons seeking to review demographics, national and neurosurgical preparedness, and change in clinical services in April 2020. RESULTS: A total of 316 responses from 42 countries were received. Of these, 81.6% of respondents were male and 79.11% were under the age of 45 years. In our sample, 123 (38.92%) respondents were in training. Most (94.3%) respondents stated they had COVID-19 cases reported in their country as of April 2020. Only 31 (41.50%) had received training on managing COVID-19. A total of 173 (54.70%) respondents were not performing elective surgery. There was a deficit in the provision of personal protective equipment (PPE): surgical masks (90.80%), gloves (84.80%), N95 masks (50.80%), and shoe covers (49.10%). Health ministry (80.40%), World Health Organization (74.50%), and journal papers (41.40%) were the most common sources of information on COVID-19. A total of 43.60% had a neurosurgeon in the COVID-19 preparedness team; 59.8% were concerned they may contract COVID-19 at work with a further 25.90% worried they may infect their family. Mental stress as a result of COVID-19 was reported by 14.20% of respondents. As of April 2020, 73.40% had no change in their income. CONCLUSIONS: Most African countries have a national COVID-19 policy response plan that is not always fully suited to the local neurosurgery services. There is an ongoing need for PPE and training for COVID-19 preparedness. There has been a reduction in clinical activities both in clinic and surgeries undertaken.