Ethical triage during the COVID-19 pandemic: a toolkit for neurosurgical resource allocation.

BACKGROUND: The COVID-19 pandemic confronts healthcare workers, including neurosurgeons, with difficult choices regarding which patients to treat. METHODS: In order to assist ethical triage, this article gives an overview of the main considerations and ethical principles relevant when allocating resources in times of scarcity. RESULTS: We discuss a framework employing four principles: prioritizing the worst off, maximizing benefits, treating patients equally, and promoting instrumental value. We furthermore discuss the role of age and comorbidity in triage and highlight some principles that may seem intuitive but should not form a basis for triage. CONCLUSIONS: This overview is presented on behalf of the European Association of Neurosurgical Societies and can be used as a toolkit for neurosurgeons faced with ethical dilemmas when triaging patients in times of scarcity.

Surgical Treatment of Chronic Subdural Hematoma: Predicting Recurrence and Cure.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common neurosurgical condition, especially among elderly patients. Here we have analyzed our institutional experience with surgical management of CSDH. We aimed at identifying predictors of hematoma recurrence and cure, and the respective time course. METHODS: Pertinent data were collected from all 208 patients (136 males; median age, 78 years) treated for unilateral CSDH in our department from 2014 to 2016 after exclusion of cases with CSDH following previous head surgery or missing postoperative imaging. Pre- and postoperative neuroimaging studies were subjected to computer-assisted volumetric analyses. CSDH composition and anatomy were assessed using a modified Nakaguchi classification. RESULTS: A total of 67.8% of the patients presented with neurologic deficits, and 51.4% were at least on 1 anticoagulant agent. Burr hole trephinations were performed in 94.7%. The median residual hematoma volume was 35.0 mL (44.1 mL including air). Surgical recurrences were seen in 17.8%. The median time to repeat surgery was 17 days, and 91.9% of recurrences occurred within 60 days. Recurrence rates varied between 36.4% (separated or trabecular subtypes and postoperative CSDH volume ≥35.0 mL) and 3.7% (all other subtypes and postoperative CSDH volume <35.0 mL). A neuroimaging proven cure could be documented in an estimated 90% of cases at 145 days after first surgery. CONCLUSIONS: Postoperative CSDH volume and the Nakaguchi classification subtypes proved the most powerful predictors of recurrence, cure, and the time to recurrence and cure. Although our results demonstrate the important impact of CSDH volume, composition, and anatomy, they also show that other so far unknown factors play a significant role as well.