Impact of the COVID-19 pandemic on people with epilepsy: Findings from the Brazilian arm of the COV-E study.

The COVID-19 pandemic has had an unprecedented impact on people and healthcare services. The disruption to chronic illnesses, such as epilepsy, may relate to several factors ranging from direct infection to secondary effects from healthcare reorganization and social distancing measures. OBJECTIVES: As part of the COVID-19 and Epilepsy (COV-E) global study, we ascertained the effects of COVID-19 on people with epilepsy in Brazil, based on their perspectives and those of their caregivers. We also evaluated the impact of COVID-19 on the care delivered to people with epilepsy by healthcare workers. METHODS: We designed separate online surveys for people with epilepsy and their caregivers. A further survey for healthcare workers contained additional assessments of changes to working patterns, productivity, and concerns for those with epilepsy under their care. The Brazilian arm of COV-E initially collected data from May to November 2020 during the country's first wave. We also examined national data to identify the Brazilian states with the highest COVID-19 incidence and related mortality. Lastly, we applied this geographic grouping to our data to explore whether local disease burden played a direct role in difficulties faced by people with epilepsy. RESULTS: Two hundred and forty-one people returned the survey, 20% were individuals with epilepsy (n = 48); 22% were caregivers (n = 53), and 58% were healthcare workers (n = 140). Just under half (43%) of people with epilepsy reported health changes during the pandemic, including worsening seizure control, with specific issues related to stress and impaired mental health. Of respondents prescribed antiseizure medication, 11% reported difficulty taking medication on time due to problems acquiring prescriptions and delayed or canceled medical appointments. Only a small proportion of respondents reported discussing significant epilepsy-related risks in the previous 12 months. Analysis of national COVID-19 data showed a higher disease burden in the states of Sao Paulo and Rio de Janeiro compared to Brazil as a whole. There were, however, no geographic differences observed in survey responses despite variability in the incidence of COVID-19. CONCLUSION: Our findings suggest that Brazilians with epilepsy have been adversely affected by COVID-19 by factors beyond infection or mortality. Mental health issues and the importance of optimal communication are critical during these difficult times. Healthcare services need to find nuanced approaches and learn from shared international experiences to provide optimal care for people with epilepsy as the direct burden of COVID-19 improves in some countries. In contrast, others face resurgent waves of the pandemic.

How I do it: Management of venous bleeding from the superior petrosal vein during endoscopic microvascular decompression.

BACKGROUND: A repair strategy for venous bleeding from the superior petrosal vein (SPV) is essential during endoscopic microvascular decompression. METHOD: Sliced oxycellulose seats are rounded off, making balls around 10 mm in diameter. When venous bleeding arises from the SPV, the first oxycellulose ball is placed just behind the SPV in the surgical view. A second ball is then applied in front of the SPV. The SPV is thus immediately and entirely covered by oxycellulose, and hemostasis is safely achieved with the preservation of the SPV. CONCLUSION: This oxycellulose ball technique offers simple, reliable control of venous bleeding from the SPV.

Evaluating risk to people with epilepsy during the COVID-19 pandemic: Preliminary findings from the COV-E study.

The COVID-19 pandemic has caused global anguish unparalleled in recent times. As cases rise, increased pressure on health services, combined with severe disruption to people's everyday lives, can adversely affect individuals living with chronic illnesses, including people with epilepsy. Stressors related to disruption to healthcare, finances, mental well-being, relationships, schooling, physical activity, and increased isolation could increase seizures and impair epilepsy self-management. We aim to understand the impact that COVID-19 has had on the health and well-being of people with epilepsy focusing on exposure to increased risk of seizures, associated comorbidity, and mortality. We designed two online surveys with one addressing people with epilepsy directly and the second for caregivers to report on behalf of a person with epilepsy. The survey is ongoing and has yielded 463 UK-based responses by the end of September 2020. Forty percent of respondents reported health changes during the pandemic (n = 185). Respondents cited a change in seizures (19%, n = 88), mental health difficulties (34%, n = 161), and sleep disruption (26%, n = 121) as the main reasons. Thirteen percent found it difficult to take medication on time. A third had difficulty accessing medical services (n = 154), with 8% having had an appointment canceled (n = 39). Only a small proportion reported having had discussions about epilepsy-related risks, such as safety precautions (16%, n = 74); mental health (29%, n = 134); sleep (30%, n = 140); and Sudden Unexpected Death in Epilepsy (SUDEP; 15%, n = 69) in the previous 12 months. These findings suggest that people with epilepsy are currently experiencing health changes, coupled with inadequate access to services. Also, there seems to be a history of poor risk communication in the months preceding the pandemic. As the UK witnesses a second COVID-19 wave, those involved in healthcare delivery must ensure optimal care is provided for people with chronic conditions, such as epilepsy, to ensure that avoidable morbidity and mortality is prevented during the pandemic, and beyond.

How I do it: endoscopic microvascular decompression for glossopharyngeal neuralgia.

BACKGROUND: Microvascular decompression (MVD) for glossopharyngeal neuralgia (GPN) is associated with high complication and incomplete cure rates because of its poor ability to visualize neurovascular conflicts. METHOD: Fully endoscopic MVD for GPN was carried out through a retrosigmoid keyhole approach. Neurovascular conflicts were clearly demonstrated with a loop of the posterior inferior cerebellar artery (PICA) under a 30° endoscopic view, and no significant cerebellar retraction was observed. The loop of the PICA was safely decompressed and the perforators were preserved while offering an excellent operative view. CONCLUSION: Endoscopic MVD is a reliable and minimally invasive method for GPN.

Efficacy of combined treatment with medial branch radiofrequency neurotomy and steroid block in lumbar facet joint arthropathy.

PURPOSE: To evaluate the long-term efficacy of combined radiofrequency (RF) neurotomy and steroid nerve block in patients with lumbar facet joint arthropathy. MATERIALS AND METHODS: Combined RF neurotomy and steroid nerve block was performed in 34 patients with chronic paravertebral low back pain. The diagnosis was confirmed by comparative double diagnostic block of the medial branch with bupivacaine and lidocaine. Under fluoroscopy, RF thermal ablation of the medial branch was performed (at RF needle tip temperature 85°C for 90 seconds), three times for each target nerve. At the end of the procedure, 20 mg of methylprednisolone acetate (sustained-release preparation) was infiltrated on each ablated nerve. Outcome variable was the degree of improvement in pain using visual analog scale (VAS) and numerical rating scale (NRS). Improvement in the quality of life was assessed using the Roland-Morris (RM) questionnaire. The procedure was repeated in cases of unbearable pain (>5 VAS score). RESULTS: Patients had a mean VAS score of 8.6 before the procedure. Thereafter, VAS score was 0.91 immediately after the procedure and 3.0, 2.8, 3.7, and 3.6 at 1 month, 2 months, 6 months, and 1 year. NRS showed pain relief after the procedure of 85%, 65%, 78%, 62%, and 59.5% at the same time points. RM score was 18 before the procedure, 7.6 at 6 months after the procedure, and 8.5 at 1 year after the procedure. No major complication was noted except local pain in all patients and numbness of the back in six patients after the procedure. CONCLUSIONS: Combined RF neurotomy and steroid nerve block produced substantial improvement in terms of long-term pain relief and quality of life.

The efficacy of transforaminal epidural steroid injections in lumbosacral radiculopathy.

BACKGROUND: Transformational epidural steroid (TFES) is commonly used to treat lumbosacral radicular pain. However, very few studies have systematically evaluated the quality of analgesia following such procedures with respect to time. OBJECTIVE: To evaluate long-term efficacy of TFES in patients with lumbosacral radiculopathy. MATERIALS AND METHODS: A prospective study including 30 patients having lumbosacral radiculopathy secondary to prolapsed disc. Outcome variables were the amount of improvement just after the procedure and thereafter at 24 hrs, 1 month, 6 month and 1 year post-procedure, respectively, using visual analog scale (VAS) and numeric rating scale (NRS). Patients also filled Roland-Morris questionnaire pre-procedure, 6 month and 1 year follow-up. All patients received Ibuprofen for 3 days following the procedure, to alleviate post- procedural pain. An option of rescue surgery was reserved in case of unbearable pain (>7 VAS), appearance of sudden motor deficit or if patient opts for surgery. Same injection was repeated if at any point of time pain had >5 in VAS. RESULTS: As per NRS, almost all patients had complete pain relief (mean 98%) immediate postprocedure. At 24 hrs, the score was 79%, at 1 month 60%, at 6 months 58.5% and at 1 year 59%. Preprocedure VAS was 9.2 and thereafter 0.6, 1.8, 3.9, 3.8 and 4.2 at similar time points. Roland-Morris score was 18/24, 10/24, 9/24, at pre-procedure, at 6 months and at 1 year, respectively. No complication was noted in any patient except post procedural local pain. CONCLUSION: Quality of pain relief produced by TFES was significant. Long-term quality of pain relief was better in patients with pain duration less than 6 months. Even though, the study was designed to inject the drug once, many of the patients required second injection. A further study with multiple injections at prefixed time interval might probably result in a better overall outcome.

Aneurysmal subarachnoid hemorrhage in young adults.

OBJECT: The authors reviewed the management protocols for young adults who presented with subarachnoid hemorrhage (SAH) at the Regional Neurosurgery Unit in Newcastle during a study period of 9 years. Aneurysmal SAH is uncommon in the age group selected (18-39 years) and, therefore, the performance of these patients has not been extensively reported in the literature. The authors also evaluated the good-grade rebleed rate (an index of management efficiency) in this cohort of patients. METHODS: The Newcastle neurosurgical unit serves a population of close to 3 million people, and an average of 180 patients with SAH are seen each year. The majority of patients are transferred from other hospitals in the region. This study includes patients admitted between January 1990 and December 1998. A total of 1,609 patients were admitted during this period, of whom 295 (18.4%) between the ages of 18 and 39 years constituted the study population of young adults. Two hundred ninety-five young adults presented with SAH; 181 (61.4%) were women and 114 (38.6%) were men, a ratio of 3:2. Of 246 patients in whom this value was recorded, 15 (6.1%) presented with a history of hypertension, and there was an association between hypertension and the occurrence of multiple aneurysms (Fisher two-tailed exact test, p = 0.008). Thirty-five patients (11.9%) presented with a hematoma on computerized tomography scans; of these, 20 (57%) were women and 15 were men. In six patients the lesion had rebled before treatment. The good-grade rebleed rate was three (1.7%) of 178. The overall favorable outcome rate was 83.8% (Glasgow Outcome Scale [GOS] 4 and 5) and unfavorable outcome occurred in 16.2% (GOS 1-3), with a total of 40 deaths in this group (13%). Age had no influence on outcome in young adults. Comparing the outcome at discharge with the follow-up evaluation at 6 months revealed that patients in the moderate and severe disability groups continued to improve and many achieved good recovery. CONCLUSIONS: In this report the authors detail the outcome of a large number of young adults with SAH. The incidence of SAH was higher in the female population, although the ratio was not as high as previously reported. The authors have also demonstrated a progressive increase in the incidence of aneurysmal SAH with age, even in young adults. Hypertension but not age influenced the occurrence of multiple aneurysms. The good-grade rebleed rate is low, although it is not zero. Generally, a satisfactory outcome was obtained and significant continuing improvements were noted between discharge and follow-up evaluation. This reflects the power of recovery in young adults. These are people whose economic productivity and fertility are at peak levels and therefore the financial and social burden occasioned by less-than-perfect outcomes is large.