key: cord-0825108-lnhb5zvm
authors: Koester, Stefan W.; Catapano, Joshua S.; Lawton, Michael T.
title: Letter to the Editor response regarding "COVID-19 and neurosurgery consultation call volume at a single large tertiary center with a propensity-adjusted analysis"
date: 2021-01-11
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.12.167
sha: a1a8516773d57a70bda97ff2b5921cf1c70ae2b3
doc_id: 825108
cord_uid: lnhb5zvm

nan

December 29, 2020

Edward Benzel, MD Editor-in-Chief World Neurosurgery RE: Letter to the Editor response regarding "COVID-19 and neurosurgery consultation call volume at a single large tertiary center with a propensity-adjusted analysis" Dear Dr. Benzel:

We would like to submit the following Letter to the Editor Response for your review.

Sincerely, Michael T. Lawton, MD

In Reply to the Letter to the Editor "COVID-19 and neurosurgery consultation call volume at a single large tertiary center with a propensity-adjusted analysis," we would like to thank you for the opportunity to respond to the comments and points made by Maiguel-Lapeira et al. 1 We would also like to thank Dr. Maiguel-Lapeira and the authors for taking the time to express their concerns.

In their response, Dr. Maiguel-Lapeira and colleagues raised concern over the volume of neurosurgical consultations for inpatient referrals regarding complications that are different than the initial reason for admission, the increasing severity of neurological symptoms associated with presentation due to coronavirus disease 2019 (COVID-19), and changing patient analysis of symptomology of neurological disease. The single-center, retrospective review by Manco et al. quantified trends in the neurological presentation of patients with COVID-19 and found that, among 35 complications, the most common presentations were stroke (31%) and encephalopathy (20%). 2 A systematic review by Ghannam et al. found that, among neurology patients with COVID-19 reported in the literature, 49% presented with cerebrovascular insults. 3 Although we feel that the potential for COVID-19 to cause complications associated with vasculitis is significant, our paper focused on direct emergency consultations because the majority of vascular complications among COVID-19 patients are managed by our neurologists, and the neurosurgical department is seldom consulted. This aspect of our study was also obscured by our changing understanding of COVID-19 symptomology at the time. However, to improve the clarity of their findings, future papers should analyze in-hospital referrals, now that hospitals are more regimented in their management of COVID-19 patients and have a better understanding of the symptomology.

We found the commentary on the increased severity of neurological symptoms associated with COVID-19 to be fascinating. The retrospective review by Yaghi et al., analyzing 3556 patients with a confirmed COVID-19 diagnosis, found that COVID-19 patients were associated with higher National Institutes of Health Stroke Scale scores and greater mortality when compared with historical controls. 4 Xiong et al. also found that the majority of new-onset COVID-19 neurological manifestations were critical events, including lost consciousness, stroke, central nervous system infection, seizure, and status epilepticus. 5 In our study, this could be a potential explanation for why we witnessed an increase in the percentage of emergency consultations admitted after the onset of the pandemic (76% vs. 85%, p = 0.03) as well as an increase in the percentage of consultations that were admitted to the intensive care unit (47% vs. 56%, p = 0.08). However, because of the lack of initial screening for COVID-19 in March 2020, we were not able to analyze whether these admissions were COVID-19 related. Also, because our institution is one of the main neurosurgical care centers in a highly populated city center, we expected that a greater percentage of admissions would be related to cerebrovascular issues. Instead, we saw a relative decrease in such admissions after the onset of the pandemic (11% vs. 9%).

Finally, Dr. Maiguel-Lapeira et al. suggested that an effort be made to provide consultations, recommendations, and action plans to patients to help guide and educate them about symptomology that may be more urgent. We agree that steps should be taken to improve this patient-physician communication. At the Barrow Neurological Institute, we have implemented full telemedicine clinics for patients who would rather not come to clinic and patients at high risk for severe COVID-19. 

Letter to the editor regarding "COVID-19 and neurosurgery consultation call volume at a single large tertiary center with a propensity-adjusted analysis

Neurological reasons for consultation and hospitalization during the COVID-19 pandemic

Neurological involvement of coronavirus disease 2019: a systematic review

SARS-CoV-2 and stroke in a New York healthcare system. Stroke

New onset neurologic events in people with COVID-19 in 3 regions in China