key: cord-0874793-bedog6yv authors: Panciani, Pier Paolo; Saraceno, Giorgio; Zanin, Luca; Renisi, Giulia; Signorini, Liana; Fontanella, Marco Maria title: Letter: COVID-19 Infection Affects Surgical Outcome of Chronic Subdural Hematoma date: 2020-04-18 journal: Neurosurgery DOI: 10.1093/neuros/nyaa140 sha: a76916f5f27fdcff98b0e39802cf4bf9ecaf1349 doc_id: 874793 cord_uid: bedog6yv nan negative cases. COVID-19 positive patients started anti-retroviral therapy with lopinavir/ritonavir and hydroxychloroquine. Daily arterial blood gas analysis and CXR were performed. Surgery or endovascular treatment were indicated when the CSDH was symptomatic (presence of focal neurological deficits or mental status changes) and the maximum thickness was greater than 1 cm (Figures 1-4) . One case did not present severe neurological impairment and was treated conservatively ( Figure 5 ). No preoperative respiratory impairment was observed. We treated all the CSDH patients under general anesthesia. Three patients were operated (2 through craniotomy and 1 with a burr hole). Endovascular occlusion of the middle meningeal artery (MMA) was performed in 1 case (Figure 2 ). In the surgical cases we placed a subdural drainage for 48 h. After its removal patients underwent a CT head scan (Figures 1, 3 , and 4). Afterwards the patients started low-molecular-weight heparin at prophylactic dose before mobilization. The cases are reported in the supplementary material section (Supplemental Digital Content). CSDHs mostly occur in elderly, with an average age of 63. 1 Head trauma is the major risk factor, identified in less than 50% (often minor head trauma). 8 Other risk factors are described like alcohol abuse, seizures, CSF shunts and coagulopathies, including therapeutic anticoagulation. CSDHs are bilateral in 20% to 25% of cases. 9 At present there is no scientific experience regarding surgical outcome of COVID-19 patients. We compared the recent cohort of COVID-19 CSDH patients with our historical series. Between May 2018 and September 2019, we operated 142 patients for CSDH and we observe 5 death at our Institution. Our mortality rate was 3.7% according to the literature. 10 In our recent experience, we observed 4 death in 5 COVID-19 patients suffering from CSDH. Therefore, we observed a mortality rate of 80% about 21,6 times greater than our control data. We observed 2 cases of mild thrombocytopenia (Table) . In these cases, we observed a re-bleeding (Figures 3 and 4 ) that led from a rapid neurological worsening to death within 5 d. This condition could be related to COVID-19 infection, as reported in literature. 11 Independently from the hemorrhagic risk, Lippi et al 12 showed that low platelet count is associated with increased risk of severe disease and mortality in patients with COVID-19, and this should serve as clinical indicator of worsening illness during hospitalization. 12 In our series, we suppose that thrombocytopenia led to re-bleeding and was associated with poor outcome. Dyspnoea and fatigue occurred in all our patients within 48 hours from surgery. CXR revealed severe IP (Figures 1-4) . Ground glass opacity and bilateral patchy shadowing were observed on the chest CT ( Figure 3 ). 5,13 All our patients had COVID-19 infection without pre-operative respiratory symptoms. Immune system could be impaired following surgical procedures and this may have unmasked a subclinical infection. 14, 15 On the other hand no respiratory failure was observed in the conservative-treated case ( Figure 5 ). In our experience IP occurred in all cases after treatment and worsened the outcome. This evenience represents a possible complication, often fatal, of COVID-19 infection. 5 Nowadays, Italian health care system is the most afflicted in the pandemic scenario. 16 The overload of the intensive care units in Lombardy, despite the efforts made, has necessarily influenced the resuscitation possibilities of elderly patients. 17 Therefore, we cannot exclude that our results could be affected by the health emergency status. Seung et al. reported good bleeding control from CSDH membrane with MMA embolization, prevention of further growth of hematoma and even spontaneous resolution without surgery. 18 Anyway our endovascular treated patient showed the same poor outcome of the surgical cases. Although statistical analysis of these preliminary data is not possible, COVID-19 patients appear to suffer from a negative Evidence based diagnosis and management of chronic subdural hematoma: a review of the literature Chronic subdural haematoma: time to rationalize treatment? 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Italy death toll overtakes china's. Nature Critical care utilization for the COVID-19 outbreak in lombardy, italy Middle meningeal artery embolization for chronic subdural hematoma Report of the case series. Case 1, 3, and 4: surgical series. Case 2: endovascular MMA occlusion. Case 5: conservative treatment Copyright C 2020 by the Congress of Neurological Surgeons