key: cord-0923250-3z8iyyyy authors: Fiore, G.; Remore, L. G.; Tariciotti, L.; Carrabba, G.; Schisano, L.; Pluderi, M.; Bertani, G.; Borsa, S.; Locatelli, M. title: Does COVID-19 affect survival and functional outcome in emergency and urgent neurosurgical procedures? A single center prospective experience during the pandemic date: 2021-06-22 journal: World Neurosurg DOI: 10.1016/j.wneu.2021.06.071 sha: b5b32adf54ad9bf1c0d93eb6bb99a9974dae8f06 doc_id: 923250 cord_uid: 3z8iyyyy Objective To assess the organization and technical difficulties of neurosurgical procedures during the COVID-19 pandemic and their possible impact on survival and functional outcome; in addition, to evaluate the virological exposure risk of the medical personnel. Methods We prospectively collected data for all urgent surgical procedures performed in the COVID-19-dedicated theatre. Pre and postoperative variables were gathered: demographics, pathology, KPS and neurological status at admission, type of surgical procedures and their duration, length of in-ward stay(LOS), postoperative KPS and functional outcome comparison, destination at discharge. We defined five classes of pathologies - trauma, oncology, vascular, infection and hydrocephalus – and three surgical categories: burr hole(BH), craniotomy, CSF shunting and spine surgery. A postoperative Sars-Cov-2-infection was checked in all the operators. Results We identified 11 traumatic cases(44%), 4 infections(16%), 6 vascular events(24%), 2 hydrocephalus conditions(8%) and 2 oncological cases(8%). The surgical procedures were represented by 11 BHs(44%), 7 craniotomies(28%), 6 CSF shunts(24%) and one spine surgery(4%). The mean age was 57.8 years. The most frequent clinical presentation was coma(44). Mean KPS ad admission was 20±10, mean surgery duration was 85±63 minutes, mean LOS was 27±12 days. Mean KPS at discharge was 35±25. Outcome comparison resulted improved for sixteen patients. Four patients died. Mean follow-up was 6±3 months. None of the operators developed a post-operative Cov-Sars-2-infection. Conclusion Standardized protocols are mandatory to guarantee a high standard of care for emergency and urgent surgeries during the pandemic. Personal protective equipment affects maneuverability, dexterity and duration of interventions without affecting survival and functional outcome. The Sars-Cov2 virus is causing a dreadful pandemic still raging worldwide. Health Care Systems all over the world have to cope with Corona-Virus-Disease-19 (COVID-19), with hospitals being forced to reorganize and direct their resources to dedicated COVID-19 units, both in terms of medical personnel and equipment. 1 Many departments reduced their activity; this was especially true for the surgical ones: elective surgeries were aborted or rescheduled, while emergencies were performed under selective indications and following standardized protocols. [2] [3] [4] [5] Lombardy, in northern Italy, was the first and most affected Italian region, during the COVID-19 pandemic in 2020. Our university hospital in Milan was organized as a COVID-19 Hub, admitting SARS-COV-2 positive patients affected by both clinical and surgical disorders. 6 In this setting, the SARS-COV-2 positive patients suffering from neurosurgical pathologies and eligible for elective surgery were waived until a COVID-19 negative result was obtained; consequently, the overall elective caseload of our division was reduced, by Italian and regional regulations and laws. On the other hand, urgent surgical procedures were guaranteed through a dedicated COVID-19 operating room (OR). The neurosurgical outcome of all urgent and emergency surgeries was analyzed and hereby reported; in addition, considerations about the organizational and technical surgical difficulties, their possible impact on survival and functional outcome, and an analysis on the virological exposure risk of medical personnel, were made and discussed. Ethical approval was waived by the local Ethics Committee of "University of Milan" because all the procedures being performed were part of routine care. We prospectively collected data from our electronic database for all urgent surgical procedures being performed in the COVID-19-dedicated theatre. Pre-surgical and postoperative variables were gathered: demographics, pathology, KPS and neurological status at admission, surgical procedure types and their duration, length of postoperative in-ward stay (LOS), KPS at discharge (postoperative KPS) and functional outcome comparison, destination at discharge. We defined five classes of pathologies: trauma, oncology, vascular, infection and hydrocephalus. The KPS at admission was calculated and registered for all the patients being enrolled in the study. The neurological impairment at admission was defined as 1) Mild, if the patient had slight cognitive impairment without focal neurological deficits; 2) Severe, in case of focal neurological deficits being observed; 3) Coma, for patients with a Glasgow Coma Scale score (GCS) inferior to 9. The surgical procedures were allocated in 4 categories: burr hole (BH), craniotomy, CSF shunting (including EVD, VPS, shunt revision) and spine surgery. Functional outcome comparison was classified as: Improved, Unchanged and Worsened, relying on pre-and post-operative KPS comparison. The destination at discharge was collected as follows: 1) Home, 2) Rehabilitation, 3) Hospice and 4) Exitus. To assess the risk of operators' virological exposure, the appearance of COVID-19 typical symptoms in association with a Sars-CoV-2 nasopharyngeal swab positivity was collected during the ten days following the surgical procedure. Our COVID-Hub was organized so that patients with possible SARS-CoV-2 infection were screened by telehealth: a trained physician delivered a questionnaire to paramedics by telephone, regarding COVID-19-related symptoms and their severity. 7 The more severe COVID-19 patients were admitted to our emergency ward; they underwent a molecular nasopharyngeal swab test and waited for the result in a dedicated area called "grey zone". The negative swab patients followed a dedicated COVID19-free path, while the positive ones were transferred to the COVID-19 ward which was organized in three levels of severity: green, yellow or red. Patients in critical conditions requiring intubation underwent nasopharyngeal swab and also a bronchoalveolar lavage. In case of emergency and urgent surgeries, patients were operated on in a dedicated COVID-19 OR. The latter was a negative pressure surgical room set up in the emergency department. All the medical personnel wore specific personal protective equipment (PPE): disposable medical protective uniforms and shoe coverings were available before entering the COVID-19 OR. Operators had to wear two pairs of latex or nitrile gloves, an N95 medical protective mask with a surgical mask upon it, a surgical cap and a plastic face shield. According to shared surgical guidelines, procedures at risk for aerosolizing viral particlessuch as high-speed drilling -were limited. 8 The medical personnel left the OR via a separated clean pathway only after PPE being removed according to a standardized protocol. To avoid undesirable contamination after surgery, instructions about the correct disposal of PPE were displayed and followed. We prospectively collected data of 25 emergency and urgent surgical procedures of SARS-CoV-2positive patients, being performed at our institution in the COVID19-dedicated OR. Patient population characteristics are summarized in Table 1 . Pre-operative and post-operative variables, J o u r n a l P r e -p r o o f for each patient, are available in Tables 2 and 3 . Complications were type-sorted and reported in Table 4 . We identified 11 traumatic cases (44%), 4 infections (16%), 6 vascular cases (24%), 2 hydrocephalus (8%) and 2 oncological cases (8%). The surgical procedures were represented by 11 BH (44%), 7 craniotomies (28%), 6 CSF shunts (24%) and one spine surgery (4%). The mean age was 57.8 years. Seven patients were females. The most frequent clinical presentation was coma (11 patients, 44%), followed by 8 patients suffering from a severe neurological impairment. The mean KPS at admission was 20 ± 10, the mean surgery duration was 85 ± 63 minutes, the mean LOS was 27 ± 12 days. Seven patients were discharged to home, thirteen patients were referred to a rehabilitation center and one patient to a hospice. For these, the mean KPS at discharge was 35 ± 25. The outcome comparison resulted improved for sixteen patients and unchanged for five. Four patients in our series died. The mean follow-up was 6 ± 3 months. Among the 11 traumatic cases were included: 8 chronic subdural hematomas (73%), 1 acute subdural hematoma (9%), 1 acute epidural hematoma (9%) and 1 gunfire brain injury (9%). The mean age of trauma patients was 66 ± 19 years, with 7 (64%) being males. The majority of patients suffered from mental deterioration (6/11, 54.5%) and the mean KPS at admission was 20 ± 15. The most common surgical procedure being performed was BH (7/11, 64%). The mean surgery duration was 90 ± 65 minutes and the mean LOS was 19 ± 11 days. Most patients were referred to a rehabilitation facility (6/11, 55%) with a mean KPS of 40 ± 30. The patient suffering from acute subdural hematoma died. Four patients needed surgery for infectious conditions: 3 brain abscesses (75%) and 1 lumbar epidural empyema (25%). The mean age of patients was 67 ± 9 years. All patients were males. The mean KPS at admission was 20 ± 15. Severe neurological impairment was evident at the first clinical examination in three patients (75%). Guided navigation drainages through a BH were employed for two patients (50%) suffering from brain abscesses, while the third underwent surgical evacuation through a craniotomy. The patient suffering from an epidural empyema was subjected to a lumbar laminectomy. The mean surgery duration was 66 ± 26 minutes. The mean LOS was 44 ± 17 days. Three patients (75%) needed a postoperative rehabilitative hospitalization. The patient who received the craniotomy was discharged at home. The mean KPS at discharge was 40 ± 15. The oncological case concerned a patient with a voluminous cystic intra-axial lesion (anaplastic astrocytoma, IDH wild-type, grade III WHO); the patient underwent the cystic component surgical drainage in emergency conditions and, the day after, a craniotomy for surgical resection. The KPS at admission was 20. The mean duration of surgical procedures was 142 ± 158 minutes. The LOS was of 23 days, during which temozolomide was administered when the patient was deemed cured of COVID-19. Three days after the chemotherapy was stopped since the patient returned to be Sars-Cov2 +. The patient, stable, was discharge at home (KPS 30). Six cerebrovascular cases were included: 2 subarachnoid hemorrhages from aneurysmal rupture, 2 cerebellar and 2 intracerebral hemorrhages. The mean age was 55 ± 9 years. Half of the patients were males (3/6, 50%). All patients were comatose at admission (KPS 10). Four patients (66.6 %) were subjected to a ventricular shunting procedure and two (33.4%) underwent craniotomy. The mean surgery duration was 65 ± 47 minutes and the mean LOS was 34 ± 5 days. Half of the patients were moved to a rehabilitation facility, with a mean KPS of 15 ± 15, and three died. The last two surgical procedures concerned a one-year-old male patient, who underwent two shunting procedures for VPS malfunction. Before either procedure, the patient was comatose (KPS 10). The mean duration of surgeries was 105 ± 64 minutes. After 12 days in the pediatric ward, the patient was discharged at home with a KPS of 50. The mean age of patients who underwent BH was 73 ± 13. Seven patients were males (64%). This procedure was more frequently performed on patients with mental deterioration (6/11, 55%) at admission and a mean KPS of 25 ± 15. The mean surgical time was 55 ± 31 minutes. The mean LOS was 27 ± 17 days, and rehabilitation was deemed necessary for the majority of patients (8/11, 73%). The mean postoperative KPS was 45 ± 25. Craniotomy was more commonly performed for patients who were comatose at admission (5/7, 71%), with a mean KPS of 15 ± 10. These patients were 53 ± 12 years old on average, and 6 out of 7 were male. The mean duration of surgical procedures was 155 ± 68 minutes. The mean LOS was 30 ± 8 days. Two patients were discharged at home, one was referred to a rehabilitation facility and one to a hospice. The mean KPS at discharge was 40 ± 20. Three patients in this group died. CSF shunting procedures were performed on patients who were 36 ± 27 years old on average (male/female ratio = 4/2). Coma was the clinical presentation for all these patients (KPS 10). The mean surgical duration was 60 ± 46 minutes. The mean LOS was 26 ± 11 days. Three patients were J o u r n a l P r e -p r o o f discharged at home and two were referred to rehabilitation centers. The mean KPS at discharge was 40 ± 10. One patient died. One patient was subjected to a lumbar laminectomy to drain an epidural empyema. The patient, a 58-year old male, was admitted to our emergency ward suffering from a mild paraparesis (MRC = 3/5) with a KPS of 30. He was referred to a rehabilitation facility after 38 days of in-ward stay, in stable neurological conditions. The length of in-ward stay after surgery was statistically longer among infectious diseases (p = 0.01). Chances to be discharged at home resulted statistically higher in oncological cases (p = 0.03) and non-hemorrhagic hydrocephalus (p = 0.03). The KPS at discharge resulted statistically improved compared to the preoperative one (20 ± 10 vs 35 ± 25; p < 0,001). Lombardy is the most populated region in Italy and one of the most affected by the COVID-19 pandemic. Therefore, the health care system in Lombardy was reorganized following the Hub-and-Spoke organizational model. 6 Few Hub centers accounting for specific pathologies and medical specialties were defined, while the remaining centers served as Spoke referring patients to the Hubs and managing COVID-19 patients with low or intermediate levels of severity. Our institution was a COVID-19 Hub managing highly severe medical and surgical COVID-19 patients. In this perspective, our neurosurgical unit limited elective surgeries to the nondeferrable ones, referring most of the non-COVID-19 traumatic and oncological cases to neurosurgical trauma and oncology Hubs. We identified 25 SARS-COV-2 positive surgical patients who underwent emergency and urgent surgeries in the dedicated COVID-19 OR. We recognize that our sample population was small, paucity of data from available literature of systematically organized COVID-19 neurosurgical urgent case series might make this study useful to improve the management of this type of patients, during a dramatic pandemic that shows no signs of stopping in its ruthlessness. [9] [10] [11] Trauma Traumatic cases were the most common, with eight being chronic subdural hematoma and only two being represented by acute subdural or epidural hematoma. The prevalence of post-traumatic pathologies related to minor trauma could be explained by restricted mobility and outdoor activity, consequent to Italian government restrictions being imposed to limit the pandemic. The patients suffering from post-traumatic pathologies showed the highest COVID-19-positivity rate. Being trauma the most common reason for emergency ward admittance, these patients were more frequently subjected to nasopharyngeal swab testing. Patients suffering from infectious pathologies frequently showed a serious clinical impairment needing urgent or emergency treatment. In the meantime, they spent more days in the ward after surgery, which could be related to the need for long-term use of antibiotics not administrable at home. The treatment of oncological Sars-Cov2-positive patients was delayed until viral negativity in most of our case series in 2020. Therefore, the oncological patient in the current study was not expected to survive without the operation (ASA class score: V). The patient showed a COVID-19 relapse after temozolomide administration. Once again, COVID-19 puts physicians in ethical difficulty: is it right to administer chemotherapy, exposing oncological patients to the risks of COVID-19 J o u r n a l P r e -p r o o f relapse? On the other hand, is it right not to administer the only medical treatment available for high-grade glioma patients because of the risk of COVID-19 relapse? The data present in the literature are too scarce to answer these questions, confirming the need to fill the gaps with further clinical experiences. 12 The cerebrovascular disease group was the second most represented in our series. Considering that only a small percentage of patients with cerebrovascular disorders require neurosurgical treatments, we are here considering only the tip of an iceberg which is constituted by a multitude of patients with ischemic stroke or with hemorrhagic brain diseases not amenable to neurosurgical treatment (being SAHs and ICHs often amenable to medical and endovascular treatments). Therefore, in agreement with a recent systematic review, cerebrovascular events are relatively common findings during the COVID-19 pandemic, with the infection appearing to help trigger the vascular event. 13 We registered the highest death rate among these patients. However, this is likely to be attributable to the deadly nature of cerebrovascular diseases rather than surgical treatment; all the deceased patients were comatose at admission. CSF shunting procedures seemed to be the least influenced by the COVID-19 setting protocols. A possible explanation could be that patients needing an urgent CSF shunt underwent an EVD, which is a procedure with little susceptibility to dexterity limitations of surgical gestures, both in terms of operative time and outcome. Overall, the mean duration of the surgeries being performed in the COVID-19-dedicated OR was longer compared to the usual OR setting (data from electronic registers). According to an internal survey conducted in our neurosurgical unit, almost every surgeon complained about several J o u r n a l P r e -p r o o f discomforts in the COVID-19 OR. Main complaints concerned the hand dexterity reduction related to multiple pairs of gloves (two disposable and one sterile), as well as the poor visual acuity due to the tarnished face shields. These discomforts even persisted in later surgeries and were independent of personal surgical expertise (attendants vs residents). An increased LOS was registered in this series. Eshan Dowlati et al. pointed out that COVID-19 patients were more likely to develop an in-hospital complication other than the COVID-19 diagnosis. 14 In agreement, about half of the patients in our series presented an infectious disease complication. We share the impression coming from previous reports of a greater risk of COVID-19 neurosurgical patients to experience longer-than-average in-ward stay. Nonetheless, major hospitalization-related complications were not observed. The outcome comparison in this series highlights no worsening of KPS at discharge compared to the preoperative one. In our experience, the aforementioned technical difficulties imposed by the COVID-19-dedicated OR protocols seem not to have great repercussions on the surgical outcome, except for the surgical duration. Moreover, none of the patients in our series died from COVID-19related causes. Nonetheless, the postoperative functional outcome remains unsatisfactory. We think that it might be mainly attributable to patient clinical presentation severity at admission, being the percentage of the comatose ones high. Fortunately, none of the operators developed a post-operative Cov-Sars-2 infection. This reassuring data must make the health professionals involved in the pandemic confident: compliance with safety protocols is fundamental and effective in safeguarding their health. The main limitation of this study is the characteristics of the cohort which is made up of a limited number of heterogeneous patients in serious clinical conditions. Nevertheless, Sars-CoV-2 + neurosurgical patients are most often operated on with extreme urgency, likely having characteristics comparable to those of this series. Broader sample size is, in any case, desirable, to reduce the heterogeneity and selection bias intrinsic to the inclusion of patients with different pathologies and subjected to different surgical procedures. Moreover, the findings of this study should be generalized to other institutions with a similar setting and a comparable experience with the pandemic. The current surgical series reports the experience of a dedicated surgical COVID-19-Center facing emergency and urgent surgical cases during the active phase of the pandemic. The investigated case series suggests that standardized protocols for referral and in-hospital management are mandatory to guarantee a high standard of care in these emergency cases. For these reasons, neurosurgical COVID-19-positive cases should be referred to specialized centers as the Hubs defined in our region. PPE affects maneuverability, dexterity and duration of interventions, according to dedicated surgical team witnesses and electronic registers; nonetheless, survival and the overall functional outcome seem not to be far affected by technical concerns. The absence of Sars-CoV2 infections among the medical personnel is also worthy of being highlighted. Further investigations are needed to clarify the impact of SARS-COV-2 on the management of urgent neurosurgical procedures. 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CONTINUATION OF TEMOZOLOMIDE CHEMOTHERAPY IN A GLIOBLASTOMA PATIENT AFTER RESOLUTION OF COVID-19 PNEUMONIA COVID-19 and Cerebrovascular Diseases: A Systematic Review and Perspectives for Stroke Management Case Volumes and Perioperative Coronavirus Disease 2019 Incidence in Neurosurgical Patients During a Pandemic: Experiences at Two Tertiary Care Centers in Washington CRediT author statement Giorgio Fiore: Methodology; Validation; Formal Analysis; Investigation; Resources Writing -Original Draft/Review & Editing Luigi Gianmaria Remore: Validation; Data Curation; Formal Analysis; Writing -Original Draft Tariciotti: Validation; Data Curation; Formal Analysis; Writing -Review & Editing; Supervision Methodology; Validation; Data Curation; Writing -Review & Editing; Supervision Luigi Schisano: Validation; Data Curation; Formal Analysis; Writing -Review & Editing; Supervision Methodology; Validation; Data Curation; Writing -Review & Editing; Supervision. Giulio Andrea Bertani: Methodology; Validation; Data Curation; Investigation; Data Curation; Writing -Original Draft/Review & Editing Methodology; Validation; Data Curation; Writing -Original Draft/Review & Editing; Supervision Methodology; Validation; Data Curation; Writing -Review & Editing; Supervision J o u r n a l P r e -p r o o f * Number of patients suffering from any complication type (see Table 4 for more information)J o u r n a l P r e -p r o o f ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:J o u r n a l P r e -p r o o f