key: cord-1013913-23lbs8al authors: Zacharia, Brad E; Eichberg, Daniel G; Ivan, Michael E; Hanft, Simon; Boockvar, John A; Isildak, Huseyin; Mansouri, Alireza; Komotar, Ricardo J; D’Amico, Randy S title: Letter: Surgical Management of Brain Tumor Patients in the COVID-19 Era date: 2020-04-29 journal: Neurosurgery DOI: 10.1093/neuros/nyaa162 sha: 06f6376ee6de72fb600cb82dedece2c151f39d5f doc_id: 1013913 cord_uid: 23lbs8al nan Decisions regarding surgical intervention in this resourcescarce time must undergo rigorous ethical and clinical evaluation. Except in emergency cases, we advocate using multidisciplinary conferences to gather consensus regarding surgical urgency. [1] [2] [3] [4] Table 1 outlines our stratification used to guide surgical timing. In regions with high baseline COVID-19 rates and available testing, all patients should undergo testing as close as possible to surgery. Some institutions recommend 2 tests given the relatively high false-negative test rate. 5 In regions where COVID-19 testing is not readily available, all patients should be screened with a questionnaire to assess the likelihood of active disease and prior exposure. Positive-screened patients should undergo testing when available or undergo 14-d preoperative quarantine. If testing FIGURE. Illustration of SARS-CoV-2, the virus that causes remains unavailable, enhanced personal protective equipment (PPE) ( Table 1) precautions should be considered. 6 In institutions without routine testing availability and without high rates of disease presence, those patients who screen negative may likely proceed to the operating room with standard precautionary measures. Enhanced PPE should be utilized for these procedures in patients who screen positive via questionnaire or testing. Only essential staff should be permitted in the operating room. Aerosolization of the virus prior to and during intubation remains possible where it can deposit on fomites in the operating room, or even possibly remain suspended in the air. 7, 8 All staff nonessential to intubation should leave the room during intubation. Given the high viral load in the upper airway of infected patients, aerosolization of SARS-CoV-2 may be extremely high during sinonasal and upper airway procedures, particularly when powered instruments (such as drills) are employed. 9 The American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) recommends deferring endoscopic endonasal procedures unless emergent or until preoperative COVID-19 testing can be performed. 10 Several scenarios, including high-flow cerebrospinal fluid (CSF) leak, pituitary apoplexy, and progressive neurological deficits secondary to an enlarging sellar lesion, may be deemed emergent. Per the AAO-HNS, all surgeries should be performed using enhanced PPE, regardless of COVID-19 testing status. 10 Strong consideration should be given to transcranial approaches to the sella when feasible (Table 2) . Given that the paranasal sinuses are in direct communication with the upper airway, extreme caution should be exercised to avoid sinus entry during transcranial surgery. Previous publications have reported coronavirus (although not specifically SARS-CoV-2) involving the middle ear 11, 12 ; as mastoid drilling can aerosolize the virus, surgical approaches involving mastoid drilling should be either deferred if nonurgent or avoided in favor of safer approaches. Although SARS-CoV-2 transmission during an awake craniotomy has never been reported, there is a theoretically high risk of viral transmission, as a laryngeal mask airway may be repeatedly inserted and removed throughout the surgery and virus particles may be transmitted while the patient is breathing and speaking. It may be prudent to use nonawake strategies for eloquent area mapping, such as asleep intraoperative electromyography. 13 Biopsy rather than surgical resection with the speech Neurosurgeons should maintain extreme vigilance with PPE. For surgeries likely to result in prolonged hospitalization, surgical staging may be prudent. If a smaller surgical intervention is planned, the neurosurgeon should consider operating without an assistant. Reflexive intensive care unit (ICU) care for postoperative craniotomy patients can likely be avoided following most straightforward operations. Rapid discharges with close telemedicine follow-up should be employed. For patients with extensive preoperative neurological disability preventing early home discharge, social services should be activated upon hospital admission for swift rehab disposition. Expeditious but safe discharges can conserve hospital beds for COVID-19 patients. Brain tumor patients are particularly vulnerable in the COVID-19 era. Patients frequently suffer from neurological and functional impairment, thus requiring support via family, home nursing services, and physical, occupational, and speech therapy, many of which cannot be currently delivered. Preoperative consideration of these issues is paramount. Patients undergoing radiation and/or chemotherapy are frequently immunosuppressed and are at exquisite risk for the development of infection. As per National Cancer Institute recommendations, patients should practice respiratory precautions, limit exposure to others, and have access to several weeks of medications. 14 Disclosures Letter: academic neurosurgery department response to COVID-19 pandemic: the University of Miami/Jackson Memorial Hospital model Neurosurgery during the COVID-19 pandemic: update from Lombardy, Northern Italy Preliminary recommendations for surgical practice of neurosurgery department in the central epidemic area of 2019 coronavirus infection Letter: the coronavirus disease 2019 global pandemic: a neurosurgical treatment algorithm Combination of RT-qPCR testing and clinical features for diagnosis of COVID-19 facilitates management of SARS-CoV-2 outbreak A commentary on safety precautions for otologic surgery during the COVID-19 pandemic Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists Staff safety during emergency airway management for COVID-19 in Hong Kong COVID-19 and the otolaryngologist-preliminary evidence-based review Academy Supports CMS, Offers Specific Nasal Policy Polymerase chain reaction-based detection of rhinovirus, respiratory syncytial virus, and coronavirus in otitis media with effusion Detection of rhinovirus, respiratory syncytial virus, and coronavirus infections in acute otitis media by reverse transcriptase polymerase chain reaction Identification of motor pathways during tumor surgery facilitated by multichannel electromyographic recording Coronavirus: What People With Cancer Should Know The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Dr Zacharia is a member of the NICO Corporation Speakers Bureau and is a consultant for Medtronic Incorporated. We would like to thank Roberto Suazo for contributing original high-quality artwork.