key: cord-0933254-2qf00jtf
authors: Marenco-Hillembrand, Lina; Erben, Young; Suarez-Meade, Paola; Franco-Mesa, Camila; Sherman, Wendy; Eidelman, Benjamin H.; Miller, David A.; O’Keefe, Nancy L.; Bendok, Bernard R.; Spinner, Robert J.; Chaichana, Kaisorn L.; Meschia, James F.; Quiñones-Hinojosa, Alfredo
title: Outcomes and Surgical Considerations for Neurosurgical Patients Hospitalized With COVID-19 - A Multi-center Case Series
date: 2021-07-06
journal: World Neurosurg
DOI: 10.1016/j.wneu.2021.06.147
sha: 224f72bbc86ffe98fa68151bd511d2d8132b43ab
doc_id: 933254
cord_uid: 2qf00jtf

Objective Neurosurgical patients are at a higher risk of having a severe course of Coronavirus disease 2019 (COVID-19). The objective of this study was to determine morbidity, hospital course and mortality of neurosurgical patients during the COVID-19 pandemic in a multi-center health care system. Methods A retrospective, observational study was conducted to identify all hospitalized neurosurgical patients positive for COVID-19 from 3/11/20 to 11/02/20 at Mayo Clinic and the Mayo Clinic Health System. Results Eleven hospitalized neurosurgical patients (0.68%) were positive for COVID-19. Four patients (36.6%) were men and 7 (63.3%) were women. The mean age was 65.7 years (range: 35-81 years). All patients had comorbidities. The mean length of stay was 13.4 days (range: 4-30 days). Seven patients had a central nervous system malignancy (4 metastases, 1 meningioma, 1 glioblastoma, and 1 schwannoma). Three patients presented cerebrovascular complications including two spontaneous intraparenchymal hemorrhages and 1 ischemic large vessel stroke. One patient presented with an unstable traumatic spinal burst fracture. Four patients underwent neurosurgical/neuroendovascular interventions. Discharge disposition was to home in 5, rehabilitation facility in 3 and hospice in 3 patients. Five patients expired on follow-up, three within 30-days from COVID-19 complications and two from progression of their metastatic cancer. Conclusion COVID-19 is rare among the inpatient neurosurgical population. In all cases, patients had multiple comorbidities. All symptomatic patients from the respiratory standpoint had complications during their hospitalization. Three patients, who expired within 30-days of hospitalization were all related to COVID-19 complications. Neurosurgical procedures were only performed if deemed emergent.

A total of 15 (0.92%) neurosurgical-related patients out of 1,624 hospitalized with COVID-126 19 were identified. From this list of 15 cases, four patients were excluded from further review, as 127 they had resolution/no active neuro-oncological disease on MRI at the time of hospitalization. This resulted in a final series of 11 hospitalized neurosurgical patients (0.68%). 129

During the same time period, there were 3,407 non-COVID-19 related discharges for elective 130 neurosurgical procedures across campuses. Neurosurgical discharges in 2019 during a similar 131 period between 03/11/19 to 11/02/19 were 4,038, which demonstrates a 16% drop in practice 132 volume caused by the pandemic. 133 134

Four patients (36.6%) were male and 7 (63.6%) were female. The mean age of all patients 136 was 65.7 years (range: 35-81 years). Seven patients had a CNS malignancy (4 metastases, 1 137 meningioma, 1 glioblastoma (GBM), and 1 schwannoma). All patients with metastases had 138 disseminated disease. Two patients were undergoing chemotherapy at the time of COVID-19 139 diagnosis. Table 1 shows the demographic and clinical characteristics of the series. Three patients 140 presented with a cerebrovascular complication either at admission or during the course of their 141 hospitalization (2 spontaneous intraparenchymal hemorrhages (ICH) and 1 large-vessel ischemic 142 stroke). One patient with a past medical history of diffuse idiopathic skeletal hyperostosis (DISH) 143

presented with an unstable traumatic spinal burst fracture after sustaining a fall. Nine patients 144 presented with respiratory symptoms at the time of admission; chest x-ray demonstrated atypical 145 interstitial pneumonia. Two patients were asymptomatic from the respiratory perspective and 146 COVID-19 infection was detected as part of their preoperative screening protocol. These two 147 patients were the following: a 35-year-old woman with a metastatic sarcoma and a 65-year-old 148 man with a large-vessel stroke, who both underwent neurosurgical or neurointerventional 149 procedures. All subjects had significant comorbidities. Two patients developed spontaneous ICH. The first one was in a 61-year-old woman and 160 the second one was a 70-year-old man. Both patients were admitted through the emergency 161 department due to shortness of breath secondary to COVID-19 pneumonia. In both cases the 162 patients had several cerebrovascular risk factors, including hypertension, diabetes, chronic kidney 163 disease and hypercholesterolemia (Table 1) . During their hospitalization, both patients developed 164 acute kidney injury prior to the development of ICH ( Figure 1A and 1B) . Four patients (36.36%) required urgent neurosurgical intervention. All operations were 183 classified as emergent procedures (Table 2) . Of these four patients, two did not have respiratory 184 symptoms; but were positive for SARS-CoV-2 PCR testing at the time of preoperative screening. 185

The decision to proceed with neurosurgical intervention was due to rapid neurological performed included a right frontal craniotomy for resection of a metastatic sarcoma located on the 188 right falx due to rapid radiographic progression with edema and midline shift (Figure 2 A- 

COVID-19) Pandemic. World Neurosurg

Reconversion of 332 neurosurgical practice in times of the SARS-CoV-2 pandemic: a narrative review of the literature 333 and guideline implementation in a Mexican neurosurgical referral center

Neuro-Oncology During the COVID-19

Outbreak: A Hopeful Perspective at the End of the Italian Crisis. Opinion. Frontiers in Medicine

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COVID-19 Pandemic With a Focus on WHO Grade III and IV Gliomas

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Severe Acute Respiratory Syndrome Coronavirus 2 ARDS: Acute Respiratory Distress Syndrome CNS: Central nervous system PCR: Polymerase chain reaction EOR: Extent of resection GTR: Gross-total resection NTR: Near-total resection STR: Subtotal resection DVT: Deep venous thrombosis PE: Pulmonary embolism