key: cord-1049616-zpdjytxh authors: Okunlola, Abiodun Idowu title: Awake craniotomy in a Covid-19 positive patient: The challenges and outcome date: 2020-12-21 journal: Interdiscip Neurosurg DOI: 10.1016/j.inat.2020.101064 sha: b0ceee167e5d32e004ba0d02a6cb111cdfe4d68f doc_id: 1049616 cord_uid: zpdjytxh BACKGROUND: The SARS-COV-2 is a novel coronavirus which is the etiological agent of the COVID-19 infection. The neurosurgical practice is not exempted from the impact of the COVID-19 pandemic. Awake craniotomy in a COVID-19 positive patient pose a significant risk for theatre staff but intubation of a COVID-19 positive patient for surgery under general anesthesia also pose similar risk. METHOD: Federal Teaching Hospital Ido Ekiti is a tertiary hospital in suburban community in Southwest Nigeria with 300-bed capacity. The hospital is a designated COVID-19 treatment centre. A 69-year-old female patient was referred from a nearby COVID-19 treatment hospital on account of left parieto-occipital high grade glioma. She had awake craniotomy and gross total tumor excision. RESULT: There was no need to convert to general anesthesia and she had immediate post-operative neurological improvement. Repeat COVID-19 test on post-operative day 4 was negative and she was discharged home. Thirty-day post-operative review confirmed progressive motor gain. CONCLUSION: Awake craniotomy in COVID-19 positive patient with appropriate use of necessary PPEs is achievable. The SARS-COV-2 virus is a novel coronavirus which is the etiological agent of the COVID-19 infection [1] . It is an infectious disease and the virus biology is not fully understood [2, 3] . Though, the infection started in late 2019 at the Wuhan province of China, it has spread globally leading to one of the most dreaded pandemic in human history [1, 2] . There is a double jeopardy as regards the impact of the novel coronavirus-1) the direct mortalities and morbidities associated with it and 2) the impact of its pandemic on health care delivery system leading to indirect mortalities and morbidities on patients who could not access adequate and prompt medical attention [4, 5] . The neurosurgical practice is not exempted from the impact of the COVID-19 pandemic [6, 7] . Awake craniotomy facilitate maximum tumor excision in eloquent brain region with optimal outcome and at the same time reduces the patient exposure to general anesthetic agents and its sequelae [7, 8] . There are several guidelines for surgical practice during COVID-19 pandemic to prevent exposure of uninfected patient to infected asymptomatic hospital staff and vice versa [6, 9] . This involved the use of various levels of Personal Protective Equipment (PPE). The use of PPE can be easily tolerated by patient under general anesthesia but this may be a challenge in awake patient during awake craniotomy. Awake craniotomy in a COVID-19 positive patient pose a significant risk to theatre staff but intubation of a COVID-19 positive patient for general anesthesia also pose similar risk because of high concentration of the virus in the respiratory tract [4, 5, 10] . The objective of this review is to document the challenges and outcome of our first awake craniotomy in a COVID-19 positive patient. Federal Teaching Hospital Ido Ekiti is a tertiary hospital in suburban community in Southwest Nigeria with 300-bed capacity. The hospital is a designated COVID-19 treatment centre. There is a holding ward for suspected COVID-19 patients and a COVID-19 treatment ward for confirmed COVID-19 positive patients. The hospital management recruited the existing personnel including the consultant neurosurgeon as a frontline doctor. A 69-year-old female patient was referred from a nearby COVID-19 treatment hospital with 6-year history of recurrent seizures associated with 2-week history of progressive right hemibody weakness. She had history of contact and screening test was positive. She was a known E-mail address: okunlolaai@abuad.edu.ng. hypertensive patient with good drug compliance. Examination revealed an elderly woman with normal vital signs. She was awake and alert. There was right supra-nuclear facioparesis and right hemiplegia but detailed ophthalmic examination was not conducted to limit exposure. The examination of other systems was normal. Clinical diagnosis of left hemispheric deficit secondary to left supratentorial space occupying lesion was made. Brain MRI showed left parieto-occipital intra-axial tumor measuring 70 mm by 42 mm by 30 mm, extending from the ventricular lining to the cortical surface with irregular peripheral contrast enhancement and extensive perilesional edema extending to the motor strip (Fig. 1 ) Radiological diagnosis of glioblastoma was made and family desire surgery to improve quality of life and histological confirmation. Repeat COVID-19 screening was not possible in our hospital at the time of admission because of none availability of the testing kits. She was admitted and scheduled for awake craniotomy and tumor excision. The surgery was scheduled for 8.00am but it was delayed till 11.00am because some staff declined participation in the surgery. The participation was voluntary and the hospital management provided full PPE for the 6-man team who participated in the surgery. All team members were on full Personal Protective Equipment including face shield and KN 95. The theatre positions were maintained which gave adequate distancing except the surgeon and assistant surgeon. The scrub nurse with the instrument tray was positioned on the far left, anesthetist machine was positioned on the far right with the anesthetist and technician on either side of the machine. The circulating nurse was at the corner offering assistance when needed. She was sedated with intravenous 1% propofol (60 mg bolus) for scalp nerve block with local anesthetic solution containing 0.5% xylocaine with adrenaline and 0.125% bupivacaine and she was thereafter awake throughout the procedure [8, 11] . Limited intraoperative clinical observation was conducted to limit exposure of the personnel to COVID-19 and the patient applied the face mask throughout the procedure. Intra-operative communication with the patient was difficult and limited. The duration of surgery was 2 h. There was no need to convert to general anesthesia and she had immediate post-operative improvement in the motor function. Power improved from grade 0 to grade 3 on postoperative day one. Post-operative cranial CT scan showed gross total tumor excision (Fig. 2) and histology report showed glioblastoma. She was treated with Tab azithromycin 500 mg daily, and Tab Augmentin 1 g 12-hourly. Nasal swab for RT-PCR test was repeated on post-operative day 4. She also had a short course of intravenous dexamethasone which was tailed-off over a week. Result of the repeat RT-PCR test was negative and she was discharged home. Thirty-day post-operative review confirmed progressive motor gain. She was standing with minimal support. COVID-19 pandemic has lasted beyond six months. The effect is being felt in both developed and developing countries like ours. It poses challenges to patients care, both the COVID-19 positive and negative patients [4, 12] . There are controversies about the peri-operative care with many suggesting routine COVID-19 screening for all surgical patients to prevent unnecessary exposure of the health care workers to this dreaded virus [7, 9] . Some proposed the use of full PPEs for all surgical patients but this is not feasible due to inadequate supply which has affected almost all countries of the world. The initial attempt to postpone all elective neurosurgical cases is no longer feasible and we should modify our practice to optimize patients' outcome [7, 9, 13] . Neurosurgical procedure in COVID-19 patient is challenging since the operation field is close to the respiratory tract which has the highest concentration of the virus in the body [6] . There is also a high chance of the virus spreading during intubation and awake craniotomy with no need for endotracheal intubation may be safer [7] . Major surgery like neurosurgical procedure in awake patient has its own challenges ranging from the possible anxiety generated by the sight of theatre equipment and unfamiliar faces to the stigmatization of the COVID-19 positive patients which may reflect in hospital staff attitudes. There is fear of contracting COVID-19 infection worldwide, healthcare workers are also inclusive knowing fully well that full PPE is not 100% protective [5] . It is reasonable, therefore, that some hospital staff may decline participation in surgical procedure in COVID-19 positive patient [13] . The index patient had high grade glioma in eloquent brain region and family desired surgery which require awake craniotomy in pre-COVID-19 period and we were able to achieve optimal tumor resection without additional morbidity using awake craniotomy in COVID-19 era. The intraoperative monitoring was a major challenge because the use of the face mask by the patient limits clinical observation. The COVID-19 pandemic may last longer than previously predicted and we should adapt and modify our practice to optimize patients' care in the face of this deadly viral infection. Awake craniotomy in COVID-19 positive patient with appropriate use of necessary PPE is achievable. Institutional ethical approval was obtained. 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