Letter: Neurosurgery and Coronavirus (COVID-19) Epidemic: Doing our Part

Clinical, Radiologic, and Surgical Features of Brain Metastases in Colorectal Cancer. A Strong Correlation Between Surgical Patterns and Outcome

BACKGROUND

Brain metastases (BMs) from colorectal cancer (CRC) are a small percentage of metastatic patients and surgery is considered the best choice to improve survival. While most research has focused on the risk of CRC spreading to the brain, no studies have examined the characteristics of BMs in relation to surgery and outcome. In this study, we evaluate the clinical and radiologic features of BMs from CRC patients who underwent surgery and analyze their outcomes.

METHODS

The study is a retrospective observational analysis that included a cohort of 31 patients affected by CRC surgically-treated for their related BMs. For all patients, clinical and surgical data (number, site, side, tumor and edema volume, and morphology) were recorded.

RESULTS

Analysis found that synchronous diagnosis and lesion morphology, particularly cystic versus solid, had the most significant impact on survival (6 vs. 22 months, P = 0.04). To compare BMs with cystic morphology to those with solid morphology, a multivariate analysis was conducted. No significant differences were observed between the 2 groups in terms of age, sex, clinical onset, or performance status. The analysis revealed no significant differences in localization with regard to site, tumor and edema volume, biology, or complications rate.

CONCLUSIONS

BMs derived from CRC have a significantly different prognosis depending on whether they present as a solid or cystic pattern. Although solid pattern is more common, cystic BMs in this tumor type are less frequent and are associated with a poorer prognosis, regardless of molecular expression, location, size, and adjuvant treatment.

The Impact of the COVID-19 Pandemic and Lockdown on the Outcome of Glioblastoma

BACKGROUND

 Rapid spread of the SARS-CoV-2 pandemic in 2020 led to an indirect effect on non-COVID patients. Since neuro-oncology cases are unique and brain tumors need a specific therapeutic protocol at proper doses and at the right times, the effects of the pandemic on health care services for patients with glioblastomas (GBs) and their impact on overall survival (OS) and quality of life are not yet known.

METHODS

 We conducted a retrospective study of 142 GB patients who underwent surgery, radiation, and chemotherapy before and after the lockdown period, aiming to determine the differences in access to care, treatment modality, and adjuvant therapies, and how the lockdown changed the prognosis.

RESULTS

 The number of procedures performed for GB during the pandemic was comparable to that of the prepandemic period, and patients received standard care. There was a significant difference in the volume of lesions measured at diagnosis with a decreased number of "accidental" diagnoses and expression of a reduced use by the patient for a checkup or follow-up examinations. Patients expressed a significantly lower performance index in the lockdown period with longer progression-free survival (PFS) in the face of a comparable mean time to OS.

CONCLUSION

 Patients treated surgically for GB during the pandemic period had a more pronounced and earlier reduction in performance status than patients treated during the same period the year before. This appears to be primarily due to lower levels of care in the rehabilitation centers and more frequent discontinuation of adjuvant care.

Does the COVID-19 Screening Test Affect the Postoperative Prognosis of Patients Who Undergo Emergency Surgery for Cerebral Hemorrhage?

Objective

The coronavirus disease 2019 (COVID-19) pandemic has affected all medical fields, including neurosurgery. Particularly, performing preoperative screening tests has become mandatory, potentially extending the time from admission to the emergency room and operating room, thus possibly affecting patients' prognosis. This study aimed to determine the influence of COVID-19 screening time on patients' postoperative prognosis.

Methods

From September 10, 2020, to May 31, 2021, we retrospectively evaluated 54 patients with cerebral hemorrhage who underwent emergency surgery in the emergency room after the screening test. The control group included 89 patients with cerebral hemorrhage who underwent emergency surgery between January 2019 and March 2020, i.e., the period before the COVID-19 pandemic. Prognosis was measured using the Glasgow Coma Scale scores, which were obtained preoperatively, postoperatively, and at discharge, and the modified Rankin Scale (mRS). Additionally, unfavorable outcomes (mRS score 3-6) and in-hospital mortality rates were investigated for postoperative prognostic assessments.

Results

No remarkable differences were observed in the time to surgical intervention and prognostic evaluation scores between patients with cerebral hemorrhage who underwent COVID-19 screening tests and subjects in the control group.

Conclusion

This study confirmed that patient treatment and prognosis were not significantly affected by additional preoperative screening testing times during the pandemic. We believe that our results are informative for the evaluation and performance of emergency neurosurgery during the pandemic.

Neuro-oncology practice guidelines from a high-volume surgeon at the COVID-19 epicenter

BACKGROUND

During the coronavirus 19 (COVID-19) pandemic, physicians have begun adapting their daily practices to prevent transmissions. In this study we aimed to provide surgical neuro-oncologists with practice guidelines during the COVID-19 pandemic based on objective data from a high-volume brain tumor surgeon at the current COVID-19 epicenter.

METHODS

All outpatient visits and surgeries performed by the senior author during the COVID-19 pandemic were compared between the initial quarantine (3/23/20-5/4/20), the plateau period following quarantine (5/5/20-6/27/20), and the second peak (6/28/20-7/20/20). In-person and telemedicine visits were evaluated for crossovers. Surgeries were subdivided based on lesion type and evaluated across the same time period.

RESULTS

From 3/23/20-7/20/20, 469 clinic visits and 196 surgeries were identified. After quarantine was lifted, face-to-face visits increased (P < 0.01) yet no change in telehealth visits occurred. Of 327 telehealth visits, only 5.8% converted to in-person during the 4-month period with the most cited reason being patient preference (68.4%). Of the 196 surgeries performed during the pandemic, 29.1% occurred during quarantine, 49.0% during the plateau, and 21.9% occurred in the second peak. No COVID negative patients developed symptoms at follow-up. 55.6% were performed on malignant tumors and 31.6% were benign with no difference in case volumes throughout the pandemic.

CONCLUSIONS

Despite exceptional challenges, we have maintained a high-volume surgical neuro-oncology practice at the epicenter of the COVID-19 pandemic. We provide the protocols implemented at our institution in order to maximize neuro-oncology care while mitigating risk of COVID-19 exposure to both patients and providers.

An Evaluation of Neurosurgical Practices During the Coronavirus Disease 2019 Pandemic

Objective

We sought to understand how the coronavirus disease 2019 pandemic has affected the neurosurgical workforce.

Methods

We created a survey consisting of 22 questions to assess the respondent's operative experience, location, type of practice, subspecialty, changes in clinic and operative volumes, changes to staff, and changes to income since the pandemic began. The survey was distributed electronically to neurosurgeons throughout the United States and Puerto Rico.

Results

Of the 724 who opened the survey link, 457 completed the survey. The respondents were from throughout the United States and Puerto Rico and represented all practices types and subspecialties. Nearly all respondents reported hospital restrictions on elective surgeries. Most reported a decline in clinic and operative volume. Nearly 70% of respondents saw a decrease in the work hours of their ancillary providers, and almost one half (49.1%) of the respondents had had to downsize their practice staff, office assistants, nurses, schedulers, and other personnel. Overall, 43.6% of survey respondents had experienced a decline in income, and 27.4% expected a decline in income in the upcoming billing cycle. More senior neurosurgeons and those with a private practice, whether solo or as part of a group, were more likely to experience a decline in income as a result of the pandemic compared with their colleagues.

Conclusion

The coronavirus disease 2019 pandemic will likely have a lasting effect on the practice of medicine. Our survey results have described the early effects on the neurosurgical workforce. Nearly all neurosurgeons experienced a significant decline in clinical volume, which led to many downstream effects. Ultimately, analysis of the effects of such a pervasive pandemic will allow the neurosurgical workforce to be better prepared for similar events in the future.

Neurosurgical Practice During Coronavirus Disease 2019 (COVID-19) Pandemic

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly contagious life-threatening condition with unprecedented impacts for worldwide societies and health care systems. Since the first detection in China, it has spread rapidly worldwide. The increased burden has substantially affected neurosurgical practice and intensive modifications have been required in surgical scheduling, inpatient and outpatient clinics, management of emergency cases, and even in academic activities. In some systems, nonoverlapping teams have been created to minimize transmission among health care workers. In cases of a massive burden, neurosurgeons may need to be reassigned to COVID-19 wards, or teams from other regions may need to be sent to severely affected areas. Recommendations are as following. In outpatient practice, if possible, appointments should be undertaken via telemedicine. All staff assigned to the non-COVID treatment unit should be clothed in level 1 personal protective equipment. If possible, postponement is recommended for operations that do not require urgent or emergent intervention. All patients indicated for surgery must receive COVID-19 screening, including a nasopharyngeal swab and thorax computed tomography. Level 2 protection measures are appropriate during COVID-19-negative patients' operations. Operations of COVID-19-positive patients and emergency operations, in which screening cannot be obtained, should be performed after level 3 protective measures. During surgery, the use of high-speed drills and electrocautery should be reduced to minimize aerosol production. Screening is crucial in all patients because the surgical outcome is highly mortal in patients with COVID-19. All educational and academic conferences can be undertaken as virtual webinars.

Remodulation of neurosurgical activities in an Italian region (Emilia-Romagna) under COVID- 19 emergency: maintaining the standard of care during the crisis

BACKGROUND

The impact of COVID-19 outbreak in the neurosurgical practice has been dramatic, imposing several limitations. The aim of this study is to present how the neurosurgical departments of Emilia-Romagna, a northern Italian region, have re-set their organization to maintain the higher standard of care as possible.

METHODS

All OR and out-patients activities performed during the COVID-19 emergency in the neurosurgical department of Emilia-Romagna have been collected and compared to the means of the same timeframe in 2018 and 2019.

RESULTS

In 2020, 205 surgical procedures and 466 out-patients consultations have been performed, representing respectively 28.8% and 26.4% of the previous biennium. The most of OR procedures had been emergencies/urgencies and oncological patients (respectively 113 and 66 vs 164.5 and 84.5 of the previous biennium), while elective surgeries decrease up to -97.1%, as for spinal nerves and endoscopic skull base procedures. The patients phone contacts and telemedicine evaluations of their examinations have permitted to reduce the hospital access for outpatients of 75.6%, but these modalities have, also, permitted to follow-up a large number of cases.

CONCLUSIONS

The outbreak of COVID-19 has imposed several limits to our current practice, however this should not represent an excuse to reduce the standard of care. In our experience, the net integration of different local centers has permitted for each of them to effectively cope the crisis, managing the local cases requiring a prompt surgery and keeping the care continuity with already discharged patients.