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 Table of Contents  
INVITED EDITORIAL
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 73-77

Aneurysm surgery during the COVID-19 pandemic: Ecstasy, agony and dilemma


Department of Neurosurgery, G B Pant Institute of Postgraduate Medical Education and Research, University of Delhi, Delhi, India

Date of Submission04-Jan-2021
Date of Decision05-Jan-2021
Date of Acceptance05-Jan-2021
Date of Web Publication3-Feb-2021

Correspondence Address:
Prof. Daljit Singh
G B Pant Institute of Postgraduate Medical Education and Research, University of Delhi, Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvs.jcvs_3_21

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How to cite this article:
Singh D. Aneurysm surgery during the COVID-19 pandemic: Ecstasy, agony and dilemma. J Cerebrovasc Sci 2020;8:73-7

How to cite this URL:
Singh D. Aneurysm surgery during the COVID-19 pandemic: Ecstasy, agony and dilemma. J Cerebrovasc Sci [serial online] 2020 [cited 2021 Sep 17];8:73-7. Available from: http://www.jcvs.com/text.asp?2020/8/2/73/308634



As on 1st January 2021, there were 84,463,859 cases of COVID-19 all over the world with 1,837,247 deaths. The USA had maximum cases followed by India which had 10,305,758 cases and 149,218 deaths.

COVID-19 is a horrifying episode of lifetime for each one of us. It has redefined life, our way of living and has significantly highlighted the importance of health, healthcare and responsibility of the state in providing infrastructure and resources. It is a mammoth task for the future which would require the world to unite for the future of our survival, our existence. We have limited number of beds across India, limited workforce and resources through which every medical professional is struggling during COVID care directly or indirectly.

Collateral damage, i.e., indirect untoward deleterious effort on health that results due to SARS-CoV-2, has emerged as an additional concern. It may create shortage of resources, wrong diagnosis, poor health services, deviation in standard treatment protocol or reluctance on part on healthcare workers (HCWs). Maximum suffering occurs on health sector including economy.

Optimising the services by re-organisation of beds and workforce in several setups across the world, including India, resulted in over load to some centres which were enthused to manage non-COVID patients. GIPMER was one such place in Delhi. We were allowed surgery on non-COVID patients. There was a fall in number of cases reporting to us up to 60% despite functioning outpatient department (OPD) and operation theatres (OTs). The intent to treat was lacking, particularly during the months of May and June 2020 due to high positivity rates and rising mortality. The scenario changed in the subsequent months, but the number of total surgeries had reduced by almost 50% as compared to previous years.

In India, the decline in the number of neurosurgical patients was reported to be up 76% in OPDs, 70% in surgeries, and 53% in research studies.[1] A consensus statement from the Neurological Society of India categorised various surgeries into immediate (24 h), subacute (7 days) and chronic (30 days).[2] Emphasis was laid on self-protection even in dealing with a COVID negative patient, for personal safety.[3] With frequent changing criteria for diagnosis and mode of treatment, prognosis in COVID is certainly improving, but the treatment of emergency cases is no longer straight forward towards the ethic of primum non nocere. The interest and safety of health care workers has emerged as an equally important aspect in protecting health and life of treating patients.

A lot of alertness is needed to manage suspected COVID or confirmed COVID cases to prevent further spread. Several guidelines have been proposed by various societies. In addition, institutions have made their own protocol. Essence of all is to have protection for self and others. A range of recourse, devices and change in infrastructure have been in practice, such as, using personal protective equipment, eye covers, isolating chambers, close circuits, minimal intervention, separate intubation and extubation chambers, care of air flow, exhaust fans, patient transfer covers, care of transfer trolley, interval between two cases, fumigation, use of hypochlorite, ultraviolet lamp, prophylactic hydroxychloroquine and ivermectin, creation of separate corridors and operating theatres, have been practiced, with variable outcome.

Across the world, there has been a decline in number of non-COVID patients reporting to hospital. In the Veneto region Italy, as compared to the last 4 years, there has been a reported decline of 42% since March 2020. Surgical procedures declined by 78%, coiling specifically declined by 27%, and the apparent incidence of stroke was seen to increase by 33%.[4]

In another analysis in 35 centers globally, on impact of COVID on specialized neuro-interventional units, elective procedures were cancelled across all sites within median of 14 days. It was also observed that self-quarantine was largest amongst nurses (50%) vs. interventionist 6% (P < 0.5).[5]

Another survey in over 101 institutes, on clinical trials in neuro-endovascular procedures in strokes and aneurysms during the COVID-19 pandemic, showed that enrolment was suspended in 78% of the sites and protocol deviation occurred in 42% of the sites. A greater role of remote consent was emphasised.[6]

In an analysis of case load adaptation, Mathiesen in a survey involving 34 neurosurgery departments in Europe found a significant decrease in number of neurosurgical beds and neurointensive care unit (ICU) beds from December 2019 to March 2020. There was 80% reduced activity noted in providing legitimate medical needs during this period of COVID.[7]

Going back to the basics, the first case of COVID-19 was diagnosed in Wuhan city in Central China on December 8, 2019. Since then, the world witnessed its spread, panic, catastrophes and recoveries in 2019–2020. There has been a surge of articles on COVID recently. PubMed alone shows over 85,000 research article on various aspects of COVID. Vaccination has already started in Europe, the USA, China and Russia, and it is soon expected to be launched in India in January 2021.

Much of current knowledge of COVID-19 disease spectrum has emerged from initial experience with SARS and MERS in Middle East. SARS-CoV-2 is however, much more contagious than those viruses. It is 100 nm in size, belonging to the coronaviridae family, and has a single stranded RNA, with the positive strand (+ss-RNA) having a 30 kilo-base length. The full sequence of SARS-CoV-2 was revealed on January 7, 2020. It revealed that structure is similar to beta-coronavirus responsible for 15% of acute viral common cold.[8] It lies in helical nucleocapsid however has a unique sequence which has a polybasic cleavage site on its spike protein that determines its transmission.[9]

The spectrum of neurological manifestatations of COVID-19 is wide, involving almost every part of of the nervous system.[10] Neurological manifestations are common in advanced stages of disease and are often serious, but are mild in the initial stages, with anosmia being the only manifestation of COVID-19 which is disabling. Neurological manifestation lead to prolong stage .[11]

A meta-analysis[12] published in April 2020, noted a sex ratio of male to female of 1.06, with diabetes mellitus, hypertension, and cardiovascular disease being comorbidities which act as factor for poor outcome. Similar observations have been reported by others. Approximately 12% of patients required ventilator support with 21% mortality.[13],[14]


  Pathophysiology Top


SARS-COV-2 utilises angiotensin-converting enzyme 2 (ACE-2) receptor for entry into host cells. These receptors are present profusely in the lung parenchyma, endothelial lining of artery and veins of brain capillaries.

Additionally, these receptors are present in the kidneys which alters blood pressure control in COVID and enhances risk of cerebrovascular accidents. The major mechanism which results in catastrophe in COVID is profound, sudden, coagulopathy which can result in deterioration and mortality. The hallmarks of COVID coagulopathy are thrombocytopemia, elevated prothrombin time, and raised D-dimer and ferritin levels. Coagulopathy predisposes to stroke and other prothrombotic events.[15],[16]

Cytokine storm plays a crucial role in sudden deterioration. Presence of raised levels of pro-inflammatory cytokines such has IL6, IL2, IL8 along with lymphopoenia and increased neutrophils are characteristic changes seen.[11],[13],[16] Autoimmune demyelination[16] may contribute to meningeal manifestation.


  Diagnosis Top


The World Health Organization (WHO) and Indian Council for Medical Research (ICMR) recommends Reverse Transcriptase – Polymerase Chain Reaction (RT-PCR) as the reliable test for COVID positivity. It has 100% specificity and 79% sensitivity.[17],[18] Rapid antigen test (RAT) is recommended in emergency use as a screening test. It has a low specificity. Several institutes prefer to repeat test RT-PCR after 7 days before a patient is taken for surgery as per ICMR guidelines. Additional reliability has been made on computed tomography (CT) chest as a more sensitive test in picking early COVID and many centres practise pre-operative C.T. chest as screening test to rule out and prognosticate COVID-19. 1gM and 1gG antibody titres in serum, is a useful test in studying immunity in the population.

The treatment of COVID is largely medical, however, successful lung transplant has been conducted. The use of drugs such as dexamethasone and anticoagulant has made a significant impact on outcome of serious patients.

The antiviral drug Remedesivir, monoclonal anibodies, plasma exchange, and drugs like Hydroxychloroquine and Ivermectin, have yielded variable results in various studies.


  Neurological Manifestation in COVID Top


There has been a paucity of literature on larger cohorts, hence reliance has been placed on published case series. Although lung is the primary organ to get affected, COVID-19 is neuroinvasive. It has resulted in wide range of clinical manifestation. The portal of entry is nasal mucosa and the initial neurological manifestation is anosmia.[11],[19],[20],[21]

The virus can penetrate the central nervous system (CNS) directly via the olfactory nerve/bulb or indirectly through the hematogenous route as human coronavirus can infect human macrophaghes and monocytes.[22]

Factors that play important role in CNS manifestation is ACE-2 receptors as described earlier. Additionally enhanced vagal tone,[23] and decreased brain catecholamine activity contribute to neurological manifestations.[24] Neuro-invasiveness and neuro-virulence with a hyper- coagulable, state adds to cascade which results in protean presentations in COVID.

Some of the reported neurological presentations apart from anosmia are, Bell's palsy, Gullian Barre Syndrome, encephalitis, meningitis, seizures, headache, peripheral neuropathy, and other other cranial nerve involvement. Stroke due to hyper coagulation state has been widely reported. Recovery of anosmia and facial palsy occurs over period of 6-8 weeks.[25],[26]


  COVID-19 and Aneurysm Subarachnoid Haemorrhage Top


There have been several reports on neurological sequelae of COVID-19, with emphasis on stroke and intracerebral haemorrhage (ICH). Literature is essentially scanty on subarachnoid haemorrhage (SAH) due to rupture of aneurysm in patients with COVID infection. Pseudoaneurysm rupture resulting in haematoma in adolescent girl was attributed to mycotic infection.[27] An isolated report from Poland[28] reported clipping of middle cerebral artery aneurysm in December 2019 on a 70-year-old male with good recovery with no staff getting infected.

In a study from Berlin, Hecht[29] reported that during the pandemic, the percentage of neuroemergencies amongst all neurological admissions remained similar, but larger proportion presented in emergency than through OPD. Total number of neurological emergencies was significantly reduced (P < 0.001) across all cases. For SAH, number of cases, SAH grade, location and treatment modality did not change, but elderly patients with chronic SDH were less frequent. They further adopted neurosurgery emergency scale proposed by German society in 1–6 categories (29) wherein SAH was put in category 1.

Bengar et al.[30] in a retrospective case series reported ICH in COVID patients. It was observed that haematoma was in more in younger age 52.2 years (41–64 years), lobar in location (4/5) and a notable delay between time of COVID-19 to bleed with a median time lag of 32 days.

Neurosurgical practice during COVID-19 and aneurysm poses several unanswered questions. First, it is unclear whether there is an increased risk of rupture of aneurysm due to changes in endothelial lining due to COVID in aneurysm wall or whether there is a rise in incidence of aneurysm formation.

The second important issue is if the prognosis of SAH during COVID period different. There are reports of stormy post-operative recovery period due to risk of added infection, i.e., bacterial and fungal, which can pose threat to life in post-operative period of COVID-positive patients. Fearing the risk many patients preferred to get their surgery postponed. There may be a higher incidence of thrombosis and vasospasm following surgery in aneurysm. Such analogy has convincing arguments and justification in making a decision for postponing of elective cases. However, it opens avenues for ethical discussions on risk versus benefit in waiting in emergency.

Delay in surgery for COVID-positive patients with SAH till reports became negative was opted by two patients. Both were operated later on after 4 weeks successfully. The risk of waiting such cases till all biochemical parameters normalise has to be carefully weighed after detailed discussion with patients to avid litigations.

A major concern has emerged on type of care on a patient admitted in ICU. The observations in COVID time are that largely the care of patients is suboptimal. Fear of infection in HCWs, actual infection in HCW during duty, death of colleagues due to COVID, non-availability of protective gadgets freely, relocation of staff to COVID centres resulting in shortage of workforce and delay in supply of medicines due to lockdown are some of the genuine contributing attributes in devoting less time on patient care.


  Coiling Versus Clipping in COVID Patients Top


The third important concern is choosing the method of treatment of aneurysm on a COVID-positive case. The debate on coiling vs clipping has become more interesting in the COVID era. Debate on coiling versus clipping has become more interesting in COVID time. Merit of coiling seems to have edge over clipping as it utilises irrigation of heparin during procedure. It will compensate risk of hypercoagulation state of an underlying COVID condition. In addition, duration of procedure is short and patients can be discharged with short hospital stay.

In our data of treatment of aneurysm from January 2019 to December 2019, 179 aneurysms were treated, of which 100 patients underwent clipping and 79 coiling. During COVID time, there were some falls in number of cases. In the year 2020, 142 patients underwent treatment of aneurysm (86 – clipping and 56 – coiling) [Figure 1].
Figure 1: Comparison of number of aneurysm cases in 2019 versus 2020

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The significant fall in total number of cases reported for treatment was observed in the second quarter of the year 2020. From April to June during the first phase of COVID in Delhi, only 18 patients of aneurysms were treated as against 44 in the year 2019 at GIPMER. The number of cases increased in later months.

Our observation was that there was late reporting of even emergency cases due to the lockdown from April 2019 onwards. Due to closure of most of public sector hospitals for non-COVID care, GIPMER is the exclusive place for treatment in Delhi from April 2019 till date. There was reluctance in reporting COVID patients for the fear of notice tagged outside home by the authorities, forced isolation and quarantine of family, even transport from other states to Delhi was difficult in June to August 2019.

There is an emerging role of telemedicine during COVID.[31] Teleconsultation was legalised in India to cope up challenges of pandemic. Greater responsibility lies to handle mitigation measures.[32] Care of emergent neurovascular cases will require added role of societies to handle consequences of pandemic[33] which still looms at large. With vaccination on, one prays for stabilisation of COVID but emerging new strains are posing additional threats. We have to watch progress with caution and continue to adopt all protective measure with no complacency till unknown period.



 
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