Surgical treatment of patients with neurosurgical pathology combined with COVID-19

The objective is to present first-hand experience of microsurgical operations in patients with neuro-oncological diseases, vascular pathology and COVID-19 in the absence of unified standards of work during the pandemic, as well as summarize literature data on this problem.

Clinical cases. Five cases of surgical interventions in patients with moderate COVID-19 pneumonia are presented: 1) microsurgical clipping of a saccular aneurysm of the posterior communicating artery which caused massive basal subarachnoid hemorrhage with bleeding into the IV ventricle; 2) microsurgical resection of glioblastoma of the right temporal lobe; 3) resection of an intracerebral hematoma in the right temporal, occipital and parietal lobes with total volume of 100 cm3 which caused transverse brain dislocation up to 10 mm to the left; 4) micro coil embolization of a ruptured aneurysm of the posterior communicating artery; 5) microcoil embolization of a ruptured aneurysm of the right middle cerebral artery. All surgeries were performed in personal protective gear and FFP3 masks.

In 3 patients, positive pneumonia dynamics were observed; in 2 patients (with glioblastoma and subarachnoid hemorrhage from an aneurysm of the right middle cerebral artery), dynamics were negative. Among 5 patients, 4 were discharged in stable condition, 1 case ended in death (despite the absence of coagulopathy, massive brain ischemia with hemorrhagic transformation developed, probably due to endothelial cell dysfunction, high vascular permeability of cerebral arteries in conjunction with coronavirus effect on angiotensin transforming enzyme receptors).

Literature analysis. Summarizing experiences of other researchers, the following changes in organization of neurosurgical practice during the pandemic can be recommended: 1) all patients should be considered potentially infected; 2) emergency surgeries should be performed under local anesthesia and/or in separate operating rooms; 3) in emergency cases of vascular pathology of the brain, endovascular interventions are the preferred approach; 4) surgeries should be performed in FFP2/FFP3 masks, protective goggles, two pairs of gloves, protective suits and shoe covers; 5) the number of personnel in the operating room should be minimized; 6) manipulations that can potentially lead to increased formation of aerosol (craniotomies, coagulations) should be performed with special care, craniotome rotation speed should be decreased to minimize formation of bone particles, opening of paranasal sinuses and mastoid cells should be avoided if possible; 7) negative pressure (—5 Pa) should be maintained in the operative room, frequency of interruption of the artificial lung ventilation machine circuit should be minimized, patients’ nose and mouth should be covered with wet wipes; 8) the personnel should be divided into several teams working in turns; 9) personnel older than 65 years should be isolated; 10) planned surgeries should be postponed indefinitely and patients should be consulted by phone, hospitalized only if their condition worsens; 11) during admission, patients should be placed in observation rooms, where thermometry, computed tomography of the lungs and pharyngeal swab for SARS-CoV-2 should be performed; 12) regardless of the SARS-CoV-2 analysis result, patients after surgery should be quarantined for 14 days.

Conclusion. Our experience shows that patients with concomitant COVID-19 infection can receive neurosurgical help. Compliance with the guidelines leads to low risk of infection for the personnel and sufficient quality of medical care.

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