Neurology India
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Even in ideal circumstances, the performance of safe and effective endoscopic transsphenoidal pituitary surgery requires complicated orchestration of care amongst multiple medical and surgical teams in the preoperative, intraoperative, and postoperative settings. The current COVID-19 pandemic further complicates this highly orchestrated effort. Healthcare systems around the globe are working to adapt to the rapidly changing healthcare landscape as information about the SARS-CoV-2 virus is discovered and disseminated. The nature of the transsphenoidal corridor exposes the pituitary surgery team to increased risk of virus exposure.
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Pituitary adenomas are one of the common indications for gamma knife radiosurgery. Gamma knife enables one to deliver a very high radiation dose to the target in a single fraction. Due to steep radiation fall out of Gamma Knife, the adjacent visual apparatus gets minimal radiation. ⋯ Control rates varies from 76-87% at 10 years are described in non-functional pituitary adenomas. In functional adenomas, to achieve hormonal remission a higher marginal dose up to 25 Gy is needed. However, primary gamma knife radiosurgery is needed in some situations - for instance, when the patient is unfit for surgery due to various reasons or surgical difficulties like the presence of kissing carotids.
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The COVID-19 pandemic is currently an evolving situation. Operating rooms (OR) are high-risk areas for the transmission of any respiratory infection with multiple personnel involved, in close proximity. Of concern to neurosurgeons, is the high-risk of aerosol generating procedures (AGPs) like transsphenoidal and endonasal surgery. Endonasal AGPs theoretically present a higher risk of viral exposure due to the longer duration of exposure and aggressive disruption of potentially virus-containing mucosa. ⋯ In all emergency patients, it is preferable to consider transcranial surgery or a sub-labial approach avoiding exposure to mucosa. Due to laboratory constraints routine swabs is not always available. Therefore, routine preoperative screening computed tomography (CT) chest is performed in all patients. Based on risk of transmission of infection to others, we propose a classification of patients for skull-based surgery into low, high and very high risk groups and suggest suitable personal protective equipment. Additionally, we discuss avoiding use of powered drills in or any AGP. However, cold procedures involving shavers and microdebriders generate lesser amounts of aerosol. Post-operatively, the length of stay could be reduced with a multidisciplinary approach.
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COVID-19, in most patients, presents with mild flu-like illness. Elderly patients with comorbidities, like hypertension, diabetes, or lung and cardiac disease, are more likely to have severe disease and deaths. Neurological complications are frequently reported in severely or critically ill patients with comorbidities. ⋯ Myalgia/fatigue is also common, and elevated creatine kinase levels indicate muscle injury. Most of the reports about neurological complications are currently from China. COVID-19 pandemic is spreading to other parts of the world; the spectrum of neurological complications is likely to widen further.
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The COVID-19 pandemic has within months turned the world upside down. With personal distancing and shortage of personal protective equipment, face-to-face health care encounters are increasingly becoming problematic. Neurological manifestations are also being observed in clinical presentations. ⋯ With possible reduction in face-to-face consultations, remote evaluation may become mainstream. Webinars will play an increasing role. CME's and resident training will become more and more digital. The world will never be the same again. It is imperative that we accept and start deploying the "New Normal".