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Letter to the Editor Regarding “Coronavirus Disease 2019 (COVID-19) and Neurosurgery: Literature and Neurosurgical Societies Recommendations Update” LETTER: We read with great interest the article by Germanò et al,1 “COVID-19 and Neurosurgery; Literature and Neurosurgical Societies Recommendations Update.” This paper provides a relevant insight into the management of neuro-oncologic patients during the COVID-19 pandemic, which has fast spread worldwide and critically impacted the health care system. Italy has been one of the most affected countries, witnessing dramatic revolutions in routine practice.1-9 In such intense atmosphere, neurosurgical departments are balancing between the urgent and emergency cases, public-opinion concerns about transmission, and safety of the staff and patients.1-8 Regarding neurooncologic patients, as already reported by Zoia et al,2 a priority criteria were established in order to stratify the urgency of the cases: Class Aþþ represents patients who require immediate treatments, with intracranial or spinal oncologic pathology (rapidly evolving intracranial hypertension with deteriorating state of consciousness, acute hydrocephalus, spinal cord compression with rapid tetraparesis or paraparesis); Class Aþ comprises patients who require treatment within a maximum of 7e10 days, with intracranial tumors with mass effect or with progressive neurologic deficit, without deterioration of consciousness; and patients requiring treatment within a month, namely Class A, with neurologic alteration or suspected malignant lesion related to oncologic pathology. We report a survey conducted by the neurosurgical team of the Emergency Regional Hospital of Ancona (Italy), which serves approximately 1.5 million inhabitants. During the past 3 months, from February to April 2020, despite the halving of elective cases in the weekly schedule, due to the redistribution of staff, the number of oncologic patients who underwent surgical treatment in our department was approximately analogous to the same time period in 2019 (FebruaryApril, 49 patients in 2020 and 45 patients in 2019). Nonetheless, the amount of urgent or emergency cases, accessing from emergency room, substantially rocketed, reaching 57.1% compared with 31.1% in 2019, as reported in Table 1. Interestingly, patients with spinal lesions were the most affected, recording 76.9% with emergency department access (10 out of 13 patients), while the same feature in 2019 was slightly more than 45% (5 out of 11 patients). As highlighted in Table 1, the most common symptom was a progressive paraparesis and all patients reported a previous history of neglected upper or low back pain. These data, in our survey, were related to a public health concern, in the patient’s point of view, about visiting hospitals during the COVID-19 crisis, especially for not apparently alarming symptoms, usually related to degenerative spine pathologies such as back pain. In addition, the temporary difficult access to radiologic examinations may have also influenced the postponement in diagnosis. This resulted in progression of neurologic symptoms, without an early neurosurgical evaluation, until the onset of acute deficit, which actually led to emergency department access. The same patient’s attitude, even if with minor impact, was registered in those affected by brain lesions, in which the percentage of patients with acute onset, and subsequent via emergency room evaluation, dramatically increased in the past 3 months compared with 2019. As a matter of fact, the most common symptoms were consciousness alteration and seizures; in our survey approximately 10.7% of acute-onset patients reported to have previously refused surgical treatment, in the weeks before, correlated to concerns about hospitalization during the coronavirus emergency. Even if it is widely known that time is essential for clinical and neurologic outcomes, our survey did not have sufficient follow-up to properly compare the outcomes between the 2 time periods analyzed, so further evaluations would be indispensable to appropriately investigate this aspect. In conclusion, during the COVID-19 pandemic the neurosurgical urgent and emergency onset of neurooncologic cases increased, in comparison with 2019. Our survey highlighted how this trend is Table 1. Neuro-oncologic Patients’ Access, Comparing the COVID-19 Time Period and 2019 Characteristics FebruaryLApril 2020 FebruaryLApril 2019 Total number of neurooncologic cases 49 45 Ratio emergency/elective total cases 28/49 (57.1%) 14/45 (31.1%) Ratio emergency/elective cases of spinal lesions 10/13 (76.9%) 5/11 (45.1%) Ratio emergency/elective cases of cranial lesions 18/36 (50%) 9/34 (26.5%) Acute presenting symptoms of spinal lesions 10 5 Paraparesis or tetraparesis 5/10 (50%) 3/5 (60%) Sphincteric disturbance 2/10 (20%) 1/5 (20%) Combination 3/10 (30%) 1/5 (20%) Acute presenting symptoms of cranial lesions 18 9 Acute hydrocephalus 2/18 (11.1%) 1/9 (11.1%) Seizures 12/18 (66.6%) 2/9 (22.2%) Hemiparesis 7/18 (38.8%) 5/9 (55.5%) Consciousness deterioration 10/18 (55.5%) 3/9 (33.3%) Cranial nerve palsy 7/18 (38.8%) 1/9 (11.1%) Patients who refused hospitalization and who had further emergency access 3/28 (10.7%) None Patients who underestimated their symptoms 20/28 (71.4%) 1/14 (7.1%) Patients who had difficult access to radiologic examinations 3/28 (10.7%) None Patients who refused hospitalization due to infection risk 10/28 (35.7%) None WORLD NEUROSURGERY -: ---, MONTH 2020 www.journals.elsevier.com/world-neurosurgery 1 Letter to the Editor minorly related to a combination of difficulty accessing radiologic examinations and mostly to patients’ concerns about hospitalization. The consequent apprehension should be restoring the public health judgement in order to rebalance this trend and subsequently improve the clinical outcome of patients. A reasonable response in this contest can be the intensification of telemedicine clinic visits, as well as ameliorating the clinic scheduling safety, concomitantly to the mass media impact on public health opinion, in order to reestablish confidence in the health care system, in such an intense atmosphere of fear. Alessandra Marini, Maurizio Iacoangeli, Mauro Dobran Clinic of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedali Riuniti, and Department of Neurosurgery, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy To whom correspondence should be addressed: Alessandra Marini, M.D. [E-mail: marini.alessandra.am@gmail.com] Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. https://doi.org/10.1016/j.wneu.2020.05.160. REFERENCES 1. Germanò A, Raffa G, Angileri FF, Cardali SM, Tomasello F. Coronavirus disease 2019 (COVID-19) and neurosurgery: literature and neurosurgical societies recommendations update [e-pub ahead of print]. World Neurosurg. https://doi.org/ 10.1016/j.wneu.2020.04.181, accessed April 1, 2020. 2. Zoia C, Bongetta D, Veiceschi P, et al. 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Neurosurgery. https://doi.org/10. 1093/neuros/nyaa118, accessed April 11, 2020. 6. Zacharia BE, Eichberg DG, Ivan ME, et al. Letter: surgical management of brain tumor patients in the COVID-19 era [e-pub ahead of print]. Neurosurgery. https:// doi.org/10.1093/neuros/nyaa162, accessed April 29, 2020. 7. Ramakrishna R, Zadeh G, Sheehan JP, Aghi MK. Inpatient and outpatient case prioritization for patients with neuro-oncologic disease amid the COVID-19 pandemic: general guidance for neuro-oncology practitioners from the AANS/ CNS Tumor Section and Society for Neuro-Oncology [e-pub ahead of print]. J Neurooncol. https://doi.org/10.1007/s11060-020-03488-7, accessed April 9, 2020. 8. Dobran M, Paracino R, Iacoangeli M. Letter to the editor by Dobran Mauro, Paracino Riccardo, and Iacoangeli Maurizio regarding “Neurosurgery during the COVID-19 pandemic: update from Lombardy, northern Italy.” Zoia C, Bongetta D, Veiceschi P, Cenzato M, Di Meco F, Locatelli D, Boeris D, Fontanella MM. Acta Neurochir (Wien). 2020 Mar 28. doi:10.1007/s00701-020-04305-w. Acta Neurochir. 2020;162:1223-1224. 9. Dobran M, Marini A, Splavski B, et al. Surgical treatment and predictive factors for atypical meningiomas: a multicentric experience [e-pub ahead of print]. World Neurosurg. https://doi.org/10.1016/j.wneu.2020.03.201, accessed April 1, 2020. 2 www.SCIENCEDIRECT.com -: ---, MONTH 2020 WOR
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