To the Editor:
Chronic subdural hematomas (CSDHs) are encapsulated collections of blood breakdown
products and fluid between the dura mater and the arachnoid.
1
Their global incidence is estimated to be about 5/100 000/yr in patients younger than
65 yr,
2
increasing to 58/100 000/yr in patients over 65 yr.
1
Surgery usually allows a good outcome even in elderly. The clinical outcome of CSDH
is conditioned by comorbidities including pulmonary diseases.
Nowadays, we are facing a new possible condition related to coronavirus disease 2019
(COVID-19) that could affect the outcome. The spread of this infection started in
2019, December 31st when China alerted WHO about cases of unusual amount of interstitial
pneumonia (IP) in Wuhan. After 7 d, on January 7th, scientists announced they had
identified a new virus named COVID-19 similar to SARS-CoV. Italy is dealing with pandemic
spread of COVID-19. As a matter of fact, on 19th March, it became the country with
the highest number of confirmed deaths in the world. On March 23rd 2020 Italy was
the world's centre of the epidemic with 69.176 confirmed cases, 6.820 deaths, and
21.137 recoveries.
3
Clinically COVID-19 could lead to a severe IP and acute respiratory distress syndrome
(ARDS), especially in older patients with multiple comorbidities.
4
No studies about surgery in COVID-19 patients have been reported so far. We aim to
describe our surgical experience with CSDH in a COVID-19 neurosurgical center.
We admitted 5 patients with CSDH to the Neurosurgical Department of Brescia University
Hospital between February 21, 2020 (first COVID-19 case reported in Italy) and March
23, 2020. The patients were positive for COVID-19 real-time polymerase chain reaction
obtained by nasopharyngeal swab.
5,6
We gathered the following data for each patient: age and sex, Cumulative Illness Rating
Scale,
7
antithrombotic therapy and perioperative mortality (within 30 d). All the patients
had signed a consent form approved by the Local Ethic Committee regarding the use
of their clinical data. We compared the mortality rate of this new cohort with the
data extracted from our pre-COVID-19 CSDH case series.
All the patients underwent pre-operative chest X-Ray (CXR) or computed tomography
(CT) and routine blood test. An anesthesiological evaluation was performed for each
patient. We cohortized our neurosurgical ward to separate COVID-19 positive from negative
cases. COVID-19 positive patients started anti-retroviral therapy with lopinavir/ritonavir
and hydroxychloroquine. Daily arterial blood gas analysis and CXR were performed.
Surgery or endovascular treatment were indicated when the CSDH was symptomatic (presence
of focal neurological deficits or mental status changes) and the maximum thickness
was greater than 1 cm (Figures 1-4). One case did not present severe neurological
impairment and was treated conservatively (Figure 5). No preoperative respiratory
impairment was observed.
FIGURE 1.
A and B, Head CT scan, axial view: pre- and postoperative CDSH. C, CXR showing bilateral
and diffuse IP.
FIGURE 2.
A, Head CT scan, axial view: bilateral CSDH. B, CXR showing bilateral and diffuse
IP. C and D, MMA embolization procedure.
FIGURE 3.
A, Head CT scan, axial view: preoperative CSDH. B, Head CT scan, axial view: postoperative
CSDH with signs of recent rebleeding. C, CXR showing bilateral and IP. D, Chest CT
scan, axial view, showing ground glass opacity.
FIGURE 4.
A, Head CT scan, axial view: preoperative left CSDH. B, Head CT scan, axial view:
postoperative CSDH with signs of recent rebleeding. C, CXR showing bilateral IP.
FIGURE 5.
A, Head CT scan, axial view: left CSDH. B, normal CXR.
We treated all the CSDH patients under general anesthesia. Three patients were operated
(2 through craniotomy and 1 with a burr hole). Endovascular occlusion of the middle
meningeal artery (MMA) was performed in 1 case (Figure 2). In the surgical cases we
placed a subdural drainage for 48 h. After its removal patients underwent a CT head
scan (Figures 1, 3, and 4). Afterwards the patients started low-molecular-weight heparin
at prophylactic dose before mobilization. The cases are reported in the supplementary
material section (
Supplemental Digital Content
).
CSDHs mostly occur in elderly, with an average age of 63.
1
Head trauma is the major risk factor, identified in less than 50% (often minor head
trauma).
8
Other risk factors are described like alcohol abuse, seizures, CSF shunts and coagulopathies,
including therapeutic anticoagulation. CSDHs are bilateral in 20% to 25% of cases.
9
At present there is no scientific experience regarding surgical outcome of COVID-19
patients.
We compared the recent cohort of COVID-19 CSDH patients with our historical series.
Between May 2018 and September 2019, we operated 142 patients for CSDH and we observe
5 death at our Institution. Our mortality rate was 3.7% according to the literature.
10
In our recent experience, we observed 4 death in 5 COVID-19 patients suffering from
CSDH. Therefore, we observed a mortality rate of 80% about 21,6 times greater than
our control data.
HEMATOLOGICAL DISORDERS
We observed 2 cases of mild thrombocytopenia (Table). In these cases, we observed
a re-bleeding (Figures 3 and 4) that led from a rapid neurological worsening to death
within 5 d. This condition could be related to COVID-19 infection, as reported in
literature.
11
Independently from the hemorrhagic risk, Lippi et al
12
showed that low platelet count is associated with increased risk of severe disease
and mortality in patients with COVID-19, and this should serve as clinical indicator
of worsening illness during hospitalization.
12
In our series, we suppose that thrombocytopenia led to re-bleeding and was associated
with poor outcome.
TABLE.
Clinical Features of our Cohort
Sex
Age
CIRS
AT
Side
COVID-19
IP
TP*
Surgery
Time to death(d)
M
82
13
Yes
Left
+
+
No
Burr-hole
14
M
86
18
No
Bilateral
+
+
No
MMA embolization
10
M
77
20
No
Right
+
+
Yes
Craniotomy
5
M
85
22
Yes
Left
+
+
Yes
Burr-hole
5
M
78
19
Yes
Left
+
–
No
NO
Alive
*TP (Thrombocytopenia): 100.000<PLTs<150.000
All patients developed IP after surgery. Thrombocytopenia was observed in 2 cases
(40%). The patients suffered rebleeding and showed a shorter time to death. CIRS (Cumulative
Illness Rating Scale), AT (antithrombotic drugs), IP (Interstitial Pneumonia), COVID-19
(Coronavirus Disease 2019).
INTERSTITIAL PNEUMONIA
Dyspnoea and fatigue occurred in all our patients within 48 hours from surgery. CXR
revealed severe IP (Figures 1-4). Ground glass opacity and bilateral patchy shadowing
were observed on the chest CT (Figure 3).
5,13
All our patients had COVID-19 infection without pre-operative respiratory symptoms.
Immune system could be impaired following surgical procedures and this may have unmasked
a subclinical infection.
14,15
On the other hand no respiratory failure was observed in the conservative-treated
case (Figure 5).
In our experience IP occurred in all cases after treatment and worsened the outcome.
This evenience represents a possible complication, often fatal, of COVID-19 infection.
5
HEALTH EMERGENCY
Nowadays, Italian health care system is the most afflicted in the pandemic scenario.
16
The overload of the intensive care units in Lombardy, despite the efforts made, has
necessarily influenced the resuscitation possibilities of elderly patients.
17
Therefore, we cannot exclude that our results could be affected by the health emergency
status.
Seung et al. reported good bleeding control from CSDH membrane with MMA embolization,
prevention of further growth of hematoma and even spontaneous resolution without surgery.
18
Anyway our endovascular treated patient showed the same poor outcome of the surgical
cases.
Although statistical analysis of these preliminary data is not possible, COVID-19
patients appear to suffer from a negative surgical outcome. It is our belief that
conservative treatment should be preferred whenever surgery could be postponed.
Disclosures
The authors have no personal, financial, or institutional interest in any of the drugs,
materials, or devices described in this article.
Supplementary Material
nyaa140_Supplemental_File
Click here for additional data file.