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EDITORIAL
Year : 2020  |  Volume : 68  |  Issue : 2  |  Page : 244--245

The COVID-19 Pandemic: Challenges for the Neurosurgeons and Neurologists

GC Khilnani 
 PSRI Institute of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital; Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India

Correspondence Address:
G C Khilnani
PSRI Institute of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, Sheikh Sari Phase II, New Delhi - 110 017
India




How to cite this article:
Khilnani G C. The COVID-19 Pandemic: Challenges for the Neurosurgeons and Neurologists.Neurol India 2020;68:244-245


How to cite this URL:
Khilnani G C. The COVID-19 Pandemic: Challenges for the Neurosurgeons and Neurologists. Neurol India [serial online] 2020 [cited 2020 Jun 1 ];68:244-245
Available from: http://www.neurologyindia.com/text.asp?2020/68/2/244/283762


Full Text

[AUTHOR:1]

Outbreaks of viral infections have threatened human life for long. The Spanish Flu of 1981 is the burning example where an estimated 50-100 million people lost their lives. Corona virus is prevalent in animals and has caused two major outbreaks in humans (SARS 2002, MERS 2012). In December 2019, several cases of unexplained severe pneumonia were seen which were later diagnosed to be due to corona virus infection. Since the clinical presentation was of Severe Respiratory Distress Syndrome (SARS) and both shared same receptor (Angiotensin Converting Enzyme 2), it was named SARS Corona virus-2 (SARS Co V2). Subsequently, WHO termed the same as COVID-19.[1],[2] Till date (3.4.2010), there are more than one million confirmed cases of COVID-19 and more than fifty thousand people have lost their lives to this deadly disease.

Understanding of clinical profile of this new viral disease is by retrospective studies. The clinical features are of any other 'flu', i.e., fever, cough, sore throat running nose, sneezing, and in severe cases, breathlessness. A retrospective study of 1099 cases revealed that only 43.8% cases had fever at the presentation and 12.3% patients did not have fever throughout the illness. In this study 5% required ICU care, 2.3% were put on mechanical ventilation and 1.4% cases died.[3] The worst affected people with this infections are elderly, those with co-morbidities such as hypertension, diabetes, chronic kidney and liver disease, cancers and pre-existing structural lung disease.[4],[5]

There are some characteristics of this infection which make the control of this outbreak difficult. This is important because till date there is no effective antiviral treatment and the vaccine is not going to be available in near future. The route of infection is by respiratory tract and transmission is by droplets and fomites. The peculiar character is that droplets do not go beyond distance of one meter, while the virus survives on fomites for up to 7-9 days, making social distancing and sanitization of hands and fomites primary targets for prevention of transmission. The virus is also excreted in faeces, however, faeco-oral transmission has not been documented and hence not important.

Covid-19 disease to start with has respiratory involvement, however, systemic manifestations are also there. As the disease becomes severe nervous system is also involved. With any disease which causes disseminated intravascular coagulation and multi-organ dysfunction, there would be nervous system involvement. In a retrospective study from China, neurological manifestations were seen in 34.6% patients (45.5% is severe cases). The most common neurological complaints were dizziness (16.8%) and headache (13.1%). The patients also presented with Hypogeusia (5.6%) and hyposmia (5.1%).[6] Acute cerebrovascular strokes, impaired consciousness and skeletal muscle injury was also seen. Patients with neurological symptoms were found to have lower lymphocyte counts, platelet counts and deranged renal functions.[6] Markers of inflammation like CRP were found to be higher in patients with skeletal muscle injury. Also, Creatinine phosphokinase (CPK) and lactate dehydrogenase (LDH) were found to be raised in these patients, which is a marker of muscle injury in other disorders as well.

Angiotensin converting enzyme-2 (ACE2) is recognized as functional receptor for SARS-CoV2 which is present in many organ systems including nervous system and skeletal muscle which may contribute to neurological injury.[7] Neurological injury has been seen in other Corona virus infections as well. SARS-CoV nucleic acid have been found in cerebrospinal fluids of patients and also in brain tissue on autopsy.[8],[9] As with other Corona viruses, the spread of this virus to the nervous system is proposed to be haematogenous or retrograde neuronal route which may be the cause of anosmia in these patients. A direct viral injury to neurological tissue also seems to be a possibility as other non-human Corona viruses are seen to be neurotropic, has not been demonstrated in any of the current data. There is still no data if this virus can lead to acute demyelinating encephalomyelitis (ADEM) or Gullian Barre Syndrome (GBS), but we should be on look out as these can be potential post-infectious complications. In view of report from Italy of increased number patients coming with CNS symptoms and complications like cerebrovascular events, there is a need for more investigations of virus link with nervous system.

During this pandemic, while seeing Neurology and Neurosurgery patients, SARS-CoV2 (Covid-19) should be kept in mind to avoid delayed diagnosis. Missing diagnosis of Covid-19 would be detrimental to other patients in the neurology/neurosurgery wards and ICUs, leading to delayed diagnosis and spread of this deadly infection. At the same time, the treating doctor should also pay close attention to neurological problems associated with COVID-19, as these are associated with poor prognosis.(1) As with other departments, it is advisable to take history of travel and contact with Covid-19 from all the patients during this time of pandemic. A large proportion of patients with neurological diseases are elderly with co-morbidities. During the pandemic, it is advisable to encourage home care instead of admitting them to hospital. There by avoiding their, non urgent cases, exposure to the hospital environment with potential Covid patients. Neurosurgeons should restrict routine surgical procedure and there should be higher level of disinfection of operating rooms and the post-operative units when emergency surgeries are undertaken. Use of personal protective equipment and N 95 masks while treating all suspected patients will go a long way to protect Health care workers.

In the event of community transmission and high load of Covid patients in the area, Neurology/Neurosurgery departments may be required to make special COVID-19 units as done in Italy. Healthcare workers, including those working in Neurology and Neurosurgery, should be well versed with donning and doffing of personal protective equipment. It is important to protect yourself and through this exercise of caution, your patients and colleagues.

References

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2Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: Implications for virus origins and receptor binding. Lancet 2020;395:565-74.
3Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020. doi: 10.1056/NEJMoa2002032.
4Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020 ; doi: 10.1001/jama.2020.2648. [Epub ahead of print].
5Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et, al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020; 395:1054-1062.
6Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 2020 Apr 10. doi:10.1001/jamaneurol.2020.1127. [Epub ahead of print].
7Hamming I, Timens W, Bulthuis MLC, Lely AT, Navis G, van Goor H. Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol 2004;203:631-7.
8Desforges M, Favreau DJ, Brison E, Desjardins J, Messen-Pinard M, Jacomy H, et al. Human coronavirus: respiratory pathogens revisited as infectious neuroinvasive, neurotropic, and neurovirulent agents. In Singh SK, Ruzek D. (ed), Neuroviral infections: RNA viruses and retroviruses. CRC Press LLC, New York, NY; 2013. p 93-121.
9Arabi YM, Balkhy HH, Hayden FG, Bouchama A, Luke T, Baillie JK, et al. Middle East respiratory syndrome. N Engl J Med 2017;376:584-94.