Coronavirus disease (COVID-19) in neurology and neurosurgery: A scoping review of the early literature
Identifieur interne : 000889 ( Pmc/Corpus ); précédent : 000888; suivant : 000890Coronavirus disease (COVID-19) in neurology and neurosurgery: A scoping review of the early literature
Auteurs : Mitchell P. Wilson ; Andrew S. JackSource :
- Clinical Neurology and Neurosurgery [ 0303-8467 ] ; 2020.
Abstract
Pre-existing cerebrovascular disease may be a risk factor for poor outcome in patients infected with COVID-19. COVID-19 infection may manifest as neurological symptomatology, including: headache, dizziness, hypogeusia and/or anosmia, altered level of consciousness, acute cerebrovascular events, seizure(s), and ataxia. Although the mechanism of invasion is not fully understood, COVID-19 appears to demonstrate neuroinvasive potential. Viral encephalitis +/- hemorrhagic necrosis involving mesial brain structures such as the mesial temporal lobes and thalami have been reported to date. Long-term neurodegenerative effects of COVID-19 have yet to be elucidated, but are theorized based on past experience with other beta-coronaviruses. Neurology and neurosurgical practice patterns are being changed dramatically and constantly updated with publications demonstrating early experiences and recommendations based on facilities and regions most affected.
Url:
DOI: 10.1016/j.clineuro.2020.105866
PubMed: NONE
PubMed Central: 7179494
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Coronavirus disease (COVID-19) in neurology and neurosurgery: A scoping review of the early literature</title><author><name sortKey="Wilson, Mitchell P" sort="Wilson, Mitchell P" uniqKey="Wilson M" first="Mitchell P" last="Wilson">Mitchell P. Wilson</name><affiliation><nlm:aff id="aff0005">Department of Radiology and Diagnostic Imaging, University of Alberta, 2B2.41 WMC, 8440-112 Street NW, T6G 2B7, Edmonton, Alberta, Canada</nlm:aff></affiliation></author><author><name sortKey="Jack, Andrew S" sort="Jack, Andrew S" uniqKey="Jack A" first="Andrew S" last="Jack">Andrew S. Jack</name><affiliation><nlm:aff id="aff0010">Department of Neurosurgery, University of California, San Francisco (UCSF), 400 Parnassus Ave, 94143, San Francisco, California, United States</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmc">7179494</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179494</idno><idno type="RBID">PMC:7179494</idno><idno type="doi">10.1016/j.clineuro.2020.105866</idno><idno type="pmid">NONE</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000889</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000889</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Coronavirus disease (COVID-19) in neurology and neurosurgery: A scoping review of the early literature</title><author><name sortKey="Wilson, Mitchell P" sort="Wilson, Mitchell P" uniqKey="Wilson M" first="Mitchell P" last="Wilson">Mitchell P. Wilson</name><affiliation><nlm:aff id="aff0005">Department of Radiology and Diagnostic Imaging, University of Alberta, 2B2.41 WMC, 8440-112 Street NW, T6G 2B7, Edmonton, Alberta, Canada</nlm:aff></affiliation></author><author><name sortKey="Jack, Andrew S" sort="Jack, Andrew S" uniqKey="Jack A" first="Andrew S" last="Jack">Andrew S. Jack</name><affiliation><nlm:aff id="aff0010">Department of Neurosurgery, University of California, San Francisco (UCSF), 400 Parnassus Ave, 94143, San Francisco, California, United States</nlm:aff></affiliation></author></analytic><series><title level="j">Clinical Neurology and Neurosurgery</title><idno type="ISSN">0303-8467</idno><idno type="eISSN">1872-6968</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>Highlights</title><p><list list-type="simple" id="lis0005"><list-item id="lsti0005"><label>•</label><p id="par0005">Pre-existing cerebrovascular disease may be a risk factor for poor outcome in patients infected with COVID-19.</p></list-item><list-item id="lsti0010"><label>•</label><p id="par0010">COVID-19 infection may manifest as neurological symptomatology, including: headache, dizziness, hypogeusia and/or anosmia, altered level of consciousness, acute cerebrovascular events, seizure(s), and ataxia.</p></list-item><list-item id="lsti0015"><label>•</label><p id="par0015">Although the mechanism of invasion is not fully understood, COVID-19 appears to demonstrate neuroinvasive potential. Viral encephalitis +/- hemorrhagic necrosis involving mesial brain structures such as the mesial temporal lobes and thalami have been reported to date.</p></list-item><list-item id="lsti0020"><label>•</label><p id="par0020">Long-term neurodegenerative effects of COVID-19 have yet to be elucidated, but are theorized based on past experience with other beta-coronaviruses.</p></list-item><list-item id="lsti0025"><label>•</label><p id="par0025">Neurology and neurosurgical practice patterns are being changed dramatically and constantly updated with publications demonstrating early experiences and recommendations based on facilities and regions most affected.</p></list-item></list></p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Paules, C I" uniqKey="Paules C">C.I. Paules</name></author><author><name sortKey="Marston, H D" uniqKey="Marston H">H.D. Marston</name></author><author><name sortKey="Fauci, A S" uniqKey="Fauci A">A.S. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Clin Neurol Neurosurg</journal-id><journal-id journal-id-type="iso-abbrev">Clin Neurol Neurosurg</journal-id><journal-title-group><journal-title>Clinical Neurology and Neurosurgery</journal-title></journal-title-group><issn pub-type="ppub">0303-8467</issn><issn pub-type="epub">1872-6968</issn><publisher><publisher-name>Elsevier B.V.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmc">7179494</article-id><article-id pub-id-type="publisher-id">S0303-8467(20)30209-2</article-id><article-id pub-id-type="doi">10.1016/j.clineuro.2020.105866</article-id><article-id pub-id-type="publisher-id">105866</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Coronavirus disease (COVID-19) in neurology and neurosurgery: A scoping review of the early literature</article-title></title-group><contrib-group><contrib contrib-type="author" id="aut0005"><name><surname>Wilson</surname><given-names>Mitchell P</given-names></name><email>mitch.wilson@ualberta.ca</email><xref rid="aff0005" ref-type="aff">a</xref><xref rid="cor0005" ref-type="corresp">⁎</xref></contrib><contrib contrib-type="author" id="aut0010"><name><surname>Jack</surname><given-names>Andrew S</given-names></name><email>asjack@ualberta.ca</email><xref rid="aff0010" ref-type="aff">b</xref></contrib><aff id="aff0005"><label>a</label>Department of Radiology and Diagnostic Imaging, University of Alberta, 2B2.41 WMC, 8440-112 Street NW, T6G 2B7, Edmonton, Alberta, Canada</aff><aff id="aff0010"><label>b</label>Department of Neurosurgery, University of California, San Francisco (UCSF), 400 Parnassus Ave, 94143, San Francisco, California, United States</aff></contrib-group><author-notes><corresp id="cor0005"><label>⁎</label>Corresponding author. <email>mitch.wilson@ualberta.ca</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>23</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>23</day><month>4</month><year>2020</year></pub-date><elocation-id>105866</elocation-id><history><date date-type="received"><day>11</day><month>4</month><year>2020</year></date><date date-type="rev-recd"><day>16</day><month>4</month><year>2020</year></date><date date-type="accepted"><day>17</day><month>4</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 Elsevier B.V. All rights reserved.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract abstract-type="author-highlights" id="abs0005"><title>Highlights</title><p><list list-type="simple" id="lis0005"><list-item id="lsti0005"><label>•</label><p id="par0005">Pre-existing cerebrovascular disease may be a risk factor for poor outcome in patients infected with COVID-19.</p></list-item><list-item id="lsti0010"><label>•</label><p id="par0010">COVID-19 infection may manifest as neurological symptomatology, including: headache, dizziness, hypogeusia and/or anosmia, altered level of consciousness, acute cerebrovascular events, seizure(s), and ataxia.</p></list-item><list-item id="lsti0015"><label>•</label><p id="par0015">Although the mechanism of invasion is not fully understood, COVID-19 appears to demonstrate neuroinvasive potential. Viral encephalitis +/- hemorrhagic necrosis involving mesial brain structures such as the mesial temporal lobes and thalami have been reported to date.</p></list-item><list-item id="lsti0020"><label>•</label><p id="par0020">Long-term neurodegenerative effects of COVID-19 have yet to be elucidated, but are theorized based on past experience with other beta-coronaviruses.</p></list-item><list-item id="lsti0025"><label>•</label><p id="par0025">Neurology and neurosurgical practice patterns are being changed dramatically and constantly updated with publications demonstrating early experiences and recommendations based on facilities and regions most affected.</p></list-item></list></p></abstract><abstract id="abs0010"><p>Coronavirus disease 2019 (COVID-19) is a devastating respiratory illness that has dramatically changed the medical landscape around the world. In parallel with a rise in the number of cases globally, the COVID-19 literature has rapidly expanded with experts around the world disseminating knowledge and collaborating on best practices. To date, the literature has predominantly consisted of case reports, case series, and systemic protocols for dealing with this deadly disease from a plethora of specialties with larger observational and randomized studies only now starting to emerge. This scoping review of MEDLINE, EMBASE, SCOPUS, and the Cochrane Library aims to evaluate and summarize the current status of the COVID-19 literature at it applies to neurology and neurosurgery. Neurological symptomatology, neurological risk factors for poor prognosis, pathophysiology for neuroinvasion, and actions taken by neurological or neurosurgical services to manage the current COVID-19 crisis are reviewed.</p></abstract><kwd-group id="kwd0005"><title>Abbriviations</title><kwd>SARS-CoV-2, severe acute respiratory syndrome coronavirus 2</kwd><kwd>COVID-19, coronavirus disease 2019</kwd><kwd>SARS-CoV, severe acute respiratory syndrome coronavirus</kwd><kwd>ACE2, angiotensin-converting enzyme 2</kwd></kwd-group><kwd-group id="kwd0010"><title>Keywords</title><kwd>SARS-CoV-2</kwd><kwd>COVID-19</kwd><kwd>neurology</kwd><kwd>neurosurgery</kwd><kwd>brain</kwd></kwd-group></article-meta></front><body><sec id="sec0005"><label>1</label><title>INTRODUCTION</title><p id="par0030">Several cases of pneumonia occurring in Wuhan, China including several patients with exposure to a large seafood market selling live animals was announced by Chinese authorities in late December 2019 [<xref rid="bib0005" ref-type="bibr">1</xref>]. The pathogen was isolated as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulting in Coronavirus Disease 2019 (COVID-19). The disease has since spread rapidly to most countries around the world. The World Health Organization declared COVID-19 a global pandemic as of March 11, 2020.</p><p id="par0035">Early reports have demonstrated respiratory predominant symptomatology including fever, cough, dyspnea, and fatigue [<xref rid="bib0010" ref-type="bibr">2</xref>]. However, as the prevalence of COVID-19 continues to increase globally, other disease manifestations such as those affecting the central nervous system (CNS) are reported [<xref rid="bib0015" ref-type="bibr">3</xref>]. Furthermore, the emergence of cases involving less commonly afflicted organ systems has necessitated rapid and dramatic changes in practice patterns and has significant implications for all specialties of medicine. This scoping review evaluates the current status of the COVID-19 literature as it relates to neurology and neurosurgery.</p></sec><sec id="sec0010"><label>2</label><title>METHODS</title><p id="par0040">The 26-item 2018 PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist was used as an outline for this study [<xref rid="bib0020" ref-type="bibr">4</xref>]. An a priori protocol was not pre-registered. A search of MEDLINE, EMBASE, Scopus, and the Cochrane Library (including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and the Cochrane Special Collections) from inception to April 7, 2020 was performed in order to identify articles evaluating both COVID-19 and neurology or neurosurgery. Variations of “COVID” AND “neuro OR brain OR spine OR peripheral nerve” related title/abstract/keywords and medical subject heading terms were performed with individual database search strategies outlined in <xref rid="tbl0005" ref-type="table">Table 1</xref>. No language restrictions were applied. Database searches were combined and duplicates were removed.<table-wrap position="float" id="tbl0005"><label>Table 1</label><caption><p>Search strategy by database. The systematic search was performed on April 7, 2020.</p></caption><alt-text id="at0005">Table 1</alt-text><table frame="hsides" rules="groups"><tbody><tr><td align="left">MEDLINE: (COVID.mp. OR COVID-19.mp. OR coronavirus disease 2019.mp. OR 2019-nCoV.mp. OR severe acute respiratory syndrome coronavirus 2.mp.) AND ([neurosurgery.mp. OR exp Nuerosurgery/] OR [neurology.mp. OR exp Neurology/] OR [neuroscience.mp. OR exp Neurosciences/] OR [exp Brain/ OR brain.mp.] OR [exp Spine/ OR spine.mp.] OR [peripheral nerve.mp. OR exp Peripheral Nerves/] OR [cerebrospinal fluid.mp. OR exp Cerebrospinal Fluid/])</td></tr><tr><td align="left">EMBASE: (COVID OR COVID 19 OR coronavirus disease 2019.mp. OR 2019-nCoV.mp. OR SARS-CoV-2.mp. OR severe acute respiratory syndrome coronavirus 2.mp.) AND ([neurosurgery.mp. OR exp Nuerosurgery/] OR [neurology.mp. OR exp Neurology/] OR [neuroscience.mp. OR exp Neuroscience/] OR [exp Brain/ OR brain.mp.] OR [exp Spine/ OR spine.mp.] OR [peripheral nerve.mp. OR exp Peripheral Nerves/] OR [cerebrospinal fluid.mp. OR exp Cerebrospinal Fluid/])</td></tr><tr><td align="left">Scopus: (TITLE-ABS-KEY(COVID OR COVID 19 OR [coronavirus AND disease 2019] OR 2019-nCoV OR SARS-CoV-2 OR [severe AND acute AND respiratory AND syndrome AND coronavirus 2]) AND TITLE-ABS-KEY(neurosurgery OR neurology OR neuroscience OR brain OR spine OR [peripheral AND nerve] OR [cerebrospinal AND fluid]))</td></tr><tr><td align="left">Cochrane Library: COVID AND (neuro* OR brain OR spine OR peripheral nerve OR cerebrospinal fluid</td></tr></tbody></table></table-wrap></p><p id="par0045">Title and abstracts were then reviewed for relevance and articles evaluating COVID-19 with relevance to neurology and/or neurosurgery were reviewed in full text by two authors with 6 and 9 years of experience in the neurosciences. Studies not relating to COVID-19 or the clinical neurosciences were excluded from review. Relevant references were reviewed. Forward searching of key articles was also performed in Google Scholar. A gray literature search of conference abstracts was not performed given the short interval since inception of COVID-19.</p><p id="par0050">Relevant content related to neurological symptomatology, neurological risk factors for poor prognosis, pathophysiology for neurological involvement, and action taken by neurological or neurosurgical services to manage the current COVID-19 crisis was collected. Critical appraisal of individual sources of evidence was not applied given variability of relevant content by study. Data from each article was extracted into Microsoft Excel v15.14 (Microsoft, Redmond, Washington, USA).</p></sec><sec id="sec0015"><label>3</label><title>RESULTS</title><p id="par0055">A total of 29 articles were identified from the databases after duplicate removal. Nineteen articles were excluded for lack of relevance to COVID-19 or the clinical neurosciences. A total of 10 articles including 4 articles discussing clinical symptomatology and/or the neuroinvasive potential of SARS-CoV-2 [<xref rid="bib0025" ref-type="bibr">[5]</xref>, <xref rid="bib0030" ref-type="bibr">[6]</xref>, <xref rid="bib0035" ref-type="bibr">[7]</xref>, <xref rid="bib0040" ref-type="bibr">[8]</xref>] and 6 articles discussing recommendations for modified neurosurgical [<xref rid="bib0045" ref-type="bibr">[9]</xref>, <xref rid="bib0050" ref-type="bibr">[10]</xref>, <xref rid="bib0055" ref-type="bibr">[11]</xref>], stroke [<xref rid="bib0060" ref-type="bibr">12</xref>], and spine [<xref rid="bib0065" ref-type="bibr">13</xref>,<xref rid="bib0070" ref-type="bibr">14</xref>] practices during the COVID-19 crisis. Three additional articles discussing neurological symptoms and invasive neurological potential of SARS-CoV-2 were identified through search article references and forward searching [<xref rid="bib0075" ref-type="bibr">[15]</xref>, <xref rid="bib0080" ref-type="bibr">[16]</xref>, <xref rid="bib0085" ref-type="bibr">[17]</xref>].</p><sec id="sec0020"><label>3.1</label><title>Neurological Symptoms and Prognostic Risk Factors in COVID-19</title><p id="par0060">Neurological symptomatology has been increasingly reported in recent publications. More frequent neurological symptoms can include headache (11-13%), dizziness (8-17%), and altered level of consciousness (8-9%) [<xref rid="bib0025" ref-type="bibr">5</xref>,<xref rid="bib0075" ref-type="bibr">15</xref>]. Several peripheral nervous system findings are also now reported in up to 5% of cases including include hypogeusia, hyposomia or anosmia, and neuralgia [<xref rid="bib0075" ref-type="bibr">15</xref>]. Less commonly, acute cerebrovascular disease (3%), epilepsy (1%), and ataxia (1%) have also been reported [<xref rid="bib0075" ref-type="bibr">15</xref>]. Although uncommon, background cerebrovascular disease may be a risk factor for poor outcome in COVID-19 patients [<xref rid="bib0025" ref-type="bibr">5</xref>].</p></sec><sec id="sec0025"><label>3.2</label><title>Invasive neurological potential of COVID-19</title><p id="par0065">SARS-CoV-2 is a single stranded RNA enveloped virus with an amino acid sequence similar to severe acute respiratory syndrome coronavirus (SARS-CoV) [<xref rid="bib0040" ref-type="bibr">8</xref>]. The virus is believed to use the angiotensin-converting enzyme 2 (ACE2) receptor for cellular adherence [<xref rid="bib0005" ref-type="bibr">1</xref>]. Typically causing respiratory or gastrointestinal disease, these ACE2 receptor epithelial and endothelial cells have been identified throughout the chest and abdomen [<xref rid="bib0090" ref-type="bibr">18</xref>,<xref rid="bib0095" ref-type="bibr">19</xref>]. Although the expression of ACE2 is low in the brain, autopsy studies have previously demonstrated SARS-CoV particle presence brain tissue [<xref rid="bib0100" ref-type="bibr">20</xref>]. Moreover, neurological deposition has been demonstrated in most other beta-coronaviruses including SARS-CoV, MERS-CoV, HCoV-229E, HCoV-229E, mouse hepatitis virus, and porcine hemagglutinating encephalomyelitis coronavirus (HEV) [<xref rid="bib0030" ref-type="bibr">6</xref>]. Some authors have postulated a mechanism other than ACE2 epithelial or endothelial cell adherence as a route for CNS infiltration such as trans-synaptic viral transfer after initial peripheral nerve invasion [<xref rid="bib0030" ref-type="bibr">6</xref>]. This would then explain findings of some studies demonstrating the virus’ predominant presence in neurons [<xref rid="bib0100" ref-type="bibr">[20]</xref>, <xref rid="bib0105" ref-type="bibr">[21]</xref>, <xref rid="bib0110" ref-type="bibr">[22]</xref>]. However, the higher relative prevalence of SARS-CoV in the cerebrum (where glial cells are more common) compared to the cerebellum in autopsy studies has led others to postulate a glial presence of ACE2 [<xref rid="bib0085" ref-type="bibr">17</xref>,<xref rid="bib0100" ref-type="bibr">20</xref>].</p><p id="par0070">Human cases of SARS-CoV related polyneuropathy and encephalitis have been previously reported and a similar risk has been assumed for SARS-CoV-2 [<xref rid="bib0040" ref-type="bibr">8</xref>,<xref rid="bib0115" ref-type="bibr">23</xref>]. To date, at least three case reports of SARS-CoV-2 encephalitis have been reported [<xref rid="bib0120" ref-type="bibr">[24]</xref>, <xref rid="bib0125" ref-type="bibr">[25]</xref>, <xref rid="bib0130" ref-type="bibr">[26]</xref>]. The first case was reported in a Beijing hospital upon a SARS-CoV-2 RNA positive test of a patient’s cerebrospinal fluid (CSF) [<xref rid="bib0040" ref-type="bibr">8</xref>,<xref rid="bib0080" ref-type="bibr">16</xref>,<xref rid="bib0120" ref-type="bibr">24</xref>]. The second case was a 24-year-old Japanese man with sinusitis complicated by medial temporal lobe encephalitis and lateral ventriculitis [<xref rid="bib0125" ref-type="bibr">25</xref>]. The CSF also tested positive for SARS-SoV-2 RNA in the latter patient. A third case involving hemorrhagic necrotizing encephalopathy of the medial temporal lobes and thalami in a female airline worker in her fifties was recently reported in the United States [<xref rid="bib0130" ref-type="bibr">26</xref>].</p><p id="par0075">The mechanism of action for SARS-CoV-2 neurological invasion is not yet specified. Several theories have been postulated including: direct invasion, blood circulation pathway, neuronal pathway, hypoxia injury, immune injury/cytokine storm syndromes, ACE2 receptor expression, among others [<xref rid="bib0040" ref-type="bibr">8</xref>,<xref rid="bib0130" ref-type="bibr">26</xref>]. As previously described, perhaps the leading current theory is direct seeding and trans-synaptic infiltration via the olfactory nerve or perineuronal cells. This route of invasion has been documented in animal studies for other coronaviruses [<xref rid="bib0135" ref-type="bibr">[27]</xref>, <xref rid="bib0140" ref-type="bibr">[28]</xref>, <xref rid="bib0145" ref-type="bibr">[29]</xref>, <xref rid="bib0150" ref-type="bibr">[30]</xref>]. For example, experimental studies in transgenic mice injected intra-nasally with SARS-CoV have demonstrated brain entry via the olfactory nerves with subsequent rapid spread to medial brain structures including the medial temporal lobe, basal ganglia, thalami, and midbrain [<xref rid="bib0150" ref-type="bibr">30</xref>]. These findings would be consistent with the limited case report data available to date.</p><p id="par0080">Animal studies of other beta-coronaviruses have also suggested a link with some long-term neurodegenerative diseases [<xref rid="bib0155" ref-type="bibr">31</xref>]. Long-term persistent psychological distress has been shown in SARS survivors [<xref rid="bib0160" ref-type="bibr">32</xref>]. The potential long-term neurodegenerative and psychological effects of COVID-19 have yet to be determined.</p></sec><sec id="sec0030"><label>3.3</label><title>Impact of COVID-19 on Practice Management</title><p id="par0085">COVID-19 has dramatically altered practice patterns around the world. Early studies have been published with experiences and recommendations, predominantly from locations substantially affected by the COVID-19 crisis including China [<xref rid="bib0045" ref-type="bibr">9</xref>,<xref rid="bib0060" ref-type="bibr">12</xref>,<xref rid="bib0065" ref-type="bibr">13</xref>] and Northern Italy [<xref rid="bib0050" ref-type="bibr">10</xref>,<xref rid="bib0055" ref-type="bibr">11</xref>]. Thus far, early experience and recommendations in neurosurgical [<xref rid="bib0045" ref-type="bibr">[9]</xref>, <xref rid="bib0050" ref-type="bibr">[10]</xref>, <xref rid="bib0055" ref-type="bibr">[11]</xref>,<xref rid="bib0165" ref-type="bibr">33</xref>], stroke [<xref rid="bib0060" ref-type="bibr">12</xref>], and spine [<xref rid="bib0065" ref-type="bibr">13</xref>,<xref rid="bib0070" ref-type="bibr">14</xref>] practices have been reported (<xref rid="tbl0010" ref-type="table">Table 2</xref>). Included among these are algorithms pertaining to the deployment of healthcare personnel, and the prioritization, scheduling and cancelling of surgical cases. Algorithms and protocols such as these have been created through interdisciplinary expert panel consensus with the goal of addressing critical neurological and neurosurgical issues and allowing for the safe and continued care of neurological patients in the context of the COVID-19 pandemic. Ongoing study of the effectiveness of these treatment algorithms will be necessary to ensure the implementation of optimum patient management strategies during this pandemic.<table-wrap position="float" id="tbl0010"><label>Table 2</label><caption><p>Early experience and recommendations for neurosurgical, stroke, and spine practices during the COVID-19 crisis.</p></caption><alt-text id="at0010">Table 2</alt-text><table frame="hsides" rules="groups"><thead><tr><th align="left">Author</th><th align="left">Service</th><th align="left">Practice Location</th><th align="left">Experience and/or Recommendations</th></tr></thead><tbody><tr><td align="left" rowspan="8">Tan</td><td align="left" rowspan="8">Neurosurgery</td><td align="left" rowspan="8">Wuhan, China</td><td align="left">Screened and used proper protection for all patients</td></tr><tr><td align="left">All admitted patients were screened with throat swab and chest CT</td></tr><tr><td align="left">Segmented the neurosurgery unit into infected and clean areas</td></tr><tr><td align="left">Daily sterilization of each room was performed</td></tr><tr><td align="left">Anesthetist pre-operative consultation for all cases was obtained</td></tr><tr><td align="left">Operations performed in negative pressure suction room for COVID-19 cases</td></tr><tr><td align="left">Optimized surgical team to shorten duration of operation</td></tr><tr><td align="left">Decreased speed of bone drilling to reduce spread of bone dust</td></tr><tr><td align="left" rowspan="5">Veiceschi</td><td align="left" rowspan="5">Neurosurgery</td><td align="left" rowspan="5">Bergamo, Italy</td><td align="left">Discontinued elective surgeries where possible</td></tr><tr><td align="left">Created a “Neuro-COVID” unit of the hospital</td></tr><tr><td align="left">Specifically assigned neurosurgical staff to COVID patients/units (25% → 50% → 75% neurosurgeons)</td></tr><tr><td align="left">Regionalized neurosurgical services by hospital into 4 hubs (3 general cranial or spinal emergencies and 1 for oncologic pathologies)</td></tr><tr><td align="left">Combined private and public hospitals to achieve regional efforts</td></tr><tr><td align="left" rowspan="4">Zoia</td><td align="left" rowspan="4">Neurosurgery</td><td align="left" rowspan="4">Lombardy, Italy</td><td align="left">Suspended all non-urgent outpatient activities</td></tr><tr><td align="left">Four surgical “hub” hospitals were created with 3 guaranteeing 24/7 acceptance; 4<sup>th</sup> hub for urgent oncological cases</td></tr><tr><td align="left">Oncological patients categorized into 3 levels of priority: [<xref rid="bib0005" ref-type="bibr">1</xref>] immediate (ex: worsening level of consciousness) [<xref rid="bib0010" ref-type="bibr">2</xref>]; 7-10 day (ex: mass effect or progressive defect without alteration of consciousness) [<xref rid="bib0015" ref-type="bibr">3</xref>]; within 1 month (ex: mass with neurological deficit)</td></tr><tr><td align="left">Improved collaboration between hospitals for resources including personnel</td></tr><tr><td align="left" rowspan="8">Zhao</td><td align="left" rowspan="8">Stroke</td><td align="left" rowspan="8">Shanghai, China</td><td align="left">In addition to challenges in hospital management, some patient may be reluctant to present to hospital risking late presentation</td></tr><tr><td align="left">Cases of wrong hospital presentation and suboptimal management were experienced in as the system rapidly evolved to adjust to the COVID-19 crisis</td></tr><tr><td align="left">Cases in Shanghai decreased by 50% in the first month of crisis</td></tr><tr><td align="left">Establish stroke networks and care systems able to deliver emergent stroke care in time of crisis</td></tr><tr><td align="left">Establish centralized stroke treatment centers where sufficient stroke care resources can be secured</td></tr><tr><td align="left">Notify emergency medical system that stroke centers are protected and will remain open during crisis</td></tr><tr><td align="left">Improve education of health professionals and public, especially those at risk of stroke, to recognize the recognize stroke and call for help immediately</td></tr><tr><td align="left">Recommend improved online resources for patients and physicians during time of crisis</td></tr><tr><td align="left" rowspan="11">Zou</td><td align="left" rowspan="11">Spine</td><td align="left" rowspan="11">Suzhou, China</td><td align="left">Appropriate screening for all cases</td></tr><tr><td align="left">Favor conservative management where appropriate</td></tr><tr><td align="left">Divide waiting rooms between symptomatic and non-symptomatic</td></tr><tr><td align="left">Surgery for patients with severe nerve compression, spinal cord injury, progressive aggravation of nerve dysfunction, or spinal fracture with displacement or compression</td></tr><tr><td align="left">Patients with COVID-19 requiring operation:</td></tr><tr><td align="left">• Use minimally invasive surgery where possible</td></tr><tr><td align="left">• Reduce scope and time of operation where possible</td></tr><tr><td align="left">• Prone position is preferred</td></tr><tr><td align="left">• Reduce risk of aerosolizing where possible (ex: use suction with caution)</td></tr><tr><td align="left">• Reduce splatter in operative field</td></tr><tr><td align="left">• Screening of operating room staff is also necessary</td></tr><tr><td align="left" rowspan="4">Donnally</td><td align="left" rowspan="4">Spine</td><td align="left" rowspan="4">Philadelphia, United States</td><td align="left">Divide spine list into three levels of urgency:</td></tr><tr><td align="left">Level 1 (proceed with surgical intervention): cervical or thoracic myelopathy, acute spine trauma, oncology, epidural abscess, cauda equine or sever nerve root compression</td></tr><tr><td align="left">Level 2 (proceed with surgical intervention at ambulatory surgical center versus consider at hospital if low COVID-19 census): Acute or subacute lumbar disc herniations, cervical radiculopathy, acute hardware failure, lumbar adjacent segment disease</td></tr><tr><td align="left">Level 3 (defer surgery if able): Compression fracture, odontoid fracture, adult degenerative scoliosis, lumbar degenerative stenosis, proximal junction kyphosis, axial back pain</td></tr><tr><td align="left" rowspan="4">Burke</td><td align="left" rowspan="4">Neurosurgery</td><td align="left" rowspan="4">San Francisco, United States</td><td align="left">Created a three tier surge level based on factors including: number of community cases, number of COVID-19 positive inpatients, and percentage of staffing shortages<break></break>Created a checklist to determine the case urgency and to determine the availability of operating rooms and post-operative beds dependent on needs</td></tr><tr><td align="left">Green surge level (1-9 community cases, or <6 COVID-19 positive patients, and no staffing shortages): operate on all emergent, urgent, and elective cases<break></break>Yellow surge level (10-99 community cases, or 7-16 COVID-19 positive inpatients, or < 20% staffing shortages): Proceed with emergent and urgent cases. Limit operating room schedule for elective cases over a 3 week period including a 25% reduction in procedural cases and re-assess<break></break>Red surge level (> 100 community cases, or > 17 COVID-19 positive inpatients, or > 21% staffing shortages): Proceed with emergent and urgent cases. Limit operating room schedule for elective cases over a 3 week period including a 50% reduction in procedural cases and re-assess<break></break>Black surge level (significant assistance needed from outside institutions): Emergent cases only</td></tr><tr><td align="left">Created a three tiered coverage plan including two teams and an alternate team for each of four local hospitals</td></tr><tr><td align="left">Promoted reduction in people as possible including: increased teleconferencing as able, restricting hospital access to workers over the age of 65, not allowing patient visitors</td></tr></tbody></table></table-wrap></p><p id="par0090">Preliminary consensus guidelines surrounding specific COVID-19 related management are also beginning to be published in subspecialties within neurology and neurosurgery based on pre-COVID-19 literature and expert consensus. For example, early guidelines are recommending strict precautions in patients with unknown or suspected COVID-19 requiring emergent endovascular thormbectomy [<xref rid="bib0170" ref-type="bibr">34</xref>]. At present, best practice regarding general anesthesia and monitored anesthesia care remains unclear and controversial, but more conservative measures with decreased risk of aerosolizing virus are favored when possible [<xref rid="bib0170" ref-type="bibr">34</xref>].</p></sec></sec><sec id="sec0035"><label>4</label><title>DISCUSSION</title><p id="par0095">Limited literature is available to date on the COVID-19 as it relates to the clinical neurosciences. This scoping review identifies several significant findings pertaining to the practice of neurology and neurosurgery, including:<list list-type="simple" id="lis0010"><list-item id="lsti0030"><label>1</label><p id="par0100">Pre-existing cerebrovascular disease may be a risk factor for poor outcome in patients infected with COVID-19.</p></list-item><list-item id="lsti0035"><label>2</label><p id="par0105">COVID-19 infection may manifest as neurological symptomatology, including: headache, dizziness, hypogeusia and/or anosmia, altered level of consciousness, acute cerebrovascular events, seizure(s), and ataxia.</p></list-item><list-item id="lsti0040"><label>3</label><p id="par0110">Although the mechanism of invasion is not fully understood, COVID-19 appears to demonstrate neuroinvasive potential. Viral encephalitis +/- hemorrhagic necrosis involving mesial brain structures such as the mesial temporal lobes and thalami have been reported to date.</p></list-item><list-item id="lsti0045"><label>4</label><p id="par0115">Long-term neurodegenerative effects of COVID-19 have yet to be elucidated, but are theorized based on past experience with other beta-coronaviruses.</p></list-item><list-item id="lsti0050"><label>5</label><p id="par0120">Neurology and neurosurgical practice patterns are being changed dramatically and constantly updated with publications demonstrating early experiences and recommendations based on facilities and regions most affected.</p></list-item></list></p><p id="par0125">As an early scoping review of available literature to date, this study has certain limitations. First, symptoms classified as neurological including headache, dizziness, and altered level of consciousness are non-specific with multiple potential causes. These symptoms may relate to an alternative system of origin, may be therapy related, and/or may be of psychosocial origin. The extent to which these symptoms may impact the practice of neurology and neurosurgery is uncertain. Second, the predominant limitation of this scoping review pertains to limited available early literature. As the number of COVID-19 cases continues to rise dramatically across the world, we anticipate that the literature will also continue to evolve. As the prevalence of COVID-19 increases, more cases reporting rare neurological presentations of COVID-19 are likely to be published. A better understanding of the mechanism and therapeutic options for invasive neurological cases may also evolve. Consensus statements and society guidelines will likely require continual refinement based on emerging COVID-19 specific data. Finally, optimal practice patterns will likely vary widely with nuanced configurations based on regional prevalence and available health care resources. In order to ensure optimum neurological patient management, ongoing study of treatment algorithms will be essential for updating and adapting these approaches as the COVID-19 pandemic evolves.</p></sec><sec id="sec0040"><title>FUNDING SUPPORT</title><p id="par0130">None.</p></sec></body><back><ref-list id="bibl0005"><title>REFERENCES</title><ref id="bib0005"><label>1</label><element-citation publication-type="journal" id="sbref0005"><person-group person-group-type="author"><name><surname>Paules</surname><given-names>C.I.</given-names></name><name><surname>Marston</surname><given-names>H.D.</given-names></name><name><surname>Fauci</surname><given-names>A.S.</given-names></name></person-group><article-title>Coronavirus infections – more than just the common cold</article-title><source>JAMA</source><year>2020</year><comment>Epub ahead of print</comment></element-citation></ref><ref id="bib0010"><label>2</label><element-citation publication-type="journal" id="sbref0010"><person-group person-group-type="author"><name><surname>Yang</surname><given-names>J.</given-names></name><name><surname>Zheng</surname><given-names>Y.</given-names></name><name><surname>Gou</surname><given-names>X.</given-names></name></person-group><article-title>Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis</article-title><source>Int J Infect Dis</source><year>2020</year><comment>Epub ahead of print</comment></element-citation></ref><ref id="bib0015"><label>3</label><element-citation publication-type="journal" id="sbref0015"><person-group person-group-type="author"><name><surname>Wang</surname><given-names>D.</given-names></name><name><surname>Hu</surname><given-names>B.</given-names></name><name><surname>Hu</surname><given-names>C.</given-names></name></person-group><article-title>Clinical characteristics of 138 hospitalized patients with novel coronavirus-infected pneumonia in Wuhan, China</article-title><source>JAMA</source><year>2020</year><comment>Epub ahead of print.</comment></element-citation></ref><ref id="bib0020"><label>4</label><element-citation publication-type="journal" id="sbref0020"><person-group person-group-type="author"><name><surname>Tricco</surname><given-names>A.C.</given-names></name><name><surname>Lillie</surname><given-names>E.</given-names></name><name><surname>Zarin</surname><given-names>W.</given-names></name></person-group><article-title>PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation</article-title><source>Ann Intern Med</source><volume>169</volume><year>2018</year><fpage>467</fpage><lpage>473</lpage><pub-id pub-id-type="pmid">30178033</pub-id></element-citation></ref><ref id="bib0025"><label>5</label><element-citation publication-type="journal" id="sbref0025"><person-group person-group-type="author"><name><surname>Chen</surname><given-names>T.</given-names></name><name><surname>Wu</surname><given-names>D.</given-names></name><name><surname>Chen</surname><given-names>H.</given-names></name></person-group><article-title>Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study</article-title><source>BMJ</source><volume>368</volume><year>2020</year><fpage>m1091</fpage><pub-id pub-id-type="pmid">32217556</pub-id></element-citation></ref><ref id="bib0030"><label>6</label><mixed-citation publication-type="other" id="oref0005">Li Y.C., Bai W.Z., Hashikawa T. 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