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OBJECTIVE: This observational cross-sectional multicenter study aimed to evaluate the longitudinal impact of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical practice. METHODS: We included 29 participating neurosurgeons in centers from all geographical regions in the Kingdom of Saudi Arabia. The study period, which was between March 5, 2020 and May 20, 2020, was divided into three equal periods to determine the longitudinal effect of COVID-19 measures on neurosurgical practice over time. RESULTS: During the 11-week study period, 474 neurosurgical interventions were performed. The median number of neurosurgical procedures per day was 5.5 (interquartile range [IQR]: 3.5-8). The number of cases declined from 72 in the first week and plateaued at the 30's range in subsequent weeks. The most and least number of performed procedures were oncology (129 [27.2 %]) and functional procedures (6 [1.3 %]), respectively. Emergency (Priority 1) cases were more frequent than non-urgent (Priority 4) cases (178 [37.6 %] vs. 74 [15.6 %], respectively). In our series, there were three positive COVID-19 cases. There was a significant among-period difference in the length of hospital stay, which dropped from a median stay of 7 days (IQR: 4-18) to 6 (IQR: 3-13) to 5 days (IQR: 2-8). There was no significant among-period difference with respect to institution type, complications, or mortality. CONCLUSION: Our study demonstrated that the COVID-19 pandemic decreased the number of procedures performed in neurosurgery practice. The load of emergency neurosurgery procedures did not change throughout the three periods, which reflects the need to designate ample resources to cover emergencies. Notably, with strict screening for COVID -19 infections, neurosurgical procedures could be safely performed during the early pandemic phase. We recommend to restart performing neurosurgical procedures once the pandemic gets stabilized to avoid possible post pandemic health-care system intolerable overload.

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OBJECTIVE: Quantitative documentation of the effects of outbreaks, including the coronavirus disease 2019 (COVID-19) pandemic, is limited in neurosurgery. Our study aimed to evaluate the effects of the COVID-19 pandemic on neurosurgical practice and to determine whether surgical procedures are associated with increased morbidity and mortality. METHODS: A multicenter case-control study was conducted, involving patients who underwent neurosurgical intervention in the Kingdom of Saudi Arabia during 2 periods: pre-COVID-19 and during the COVID-19 pandemic. The surgical intervention data evaluated included diagnostic category, case priority, complications, length of hospital stay, and 30-day mortality. RESULTS: A total of 850 procedures were included, 36% during COVID-19. The median number of procedures per day was significantly lower during the COVID-19 period (5.5 cases) than during the pre-COVID-19 period (12 cases; P < 0.0001). Complications, length of hospital stay, and 30-day mortality did not differ during the pandemic. In a multivariate analysis comparing both periods, case priority levels 1 (immediate) (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.24-2.67), 1 (1-24 h) (OR, 1.63; 95% CI, 1.10-2.41), and 4 (OR, 0.28; 95% CI, 0.19-0.42) showed significant differences. CONCLUSIONS: During the early phase of the COVID-19 pandemic, the overall number of neurosurgical procedures declined, but the load of emergency procedures remained the same, thus highlighting the need to allocate sufficient resources for emergencies. More importantly, performing neurosurgical procedures during the pandemic in regions with limited effects of the outbreak on the health care system was safe. Our findings may aid in developing guidelines for acute and long-term care during pandemics in surgical subspecialties.

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BACKGROUND: Patients who leave hospital against medical advice (AMA) may be at risk of adverse health outcomes, medical complications, and readmission. In this study, we examined the characteristics of patients who left AMA after traumatic brain injury (TBI), their rates of follow-up visits, and readmission. METHODS: We retrospectively studied 106 consecutive patients who left the tertiary trauma center AMA (1.8% of all admitted patients with a TBI). Preinjury health and social issues, mechanism of injury, computed tomography findings, and injury markers were collected. They were correlated to compliance with follow-up visits and unplanned emergency room (ER) visits and readmission rates. RESULTS: The most prevalent premorbid health or social-related issues were alcohol abuse (33%) and assault as a mechanism of trauma (33%). Only 15 (14.2%) subjects came to follow-up visit for their TBI. Sixteen (15.1%) of the 106 subjects had multiple readmissions and/or ER visits related to substance abuse. Seven (6.6%) had multiple readmissions or ER visits with psychiatric reasons. Those patients with multiple readmissions and ER visits showed in higher proportion preexisting neurological condition (p=0.027), homelessness (p=0.012), previous neurosurgery (p=0.014), preexisting encephalomalacia (p=0.011), and had a higher ISS score (p=0.014) than those who were not readmitted multiple times. CONCLUSIONS: The significantly increased risks of multiple follow-up visits and readmission among TBI patients who leave hospital AMA are related to a premorbid vulnerability and psychosocial issues. Clinicians should target AMA TBI patients with premorbid vulnerability for discharge transition interventions.

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Patients in acute neurological extremes secondary to refractory intracranial hypertension are challenging because of the complex management options available to them, especially when compounded with signs of brainstem compromise. Objective evidence of cerebral circulatory compromise is often lacking. We present a case in which an objective evaluation of a cerebral circulatory compromise was documented using transcranial Doppler as well as its resolution with hyperosmolar therapy.