To the Editor: We read with interest the letter “COVID-19 Infection Affects Surgical Outcome of Chronic Subdural Hematoma” by Panciani et al.1 These authors reported high mortality in 5 patients with chronic subdural hematoma (CSDH) and COVID-19. On one hand, the viral infection provoked thrombocytopenia, thus increasing the risk of postoperative hemorrhages. On the other hand, the immune system could have been impaired by surgical procedures, thus facilitating the development of interstitial pneumonia (IP). Indeed, as the authors correctly stated, presently, there are no reliable data regarding the neurosurgical outcome of COVID-19 patients. After the outbreak of the COVID-19 contagion in Lombardy, our department suspended elective surgery and became one of 3 regional hubs for neurosurgical emergencies. During the last month, we surgically managed 4 symptomatic patients with CSDH and COVID-19: 2 males and 2 females. Mean age was 75.5 yr. None presented preoperative respiratory symptoms. Of these patients, 2 were taking chronic antiplatelet drugs and 1 had a history of chronic liver failure. In all cases, the CSDH was monolateral. All patients were operated under local anesthesia and received postoperative prophylaxis by low-molecular-weight heparin before mobilization. There was 1 case of severe postoperative IP: an 85-yr-old woman died 3 wk after surgery. Mild thrombocytopenia was found in 2 patients and was promptly corrected without any significant problem or postoperative rebleeding. Three patients fared well for what concerns both the CSDH and the evolution of COVID-19. Of course, this series is too small to draw any conclusion. Undoubtedly, neurosurgical procedures may have the potential to worsen the course of COVID-19. However, IP occurred only in our oldest patient, and age is a well-known risk factor regardless of the surgical treatment. Except for this case, neurosurgical treatment and COVID-19 did not seem to influence each other significantly. We suppose that a role could have been played by anesthesia: All our patients were managed under local anesthesia, whereas Panciani and colleagues1 operated their patients under general anesthesia. In our experience, general anesthesia did not represent a problem in younger COVID-19 patients. Accordingly, the combined effect of age and anesthesia might be crucial. A final brief comment is deserved by the reliability of nasopharyngeal swab in these patients. Two individuals underwent surgery with an already ascertained diagnosis of COVID-19 and early started antiretroviral therapy with lopinavir/ritonavir and hydroxychloroquine. Conversely, both the remaining 2 patients were studied by 2 repeated preoperative swabs, which always resulted negative. The diagnosis was ascertained postsurgery. Since one of these 2 patients was the elderly woman who developed lethal IP, perhaps this diagnostic delay could have been important.

中文翻译：

---

回复：COVID-19 感染影响慢性硬膜下血肿的手术结果

致编辑：我们饶有兴趣地阅读了 Panciani 等人写的“COVID-19 感染影响慢性硬膜下血肿的手术结果”1 这些作者报告了 5 名慢性硬膜下血肿 (CSDH) 和 COVID-19 患者的高死亡率。一方面，病毒感染引起血小板减少，从而增加术后出血的风险。另一方面，免疫系统可能因外科手术而受损，从而促进间质性肺炎 (IP) 的发展。事实上，正如作者正确指出的那样，目前没有关于 COVID-19 患者神经外科手术结果的可靠数据。在伦巴第大区爆发 COVID-19 传染病后，我们部门暂停了择期手术，成为 3 个区域性神经外科急诊中心之一。在过去的一个月里，我们手术治疗了 4 名有症状的 CSDH 和 COVID-19 患者：2 名男性和 2 名女性。平均年龄为 75.5 岁。没有出现术前呼吸道症状。在这些患者中，2 名正在服用慢性抗血小板药物，1 名有慢性肝功能衰竭病史。在所有情况下，CSDH 都是单边的。所有患者均在局部麻醉下进行手术，并在活动前给予低分子肝素预防术后。术后重度 IP 1 例：85 岁女性，术后 3 周死亡。2 例患者出现轻度血小板减少症，并及时纠正，无任何严重问题或术后再出血。三名患者在 CSDH 和 COVID-19 的演变方面表现良好。当然，这个系列太小，无法得出任何结论。无疑，神经外科手术可能会使 COVID-19 的病程恶化。然而，IP 仅发生在我们年龄最大的患者身上，无论采用何种手术治疗，年龄都是众所周知的危险因素。除了这个案例，神经外科治疗和 COVID-19 似乎没有显着的相互影响。我们认为麻醉可能起到了一定的作用：我们所有的患者都在局部麻醉下进行管理，而 Panciani 及其同事 1 在全身麻醉下对他们的患者进行操作。根据我们的经验，全身麻醉在年轻的 COVID-19 患者中并不构成问题。因此，年龄和麻醉的综合影响可能是至关重要的。鼻咽拭子在这些患者中的可靠性值得做最后的简短评论。两名患者接受了手术，确诊为 COVID-19，并早期开始使用洛匹那韦/利托那韦和羟氯喹进行抗逆转录病毒治疗。相反，其余 2 名患者均通过 2 次重复的术前拭子进行研究，结果始终为阴性。术后确诊。由于这 2 名患者中的一名是发生致命 IP 的老年妇女，因此这种诊断延迟可能很重要。