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Minimizing SARS-CoV-2 exposure when performing surgical interventions during the COVID-19 pandemic
  1. Aditya S Pandey1,
  2. Andrew J Ringer2,
  3. Ansaar T Rai3,
  4. Peter Kan4,
  5. Pascal Jabbour5,
  6. Adnan H Siddiqui6,
  7. Elad I Levy7,8,
  8. Kenneth V Snyder8,9,
  9. Howard Riina10,
  10. Omar Tanweer10,
  11. Michael R Levitt11,
  12. Louis J Kim12,
  13. Erol Veznedaroglu13,
  14. Mandy J Binning14,
  15. Adam S Arthur15,16,
  16. J Mocco17,
  17. Clemens Schirmer18,19,
  18. Byron Gregory Thompson1,
  19. David Langer20
  20. for the Endovascular Neurosurgery Research Group (ENRG)
    1. 1 Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
    2. 2 Neurosurgery, Mayfield Clinic, University of Cincinnati, Cincinnati, Ohio, USA
    3. 3 Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
    4. 4 Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
    5. 5 Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    6. 6 Neurosurgery, University at Buffalo, Buffalo, New York, USA
    7. 7 Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
    8. 8 Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
    9. 9 Neurosurgery and Neurology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
    10. 10 Department of Neurosurgery, New York University - Langone Medical Center, New York, New York, USA
    11. 11 Neurological Surgery, Radiology and Mechanical Engineering, University of Washington, Seattle, Washington, USA
    12. 12 Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
    13. 13 Drexel Neuroscience Institute and GNI, Philadelphia, Pennsylvania, USA
    14. 14 Drexel Neurosciences Institute, Philadelphia, Pennsylvania, USA
    15. 15 Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
    16. 16 Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
    17. 17 The Mount Sinai Health System, New York, New York, USA
    18. 18 Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA, USA
    19. 19 Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
    20. 20 Neurosurgery, Lenox Hill Hospital, New York, New York, USA
    1. Correspondence to Dr Aditya S Pandey, Neurosurgery, University of Michigan, Ann Arbor, MI 48109, USA; adityap{at}


    Background Infection from the SARS-CoV-2 virus has led to the COVID-19 pandemic. Given the large number of patients affected, healthcare personnel and facility resources are stretched to the limit; however, the need for urgent and emergent neurosurgical care continues. This article describes best practices when performing neurosurgical procedures on patients with COVID-19 based on multi-institutional experiences.

    Methods We assembled neurosurgical practitioners from 13 different health systems from across the USA, including those in hot spots, to describe their practices in managing neurosurgical emergencies within the COVID-19 environment.

    Results Patients presenting with neurosurgical emergencies should be considered as persons under investigation (PUI) and thus maximal personal protective equipment (PPE) should be donned during interaction and transfer. Intubations and extubations should be done with only anesthesia staff donning maximal PPE in a negative pressure environment. Operating room (OR) staff should enter the room once the air has been cleared of particulate matter. Certain OR suites should be designated as covid ORs, thus allowing for all neurosurgical cases on covid/PUI patients to be performed in these rooms, which will require a terminal clean post procedure. Each COVID OR suite should be attached to an anteroom which is a negative pressure room with a HEPA filter, thus allowing for donning and doffing of PPE without risking contamination of clean areas.

    Conclusion Based on a multi-institutional collaborative effort, we describe best practices when providing neurosurgical treatment for patients with COVID-19 in order to optimize clinical care and minimize the exposure of patients and staff.

    • infection
    • standards
    • aneurysm
    • arteriovenous malformation
    • hemorrhage

    This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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    • Twitter @Ansaar_Rai, @PascalJabbourMD, @AdamArthurMD

    • Collaborators Endovascular Neurosurgery Research Group (ENRG) collaborators: Mark Bain; Bernard Bendock; Alan S. Boulos; Webster Crowley; Richard Fessler; Andrew Grande; Lee Guterman; Ricardo Hanel; Daniel Hoit; L. Nelson Hopkins, III; Jay Howington; Robert James; Brian Jankowitz; Alex A Khalessi; Giuseppe Lanzino; Demetrius Lopes; William Mack; Robert Mericle; Chris Ogilvy; Robert Replogle; Rafael Rodriguez; Eric Saugaveau; Alex Spiotta; Ali Sultan; Rabih Tawk; Ajith Thomas; Raymond Turner; Babu Welch; Jonathan White.

    • Contributors All authors contributed their best practices and also revised the article and reviewed the final draft. ASP drafted the article and constructed the final draft after the input of all authors.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests There are no competing interests for any author.

    • Patient consent for publication Not required.

    • Ethics approval This study did not involve human participants, and institutional review board approval was not sought.

    • Provenance and peer review Not commissioned; externally peer reviewed.