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Strategies to continue epilepsy surgery during the coronavirus disease (COVID-19) crisis Mini-Review

Coronavirus disease 2019 (COVID-19) is a novel infectious disease caused by severe acute respiratory syndrome coronavirus 2. COVID-19 was initially detected in Wuhan, China in late 2019, and has rapidly spread worldwide. As the battle against COVID-19 becomes more and more long-term, it has become important to consider how to perform epilepsy surgery in the environment with the COVID-19 crisis. In this review article, we propose strategies for institutions that perform epilepsy surgery. First, we discuss the importance of coordinating neurosurgical team and inter-hospital collaboration as a hospital-based initiative. Next, we describe three surgical activities: preoperative evaluation, perioperative management, and during operation. We also discuss management of outpatients as a postoperative strategy. Finally, we mention the importance of psychological support for medical staff, patients, and caregivers. By utilizing these strategies, we should make the best efforts to provide the necessary surgical treatment to patients with epilepsy, even in the COVID-19 era. Abstract


Introduction
Surgical intervention should be considered for patients with intractable epilepsy. Coronavirus disease 2019  which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) initially occurred in Wuhan, China in the late 2019 and rapidly spread globally. Various surgeries have been postponed to date because of the impact of COVID-19. However, as the battle against COVID-19 becomes more prolonged, it has become important to consider how to perform epilepsy surgery in this environment. Therefore, we discuss the strategies of how to continue epilepsy surgery in the COVID-19 setting. In addition, Figure 1 shows a summary of these strategies.

Coordinating teams
To maintain epilepsy surgical practices, maintaining the number of neurosurgeons and teaming is crucial. We need to prepare a backup system for neurosurgeons who could become infected with COVID-19 and would need to self-quarantine for 2 weeks. Higher rates of severe and critical COVID-19 infections in health care workers have been reported compared to reports of COVID-19 infections in the general population [1]. A paircoverage system is recommended [2]. Each hospital has two independent neurosurgery teams, with each team member maintaining contact only within the respective team. An additional "alternate pool" group of neurosurgeons needs to be established. In situations where neurosurgeons are infected and need to self-quarantine, additional staff should be available to cover for the lack of neurosurgeons. With these pair-coverage and alternate pool systems, even when some neurosurgeons are infected with COVID-19, dysfunction in neurosurgical practice will not occur. However, these systems require a large number of neurosurgeons. In small to middle-size hospitals, it is not easy to set up two neurosurgical teams. In such situation, we need to set up a network system to smoothly communicate with different institutions. This network system would help each institution determine and play a role in each local area or district. An article supports a system that categorizes medical institutions by surge level of COVID -19 [3]. Another article introduced a "hub-and -spoke system", which is one of the network systems [4]. Hub hospitals allow the referral of emergency patients 24 hours a day and 7 days a week. Any spoke hospital belongs to a hub hospital can refer emergency patients to their hub hospital.
Age is a known risk factor for COVID-19 [5]. Hence, we should consider excluding medical staff members who are pregnant or over 60 years of age from work shifts, due to a higher risk of developing COVID-19 [6].
Thus, coordinating a team is one of the most important functions in all the departments related to surgery, rather than a strategy specific to epilepsy surgery.

Preoperative evaluation
Based on the preoperative evaluation, a conference is essential to determine the necessity and urgency of surgery. All surgical cases should be categorized in terms of emer-  [2]. Urgent categories have been suggested by relevant medical societies and associations. Some medical societies associated with subspecialties have recommended changing the management in pertaining fields. In cases of epilepsy with progressive worsening of the condition that is difficult to control with non-surgical interventions, epilepsy surgeries are categorized as emergency operations. Problems associated with device dysfunction or battery depletion related to vagus nerve stimulation (VNS), deep brain stimulation (DBS), or responsive neurostimulation (RNS) also need emergency interventions [7]. Additionally, some patients with low activities of daily living, which may be improved with surgical intervention, could undergo surgery in this period. These cases require decision-making on a case-by-case basis, with a conference among specialists [8]. Implantation of intracranial electroencephalogram (EEG) electrodes followed by resective surgery requires a longer hospital stay than a one-stage surgery for monitoring. Therefore, it may increase the likelihood of exposure to SARS-CoV-2 for patients. Indication for a two-stage surgery should be decided with caution.
In the case of situations necessitating neuroimaging with sedation, postponement should be considered as sedation may require breathing assistance, and this procedure causes the spread of aerosols [9]. In particular, we should note that the patients who undergo epilepsy surgery are often children or those with developmental disability, which often require sedation. If sedation cannot be avoided, it should be performed under safe conditions with standard protocols by healthcare providers well trained in sedation, with adequate personal protective equipment (PPE).
EEG is an essential test to identify the epileptogenic zone as a preoperative test. Particularly in the case of preoperative examination, long-term EEG is often required. The impact of COVID-19 should also be considered for these examinations. In fact, in April 2020, the number of EEG recording was reduced by 76% in 206 Italian epilepsy centers compared to pre-COVID-19 period [10]. According to International Federation of Clinical Neurophysiology, EEG staff who are pregnant, over 60 years of age, or have a chronic illness known to be at a risk for COVID-19 [5] should avoid conducting EEG studies as far as possible. It is also recommended that the number of staff members with patient contact should be kept to a minimum and fixed to the same members. Recording and monitoring should be performed remotely. Moreover, if possible, considering outpatient EEG testing rather than inpatient EEG testing can reduce the risk of exposure to SARS-CoV-2. We should also consider using an ambulatory EEG, which allows inhome EEG monitoring [11]. It is important to classify the patient's COVID-19 risk through preliminary questioning and equip the staff with PPE according to that classification [12]. According to the Japan Epilepsy Society, unnecessary activation tasks, especially hyperventilation, should be avoided to prevent spreading and exposing the SARS-CoV-2 (https://square.umin.ac.jp/jes/images/COVID -19-sisin20200430.pdf). According to the International League Against Epilepsy (ILAE) Commission for Surgical Therapy (https:// www.ilae.org/files/dmfile/Video-EEG-Telemetry-for-Epilepsy-Surgery-2020-08.pdf), frequent seizures with injuries, tonicclonic seizures with high risk of sudden unexpected death in epilepsy and injury, and recurrent episodes of status epilepticus should be considered as urgent cases for epilepsy surgery rather than elective. They also mentioned that the necessity of video EEG for preoperative assessment purposes should be carefully considered during the COVID-19 crisis.

Perioperative management
A multicenter cohort study reported that 1128 patients with perioperative COVID-19 infection had high 30-day mortality rate (23.8%) and pulmonary complications (51.2%) [13]. Therefore, all surgical candidates in an epidemic area as well as those undergoing procedures with a high risk of virus exposure need to be screened for COVID-19. Additionally, in non-epidemic areas or for procedures that do not carry a high risk, patients presenting with a high risk for COVID-19 or symptoms consistent with COVID-19 should undergo preoperative screening. Screening of COVID-19 for all preoperative patients is recommend [2]. This would depend on the situation of the epidemic, healthcare systems, and government policy in each country or region. However, we recommend establishing a protocol regarding indications for preoperative COVID-19 screening as well as postoperative re-testing or isolation.
In the case of wards housing postoperative patients who have undergone neurosurgical interventions, distance should be maintained from wards housing patients with COVID-19 [6]. Considering the limited medical re-sources, some postoperative patients could be observed in the non-intensive care unit (ICU) rather than in the ICU [2]. Some ICU beds need to be reserved to prepare for an increase in number of critically ill patients with COVID-19. Standards or protocols for observation in the post-epilepsy surgery ICU need to be reviewed and clarified. Hu et al. [14] recommended that all postoperative patients should be regarded as suspected COVID-19 cases and should be quarantined for at least 2 weeks in areas with the epidemic. Moreover, it is crucial to limit the number of visitors when feasible [2].
Thus, perioperative management is one of the most important aspects in all the departments related to surgery. In epilepsy surgery, seizures may occur before and after surgery. Droplets from saliva, sputum, and coughing associated with seizure as well as contact with patients having seizures by securing their airways may spread COVID-19 infection. Screening of COVID-19 for all perioperative patients is necessary. In addition, PPE should always be readily available to health care personnel providing care for patients undergoing epilepsy surgery.

During operation
Personal protective equipment is necessary for working medical staff. However, exposure risks depend on the situation and region. Therefore, we should utilize some levels of PPE during different activities in various settings [2]. As for PPE, adequate intraoperative infection precautions should be taken, depending on the risk of each case. Hu et al. [14] adopted three levels of protection to avoid occupational exposure to the novel coronavirus during surgery. Furthermore, the use of a reusable gown and face shield should be considered instead of disposable ones, taking into account equipment shortage.
In terms of the prevention policy of institutions, zoning areas are crucial. The entry and exit into operation rooms should be categorized into five zones (entry dressing room, anteroom, operation room, exit room, and exit dressing room) [15]. This zoning system helps prevent SARS-CoV-2 from entering the operating room from outside or spreading from surgical patients to outside the operation room. The American Society of Pediatric Neurosurgeons proposed a system in the operating room [9]. Intubation in the operation room should be performed with minimum staff present. Following intubation, entry into the operating room should be avoided for 30 min to reduce the risk of virus exposure, which might spread in the air during intubation.
As an intraoperative technique, minimally invasive surgery and gentle procedures are required. Surgical interventions should be gentle and careful to avoid body fluid spatter (including sputum, blood, saliva, and urine) and instrument-induced injuries [2,16,17]. In addition, health care workers involved in the surgery should pay attention to prevent virus spreading in washing and possibly showering areas that have been exposed to body fluids after the surgery. Health care providers should also be encouraged to wash their hands frequently, avoid touching their nose and mouth, and avoid rubbing their eyes to prevent their own infection.

Management of outpatients
For outpatient management, telemedicine has been recommended to reduce the risk of exposing patients to SARS-CoV-2 [18]. Using telemedicine, patients should be guided as to when and how they should attend a medical institution in person based on their conditions [19]. Focusing on postoperative followup of epilepsy surgery, device settings after device surgeries such as VNS, DBS and RNS would require a hospital visit [19]. On the other hand, follow-up of postoperative seizure and adjustment of antiepileptic drugs could be done by telemedicine. To reduce unnecessary exposure, we should inform our patients when they should come to the clinic. When they attend a clinic, they should be separated at the entrance and exit, and a set time should be provided to prevent contact with other patients. Further, all patients should be asked to wear a mask when attending. In addition, as a basic measure, all healthcare providers should also ensure that they wear masks. Patients with symptoms of COVID-19 should attend medical institutions equipped with COVID-19 testing and treatment. It should be emphasized that patients must call before attending any medical institution [8]. We should also inform the patients when they should go to the emergency room.
In particular, interventions for superintractable epilepsy or problems associated with device dysfunction or battery depletion need to be recognized by the patients as emergency operations, as mentioned in the section "Preoperative evaluation" [7].

Psychological support for medical staff, patients, and caregivers
Globally, the fearful aspects of COVID-19 have been stressful for individuals. The poli-

Continuing epilepsy surgery during COVID-19 crisis Naoto Kuroda & Takafumi Kubota
cies, recommendations, and suggestions of each government require patient consideration. People with chronic diseases would be more anxious because of the consideration of whether or not they are at a higher risk for COVID-19. To reduce anxiety, some specific medical societies provide information regarding COVID-19 for relevant patients [8,20]. Additionally, clinicians can inform their patients regarding these suggestions to alleviate excessive stress. In addition to patients, medical staff has been under immense pressure in this COVID-19 crisis [21]. They are exposed to a high risk of COVID-19 infection [1]. Each government and institution should have a policy to guard their mental health.

Conclusion
This article describes the strategies to continue epilepsy surgery in the environment with COVID-19. While the battle against COVID-19 is ongoing, we are gradually approaching the time when we should resume elective surgery and non-emergency medical care. By utilizing these strategies, we should make the best efforts to provide the necessary surgical treatments to patients with epilepsy, even in the COVID-19 era.