COVID-19 in traumatic brain injury
The Covid-19 global pandemic has taken us all aback. These times of uncertainty bear a significant impact on the scientific and medical community. However, positive changes have arisen in the pursuit of overcoming adversity.
It is worth taking a glance at the impact which the pandemic had on the research and treatment of Traumatic Brain Injury (TBI) and discussing the approach of the scientific and medical community. COVID-19, as the World Health Organization states, “ is now a pandemic affecting many countries globally” (1). Although it mainly affects the upper respiratory system, the disease, as well as its impact on all the vital systems, is more complex. Due to this matter, the scientific community is still working towards understanding all its intricacies. The COVID-19 has profoundly impacted clinical research through the redirection of resources, the stammering of in-person visits, and the addition of unforeseen confoundings (increased hospitalization, mortality, deferral of care) (2) Beyond the crisis, the world has taken a valuable step towards innovation, digitalization and the fostering of a community mindset. These changes have the potential to bring a positive impact on the overall conduct of clinical research, for the long run. As one physician states, “COVID-19 is with us for the long haul, a marathon that we will run for months or years to come” (2). For this, we are no longer discussing special measures, but rather a transition to a new reality of life, that might extend over several years. One approach for tackling the issue refers to the creation of multi-speciality teams and the adoption of a holistic approach to the matter (3). Furthermore, remote technologies and home-based testing make for a useful tool in order to limit exposure to pathogens, as some physicians point out (2). In addition to these practices, home administration of treatment, where the context makes it possible, is yet another tool for limiting risks. An undeniable impact can also be seen on physician-scientists, who had to switch from research to patient care, often ending up with an increased workload (4).
Risk of TBI
The risk of COVID-19 for individuals with brain injury is hard to assess, yet the likelihood of contracting the virus seems to be elevated in this population (5). The issue of suppressed immune systems, as well as that of comorbidities leading to complications, pose a challenge in the management of TBI cases during these times (5). Furthermore, the disease could result in further brain damage for this population, leading to neurological symptoms that might or might not be permanent (5). Some changes that occur with the disease, such as a change in the perception of taste and smell, fatigue, headache, disorders of consciousness, muscle damage, can hold an impact on the nervous system (1). Other complications such as heart damage and renal damage can potentially add to neurological injury (5). Some reports discuss the large prevalence of coagulopathies associated with COVID-19, which could lead to further complications (6). Existent research speculates that there is an increased risk for viral infection of the brain, after brain injury (5). “Severe traumatic brain injury (TBI), as one of the critical conditions in the department of neurosurgery, requires an early and effective treatment”, physicians note (8). However, at this point, research on the full effects of COVID-19 on the brain remains scarce. Speculation remains the key-word, at this point, when discussing the permanence of neurologic symptoms, and the long-term effect of the injury of people living with TBI. Nonetheless, precaution finds itself at the core of the approach, and vulnerable populations are advised to take precautionary measures in order to avoid possible long-term complications. Some studies (8), (9), (10), (11), show a decline in the number of TBI during the lockdown portion of the pandemic, as well as a decline in neurotrauma surgical cases (9), (11). “Population seclusion had a direct effect on the frequency of neurotrauma” (9), it is stated. This might be, in part, due to the travel restrictions combined with decreased traffic (9). Furthermore, construction businesses have leapt forward, and people have spent more time at home doing repairs, explaining the increase in accidents due to “falls from heights” (9). However, precaution must be taken when assessing these results, as it is important to consider patients’ unwillingness to address the emergency department following minor accidents, for fear of contracting the virus (9). The elderly represent the most vulnerable population, due to the existence of comorbidities associated with TBI (8). As far as precautions go,
screening remains the primary measure before admission, followed by other precautionary measures such as masks and social distancing (2). As TBI often presents with consciousness disorders, the epidemiological histories can be quickly collected from family members, and further assessments such as Brain computed tomography (CT) and chest CT are subsequent essential steps of the routine. Consultations with other medical specialities remain of great importance when facing doubt (8), as well as the establishment of multidisciplinary teams organized for patient admission (2). In some cases, telemedicine as a way to provide consultation can be of help, as the traditional “one-on-one” method is not recommended for patients suspected of COVID-19 (8). With regards to the protection of medical providers and other patients, practices such as isolated operation rooms and negative pressure operating rooms with a separation of the contaminated area and clean area, make for additional measures (8).
Although the pandemic shifted the focus of academic research towards research on COVID-19, plenty of lessons have been learned about health systems’ capacity, about the importance of innovation, resilience and adaptability, as well as about using the importance of building on a multi-sectoral approach. The pandemic puts a focal point on the importance of research infrastructure and the funding of public health emergency, response and resiliency. Global stakes in this pandemic are high, be them medical, economic or political. High-quality research is vital for pandemic mitigation in TBI as well as all other focus areas. As one study points out, “biomedical research also provides data critical to manage and restore economic and social welfare” (6). During this pandemic, some previous challenges in research came to light, including matters of efficacy and cost-effectiveness (5). Perhaps this will make for a chance to build new paradigms for research. Nonetheless, we can safely form the conclusion that COVID-19 significantly impacted the incidence of neurotrauma and neurosurgical interventions, mainly reducing the incidence of certain injuries, such as vehicular trauma (9). In uncertain scenarios, communication remains a key element. With the aid of proactive measures, it is likely to maintain quality in clinical research (2). With community support, resilience and focus on the goals, we can overcome these adverse times and build a better future for research and innovation.
1.“Coronavirus Disease (COVID-19) – World Health Organization.” Accessed September 22, 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019.
2.“COVID-19 Impact on Research, Lessons Learned from COVID-19 Research, Implications for Pediatric Research | Pediatric Research.” Accessed September 22, 2020. https://www.nature.com/articles/s41390-020-1006-3.
3.Progress in Disaster Science. Accessed September 23, 2020. https://www.journals.elsevier.com/progress-in-disaster-science/news/covid-19-multi-sector-approach-vital.
4.McCallum, Richard. “Physician-Scientist and the COVID-19 Dilemma.” Journal of Investigative Medicine, August 26, 2020. https://doi.org/10.1136/jim-2020-001582.
5.“COVID-19 Risk Factors for Traumatic Brain Injury |.” Accessed September 22, 2020. https://www.neuroskills.com/neuro-landscape-blog/2020/04/29/covid-19-risk-factors-for-traumatic-brain-injury/.
6.Becker, Richard C. “COVID-19 Update: Covid-19-Associated Coagulopathy.” Journal of Thrombosis and Thrombolysis, May 15, 2020, 1–14. https://doi.org/10.1007/s11239-020-02134-3.
7.Tuttle, Katherine R. “Impact of the COVID-19 Pandemic on Clinical Research.” Nature Reviews Nephrology 16, no. 10 (October 2020): 562–64. https://doi.org/10.1038/s41581-020-00336-9.
8.“Perioperative Management Strategy of Severe Traumatic Brain Injury during the Outbreak of COVID-19.” Accessed September 22, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242933/.
9.Figueroa, Javier M., James Boddu, Michael Kader, Katherine Berry, Vignessh Kumar, Veronica Ayala, Steven Vanni, and Jonathan Jagid. “The Effects of Lockdown During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Neurotrauma-Related Hospital Admissions.” World Neurosurgery, August 19, 2020. https://doi.org/10.1016/j.wneu.2020.08.083.
10.Figueroa, Javier M., James Boddu, Michael Kader, Katherine Berry, Vignessh Kumar, Veronica Ayala, Steven Vanni, and Jonathan Jagid. “The Effects of Lockdown During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Neurotrauma-Related Hospital Admissions.” World Neurosurgery, August 19, 2020. https://doi.org/10.1016/j.wneu.2020.08.083.
11.Pinggera, Daniel, Barbara Klein, Claudius Thomé, and Lukas Grassner. “The Influence of the COVID-19 Pandemic on Traumatic Brain Injuries in Tyrol: Experiences from a State under Lockdown.” European Journal of Trauma and Emergency Surgery, July 22, 2020. https://doi.org/10.1007/s00068-020-01445-7.