Neurosurgical Experience of Beirut Blast in the Era of Coronavirus Disease 2019 (COVID-19) from a Tertiary Referral Center

Background

In this paper, we shed the light on Beirut’s blast that took place in the coronavirus disease 2019 (COVID-19) era. An explosion that ripped the heart of Beirut, it produced a destructive shock wave that left thousands of casualties and people homeless. This explosion, which had a mushroom-like cloud appearance similar to that of Hiroshima and Nagasaki, was described as the third-biggest explosion in human history. It was a blast that not only destroyed lives but also fell as a heavy burden on the shoulders of a country that was suffering from unprecedented economic crisis on top of the COVID-19 pandemic. Facing all this, health care providers were the first line of defense in what looked like an impossible mission.

Objective

We seek to share with the medical community our experience and the challenges we faced, as a neurosurgery team, during this event, particularly that we were short of basic medical equipment as well as intensive care unit beds since we were in the middle of an economic crisis and the peak of the COVID-19 pandemic. This prohibited us from delivering proper care, whether in the triage of patients or in the operating room, as well as postoperative care. Now, 1 year after this sad event, we revisit the whole situation and examine all the pitfalls that could have been avoided. Thus, we discuss the importance of initiating a disaster response, in particular the neurosurgical emergency response, to be better prepared to face future potential events.

Conclusions

The rate-limiting step in such disasters is definitely a well-prepared trained team with a prompt and fast response. And, since time is brain, then what saves the brain is proper timing.

Acute ischemic stroke biomarkers: a new era with diagnostic promise?

Stroke is considered as the first cause of neurological dysfunction and second cause of death worldwide. Recombinant tissue plasminogen activator is the only chemical treatment for ischemic stroke approved by the US Food and Drug Administration. It was the only standard of care for a long time with a very narrow therapeutic window, which usually ranges from 3 to 4.5 h of stroke onset; until 2015, when multiple trials demonstrated the benefit of mechanical thrombectomy during the first 6 h. In addition, recent trials showed that mechanical thrombectomy can be beneficial up to 24 h if the patients meet certain criteria including the presence of magnetic resonance imaging/computed tomography perfusion mismatch, which allows better selectivity and higher recruitment of eligible stroke patients. However, magnetic resonance imaging/computed tomography perfusion is not available in all stroke centers. Hence, physicians need other easy and available diagnostic tools to select stroke patients eligible for mechanical thrombectomy. Moreover, stroke management is still challenging for physicians, particularly those dealing with patients with "wake-up" stroke. The resulting brain tissue damage of ischemic stroke and the subsequent pathological processes are mediated by multiple molecular pathways that are modulated by inflammatory markers and post-transcriptional activity. A considerable number of published works suggest the role of inflammatory and cardiac brain-derived biomarkers (serum matrix metalloproteinase, thioredoxin, neuronal and glial markers, and troponin proteins) as well as different biomarkers including the emerging roles of microRNAs. In this review, we assess the accumulating evidence regarding the current status of acute ischemic stroke diagnostic biomarkers that could guide physicians for better management of stroke patients. Our review could give an insight into the roles of the different emerging markers and microRNAs that can be of high diagnostic value in patients with stroke. In fact, the field of stroke research, similar to the field of traumatic brain injury, is in immense need for novel biomarkers that can stratify diagnosis, prognosis, and therapy.

Clinical utility of degradomics as predictors of complications and clinical outcome in aneurysmal subarachnoid hemorrhage

Most of the debilitating conditions following aneurysmal subarachnoid hemorrhage result from symptomatic cerebral vasospasm and delayed cerebral ischemia. Several scales are being used, but they still lack objectivity and fail to quantify complications considered essential for prognostication routine use of biomarkers to predict complications and outcomes after aneurysmal rupture is still experimental. Degradomics were studied extensively in traumatic brain injury, but there is no discussion of these biomarkers related to aneurysmal subarachnoid hemorrhage. Degradomics involve the activation of proteases that target specific substrates and generate specific protein fragments called degradomes. While the proteolytic activities constitute the pillar of development, growth, and regeneration of tissues, dysregulated proteolysis resulting from pathological conditions like aneurysmal subarachnoid hemorrhage ends up in apoptotic processes and necrosis. To our knowledge, this is the first overview that lists a panel of degradomics with cut-off values in serum and cerebrospinal fluid, where specificity and sensitivity are only found in Kallikrein 6, Ubiquitin C Terminal Hydrolase 1 and Alpha-II-Spectrin.

Can we improve the prediction of complications and outcome in aneurysmal subarachnoid hemorrhage? The clinical implications of serum proteomics

Aneurysmal subarachnoid hemorrhage is a devastating condition, often leading to a debilitating outcome. Delayed ischemic neurological deficits are considered the feared sequelae. Proteomics is a large-scale study of proteins incorporating structural and functional properties in complex biological fluids. Analysis of proteomes has led to identifying relevant complex proteins related to specific pathophysiological processes reflecting the severity and extent of diseases. Proteomics has evolved in the past few years; more biomarkers are deemed clinically relevant to diagnose, monitor, and define prognosis in patients with aneurysmal subarachnoid hemorrhage. Despite the absence of candidate biomarkers in the clinical routine, many have shown promising results. The complexity of proteins implicated in aneurysmal subarachnoid hemorrhage rendered these biomarkers' clinical use paved with various pitfalls and technical difficulties, especially when data about the perfect timing and values are lacking. We review the latest literature concerning serum proteomics and their clinical utility regarding the prediction of cerebral vasospasm and other complications of aneurysmal subarachnoid hemorrhage, as well as the clinical outcome. Future prospective studies will allow changing the disease's course, label patients according to their prognosis to provide earlier and better management and improve outcomes.

Safety of stent-assisted coiling for the treatment of wide-necked ruptured aneurysm: A systematic literature review and meta-analysis of prevalence

BACKGROUND

Stent-assisted coil embolization of ruptured wide-necked aneurysms is a controversial treatment modality due to concerns on the peri-procedural safety of anti-platelet therapy in the setting of acute subarachnoid hemorrhage. Our aim was to systematically review the literature on stent-assisted coil embolization of acutely ruptured wide-neck aneurysms to calculate the pooled prevalence of clinical outcome, thromboembolic and hemorrhagic complication rates and overall mortality.

METHODS

We searched PubMed and Google Scholar for articles published between 2009 and 2019 and stratified selected articles based on risk of publication bias. Data on thromboembolic and hemorrhagic complications, clinical outcomes and mortality rates were analyzed using quality-effects model and double arcsine transformation.

RESULTS

24 articles were included featuring a total of 1582 patients. Thromboembolic and hemorrhagic complication rates were witnessed in 9.1% [95% CI: 6.0% - 12.7%; I² = 72.8%] and 8.7% [95% CI: 5.4 - 12.6%; I² = 77.2%] of patients, respectively. 245 patients received external ventricular drains, of which 33 (13.5%) had EVD-related hemorrhages. Total complication rate was 20.8% [95% CI: 14.2 - 28.1%; I² = 87.0%]. 57% of aneurysms were completely occluded and a favorable clinical outcome was reported in 74.7% [95% CI: 66.4 - 82.2%; I² = 86.0] of patients. Overall mortality rate came at 7.8% [95% CI: 4.8 - 11.6%; I² = 76.9%].

CONCLUSION

Stent-assisted coiling of ruptured intracranial aneurysm is a technically feasible procedure with controlled thromboembolic complication rate but may be associated with higher hemorrhagic and total complication rates compared to coiling alone. While stent-assisted coiling of ruptured wide-necked aneurysm seems to yield a lower rate of favorable clinical outcome, overall mortality is comparable to that of endovascular coiling alone.