Letter to the Editor Regarding “‘Staying Home’—Early Changes in Patterns of Neurotrauma in New York City During the COVID-19 Pandemic”

We read with great interest the article by Lara-Reyna et al.¹ The authors have described the impact of COVID-19 pandemic on neurotrauma in New York City, which was the epicenter of the pandemic when the study was conducted. Mount Sinai Morningside, the institute where this study was conducted, is a level 2 trauma center on the Upper West Side of Manhattan. The authors collected data on neurotrauma admissions from November 1, 2019, to April 26, 2020, and dichotomized it into pre-COVID-19 (before March 1) and COVID-19 groups (after March 1) as the first case in New York City was diagnosed on March 1, 2020. In the pre-COVID-19 period, an average of 25.5 cases of head injury were admitted per month, compared with 24.5 during the COVID-19 period. During the COVID-19 period, an average of 1 case/day was admitted during March 2020 and it decreased further to 0.6 case/day during April 2020. Lara-Reyna et al. report an inverse relationship between the number of positive cases in the city and the frequency of neurotrauma admissions in the hospital between March 1 and April 26, 2020. They noticed a drop in the frequency of neurotraumas, especially since the cancellation of nonessential activities in New York on March 16, 2020, whereas an increase in the frequency of cases was observed in the second week of April, which was observed concomitant with the decrease in number of new COVID-19 cases in the city.

Our institute, the All India Institute of Medical Sciences, Rishikesh, is a 960-bed hospital catering to the Himalayan state of Uttarkahand with a population of about 11 million. Boasting the only helipad for air ambulance services in the country, the trauma center at our institute has facilities for neurotrauma, orthopedics, and general trauma specialties. We have observed a major change in the volume and spectrum of the neurotrauma patients, similar to what Lara-Reyna et al. have reported. We analyzed all admissions of head injury under the neurosurgery department from March 25 to September 15, 2020, and compared the same to data during the same period in 2019.² During the COVID-19-related pandemic (from March 25 to September 15, 2020), 129 patients were admitted, compared with 155 during the same period in 2019, representing a decrease of 16.8%. On comparing the period of lockdown in the country (March 25 to May 31, 2020) with the unlock period, when the lockdown restrictions were eased (June 1 to September 15, 2020), it was observed that number of admissions were 2.7 per week during lockdown period while during the unlock period, it increased to 6.8 per week. When we compared this data with data from the same duration last year, we found that during the lockdown period (March 25 to May 31), there were only 38.8% hospital admissions of head injury patients as compared with the previous year. Whereas in the unlock period (June 1 to September 15), this proportion increased to 117.0% compared with the same duration in the previous year. This change was found to be statistically significant (P < 0.0001). The number of admissions reached the lowest point during the lockdown in May, when only 8 cases of head injury were admitted, compared with 28 admissions in May last year.

In our study, the most common mode of injury was road traffic accidents (49.65%), followed by fall from height (37.67%). During the lockdown period, road traffic accidents accounted for 29.6% patients, while during the unlock period, 56.9% suffered head injury due to road traffic accidents (P = 0.000).² In Lara-Reyna et al.’s study, overall, the most common mode of head injury was mechanical fall (40.8%) and motor vehicle accident/transit-related injuries accounted for only 18.4%. This difference may be because of the difference in quality of roads and better implementation of traffic rules in the United States compared with India. Road traffic accidents and violence-related trauma showed a statistically significant increase in frequency during COVID-19 in New York.¹

During the COVID-19 era, the most common radiologic diagnoses in our study were acute subdural hematoma/contusion (58.9%), acute epidural hematoma (11.6%) and chronic subdural hematoma(6.2%), while in Lara-Reyna's study, subdural hematoma, traumatic subarachnoid hemorrhage, and intracerebral contusion accounted for most of the cases (42.9%, 32.7%, 12.2% respectively). In our experience, acute epidural hematoma and chronic subdural hematoma decreased in proportion during the COVID-19 era compared with the pre-COVID-19 era (P = 0.016). In our study, mean Glasgow Coma Scale score of the patients admitted during the ongoing COVID-19 pandemic was significantly worse (10.43 ± 4.04) than during the pre-COVID-19 era (12.32 ± 2.91) (P = 0.000). Compared with pre-COVID-19 era, mild and moderate cases decreased by 41% and severe cases increased by 156.25% during the COVID-19 pandemic. Associated injuries were present in 16.3% of patients in the COVID-19 era, which was higher than that in the pre-COVID-19 era (13.5%) (P = 0.615). As a result of the higher proportion of severe head injuries and associated injuries, mortality in our patients increased from 12.4% to 22.5% during the COVID-19 era and this result was statistically significant (P = 0.009).

In our experience, the majority of the patients were managed conservatively in both time periods, with a statistically significant decrease in number of surgical cases during the COVID-19 period. In Lara-Reyna et al.’s study as well, most patients were managed conservatively. In our experience, 2 out of the 129 head injury patients (1.55%) tested positive for COVID-19 during the ongoing COVID-19 pandemic. This is lower compared with the figures reported by Lara-Reyna et al. from New York City, who reported positive COVID-19 test in 3 of their 49 neurotrauma patients (6.1%). This difference can be attributed to the much higher prevalence of COVID-19 in New York at the time when the study was conducted.

Much has been discussed about postponement/cancellation of non-emergent cases.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 However, our experience and that of Lara-Reyna et al. suggests that the decline in volume of cases during the ongoing pandemic is not restricted to non-emergent cases alone and even emergent cases, including neurotrauma, have been affected. Authors from other parts of the world have also voiced similar concerns. Christey et al. have reported reduction in injury-related admissions in New Zealand during the lockdown there.³⁵ Zoi et al. reported a decrease in the number of traumatic cases during the lockdown in Italy.¹⁰ Medical institutions and hospitals should make provisions to continue uninterrupted neurotrauma care during the COVID-19 pandemic to prevent the huge collateral damage.²