strong course=”kwd-title” Abbreviations: COVID-19, coronavirus disease 2019; CT, computed tomography; ED, emergency department; ICU, rigorous care unit; NIHSS, National Institutes of Health Stroke Scale Copyright ? 2020 Elsevier Inc. by Elsevier for as long as the COVID-19 source centre remains active. Dear Editor, New York is just about the epicenter in the United States for the coronavirus disease 2019 (COVID-19) pandemic with approximately 202,829 infected, 52,697 hospitalized, and 17,055 confirmed deaths as of June 5, 2020.15 The large influx of critically ill patients resulted in widespread policy and practice changes to counter this new resource-limited establishing. All elective surgeries were cancelled. Urgent instances required authorization and were limited significantly, resulting in primarily emergency instances. Neurosurgery and neurology represent smaller market subspecialties, making up less than 1% of all physicians.2 As facilities prepared to accommodate the influx of COVID-19 individuals, neurosurgeons were called on to care for non-neurosurgical individuals.3 Specialty solutions have had to adapt to decreased staff availability having a need to remain available for specialty specific emergencies. GPI-1046 The triaging of neurosurgical instances into elective, urgent, and emergent is not straightforward, necessitating thought of disease acuity, individual age, comorbidities, and prognosis with the inpatient-related risks of the coronavirus pandemic.1 , 8 , 9 , 11 , 12 In ischemic and hemorrhagic stroke care, rapid care remains paramount and the ability GPI-1046 to deliver timely efficacious care must be balanced GPI-1046 with the risk of infectious exposure to the clinical staff.10 This has led to amendments to the protocolized triage and management plans for individuals with suspected stroke. Patients with dominating hemisphere occlusions, high National Institutes of Health Stroke Scale scores (NIHSS), low Glasgow Coma Level scores, or posterior blood circulation strokes are recommended to be considered for prophylactic intubation.4 , 7 There have been fewer admissions for common emergencies such as heart attack and stroke, largely believed to be due to patient concerns about in-hospital acquisition of the disease.5 , 13 , 14 As individuals avoid coming to the hospital, there has been a 6-fold increase in at home deaths in New York City, many of which are likely non-COVID-19 related.6 Herein we present several case examples of neurological individuals who suffered unintended indirect negative consequences from your pandemic that were not due to an active COVID-19 infection. Case 1 A 50-year-old woman was evaluated in an outpatient medical center for an incidental unruptured 1cm basilar artery aneurysm ( Fig. 1a). After discussion about the rupture risk of the aneurysm and the risks and benefits of treatment, a mutual decision was agreed upon to defer treatment for a few weeks during the peak of the pandemic. Unfortunately, she presented to the emergency department (ED) one week later with a worst headache of life and subarachnoid hemorrhage due to rupture of the basilar artery aneurysm (Fig. 1b). She required emergent ventriculostomy, coil embolization of GPI-1046 the aneurysm, and intra-arterial therapy for vasospasm during her 21 day hospitalization. Open in a separate window Fig. 1 A right vertebral artery digital subtraction angiogram showing a 1cm basilar artery apex aneurysm (a) and an axial non-contrast computed tomography (CT) scan showing diffuse subarachnoid hemorrhage in the basal cisterns (b) for case 1. A CT scan of case 2 showing a large right sided intraparenchymal hemorrhage with significant mass effect, cerebral edema, effacement of the right lateral ventricle, midline shift, and intraventricular hemorrhage (c). A CT scan of case 3 showing a right frontal hemorrhagic tumor with associated mass effect and midline shift (d). Case 2 A 40-year-old male with poorly controlled hypertension developed left sided weakness while following the stay-at-home KLKB1 (H chain, Cleaved-Arg390) antibody executive orders and was reluctant to seek medical attention. His weakness progressed.