Aneurismal subarachnoid hemorrhage during the COVID-19 outbreak in a Hub and Spoke system: observational multicenter cohort study in Lombardy, Italy

Abstract

Background Lombardy was the most affected Italian region by the first phase of the COVID-19 pandemic and underwent urgent reorganization for the management of emergencies, including subarachnoid hemorrhage from a ruptured cerebral aneurysm (aSAH). The aim of the study was to define demographics, clinical, and therapeutic features of aSAH during the COVID-19 outbreak and compare these with a historical cohort. Methods In this observational multicenter cohort study, patients aged 18 years or older, who were diagnosed with aSAH at the participating centers in Lombardy from March 9 to May 10, 2020, were included (COVID-19 group). In order to minimize bias related to possible SAH seasonality, the control group was composed of patients diagnosed with aSAH from March 9 to May 10 of the three previous years, 2017–2018-2019 (pre-pandemic group). Twenty-three demographic, clinical, and therapeutic features were collected. Statistical analysis was performed. Results Seventy-two patients during the COVID-19 period and 179 in the control group were enrolled at 14 centers. Only 4 patients were positive for SARS-CoV-2. The “diagnostic delay” was significantly increased (+ 68%) in the COVID-19 group vs. pre-pandemic (1.06 vs. 0.63 days, respectively, p-value = 0.030), while “therapeutic delay” did not differ significantly between the two periods (0.89 vs. 0.74 days, p-value = 0.183). Patients with poor outcome (GOS at discharge from 1 to 3) were higher during the COVID-19 period (54.2%) compared to pre-pandemic (40.2%, p = 0.044). In logistic regression analysis, in which outcome was the dichotomized Glasgow Outcome Scale (GOS), five variables showed p-values < 0.05: age at admission, WFNS grade, treatment (none), days in ICU, and ischemia. Conclusions We documented a significantly increased “diagnostic delay” for subarachnoid hemorrhages during the first COVID-19 outbreak in Lombardy. However, despite the dramatic situation that the healthcare system was experiencing, the Lombardy regional reorganization model, which allowed centralization of neurosurgical emergencies such as SAHs, avoided a “therapeutic delay” and led to results overall comparable to the control period.

Impact of COVID-19 on incidence and treatment of intracranial aneurysms in Poland: a national study

“…Lombardy in Italy was one of the first regions in the world to be heavily affected by the outbreak. Neurosurgeons practicing in this area swiftly adapted to the situation by introducing a 'Hub and Spoke' system which Grzegorz Miękisiak et al, Impact of COVID-19 on IAs in Poland avoided therapeutic delay and led to results overall that were comparable to the control period [10]. The EANS Individual Membership Committee emphasised that neurosurgeons should learn a somewhat new skill of reactive management [11].…”

Hospital admissions of spontaneous subarachnoid hemorrhage during the COVID-19 pandemic: Southeastern Turkey experience

“…Fiorindi et al and Aboukais et al found a significant diagnostic delay during the pandemic compared to pre-pandemic. 4,6 Fiorindi et al attributed this to overcrowding in health centers and patients' fear of hospitalization. 6 According to Aboukais et al, the patients, especially those with mild symptoms, might have avoided admission to the hospital due to potential encounters with COVID-19 individuals.…”

“…4,6 Fiorindi et al attributed this to overcrowding in health centers and patients' fear of hospitalization. 6 According to Aboukais et al, the patients, especially those with mild symptoms, might have avoided admission to the hospital due to potential encounters with COVID-19 individuals. 4 Also, the oversaturation of the health centers might have discouraged them to seek healthcare.…”

“…4 On the contrary, in Fiorindi et al's study, despite a significant diagnostic delay, there was no significant difference in WFNS and Fisher scores at admission between pandemic and pre-pandemic era. 6 This discriminancy between two studies might have arised from amount of delay. In Aboukais et al's study difference between mean time-to-admissions was close to 2 days while it was less than half a day in Fiorindi et al's study.…”

“…5 Papers focused on admission patterns of SAH cases during COVID-19 pandemic are scarce and mostly of European and United States origin. 4,[6][7][8][9][10][11] To the best of our knowledge, apart from a multinational study, there is no study that reports admission patterns of SAH in Middle East countries which has different health care structuring and social behavioural pattern. 7 In this study, we aimed to evaluate if COVID-19 had an impact on admission patterns of patients with SAH at various time points during the 1st year of COVID-19 pandemic as observed in a single institution located in southeastern part of Turkey.…”