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

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 Out-come 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.