SCCM Resource Library-13-Delays to Presentation and Outcomes After Aneurysmal Subarachnoid Hemorrhage in the SARS-CoV-2 Era

Video Transcription

Hello, my name is Faris Akdik, and I'm one of the neurointensivists at Emory University. And on behalf of our entire team, I'd like to thank you for the opportunity to share  our data regarding aneurysmal subarachnoid hemorrhage in the COVID era. We have nothing to disclose.  And obviously, measuring the total public health burden of COVID-19 has been a challenge. There is clearly a direct impact of COVID-19 on outcomes, including pneumonia or adrenal  failure, etc. But there's likely an indirect impact of the pandemic on non-COVID-related health outcomes and diseases.  So, for instance, if you go back to the first wave in the spring of 2020, and you look at  the mortality associated with heart disease, with diabetes, and with cerebrovascular disease, there's this unusual spike at the same time as the first surge of COVID.  And this suggests that there's likely collateral damage in addition to the COVID-19-associated deaths that are probably indirectly associated deaths with COVID-19.  And interestingly, this parallels what we see in the emergency department. So everyone has noticed that ED volumes have gone down in the COVID era, and this is a  national registry to demonstrate the point that as the blue line here with COVID cases ticking up, the darker line started to precipitously drop, and that's the ED volume.  And when we asked patients, so the ASEP survey asked a bunch of patients across the country,  and 80% of them said that they were afraid of contracting COVID by coming to the emergency department, which is likely driving a lot of this aversion and avoidance.  And unfortunately, this is including patients who have both acute and non-acute diseases. So folks who need urgent catheterizations, craniotomies, etc.  These are folks who are not coming into the emergency department, and this is an observation confirmed across multiple health systems, as well as highlighted by the CDC as a major  public health barrier in the COVID era. And while this has already been shown in the stroke and the myocardial infarction literature  with delayed presentations and worse outcomes, it's totally unknown how this relates to the aneurysmal subarachnoid hemorrhage population.  And this is particularly interesting because subarachnoid hemorrhage is a kind of complex  multi-system critical care dilemma as patients progress through their two or three-week stay with us.  At the very beginning, there are more concerns for fulminant hydrocephalus, seizures, edema, etc.  As things progress, the basal spasm window starts to open up, and then we start to have cerebral hemodynamic problems, and there's obviously the DCI, the delayed cerebral ischemia  window that's open for, you know, two weeks or more. And so you can imagine if patients come at different time points, they're subjecting  themselves to different risks and are potentially accruing damage in that process. And so this presents an interesting question of how the COVID pandemic has affected aneurysmal  hemorrhages. And just as a brief primer, for those of you who don't take care of subarachnoid hemorrhage  patients very often, we do use the Hutton-Hess grading system to stratify patients into kind  of low and medium risk, so patients in grades one through three, versus high-grade disease, so that's four and five.  And so you can imagine a patient comes in either asymptomatic, a mild headache, a really bad headache, or just some mild neurologic deficits, they're somewhere between a grade  one and three, whereas the more kind of fulminant presentations where folks come in comatose or stuporous, that's grades four and five.  And anecdotally, the patients who were coming in low-grade in the early COVID days were telling us they were kind of waiting it out at home until they couldn't.  And so that begs the question, are these patients waiting to come into the hospital?  Are they delaying their presentations to the emergency department? Are we seeing any worse outcomes after ruptured aneurysms in the COVID era?  And then finally, if we do see these changes, what's driving it? To ask this question, we leveraged our ruptured aneurysm database at Emory University Hospital,  which includes all patients admitted here with a confirmed aneurysm at least 18 years or older, and having been admitted 2012 through present day.  And notably, COVID was first reported in Georgia on March 2nd, 2020. And so we defined our cohorts of interest as March 2nd through the end of June of 2020,  and then for that same period, that same time point, March 2nd to June 30th of every year prior back to 2012.  And with this, we generated two groups, the COVID era group, which had 37 patients, and the pre-COVID era group, which had 433 patients.  If you look at the pre-versus-COVID era patients, there's not a meaningful difference in their  baseline demographics in terms of age, sex, comorbidities that we know have some relevance to aneurysmal subarachnoid hemorrhage outcomes and complications.  Similarly, when we compare the Hunt-Hess grade on presentation, you know, comparing essentially the group of low to mid-grade subarachnoid hemorrhage versus high-grade subarachnoid  hemorrhage, there's no difference in the pre-COVID versus COVID era. And when we look at the interventions that were offered, so surgical clipping, endovascular  treatment versus nothing, again, there's no significant difference between the pre- and the COVID era, suggesting that these are relatively comparable groups of patients.  We do, however, notice that patients are presenting later in the COVID era. And so when you look at the black bar here in terms of days to presentation, in the pre-COVID  era, most folks with a ruptured aneurysm come in in the first day. However, in the COVID era, the average day of arrival is around two days or so.  And in fact, if you ask the question of if you just bifurcate patients coming in after two days post-ictus, COVID era patients are about four times more likely to come in when  controlling for age and grade. And so we do see a very strong signal here. And interestingly, this effect is driven by low to mid-grade subarachnoid hemorrhage  and not so much by high-grade subarachnoid hemorrhage. And this makes sense, right? If you have a low to mid-grade subarachnoid hemorrhage patient, they can still get around  at home. They have a really bad headache, maybe their eye's a little bit droopy, et cetera, but  they're functional at home and they're going to try to ride this out as long as they can. And so in those patients, when we just been kind of low to mid-grade patients, we see  a significant difference in independent association and multivariate assumptions for COVID era with a fourfold odds ratio.  But when we look at just high-grade patients, so these are patients who essentially keel over and have a devastating neurologic event, those folks come in promptly still, and that's  obvious, right? They're not going to be able to ride that out at home. And those are the patients for whom we don't see any difference in the delays to presentation.  Now when thinking about the clinical consequences, we went back and we just asked a simple question, how are folks doing in terms of in-hospital death or discharge to hospice?  And when we do a multivariate regression looking for things that associate with this independently,  we find that the COVID era, Hutton-Hess grade and age are all independently associated with this combined outcome.  What you don't see, however, is the latency to presentation, which I think is notable and you see kind of a wide confidence interval around that.  And the reality is that this is a pretty heterogeneous group when you think about late presenters.  And so some of them are going to be these grade one patients who more or less are going to do well and are riding it out as long as they can at home, and some of them are going  to be higher risk kind of intermediate grade patients for whom we can do a lot in terms of securing the aneurysm, protecting them from complications, et cetera.  And so this is going to be a heterogeneous group and it's going to be difficult to kind of parse this out further with an experimental group of about 37 patients.  But at the very least, we can say that there is a mortality phenotype in the COVID era, which is an unfortunate surprise.  And I want to highlight that this is a big difference from our recent experience at Emory.  We just published a 15-year experience demonstrating that outcomes have improved over time.  And here we are saying that in the last year or so, there's been a big drop in our mortality outcomes.  And I think it's important to highlight here that A, that's a big change from our recent  experience and B, more importantly, that these improvements are driven by these low and medium grade subarachnoid hemorrhages in both survival and in functional outcome.  The high grade patients are unfortunately not having any significant benefit despite all these years. And so it's these patients who are the ones who are delaying coming in.  And so these are the folks who are bearing the brunt of these delays and unfortunately these complications.  So in trying to better define why we're seeing increased mortality, the first thing we looked at was re-rupture.  And so we define re-rupture as between the time the patient hits the ED and the time  they go down to have the aneurysm secured. Is there a re-bleeding event? And you can imagine this is pretty rare, but in the COVID era, it's actually been much more noticeable.  And in fact, when we do multivariate analysis, we find that the COVID era is independently associated with increased re-rupture rates.  And obviously this can certainly contribute to worse outcomes in death. The second option is, well, maybe they just have COVID and they're dying of COVID as well.  The reality is only one of our patients had an incidental co-infection and that patient died essentially on presentation of cerebral edema and neurologic catastrophe.  The third thing we had considered is about vasospasm and DCI. So the question being, if they're coming in later, are they having worse spasm? Are they accruing damage, et cetera?  And there is some anecdotal evidence of this, but we're, you know, efforts are ongoing to better characterize this in a rigorous way.  So in summary, we've shown here that patients are presenting in a delayed fashion in the COVID era.  And this delay is largely driven by a low and medium grade subarachnoid hemorrhage. And unfortunately the COVID era is also associated with increased in-hospital death and hospice  disposition. And these are non-COVID deaths that are happening in the COVID era. And another example of the collateral damage of the pandemic.  And then finally, when thinking about the mechanism, this remains unclear, but there is an increased risk of re-rupture in the COVID era, and we're still working to figure  out if vasospasm and DCI are going to play a role here. And so with that, I just want to thank our entire team for making this possible.  And in particular, the interdisciplinary and collaborative team that we've worked with,  with the Neurocritical Care Division, Neurosurgery, and Neurointervention, all working together to make this possible.  And of course, I want to thank you for the opportunity to share our data with you.  Thank you.

Video Summary

A study conducted by Emory University looked at the impact of the COVID-19 pandemic on patients with aneurysmal subarachnoid hemorrhage (SAH), a type of brain bleeding caused by a ruptured brain aneurysm. The study found that patients were presenting to the hospital later than usual, particularly those with low to medium-grade SAH. The delay in presentation was associated with increased in-hospital deaths and hospice disposition. The study also found an increased risk of re-rupture of the aneurysm in the COVID era. The exact reasons for these findings are still unclear, but it highlights the collateral damage of the pandemic on non-COVID-related health outcomes.

Asset Subtitle

Neuroscience, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Feras Akbik, MD, PhD

Introduction/Hypothesis: Increasing reports suggest that patients have been reluctant to present for care due to fear of contracting severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), even in the setting of ischemic stroke or myocardial infarction. The impact of the ongoing pandemic on patients with aneurysmal subarachnoid hemorrhage (aSAH) remains unknown.

Methods: We performed a retrospective cohort study of all patients presenting to a single referral center in Atlanta, Georgia, USA with aSAH between 2012 and 2020. SARS-CoV-2 was first reported in Georgia on March 2, 2020. All patients presenting from March through June of a given calendar year were compared from the pre-SARS-CoV-2 era (2012-2019) to the SARS-CoV-2 era (2020). Patient characteristics, latency from ictus to presentation, and clinical outcomes were compared.

Results: A total of 472 patients presented with aSAH during the study period, with comparable distribution in the age, sex, and Hunt and Hess grade on presentation. The mean latency in days from ictus to presentation was significantly longer in 2020 when compared to the pre-SARS-CoV-2 era (2.3, + 3.0 vs. 0.9 + 2.2, respectively, p<.05). Absolute rates of discharge home or in-hospital mortality were not significantly different. In binary regression analysis, patients were more likely to present post-bleed day 2 or after (OR 3.9, 1.9-8.1, p<.05). This effect was driven by delays to presentation in low grade aSAH (OR 3.2, 1.1-9.25, p<.05) with no difference to time in presentation in high-grade aSAH (2.3, 0.25 â€“ 21.6). The delay to presentation was persistent on multiple binary regression analysis after controlling for age and grade (aOR 3.7, 1.7-8.0, p<.05). There was a non-significant trend towards increased mortality in the SARS-CoV-2 era on multiple regression analysis (2.78, 0.95-8.16).

Conclusions: Similar to patients with myocardial and cerebral infarctions, patients are presenting for care later after an aSAH. This effect is driven by low grade aSAH, as high grade aSAH patients with a more fulminant presentation are still largely presenting within the first day, similar to the pre-SARS-CoV-2 era. These data highlight the ongoing collateral damage of the SARS-CoV-2 pandemic and need for vigilant public health efforts to encourage rapid presentation for care.

Meta Tag

Content Type Presentation

Knowledge Area Neuroscience

Knowledge Area Crisis Management

Knowledge Level Advanced

Membership Level Select

Tag Aneurysmal Subarachnoid Hemorrhage

Tag COVID-19

Year 2021

Keywords

COVID-19 pandemic

aneurysmal subarachnoid hemorrhage

ruptured brain aneurysm

delay in presentation

increased in-hospital deaths

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