Incidence of hemorrhagic cerebrovascular disease due to vascular malformations during the COVID-19 national quarantine in Italy
Introduction
Hemorrhagic cerebrovascular disease (HCVD) accounts for 5% of all strokes. [1,2] One-third of patients die within the initial day to weeks after the hemorrhage, most survivors present a certain degree of disability. [1,2] The crude incidence of HCVD was previously estimated to be 9 per 100 000 people/year. In the last years, following the decrease of cigarette smoking rates and the increase of grade 0 aneurysms diagnosis, the incidence of hemorrhage decreased to about 6–7 per 100 000 people/year. [1,2]
HCVD includes subarachnoid hemorrhage due to ruptured aneurysms as well as ruptured arteriovenous malformations, arteriovenous fistulas, and cavernomas. [3]
From March 10th, 2020 to May 18th, 2020, the Italy Prime Minister imposed a national quarantine (Italian lockdown), restricting the movement of the population except for absolute necessity and health circumstances, in response to the growing Coronavirus disease 2019 (COVID-19) pandemic in the country.
Cardiologists from Italy and Hong Kong reported a dramatic reduction in the number of hospitalizations for acute myocardial infarction during the COVID-19 pandemic. [4,5] In fact, admissions for acute myocardial infarction were halved during the pandemic compared with the equivalent period of the previous year. Moreover, the authors observed a larger time interval from symptom onset to first medical contact.
Similarly, a large Chinese study observed a significant drop in admissions, thrombolysis, and thrombectomy in patients with stroke. [6]
HCVD represents an emergency for neurosurgery and neuro-interventional departments.
No data are currently available on the impact of the COVID-19 pandemic on the incidence and treatment of patients with hemorrhagic cerebrovascular disease due to vascular malformations, although the Paris group of Froelich observed a “surprising” decrease of subarachnoid hemorrhage with even no recruitment. [7]
The aim of this study was therefore to verify the hypothesis that there would have been a reduction in HCVD hospital admissions during the Italian lockdown, compared to the same calendar period (Mar 15th to May 15th) in 2019 and 2018.
Section snippets
Materials and methods
A multicenter, observational survey was conducted to collect data on admissions for hemorrhagic cerebrovascular disease due to vascular malformations throughout two months (March 15th to May 15th, 2020) during the COVID-19 Italian lockdown (March 10th-May 18th, 2020), compared with the same calendar periods in 2019 and 2018.
Centre-North Italy tertiary referral centers of Piedmont (Turin), Liguria (Genoa), Emilia-Romagna (Bologna, Ferrara, Cesena), and Lazio (Rome Gemelli Hospital, Rome S.
Statistical analysis
We computed the rates (per million population) of admissions and treatments for hemorrhagic cerebrovascular disease due to vascular malformations during the same two months (March 15th to May 15th) of the last three years (2018, 2019, and 2020).
The statistical significance of the difference between the event rate of one period versus the previous (e.g. 2020 vs 2019) was evaluated using Poisson Means test, which can be used to assess the potential changes in count data across different periods,
Results
The centers involved in this study present a catchment area of about 8 million people (Table 1).
During the 2020 lockdown, the total number of admissions for HCVD was 92 (79 aneurysms, 8 AVMs, 3 cavernous malformations, 2 DAVFs) compared with 116 (108 aneurysms, 6 AVMs, 2 DAVFs) in 2019 and 95 (83 aneurysms, 5 AVMs, 4 cavernous malformations, 3 DAVFs) in 2018. These differences were not significant (see Table 2 for details).
The number of treated patients (surgery and/or endovascular treatment)
Discussion
In this study, the hypothesis of a reduction of admissions for hemorrhagic cerebrovascular disease due to vascular malformations (HCVD) in Italian hospitals during the COVID-19 lockdown was not confirmed. Admitted cases were not significantly different from previous years.
While most healthcare resources were re-located to manage the pandemic (including a significant reduction of elective surgery), neurosurgery and endovascular departments were allowed to continue to manage urgent and emergent
Limitations of the study
This is simply a descriptive, observational study on the incidence of disease in a particular historical period. No demonstration of cause can be drawn from this study. Therefore, the incidence of COVID-19 infection among patients with HCVD was not investigated, nor did we investigate whether the virus infection affected the outcome. Non-essential but potentially relevant variables, such as patient age and comorbidities, and outcome, were not collected. The study period was limited to 2 months
Conclusions
Reduction of admissions for hemorrhagic cerebrovascular disease due to vascular malformations in Italian hospitals during the COVID-19 lockdown was not confirmed. Nevertheless, some patients reached the emergency rooms only several days after symptoms onset, resulting in a worse clinical condition at admission.
Disclosures
All authors contributed to the present paper, have not financial disclosures nor conflict of interests.
CRediT authorship contribution statement
Pasquale De Bonis: Conceptualization, Writing - original draft. Michele Alessandro Cavallo: Investigation, Supervision. Carmelo Lucio Sturiale: Data curation, Writing - original draft. Cecilia Martellucci: Methodology, Validation. Maria Elena Flacco: Data curation, Methodology. Michele Dughiero: Conceptualization, Validation. Anna Maria Auricchio: Validation, Writing - reviewing & editing. Luca Ricciardi: Conceptualization, Data curation. Antonino Raco: Investigation, Supervision. Carlo
References (8)
- et al.
Assessment of coma and impaired consciousness. A practical scale
Lancet
(1974) - et al.
Worldwide incidence of aneurysmal subarachnoid hemorrhage according to region, time period, blood pressure, and smoking prevalence in the population: a systematic review and meta-analysis
JAMA Neurol.
(2019) - et al.
Incidence of subarachnoid hemorrhage is decreasing together with decreasing smoking rates
Neurology
(2016) - et al.
Prospective, population-based detection of intracranial vascular malformations in adults: the Scottish Intracranial Vascular Malformation Study (SIVMS)
Stroke
(2003)