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Need for Ensuring Care for Neuro-Emergencies – Lessons Learned from the COVID-19 Pandemic

Background: Patients with critical emergency conditions may currently not be seeking or receiving the medical care that they require. Here, we characterized the reality of care for patients presenting with Neuro-emergencies at a large academic center during the first phase of the COVID-19 pandemic. 
 
Methods: In this observational, longitudinal cohort study, all neurosurgical admissions that presented to our Department between February 1st and April 15th during the COVID-19 pandemic and during the same time-period in 2019 were identified and categorized according to the presence of a Neuro-emergency, the route of admission, management, and the category of disease. Further, the clinical course of patients with chronic subdural hematoma (cSDH) was investigated in more detail as a representative Neuro-emergency that presents with a wide variety of semi-urgent symptoms. 
 
Findings: During the pandemic, the proportion (2020: 37%; 2019: 33%) and distribution of Neuro-emergencies among all neurosurgical admissions remained similar as in 2019 but a larger proportion presented through the emergency department than through the outpatient clinic or by referral (*p=0·009). The total number of Neuro-emergencies was significantly reduced (*p=0·0007) across all categories of disease, particularly in severe vascular (*p=0·036) but also in spinal (*p=0·007) and hydrocephalus (*p=0·048) emergencies. Strikingly, elderly patients with cSDH and mild to moderate symptoms presented less frequently, with more severe symptoms (*p=0·046) and were less likely to reach favorable outcome (*p=0·003). 
 
Interpretation: Despite pandemic-related restrictive measures and reallocation of resources, patients with Neuro-emergencies continue to present across the entire spectrum and patients should be encouraged to present regardless of the severity of symptoms because deferred presentation may result in adverse outcome. Thus, conservation of critical healthcare resources remains essential in spite aggressively addressing COVID-19. 
 
Funding Statement: None. 
 
Declaration of Interests: The authors have nothing to disclose. 
 
Ethics Approval Statement: This observational, longitudinal cohort study was approved by the local ethics committee of the Charite University Hospital in Berlin, Germany and is reported according to the STROBE statement. Informed consent was waived due to the retrospective nature of the study.