Referral pathways for aneurysmal subarachnoid haemorrhage in KwaZulu-Natal Province, South Africa: Mapping access to neurosurgical care

Background. Aneurysmal subarachnoid haemorrhage (aSAH) presents unique challenges within the African healthcare context. The reported incidence of aSAH in sub-Saharan Africa remains limited, creating the impression of a low disease burden in regions such as KwaZulu-Natal Province (KZN), South Africa. However, this perceived low incidence may reflect underdiagnosis, limited access to neuroimaging and gaps in referral pathways rather than a true epidemiological rarity. Objectives. To document the referral pathways, minimum detected incidence and seasonal presentation of patients with aSAH in KZN. Methods. This retrospective chart review included 445 patients diagnosed with aSAH from 11 health districts across KZN and Eastern Cape provinces who presented to a quaternary hospital in KZN between 2012 and 2021. Data collected comprised patient demographics (age and sex), time from ictus to presentation, and referral hospitals, which were categorised according to their respective health districts. Spearman’s rank correlation was used to assess the association between time to presentation and distance across health districts. Poisson regression analysis was performed to examine the relationship between health districts and the seasonal presentation of aSAH. Results. Most referrals originated from regional hospitals (66%). The patients’ ages ranged from 34 to 57 years, with a male-to-female ratio of 1:2. The cohort was predominantly black African, and 38% had hypertension as a comorbidity. The overall incidence of aSAH was 3.43 per 100 000 population. The time from ictus to presentation ranged from 2 to 14 days, and 23.6% of patients were HIV positive across the health districts. The annual highest minimum detected incidences were recorded in 2013 and 2018. OR Tambo district represented the farthest referral distance to the quaternary hospital. No significant correlation was observed between distance and time-based outcomes, including admission-to-endovascular treatment time (p=0.903) and length of stay (p=0.238). The rate of aSAH presentation was significantly higher in spring compared with autumn (incidence rate ratio 1.34, 95% confidence interval 1.03 - 1.74, p=0.030). Conclusion. The observed low incidence of aSAH in this setting likely reflects systemic factors, including under-reporting, a critical shortage of neurosurgical specialists and limited availability of definitive care services.