Low stroke incidence in the TEMPiS telestroke network during COVID-19 pandemic: Effect of lockdown on thrombolysis and thrombectomy

Abstract

Background: During the COVID-19 pandemic emergency departments have noted a significant decrease in stroke patients. We performed a timely analysis of the Bavarian telestroke TEMPiS "working diagnosis" database.

Methods: Twelve hospitals from the TEMPiS network were selected. Data collected for January through April in years 2017 through 2020 were extracted and analyzed for presumed and definite ischemic stroke (IS), amongst other disorders. In addition, recommendations for intravenous thrombolysis (rtPA) and endovascular thrombectomy (EVT) were noted and mobility data of the region analyzed. If statistically valid, group-comparison was tested with Fisher's exact test considering unpaired observations and ap-value < 0.05 was considered significant.

Results: Upon lockdown in mid-March 2020, we observed a significant reduction in recommendations for rtPA compared to the preceding three years (14.7% [2017-2019] vs. 9.2% [2020], p = 0.0232). Recommendations for EVT were significantly higher in January to mid-March 2020 compared to 2017-2019 (5.4% [2017-2019] vs. 9.3% [2020], p = 0.0013) reflecting its increasing importance. Following the COVID-19 lockdown mid-March 2020 the number of EVT decreased back to levels in 2017-2019 (7.4% [2017-2019] vs. 7.6% [2020], p = 0.1719). Absolute numbers of IS decreased in parallel to mobility data.

Conclusions: The reduced stroke incidence during the COVID-19 pandemic may in part be explained by patient avoidance to seek emergency stroke care and may have an association to population mobility. Increasing mobility may induce a rebound effect and may conflict with a potential second COVID-19 wave. Telemedical networks may be ideal databases to study such effects in near-real time.

Keywords: COVID-19; Telestroke; lockdown; stroke; telehealth; thrombolysis.

Figure 1.

(a) Incidence of new COVID-19 infections in Bavaria on April 18, 2020. Red dots indicate network hospitals, and green and yellow squares depict the two academic stroke centres that alternate weekly for the TEMPiS consult service. Modified with permission from the Bavarian State Office for Health and Food Safety. http://www.lgl.bayern.de/gesundheit/infektionsschutz/infektionskrankheiten_a_z/coronavirus/karte_coronavirus/; (b) Mobility data according to COVID-19 - Mobility Trends Reports - Apple. The data reflect requests for routing in Apple maps for Munich, which resides in the centre of the TEMPiS network, and for Milan near Piacenza, where the first decline in the number of strokes was reported (Morelli et al.). Horizontal dotted line indicates reported reduced stroke activity in Piacenza. (c) Recommendations (absolute numbers) for application of IV thrombolysis and thrombectomy. Vertical dashed line indicates the official beginning of lockdown in Bavaria. Time and patient numbers on y-axis are standardized to 15-day periods (x-axis) in each month to compensate for shorter (February) and longer (January and March) months. 2020 J1 = January first half, 2020 J2 – January second half; F = February, M = March, A = April. (d) Working diagnoses of the telestroke consultations. Vertical dashed line indicates the official beginning of lockdown in Bavaria. Time and patient numbers on y-axis are standardized to 15-day periods (x-axis) in each month to compensate for shorter (February) and longer (January and March) months. 2020 J1 = January first half, 2020 J2 – January second half; F = February, M = March, A = April.