Where have our patients gone? The impact of COVID‐19 on stroke imaging and intervention at an Australian stroke center

Abstract

Introduction: Australia has fortunately had a low prevalence coronavirus disease 2019 (COVID-19), and our healthcare system has not been overwhelmed. We aimed to determine whether, despite this, a decline in acute stroke presentations, imaging and intervention occurred during the pandemic at a busy stroke centre. Methods: The number of 'code stroke' activations, multimodal CTs and endovascular clot retrievals (ECRs) performed during the pandemic period (3/1/2020-5/10/2020) at a large comprehensive stroke centre was compared against the pre-pandemic period (3/1/2019-1/31/2019) using Z-statistics. Year-on-year comparison of the number of patients with large vessel occlusions (LVOs) and ECRs performed per month was also made. Results: The number of 'code stroke' activations and patients undergoing multimodal CT per month decreased significantly (P < 0.0025) following lockdown on 29th March. The number of ECRs also decreased (P = 0.165). The nadir in the weekly number of CTs coincided with lockdown and the peak of new COVID-19 cases. The number of patients with LVOs and ECRs increased by 15% and 14%, respectively, in March but decreased by 55% and 48%, respectively, in April. Conclusions: The significant decrease in volume of 'code stroke' activations and acute stroke imaging following lockdown was accompanied by a concomitant decrease in patients with LVOs and ECRs. The decrease in imaging was therefore not driven purely by patients with mild strokes and stroke mimics, but also included those with severe strokes. Since Australia had a low prevalence of COVID-19, this observed decrease cannot be attributed to hospital congestion and is instead likely driven by patient fear.

Decline and Recurrence of Stroke Consultations during the COVID-19 Pandemic Lockdown Parallels Population Activity Levels

“…The decline of severe stroke cases requiring IV rtPA and even EVT observed in the TEMPIS telestroke network after initiation of the lockdown parallels the development in a large variety of vascular diseases as shown by several groups [ 18 , 27 , 28 , 29 , 32 , 33 , 34 ]. The general notion in the stroke expert field toward falling numbers of stroke cases strongly suggest that patients and stroke symptoms observing persons refrain to seek medical help because of the risk of SARS-Cov-2 infection in the hospital [ 35 , 36 ].…”

“…The common perspective is that altered prehospital awareness and reluctant behavior to seek medical help during the lockdown resulted in diminished and less timely stroke code alerts, yet also different physical activity levels and especially an overall lower risk of general infection due to social distancing and wearing of mouth-nose masks may play a role. The decline of severe stroke cases requiring IV rtPA and even EVT observed in the TEMPIS telestroke network after initiation of the lockdown parallels the development in a large variety of vascular diseases as shown by several groups [18,[27][28][29][32][33][34]. The general notion in the stroke expert field toward falling numbers of stroke cases strongly suggest that patients and stroke symptoms observing persons refrain to seek medical help because of the risk of SARS-Cov-2 infection in the hospital [35,36].…”

Patient Characteristics and Outcomes Associated with Decline in Stroke Volumes During the Early COVID-19 Pandemic

“…These findings are comparable to those from other parts of the country 1 , 2 and world. 9 , 10 , 11 , 12 This analysis also included more recent data, which demonstrated recovery of stroke volumes from March 27 – June 23, 2020, though at a more gradual rate of 0.15 strokes/day.…”

“…Several hypotheses have been proposed to explain the decrease in stroke presentations during the early pandemic, including concerns of hospital overcrowding, 10 , 12 patient anxiety over contracting COVID-19 at the hospital, 1 , 10 , 12 social isolation 1 , 9 and decreased exposure to pollution due to stay-at-home measures. 13 , 14 A subject of debate is whether the decrease in stroke volumes during the early pandemic was primarily the result of patients with relatively mild symptoms not seeking medical care.…”

Request of hospital care dropped for TIA but remained stable for stroke during COVID-19 pandemic at a large Italian university hospital

“…Several papers reported decreased stroke incidence during the current COVID-19 pandemic [1][2][3][4][5][6][7][8]. Actual stroke reduction due to biological effects of the COVID-19 virus [9] and fear of patients to go to the hospital [7] have been invoked as possible causes of this decrease, but reduced air pollution has also been suggested as the possible cause of reduced stroke incidence during the 2020 pandemic [10].…”