Clinical Characteristics of Stroke with COVID-19: A Systematic Review and Meta-Analysis

Abstract

Background The coronavirus disease 2019 (COVID-19) potentially increases the risk of thromboembolism and stroke. Numerous case reports and retrospective cohort studies have been published with mixed characteristics of COVID-19 patients with stroke regarding age, comorbidities, treatment, and outcome. We aimed to depict the frequency and clinical characteristics of COVID-19 patients with stroke. Methods PubMed and EMBASE were searched on June 10, 2020, to investigate COVID-19 and stroke through retrospective cross-sectional studies, case series/reports according to PRISMA guidelines. Study-specific estimates were combined using one-group meta-analysis in a random-effects model. Results 10 retrospective cohort studies and 16 case series/reports were identified including 183 patients with COVID-19 and stroke. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% ([95% confidential interval (CI)]: [0.6-1.6], I 2 = 62.9%). Mean age was 66.6 ([58.4-74.9], I 2 = 95.1%), 65.6% was male (61/93 patients). Mean days from symptom onset of COVID-19 to stroke was 8.0 ([4.1-11.9], p < 0.001, I 2 = 93.1%). D-dimer was 3.3 μg/mL ([1.7-4.9], I 2 = 86.3%), and cryptogenic stroke was most common as etiology at 50.7% ([31.0-70.4] I 2 = 64.1%, 39/71patients). Case fatality rate was 44.2% ([27.9-60.5], I 2 = 66.7%, 40/100 patients). Conclusions This systematic review assessed the frequency and clinical characteristics of stroke in COVID-19 patients. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% and associated with older age and stroke risk factors. Frequent cryptogenic stroke and elevated d-dimer level support increased risk of thromboembolism in COVID-19 associated with high mortality. Further study is needed to elucidate the pathophysiology and prognosis of stroke in COVID-19 to achieve most effective care for this population.

Changed pattern of hospital admission in stroke during COVID-19 pandemic period in Iran: a retrospective study

“…A previous large scale cohort study (the Global COVID-19 Stroke Registry) also reported findings similar to our study [ 16 ]. The time from COVID-19 symptoms to the onset of stroke in our study cohort was virtually similar to previous studies; however, 27.7% of stroke cases with COVID-19 infection were asymptomatic [ 19 , 21 ]. In addition, we found a significantly higher frequency for cryptogenic stroke subtype among COVID-19-infected patients which is in line with previous reports [ 11 , 20 , 22 ].…”

“…We also examined the differences in clinical characteristics of ischemic stroke between the patients with positive and negative COVID-19 infection which was consistent with previous reports [ 16 – 20 ]. In contrast to the early reported cases [ 18 ] which included young patients without comorbid conditions, we found a higher mean age as well as high prevalence of preexisting comorbid conditions in COVID-19-positive stroke cases which is also supported by a systematic review of 26 studies involving 183 stroke patients with COVID-19 infection [ 19 ]. Similar to our study, an increase in the frequency of impaired level of consciousness as a presenting stroke symptom in COVID-19-positive cases compared with negative ones was reported previously.…”

SARS-CoV-2 Is a Culprit for Some, but Not All Acute Ischemic Strokes: A Report from the Multinational COVID-19 Stroke Study Group

“…The majority of adverse outcomes among patients with stroke [ 39 , 40 ] or acute coronary syndrome [ 11 , 12 , 13 , 14 , 15 ] were related to the declining trend in seeking urgent care, hospitalization, and receiving guideline indicated measures. On the other hand, the meta-analyses of AIS infected patients presented a mean age of over 65 years and a high load of comorbidities [ 21 , 22 ]. Thereby, there might be a specific group of AIS patients with prior SARS-CoV-2 infection that can be attributed to the virus, while the incidence of stroke among other patients, especially older patients, might be related to their vascular risk factors or critical illness.…”

“…The first report from our Multinational COVID-19 Stroke Study Group and recent meta-analyses on reported infected patients presented a stroke incidence rate of 0.5–1.4% [ 20 , 21 , 22 ]. The odds of stroke after SARS-CoV-2 may not be greater than in non-infected patients [ 23 ].…”

“…The odds of stroke after SARS-CoV-2 may not be greater than in non-infected patients [ 23 ]. In addition, meta-analyses of the reported patients presented that SARS-CoV-2 infected patients who experienced a stroke had a mean age of over 65 years, carried a load of comorbidities, and were affected by more severe infections [ 21 , 22 ]. Thereby, in some patients, stroke may be a coincidence or an indirect consequence of critical illness [ 24 , 25 ] and not a direct complication of the SARS-CoV-2 infection.…”