Stroke and Novel Coronavirus Infection in Humans: A Systematic Review and Meta-Analysis

Lee, Kai Wei; Khan, Abdul Hanif Khan Yusof; Ching, Siew Mooi; Chia, Peck Kee; Loh, Wei Chao; Rashid, Anna Misyail Abdul; Baharin, Janudin; Mat, Liyana Najwa Inche; Sulaiman, Wan Aliaa Wan; Sivaratnam, Dhashani; Basri, Hamidon; Hoo, Fan Kee

doi:10.3389/fneur.2020.579070

Cited by 33 publications

(41 citation statements)

References 86 publications

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“…In a meta-analysis of 28 articles related to stroke and COVID-19, the average number of days to develop stroke among patients after the onset of COVID-19 infection was 6.9 ± 4.5 days. (6) Some series, similar to our data, have reported that patients may present with stroke with simultaneous asymptomatic COVID-19 infection. (11,17) In concordance with stroke data in non-COVID-19 times, and with data published on stroke in COVID-19, the vast majority of our CVAs were infarcts.…”

Section: Discussionsupporting

confidence: 86%

“…(1–5) A pooled frequency of seven studies using the fixed effect model, estimated the incidence of acute stroke in COVID-19 to be 1.1%. (6) The proposed mechanisms include a virus induced prothrombotic state, endothelial injury, vasculitis, cardiomyopathy, microvascular thrombosis and cytokine storm. (7–9) We report our experience of COVID-19 with stroke over a period of eight months spanning March to October 2020.…”

Section: Introductionmentioning

confidence: 99%

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COVID-19 Associated Stroke—A Single Centre Experience

Sundar

Karnik

Mukhopadhyay

et al. 2021

Preprint

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Background and Purpose: Various neurological complications have been reported in association with COVID-19. We report our experience of COVID-19 with stroke at a single center over a period of eight months spanning 1 March to 31 October 2020. Methods: We recruited all patients admitted to Internal Medicine with an acute stroke, who also tested positive for COVID-19 on RTPCR. We included all stroke cases in our analysis for prediction of in-hospital mortality, and separately analyzed arterial infarcts for vascular territory of ischemic strokes. Results: There were 62 stroke cases among 3923 COVID-19 admissions (incidence 1.6%). Data was available for 58 patients {mean age 52.6 years; age range 17 − 91; F/M=20/38; 24% (14/58) aged ≤ 40; 51% (30/58) hypertensive; 36% (21/58) diabetic; 41% (24/58) with O2 saturation <95% at admission; 32/58 (55.17 %) in-hospital mortality}. Among 58 strokes, there were 44 arterial infarcts, seven bleeds, three arterial infarcts with associated cerebral venous sinus thrombosis, two combined infarct and bleed, and two of indeterminate type. Among the total 49 infarcts, Carotid territory was the commonest affected (36/49; 73.5%), followed by vertebrobasilar (7/49; 14.3%) and both (6/49; 12.2%). Concordant arterial block was seen in 61% (19 of 31 infarcts with angiography done). 'Early stroke' (within 48 hours of respiratory symptoms) was seen in 82.7% (48/58) patients. Patients with poor saturation at admission were older (58 vs 49 years) and had more comorbidities and higher mortality (79% vs 38%). Mortality was similar in young strokes and older patients, although the latter required more intense respiratory support. Logistic regression analysis showed that low GCS and requirement for increasing intensity of respiratory support predicted in-hospital mortality. Conclusions: We had a 1.6% incidence of COVID-19 related stroke of which the majority were carotid territory infarcts. In-hospital mortality was 55.17%, predicted by low GCS at admission.

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Section: Discussionsupporting

confidence: 86%

Section: Introductionmentioning

confidence: 99%

COVID-19 Associated Stroke—A Single Centre Experience

Sundar

Karnik

Mukhopadhyay

et al. 2021

Preprint

View full text Add to dashboard Cite

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“…This result is lower than a previously reported incidence (0.7%; 95% CI 0.50%–0.9%) 51 . The incidence of hemorrhagic stroke among all stroke types in COVID-19 patients fluctuated, with 12.2% in May 2020 52 , 9.7% in June 2020 53 , 17.2% in July 2020 54 , 11.6% in September 2020 55 , and 28.42% in the present systematic review.…”

Section: Discussionmentioning

confidence: 56%

“…The cause of ischemic stroke is multifactorial in those with SARS-CoV-2 infection, and it may be due to systemic embolization and diffuse microvascular thrombosis (attributed to a significant increase in prothrombotic factors) 53 . In our systematic review, the mortality rate of COVID-19 patients who experienced ischemic stroke was 36.23%.…”

Section: Discussionmentioning

confidence: 99%

Hemorrhagic and ischemic stroke in patients with coronavirus disease 2019: incidence, risk factors, and pathogenesis - a systematic review and meta-analysis

et al. 2021

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Background: In this study, we aimed to determine the global prevalence, chronological order of symptom appearance, and mortality rates with regard to hemorrhagic and ischemic stroke in patients with coronavirus disease 2019 (COVID-19) and to discuss possible pathogeneses of hemorrhagic and ischemic stroke in individuals with the disease. Methods: We searched the PubMed, Scopus, and Web of Science databases for relevant articles published up to November 8, 2020. Data regarding study characteristics, hemorrhagic stroke, ischemic stroke, and COVID-19 were retrieved in accordance with the PRISMA guidelines. The Newcastle-Ottawa scale was used to assess the quality of the eligible studies. The pooled prevalence and mortality rate of hemorrhagic and ischemic stroke were calculated. Results: The pooled estimate of prevalence of hemorrhagic stroke was 0.46% (95% CI 0.40%–0.53%; I2=89.81%) among 67,155 COVID-19 patients and that of ischemic stroke was 1.11% (95% CI 1.03%–1.22%; I2=94.07%) among 58,104 COVID-19 patients. Ischemic stroke was more predominant (incidence: 71.58%) than hemorrhagic stroke (incidence: 28.42%) in COVID-19 patients who experienced a stroke. In COVID-19 patients who experienced a stroke, hospital admission with respiratory symptoms was more commonly reported than that with neurological symptoms (20.83% for hemorrhagic stroke and 5.51% for ischemic stroke versus 6.94% for hemorrhagic stroke and 5.33% for ischemic stroke, respectively). The pooled mortality rate of COVID-19 patients who experienced a hemorrhagic and ischemic stroke was 44.72% (95% CI 36.73%–52.98%) and 36.23% (95% CI 30.63%–42.24%), respectively. Conclusions: Although the occurrence of hemorrhagic and ischemic stroke is low, the mortality rates of both stroke types in patients with COVID-19 are concerning, and therefore, despite several potential pathogeneses that have been proposed, studies aimed at definitively elucidating the mechanisms of hemorrhagic and ischemic stroke in individuals with COVID-19 are warranted. PROSPERO registration: CRD42020224470 (04/12/20)

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“…A wide sample of neurological symptoms and SARS-CoV2 infection-associated diseases have already been described—large vessel strokes being one of the most life-threatening events related to COVID-19 ( 2 , 3 ).…”

Section: Introductionmentioning

confidence: 99%

Case Report: Decompressive Craniectomy for COVID-19 Malignant Cerebral Artery Infarction. Is Surgery a Good Option?

et al. 2021

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SARS-CoV2 infection can lead to a prothrombotic state. Large vessel occlusion, as well as malignant cerebral stroke have been described in COVID-19 patients. In the following months, given the increase in COVID-19 cases, an increase in malignant cerebral SARS-CoV2 associated strokes are expected. The baseline situation of the patients as well as the risk of evolution to a serious disease due to the virus, depict a unique scenario. Decompressive craniectomy is a life-saving procedure indicated in patients who suffer a malignant cerebral stroke; however, it is unclear whether the same eligibility criteria should be used for patients with COVID-19. To our knowledge seven cases of decompressive craniectomy and malignant cerebral stroke have been described to date. We report on a 39-year-old female with no major risk factors for cerebrovascular disease, apart from oral contraception, and mild COVID-19 symptoms who suffered from left hemispheric syndrome. The patient underwent endovascular treatment with stenting and afterward decompressive craniectomy due to a worsening neurological status with unilateral unreactive mydriasis. We present the case and provide a comprehensive review of the available literature related to the surgical treatment for COVID-19 associated malignant strokes, to establish whether the same eligibility criteria for non-COVID-19 associated strokes should be used. Eight patients, including our case, were surgically managed due to malignant cerebral stroke. Seven of these patients received decompressive craniectomy, and six of them met the eligibility criteria of the current stroke guidelines. The mortality rate was 33%, similar to that described in non-COVID-19 cases. Two patients had a left middle cerebral artery (MCA) and both survived after decompressive craniectomy. Our results support that decompressive craniectomy, using the current stroke guidelines, should be considered an effective life-saving treatment for COVID-19-related malignant cerebral strokes.

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Stroke and Novel Coronavirus Infection in Humans: A Systematic Review and Meta-Analysis

Cited by 33 publications

References 86 publications

COVID-19 Associated Stroke—A Single Centre Experience

COVID-19 Associated Stroke—A Single Centre Experience

Hemorrhagic and ischemic stroke in patients with coronavirus disease 2019: incidence, risk factors, and pathogenesis - a systematic review and meta-analysis

Case Report: Decompressive Craniectomy for COVID-19 Malignant Cerebral Artery Infarction. Is Surgery a Good Option?

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