Abstract
Background: As the world witnessed the devastation caused by the coronavirus disease 2019 (COVID-19) outbreak, a growing body of literature on COVID-19 is also becoming increasingly available. Stroke has increasingly been reported as a complication of COVID-19 infection. However, a systematic synthesis of the available data has not been conducted. Therefore, we performed a systematic review and meta-analysis of currently available epidemiological, clinical, and laboratory data related to both stroke and COVID-19 infection.Methods: We systematically searched Medline, Cinahl, and PubMed for studies related to stroke and COVID-19 from inception up to June 4, 2020. We selected cohort studies, case series, and case reports that reported the occurrence of stroke in COVID-19 patients. A fixed-effects model was used to estimate the pooled frequency of stroke in COVID-19 patients with a 95% confidence interval (CI).Results: Twenty-eight studies were included in the systematic review and seven studies for the meta-analysis. The pooled frequency of stroke in COVID-19 patients was 1.1% (95% CI: 0.8, 1.3). The heterogeneity was low (I2 = 0.0%). Even though the frequency of stroke among patients having COVID-19 infection was low, those with concomitant COVID-19 infection and stroke suffered from a more severe infection and eventually had a poorer prognosis with a higher mortality rate (46.7%) than COVID-19 alone. Many COVID-19 patients shared the common traditional risk factors for stroke. We noted that ischemic stroke involving the anterior circulation with large vessels occlusion is the most common type of stroke with more strokes seen in multi-territorial regions, suggesting systemic thromboembolism. An elevated level of D-dimers, C-reactive protein, ferritin, lactic acid dehydrogenase, troponin, ESR, fibrinogen, and a positive antiphospholipid antibody were also noted in this review.Conclusions: The occurrence of stroke in patients with COVID-19 infection is uncommon, but it may pose as an important prognostic marker and indicator of severity of infection, by causing large vessels occlusion and exhibiting a thrombo-inflammatory vascular picture. Physicians should be made aware and remain vigilant on the possible two-way relationship between stroke and COVID-19 infection. The rate of stroke among patients with COVID-19 infection may increase in the future as they share the common risk factors.
Highlights
In December 2019, an outbreak of a novel respiratory infection was first detected in Wuhan, China, linked to three cases of patients presenting with pneumonia (1, 2)
The main outcomes we examined in this review were percentage or frequency of stroke that occurs after COVID19 infection, whereby the stroke incidence could be an ischemic and hemorrhagic stroke, venous stroke due to venous sinus thrombosis, or transient ischemic attack
Out of 27 studies, eight studies were of retrospective cohort study design, 11 were case series, and nine were case reports
Summary
In December 2019, an outbreak of a novel respiratory infection was first detected in Wuhan, China, linked to three cases of patients presenting with pneumonia (1, 2). The cause of the pneumonia was found to be a viral infection known as novel coronavirus disease (COVID-19), and by March 2020, the World Health Organization (WHO) declared this disease as a pandemic caused by a virus known as SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) (3, 4). COVID-19’s main presentation relates to the infection of the upper respiratory system, with clinical features such as fever, dry cough, myalgia, and malaise, and in more severe cases, patients may develop pneumonia that may proceed to the lifethreatening acute respiratory distress syndrome (ARDS) (7). Due to COVID-19, literature has reported an increasing number of premature strokes in the younger generation (16). We performed a systematic review and meta-analysis of currently available epidemiological, clinical, and laboratory data related to both stroke and COVID-19 infection
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