The Impact of SARS-CoV-2 on Stroke Epidemiology and Care: A Meta-Analysis

Abstract

Objective: Emerging data indicate an increased risk of cerebrovascular events with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and highlight the potential impact of coronavirus disease (COVID-19) on the management and outcomes of acute stroke. We conducted a systematic review and meta-analysis to evaluate the aforementioned considerations.

Methods: We performed a meta-analysis of observational cohort studies reporting on the occurrence and/or outcomes of patients with cerebrovascular events in association with their SARS-CoV-2 infection status. We used a random-effects model. Summary estimates were reported as odds ratios (ORs) and corresponding 95% confidence intervals (CIs).

Results: We identified 18 cohort studies including 67,845 patients. Among patients with SARS-CoV-2, 1.3% (95% CI = 0.9-1.6%, I² = 87%) were hospitalized for cerebrovascular events, 1.1% (95% CI = 0.8-1.3%, I² = 85%) for ischemic stroke, and 0.2% (95% CI = 0.1-0.3%, I² = 64%) for hemorrhagic stroke. Compared to noninfected contemporary or historical controls, patients with SARS-CoV-2 infection had increased odds of ischemic stroke (OR = 3.58, 95% CI = 1.43-8.92, I² = 43%) and cryptogenic stroke (OR = 3.98, 95% CI = 1.62-9.77, I² = 0%). Diabetes mellitus was found to be more prevalent among SARS-CoV-2 stroke patients compared to noninfected historical controls (OR = 1.39, 95% CI = 1.00-1.94, I² = 0%). SARS-CoV-2 infection status was not associated with the likelihood of receiving intravenous thrombolysis (OR = 1.42, 95% CI = 0.65-3.10, I² = 0%) or endovascular thrombectomy (OR = 0.78, 95% CI = 0.35-1.74, I² = 0%) among hospitalized ischemic stroke patients during the COVID-19 pandemic. Odds of in-hospital mortality were higher among SARS-CoV-2 stroke patients compared to noninfected contemporary or historical stroke patients (OR = 5.60, 95% CI = 3.19-9.80, I² = 45%).

Interpretation: SARS-CoV-2 appears to be associated with an increased risk of ischemic stroke, and potentially cryptogenic stroke in particular. It may also be related to an increased mortality risk. ANN NEUROL 2021;89:380-388.

FIGURE 1

Flow chart presenting the selection of eligible studies.

FIGURE 2

Pooled analysis on the probability of (A) ischemic stroke (IS) and (B) cryptogenic ischemic stroke (CS) in patients infected with SARS‐CoV‐2 compared to contemporary or historical controls. C.I. = confidence interval; ICU = intensive care unit; NA = not applicable. [Color figure can be viewed at www.annalsofneurology.org]

FIGURE 3

Pooled analysis on the probability of treatment delivery with (A) intravenous thrombolysis and (B) endovascular thrombectomy (EVT) for acute ischemic stroke (IS) patients infected with SARS‐CoV‐2 compared to contemporary or historical noninfected IS patients. C.I. = confidence interval; tPA = tissue plasminogen activator. [Color figure can be viewed at www.annalsofneurology.org]

FIGURE 4

Pooled analysis of the probability of in‐hospital mortality for patients with cerebrovascular events infected with SARS‐CoV‐2 compared to contemporary or historical noninfected patients with cerebrovascular events. C.I. = confidence interval. [Color figure can be viewed at www.annalsofneurology.org]

FIGURE 5

Funnel plot on the reported prevalence rates of (A) ischemic stroke and (B) hemorrhagic stroke in patients infected with SARS‐CoV‐2. ES=effect estimate; se=standard error. [Color figure can be viewed at www.annalsofneurology.org]