Trends in Stroke Presentations before and during the COVID-19 Pandemic: A Meta-Analysis

Abstract

Background and purpose: There are reports of decline in the rates of acute emergency presentations during coronavirus disease 2019 (COVID-19) pandemic including stroke. We performed a meta-analysis of the impact of COVID-19 pandemic on rates of stroke presentations and on rates of reperfusion therapy.

Methods: Following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines, we systematically searched the literature for studies reporting changes in stroke presentations and treatment rates before and during the COVID-19 pandemic. Aggregated data were pooled using meta-analysis with random-effect models.

Results: We identified 37 observational studies (n=375,657). Pooled analysis showed decline in rates of all strokes (26.0%; 95% confidence interval [CI], 22.4 to 29.7) and its subtypes; ischemic (25.3%; 95% CI, 21.0 to 30.0), hemorrhagic (27.6%; 95% CI, 20.4 to 35.5), transient ischemic attacks (41.9%; 95% CI, 34.8 to 49.3), and stroke mimics (45.6%; 95% CI, 33.5 to 58.0) during months of pandemic compared with the pre-pandemic period. The decline was most evident for mild symptoms (40% mild vs. 25%-29% moderate/severe). Although rates of intravenous thrombolytic (IVT) and endovascular thrombectomy (EVT) decreased during pandemic, the likelihood of being treated with IVT and EVT did not differ between the two periods, both in primary and in comprehensive stroke centers (odds ratio [OR], 1.08; 95% CI, 0.94 to 1.24 and OR, 0.95; 95% CI, 0.83 to 1.09, respectively).

Conclusions: Rates of all strokes types decreased significantly during pandemic. It is of paramount importance that general population should be educated to seek medical care immediately for stroke-like symptoms during COVID-19 pandemic. Whether delay in initiation of secondary prevention would affect eventual stroke outcomes in the long run needs further study.

Keywords: COVID-19; Fibrinolysis; Hospitalization; Meta-analysis; Stroke; Thrombectomy.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram of the observational studies selection process.

Figure 2.

Percent change in all strokes by geographic region. ES, effect size; CI, confidence interval.

Figure 3.

Percent change in the number of ischemic strokes. ES, effect size; CI, confidence interval.

Figure 4.

Percent change in the number of hemorrhagic strokes. ES, effect size; CI, confidence interval.

Figure 5.

Probability of receiving intravenous thrombolytic (IVT) based on type of stroke center. CI, confidence interval; REML, restricted maximum likelihood.

Figure 6.

Probability of being treated with endovascular thrombectomy (EVT) based on type of stroke center. CI, confidence interval; NA, not appplicable; REML, restricted maximum likelihood.