AccScience Publishing / AN / Volume 1 / Issue 1 / DOI: 10.36922/an.v1i1.28

Clinical characteristics and outcomes of acute ischemic stroke in patients with COVID-19: A systematic review and meta-analysis of global data

Zhelv Yao1,2,3,4 Lili Huang1,2,3,4 Yue Cheng1,2,3,4 Ruowen Qi5 Biyun Xu5 Qingxiu Zhang1,2,3,4* Liqun Zhang6*
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1 Department of Neurology of Drum Tower Hospital, Medical School and the State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing 210008, China
2 Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
3 Nanjing Neurology Clinic Medical Center, Nanjing 210008, China
4 Institute of Brain Science, Nanjing University, Nanjing 210008, China
5 Medical Statistics and Analysis Center, Nanjing Drum Tower Hospital, Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, China
6 St George’s University Hospital NHS Foundation Trust, London, Blackshaw Rd, London SW17 0QT, United Kingdom
Advanced Neurology 2022, 1(1), 28
Submitted: 8 December 2021 | Accepted: 2 March 2022 | Published: 24 March 2022
© 2022 by the Authors. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License ( )

Objective. There is increased concern regarding acute ischemic stroke (AIS) in patients with coronavirus disease 2019 (COVID-19). The aim of this study was to depict the manifestations and outcomes of COVID-19-associated AIS.

Methods. We systematically searched for eligible studies describing AIS in patients with COVID-19 using PubMed, Embase, and Web of Science up to November 29, 2021. We complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used the Newcastle–Ottawa Scale to assess data quality. The data were pooled using fixed- and random-effects models.

Results. Thirty-eight eligible studies involving 76,894 participants were included in this meta-analysis. Compared with AIS patients who did not have COVID-19, patients with COVID-19 were more likely to have anterior circulation stroke (odds ratio [OR]: 2.29, 95% confidence interval [CI]: 1.03 – 5.10; I2: 37%), particularly involving the internal carotid artery (OR: 1.85, 95% CI: 1.19 – 2.88; I2: 0); more severe neurological deficit (National Institutes of Health Stroke Scale [NIHSS]) (weighted mean difference [WMD]: 3.21, 95% CI: 2.13 – 4.29; I2: 64%); higher proportion of cryptogenic stroke (OR: 1.83, 95% CI: 1.24 – 2.70; I2: 62%), large vessel occlusion (OR: 1.68, 95% CI: 1.10 – 2.57; I2: 75%), and multi-territory involvement (OR: 2.64, 95% CI: 1.62 – 4.29; I2: 0%); higher C-reactive protein levels (WMD: 55.90, 95% CI: 33.32 – 78.49; I2: 67%), and D-dimer levels (standardized mean difference: 0.81, 95% CI: 0.52 – 1.10; I2: 59%). The proportion of poor outcomes were higher among patients with COVID-19, including increased risk of in-hospital death (OR: 3.70, 95% CI: 2.73 – 5.02; I2: 64%) and lower possibility of favorable discharge (OR: 0.49, 95% CI: 0.39 – 0.61; I2: 0). However, COVID-19 did not increase the risk of hemorrhagic transformation (OR: 1.34, 95% CI: 0.91 – 1.98; I2: 39%) and symptomatic intracerebral hemorrhage (OR: 1.46, 95% CI: 0.81 – 2.62; I2: 0).

Conclusion. AIS patients with COVID-19 seem to display a pattern of large vessel occlusion and multi-territory infarcts. These patients have high inflammatory marker levels and increased D-dimer levels, which implies that thrombosis and/or thromboembolism might be the underlying mechanism. These patients tend to have worse prognosis regardless of whether they receive reperfusion treatment.

Acute ischemic stroke
Clinical characteristics and outcomes
National Natural Science Foundation of China

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Conflict of interest
The authors declare that they have no conflicts of interest.
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