Hemorrhagic and ischemic stroke in patients with coronavirus disease 2019: incidence, risk factors, and pathogenesis - a systematic review and meta-analysis [version 1; peer review: 2 approved]
Syahrul Syahrul,
Helnida Anggun Maliga,
Muhammad Ilmawan,
Marhami Fahriani,
Sukamto S. Mamada,
Jonny Karunia Fajar,
Andri Frediansyah,
Faza Nabila Syahrul,
Imran Imran,
Salim Haris,
Aldy Safruddin Rambe,
Talha Bin Emran,
Ali A. Rabaan,
Ruchi Tiwari,
Kuldeep Dhama,
Firzan Nainu,
Endang Mutiawati,
Harapan Harapan
Affiliations
Syahrul Syahrul
Department of Neurology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
Helnida Anggun Maliga
Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65117, Indonesia
Muhammad Ilmawan
Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65117, Indonesia
Marhami Fahriani
Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
Sukamto S. Mamada
Faculty of Pharmacy, Hasanuddin University, Makassar, South Sulawesi, 90245, Indonesia
Jonny Karunia Fajar
Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65117, Indonesia
Andri Frediansyah
Research Division for Natural Product Technology (BPTBA), Indonesian Institute of Sciences (LIPI), Wonosari, 55861, Indonesia
Faza Nabila Syahrul
Department of Neurology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
Imran Imran
Department of Neurology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
Salim Haris
Department of Neurology, Faculty of Medicine, Universitas Indonesia, Jakarta, 10430, Indonesia
Aldy Safruddin Rambe
Department of Neurology, Faculty of Medicine, Universitas Sumatera Utara, Medan, North Sumatra, 20155, Indonesia
Talha Bin Emran
Department of Pharmacy, BGC Trust University Bangladesh, Chittagong-4381, Bangladesh
Department of Veterinary Microbiology and Immunology, College of Veterinary Sciences, UP Pandit Deen Dayal Upadhayay Pashu Chikitsa Vigyan Vishwavidyalay Evum Go-Anusandhan Sansthan (DUVASU), Mathura, Uttar Pradesh, 281 001, India
Kuldeep Dhama
Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, 243122, India
Firzan Nainu
Faculty of Pharmacy, Hasanuddin University, Makassar, South Sulawesi, 90245, Indonesia
Endang Mutiawati
Department of Neurology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
Harapan Harapan
Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
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)
