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

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          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%, I 2 = 87%) were hospitalized for cerebrovascular events, 1.1% (95% CI = 0.8–1.3%, I 2 = 85%) for ischemic stroke, and 0.2% (95% CI = 0.1–0.3%, I 2 = 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, I 2 = 43%) and cryptogenic stroke (OR = 3.98, 95% CI = 1.62–9.77, I 2 = 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, I 2 = 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, I 2 = 0%) or endovascular thrombectomy (OR = 0.78, 95% CI = 0.35–1.74, I 2 = 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, I 2 = 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 2020

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          A Novel Coronavirus from Patients with Pneumonia in China, 2019

          Na Zhu, Dingyu Zhang, Wenling Wang … (2020)
          Summary In December 2019, a cluster of patients with pneumonia of unknown cause was linked to a seafood wholesale market in Wuhan, China. A previously unknown betacoronavirus was discovered through the use of unbiased sequencing in samples from patients with pneumonia. Human airway epithelial cells were used to isolate a novel coronavirus, named 2019-nCoV, which formed a clade within the subgenus sarbecovirus, Orthocoronavirinae subfamily. Different from both MERS-CoV and SARS-CoV, 2019-nCoV is the seventh member of the family of coronaviruses that infect humans. Enhanced surveillance and further investigation are ongoing. (Funded by the National Key Research and Development Program of China and the National Major Project for Control and Prevention of Infectious Disease in China.)
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            Is Open Access

            The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.

            Alessandro Liberati, Douglas G. Altman, Jennifer Tetzlaff … (2009)
            Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users. Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement--a reporting guideline published in 1999--there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions. The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
            Article 0 comments Cited 2346 times – based on 0 reviews     Review now
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              Bias in meta-analysis detected by a simple, graphical test.

              M. Egger, G Davey Smith, M. Schneider … (1997)
              Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30% of the trial); analysis of funnel plots from 37 meta-analyses identified from a hand search of four leading general medicine journals 1993-6 and 38 meta-analyses from the second 1996 issue of the Cochrane Database of Systematic Reviews. Degree of funnel plot asymmetry as measured by the intercept from regression of standard normal deviates against precision. In the eight pairs of meta-analysis and large trial that were identified (five from cardiovascular medicine, one from diabetic medicine, one from geriatric medicine, one from perinatal medicine) there were four concordant and four discordant pairs. In all cases discordance was due to meta-analyses showing larger effects. Funnel plot asymmetry was present in three out of four discordant pairs but in none of concordant pairs. In 14 (38%) journal meta-analyses and 5 (13%) Cochrane reviews, funnel plot asymmetry indicated that there was bias. A simple analysis of funnel plots provides a useful test for the likely presence of bias in meta-analyses, but as the capacity to detect bias will be limited when meta-analyses are based on a limited number of small trials the results from such analyses should be treated with considerable caution.
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                Author and article information

                Contributors
                Georgios Tsivgoulis:
                ORCID: https://orcid.org/0000-0002-0640-3797
                tsivgoulisgiorg@yahoo.gr
                Journal
                Journal ID (nlm-ta): Ann Neurol
                Journal ID (iso-abbrev): Ann Neurol
                Journal ID (doi): 10.1002/(ISSN)1531-8249
                Journal ID (publisher-id): ANA
                Title: Annals of Neurology
                Publisher: John Wiley & Sons, Inc. (Hoboken, USA )
                ISSN (Print): 0364-5134
                ISSN (Electronic): 1531-8249
                Publication date (Electronic): 09 December 2020
                Electronic Location Identifier: 10.1002/ana.25967
                Affiliations
                [ 1 ] Division of Neurology McMaster University/Population Health Research Institute Hamilton Ontario Canada
                [ 2 ] Second Department of Neurology, Attikon Hospital, School of Medicine National and Kapodistrian University of Athens Athens Greece
                [ 3 ] Neuroscience Institute, Geisinger Health System Danville PA
                [ 4 ] Department of Neurology NYU Langone Health New York NY
                [ 5 ] Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology Weill Cornell Medicine New York NY
                [ 6 ] Department of Neurology Paris Psychiatry and Neurosciences University Hospital Group, Sainte Anne Hospital Paris France
                [ 7 ] University of Paris Paris France
                [ 8 ] INSERM U1266 Paris France
                [ 9 ] FHU Neurovasc Paris France
                [ 10 ] Neurology Unit Maurizio Bufalini Hospital Cesena Italy
                [ 11 ] Neurology Clinic, University of Perugia–S. Maria del la Misericordia Hospital Perugia Italy
                [ 12 ] Division of Neurology, Department of Medicine, National University Hospital, Singapore and School of Medicine National University of Singapore Singapore
                [ 13 ] Department of Primary Education University of Ioannina Ioannina Greece
                [ 14 ] Faculty of Medicine Paris Descartes University Paris France
                [ 15 ] Department of Neurology, School of Medicine Democritus University of Thrace Alexandroupolis Greece
                [ 16 ] First Department of Cardiology, Medical School National and Kapodistrian University of Athens, Hippokration Hospital Athens Greece
                [ 17 ] Department of Hygiene, Epidemiology, and Medical Statistics, School of Medicine National and Kapodistrian University of Athens Athens Greece
                [ 18 ] Department of Epidemiology Harvard T. H. Chan School of Public Health Boston MA
                [ 19 ] Department of Neurology University of Tennessee Health Science Center Memphis TN
                [ 20 ] Fourth Department of Internal Medicine, Attikon University Hospital National and Kapodistrian University of Athens Athens Greece
                [ 21 ] National Public Health Organization of Greece Athens Greece
                Author notes
                [*] [* ] Address correspondence to Dr Tsivgoulis, Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Iras 39, Gerakas Attikis, Athens 15344, Greece. E‐mail: tsivgoulisgiorg@ 123456yahoo.gr

                Author information
                https://orcid.org/0000-0002-9477-0094
                https://orcid.org/0000-0003-0031-1004
                https://orcid.org/0000-0002-5745-0307
                https://orcid.org/0000-0001-8424-6128
                https://orcid.org/0000-0002-2802-1626
                https://orcid.org/0000-0002-0640-3797
                Article
                Publisher ID: ANA25967
                DOI: 10.1002/ana.25967
                PMC ID: 7753413
                PubMed ID: 33219563
                SO-VID: 34021e4f-06e6-4bfc-b26a-7bc9aa29d523
                Copyright © © 2020 American Neurological Association
                License:

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                History
                Date received : 18 August 2020
                Date revision received : 15 November 2020
                Date accepted : 17 November 2020
                Page count
                Figures: 5, Tables: 1, Pages: 9, Words: 6154
                Categories
                Subject: Research Article
                Subject: Research Articles
                Custom metadata
                source-schema-version-number 2.0
                edited-state corrected-proof
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.9.6 mode:remove_FC converted:22.12.2020

                ScienceOpen disciplines: Neurology
                Data availability:
                ScienceOpen disciplines: Neurology

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