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Advanced Neurology AIS in patients with COVID-19

discharge (OR: 0.49, 95% CI: 0.39 – 0.61; I : 0; 10 studies; inflammation or immune thrombosis. Viral translation
2
Figure 5). COVID-19 was not associated with hemorrhagic through angiotensin-converting enzyme 2 receptors
transformation (OR: 1.34, 95% CI: 0.91 – 1.98; I : 39%; expressed in vessel walls may contribute to endothelial
2
6 studies) or symptomatic intracerebral hemorrhage (OR: dysfunction and thrombosis. Thrombo-inflammation is
2
1.46, 95% CI: 0.81 – 2.62; I : 0; 6 studies; Table 3). We then secondary to activation of immune cells involved in the
omitted one study at a time to assess whether the statistical defense against the virus and amplification of the cytokine
significance had changed. No study substantially influenced system and complement cascade, resulting in activation
the results of the summary estimates (Figures 6 and 7). of downstream pro-coagulant pathways . COVID-19
[56]
In patients who received intravenous thrombolysis, infection may also induce cardiac arrhythmias resulting in
[57]
those with COVID-19 had a higher rate of hemorrhagic embolic infarcts . Further studies are needed to explore
transformation (OR: 1.96, 95% CI: 1.20 – 3.19; I : 51%; the potential underlying mechanisms are needed.
2
2 studies) and increased risk of in-hospital mortality (OR: In this study, we also found that D-dimer levels
2.84, 95% CI: 1.72 – 4.68; I : 0; 2 studies), in comparison were high in most patients with COVID-19, surpassing
2
with patients who did not have COVID-19 (Table 3). the threshold that has been identified as a predictor of
In patients who were treated with thrombectomy, those in-hospital death . This highlights the need to closely
[58]
with COVID-19 were less likely to achieve functional monitor patients with high levels of CRP and D-dimer
independence on discharge (OR: 0.56, 95% CI: 0.38 – 0.82; for potential stroke, although the prevalence is relatively
I : 0; 2 studies), and these patients had a higher mortality low. Consistent with previous studies [59,60] , our meta-
2
rate (OR: 3.22, 95% CI: 2.16 – 4.79; I : 1%; 4 studies; Table 3). analysis showed that patients with AIS and COVID-19
2
were more likely to have LVO and multi-territory infarcts;
4. Discussion rapid patient evaluation is crucial for effective reperfusion
In this systematic review and meta-analysis investigating treatment.
the clinical characteristic and outcomes of stroke in It is suggested that D-dimer and CRP levels may
patients with COVID-19, we found that in comparison be associated with the severity of AIS in patients with
with patients not infected with COVID-19, those with COVID-19 [61,62] . Hence, for patients with hypercoagulable
COVID-19 were more likely to develop cryptogenic states, proper use of antithrombotic agents or
large vessel stroke that involved multiple territories, antithrombotic therapy could be effective [63,64] . Tracking
present with more severe stroke syndromes, have higher these biological markers will allow for early identification
CRP and D-dimer levels, and have prolonged APTT/PT. and even prediction of disease progression. Intensive
Furthermore, COVID-19 was associated with an increased studies on these markers may provide the basis for
risk of in-hospital mortality and lower rates of functional development of therapeutic and preventive strategies
independence on discharge in ischemic stroke patients, against COVID-19-related stroke.
especially after reperfusion treatment.
Our meta-analysis demonstrated poor prognosis and
In this meta-analysis, we found that patients with AIS high mortality in patients with COVID-19. The previous
and COVID-19 tended to have multi-territory infarcts meta-analyses have reported a high mortality rate of
with LVO. In this study, we first observed abnormalities 29.2% amongst patients with COVID-19 . Our study
[65]
in several coagulation and inflammatory markers reinforced this finding and found that patients with AIS
in patients with COVID-19. Compared with non- and COVID-19 infection had a nearly 4-fold higher risk of
COVID-19 patients, AIS patients with COVID-19 had mortality compared with their counterparts who did not
higher or longer D-dimer, PT, and APTT levels. These have COVID-19 infection, as well as highly unfavorable
results suggested that AIS in patients with COVID-19 may outcome at discharge, even for younger patients. We
be a manifestation of SARS-CoV-2-related coagulation noted that patients with AIS and COVID-19 who received
disorders . Furthermore, recent clinical research intravenous thrombolysis treatment had higher rates of
[52]
reported that elevated CRP levels were closely related to hemorrhagic transformation, which may be related to
increased stroke severity, hemorrhagic transformation, the deranged coagulation status in these patients. We
and in-hospital mortality [53,54] , which suggested that CRP found that patients with COVID-19 who developed AIS
might not only be a biomarker of inflammation but also and who received reperfusion treatment tended to have
acts as a direct participant in the pathological process of poor outcomes and high mortality. Several aspects related
ischemic stroke . Accumulated studies have shown that to COVID-19 infection may explain our observation,
[55]
several potential mechanisms with COVID-19 are involved including respiratory distress, multiorgan failure , a
[21]
in the occurrence of AIS, mainly inducing thrombo- high proportion of LVO and multi-territory involvement.

Volume 1 Issue 1 (2022) 12 https://doi.org/10.36922/an.v1i1.28