








key: cord-344911-pw0ghz3m
authors: July, Julius; Pranata, Raymond
title: Impact of the coronavirus disease pandemic on the number of strokes and mechanical thrombectomies: A systematic review and meta-analysis: COVID-19 and Stroke Care
date: 2020-07-22
journal: J Stroke Cerebrovasc Dis
DOI: 10.1016/j.jstrokecerebrovasdis.2020.105185
sha: 
doc_id: 344911
cord_uid: pw0ghz3m

BACKGROUND: This systematic review and meta-analysis aimed to evaluate the impact of the coronavirus disease (COVID-19) pandemic on stroke care, including the number of stroke alerts/codes, number of reperfusions, and number of thrombectomies during the pandemic compared to those during the pre-pandemic period. METHODS: A systematic literature search was performed using the PubMed, EuropePMC, and Cochrane Central databases. The data of interest were the number of strokes, reperfusions, and mechanical thrombectomies during the COVID-19 pandemic versus that during the pre-pandemic period (in a historical comparator group over a specified period of same period length). RESULTS: The study included 59,233 subjects from 9 studies. Meta-analysis showed that the number of stroke alerts during the pandemic was 64% (56-71%) of that during the pre-pandemic period. The number of reperfusion therapies during the pandemic was 69% (61-77%) of that during the pre-pandemic period. Pooled analysis showed that the number of mechanical thrombectomies performed during the pandemic was 78% (75-80%) of that during the pre-pandemic period. The number of mechanical thrombectomies per stroke patient was higher during the pandemic (OR 1.23 [1.12-1.36], p<0.001; I(2): 0%, p=0.845). CONCLUSION: This meta-analysis showed that the number of stroke alerts, reperfusions, and mechanical thrombectomies was reduced by 36%, 31%, and 22%, respectively, during the pandemic. However, the number of patients receiving mechanical thrombectomy per stroke increased.

As of 13 th July 2020, there have been 12,768,307 cases of coronavirus disease (COVID- 19) , which has resulted in 566,654 deaths. 1 Although most COVID-19 patients are asymptomatic, a significant proportion develops severe manifestations that may lead to death. Patients with advanced age and preexisting comorbidities are more likely to develop severe disease. [2] [3] [4] [5] [6] [7] The incidence of acute conditions such as myocardial infarction was shown to be -reduced‖ during the pandemic. 8 Because of the looming possibility of in-hospital COVID-19 transmission, people are more reluctant to visit the hospital. This was reflected in a study on patients with myocardial infarction, which showed that 27% of patients avoided hospitals because of the fear of COVID-19 transmission. 9 Similarly, a study showed that the COVID- 19 pandemic disrupted prehospital and in-hospital care, resulting in a significant drop in admissions, thrombolysis, and thrombectomy. 10 However, other factors such as decreased pollution during pandemic may decrease myocardial infarction or stroke. 11, 12 Delays in the prehospital and in-hospital chain may lead to a prolonged time to presentation, beyond the golden hour for reperfusion, which may reduce the number of reperfusion and thrombectomy. Less result may result in increased morbidity and mortality. This systematic review and meta-analysis aimed to evaluate the impact of this pandemic on stroke care, including the number of stroke alerts/codes, number of reperfusions, and number of thrombectomies during the COVID-19 pandemic compared to the pre-pandemic period.

A systematic literature search was performed using the keywords -stroke,‖ -cerebrovascular diseases,‖ -cerebral infarction,‖ -brain ischemia,‖ -stroke alert,‖ or -thrombectomy‖ and -COVID-19‖ or -Coronavirus Disease 2019‖ or -2019 n-CoV,‖ or -SARS-CoV-2‖ or -pandemic‖ on PubMed, EuropePMC, and Cochrane Central Database. Hand-sampling from potential articles cited by other studies was also used to identify published studies from 1 January 2020 to 8 June 2020. This initial search was performed by two independent researchers, and the resulting discrepancies were solved by discussion. Inclusion and exclusion criteria were then applied to the retrieved records.

The inclusion criteria for this systematic review and meta-analysis were original articles, research letters, short reports, and case series containing primary data. The data of interest were the number of strokes, reperfusions, and mechanical thrombectomies during the COVID-19 pandemic versus the comparator period. The comparator group was a historical control over a specified period of time (same period length) before the pandemic. The exclusion criteria were preprints, case reports, review articles, and articles in a non-English language.

Data extraction and quality assessment were performed by two independent researchers using extraction forms for the first author, year of publication, sample size, study design, number of stroke alerts/codes, number of reperfusions, and number of mechanical thrombectomies.

Quality assessment was performed using Oxford CEBM Critical Appraisal tool.

The number of reperfusions was defined as the number of patients with acute ischemic stroke receiving thrombolysis and mechanical thrombectomy alone or with intra-arterial thrombolysis. Mechanical thrombectomy was defined as revascularization for acute ischemic stroke with either mechanical thrombectomy alone or with the addition of intra-arterial thrombolysis.

Meta-analysis of proportion was used to determine the number of stroke alerts/codes, reperfusions, and mechanical thrombectomies during the pandemic compared to that during the historical pre-pandemic control period. STATA 16.0 (StataCorp 2019 LLC) was used to perform the meta-analysis with a random-effects model, regardless of heterogeneity.

Heterogeneity was calculated using I 2 statistics and Cochran's Q test, in which I 2 >50% or p<0.10 indicated significant heterogeneity. Assessment for publication bias and metaregression analysis was not performed because of the limited number of studies (<10 studies).

There were a total of 1,760 records, of which 1,305 remained after removal of duplicates. A total of 1,290 records were excluded after screening the titles and abstracts, leaving 15 eligible studies. After the full texts were screened for eligibility, we excluded 6 more articles for the following reasons: 1) no data on outcome of interest (n=4), 2) preprint (n=1), or 3) report was per 100,000 inhabitants (n=1). We included 9 studies for our qualitative and quantitative analyses [ Figure 1 ]. There were a total of 59,233 subjects from 9 studies. 10, [13] [14] [15] [16] [17] [18] [19] [20] Characteristics of the included studies are presented in Table 1 .

The meta-analysis showed that the number of stroke alerts during the pandemic was 64% (56-71%) of that during the pre-pandemic period [ Figure 2 ].

The number of reperfusion therapies undertaken during the pandemic was 69% (61-77%) of that during the pre-pandemic period [ Figure 3 ].

Pooled analysis showed that the number of mechanical thrombectomies performed during the pandemic was 78% (75-80%) of that during the pre-pandemic period [ Figure 4 ]. However, the number of mechanical thrombectomies per stroke patient was higher during the pandemic (OR 1.23 [1.12-1.36], p<0.001; I 2 : 0%, p=0.845).

A meta-analysis of 9 studies showed that the number of stroke alerts/codes, reperfusions, and mechanical thrombectomies was less during the pandemic period than during the prepandemic period. However, the number of patients receiving mechanical thrombectomy per stroke increased.

The number of strokes was lower during the pandemic; this might be explained by hospital avoidance due to fear of contracting the COVID-19 virus. Nevertheless, further research is needed to better understand the reasons for not seeking care. It should be noted that COVID-19 is associated with coagulopathy 21, 22 and may increase the risk of stroke. 2 Although the number of COVID-19-related stroke cases is unclear-along with the non-compliance/nonadherence to chronic medications (due to accessibility or drug rumours unproven to be true) 23 and sedentary lifestyle 24 -the incidence of stroke might actually be higher than is usual.

Reduction in the number of strokes in this pooled analysis reflects the unmet need for medical attention. However, reduced pollution due to lockdown and other restriction, shift in dietary patterns such as decreased consumption of high-sodium, fast-food intake, may lead to a decreased acute cardio-cerebrovascular events related to pollution. 11, 12 Disruption in prehospital and in-hospital care may lead to delayed onset-to-door time. Teo et al. showed that only 54.8% of the patients were attended to within 4.5 hours during the pandemic compared to 71.9% during the pre-pandemic period. 18 Delayed presentation may lead to a reduced number of salvageable areas and also reduce the number of patients eligible for thrombolysis. 13, 25 Our meta-analysis showed that the number of reperfusion episodes during the pandemic was only two-third of that during the prepandemic period. Our result strengthens the conclusion of prior observation that showed marked fall in stroke presentations and services due to COVID-19 in April 2020. 26, 27 Mechanical thrombectomy-which carries the risk of transmission to health care workershas become the procedure of choice in the late presenters. 28 The absolute number of mechanical thrombectomies performed was reduced; however, the number of patients receiving thrombectomy per patient with a stroke actually increased. This is possibly because of an increase in late presenters. Another possibility could be due to differences in proportions of patients with large vessel occlusion that are eligible for thrombectomy, or a greater tendency of more severe strokes, also those who would be candidates for thrombectomy, to present to emergency department during the pandemic compared to those with less severe stroke. 29 Regardless of severity of stroke, people experiencing symptoms of cardio-cerebrovascular diseases should be encouraged to seek emergency medical care.

The limitation of this systematic review and meta-analysis is that the limited data on clinical outcomes prohibit us from calculating the impact of the pandemic in terms of morbidity and mortality. The out-of-hospital deaths in specific regions, which may provide insight on patients with unmet medical needs, cannot be addressed in this meta-analysis. There might be an increasing trend of mechanical thrombectomy due to advances in technology and an increase/decrease in the real stroke incidence. There is no data on other possible factors such as pollution and dietary patterns that may affect the incidence of stroke. The data on proportion of patients with large vessel occlusion eligible for thrombectomy during pandemic compared to pre-pandemic is not thoroughly available.

This meta-analysis showed that the number of stroke alerts/codes, reperfusions, and mechanical thrombectomies was reduced by 36%, 31%, and 22%, respectively, during the pandemic. However, the number of patients receiving mechanical thrombectomy per stroke increased. *Data was not presented by grouping of the pandemic period vs. the pre-pandemic period.

World Health Organization. Coronavirus Disease (COVID-19) Situation Report -164

Impact of Cerebrovascular and Cardiovascular Diseases on Mortality and Severity of COVID-19 -Systematic Review, Meta-analysis, and Meta-regression

Effect of chronic obstructive pulmonary disease and smoking on the outcome of COVID-19

Hypertension is associated with increased mortality and severity of disease in COVID-19 pneumonia: A systematic review, meta-analysis and meta-regression

Diabetes mellitus is associated with increased mortality and severity of disease in COVID-19 pneumonia -A systematic review, meta-analysis, and meta-regression

Lymphopenia in severe coronavirus disease-2019 (COVID-19): systematic review and meta-analysis

Elevated N-terminal pro-brain natriuretic peptide is associated with increased mortality in patients with COVID-19: systematic review and meta-analysis

The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction

Impact of COVID-19 pandemic on STelevation myocardial infarction in a non-COVID-19 epicenter

Impact of the COVID-19 Epidemic on Stroke Care and Potential Solutions

Fewer Hospitalizations for Acute Cardiovascular Conditions During the COVID-19 Pandemic

A time-to-event analysis on air pollutants with the risk of cardiovascular disease and mortality: A systematic review and meta-analysis of 84 cohort studies

Mechanical Thrombectomy for Acute Ischemic Stroke Amid the COVID-19 Outbreak

Has COVID-19 played an unexpected -stroke‖ on the chain of survival?

Impact of the Covid-19 outbreak on acute stroke pathways -Insights from the Alsace region in France

Acute Stroke Care Is at Risk in the Era of COVID-19: Experience at a Comprehensive Stroke Center in Barcelona

Delayed presentation of acute ischemic strokes during the COVID-19 crisis

Delays in Stroke Onset to Hospital Arrival Time During COVID-19

Impact of the COVID-19 pandemic on the process and outcome of thrombectomy for acute ischemic stroke

Need for ensuring care for neuro-emergencies-lessons learned from the COVID-19 pandemic

C-reactive protein, procalcitonin, D-dimer, and ferritin in severe coronavirus disease-2019: a metaanalysis

Multiorgan Failure With Emphasis on Acute Kidney Injury and Severity of COVID-19: Systematic Review and Meta-Analysis

The use of renin angiotensin system inhibitor on mortality in patients with coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

A wave of non-communicable diseases following the COVID-19 pandemic

Acute Stroke Intervention

Approaches to global stroke care during the COVID-19 pandemic

COVID-19 and stroke-A global World Stroke Organization perspective

Mechanical Thrombectomy in the Era of the COVID-19 Pandemic: Emergency Preparedness for Neuroscience Teams

What has caused the fall in stroke admissions during the COVID-19 pandemic?

The authors declare that they have no competing interests.

