Clinical Characteristics of Stroke with COVID-19: A Systematic Review and Meta-Analysis

BackgroundThe coronavirus disease 2019 (COVID-19) potentially increases the risk of thromboembolism and stroke. Numerous case reports and retrospective cohort studies have been published with mixed characteristics of COVID-19 patients with stroke regarding age, comorbidities, treatment, and outcome. We aimed to depict the frequency and clinical characteristics of COVID-19 patients with stroke.MethodsPubMed and EMBASE were searched on June 10, 2020, to investigate COVID-19 and stroke through retrospective cross-sectional studies, case series/reports according to PRISMA guidelines. Study-specific estimates were combined using one-group meta-analysis in a random-effects model.Results10 retrospective cohort studies and 16 case series/reports were identified including 183 patients with COVID-19 and stroke. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% ([95% confidential interval (CI)]: [0.6-1.6], I² = 62.9%). Mean age was 66.6 ([58.4-74.9], I² = 95.1%), 65.6% was male (61/93 patients). Mean days from symptom onset of COVID-19 to stroke was 8.0 ([4.1-11.9], p< 0.001, I² = 93.1%). D-dimer was 3.3 μg/mL ([1.7-4.9], I² = 86.3%), and cryptogenic stroke was most common as etiology at 50.7% ([31.0-70.4] I² = 64.1%, 39/71patients). Case fatality rate was 44.2% ([27.9-60.5], I² = 66.7%, 40/100 patients).ConclusionsThis systematic review assessed the frequency and clinical characteristics of stroke in COVID-19 patients. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% and associated with older age and stroke risk factors. Frequent cryptogenic stroke and elevated d-dimer level support increased risk of thromboembolism in COVID-19 associated with high mortality. Further study is needed to elucidate the pathophysiology and prognosis of stroke in COVID-19 to achieve most effective care for this population.     

Stroke as a Neurological Complication of COVID-19: A Systematic Review and Meta-Analysis of Incidence,Outcomes and Predictors

IntroductionCOVID-19 is a multi-system infection which predominantly affects the respiratory system, but also causes systemic inflammation, endothelialitis and thrombosis. The consequences of this include renal dysfunction, hepatitis and stroke. In this systematic review, we aimed to evaluate the epidemiology, clinical course, and outcomes of patients who suffer from stroke as a complication of COVID-19.MethodsWe conducted a systematic review of all studies published between November 1, 2019 and July 8, 2020 which reported on patients who suffered from stroke as a complication of COVID-19.Results326 studies were screened, and 30 studies reporting findings from 55,176 patients including 899 with stroke were included. The average age of patients who suffered from stroke as a complication of COVID-19 was 65.5 (Range: 40.4–76.4 years). The average incidence of stroke as a complication of COVID-19 was 1.74% (95% CI: 1.09% to 2.51%). The average mortality of stroke in COVID-19 patients was 31.76% (95% CI: 17.77% to 47.31%). These patients also had deranged clinical parameters including deranged coagulation profiles, liver function tests, and full blood counts.ConclusionAlthough stroke is an uncommon complication of COVID-19, when present, it often results in significant morbidity and mortality. In COVID-19 patients, stroke was associated with older age, comorbidities, and severe illness.     

Endovascular and Antithrombotic Treatment in Blunt Cerebrovascular Injuries: A Systematic Review and Meta-Analysis

ObjectivesIschemic stroke has been estimated to occur in up to 26% of patients with blunt cerebrovascular injury (BCVI). Antithrombotic therapy (AT) may be used for stroke prevention, but the role of endovascular treatment (ET) remains unclear. We systematically reviewed the literature on AT and ET for the treatment of patients with BCVIs.Materials and methodsPubMed, EMBASE, Web of Science, and Cochrane were searched upon the PRISMA guidelines to include studies reporting the use of ET in BCVI patients. Post-ET neurologic outcomes, radiographic responses, and complication rates were assessed. A fixed-effect model meta-analysis was performed to compare treatment-related post-BCVI ischemic stroke rates between AT and ET protocols.ResultsWe included 16 studies comprising 352 patients undergoing ET for BCVI. Mean post-ET rates of good neurologic outcomes and radiologic responses were 86.9% (range, 63.6–100%) and 94.0% (range 57.1–100%), respectively. Mean post-ET complication rate was 5.2% (range, 0–66.7%). Seven studies compared the roles of AT (delivered in 805 patients) and ET (performed in 235 patients) for preventing the onset of post-BCVI ischemic strokes. No significant difference in rates of post-BCVI ischemic stroke was found between patients receiving AT vs patients undergoing ET (OR 0.71, 95% CI: 0.35–1.42, p = 0.402).ConclusionAT and ET may be comparable in preventing the occurrence of ischemic stroke following BCVIs. AT may be preferred as the less-invasive first-line therapy, but ET showed favorable rates of post-treatment clinical and radiologic outcomes, coupled with low rates of treatment-related complications.     

The Prevalence of Post-Traumatic Stress Disorder in the General Population during the COVID-19 Pandemic: A Systematic Review and Single-Arm Meta-Analysis

ObjectiveTo investigate the prevalence of post-traumatic stress disorder (PTSD) in the general population during the COVID-19 pandemic by a systematic review and single-arm meta-analysis. MethodsCNKI, PubMed, EMBASE, and MEDLINE were searched to collect literature on the prevalence of PTSD in the general population during the epidemic. The retrieval time is from the database construction to 31/08/2020. Meta-analysis was performed on the included articles by using Review Manger 5.3 and Stata 16.0 software. ResultsThe prevalence of PTSD in the general population during the COVID-19 pandemic was 15% (95% CI: 11–21%, p<0.001). ConclusionThe COVID-19 pandemic brought certain mental pain to general population, leading to a rise in the incidence of PTSD in a short time.     

Transcarotid Access for Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis and Systematic Review

ObjectivesDespite the success of mechanical thrombectomy in large vessel acute ischemic stroke, recanalization may fail due to difficult anatomic access or peripheral arterial occlusive disease. In these cases, transcarotid access may be used as an alternative, but it has not gained prominence due to safety concerns. Our objective was to assess the efficacy and safety of transcarotid access for mechanical thrombectomy.Materials and MethodsPreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform a systematic review with articles published from 2010 to 2020 summarizing pre-intervention characteristics, techniques utilized, and outcomes of patients undergoing mechanical thrombectomy via trans-carotid puncture. We performed a meta-analysis of clinical outcomes, reperfusion times and overall complications rates of trans-carotid approach.ResultsSix studies describing 80 total attempts at carotid access, 72 of which were successful (90% success rate), were included. Direct carotid puncture was most often used as a rescue technique (87% of patients) secondary to failed femoral access. Successful recanalization was achieved in 76% of patients. 90 day modified Rankin Scale ≤ 2 was achieved in 28% of patients. Carotid puncture-reperfusion time was 32 min (CI = 24–40, p < 0.001). Cervical complications occurred at a rate of 26.5% (95% CI = 17%–38%). Only 1.3% (1/80 patients) had a fatal outcome and 96% of complications required no intervention.ConclusionsOur results on the safety and efficacy of transcarotid access suggests that this approach is a viable alternative to failed thrombectomy when transfemoral or trans-radial access may be impractical.     

Prognostic Tools for Early Mortality in Hemorrhagic Stroke: Systematic Review and Meta-Analysis

Background and Purpose

Several risk scores have been developed to predict mortality in intracerebral hemorrhage (ICH). We aimed to systematically determine the performance of published prognostic tools.

Methods

We searched MEDLINE and EMBASE for prognostic models (published between 2004 and April 2014) used in predicting early mortality (<6 months) after ICH. We evaluated the discrimination performance of the tools through a random-effects meta-analysis of the area under the receiver operating characteristic curve (AUC) or c-statistic. We evaluated the following components of the study validity: study design, collection of prognostic variables, treatment pathways, and missing data.

Results

We identified 11 articles (involving 41,555 patients) reporting on the accuracy of 12 different tools for predicting mortality in ICH. Most studies were either retrospective or post-hoc analyses of prospectively collected data; all but one produced validation data. The Hemphill-ICH score had the largest number of validation cohorts (9 studies involving 3,819 patients) within our systematic review and showed good performance in 4 countries, with a pooled AUC of 0.80 [95% confidence interval (CI)=0.77-0.85]. We identified several modified versions of the Hemphill-ICH score, with the ICH-Grading Scale (GS) score appearing to be the most promising variant, with a pooled AUC across four studies of 0.87 (95% CI=0.84-0.90). Subgroup testing found statistically significant differences between the AUCs obtained in studies involving Hemphill-ICH and ICH-GS scores (p=0.01).

Conclusions

Our meta-analysis evaluated the performance of 12 ICH prognostic tools and found greater supporting evidence for 2 models (Hemphill-ICH and ICH-GS), with generally good performance overall.     

The Association of Cerebrovascular Disease with Adverse Outcomes in COVID-19 Patients: A Meta-Analysis Based on Adjusted Effect Estimates

ObjectiveThe aim of this study was to address the association between cerebrovascular disease and adverse outcomes in coronavirus disease 2019 (COVID-19) patients by using a quantitative meta-analysis based on adjusted effect estimates.MethodA systematic search was performed in PubMed, Web of Science, and EMBASE up to August 10th, 2020. The adjusted effect estimates were extracted and pooled to evaluate the risk of the unfavorable outcomes in COVID-19 patients with cerebrovascular disease. Subgroup analysis and meta-regression were also carried out.ResultsThere were 12 studies with 10,304 patients included in our meta-analysis. A significant trend was observed when evaluating the association between cerebrovascular disease and adverse outcomes (pooled effect = 2.05, 95% confidence interval (CI): 1.34–3.16). In addition, the pooled effects showed that patients with a history of cerebrovascular disease had more likelihood to progress fatal outcomes than patients without a history of cerebrovascular disease (pooled effect = 1.78, 95% CI: 1.04–3.07).ConclusionThis study for the first time indicated that cerebrovascular disease was an independent risk factor for predicting the adverse outcomes, particularly fatal outcomes, in COVID-19 patients on the basis of adjusted effect estimates. Well-designed studies with larger sample size are needed for further verification.     

Real-World Outcomes of Acute Ischemic Stroke Treatment with Intravenous Thrombolysis: A Systematic Review and Meta-Analysis

Background

Evidence from outside the typical clinical research setting, such as the real-world setting, complements evidence coming from randomized controlled trials. The purpose of this study was to evaluate all available evidence from the real-world observational trials about long-term outcomes of treatment with intravenous (IV) recombinant tissue-type plasminogen activator (rt-PA) compared with not treated with IV rt-PA (non-rt-PA) in patients with acute ischemic stroke.

COVID-19-Associated Encephalopathy: Systematic Review of Case Reports

Background and PurposeSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily attacks the respiratory system, but there are also several reports of the involvement of the central nervous system, with one of the manifestations being encephalopathy. The relatively new emergence of COVID-19 means that few studies have investigated the clinical profile of encephalopathy associated with this disease. This study aimed to determine the clinical profile, laboratory, and imaging results of encephalopathy associated with COVID-19.MethodsThree databases, namely PubMed/MEDLINE, Embase, and Scopus, were systematically searched for case reports and case series related to COVID-19-associated encephalopathy published from January 1, 2019 to July 20, 2020.ResultsThis review included 24 studies involving 33 cases. The most-reported neurological symptoms were disorientation/confusion (72.72%), decreased consciousness (54.54%), and seizures (27.27%). Laboratory examinations revealed increases in the C-reactive protein level (48.48%), the lactate dehydrogenase level (30.30%), and lymphopenia (27.27%). Brain imaging did not produce any pathological findings in 51.51% of the cases. Electroencephalography showed generalized slowing in 45.45% of the cases. Elevated protein (42.42%) and lymphocytosis (24.24%) were found in the cerebrospinal fluid. Fifteen patients were reportedly discharged from the hospital in a stable condition, while four cases of mortality were recorded.ConclusionsThe clinical, laboratory, and imaging findings in this review support the hypothesis that cerebral damage in COVID-19-associated encephalopathy is caused by cytokine-immune-mediated inflammation rather than by direct invasion.     

Association of Hyponatremia and Risk of Short- and Long-Term Mortality in Patients with Stroke: A Systematic Review and Meta-Analysis

BackgroundHyponatremia is the most common electrolyte disorder in the clinic practice and it is closely related to the prognosis of various diseases. Studies reported that hyponatremia increased the risk of stroke mortality while yielded inconsistent findings during the follow-up period. Thus, a systematic review and meta-analysis to assess the relationship between hyponatremia and the short-term (within 90 days) and long-term (more than 1 year) prognosis of stroke patients was conducted.MethodsA computerized systematic literature search was performed before November of 2018 for relevant articles evaluating the relationship between hyponatremia and all-cause mortality risk in stroke patients. Pooled relative risk (RR) and hazard risk (HR) with 95% confidence interval (CI) were calculated using DerSimonian-Laird random-effects model. Subgroup analyses were performed according to the follow-up period, types of stroke, different controls, sample size, and sampling time.ResultsA total of 12 studies with 21,973 patients were identified. Compared to the nonhyponatremia patients, hyponatremia was associated with a higher risk of all-cause mortality in short-term (RR 1.61, 95% CI 1.33-1.96; HR 1.78 95% CI 1.19-2.75) and long-term follow-up (RR 1.77, 95% CI 1.27-2.47; HR 2.23,95% CI 1.30-3.82). Subgroups analysis showed the similar results in most subgroups.ConclusionsThis meta-analysis concludes that hyponatremia has a significant prognostic value for short- and long-term prognosis to stroke patients.     

Prognostic Value of Clot Burden Score in Acute Ischemic Stroke after Reperfusion Therapies: A Systematic Review and Meta-Analysis

Background and Aim: Clot burden score (CBS) was designed to weight the thrombus status in cerebral anterior circulation. We performed a systematic review and meta-analysis to investigate the prognostic value of CBS in acute ischemic stroke (AIS) patients undergoing reperfusion therapies. Methods: We searched relevant databases for eligible articles reporting CBS in AIS patients. The effect sizes of good functional outcome, recanalization, or hemorrhagic transformation (HT) were pooled with random-/fixed-effect models. Sensitivity analyses and heterogeneity tests were performed. Results: Fifteen eligible studies enrolling 3302 AIS patients undergoing reperfusion therapies were included. AIS patients with per 1-point increase CBS were associated with good functional outcome (pooled odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.09-1.20) and high rate of recanalization (pooled OR: 1.27, 95% CI: 1.14-1.40). Results from categorical groups indicated high CBS at baseline was associated with higher likelihood of good functional outcome (pooled OR: 1.59, 95% CI: 1.30-1.94) and superior recanalization rates (pooled OR: 2.53, 95% CI: 1.79-3.57). Further stratified analyses showed in intravenous thrombolysis (IVT) alone group, increasing CBS was associated with good functional outcome (continuous pooled OR: 1.18, 95% CI: 1.10-1.27; categorical pooled OR: 3.38, 95% CI: 2.01-5.69) or recanalization (categorical pooled OR: 4.13, 95% CI: 2.00-8.51), but not in endovascular therapy alone group. No significant association was found between CBS and HT. Conclusions: CBS could be a predictor for AIS after reperfusion therapies in functional outcome and successful recanalization particularly in patients receiving IVT alone; while CBS might not be a predictor for HT.     

A Systematic Review and Meta-Analysis of Recovery in Schizophrenia

Objective: Our primary aims were (a) to identify the proportion of individuals with schizophrenia and related psychoses who met recovery criteria based on both clinical and social domains and (b) to examine if recovery was associated with factors such as gender, economic index of sites, and selected design features of the study. We also examined if the proportions who met our definition of recovery had changed over time. Method: A comprehensive search strategy was used to identify potential studies, and data were extracted for those that met inclusion criteria. The proportion who met our recovery criteria (improvements in both clinical and social domains and evidence that improvements in at least 1 of these 2 domains had persisted for at least 2 years) was extracted from each study. Meta-regression techniques were used to explore the association between the recovery proportions and the selected variables. Results: We identified 50 studies with data suitable for inclusion. The median proportion (25%–75% quantiles) who met our recovery criteria was 13.5% (8.1%–20.0%). Studies from sites in countries with poorer economic status had higher recovery proportions. However, there were no statistically significant differences when the estimates were stratified according to sex, midpoint of intake period, strictness of the diagnostic criteria, duration of follow-up, or other design features. Conclusions: Based on the best available data, approximately, 1 in 7 individuals with schizophrenia met our criteria for recovery. Despite major changes in treatment options in recent decades, the proportion of recovered cases has not increased.Key words: schizophrenia, psychosis, recovery, outcome studies, prognosis, epidemiologyIt is widely accepted that a proportion of individuals who develop schizophrenia have a favorable prognosis. Symptoms can abate over time, and a proportion of those with schizophrenia attain good outcomes on a range of clinical and functional outcomes (eg, education, employment, and relationships). The precise proportion of cases that have favorable outcomes is less clearly understood. To a large degree, this relates to uncertainty about how to measure multifaceted outcomes such as “recovery.” Considering how much research attention has been allocated to exploring the onset of psychosis (eg, prodrome and early psychosis), it is appropriate that a comparable degree of research scrutiny also be accorded to the recovery of psychosis. ¹ With respect to the remission of clinical symptoms, operationalizable criteria are now available.^2–4 However, symptom profiles are only one component of the many facets of recovery. Many consumer-based groups conceptualize recovery as a personal journey (ie, a subjectively evaluated process dealing with symptoms over time) rather than a defined point outcome (completely recovered vs persistent illness).⁵ In contrast to most clinical symptoms, outcomes related to recovery do not lend themselves to simple, reliable metrics.^6,7 Regardless of the ongoing debate around how to define and measure recovery,³ we argue that there is a strong case to continue to explore clinical and functional outcomes of schizophrenia from an epidemiological perspective. In recent years, systematic reviews of the incidence,⁸ prevalence,⁹ and mortality of schizophrenia¹⁰ have been published. Of the 4 key epidemiologic indicators required to understand the dynamics of disorders such as schizophrenia in a population (incidence, prevalence, remission/recovery, and mortality), recovery remains the most poorly understood. Clearly, the proportion of individuals who recover over a given period is more than 0% and (sadly) appears to be substantially less than 100%. Can we identify a range of values that encompass the best available estimates of recovery?Several scholarly narrative reviews of outcome of schizophrenia have been published over recent decades.^11–14 While the definitions of remission and recovery have been the subject of a systematic review,³ to the best of our knowledge, only 3 studies have examined the empirical data on “good outcomes” in schizophrenia using systematic reviews and/or meta-analytic techniques.^15–17 According to a meta-analysis by Hegarty et al,¹⁵ based of 320 studies published between 1895 and 1992, approximately 40% of schizophrenia patients were considered as having a good outcome. However, this review did not apply a minimum duration for good outcome, and it was acknowledged that the included studies used widely different methods to allocate subjects to the good outcome category. So, subjects showing either an improvement of symptoms or good social functioning may have been rated as having good outcome. Hegarty et al¹⁵ found that studies using broad non-Kraepelinian diagnostic criteria had higher recovery percentages compared with Kraepelinian criteria, but the length of follow-up did not affect the proportion of recovery. Worryingly, this review noted that the proportion of patients with good outcome had not improved in recent decades. More recently, a systematic review by Menezes et al¹⁶ of the outcome studies of first-episode psychosis was published. This review (based on 37 studies) concluded that 42% of patients had a good outcome. However, good outcome in this review did not require both good clinical and social/functional outcomes, and there was no requirement for good outcome status to have persisted for a certain period of time. This review was exclusively based on first-episode cases, with prospective follow-up for at least 6 months, though most samples had been followed-up for only a relatively short period (mean duration of follow-up was 35.1 months). Despite these caveats, the 2 systematic reviews reported remarkably similar proportions with good outcome (42% and 40%).Warner¹⁷ analyzed 114 follow-up studies (published between 1904 and 2000) to examine recovery in schizophrenia. He defined recovery as complete recovery (loss of psychotic symptoms and return to pre-illness level of functioning) or social recovery (economic and residential independence and low social disruption). No criterion for persistence of recovery was used. According to this analysis, 11%–33% were completely recovered and 22%–53% were socially recovered. Consistent with the findings of Hegarty et al,¹⁵ with respect to changes in outcomes over time, Warner¹⁷ reported that recovery rates had not increased over time.Menezes and colleagues¹⁶ recommended that multidimensional definitions should be used in future studies for outcome in psychosis. Other commentators have suggested that such multidimensional measures should include at least 2 domains—one related to clinical remission and another related to broader social functioning outcome.^18,19 Additionally, persistence of good outcome (indicating recovery) for a minimum of 2 years has been suggested.¹⁸ Setting a duration criterion for persistent recovery does not exclude the possibility of relapses or continued recovery beyond that time. Mindful that not all outcome studies provide data on 2 or more domains and even fewer would share the same rating scales, we sought to collate the primary literature that reported outcome estimates based on these 2 domains. Previous reviews and original studies have often focused on cross-sectional outcomes, without any duration criteria. In this study, we will use the term recovery to describe very good outcome that considers both clinical and social/functional dimensions and includes a duration criteria of at least 2 years for at least 1 of these measures.The broad objective of this study was to undertake a systematic review and meta-analysis of original studies reporting proportions of individuals with schizophrenia and related psychoses who met our predefined recovery criteria. Our primary aims were to identify the proportions of individuals who met our recovery criteria and to examine the nature of the distribution of these estimates (eg, median, mean estimate, and range).We also examined potential sources of heterogeneity in the estimates in order to address selected research questions. For example, while narrative reviews have generally suggested that woman have better outcomes compared with men,²⁰ this issue was not addressed in the 3 previous systematic reviews. In recent years, there has been debate about the links between better clinical outcomes in schizophrenia and studies from sites with lower economic indices (often dichotomized to as “developing” or “developed” nations).^21,22 For example, Menezes et al¹⁶ found better prognosis for samples from “developing country of origin.” They also found an association between the methodological features of the study design and outcomes (eg, better outcome in studies with poorer representativeness and thus in studies with poorer quality). In light of the systematic reviews that have reported an association between reduced duration of untreated psychosis and better outcomes,^16,23,24 one might also predict that outcomes should have improved over time. In recent decades there has been increased focus on the detection and prompt treatment of early psychosis, which might result in better clinical outcomes.^25–27 Thus, optimistic researchers might predict that recovery proportions should improve over time as we continually attempt to improve treatments and service delivery. However, 2 earlier systematic reviews^15,17 found that the proportion of good outcomes had not improved over time—indeed there was evidence that estimates of good outcomes had declined in more recent studies. The lack of change in good outcomes over time is a finding that requires careful ongoing surveillance by the research community. We had the opportunity to reexamine this issue in this systematic review. Finally, we also wished to explore if a number of other design issues have an impact on recovery proportions (eg, first-episode status, narrow Kraepelinian definitions of schizophrenia, duration of follow-up, and study-quality score).Mindful that the primary studies included in the review may not have been designed to examine these particular issues, our a priori hypotheses were the following:

1. A greater proportion of women with schizophrenia and related psychoses would meet recovery criteria compared with men.
2. The proportion of cases who recover will not have changed over time.
3. A greater proportion of cases from studies from sites with poorer economic indices would meet recovery criteria compared with sites with richer economic indices.
4. Recovery is more prevalent in first-episode samples compared with general samples.
5. Recovery is more prevalent in samples using non-Kraepelinian vs Kraepelinian diagnostic system.
6. Recovery is more prevalent in samples with longer duration of follow-up compared with shorter follow-up.
7. Recovery is more prevalent in studies with lower quality scores.

     

Prevalence of Non-Stenotic (<50%) Carotid Plaques in Acute Ischemic Stroke and Transient Ischemic Attack: A Systematic Review and Meta-Analysis

IntroductionNon-stenotic (<50%) carotid plaques have recently been recognized as a potential source of stroke. This meta-analysis aims to summarize the prevalence of non-stenotic carotid plaques in stroke patients in general and in patients with embolic stroke of undetermined source in particular.MethodsWe performed a comprehensive systematic review of the literature and meta-analysis on acute ischemic stroke patients in whom carotid imaging was performed using the MEDLINE, Embase and Cochrane database, including studies published up to December 2019. Keywords were "stroke”, “transient ischemic attack”, “carotid”, “plaque”, “atherosclerosis” and “disease”. Included studies had ≥10 patients with acute ischemic stroke and reported the prevalence of non-stenotic (<50%%stenosis) carotid plaques detected on any imaging modality.ResultsWe included forty-five studies (n = 18304 patients, 48.4% males, mean age 63.6 years) in our meta-analysis. Imaging modalities used were ultrasound (n = 26 studies), CT-angiography (n = 7), magnetic resonance-imaging (n = 8) and catheter angiography (n = 4). The overall prevalence of non-stenotic carotid plaques was 51% (95% CI: 43 - 59). 10 studies included mainly patients with embolic stroke of undetermined source (>50% of all patients). The pooled prevalence of non-stenotic carotid plaques in these studies was 55% (95% CI: 42 - 68). 23 studies explicitly reported ipsilateral non-stenotic carotid plaques, the pooled prevalence of which was 51% (95% CI: 45 - 59).ConclusionsIn this meta-analysis, non-stenotic carotid plaques were present in more than 50% of all acute ischemic stroke patients, with a slightly higher prevalence in ESUS patients. Given the potential role of non-stenotic carotid plaques in stroke etiology, particularly in ESUS, further research should aim to identify criteria that predict the stroke risk associated with non-stenotic carotid plaques.     

Prognostic Value of Serum Cardiac Troponin in Acute Ischemic Stroke: An Updated Systematic Review and Meta-Analysis

Background and purposeCardiac troponin (cTn) is a specific biomarker of cardiac injury and elevation of cTn is related to increased mortality. However, prognostic value of cTn in patients with acute ischemic stroke (AIS) still remains to be elucidated. The aim of this review is to explore the strength of association between elevated cTn and mortality after AIS onset.MethodsPubMed, EMBASE, and Cochrane Library were searched from inception to July 12, 2021 without language restriction. All studies reporting the association between cTn on admission and mortality in AIS patients have been included in this review. Meta-analysis was performed for overall and pre-specified subgroup risk ratios (RR) were obtained using a random effect model. Study quality was assessed for each included study.ResultsThere were 20 studies included in this meta-analysis with 9779 AIS patients met the inclusion criteria. There was significant association between elevated cTn and mortality in patients with AIS (RR 3.87; 95% CI 3.24-4.63). The association was consistent across the pre-specified subgroup analyses by type of troponin (cTnT or cTnI), assay of troponin (conventional or high-sensitivity), region (Asian or Non-Asian), definite exclusion of ACS/AMI patients or not (yes or not mentioned), adjusted AF, HF and impaired renal function or not (yes or no).ConclusionsAIS patients with elevated cTn at baseline has an increased risk of mortality. Early and routine evaluation of cTn may contribute to timely detection of comorbid cardiac injury and prevent unfavorable outcomes in patients with AIS.PROSPERO registration numberCRD42020160912