Stroke after lung transplantation: a systematic review and meta-analysis

Stroke represents a significant but understudied complication following lung transplantation. No systematic review has synthesized the evidence on post-transplant stroke incidence and outcomes. This study aimed to determine the pooled incidence of stroke after lung transplantation, explore sources of heterogeneity, and synthesize evidence on mortality impact and risk factors.

We searched PubMed, Embase, Cochrane Library, and Web of Science from inception to December 2025. Studies reporting stroke incidence in adult lung transplant recipients with extractable numerator and denominator data were included. Random-effects meta-analysis was performed for incidence pooling; mortality and risk factor data were synthesized narratively.

Seventeen studies (33,175 patients) were included. The pooled stroke incidence was 3.58% (95% CI: 2.86%-4.48%), with substantial heterogeneity (I² = 69.0%; 95% prediction interval: 1.66%-7.54%). Heterogeneity was not explained by geographic region or time window, but was eliminated after exclusion of the single registry study (I² = 0%), indicating that variation in ascertainment methods was the primary source of between-study variability. Exploratory meta-regression found no association between bilateral transplant proportion and stroke incidence (p = 0.86). Sensitivity analyses yielded consistent results. Two studies reported mortality outcomes: stroke was associated with a 3-fold increase in mortality (adjusted hazard ratio 3.01; 95% CI: 2.67-3.41) and markedly higher 30-day mortality (20% vs. 1.3%). In the largest registry study, multivariable analysis identified postoperative extracorporeal membrane oxygenation (ECMO; adjusted odds ratio 2.98), bilateral transplant (adjusted odds ratio 1.71), low-volume center, and older age as risk factors.

Stroke affects approximately 1 in 28 lung transplant recipients and is associated with 3-fold increased mortality. Standardized definitions and prospective studies are needed to address gaps in risk stratification and prevention.

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=1236324, identifier [CRD420251236324].