Clinical Value of Neutrophil to Lymphocyte and Platelet to Lymphocyte Ratio After Aneurysmal Subarachnoid Hemorrhage

Association of neutrophil-to-lymphocyte ratio with stroke morbidity and mortality: evidence from the NHANES 1999-2020

Background

Stroke is closely linked to inflammation, with the neutrophil-to-lymphocyte ratio (NLR) emerging as a promising inflammatory marker. This study aims to investigate the association between NLR and both morbidity and mortality in stroke patients.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2020 were analyzed, including adults with complete neutrophil and lymphocyte count records. Multivariate logistic regression was used to examine the relationship between NLR and both stroke morbidity and all-cause mortality. Restricted cubic spline regression was employed to assess potential nonlinearity in these associations. Subgroup analyses were performed to identify influencing factors.

Results

After adjusting for confounders, the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for stroke in the higher NLR quartiles, compared to the lowest quartile, were 1.28 (1.07-1.52) and 1.36 (1.12-1.65), respectively. The restricted cubic spline curve indicated a nonlinear positive association between NLR and stroke risk. Additionally, an elevated NLR was positively associated with an increased risk of all-cause mortality.

Conclusion

The findings underscore the potential use of NLR in stratifying and predicting mortality risk in stroke patients, suggesting its relevance in clinical practice.

Association Between High Preoperative White Blood Cell-to-Hemoglobin Ratio and Postoperative Symptomatic Cerebral Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (ASAH) is a serious complication and has a strong relationship with systemic inflammatory responses. Given previously reported relationships between leukocytosis and anemia with ASAH-related cerebral vasospasm, this study examined the association between the preoperative white blood cell-to-hemoglobin ratio (WHR) and postoperative symptomatic cerebral vasospasm (SCV) in patients with ASAH.

METHODS

Demographic, preoperative (comorbidities, ASAH characteristics, laboratory findings), intraoperative (operation and anesthesia), and postoperative (SCV, other neurological complications, clinical course) data were retrospectively analyzed in patients with ASAH who underwent surgical or endovascular treatment of the culprit aneurysm. Patients were divided into high-WHR (n=286) and low-WHR (n=257) groups based on the optimal cutoff value of preoperative WHR (0.74), and stabilized inverse probability weighting was performed between the 2 groups. The predictive power of the WHR and other preoperative systemic inflammatory indices (neutrophil-to-albumin, neutrophil-to-lymphocyte, platelet-to-lymphocyte, platelet-to-neutrophil, platelet-to-white blood cell ratios, and systemic immune-inflammation index) for postoperative SCV was evaluated.

RESULTS

Postoperative SCV was more frequent in the high-WHR group than in the low-WHR group before (33.2% vs. 12.8%; P <0.001) and after (29.4% vs. 19.1%; P =0.005) inverse probability weighting. Before weighting, the predictive power for postoperative SCV was the highest for the WHR among the preoperative systematic inflammatory indices investigated (area under receiver operating characteristics curve 0.66, P <0.001). After weighting, preoperative WHR ≥0.74 was independently associated with postoperative SCV (odds ratio 1.76; P =0.006).

CONCLUSIONS

High preoperative WHR was an independent predictor of postoperative SCV in patients with ASAH.

Neutrophil-to-lymphocyte ratio as a predictor of prognosis in patients with spontaneous intracerebral hemorrhage: a systematic review and meta-analysis

Objective

To evaluate the predictive value of the neutrophil-to-lymphocyte ratio (NLR) for prognosis spontaneous intracerebral hemorrhage (ICH) patients.

Methods

PubMed, EMBASE, Cochrane Library, Web of Science were used for screening literature on NLR predicting ICH prognosis from database up to January 2024. Case-control or cohort studies that provided statistical analysis data on NLR predicting ICH prognosis were included. Data were combined using odds ratio (OR) and standard mean differences (SMD) for categorical variables and continuous variables, respectively. Meta-analysis, subgroup analyses, and sensitivity analyses were performed by Review Manager 5.4 and Stata 15.0.

Results

Meta-analysis of 21 studies with a total of 7,176 patients confirmed that NLR has a significant predictive value for mortality (SMD: 0.80, 95% CI: 0.58-1.02; OR: 1.10, 95% CI: 1.04-1.17) and neurological function outcomes (SMD: 0.66, 95% CI: 0.50-0.81; OR: 1.29, 95% CI: 1.17-1.41). NLR also significantly predicted the occurrence of stroke-associated pneumonia (SAP) (SMD: 0.54, 95% CI: 0.21-0.87). Subgroup analysis suggested that NLR had good predictive value for mortality in ICH patients aged ≥60 years, with hematoma volume > 15 mL, and NLR cut-off >7.5, and for neurological function in ICH patients, Asian patients, and those with NLR cut-off >7.5. The stability of the results was confirmed by sensitivity analysis.

Conclusion

NLR can significantly predict mortality, neurological function outcomes, and SAP occurrence in ICH patients. NLR cut-off >7.5 has good predictive value for both mortality and neurological function in ICH patients. Considering the limitations of this study, such as small sample size and potential heterogeneity, prospective studies with larger sample sizes are needed to confirm the findings of this article.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024544506.

The role of Glucose/Potassium Ratio and Neutrophil/Lymphocyte Ratio in the prognosis of patients with aneurysmal subarachnoid hemorrhage

ANTECEDENTS AND OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Traditional factors strongly associated with poor outcome are neurological condition and the amount of bleeding. Inflammation is considered a relevant mechanism of brain injury after aSAH. This study aims to investigate the potential role of new laboratory indexes related to inflammation for predicting the prognosis of aSAH patients, complementing established prognostic models.

MATERIALS AND METHODS

We conducted a retrospective observational study including adults admitted for aSAH at a single neurosurgery center from 2002 to 2023. Demographic data, clinical parameters, and blood test results at admission were collected. The main outcome variable was Glasgow Outcome Scale (GOS) six month post-bleeding. A second outcome variable was in-hospital mortality. Univariable analyses were performed to identify new laboratory predictors of poor prognosis. The independent association with outcome was evaluated after adjustment of traditional risk factors by logistic regression analysis. The additional value of new laboratory predictors was determined by comparison of the area under the receiver operating curve (AUROC).

RESULTS

Among 542 patients with aSAH, 417 met inclusion criteria (age >18 years old and complete laboratory test available upon admission with aSAH confirmed by CT angiography (CTA) or digital subtraction angiography (DSA)). Elevated glucose/potassium ratio (GKR) in the first blood test at admission was significantly associated with unfavorable outcome and in-hospital mortality according to univariate analysis. The GKR was significantly associated with a worse final prognosis (OR 1.033, 95% CI 1.008-1.040) adjusted for age, WFNS and Fisher scales, history of diabetes mellitus and kidney disease, and prior use of diuretics, oral antidiabetic medications and insulin. Additionally, the inclusion of the GKR improved the predictive accuracy of a prognostic model compared to a model including only clinical and radiological data. The neutrophil-lymphocyte ratio (NLR) was not significantly different between subgroups of patients regarding their outcome.

CONCLUSION

GKR measured in the first 24 h after aSAH may improve the discrimination of patients with higher risk of experiencing poor outcome at six month after the bleeding.

Role of the platelet-lymphocyte ratio as a prognostic indicator in patients with intracranial hemorrhage: A systematic review and meta-analysis

BACKGROUND

The prognostic value of platelet-lymphocyte ratio (PLR) in ischemic stroke had been investigated in previous studies. However, the results of studies on PLR in patients with intracranial hemorrhage (ICH) are inconsistent. We aimed to conduct a meta-analysis to determine the prognostic value of PLR in predicting functional outcome and mortality in patients with ICH.

METHODS

We searched the databases of PubMed, Embase, the Cochrane Library, and CNKI for relevant studies up to 10th June 2024. The Newcastle Ottawa Quality Assessment Scale (NOS) was applied to evaluate the quality of the included studies. We calculated the pooled odds ratios (OR) with 95% confidence intervals (CI) between PLR and both functional outcome (as measured by the modified Rankin Scale, mRS) as well as mortality. Poor functional outcomes were defined as mRS > 2.

RESULTS

A total of 6 studies with 2992 patients were included. The random effects meta-analysis demonstrated that elevated PLR exhibited an association with poor functional outcome in patients with ICH (OR = 1.69; 95% CI [1.39-2.07]; P<0.0001; I2 = 24%). Similarly, elevated PLR was associated with mortality in patients with ICH (OR = 1.65; 95% CI [1.12-2.43]; P = 0.01; I2 = 31%).

CONCLUSION

This study suggested that elevated PLR was significantly associated with poor functional outcome (mRS>2) and increased mortality, indicating that elevated PLR could serve as a reliable a prognostic factor for unfavorable clinical outcomes in patients with ICH. It is advisable to conduct extensive prospective investigations across diverse ethnic backgrounds to verify the accuracy of this correlation prior to its utilization in clinical settings.

Association between systemic inflammatory markers and all-cause mortality in patients with stroke: A prospective study using data from the UK Biobank

BACKGROUND AND AIMS

The systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) are novel inflammatory biomarkers used to determine various disease prognoses. However, the effects of these systemic inflammatory markers on all-cause mortality in patients with stroke remain unclear.

METHODS

We used data from the UK Biobank for this prospective analysis. Overall, 6,020 eligible individuals were included. Over a median follow-up of 13.4 years, 1,233 participants died. We examined the effects of systemic inflammatory markers on all-cause mortality using random survival forest (RSF) and Cox proportional hazards models. Covariate adjustments in the Cox model, selected by RSF, included age, sex, body mass index (BMI), Townsend deprivation index, smoking status, alcohol intake frequency, sleep duration, diabetes, and malignant neoplasms.

RESULTS

In the marginal effect plots and restricted cubic spline analysis for systemic inflammatory markers, LMR exhibited a linear negative correlation, NLR showed a linear positive correlation, and SII and PLR demonstrated a U-shaped association. After covariates were adjusted, the all-cause mortality risk increased by 14 % for LMR <4 (hazards ratio [HR]: 1.14, 95 % confidence interval [CI]: 1.01-1.29; p= 0.03), by 26 % for NLR ≥2 (HR: 1.26; 95 % CI: 1.11-1.43; p < 0.001),by 26 % for PLR ≥175 (HR: 1.26; 95 % CI: 1.07-1.47; p < 0.001), and by 31 % for SII ≥526 (HR: 1.31; 95 % CI, 1.16-1.47; p= 0.014). In addition, sensitivity analyses, excluding participants who had been followed-up for <2 years and those with malignant neoplasms, yielded results consistent with those of previous research.

CONCLUSION

SII, NLR, PLR, and LMR significantly correlate with all-cause mortality in stroke patients. Thresholds established by the RSF model could potentially refine prognostic decision-making in stroke care.

System Inflammation Response Index and Serum Glucose-Potassium Ratio as Prognostic Indicators for Hemorrhagic Moyamoya Disease

BACKGROUND

Hemorrhagic moyamoya disease (HMMD) can result in poor outcomes. Serum biomarkers may play a significant role in predicting HMMD outcomes. This study retrospectively analyzed the correlation between serum biomarkers at the time of admission and outcomes for patients with HMMD.

METHODS

We evaluated 270 patients with HMMD admitted to Yijishan Hopital of Wannan Medical College between July 2017 and April 2023. The patients were categorized into 2 groups according to their modified Rankin Scale scores at 3 months after discharge. Univariate and multivariate analyses were used to identify the associations between biomarkers and clinical outcomes. Receiver operating characteristic curves were obtained to investigate the potential of the biomarkers for predicting prognosis.

RESULTS

Of the 270 patients analyzed, 96 (35.6%) had unfavorable outcomes. The potential predictors were identified using the univariate analysis. The subsequent multivariate logistic regression analysis showed that the systemic inflammatory response index (SIRI) (odds ratio 0.86, 95% confidence interval 0.75-0.98, P = 0.028] and serum glucose to potassium ratio (GPR) (odds ratio 0.53, 95% confidence interval 0.38-0.76, P < 0.001) were independent risk factors of poor outcomes. The receiver operating characteristic analysis indicated that patients with a higher SIRI (≥2.12) and GPR (≥1.75) levels were more likely to have unfavorable outcomes.

CONCLUSIONS

An elevated GPR and SIRI at admission were associated with a poor clinical outcome at the 3-month follow-up for patients with HMMD. Therefore, these biomarkers could be considered in future management decisions for these patients.

The dynamic changes of peripheral blood cell counts predict the clinical outcomes of aneurysmal subarachnoid hemorrhage

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a serious type of hemorrhagic stroke. It is very important to predict the prognosis at early phase. In this work, we intend to characterize early changes in peripheral blood cells after aSAH and explore the association between peripheral blood cells and clinical outcomes after aSAH.

Methods

aSAH patients admitted between December 2019 and September 2022 were enrolled. A retrospective observational study was performed. Total leukocytes, monocytes, neutrophils, erythrocytes, lymphocytes and platelets counts were recorded on the day of admission (day 1), day 3, day 5 and day 7. Statistical tests included Chi-square test, analysis of variance and multivariate logistic regression (MLR) models. 197 patients were analyzed.

Results

Leukocytes and neutrophils were higher in poor outcome groups from day 1 to day 7 and in delayed cerebral ischemia (DCI) groups from day 3 to day 7. Lymphocytes were higher at day 5 and day 7 in good outcome groups and no DCI groups. Neutrophil-to-lymphocyte ratio (NLR) was lower from day 3 to day 7 in good outcome groups and no DCI groups. Erythrocytes were higher from day 3 to day 7 in good outcome groups and no DCI groups. Lymphocytes were negatively related to poor outcomes on day 1 (OR = 0.457), indicating higher lymphocytes predicted good outcomes, Neutrophils were positively related to poor outcomes on day 3 (OR = 3.003) indicating higher neutrophils predicted poor outcomes. Lymphocytes were negatively related to DCI on day 5 (OR = 0.388) indicating higher lymphocytes predicted no DCI, Erythrocytes were negatively related to DCI on day 5 (OR = 0.335) and day 7 (OR = 0.204) indicating higher erythrocytes predicted no DCI. The improved ability of neutrophils, lymphocytes and erythrocytes to predict DCI or poor functional outcomes were revealed by ROC curve analysis.

Conclusions

The dynamic changes of peripheral blood cell counts were related to poor functional outcomes and DCI after aSAH. Elevated neutrophils, leukocytes, NLR, and decreased lymphocytes, erythrocytes were accompanied by DCI and poor outcome. Neutrophils, lymphocytes and erythrocytes counts could be beneficial to predict DCI and outcomes after aSAH.

Can quantitative surface antigen levels and systemic immune-inflammation index be predictive as a new indicator for the initiation of treatment in chronic hepatitis b?

OBJECTIVES

The natural history of chronic HBV infection (CHB) is generally divided into four phases: HBeAg-positive chronic HBV infection (EPCI) and -hepatitis (EPCH), HBeAg-negative chronic HBV infection (ENCI) and -hepatitis (ENCH). This study aimed to investigate changes in serum quantitative surface antigen (qHBsAg), systemic immune-inflammation index (SII) and systemic inflammatory response index (SIRI) in a large number of CHB patients.

METHOD

Three hundred seventy-two CHB patients who underwent liver biopsy between January 2015 and February 2020 were evaluated.

RESULTS

The SII-values were strongly significant between EPCI-EPCH ( P = 0.002), however, there was significant difference between ENCI-ENCH ( P = 0.025). Considering the SIRI results, there was a significant difference between both EPCI-EPCH ( P = 0.009) and ENCI-ENCH ( P = 0.118). In HBeAg-positive patients HBV-DNA, qHBsAg, and SII were found to be predictive ( P = 0.029, P = 0.039, P = 0.027, respectively) while in HBeAg-negative patients, age, AST, HBV-DNA, qHBsAg, SII, and SIRI were found to be predictive ( P = 0.047, P = 0.084, P = <0.001, P = 0.001, P = 0.012, P = 0.002, respectively). In EPCH phase, whereby accuracy rate results of HBV-DNA, qHBsAg, and SII were 75.3%, 73.4%, and 60.4%, respectively, while in the ENCH phase the accuracy rates of age, AST, HBV-DNA, qHBsAg, SII, and SIRI values were 57.8%, 65.6%, 68.3%, 63.8%, 57.3% and 53.2%, respectively.

CONCLUSION

HBV-DNA, qHBsAg, and SII are predictive in EPCH patients. Age, AST, HBV-DNA, qHBsAg, SII and SIRI are all predictive in ENCH patients. In patients with CHB, we recommend using SII to distinguish between EPCI-EPCH and ENCI-ENCH. Based on its sensitivity and features, we believe that qHBsAg and SII are suitable measuring instruments in discrimination both of EPCI-EPCH and ENCI-ENCH.

Neutrophils and Neutrophil Extracellular Traps Cause Vascular Occlusion and Delayed Cerebral Ischemia After Subarachnoid Hemorrhage in Mice

BACKGROUND

After subarachnoid hemorrhage (SAH), neutrophils are deleterious and contribute to poor outcomes. Neutrophils can produce neutrophil extracellular traps (NETs) after ischemic stroke. Our hypothesis was that, after SAH, neutrophils contribute to delayed cerebral ischemia (DCI) and worse outcomes via cerebrovascular occlusion by NETs.

METHODS

SAH was induced via endovascular perforation, and SAH mice were given either a neutrophil-depleting antibody, a PAD4 (peptidylarginine deiminase 4) inhibitor (to prevent NETosis), DNAse-I (to degrade NETs), or a vehicle control. Mice underwent daily neurological assessment until day 7 and then euthanized for quantification of intravascular brain NETs (iNETs). Subsets of mice were used to quantify neutrophil infiltration, NETosis potential, iNETs, cerebral perfusion, and infarction. In addition, NET markers were assessed in the blood of aneurysmal SAH patients.

RESULTS

In mice, SAH led to brain neutrophil infiltration within 24 hours, induced a pro-NETosis phenotype selectively in skull neutrophils, and caused a significant increase in iNETs by day 1, which persisted until at least day 7. Neutrophil depletion significantly reduced iNETs, improving cerebral perfusion, leading to less neurological deficits and less incidence of DCI (16% versus 51.9%). Similarly, PAD4 inhibition reduced iNETs, improved neurological outcome, and reduced incidence of DCI (5% versus 30%), whereas degrading NETs marginally improved outcomes. Patients with aneurysmal SAH who developed DCI had elevated markers of NETs compared with non-DCI patients.

CONCLUSIONS

After SAH, skull-derived neutrophils are primed for NETosis, and there are persistent brain iNETs, which correlated with delayed deficits. The findings from this study suggest that, after SAH, neutrophils and NETosis are therapeutic targets, which can prevent vascular occlusion by NETs in the brain, thereby lessening the risk of DCI. Finally, NET markers may be biomarkers, which can predict which patients with aneurysmal SAH are at risk for developing DCI.

Isoliquiritigenin attenuates neuroinflammation after subarachnoid hemorrhage through inhibition of NF-κB-mediated NLRP3 inflammasome activation

Neuroinflammation contributes to neurological dysfunction in the patients who suffer from subarachnoid hemorrhage (SAH). Isoliquiritigenin (ISL) is a bioactive component extracted from Genus Glycyrrhiza. This work is to investigate whether ISL ameliorates neuroinflammation after SAH. In this study, intravascular perforation of male Sprague-Dawley rats was used to establish a SAH model. ISL was administered by intraperitoneal injection 6 h after SAH in rats. The mortality, SAH grade, neurological score, brain water content, and blood-brain barrier (BBB) permeability were examined at 24 h after the treatment. Expressions of tumor necrosis factor-α, interleukin-6, Iba-1, and MPO were measured by quantitative real-time polymerase chain reaction (qRT-PCR). Besides, the expression levels of NF-κB p65 and NLRP3, ASC, caspase-1, IL-1β, and IL-18 were analyzed by western blot. The experimental data suggested that ISL treatment could ameliorate neurological impairment, attenuate brain edema, and ameliorate BBB injury after SAH in rats. ISL treatment repressed the expression of proinflammatory cytokines TNF-α and IL-6, and meanwhile inhibited the expression of Iba-1 and MPO. ISL also repressed NF-κB p65 expression as well as the transport from the cytoplasm to the nucleus. In addition, ISL significantly suppressed the expression levels of NLR family pyrin domain containing 3 (NLRP3), ASC, caspase-1, IL-1β, and IL-18. These findings suggest that ISL inactivates NLRP3 pathway by inhibiting NF-κB p65 translocation, thereby repressing the neuroinflammation after SAH, and it is a potential drug for the treatment of SAH.

Combination of Albumin/Fibrinogen Ratio and Admission Hunt-Hess Scale Score as an Independent Predictor of Clinical Outcome in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

The albumin/fibrinogen ratio (AFR) is an independent predictor of clinical outcomes of some diseases; however, the prognostic value of AFR and the admission Hunt-Hess (HH) score is still unclear for patients with an aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to assess the relationship between the AFR-HH score and 6-month outcomes of aSAH patients.

METHODS

The clinical characteristics of aSAH patients admitted to our department between December 2017 and December 2021 were retrospectively analyzed. The candidate risk factors were screened using univariate regression analysis, and the independence of the resultant risk factors was evaluated by binary logistic regression analysis. The predictive value of the combined AFR and HH score for unfavorable outcomes was assessed using receiver operating characteristic curve analysis.

RESULTS

A total of 112 aSAH patients were included. Binary logistic regression analysis showed the perioperative period AFR, Glasgow coma scale score, and admission HH score were independent risk factors for unfavorable outcomes for aSAH patients. The receiver operating characteristic curve analysis showed the predictive capacity of AFR plus the admission HH score outperformed the AFR, Glasgow coma scale score, and admission HH scale alone and the combination of the AFR and Glasgow coma scale score.

CONCLUSIONS

A low AFR during the perioperative period is associated with unfavorable outcomes for aSAH patients at 6 months. The combination of the AFR and admission HH scale score provides superior predictive capacity to either the AFR or HH scale score alone.

Correlation of idiopathic benign paroxysmal positional vertigo with cerebral small vessel disease

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most prevalent form of peripheral vertigo, with vascular lesions being one of its suspected causes. The older adults are particularly vulnerable to BPPV. Cerebral small vessel disease (CSVD), on the other hand, is a clinical condition that results from damage of cerebral small vessels. Vascular involvement resulting from age-related risk factors and proinflammatory state may act as the underlying factor linking both BPPV and CSVD.

AIM

The objective of this study is to explore the potential correlation between BPPV and CSVD by examining whether individuals aged 50 and older with BPPV exhibit a greater burden of CSVD.

MATERIALS AND METHODS

This retrospective study included patients aged 50 years and older who had been diagnosed with BPPV. A control group consisting of patients diagnosed with idiopathic facial neuritis (IFN) during the same time period was also included. The burden of cerebral white matter hyperintensities (WMHs) was evaluated using the Fazekas scale. An ordinal regression analysis was conducted to investigate the potential correlation between BPPV and WMHs.

RESULTS

The study included a total of 101 patients diagnosed with BPPV and 116 patients with IFN. Patients with BPPV were found to be significantly more likely (OR = 2.37, 95% CI 1.40-4.03, p = 0.001) to have a higher Fazekas score compared to the control group. Brain infarctions, hypertension, and age were all identified as significant predictors of white matter hyperplasia on MRI, with OR of 9.9 (95% CI 4.21-24.84, P<0.001), 2.86 (95% CI 1.67-5.0, P<0.001), and 1.18 (95% CI 1.13-1.22, P<0.001) respectively.

CONCLUSION

Our findings suggest that vascular impairment caused by age-related risk factors and proinflammatory status may be contributing factors to the development of BPPV in individuals aged 50 and above, as we observed a correlation between the suffering of BPPV and the severity of WMHs.

Prognostic value of the systemic inflammation response index in patients with aneurismal subarachnoid hemorrhage and a Nomogram model construction

OBJECTIVE

To investigate the prognostic value of inflammatory markers, including neutrophil/lymphocyte ratio (NLR), derived neutrophil/lymphocyte ratio (dNLR), platelet/lymphocyte ratio (PLR), monocyte/lymphocyte ratio (MLR), prognostic nutritional index (PNI), and systemic inflammation response index (SIRI) in patients with aneurismal subarachnoid hemorrhage (aSAH), and then develop a Nomogram prognostic model.

METHODS

We analysed 178 aSAH patients who underwent surgery at Subei People's Hospital of Jiangsu province from January 2015 to December 2017. Patients were divided into two groups according to Glasgow outcome scale (GOS) score at 3 months. Univariate and multivariate analysis were used to identify the association between inflammatory markers and prognosis. Subsequently, we identified the best cutoff of SIRI for unfavorable outcome using receiver operating characteristic (ROC) curve analysis and compared the clinical data between high and low SIRI levels. We further evaluated the additive value of SIRI by comparing prognostic nomogram models with and without it.

RESULTS

A total of 47 (26.4%) patients had a poor outcome. Multivariate logistic regression analysis showed that SIRI was an independent risk factor of poor outcome. The SIRI of 4.105 × 109/L was identified as the optimal cutoff value, patients with high SIRI levels had worse clinical status and higher rates of unfavorable outcome. ROC analysis showed that a nomogram model combining the SIRI and other conventional factors showed more favorable predictive ability than the model without the SIRI.

CONCLUSIONS

SIRI was independently correlated with unfavorable outcome in SAH patients, and the nomogram model combining the SIRI had more favorable discrimination ability.

Trends in Delayed Cerebral Ischemia After Subarachnoid Hemorrhage Over Past 10 years: A Bibliometric Analysis

BACKGROUND

As a common hemorrhagic cerebrovascular disease, subarachnoid hemorrhage (SAH) has high mortality and disability. Delayed cerebral ischemia (DCI) is among the major complications after SAH, severely affecting the patient prognosis. Through bibliometric analysis, this study investigated the global research status, trends, and hotspots of DCI after SAH from 2013 to 2022, providing a scientific reference for researchers in this field.

METHODS

We searched the Web of Science Core Collection for articles and associated records from 2013 to 2022. The data were analyzed and presented using VOSviewer software.

RESULTS

This study covered 3436 articles, and the number of publications issued by DCI after SAH study increased annually. The United States published the most papers and had the highest number of citations. Harvard University and World Neurosurgery were the institutions and journals with the most published papers. Keyword analysis indicated that the recent research on DCI after SAH has focused on its pathophysiological mechanisms.

CONCLUSIONS

DCI after SAH has drawn increasing interest in academic circles during the past decade. This study presented an objective, systematic, and comprehensive analysis of the literature on DCI after SAH. Currently, the hotspots in this field focus on pathophysiological mechanisms.

Predicting the Outcome of Patients with Aneurysmal Subarachnoid Hemorrhage: A Machine-Learning-Guided Scorecard

Aneurysmal subarachnoid hemorrhage (aSAH) frequently causes long-term disability, but predicting outcomes remains challenging. Routine parameters such as demographics, admission status, CT findings, and blood tests can be used to predict aSAH outcomes. The aim of this study was to compare the performance of traditional logistic regression with several machine learning algorithms using readily available indicators and to generate a practical prognostic scorecard based on machine learning. Eighteen routinely available indicators were collected as outcome predictors for individuals with aSAH. Logistic regression (LR), random forest (RF), support vector machines (SVMs), and fully connected neural networks (FCNNs) were compared. A scorecard system was established based on predictor weights. The results show that machine learning models and a scorecard achieved 0.75~0.8 area under the curve (AUC) predicting aSAH outcomes (LR 0.739, RF 0.749, SVM 0.762~0.793, scorecard 0.794). FCNNs performed best (~0.95) but lacked interpretability. The scorecard model used only five factors, generating a clinically useful tool with a total cutoff score of ≥5, indicating poor prognosis. We developed and validated machine learning models proven to predict outcomes more accurately in individuals with aSAH. The parameters found to be the most strongly predictive of outcomes were NLR, lymphocyte count, monocyte count, hypertension status, and SEBES. The scorecard system provides a simplified means of applying predictive analytics at the bedside using a few key indicators.

Predictive nomogram models for unfavorable prognosis after aneurysmal subarachnoid hemorrhage: Analysis from a prospective, observational cohort in China

AIM

The aim of the study was to identify predictors for 3-month poor functional outcome or death after aSAH and develop precise and easy-to-use nomogram models.

METHODS

The study was performed at the department of neurology emergency in Beijing Tiantan Hospital. A total of 310 aSAH patients were enrolled between October 2020 and September 2021 as a derivation cohort, while a total of 208 patients were admitted from October 2021 to March 2022 as an external validation cohort. Clinical outcomes included poor functional outcome defined as modified Rankin Scale score (mRS) of 4-6 or all-cause death at 3 months. Least absolute shrinkage and selection operator (LASSO) analysis, as well as multivariable regression analysis, were applied to select independent variables associated with poor functional outcome or death and then to construct two nomogram models. Model performance were evaluated through discrimination, calibration, and clinical usefulness in both derivation cohort and external validation cohort.

RESULTS

The nomogram model to predict poor functional outcome included seven predictors: age, heart rate, Hunt-Hess grade on admission, lymphocyte, C-reactive protein (CRP), platelet, and direct bilirubin levels. It demonstrated high discrimination ability (AUC, 0.845; 95% CI: 0.787-0.903), satisfactory calibration curve, and good clinical usefulness. Similarly, the nomogram model combining age, neutrophil, lymphocyte, CRP, aspartate aminotransferase (AST) levels, and treatment methods to predict all-cause death also revealed excellent discrimination ability (AUC, 0.944; 95% CI: 0.910-0.979), satisfactory calibration curve, and clinical effectiveness. Internal validation showed the bias-corrected C-index for poor functional outcome and death was 0.827 and 0.927, respectively. When applied to the external validation dataset, both two nomogram models exhibited high discrimination capacity [poor functional outcome: AUC = 0.795 (0.716-0.873); death: AUC = 0.811 (0.707-0.915)], good calibration ability, and clinical usefulness.

CONCLUSIONS

Nomogram models constructed for predicting 3-month poor functional outcome or death after aSAH are precise and easily applicable, which can help physicians to identify patients at risk, guide decision-making, and provide new directions for future studies to explore the novel treatment targets.

Association between neutrophil-to-albumin ratio and long-term mortality of aneurysmal subarachnoid hemorrhage

OBJECTIVE

The prognosis of aneurysmal subarachnoid hemorrhage (aSAH) survivors is concerning. The goal of this study was to investigate and demonstrate the relationship between the neutrophil-to-albumin ratio (NAR) and long-term mortality of aSAH survivors.

METHODS

A retrospective observational cohort study was conducted at Sichuan University West China Hospital between January 2009 and June 2019. The investigation of relationship between NAR and long-term mortality was conducted using univariable and multivariable Cox regression models. To demonstrate the predictive performance of different biomarkers over time, time-dependent receiver operating characteristic curve (ROC) analysis and decision curve analysis (DCA) were created.

RESULTS

In total, 3173 aSAH patients were included in this study. There was a strong and continuous relationship between NAR levels and long-term mortality (HR 3.23 95% CI 2.75-3.79, p < 0.001). After adjustment, the result was still significant (adjusted HR 1.78 95% CI 1.49-2.12). Compared with patients with the lowest quartile (< 0.15) of NAR levels, the risk of long-term mortality in the other groups was higher (0.15-0.20: adjusted HR 1.30 95% CI 0.97-1.73; 0.20-0.28: adjusted HR 1.37 95% CI 1.03-1.82; >0.28: adjusted HR 1.74 95% CI 1.30-2.32). Results in survivors were found to be still robust. Moreover, out of all the inflammatory markers studied, NAR demonstrated the highest correlation with long-term mortality.

CONCLUSIONS

A high level of NAR was associated with increased long-term mortality among patients with aSAH. NAR was a promising inflammatory marker for long-term mortality of aSAH.

Association between platelet-lymphocyte ratio and 90-day mortality in patients with intracerebral hemorrhage: data from the MIMIC-III database

Background

Recent evidence suggested that platelet-lymphocyte ratio (PLR) may play a role in the pathophysiology of intracerebral hemorrhage (ICH), but the results are controversial. This study aimed to explore the relationship between PLR and mortality in patients with ICH.

Methods

All data were extracted from the Medical Information Mart for Intensive Care (MIMIC) III database. The study outcome was 90-day mortality. Multivariable Cox regression analyses were used to calculate the adjusted hazard ratio (HR) with a 95% confidence interval (CI), and curve-fitting (restricted cubic spline) was used to assess the non-linear relationship.

Results

Of 1,442 patients, 1,043 patients with ICH were included. The overall 90-day mortality was 29.8% (311/1,043). When PLR was assessed in quartiles, the risk of 90-day mortality for ICH was lowest for quartile 2 (120.9 to <189.8: adjusted HR, 0.67; 95% CI: 0.48-0.93; P = 0.016), compared with those in quartile 1 (<120.9). Consistently in the threshold analysis, for every 1 unit increase in PLR, there was a 0.6% decrease in the risk of 90-day mortality for ICH (adjusted HR, 0.994; 95% CI: 0.988-0.999) in those with PLR <145.54, and a 0.2% increase in 90-day mortality (adjusted HR, 1.002; 95% CI: 1.000-1.003) in participants with PLR ≥145.54.

Conclusion

There was a non-linear relationship between PLR and 90-day mortality for patients with ICH, with an inflection point at 145.54 and a minimal risk at 120.9 to <189.8 of PLR.

Inflammatory Burden Index: Association Between Novel Systemic Inflammatory Biomarkers and Prognosis as Well as in-Hospital Complications of Patients with Aneurysmal Subarachnoid Hemorrhage

Purpose

Systemic inflammation plays an important role in the pathophysiology and progression of aneurysmal subarachnoid hemorrhage (aSAH). In this study, we aimed to investigate the association between a new biomarker, the inflammatory burden index (IBI) and the prognosis as well as in-hospital complications of aSAH patients.

Patients and Methods

We analyzed data from patients with aSAH between January 2019 and September 2022 who were included in the LongTEAM (Long-term Prognosis of Emergency Aneurysmal Subarachnoid Hemorrhage) registry study. The IBI was formulated as C-reactive protein × neutrophils/lymphocytes. The unfavorable functional prognosis was assessed by the modified Rankin Scale (mRS). Receiver operating characteristic (ROC) curve analysis was conducted to determine the optimal cut-off values for IBI to distinguish the unfavorable functional prognosis. Multivariate logistic regression was applied to investigate the association between IBI and in-hospital complications. Propensity score matching was adjusted for imbalances in baseline characteristics to assess the effect of IBI on prognosis.

Results

A total of 408 consecutive patients with aSAH enrolled in the study, of which 235 (57.6%) were female patients and the mean age was 55.28 years old. An IBI equal to 138.03 was identified as the best cut-off threshold to distinguish the unfavorable prognosis at 3 months (area under the curve [AUC] [95% CI] 0.637 [0.568-0.706]). ln IBI was independently associated with 3-month functional prognosis (OR [95% CI] 1.362 [1.148-1.615]; P<0.001), pneumonia (OR [95% CI] 1.427 [1.227-1.659]; P<0.001) and deep venous thrombosis (DVT). (OR [95% CI] 1.326 [1.124-1.564]; P=0.001). After propensity score matching (57:57), an increased proportion of patients with IBI ≥138.03 had a poor functional prognosis at 3 months and in-hospital complications including developed pneumonia and DVT.

Conclusion

In patients with aSAH, high IBI level at admission was associated with unfavorable functional prognosis as well as pneumonia and deep vein thrombosis.

Platelet-to-white blood cell ratio: A feasible predictor for unfavorable functional outcome in patients with aneurysmal subarachnoid hemorrhage

This study aimed to identify the association between the platelet-to-white blood cell ratio (PWR) and outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). Data for patients diagnosed with aSAH and admitted from January 2015 to December 2020 were retrospectively analyzed. Multivariate logistic regression analysis was performed to identify factors that correlated with unfavorable outcomes at 3 months. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off value for the PWR to discriminate favorable and unfavorable outcomes at 3 months. The patients were then divided into two groups based on this cut-off value. To reduce selection bias, propensity score matching (PSM) was performed to balance the baseline characteristics. In total, 800 patients were enrolled in this study. The multivariate logistic regression analysis showed that the PWR (odds ratio, 1.05; 95% confidence interval, 1.00-1.09; p = 0.034) at admission was independently associated with unfavorable 3-month outcomes. ROC curve analysis identified 15.69 as the best cut-off PWR value for predicting clinical outcomes. After PSM, patients with a PWR < 15.69 exhibited a higher incidence of postoperative pneumonia (POP) (37.2% vs. 25.6%, p = 0.011) and unfavorable 3-month outcomes (19.3% vs. 12.1%, p = 0.043). These findings suggest that patients with aSAH showing a PWR < 15.69 at admission have a higher probability of developing POP, which may be the main factor causing unfavorable outcomes at 3 months.

The Osaka prognostic score and Naples prognostic score: novel biomarkers for predicting short-term outcomes after spontaneous intracerebral hemorrhage

OBJECTIVES

Poor immune-nutritional status has been associated with an unfavorable outcome in critical illness. The Osaka prognostic score (OPS) and the Naples prognostic score (NPS), based on inflammatory and nutritional status, has been shown to predict prognosis following cancer and other diseases. The aim of this study was to investigate the relationship between the OPS and NPS and the short-term outcomes of patients with intracerebral hemorrhage (ICH).

METHODS

We retrospectively analyzed the clinical data of patients hospitalized with spontaneous ICH (n = 340) at The Second Affiliated Hospital of Chongqing Medical University between August 2016 and August 2021. Inclusion criteria included patients aged between 18 and 70, and if a blood sample was taken for laboratory testing within 24 h of admission (serum C-reactive protein, albumin, total cholesterol, and counts for neutrophils, lymphocytes, and monocytes were collected on admission). Exclusion criteria included a non-spontaneous cause of ICH and patient death during hospitalization. Patients were divided into four groups based on OPS or five groups according to NPS. Outcomes were evaluated by the modified Rankin Scale (mRS) at six months post-ICH hospitalization. An unfavorable outcome was defined as a mRS score ≥ 3.

RESULTS

A total of 289 patients met our inclusion criteria. The unfavorable outcome group had older age, a lower Glasgow Coma Scale score, a higher rate of complications and cerebral herniation, a longer hospital stay, and higher OPS and NPS when compared with the favorable outcome group. Univariate analysis showed that both OPS and NPS were strongly correlated with mRS (r = 0.196,P < 0.001; r = 0.244, P = 0.001, respectively). Multivariate analysis further showed that OPS and NPS were both independent predictors of unfavorable outcomes for patients with ICH with adjusted odds ratios of 1.802 (95% confidence interval [CI]:1.140-2.847, P = 0.012) and 1.702 (95% CI: 1.225-2.635, P = 0.02), respectively. The area under the curve (AUC) of NPS for predicting a poor outcome was 0.732 (95% CI: 0.665-0.799), which was similar to the AUC of OPS 0.724 (95% CI: 0.657-0.792).

CONCLUSIONS

In this cohort, a higher OPS and NPS on admission was associated with poor outcome at six months following ICH, supporting their potential role as markers for predicting the outcome of patients with ICH.

Blood inflammatory biomarkers predict in-hospital pneumonia after endovascular treatment of aneurysm in patients with aneurysmal subarachoid hemorrhage

The systemic inflammatory response index (SIRI) is a well-known marker of systemic inflammation reflecting the body's inflammatory/immune state. The study aimed to evaluate the relationship between the SIRI on admission and aneurysmal subarachnoid hemorrhage (aSAH)-associated pneumonia and compare with other currently used bio-markers. We reviewed 562 successive patients with aneurysmal SAH who underwent endovascular treatment between January 2019 and September 2021. ASAH-associated pneumonia was diagnosed using the modified Centers for Disease Control and Prevention criteria. The SIRI on admission was calculated as monocyte count × neutrophil count / lymphocyte count. Multiple logistic regression models were used for data analysis. A total of 158 (28.11%) patients developed aSAH-associated pneumonia. Using the Multiple logistic regression analysis, a notable dose-response association was found between the elevated SIRI (fourth quartile) and aSAH-associated pneumonia (adjusted odds ratio = 6.759; 95% confidence interval [CI], 3.280-13.930; p < 0.001 [p for trend < 0.001]). The SIRI (0.701, 95% CI: 0.653-0.749) presented a higher area under the curve (AUC) than systemic immune- inflammation index (SII) (0.669, 95% CI: 0.620-0.718) (p = 0.089); neutrophil-to-lymphocyte ratio (NLR) (0.665, 95% CI: 0.616-0.714) (p = 0.035) and platelet-lymphocyte ratio (PLR) (0.587, 95% CI: 0.534-0.641) (p < 0.001). A higher SIRI on admission was associated with aSAH-associated pneumonia, which may guide further clinical trials of prophylactic antibiotic therapy.

Biomarkers in aneurysmal subarachnoid hemorrhage: A short review

Poor outcomes of aneurysmal subarachnoid hemorrhage (aSAH) can be the result of the initial catastrophic event or the many acute or delayed neurological complications. Recent evidence suggests that some molecules play a critical role in both events, through some unknown pathways involved. Understanding the role of these molecules in these events could allow to improve diagnostic accuracy, guide management, and prevent long-term disability in aSAH. Here we present the studies on aSAH biomarkers present in current medical literature, highlighting their roles and main results.

A retrospective study about association of dynamic systemic immune-inflammation index (SII) with 180-day functional outcome after basal ganglia intracerebral hemorrhage

Objectives

This study aimed to determine whether SII on different days of admission is associated with severity and 180-day functional outcomes after basal ganglia ICH.

Methods

In this retrospective study, data on baseline CT imaging characteristics, mRS, hematoma volume, and laboratory variables were included. The SII and NLR, LMR, and PLR were calculated from laboratory data collected on admission day, day 1, and days 5-7. Both univariate and multivariable logistic regression analyses were used to assess the association between the SII and the outcome. The receiver operating characteristic (ROC) analysis and area under the curve (AUC) were also used to evaluate the ability of the SII to predict outcomes.

Result

A total of 245 patients were enrolled in the study. On different days, the NLR, PLR, and SII were significantly lower in patients with favorable outcomes than in those with poor outcomes, and the volume of hemorrhage was positively correlated with the SII. These parameters were associated with outcomes in the univariate logistic regression. In the adjusted analyses, the SII and PLR were independent predictors of basal ganglia ICH outcomes. ROC analysis revealed that the SII showed a stronger ability to predict the 6-month outcomes of patients after basal ganglia ICH than the PLR on different days (AUC = 0.642, 0.804, 0.827 vs. 0.592, 0.725, 0.757; all P < 0.001).

Conclusion

The SII independently and strongly predicts the outcome of basal ganglia ICH. A high SII was associated with poor 6-month outcomes in patients with basal ganglia ICH.

Neutrophil-to-lymphocyte ratio predicted cerebral infarction and poor discharge functional outcome in aneurysmal subarachnoid hemorrhage: A propensity score matching analysis

Background

Neutrophil-lymphocyte-ratio (NLR) and platelet-lymphocyte-ratio (PLR) have emerged as potential biomarkers in predicting the outcomes of aneurysmal subarachnoid hemorrhage (aSAH). Since a study was never conducted on the Southeast Asian and Indonesian population, we designed the present study to evaluate the potential of NLR and PLR in predicting cerebral infarction and functional outcomes and find the optimal cutoff value.

Methods

We retrospectively reviewed patients admitted for aSAH in our hospital between 2017 and 2021. The diagnosis was made using a computed tomography (CT) scan or magnetic resonance imaging and CT angiography. Association between admission NLR and PLR and the outcomes were analyzed using a multivariable regression model. A receiver operating characteristic (ROC) analysis was done to identify the optimal cutoff value. A propensity score matching (PSM) was then carried out to reduce the imbalance between the two groups before comparison.

Results

Sixty-three patients were included in the study. NLR was independently associated with cerebral infarction (odds ratio, OR 1.197 [95% confidence interval, CI 1.027-1.395] per 1-point increment; P = 0.021) and poor discharge functional outcome (OR 1.175 [95% CI 1.036-1.334] per 1-point increment; P = 0.012). PLR did not significantly correlate with the outcomes. ROC analysis identified 7.09 as the cutoff for cerebral infarction and 7.50 for discharge functional outcome. Dichotomizing and performing PSM revealed that patients with NLR above the identified cutoff value significantly had more cerebral infarction and poor discharge functional outcome.

Conclusion

NLR demonstrated a good prognostic capability in Indonesian aSAH patients. More studies should be conducted to find the optimal cutoff value for each population.

The Clinical Value of Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio for Predicting Hematoma Expansion and Poor Outcomes in Patients with Acute Intracerebral Hemorrhage

There is little knowledge of the effect of inflammatory markers on the prognoses of hematoma expansion (HE) in patients with intracranial hemorrhage (ICH). We evaluated the impact of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) on HE and worse outcomes after acute ICH. This study included 520 consecutive patients with ICH from the registry database enrolled over 80 months. Patients' whole blood samples were collected upon arrival in the emergency department. Brain computed tomography scans were performed during hospitalization and repeated at 24 h and 72 h. The primary outcome measure was HE, defined as relative growth >33% or absolute growth <6 mL. A total of 520 patients were enrolled in this study. Multivariate analysis showed that NLR and PLR were associated with HE (NLR: odds ratio [OR], [95% CI] = 1.19 [1.12-1.27], p < 0.001; PLR: OR, [95% CI] = 1.01 [1.00-1.02], p = 0.04). Receiver operating characteristic curve analysis revealed that NLR and PLR could predict HE (AUC of NLR: 0.84, 95% CI [0.80-0.88], p < 0.001; AUC of PLR: 0.75 95% CI [0.70-0.80], p < 0.001). The cut-off value of NLR for predicting HE was 5.63, and that of PLR was 23.4. Higher NLR and PLR values increase HE risk in patients with ICH. NLR and PLR were reliable for predicting HE after ICH.

Laboratory biomarkers of delayed cerebral ischemia following subarachnoid hemorrhage: A systematic review

Delayed cerebral ischemia (DCI) substantially contributes to disability and death in subarachnoid hemorrhage (SAH) patients; however, its pathophysiology is incompletely understood and diagnostic and therapeutic strategies are lacking. Biomarkers may help to elucidate the pathophysiology, optimize early diagnosis, or provide treatment targets. We systematically searched PubMed and Embase on October 13, 2021, for studies that evaluated at least one laboratory biomarker in patients with DCI, using the most up-to-date definition of DCI as proposed by a panel of experts in 2010. Quality of studies was assessed using the Newcastle-Ottawa Scale or Cochrane Collaboration’s risk of bias assessment tool. Biomarkers of clinical and radiological DCI were analyzed separately. Results were meta-analyzed if possible, otherwise narratively reviewed. Biomarkers were classified as significant, inconclusive, or nonsignificant. We defined validated biomarkers as those with significant results in meta-analyses, or in at least two studies using similar methodologies within the same time interval after SAH. The search yielded 209 articles with 724 different biomarkers; 166 studies evaluated 646 biomarkers of clinical DCI, of which 141 were significant and 7 were validated biomarkers (haptoglobulin 2-1 and 2-2, ADAMTS13, vWF, NLR, P-selectin, F2-isoprostane); 78 studies evaluated 165 biomarkers of radiological DCI, of which 63 were significant and 1 was a validated biomarker (LPR). Hence, this review provides a selection of seven biomarkers of clinical DCI and one biomarker of radiological DCI as most promising biomarkers of DCI. Future research should focus on determining the exact predictive, diagnostic, and therapeutic potentials of these biomarkers.

Admission neutrophil-to-lymphocyte ratio predicts length of hospitalization and need for ICU admission in adults with Status Epilepticus

BACKGROUND AND OBJECTIVES

Status epilepticus (SE) is a time-dependent neurological emergency. The current study evaluated the prognostic value of admission neutrophil-to-lymphocyte ratio (NLR) in patients with status epilepticus.

METHODS

In this retrospective observational cohort study we included all consecutive patients discharged from our neurology unit with the clinical or EEG diagnosis of SE from 2012 to 2022. Stepwise multivariate analysis was conducted to test the association of NLR with length of hospitalization, need for Intensive Care Unit (ICU) admission and 30 days mortality. Receiver operating characteristic (ROC) analysis was performed to identify the best cutoff for NLR to identify patients who will need ICU admission.

RESULTS

A total of 116 patients were enrolled in our study. NLR was correlated with length of hospitalization (p = 0.020) and need for ICU admission ( p = 0.046). In addition, the risk of ICU admission increased in patients with intracranial hemorrhage and length of hospitalization was correlated with C-reactive protein-to-albumin ratio (CRP/ALB). ROC analysis identified a NLR of 3.6 as best cutoff value to discriminate need of ICU admission (area under the curve [AUC]=0.678; p = 0.011; Youden's index=0.358; sensitivity, 90.5%, specificity, 45.3%).

DISCUSSION

In patients with SE admission NLR could be a predictor of length of hospitalization and need for ICU admission.

Clinical value of the systemic immune-inflammation index in moyamoya disease

Background

Moyamoya disease (MMD) is a rare cerebrovascular disorder with unknown etiology. The underlying pathophysiological mechanism of moyamoya disease remains to be elucidated, but recent studies have increasingly highlighted that abnormal immune response may be a potential trigger for MMD. Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) are inflammatory markers that can reflect the immune-inflammation state of the disease.

Objective

The purpose of this study was to investigate SII, NLR, and PLR in patients with moyamoya disease.

Methods

A total of 154 patients with moyamoya disease (MMD group) and 321 age- and sex-matched healthy subjects (control group) were included in this retrospective case-control study. Complete blood count parameters were assayed to calculate the SII, NLR, and PLR values.

Results

The SII, NLR, and PLR values in the moyamoya disease group were significantly higher than those in the control group [754 ± 499 vs. 411 ± 205 (P < 0.001), 2.83 ± 1.98 vs. 1.81 ± 0.72 (P < 0.001), and 152 ± 64 vs. 120 ± 42 (P < 0.001), respectively]. The SII in the medium-moyamoya vessels of moyamoya disease was higher than that in the high-moyamoya vessels and low-moyamoya vessels (P = 0.005). Using the receiver operating characteristic (ROC) curve analysis to predict MMD, the highest area under the curve (AUC) was determined for SII (0.76 for SII, 0.69 for NLR, and 0.66 for PLR).

Conclusion

Based on the results of this study, patients with moyamoya disease admitted for inpatient care due to acute or chronic stroke have significantly higher SII, NLR, and PLR when compared to blood samples drawn from completely healthy controls in a non-emergent outpatient setting. While the findings may suggest that inflammation plays a role in moyamoya disease, further studies are warranted to corroborate such an association. In the middle stage of moyamoya disease, there may be a more intense imbalance of immune inflammation. Further studies are needed to determine whether the SII index contributes to the diagnosis or serves as a potential marker of an inflammatory response in patients with moyamoya disease.

Improving the models for prognosis of aneurysmal subarachnoid hemorrhage with the neutrophil-to-albumin ratio

Objective

Many peripheral inflammatory markers were reported to be associated with the prognosis of aneurysmal subarachnoid hemorrhage (aSAH). We aimed to identify the most promising inflammatory factor that can improve existing predictive models.

Methods

The study was based on data from a 10 year retrospective cohort study at Sichuan University West China Hospital. We selected the well-known SAFIRE and Subarachnoid Hemorrhage International Trialists' (SAHIT) models as the basic models. We compared the performance of the models after including the inflammatory markers and that of the original models. The developed models were internally and temporally validated.

Results

A total of 3,173 patients were included in this study, divided into the derivation cohort (n = 2,525) and the validation cohort (n = 648). Most inflammatory markers could improve the SAH model for mortality prediction in patients with aSAH, and the neutrophil-to-albumin ratio (NAR) performed best among all the included inflammatory markers. By incorporating NAR, the modified SAFIRE and SAHIT models improved the area under the receiver operator characteristics curve (SAFIRE+NAR vs. SAFIRE: 0.794 vs. 0.778, p = 0.012; SAHIT+NAR vs. SAHIT: 0.831 vs. 0.819, p = 0.016) and categorical net reclassification improvement (SAFIRE+NAR: 0.0727, p = 0.002; SAHIT+NAR: 0.0810, p < 0.001).

Conclusion

This study illustrated that among the inflammatory markers associated with aSAH prognosis, NAR could improve the SAFIRE and SAHIT models for 3 month mortality of aSAH.

Prognostic capacity of the systemic inflammation response index for functional outcome in patients with aneurysmal subarachnoid hemorrhage

Objective

We aimed to investigate the relationship between systemic inflammatory response index (SIRI) and functional outcome after aneurysmal subarachnoid hemorrhage (aSAH).

Methods

A retrospective cohort study was performed involving all consecutive aSAH patients admitted to our institution. The modified Rankin Scale (mRS) score was performed to determine the functional outcomes of all patients at 3 months after aSAH. Results were categorized as favorable (mRS score 0-2) and unfavorable (mRS score 3-6). Univariate and multivariate logistic regressive analyses were utilized to identify the prognostic significance of SIRI. To minimize the effects of confounding factors, patients were stratified according to the optimal cut-off value of SIRI with propensity score matching (PSM). Further subgroup analysis was conducted to verify the consistency of our findings and Pearson's correlation analysis was used to assess the relationship between SIRI and the severity of aSAH.

Results

In this study, 350 patients were enrolled and 126 (36.0%) of them suffered unfavorable outcomes. The SIRI of 5.36 × 10⁹/L was identified as the optimal cut-off value. Two score-matched cohorts (n = 100 in each group) obtained from PSM with low SIRI and high SIRI were used for analysis. A significantly higher unfavorable functional outcome rate was observed in patients with high SIRI before and after PSM (p < 0.001 and 0.017, respectively). Multivariate logistic regression analysis demonstrated that SIRI value ≥ 5.36 × 10⁹/L was an independent risk factor for poor outcomes (OR 3.05 95% CI 1.37-6.78, p = 0.006) after adjusting for possible confounders. A identical result was discovered in the PSM cohort. In ROC analysis, the area under the curve (AUC) of SIRI was 0.774 which shown a better predictive value than other inflammatory markers observed in previous similar studies. Pearson's correlation analysis proved the positive association between SIRI and aSAH severity.

Conclusions

Elevated SIRI at admission is associated with worse clinical status and poorer functional outcomes among patients with aSAH. SIRI is a useful inflammatory marker with prognostic value for functional outcomes after aSAH.

Postoperative red blood cell distribution width predicts functional outcome in aneurysmal subarachnoid hemorrhage after surgical clipping: A single-center retrospective study

Objective

Red blood cell (RBC) parameters are associated with outcomes following aneurysmal subarachnoid hemorrhage (aSAH), but their predictive value remains uncertain. This study aimed to detect the association between RBC parameters and functional outcome in aSAH patients undergoing surgical clipping.

Methods

This retrospective observational study included aSAH patients who underwent surgical clipping at Affiliated Hospital of North Sichuan Medical College between August 2016 and September 2019. The functional outcome following aSAH was assessed by modified Rankin Scale (mRS), and mRS 3-6 was defined as poor functional outcome.

Results

Out of 187 aSAH patients included (62% female, 51-66 years old), 73 patients had poor functional outcome. Multivariate logistic regression of admission parameters showed that World Federation of Neurosurgical Societies (WFNS) grade (odds ratio [95% CI]: 1.322 [1.023-1.707], p = 0.033) and white blood cell (WBC) (odds ratio [95% CI]: 1.136 [1.044-1.236], p = 0.003) were independently associated with poor functional outcome. In postoperative parameters, RBC distribution width (RDW) (odds ratio [95% CI]: 1.411 [1.095-1.818], p = 0.008), mean platelet volume (MPV, odds ratio [95% CI]: 1.253 [1.012-1.552], p = 0.039) and admission WFNS grade (odds ratio [95% CI]: 1.439 [1.119-1.850], p = 0.005) were independently associated with poor functional outcome. The predictive model including WFNS grade, admission WBC, and postoperative RDW and MPV had significantly higher predictive power compared to WFNS grade alone (0.787 [0.722-0.852] vs. 0.707 [0.630-0.784], p = 0.024). The combination of WFNS grade and WBC on admission showed the highest positive predictive value (75.5%) and postoperative RDW and MPV combined with admission WFNS grade and WBC showed the highest negative predictive value (83.7%).

Conclusion

Postoperative RDW is independently associated with poor functional outcome in aSAH patients undergoing surgical clipping. A combined model containing postoperative RDW may help predict good outcome in patients with aSAH after timely aneurysm clipping.

The clinical significance of peripheral blood cell ratios in patients with intracranial aneurysm

Background and objective

Inflammation is an important factor in the development of aneurysm, and has been identified as a key characteristic predictive of rupture of intracranial aneurysm (IA). However, the role of inflammatory peripheral blood cell ratios in patients with IA has not been well delineated.

Methods

A total of 1,209 patients, including 1,001 with unruptured IA and 208 with ruptured IA, were enrolled in this study. Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), platelet-to-neutrophil ratio (PNR), and platelet-to-white-blood-cell ratio (PWR) were compared between ruptured and unruptured IA.

Results

Compared with the ruptured IA group, the unruptured IA group had higher PNR {median, 65.96 [interquartile range (IQR) 48.95-85.05] vs. 37.78 (IQR, 23.17-54.05); p < 0.001} and PWR [median, 36.89 (IQR 29.38-44.56) vs. 22.39 (IQR, 16.72-29.29); p < 0.001]. In multivariate analysis, PNR and PWR were independently associated with ruptured IA (p = 0.001 and p < 0.001, respectively). Unruptured IA subgroup analyses according to the PHASES scores showed that a higher PHASES score was associated with significantly higher NLR and erythrocyte sedimentation rate (p < 0.001 and p = 0.025) and lower PNR and PWR (p < 0.001 and p = 0.007).

Conclusions

We demonstrated that lower PNR and PWR levels are associated with ruptured IA and a higher PHASES score. Unlike many other inflammatory markers and bioassays, peripheral blood cell ratios are inexpensive and readily available biomarkers that may be useful for risk stratification in patients with cerebral aneurysm. However, a long-term prospective study is needed to clarify this matter.

Development of nomogram to predict in-hospital death for patients with intracerebral hemorrhage: A retrospective cohort study

Aim

This study aimed to investigate the association between systemic immune-inflammation (SII) and the risk of in-hospital death for patients with intracerebral hemorrhage (ICH) in the intensive care units (ICU) and to further develop a prediction model related to SII in predicting the risk of in-hospital death for patients with ICH.

Methods

In this retrospective cohort study, we included 1,176 patients with ICH from the Medical Information Mart for Intensive Care III (MIMIC-III) database. All patients were randomly assigned to the training group for the construction of the nomogram and the testing group for the validation of the nomogram based on a ratio of 8:2. Predictors were screened by the least absolute shrinkage and selection operator (LASSO) regression analysis. A multivariate Cox regression analysis was used to investigate the association between SII and in-hospital death for patients with ICH in the ICU and develop a model for predicting the in-hospital death risk for ICU patients with ICH. The receiver operator characteristic curve was used to assess the predicting performance of the constructed nomogram.

Results

In the training group, 232 patients with ICH died while 708 survived. LASSO regression showed some predictors, including white blood cell count, glucose, blood urea nitrogen, SII, the Glasgow Coma Scale, age, heart rate, mean artery pressure, red blood cell, bicarbonate, red blood cell distribution width, liver cirrhosis, respiratory failure, renal failure, malignant cancer, vasopressor, and mechanical ventilation. A prediction model integrating these predictors was established. The area under the curve (AUC) of the nomogram was 0.810 in the training group and 0.822 in the testing group, indicating that this nomogram might have a good performance.

Conclusion

Systemic immune-inflammation was associated with an increased in-hospital death risk for patients with ICH in the ICU. A nomogram for in-hospital death risk for patients with ICH in the ICU was developed and validated.

The clinical value of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and D-dimer-to-fibrinogen ratio for predicting pneumonia and poor outcomes in patients with acute intracerebral hemorrhage

Background

This study aimed to investigate the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and D-dimer-to-fibrinogen ratio (DFR) as predictors of pneumonia and poor outcomes in patients with acute intracerebral hemorrhage (ICH).

Methods

We retrospectively examined patients with acute ICH treated in our institution from May 2018 to July 2020. Patient characteristics, laboratory testing data, radiologic imaging data, and 90-day outcomes were recorded and analyzed.

Results

Among the 329 patients included for analysis, 183 (55.6%) developed pneumonia. Systolic blood pressure, initial hematoma volume, D-dimer concentration, NLR, PLR, DFR, and white blood cell, platelet, neutrophil, and lymphocyte counts at admission were significantly higher in patients who developed pneumonia than in those who did not; however, the Glasgow coma scale (GCS) score at admission was significantly lower in pneumonia patients compared with non-pneumonia patients (all P <0.05). Multivariate logistic regression showed that the NLR and PLR were independent predictors of pneumonia, and the NLR and DFR were independent predictors of poor 90-day outcomes (modified Rankin scale score 4–6).

Conclusion

The NLR and PLR were independent predictors of pneumonia and the NLR and DFR were independent predictors of poor 90-day outcomes. The NLR, PLR, and DFR can provide prognostic information about acute ICH patients.

Prognostic significance of combined score of fibrinogen and neutrophil-lymphocyte ratio for functional outcome in patients with aneurysmal subarachnoid hemorrhage

Objective

To explore the relationship between fibrinogen and neutrophil to lymphocyte ratio (F-NLR) score and functional outcomes after aneurysmal subarachnoid hemorrhage (aSAH).

Method

A retrospective study was conducted that involved all consecutive patients with aSAH admitted to our institution from March 2018 to October 2021. Factors, such as demographics, comorbidities, clinical characteristics, neuroradiological data, and laboratory parameters, were collected from institutional databases. All patients achieved neurological assessment using the modified Rankin Scale (mRS) score 3 months after discharge to clarify the functional outcomes. The results were classified as favorable (mRS score 0–2) and unfavorable (mRS score 3–6). Univariate and multivariable analyses were performed to identify the relevant factors between inflammatory markers and functional outcomes after aSAH. Subsequently, a receiver operating characteristic (ROC) curve analysis was conducted to evaluate the predicting performance of variables. A propensity score match (PSM) was performed to correct imbalances in patients' baseline characteristics.

Results

Finally, 256 patients with aSAH were included in the study cohort. A total of 94 (36.7%) patients had an unfavorable outcome. F-NLR scores were 0 [interquartile range (IQR) 0–1] and 1 (IQR 1–2) in patients with favorable and unfavorable outcomes, respectively (p < 0.001). After adjustment, the F-NLR score on admission remained significantly associated with unfavorable outcomes in patients with aSAH. In the multivariable analysis, the F-NLR score was regarded as an independent risk factor of unfavorable outcomes [odds ratio (OR) 3.113, 95% CI 1.755–5.523, p < 0.001]. In ROC analysis, the optimal cutoff value of the F-NLR score was 0.5 points. Two cohorts (n = 86 in each group) obtained from PSM with low F-NLR scores (0 points) and high F-NLR scores (1–2 points) were used for analysis. A significantly higher unfavorable functional outcome rate was observed in patients with high F-NLR scores (33.7 vs. 9.3%, p < 0.001). The area under the curve (AUC) values of F-NLR scores before and after PSM were 0.767 and 0.712, respectively.

Conclusion

Fibrinogen and neutrophil to lymphocyte ratio score was an independent risk parameter associated with unfavorable functional outcomes at 3 months after aSAH. A higher F-NLR score predicts the occurrence of poor functional outcomes.

Neutrophil to lymphocyte ratio predicting poor outcome after aneurysmal subarachnoid hemorrhage: A retrospective study and updated meta-analysis

Background

The relationship between neutrophil to lymphocyte ratio (NLR) and poor outcome of aneurysmal subarachnoid hemorrhage (aSAH) is controversial. We aim to evaluate the relationship between NLR on admission and the poor outcome after aSAH.

Method

Part I: Retrospective analysis of aSAH patients in our center. Baseline characteristics of patients were collected and compared. Multivariate analysis was used to evaluate parameters independently related to poor outcome. Receiver operating characteristic (ROC) curve analysis was used to determine the best cut-off value of NLR. Part II: Systematic review and meta-analysis of relevant literature. Related literature was selected through the database. The pooled odds ratio (OR) and corresponding 95% confidence interval (CI) were calculated to evaluate the correlation between NLR and outcome measures.

Results

Part I: A total of 240 patients with aSAH were enrolled, and 52 patients had a poor outcome. Patients with poor outcome at 3 months had a higher admission NLR, Hunt & Hess score, Barrow Neurological Institute (BNI) scale score, Subarachnoid Hemorrhage Early Brain Edema Score (SEBES), and proportion of hypertension history. After adjustment, NLR at admission remained an independent predictor of poor outcome in aSAH patients (OR 0.76, 95% CI 0.69-0.83; P < 0.001). The best cut-off value of NLR in ROC analysis is 12.03 (area under the curve 0.805, 95% CI 0.735 - 0.875; P < 0.001). Part II: A total of 16 literature were included. Pooled results showed that elevated NLR was significantly associated with poor outcome (OR 1.31, 95% CI 1.14-1.49; P < 0.0001) and delayed cerebral ischemia (DCI) occurrence (OR 1.32, 95% CI 1.11-1.56; P = 0.002). The results are more reliable in large sample sizes, low NLR cut-off value, multicenter, or prospective studies.

Conclusion

Elevated NLR is an independent predictor of poor outcome and DCI occurrence in aSAH.

Scoring system to predict hospital outcome after subarachnoid hemorrhage-incorporating systemic response: The CRIG score

OBJECTIVES

Local and systemic proinflammatory and prothrombotic processes after aneurysmal subarachnoid hemorrhage (aSAH) precipitate delayed cerebral ischemia (DCI) and determine clinical outcome. Recent studies using admission and temporal trends of mean platelet volume to platelet count ratio (MPV:PLT) and neutrophil to lymphocyte ratio (NLR) have identified patients developing DCI. We examine if MPV:PLT and NLR along with admission clinical or radiological features can be used to develop a scoring system to predict DCI and in-hospital clinical outcome.

MATERIALS AND METHODS

A 7-year retrospective cohort of aSAH patients admitted to a tertiary care medical center was used to study and identify clinical, radiological and laboratory parameters to predict DCI and clinical outcome (good: discharge to home or rehabilitation facility; poor: all other discharge destinations). Using regression analyses a scoring system (Clinical, Radiological, Inflammatory, dysGlycemia, CRIG) was developed.

RESULTS

Of 271 patients, admission clinical grade (World Federation of Neurological Surgeons' scale), radiological grade (modified Fisher score), NLR and glycated hemoglobin were identified as contributors for CRIG score. CRIG_DCI score threshold of 112 and CRIG_discharge 109, respectively predicted DCI and adverse clinical outcome in score development cohort. The same threshold predicted DCI and adverse clinical outcome with 78.1 and 100% sensitivity, 44.0 and 52.2% specificity, and 63.2 and 61.4% accuracy, respectively in the score validation cohort.

CONCLUSIONS

CRIG is an easily calculable scoring system that incorporates systemic response of aSAH - thus, alluding to its multisystem nature. It can be used at the time of admission to predict DCI and clinical outcome.

Prediction of Early Mortality Among Children With Moderate or Severe Traumatic Brain Injury Based on a Nomogram Integrating Radiological and Inflammation-Based Biomarkers

Inflammation-based scores have been increasingly used for prognosis prediction in neurological diseases. This study aimed to investigate the predictive value of inflammation-based scores combined with radiological characteristics in children with moderate or severe traumatic brain injury (MS-TBI). A total of 104 pediatric patients with MS-TBI were retrospectively enrolled and randomly divided into training and validation cohorts at a 7:3 ratio. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of prognosis in pediatric patients with MS-TBI. A prognostic nomogram was constructed, and its predictive performance was validated in both the training and validation cohorts. Sex, admission platelet-to-lymphocyte ratio, and basal cistern status from initial CT findings were identified as independent prognostic predictors for children with MS-TBI in multivariate logistic analysis. Based on these findings, a nomogram was then developed and its concordance index values were 0.918 [95% confidence interval (CI): 0.837-0.999] in the training cohort and 0.86 (95% CI: 0.70-1.00) in the validation cohort, which significantly outperformed those of the Rotterdam, Marshall, and Helsinki CT scores. The proposed nomogram, based on routine complete blood count and initial CT scan findings, can contribute to individualized prognosis prediction and clinical decision-making in children with MS-TBI.

Prognostic significance of platelet-to-lymphocyte and platelet-to-neutrophil ratios in patients with mechanical thrombectomy for acute ischemic stroke

Objective

The present study aimed to analyze the correlation between platelet-to-lymphocyte ratio (PLR) and platelet-to-neutrophil ratio (PNR) with prognosis of patients who underwent mechanical thrombectomy (MT).

Methods

A total of 432 patients was included, PLR and PNR were calculated from laboratory data on admission. Prognosis was evaluated with a modified Rankin Scale at 3 months after MT. Using receiver operating characteristic (ROC) analysis, optimal cutoff values of PLR and PNR were identified to predict the prognosis after MT. Multivariate analyses were performed to identify the relationship of PLR and PLR with prognosis of MT.

Results

Patients with favorable outcomes had a lower mean PLR (135.0, standard deviation [SD] 120.3) with a higher mean PNR (47.1 [SD] 24.6) compared with patients with unfavorable outcomes (167.6 [SD] 139.3 and 35.4 [SD] 22.4) (p<0.001 and <0.001, respectively). In ROC analyses, the optimal cutoff value of PLR and PNR to predict the 3 months prognosis were 145 and 41, respectively (p=<0.001 and p=0.006). In multivariate analysis, PLR less than 145 (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.06–2.06; p=0.016) and PNR greater than 41 (OR 1.22, 95% CI 1.10–1.62; p=0.022) were predictors of favorable outcome at 3 months.

Conclusions

In patients with MT, PLR and PNR on admission could be predictive factors of prognosis and mortality at 3 months. Decreased PLR and increased PNR were associated with favorable clinical outcome 3 months after MT.

Day 2 neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for prediction of delayed cerebral ischemia in subarachnoid hemorrhage

OBJECTIVE

Recent evidence has suggested that an admission neutrophil-to-lymphocyte ratio (NLR) of ≥ 5.9 predicts delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH). The primary aims of this study were to assess reproducibility and to ascertain the predictive ability of NLR on subsequent days postictus. Secondary aims included identification of additional inflammatory markers.

METHODS

A single-center, retrospective study of all patients aged ≥ 18 years with aSAH between May 2014 and July 2018 was performed. Patient characteristics, DCI incidence, operative features, and outcomes (on discharge and at 3 months postictus) were recorded. C-reactive protein (CRP) and full blood count differentials were recorded on admission and through day 8 postictus or at discharge. In total, 403 patients were included in the final analysis.

RESULTS

Ninety-six patients (23.8%) developed DCI with a median time from ictus of 6 days (IQR 3.25–8 days). A platelet-to-lymphocyte ratio (PLR) cutoff ≥ 157 and CRP cutoff ≥ 27 was used in our cohort. In a multiple binary logistic regression model, after controlling for known DCI predictors, day 2 NLR ≥ 5.9 (OR 2.194, 95% CI 1.099–4.372; p = 0.026), day 1 PLR ≥ 157 (OR 2.398, 95% CI 1.1072–5.361; p = 0.033), day 2 PLR ≥ 157 (OR 2.676, 95% CI 1.344–5.329; p = 0.005), and CRP ≥ 27 on days 3, 4, and 5 were predictive of DCI.

CONCLUSIONS

The results of this study have confirmed the association between NLR and DCI and have demonstrated the predictive potential of PLR and CRP, suggesting that NLR and PLR at day 2, and CRP from day 3 onward, may be better predictors of DCI than those measurements at the time of ictus.

Increased systemic immune-inflammation index can predict respiratory failure in patients with Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) is a common peripheral neuropathy with relatively heterogenous clinical manifestations. In severe cases, it can result in disabling neuromuscular symptoms and respiratory failure. In this study, we assessed whether the systemic immune-inflammation index (SII) is associated with respiratory failure in GBS patients.

METHODS

We retrospectively analyzed clinicopathological data from GBS patients diagnosed in the First Affiliated Hospital of Kunming Medical University. SII was calculated based on counts of neutrophils (N), platelets (P), and lymphocytes (L). Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff values for SII, N, P, and L. Univariate and multivariate logistic regression were performed to determine the ability of the SII to predict respiratory failure.

RESULTS

Among the 369 GBS patients in this study, 61 (16.5%) suffered respiratory failure. Multivariate logistic regression showed that N ≥ 6.03 × 109/l, Hughes Functional Grading Scale (HFGS) score ≥ 3 at admission, and SII ≥ 863.04 × 109/l can independently predict respiratory failure in GBS patients. SII showed higher predictive ability than N, based on area under the ROC curve (0.75 vs. 0.72).

CONCLUSION

SII may be a novel independent prognostic indicator of respiratory failure in GBS patients, helping physicians identify those at risk in a timely manner.

Prognostic Significance of the Combined Score of Plasma Fibrinogen and Neutrophil-Lymphocyte Ratio in Patients with Spontaneous Intracerebral Hemorrhage

Background

The combination of plasma fibrinogen and neutrophil to lymphocyte ratio (F-NLR) score is a novel inflammatory marker constituted by peripheral blood fibrinogen concentration and neutrophil to lymphocyte ratio. In the current study, we aim to explore the relationship between admission F-NLR score and intracerebral hemorrhage (ICH) and assess its prognostic predictive ability in ICH patients.

Methods

The original cohort was consecutively recruited from August 2014 to September 2017, and the validation cohort was consecutively recruited between October 2018 and March 2020. The primary outcomes were 3-month functional outcome and 1-month mortality. All statistical analyses were performed using SPSS and R software.

Results

A total of 431 and 251 ICH patients were included in original cohort and validation cohort, respectively. In the original cohort, F-NLR score could independently predict the 3-month functional outcome (adjusted OR 2.013, 95% CI 1.316-3.078, p = 0.001) and 1-month mortality (adjusted OR 3.036, 95% CI 1.965-4.693, p < 0.001). Receiver operation characteristic (ROC) analyses and predictive model comparison indicated that F-NLR score had a stronger predictive ability in the 3-month outcome and 1-month mortality. Validation cohort verified the results.

Conclusion

F-NLR score was an independent indicator for both the 3-month functional outcome and 1-month mortality, and its prognostic predictive ability was superior to fibrinogen and NLR in both the original and the validation cohort.

Predictive Value of Hematologic Inflammatory Markers in Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND AND OBJECTIVE

Our study aimed to determine the ability of hematologic markers (neutrophil/lymphocyte ratio [NLR], platelet/lymphocyte ratio, and red cell distribution width [RDW]) in predicting delayed cerebral ischemia (DCI), modified Rankin Scale scores, and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

A retrospective observational 6-year review of medical records was conducted to identify all consecutive patients with aSAH admitted to the largest training hospital in the Philippines. Univariable and multivariable regression analyses were performed to determine the association of the biomarkers with the respective outcomes. Receiver operating characteristic curves were used to detect overall predictive accuracy.

RESULTS

A total of 222 patients with aSAH were included, of whom 11.71% developed DCI. Most patients with NLR ≥5.9 subsequently died (77 vs. 52%; P = 0.03). DCI was also associated with poor functional outcomes with higher modified Rankin Scale scores (3-6) on discharge (92% vs. 49%; P < 0.01), and longer duration of hospitalization (median, 20 vs. 13 days; P = 0.01). In receiver operating characteristic analyses, the value of RDW was predictive for DCI (area under the curve, 0.70; 95% confidence interval, 0.62-0.79; P < 0.01). The values of NLR (area under the curve, 0.67; 95% CI, 0.59-0.74) potentially predict functional outcome. RDW, NLR, and their combinations were poor discriminators of mortality.

CONCLUSIONS

Our study showed that some hematologic parameters analyzed could be of potential value as prognostic biomarkers in patients with aSAH. Hematologic biomarkers are widely available and practical parameters that may be of considerable clinical value in aSAH management, especially in lower-middle-income countries such as the Philippines.

Bioinformatic Analysis of Co-Expressed Differentially Expressed Genes and Potential Targets for Intracerebral and Subarachnoid Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) are serious subtypes of hemorrhagic stroke that affect adults and have a high risk of morbidity and mortality; both share certain identical risk factors and clinical features. Recent studies have shown that secondary brain injury (SBI) following ICH and SAH is more life-threatening and lacks effective therapeutic strategies. The aim of this study is to understand the molecular pathogenesis of ICH- or SAH-induced SBI and provide insights to the potential therapeutic options.

METHODS

The original gene expression profile data of tissue microarray studies (GSE24265, GSE13353) was downloaded from the Gene Expression Omnibus (GEO) database. We identified the differentially expressed genes (DEGs) for each disease and co-DEGs between ICH and SAH. The functional enrichment analyses were then analyzed and a protein-protein interaction (PPI) network was constructed to strictly select hub genes via the maximal clique centrality (MCC) method. Additionally, immune infiltration analyses were used to identify the common differently distributed cells in both diseases. Finally, potential target microRNAs (miRNAs) and related targeted drugs were predicted for further studies. The animal model microarrays were used for external validation.

RESULTS

A total of 614 ICH-DEGs, 1272 SAH-DEGs, and 158 co-DEGs were identified in our study. The co-DEGs were significantly enriched in cytotoxicity and inflammation pathways. The top 10 hub genes (CCL20, CXCL1, CXCL3, CXCL8, CXCL16, CXCR2, CXCR4, CCR7, PF4, and PPBP) were then filtered through the PPI networks. Moreover, nTreg, Th17, and dendritic cells and monocytes and macrophages were identified as the common differentially distributed immune cells between ICH and SAH. Additionally, the target miRNAs (e.g., miR-21-5p, miR-590-5p, miR-6834-3p) and related drugs (e.g., ABX-IL8, HUMAX-IL8, Rivanicline) of hub genes were predicted.

CONCLUSIONS

This study identified a variety of key genes and their respective molecular functions involved in both ICH and SAH for better understanding of the cytotoxic and inflammatory pathogenesis of SBI. The predicted targeted miRNAs and related drugs of hub genes not only provide insights into the novel therapeutic strategies but also aid in future studies and drug discovery.

XGBoost Machine Learning Algorithm for Prediction of Outcome in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Patients suffered aneurysmal subarachnoid hemorrhage (aSAH) usually develop poor survival and functional outcome. Evaluating aSAH patients at high risk of poor outcome is necessary for clinicians to make suitable therapeutical strategy. This study is conducted to develop prognostic model using XGBoost (extreme gradient boosting) algorithm in aSAH.

METHODS

A total of 351 aSAH patients admitted to West China hospital were identified. Patients were divided into training set and test set with ratio of 7:3 to testify the predictive value of XGBoost based prognostic model. Additionally, logistic regression model was also constructed and compared with XGBoost based model. Area under the receiver operating characteristic curve (AUC), sensitivity and specificity were calculated to evaluate the value of XGBoost and logistic regression.

RESULTS

There were 74 (21.1%) non-survivors and 148 (42.1%) patients with unfavorable functional outcome. Non-survivors had older age (p=0.025), lower Glasgow coma scale (GCS) (p<0.001), higher World Federation of Neurosurgical Societies WFNS score (p<0.001), mFisher score (p<0.001). The incidence of intraventricular hemorrhage (IVH) (p=0.025) and delayed cerebral ischemia (DCI) (p<0.001) was higher in non-survivors than survivors. The AUC of XGBoost model for predicting mortality and unfavorable functional outcome were 0.950 and 0.958, which were higher than 0.767 and 0.829 of logistic regression model.

CONCLUSION

XGBoost based model is more precise than logistic regression model in predicting outcome of aSAH patients. Using XGBoost prognostic model is helpful for clinicians to identify high-risk aSAH patients and therefore strengthen medical care.

Platelet-to-Lymphocyte Ratio and Neutrophil-to-Lymphocyte Ratio in Patients With Newly Diagnosed Moyamoya Disease: A Cross-Sectional Study

Inflammation has been proven to be one of the key factors in the pathogenesis of moyamoya disease (MMD). Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are cheap and reliable biomarkers of inflammation. Nevertheless, evidence regarding the relationship among PLR and NLR in patients with MMD is limited. The focus of this subject was to explore the relationship between PLR and NLR in patients with newly diagnosed MMD.

Patients and methods: A cross-sectional study was performed including 261 patients with diagnosed MMD for the first time who were enrolled from our hospital, from 24 March 2013 to 24 December 2018. The clinical characteristics were collected for each patient. Univariate analysis, smooth curve fitting and multivariate piecewise linear regression were showed.

Results: The mean levels or median values (interquartile range) of PLR and NLR were 146.979 ± 51.203 and 2.241 (1.589–2.984), respectively. A significant positive correlation between PLR and NLR levels (P < 0.001) was showed by the univariate analysis. Furthermore, a non-linear relationship was detected between PLR and NLR by smooth curve fitting after adjusting for potential confounders. A multivariate piecewise linear regression model revealed a significant positive correlation between PLR and NLR when the PLR level was lower than 219.82 (β 0.012, 95% CI 0.005, 0.019; P = 0.001). PLR was also significantly positively associated with NLR when PLR concentrations were >219.82 (β 0.098, 95% CI 0.069, 0.128; P < 0.001).

Conclusion: There seemed to be a positive association between PLR and NLR in patients with MMD. This may help to further explain the role of inflammation in the occurrence and progress of MMD.