Differential leukocyte counts on admission predict outcomes in patients with acute ischaemic stroke treated with intravenous thrombolysis

Systemic biomarker associated with poor outcome after futile reperfusion

BACKGROUND

Successful recanalization does not lead to complete tissue reperfusion in a considerable percentage of ischemic stroke patients. This study aimed to identify biomarkers associated with futile recanalization. Leukoaraiosis predicts poor outcomes of this phenomenon. Soluble tumour necrosis factor-like weak inducer of apoptosis (sTWEAK), which is associated with leukoaraiosis degrees, could be a potential biomarker.

METHODS

This study includes two cohorts of ischemic stroke patients in a multicentre retrospective observational study. Effective reperfusion, defined as a reduction of ≥8 points in the National Institutes of Health Stroke Scale (NIHSS) within the first 24 h, was used as a clinical marker of effective reperfusion.

RESULTS

In the first cohort study, female sex, age, and high NIHSS at admission (44.7% vs. 81.1%, 71.3 ± 13.7 vs. 81.1 ± 6.7; 16 [13, 21] vs. 23 [17, 28] respectively; p < .0001) were confirmed as predictors of futile recanalization. ROC curve analysis showed that leukocyte levels (sensitivity of 99%, specificity of 55%) and sTWEAK level (sensitivity of 92%, specificity of 88%) can discriminate between poor and good outcomes. Both biomarkers simultaneously are higher associated with outcome after effective reperfusion (OR: 2.17; CI 95% 1.63-4.19; p < .0001) than individually (leukocytes OR: 1.38; CI 95% 1.00-1.64, p = .042; sTWEAK OR: 1.00; C I95% 1.00-1.01, p = .019). These results were validated using a second cohort, where leukocytes and sTWEAK showed a sensitivity of 100% and specificity of 66.7% and 75% respectively.

CONCLUSIONS

Leukocyte and sTWEAK could be biomarkers of reperfusion failure and subsequent poor outcomes. Further studies will be necessary to explore its role in reperfusion processes.

Body fluids biomarkers associated with prognosis of acute ischemic stroke: progress and prospects

Acute ischemic stroke (AIS) is one of the most common strokes posing a grave threat to human life and health. Predicting the prognosis of AIS allows for an understanding of disease progress, and a better quality of life by making individualized treatment scheme. In this paper, we conducted a systematic search on PubMed, focusing on the relevant literature in the last 5 years. Summarizing the candidate prognostic biomarkers of AIS in body fluids such as blood, urine, saliva and cerebrospinal fluid is often of great significance for the management of acute ischemic stroke, which has the potential to facilitate early diagnosis, treatment, prevention and long-term outcome improvement.

Predictive role of neutrophil-to-platelet ratio in futile recanalization of patients after endovascular therapy

Aim: To explore the association between the neutrophil-to-platelet ratio (NPR) and futile recanalization (FR) in patients with acute ischemic stroke due to large vascular occlusions after endovascular therapy (EVT). Methods: FR after EVT was defined as a poor 90-day prognosis (modified Rankin scale [mRS] score ≥3) despite successful reperfusion (modified thrombolysis in cerebral infarction grade 2b-3). Patients were divided into high NPR (>35; n = 115) and low NPR (≤35; n = 81) groups. Results: The FR rate was significantly higher in the high NPR group than low NPR group (81.74 vs 55.56%; p = 0.000). NPR was independently associated with FR (odds ratio: 2.107; 95% CI: 1.017-4.364; p = 0.045). Conclusion: High NPR was associated with the risk of FR in patients with acute ischemic stroke due to large vascular occlusions.

Neutrophil activation in patients treated with endovascular therapy is associated with unfavorable outcomes and mitigated by intravenous thrombolysis

BACKGROUND

Accumulating evidence indicates that neutrophil activation (NA) contributes to microvascular thromboinflammation in acute ischemic stroke (AIS) due to a large vessel occlusion. Preclinical data have suggested that intravenous thrombolysis (IVT) before endovascular therapy (EVT) could dampen microvascular thromboinflammation. In this study we investigated the association between NA dynamics and stroke outcome, and the impact of IVT on NA in patients with AIS treated with EVT.

METHODS

A single-center prospective study was carried out, including patients treated with EVT for whom three blood samples (before, within 1 hour, 24 hours post-EVT) were drawn to measure plasma myeloperoxidase (MPO) concentration as a marker of NA. Unfavorable outcome was defined as a modified Rankin score of 3-6 at 3 months.

RESULTS

Between 2016 and 2020, 179 patients were included. The plasma MPO concentration peaked significantly 1 hour post-EVT (median increase 21.0 ng/mL (IQR -2.1-150)) and returned to pre-EVT baseline values 24 hours after EVT (median change from baseline -0.8 ng/mL (IQR -7.6-6.7)). This peak was strongly associated with unfavorable outcomes at 3 months (aOR 0.53 (95% CI 0.34 to 0.84), P=0.007). IVT before EVT abolished this 1 hour post-EVT MPO peak. Changes in plasma MPO concentration (baseline to 1 hour post-EVT) were associated with unfavorable outcomes only in patients not treated with IVT before EVT (aOR 0.54 (95% CI 0.33 to 0.88, P=0.013). However, we found no significant heterogeneity in the associations between changes in plasma MPO concentration and outcomes.

CONCLUSIONS

A peak in plasma MPO concentration occurs early after EVT and is associated with unfavorable outcomes. IVT abolished the post-EVT MPO peak and may modulate the association between NA and outcomes.

High neutrophil-to-lymphocyte ratio (NLR) predicts poor response to intravenous thrombolysis in white Caucasian stroke patients

OBJECTIVES

Our aim was to investigate usefulness of the neutrophil-to-lymphocyte ratio (NLR) for predicting poor response to intravenous rtPA in white Caucasian ischemic stroke patients treated within 4.5 hours from the onset.

MATERIALS AND METHODS

This retrospective analysis included all consecutive acute ischemic stroke patients (N = 344) treated with rtPA in a tertiary stroke center from 2011 to 2017. NLR was calculated from complete blood counts obtained on admission. The patients were classified into NLR terciles (T1 <1.75, T2<2.97, T3≥2.97). Significant neurological improvement was defined as an 8-point reduction in the NIHSS score or reaching the score of 0 to 1.

RESULTS

Compared to NLR T1, patients from NLR T3 were significantly older, more often disabled before stroke, and had longer onset-to-needle time. They less often achieved neurological improvement at day 7 (38% vs 59% p=0.002) and had higher 90-day mortality (27% vs 13%, p=0.020), with no differences in neurological improvement at 24 hours, occurrence of sICH and 7-day mortality. Each additional 4 units of NLR decreased unadjusted and adjusted odds for achieving favorable outcome at day 7 (OR 0.65, 95% CI: 0.46-0.92; aOR 0.62, 95% CI: 0.39-1.00), and increased the odds for death at 3 months (OR 1.60, 95% CI: 1.15-2.24; aOR 1.82, 95% CI:1.14-2.92) CONCLUSIONS: High NLR can predict poor response to intravenous rtPA in Caucasian patients with acute ischemic stroke, especially in terms of not achieving significant neurological improvement at day 7 and death at day 90. It encourages attempts to incorporate NLR in already validated scores.

No-Reflow Post-Recanalization in Acute Ischemic Stroke: Mechanisms, Measurements, and Molecular Markers

Acute ischemic stroke remains the primary cause of disability worldwide. For patients with large vessel occlusions, intravenous thrombolysis followed by mechanical thrombectomy remains the standard of care. Revascularization of the large vessel is typically successful. However, despite reopening of the occluded vessel, many patients fail to return to independence. Functional failure, despite macrovascular recanalization, is often referred to as the no-reflow phenomenon. Even with an extensive characterization of reperfusion in animal models, numerous mechanisms may explain no-reflow. Further, uniform measurements of this microvascular dysfunction and prognostic markers associated with no-reflow are lacking. In this review, we highlight a number of mechanisms that may explain no-reflow, characterize current multimodal measurements, and assess its molecular markers.

Soluble adhesion molecules and functional outcome after ischemic stroke: A Mendelian randomization study

OBJECTIVES

We employed Mendelian randomization to determine whether genetically predicted circulating levels of endothelial-derived adhesion molecules (soluble intercellular adhesion molecule-1 [sICAM-1]), soluble vascular-leukocyte adhesion molecule-1 [sVCAM-1], and soluble-endothelial-leukocyte adhesion molecule [sE-selectin]) were associated with functional outcome after ischemic stroke.

METHODS

Independent genetic variants robustly associated with soluble adhesion molecules, located at or close to the coding gene (cis), were used as genetic instruments. The functional outcome was evaluated using the 3-month modified Rankin Scale (mRS) score after ischemic stroke. A poor functional outcome was defined as mRS ≥ 3 at 3 months. We extracted summary data for functional outcome after ischemic stroke from the Genetics of Ischaemic Stroke Functional Outcome network (n = 6,021).

RESULTS

Genetically elevated sICAM-1 (OR 1.28, 95% CI 1.05-1.56) and sE-selectin (OR 2.69, 95% CI 1.23-5.86) levels were related with poor post-stroke outcome. However, we found no evidence that genetically elevated sVCAM-1 were associated with post-stroke outcome (OR 1.36, 95% CI 0.39-4.66).

CONCLUSIONS

We found that genetically elevated higher sICAM-1 and sE-selectin levels are associated with poor post-stroke outcome. Further studies are warranted to evaluate the potential of ICAM-1 and E-selectin to be drug targets for post-stroke recovery.

Prognostic role of dynamic neutrophil-to-lymphocyte ratio in acute ischemic stroke after reperfusion therapy: A meta-analysis

Background

The prognostic role of the neutrophil-to-lymphocyte ratio (NLR), an inflammatory marker, in acute ischemic stroke (AIS) after reperfusion therapy remains controversial. Therefore, this meta-analysis sought to assess the correlation between the dynamic NLR and the clinical outcomes of patients with AIS after reperfusion therapy.

Methods

PubMed, Web of Science, and Embase databases were searched to identify relevant literature from their inception to 27 October 2022. The clinical outcomes of interest included poor functional outcome (PFO) at 3 months, symptomatic intracerebral hemorrhage (sICH), and 3-month mortality. The NLR on admission (pre-treatment) and post-treatment was collected. The PFO was defined as a modified Rankin scale (mRS) of >2.

Results

A total of 17,232 patients in 52 studies were included in the meta-analysis. The admission NLR was higher in the 3-month PFO (standardized mean difference [SMD] = 0.46, 95% confidence interval [CI] = 0.35-0.57), sICH (SMD = 0.57, 95% CI = 0.30-0.85), and mortality at 3 months (SMD = 0.60, 95% CI = 0.34-0.87). An elevated admission NLR was associated with an increased risk of 3-month PFO (odds ratio [OR] = 1.13, 95% CI = 1.09-1.17), sICH (OR = 1.11, 95% CI = 1.06-1.16), and mortality at 3 months (OR = 1.13, 95% CI = 1.07-1.20). The post-treatment NLR was significantly higher in the 3-month PFO (SMD = 0.80, 95% CI = 0.62-0.99), sICH (SMD = 1.54, 95% CI = 0.97-2.10), and mortality at 3 months (SMD = 1.00, 95% CI = 0.31-1.69). An elevated post-treatment NLR was significantly associated with an increased risk of 3-month PFO (OR = 1.25, 95% CI = 1.16-1.35), sICH (OR = 1.14, 95% CI = 1.01-1.29), and mortality at 3 months (OR = 1.28, 95% CI = 1.09-1.50).

Conclusion

The admission and post-treatment NLR can be used as cost-effective and easily available biomarkers to predict the 3-month PFO, sICH, and mortality at 3 months in patients with AIS treated with reperfusion therapy. The post-treatment NLR provides better predictive power than the admission NLR.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022366394.

Neutrophil dynamics and inflammaging in acute ischemic stroke: A transcriptomic review

Stroke is among the leading causes of death and disability worldwide. Restoring blood flow through recanalization is currently the only acute treatment for cerebral ischemia. Unfortunately, many patients that achieve a complete recanalization fail to regain functional independence. Recent studies indicate that activation of peripheral immune cells, particularly neutrophils, may contribute to microcirculatory failure and futile recanalization. Stroke primarily affects the elderly population, and mortality after endovascular therapies is associated with advanced age. Previous analyses of differential gene expression across injury status and age identify ischemic stroke as a complex age-related disease. It also suggests robust interactions between stroke injury, aging, and inflammation on a cellular and molecular level. Understanding such interactions is crucial in developing effective protective treatments. The global stroke burden will continue to increase with a rapidly aging human population. Unfortunately, the mechanisms of age-dependent vulnerability are poorly defined. In this review, we will discuss how neutrophil-specific gene expression patterns may contribute to poor treatment responses in stroke patients. We will also discuss age-related transcriptional changes that may contribute to poor clinical outcomes and greater susceptibility to cerebrovascular diseases.

Predictive Values of White Blood Cell Count in Peripheral Blood at Admission on In-Hospital Complications and 90-Day Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: Insights from the LongTEAM Registry

PURPOSE

This study aimed to explore the relationship between white blood cells (WBCs) at admission and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH).

PATIENTS AND METHODS

We analyzed data from patients with aSAH between January 2015 and September 2021 who were included in the LongTEAM (Long-term Prognosis of Emergency Aneurysmal Subarachnoid Hemorrhage) registry study. WBC is classified into four groups according to the quartile. We used the logistic model for in-hospital complications, mortality, modified Rankin scale (mRS) at discharge and 90 days to examine the relationship between WBC and clinical outcomes. We used WBC levels near odds ratio (OR) = 1 (Q1) in restricted cubic splines as the reference to evaluate whether there is a nonlinear relationship between WBC and clinical outcomes. Another Kaplan-Meier method was used to analyze the relationship between WBC levels and the risk of developing pneumonia.

RESULTS

Of the 988 patients included, the results showed that compared with patients in the Q1 group, patients in the highest quartile (Q4) had an increased incidence of 90-day unfavorable outcomes after adjusting the confounders (adjusted OR = 1.81, 95% CI = 1.02-3.20, p = 0.042), which may be caused by the increased incidence and risk of pneumonia (adjusted OR = 2.06, 95% CI = 1.30-3.29, p = 0.002; adjusted hazard ratio [HR]=1.63, 95% CI = 1.13-2.36, p < 0.001). The restricted cubic spline indicated that the incidence of developing pneumonia and 90-day unfavorable outcomes rises with increasing WBC levels (p for nonlinear = 0.135 and 0.113).

CONCLUSION

Patients with higher WBC at admission were associated with an increased incidence of 90-day unfavorable outcomes, which might be related to pneumonia.

Stroke and Emerging Blood Biomarkers: A Clinical Prospective

Stroke constitutes the primary source of adult functional disability, exhibiting a paramount socioeconomic burden. Thus, it is of great importance that the prediction of stroke outcome be both prompt and accurate. Although modern neuroimaging and neurophysiological techniques are accessible, easily available blood biomarkers reflecting underlying stroke-related pathophysiological processes, including glial and/or neuronal death, neuroendocrine responses, inflammation, increased oxidative stress, blood–brain barrier disruption, endothelial dysfunction, and hemostasis, are required in order to facilitate stroke prognosis. A literature search of two databases (MEDLINE and Science Direct) was conducted in order to trace all relevant studies published between 1 January 2010 and 31 December 2021 that focused on the clinical utility of brain natriuretic peptide, glial fibrillary acidic protein, the red cell distribution width, the neutrophil-to-lymphocyte ratio, matrix metalloproteinase-9, and aquaporin-4 as prognostic tools in stroke survivors. Only full-text articles published in English were included. Twenty-eight articles were identified and are included in this review. All studied blood-derived biomarkers proved to be valuable prognostic tools poststroke, the clinical implementation of which may accurately predict the survivors’ functional outcomes, thus significantly enhancing the rehabilitation efficiency of stroke patients. Along with already utilized clinical, neurophysiological, and neuroimaging biomarkers, a blood-derived multi-biomarker panel is proposed as a reasonable approach to enhance the predictive power of stroke prognostic models.

Neutrophil-to-Lymphocyte Ratio Predicts Early Neurological Deterioration after Endovascular Treatment in Patients with Ischemic Stroke

The worsening of neurological status that occurs early after acute ischemic stroke (AIS) remains a serious issue, and the inflammatory response plays a key role in stroke pathobiology. Recently, endovascular treatment (EVT) has revolutionized the management and outcome of patients with AIS due to either extracranial carotid disease or intracranial disease. The neutrophil-to-lymphocyte ratio (NLR) represents an easily available inflammatory biomarker. The aim of the study was to assess the relationship between the NLR at admission and the occurrence of early neurological deterioration (END) in patients with AIS who underwent EVT. Patients with AIS and proximal arterial occlusion in the anterior circulation undergoing EVT were retrospectively identified. Absolute neutrophil count (ANC) and absolute lymphocyte count (ALC) were collected from admission blood work to calculate the NLR. The study outcome was END defined as an increase in at least 4 points in NIHSS score or death between baseline and 24 h after the ischemic event. Patients included were 211, and END occurred in 30 (14.2%). Patients with older age (OR = 1.07, 95% CI: 1.02−1.13), higher serum glucose (OR = 1.01, 95% CI: 1.01−1.02), and higher NLR (OR = 1.011, 95% CI: 1.04−1.18) had an increased risk of END. The best predictive cut-off value of NLR was 6.4, and END occurred in 24.1% and 3.9% of the patients with NLR ≥ 6.4 and <6.4, respectively (p < 0.001). In patients with AIS undergoing EVT, higher NLR values predicted a higher risk of END. Biomarkers able to identify inflammatory mechanisms might identify novel treatment targets and enhance proof-of-concept trials of immunomodulation in stroke.

High neutrophil counts before endovascular treatment for acute basilar artery occlusion predict worse outcomes

Background and purpose

Ischemic stroke is related to inflammation. We investigated leukocyte counts, neutrophil counts, and NLR (neutrophil-to-lymphocyte ratio) to explore their prognostic potential and determine if high neutrophil counts before endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO) are associated with worse outcomes at 90 days post-EVT.

Methods

Leukocyte and neutrophil counts and NLR were determined in eligible patients from the Acute Basilar Artery Occlusion Study (BASILAR). Patients were divided into four groups according to leukocyte and neutrophil counts and NLR quartiles. The primary outcome was a favorable outcome based on the modified Rankin Scale (mRS: 0–3). The secondary outcome was functional independence (mRS 0–2). The safety outcome was mortality, and an unfavorable outcome was mRS 4–6. Successful reperfusion was mTICI (modified Thrombolysis in Cerebral Infarction) of 2b or 3. All the data were collected within 90 days after EVT.

Results

We enrolled 586 patients in the study. The leukocyte and neutrophil counts and NLR were significantly associated with clinical outcomes in all patients though no effects were seen in some intervals. Of these three parameters, the neutrophil count had the most significant impact, negatively affecting the outcome. The findings were similar in patients who were successfully recanalized.

Conclusion

Higher neutrophil counts predicted worse clinical outcomes 90 days after EVT. This finding supports the deleterious role of inflammation in patients with acute BAO despite EVT or successful recanalization.

Association of White Blood Cell Count With Clinical Outcome Independent of Treatment With Alteplase in Acute Ischemic Stroke

Introduction

Higher white blood cell (WBC) count is associated with poor functional outcome in acute ischemic stroke (AIS). However, little is known about whether the association is modified by treatment with intravenous alteplase.

Methods

WAKE-UP was a randomized controlled trial of the efficacy and safety of magnetic resonance imaging [MRI]-based thrombolysis in unknown onset stroke. WBC count was measured on admission and again at 22–36 h after randomization to treatment (follow-up). Favorable outcome was defined by a score of 0 or 1 on the modified Rankin scale (mRS) 90 days after stroke. Further outcome were stroke volume and any hemorrhagic transformation (HT) that were assessed on follow-up CT or MRI. Multiple logistic regression analysis was used to assess the association between outcome and WBC count and treatment group.

Results

Of 503 randomized patients, WBC count and baseline parameters were available in 437 patients (μ = 64.7 years, 35.2% women) on admission and 355 patients (μ = 65.1 years, 34.1% women) on follow-up. Median WBC count on admission was 7.6 × 10⁹/L (interquartile range, IQR, 6.1–9.4 × 10⁹/L) and 8.2 × 10⁹/L (IQR, 6.7–9.7 × 10⁹/L) on follow-up. Higher WBC count both on admission and follow-up was associated with lower odds of favorable outcome, adjusted for age, National Institutes of Health (NIH) Stroke Scale Score, temperature, and treatment (alteplase vs. placebo, adjusted odds ratio, aOR 0.85, 95% confidence interval [CI] 0.78–0.94 and aOR 0.88, 95% CI 0.79–0.97). No interaction between WBC count and treatment group was observed (p = 0.11). Furthermore, WBC count on admission and follow-up was significantly associated with HT (aOR 1.14, 95% CI 1.05–1.24 and aOR 1.13, 95% CI 1.00–1.26). Finally, WBC count on follow-up was associated with larger stroke volume (aOR 2.57, 95% CI 1.08–6.07).

Conclusion

Higher WBC count is associated with unfavorable outcome, an increased risk of HT, and larger stroke volume, independent of treatment with alteplase. Whether immunomodulatory manipulation of WBC count improves stroke outcome needs to be tested.

Trial Registration

ClinicalTrials.gov Identifier: NCT01525290.

Thrombolysis in stroke patients with elevated inflammatory markers

Objective

To investigate the prognostic value of white blood cell count (WBC) on functional outcome, mortality and bleeding risk in stroke patients treated with intravenous thrombolysis (IVT).

Methods

In this prospective multicenter study from the TRISP registry, we assessed the association between WBC on admission and 3-month poor outcome (modified Rankin Scale 3–6), mortality and occurrence of symptomatic intracranial hemorrhage (sICH; ECASS-II-criteria) in IVT-treated stroke patients. WBC was used as continuous and categorical variable distinguishing leukocytosis (WBC > 10 × 10⁹/l) and leukopenia (WBC < 4 × 10⁹/l). We calculated unadjusted/ adjusted odds ratios with 95% confidence intervals (OR [95% CI]) with logistic regression models. In a subgroup, we analyzed the association of combined leukocytosis and elevated C-reactive protein (CRP > 10 mg/l) on outcomes.

Results

Of 10,813 IVT-treated patients, 2527 had leukocytosis, 112 leukopenia and 8174 normal WBC. Increasing WBC (by 1 × 10⁹/l) predicted poor outcome (OR_adjusted 1.04[1.02–1.06]) but not mortality and sICH. Leukocytosis was independently associated with poor outcome (OR_adjusted 1.48[1.29–1.69]) and mortality (OR_adjusted 1.60[1.35–1.89]) but not with sICH (OR_adjusted 1.17[0.94–1.45]). Leukopenia did not predict any outcome. In a subgroup, combined leukocytosis and elevated CRP had the strongest association with poor outcome (OR_adjusted 2.26[1.76–2.91]) and mortality (OR_adjusted 2.43[1.86–3.16]) when compared to combined normal WBC and CRP.

Conclusion

In IVT-treated patients, leukocytosis independently predicted poor functional outcome and death. Bleeding complications after IVT were not independently associated with leukocytosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11173-0.

Role of Neutrophil-Lymphocyte Ratio in the Prognosis of Acute Ischaemic Stroke After Reperfusion Therapy: A Systematic Review and Meta-analysis

Background

Inflammation may mediate response to acute reperfusion therapy (RT) in acute cerebral ischaemia. Neutrophil-lymphocyte ratio (NLR), an inflammatory biomarker, may play an important role in acute ischaemic stroke (AIS) prognostication.

Objective

This meta-analysis sought to examine the effect of NLR on functional outcomes, mortality and adverse outcomes in AIS patients receiving RT.

Methods

Individual studies were retrieved from PubMed/Medline, EMBASE and Cochrane databases. Data were extracted using a standardised data sheet and meta-analysis on association of admission (pre-RT) or delayed (post-RT) NLR with clinical/safety outcomes after RT was conducted.

Results

Thirty-five studies (n = 10 308) were identified for the systematic review with 27 (n = 8537) included in the meta-analyses. Lower admission NLR was associated with good functional outcomes (GFOs), defined as 3-month modified Rankin scale (mRS) 0–2 (SMD = −.46; 95% CI = −.62 to −.29; P < .0001), mRS 0–1 (SMD = −.44; 95% CI = −.66 to −.22; P < .0001) and early neurological improvement (ENI) (SMD = −.55; 95 %CI = −.84 to −.25; P < .0001). Lower delayed admission NLR was also associated with GFOs (SMD = −.80; 95%CI = −.91 to −.68; P < .0001). Higher admission NLR was significantly associated with mortality (SMD = .49; 95%CI = .12 to .85; P = .009), intracerebral haemorrhage (ICH) (SMD = .34; 95% CI = .09 to .59; P = .007), symptomatic ICH (sICH) (SMD = .48; 95% CI = .07 to .90; P = .022) and stroke-associated infection or pneumonia (SMD = .85; 95% CI = .50, 1.19; P < .0001). Higher delayed NLR was significantly associated with sICH (SMD = 1.40; 95% CI = .60 to 2.19; P = .001), ICH (SMD = .94; 95% CI = .41 to 1.46; P < .0001) and mortality (SMD = 1.12; 95% CI = .57 to 1.67; P < .0001). There were variations in outcomes across RT groups.

Conclusion

Higher admission or delayed NLR is significantly associated with worse morbidity, mortality and safety outcomes in AIS patients receiving RT.

Prognostic Role of the Neutrophil-to-Lymphocyte Ratio in Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

The neutrophil-to-lymphocyte ratio (NLR) plays an important role in the progression of intracerebral hemorrhage (ICH). An increasing number of studies have reported that a high NLR is correlated with poor clinical outcomes among patients with ICH. Here, we conducted a systematic review and meta-analysis to evaluate the prognostic value of NLR in the setting of ICH. We performed a comprehensive search of electronic literature databases to identify all relevant studies evaluating the prognostic role of NLR in patients with ICH. Two researchers independently screened the studies and extracted relevant data. We extracted, pooled, and weighted odds ratio (OR) and 95% confidence interval (CI) values using a generic inverse-variance method, and then evaluated the heterogeneity among studies using Q test and I² statistic. Finally, we selected a total of 26 studies including 7,317 patients for the current study. Overall, our results indicated that a high NLR was significantly associated with a poor outcome (OR, 1.32; 95% CI, 1.19–1.46; P < 0.00001), mortality (OR, 1.05; 95% CI, 1.01–1.09; P = 0.02), and neurological deterioration (OR, 1.65; 95% CI, 1.08–2.52; P = 0.02). We did not observe a significant association between NLR and hematoma expansion (OR, 1.04; 95% CI, 0.99–1.08; P = 0.09). Our study indicated that a high NLR is significantly associated with poor clinical outcomes in patients with ICH. As NLR is a simple and easily available biomarker, future studies should focus on exploring its application in the prognostic evaluation of patients with ICH.

Neutrophil-lymphocyte ratio in acute ischemic stroke: Immunopathology, management, and prognosis

There is an ongoing need for accurate prognostic biomarkers in the milieu of acute ischemic stroke (AIS) receiving reperfusion therapy. Neutrophil-lymphocyte ratio (NLR) has been implicated in emergency medicine and acute stroke setting as an important biomarker in the prognosis of patients. However, there are ongoing questions around its accuracy and translation into clinical practice given suboptimal sensitivity and specificity results, as well as varying thresholds and lack of clarity around which NLR time points are most clinically indicative. This article provides a comprehensive overview of the role of NLR in AIS patients receiving reperfusion therapy and perspectives on areas of future research. NLR may be an important biomarker in risk stratifying patients in AIS to identify and select those who are more likely to benefit from reperfusion therapy. Appropriate clinical decision-making tools and models are required to harness the predictive value of NLR, which could be useful in identifying and monitoring high-risk patients to guide early treatment and achieve improved outcomes. Our understanding of the role of NLR in the immunopathogenesis of AIS is also suboptimal, which hinders the ability to translate this into clinical practice.

Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Stroke: A Systematic Review and Meta-Analysis

Background: Stroke has become a major problem around the world, which is one of the main causes of long-term disability. Therefore, it is important to seek a biomarker to predict the prognosis of patients with stroke. This meta-analysis aims to clarify the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the prognosis of stroke patients.

Methods: This study was pre-registered in PROSPERO (CRD42020186544). We performed systematic research in PubMed, Web of Science, and EMBASE databases for studies investigating the prognostic value of NLR. Based on the enrolled studies, patients were divided into the low-NLR cohort and the high-NLR cohort. Odds ratios (ORs) with 95% confidence intervals (CIs) were extracted and analyzed by the Review Manager 5.3 and Stata 12.0 software. Heterogeneity was estimated by using Cochran's Q test and I² value. Sensitivity analyses and subgroup analyses were also performed to explore the potential sources of heterogeneity. Publication bias was assessed with funnel plots and assessed by Egger's tests.

Results: Forty-one studies with 27,124 patients were included. In the overall analysis, elevated NLR was associated with an increased mortality in acute ischemic stroke (AIS) patients (OR = 1.12, 95% CI = 1.07–1.16) and in acute hemorrhagic stroke (AHS) patients (OR = 1.23, 95% CI = 1.09–1.39), poorer outcomes in AIS patients (OR = 1.29, 95% CI = 1.16–1.44), and in AHS patients (OR = 1.11, 95% CI = 1.03–1.20). While in terms of hemorrhagic transformation (HT), elevated NLR was associated with an increased incidence of HT in AIS patients (OR = 1.15, 95% CI = 1.08–1.23).

Conclusions: This study demonstrated that elevated NLR was significantly associated with poor prognosis of stroke patients. High NLR is associated with a 1.1- to 1.3-fold increased risk of poor outcomes of AIS/AHS patients. NLR could be helpful as a potential prognostic biomarker to guide clinical decision making.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020186544.

Biomarkers in the Prediction of Hemorrhagic Transformation in Acute Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Hemorrhagic transformation (HT) is a complication that occurs spontaneously or after thrombolysis in acute ischemic stroke (AIS) and can increase morbidity and mortality. The association of biomarkers with the risk of HT has been variably reported. We conducted a systematic review of the literature and meta-analysis and sought to compare blood biomarkers associated with HT and its subtypes by evaluating its predictability and correlation with outcome in AIS.

METHODS

The study protocol was registered in the PROSPERO database (CRD42020201334) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Among 2,230 articles identified from Cochrane Library, PubMed, and Web of Science databases, 30 quality-appraised articles were found eligible. Meta-analysis was conducted for matrix metalloproteinase-9 (MMP-9), cellular fibronectin (c-Fn), ferritin, S100 calcium-binding protein B (S100B), and neutrophil-lymphocyte ratio (NLR). We also reviewed biomarkers for correlation with the functional outcome at 90 days from stroke onset (poor outcome modified Rankin scale >2).

RESULTS

The pooled diagnostic odds ratio (DORpooled) was the highest for baseline c-Fn levels (299.253 [95% CI, 20.508-4,366.709]), followed by MMP-9 (DORpooled, 29.571 [95% CI 17.750-49.267]) and ferritin (DORpooled, 24.032 [95% CI 2.557-225.871]). However, wide confidence intervals for ferritin and c-Fn suggested lesser reliability of the markers. Patients with MMP-9 levels ≥140 ng/mL were 29.5 times at higher risk of developing symptomatic HT after AIS (area under the curve = 0.881). S100B (DORpooled, 6.286 [95% CI, 1.861-21.230]) and NLR (DORpooled, 5.036 [95% CI, 2.898-8.749]) had lower diagnostic accuracies. Among the markers not included for meta-analysis, caveolin-1, thrombin-activated fibrinolysis inhibitor, plasminogen activator inhibitor-1, and soluble ST2 were highly sensitive. Elevated levels of MMP-9, ferritin, and NLR were found to be associated with poor functional outcomes and mortality.

CONCLUSION

Of the 5 biomarkers, there was enough evidence that MMP-9 has higher diagnostic accuracy for predicting the risk of HT before thrombolysis. MMP-9, ferritin, and NLR also predicted poor short-term outcomes.

Neutrophils Obstructing Brain Capillaries Are a Major Cause of No-Reflow in Ischemic Stroke

Despite successful clot retrieval in large vessel occlusion stroke, ∼50% of patients have an unfavorable clinical outcome. The mechanisms underlying this functional reperfusion failure remain unknown, and therapeutic options are lacking. In the thrombin-model of middle cerebral artery (MCA) stroke in mice, we show that, despite successful thrombolytic recanalization of the proximal MCA, cortical blood flow does not fully recover. Using in vivo two-photon imaging, we demonstrate that this is due to microvascular obstruction of ∼20%-30% of capillaries in the infarct core and penumbra by neutrophils adhering to distal capillary segments. Depletion of circulating neutrophils using an anti-Ly6G antibody restores microvascular perfusion without increasing the rate of hemorrhagic complications. Strikingly, infarct size and functional deficits are smaller in mice treated with anti-Ly6G. Thus, we propose neutrophil stalling of brain capillaries to contribute to reperfusion failure, which offers promising therapeutic avenues for ischemic stroke.

Temporal course of peripheral inflammation markers and indexes following acute ischemic stroke: prediction of mortality, functional outcome, and stroke-associated pneumonia

BACKGROUND

Complete blood count derived indexes such as lymphocyte-to-neutrophil ratio (NLR) may help in predicting pneumonia and prognosis in acute stroke. However, the optimal time point for using these biomarkers is not known.

METHODS

In 205 consecutive severe (NIHSS>10) acute ischemic stroke patients, daily leukocyte, lymphocyte, neutrophil, monocyte, platelet, albumin, fibrinogen, hematocrit, NLR, PLR (Platelet-to-lymphocyte-ratio), LMR (Lymphocyte-to-monocyte-ratio), and SII (systemic-immune-inflammation-index) were determined. General linear models for repeated measures (GLMR) and receiver operating characteristics [ROC] analyses were conducted to define their daily discriminative ability.

RESULTS

GLMR-prognosis modeling documented that the main determinants of significant daily variations of 12 parameters studied were age and 24th-hour-NIHSS. In addition, daily changes of NLR, neutrophil, leukocyte (all increased on day-2 and remained higher) and platelet count (decreased after day-6 and stayed lower) were related significantly to survival status (mortality in 19.5%). Albumin levels (lower after day-2) were marginally associated by functional prognosis (modified-Rankin-Score≤3 in 28%). There was a borderline relationship (p = 0.05) between NLR (between day-1 and day-8) and pneumonia development (in 36%). Useful discrimination capability (95% confidence interval lower limit of area-under-curve of ROC≥0.7) was noted for NLR measured on day-6 for mortality, NLR (for 6 days, from day-3-to-day-7, and day-11) and albumin (for every day except day-11 after day-4) for reasonable prognosis and none for pneumonia development.

CONCLUSIONS

Inflammatory parameters from peripheral routine blood tests showed significant variations during the first two weeks following stroke, but discriminative capacity of these changes is limited due to confounders such as age and post-treatment clinical stroke severity.

Prognostic value of the neutrophil-to-lymphocyte ratio in acute ischemic stroke patients treated with intravenous thrombolysis: a systematic review and meta-analysis

Background

The relationship between the neutrophil-to-lymphocyte ratio (NLR) and poor prognostics in acute ischemic stroke (AIS) patients who receive intravenous thrombolysis (IVT) remains controversial. The purpose of this systematic review and meta-analysis was to evaluate the association between the NLR and poor prognosis after IVT. Furthermore, we aimed to determine whether the NLR at admission or post-IVT plays a role in AIS patients who received IVT.

Methods

The PubMed, Embase, Web of Science and China National Knowledge Infrastructure databases were searched for relevant articles until October 7, 2020. Cohort and case-control studies were included if they were related to the NLR in AIS patients treated with IVT. Odds ratios (ORs) and 95 % confidence intervals (95 % CIs) were pooled to estimate the relationship between NLR and poor prognosis after IVT. A random effects model was used to calculate the pooled data.

Results

Twelve studies, including 3641 patients, met the predefined inclusion criteria. Higher NLRs were associated with an increased risk of hemorrhagic transformation (HT) (OR = 1.33, 95 % CI = 1.14–1.56, P < 0.001) and a poor 3-month functional outcome (OR = 1.64, 95 % CI = 1.38–1.94, P < 0.001) in AIS patients who received IVT. Subgroup analysis suggested that the NLR at admission rather than post-IVT was associated with a higher risk of HT (OR = 1.33, 95 % CI = 1.01–1.75, P = 0.039). There was no statistically significant difference between higher NLRs and 3-month mortality (OR = 1.14, 95 % CI = 0.97–1.35, P = 0.120).

Conclusions

A high NLR can predict HT and poor 3-month functional outcomes in AIS patients who receive IVT. The NLR at admission rather than the post-IVT NLR was an independent risk factor for an increased risk of HT after IVT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02222-8.

Reperfusion failure despite recanalization in stroke: New translational evidence

Current treatment for acute ischemic stroke aims at recanalizing the occluded blood vessel to reperfuse ischemic brain tissue. Clot removal can be achieved pharmacologically with a thrombolytic drug, such as recombinant tissue plasminogen activator, or with mechanical thrombectomy. However, reopening the occluded vessel does not guarantee full tissue reperfusion, which has been referred to as reperfusion failure. When it occurs, reperfusion failure significantly attenuates the beneficial effect of recanalization therapy and severely affects functional recovery of stroke patients. The mechanisms of reperfusion failure are somewhat complex and not fully understood. Briefly, after stroke, capillaries show stalls, constriction and luminal narrowing, being crowded with neutrophils, and fibrin–platelet deposits. Furthermore, after recanalization in stroke patients, a primary clot can break, dislodge, and occlude distal arterial branches further downstream. In this review, we highlight a rodent model that allows studying the pathophysiological mechanisms underlying reperfusion failure after stroke. We also describe the vascular and intravascular changes involved in reperfusion, which may provide relevant therapeutic targets for improving treatment of stroke patients.

Prognostic value of neutrophil to lymphocyte ratio in acute ischemic stroke after reperfusion therapy

The purpose of this study was to investigate whether baseline neutrophil to lymphocyte ratio (NLR) was an independent predictor for early symptomatic intracranial hemorrhage (sICH), poor functional outcome and mortality at 3 months after reperfusion therapy in acute ischemic stroke (AIS) patients. Using PubMed and EMBASE, we searched for literature published before January 19th, 2019. Two reviewers independently confirmed each study’s eligibility, assessed risk of bias, and extracted data. One reviewer combined studies using random effects meta-analysis. 9 studies with 3651 patients were pooled in the meta-analysis. Overall, baseline NLR levels were greater in patients with poor outcome. The standardized mean difference (SMD) in the NLR levels between patients with poor functional outcome (mRS > 2) and good functional outcome (mRS ≤ 2) was 0.54 units (95% credible interval [CI] [0.38, 0.70]). Heterogeneity test showed that there were significant differences between individual studies (p = 0.02; I² = 72.8%). The NLR levels were associated with sICH in four included studies (n = 2003, SMD = 0.78, 95% [CI] [0.18, 1.38], I² = 73.9%). Higher NLR levels were positively correlated with 3-month mortality (n = 1389, ES = 1.71, 95% CI [1.01,2.42], p < 0.01, I² = 0%) when data were used as categorical variables. Our meta-analysis suggests that increased NLR levels are positively associated with greater risk of sICH, 3-month poor functional outcome and 3-month mortality in AIS patients undergoing reperfusion treatments. Although there are some deficits in this study, it may be feasible to predict the prognosis of reperfusion therapy in AIS patients with NLR levels.

Elevated Levels of Inflammation Markers Predict Poor Outcomes in Acute Ischemic Stroke Patients After Intravenous Thrombolysis

OBJECTIVES

Inflammation is associated with the occurrence and prognosis of ischemic stroke. The aim of this study was to evaluate the association between inflammatory biomarkers and the short-term clinical outcomes of acute ischemic stroke (AIS) patients after intravenous thrombolysis (IVT).

MATERIALS AND METHODS

A total of 208 AIS patients treated with IVT were enrolled in this retrospective study. Blood tests of inflammatory biomarkers, including the leukocyte count, neutrophil count, lymphocyte count, neutrophil-to-lymphocyte ratio and high-sensitivity C-reactive protein level, were conducted within 24 h after IVT. The primary outcome was decent functional recovery (DFR) [modified Rankin Scale score (mRS) of 0-2] at 3 months. The secondary outcomes included symptomatic intracranial hemorrhage and 3-month mortality. A multivariate analysis was performed to evaluate the associations between inflammatory biomarkers and 3-month clinical outcomes.

RESULTS

At 3 months follow-up, 113 (62.2%) patients achieved DFR. As compared to patients with DFR, patients without DFR had higher leukocyte counts (8.5 ± 2.4 × 10⁹/L versus 6.9 ± 1.7 × 10⁹/L, P=0.000), neutrophil counts (6.1 ± 2.3 × 10⁹/L versus 4.6±1.7 × 10⁹/L, P=0.000) and neutrophil-to-lymphocyte ratio (4.6 ± 2.4 versus 3.3 ± 1.9, P=0.000). After adjusting for the stroke subtype, severity of stroke, and medical history, the leukocyte count and neutrophil count remained significantly correlated with non-DFR (adjusted odds ratio [OR] 1.488; 95% confidence interval [CI], 1.247-1.776; P=0.000 and adjusted OR 1.522; 95% CI, 1.269-1.826; P=0.000, respectively).

CONCLUSIONS

This study demonstrates that increased levels of inflammatory biomarkers are independently associated with poor outcomes at 3 months in AIS patients treated with IVT.

Association of inflammatory and platelet volume markers with clinical outcome in patients with anterior circulation ischaemic stroke after endovascular thrombectomy

Background: To determine the correlation of inflammatory and platelet volume indices with the severity of stroke and 3-month clinical outcomes in patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT).Methods: A retrospective analysis was conducted for AIS patients who underwent EVT at our hospital from 2015 to 2019. Inflammatory factors, including white blood count, neutrophil count, lymphocyte count, neutrophil to lymphocyte ratio (NLR), high-sensitivity C-reactive protein (hs-CRP), procalcitonin (PCT) and interleukin-6 (IL-6), and platelet volume indices, including platelet count (PC), mean platelet volume (MPV), platelet distribution width (PDW) and MPV/PC levels were assessed. Results were analyzed between patients with favorable and unfavorable outcomes at 3 months post-EVT.Results: A total of 257 AIS patients were included in the study. There were 86 (33.5%) patients with favorable functional outcomes at 3 months. Compared to patients with favorable outcomes, those with poor outcomes have lower lymphocyte count, higher neutrophil count and NLR levels. There were no differences in hs-CRP,PCT and IL-6 between the two groups. The correlation analysis showed that the increase in MPV, PDW, and MPV/PC was related to the high level of the NIHSS score at admission. Multivariate logistic regression analysis showed that higher NLR levels are an independent risk factor for unfavorable outcomes at 3 months (OR = 1.141; 95% CI 1.061 to 1.227, P = 0.000).Conclusions: MPV, PDW, and MPV/PC are associated with stroke severity. Higher NLR levels upon admission may predict unfavorable functional outcomes in patients with AIS after undergoing EVT.Abbreviations ACA: anterior cerebral artery; AIS: acute ischemic stroke; ASPECTS: alberta stroke program early CT score; BMI: body mass index; DBP: diastolic blood pressure; END: early neurological deterioration; EVT: endovascular thrombectomy; hs-CRP: high-sensitivity C-reactive protein; HT: hemorrhagic transformation; ICA: internal carotid artery; IL-6: interleukin-6; IS: ischemic progression; LAA: Large-Artery Atherosclerosis; MCA: middle cerebral artery; MPV: mean platelet volume; mTICI: modified thrombolysis in cerebral infarction; NIHSS: National Institute of Health stroke scale; NLR: neutrophil to lymphocyte ratio; OTP: onset-to-puncture; PC: platelet count; PCT: procalcitonin; PDW: platelet distribution width; SBP: systolic blood pressure; sICH: symptomatic intracerebral hemorrhageWBC: white blood cell.

Systemic Inflammation Indices in Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator: Clinical Yield and Utility

Inflammation indices derived from complete blood counts (CBCs) have been proposed to estimate benefit and risk of intravenous (IV) tissue plasminogen activator (tPA) in acute ischemic stroke. In 165 acute ischemic patients, the neutrophil-to-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio, and systemic immune-inflammation index (SII) were calculated before and 24 hours after IV tPA. The area under receiver operating characteristic (AUC-ROC) curves, and positive and negative likelihood ratios (+LR,-LR) were produced to measure their diagnostic accuracy and clinical utility for tPA effectiveness, hemorrhage risk and third-month prognosis. None of the indices obtained "before" IV-tPA was found to be useful in determining acute and long-term functional efficacy and bleeding risk. Lymphocyte decrease, neutrophil increase, and parallel NLR and SII increase at the 24th-hour were associated with poor functional outcome. However, their clinical utility was not sufficient due to absence of effective thresholds. NLR threshold >5.65 provided ROC-AUC 0.86, sensitivity 71.3%, specificity 65.7%, -LR 0, +LR 3.76, and SII threshold >1781 had ROC-AUC 0.802, sensitivity 58.7%, specificity 72.7%, -LR 0.11, +LR 4.52, corresponding to an acceptable clinical yield. Systemic immune-inflammation index and NLR, but not other CBC-derived inflammatory parameters, have moderate utility as marker of tPA-related symptomatic hemorrhage occurrence.

Combined utility of blood glucose and white blood cell in predicting outcome after acute ischemic stroke: The ENCHANTED trial

BACKGROUND

As hyperglycemia and leukocytosis individually predict poor outcome in acute ischemic stroke (AIS), we aimed to determine the significance of their combination on functional outcome and symptomatic intracerebral hemorrhage (sICH) among participants of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED).

METHODS

Post-hoc analyzes of the full ENCHANTED cohort, an international, multicenter, quasi-factorial, randomized, open, blinded outcome-assessed trial of low- versus standard-dose intravenous alteplase and early intensive versus standard blood pressure (BaP) lowering treatment in 4557 thrombolysis-eligible and treated AIS patients. Patients were divided into four groups according to baseline blood glucose and white blood cells (WBC) levels: A (normal glucose + WBC), B (hyperglycemia + normal WBC), C (normal glucose + high WBC), and D (hyperglycemia + high WBC). Logistic regression models were used to determine associations of each group and poor functional outcome (modified Rankin scale scores 2-6) at 90 days and sICH within 48 h, adjusted for confounders. Quality of model fit was examined with Akaike information classification (AIC), Bayesian information classification (BIC), and likelihood ratio test.

RESULTS

Of 4181 AIS patients included in analyzes, and with group A as the reference, an increasing odds of poor functional outcome was evident across groups B (odds ratio [OR] 1.38, 95 % confidence interval [CI] 1.17-1.63), C (OR 1.26, 95 %CI 0.99-1.60), and D (OR 2.26, 95 %CI 1.79-2.85) (P trend <0.001). Group D patients also had a higher rate of sICH (P trend <0.05). The model fit with the combination of blood glucose and WBC was better than models of their individual components.

CONCLUSIONS

Using a combination of blood glucose and WBC provides strong prognostic significance than either alone in thrombolyzed AIS patients.

Neutrophil-to-lymphocyte ratio, hyperglycemia, and outcomes in ischemic stroke patients treated with intravenous thrombolysis

INTRODUCTION

Increased neutrophil-to-lymphocyte ratio (NLR) and hyperglycemia on admission are associated with poor outcomes in acute ischemic stroke (AIS) patients. We sought to evaluate the combined effect of increased NLR and hyperglycemia on the prognosis of ischemia stroke treated with intravenous thrombolysis (IVT).

METHODS

Patients with acute ischemic stroke receiving IVT treatment were prospectively enrolled. All participants were followed for 3 months. According to the levels of NLR and blood glucose, patients were categorized into four groups: high NLR or nonhigh NLR with or without hyperglycemia. The associations between NLR values with or without hyperglycemia and outcomes of stroke after thrombolysis were assessed by multivariable logistic regression analysis.

RESULTS

Among the 381 stroke patients (median age 68 years, 61.68% man) included, 155 (40.68%) had a poor outcome (modified Rankin Scale score 3-6) during 3 months. After multivariate adjustment, high NLR with hyperglycemia increased the risk of 3-month poor outcome (OR = 4.42; 95% CI, 2.13-9.16), early neurological deterioration (END) (OR = 4.81; 95% CI, 2.08-11.12), and 3-month mortality (OR = 6.56; 95% CI, 1.92-22.40). A significant multiplicative interaction of NLR and blood glucose on 3-month poor outcome in ischemic stroke patients after thrombolysis was observed.

CONCLUSIONS

Ischemic stroke patients with concurrent high NLR and hyperglycemia increased risks of END, 3-month poor outcome, and mortality after thrombolysis.

The correlation between novel peripheral blood cell ratios and 90-day mortality in patients with acute ischemic stroke

BACKGROUND

We aimed to investigate the correlation between the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), platelet-to-neutrophil ratio (PNR), platelet-to-white blood cell ratio (PWR) and 90-day mortality in patients with acute ischemic stroke (AIS).

METHODS

We retrospectively included 633 patients with AIS from January 2017 to May 2018. The correlation between each indicator and the degree of neurologic deficit was assessed. Kaplan-Meier survival curves based on blood cell ratios were used to analyze the 90-day survival rate of patients with AIS.

RESULTS

A total of 663 patients with AIS were enrolled, of which 24 (3.6%) experienced recurrence and 13 (2.0%) died. NLR>3.23 (odds ratio; OR = 2.236; 95% confidence interval [CI], 1.472-3.397; P<0.001), PNR<31.14 (OR = 0.471; 95% CI, 0.297-0.749; P = 0.001), and PWR<20.62 (OR = 0.498; 95% CI, 0.309-0.800; P = 0.004) were associated with an unfavorable 90-day prognosis. NLR>3.23, PWR<20.62, and PNR<31.14 were associated with an increased risk of 90-day mortality.

CONCLUSION

PNR, PWR, and NLR were associated with the 90-day mortality of patients with AIS. Patients with high NLRs or low PWRs and PNRs may have a greater risk of mortality than other patients. These clinical indicators may help clinicians judge unfavorable prognosis early and implement the appropriate interventions.

The predictive role of the neutrophil-lymphocyte ratio in the prognosis of adult patients with stroke

Our study aimed to determine the effect of the neutrophil–lymphocyte ratio on the prognosis of adult patients with acute stroke. We searched the Web of Science, PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure databases and selected all of the potentially eligible studies. From the included studies, we extracted characteristics such as the stroke type and acquisition time until routine blood collection and the odds ratios across studies. The 95% confidence intervals and odds ratios were pooled to calculate the effect size for the neutrophil–lymphocyte ratio in acute stroke patients. We defined poor function outcomes according to the modified Rankin Scale ≥ 3 or Glasgow Outcome Scale< 3.Thirteen studies with 4443 patients were included in our analysis, including 7 ischemic and 6 hemorrhagic stroke studies. The pooled odds ratios for poor functional outcome at 3 months with a higher neutrophil–lymphocyte ratio in acute ischemic and hemorrhagic patients were 1.689 (95% CI = 1.184–2.409, p < 0.001) and 1.125 (95% CI = 1.022–1.239, p < 0.001), respectively, and the overall pooled odds ratio for poor functional outcome following stroke was 1.257 (95% CI = 1.146–1.379, p < 0.001). At the same time, the overall combined odds ratio for death at 3 months was 1.632 (95% CI = 1.155–2.306, p < 0.001).The neutrophil–lymphocyte ratio, an easily calculated marker, plays a predictive role in the short-term outcomes of adult patients (mean age ≥ 50 years) following acute ischemic and hemorrhagic stroke.

Association of Neutrophil-Lymphocyte Ratio with Mild Cognitive Impairment in Elderly Chinese Adults: A Case-control Study

Background:

Inflammation plays a significant role in the pathophysiology of cognitive impairment in previous studies. Neutrophil-lymphocyte ratio (NLR) is a reliable measure of systemic inflammation.

Objective:

The aim of this study was to investigate the association between NLR and mild cognitive impairment (MCI), and further to explore the diagnostic potential of the inflammatory markers NLR for the diagnosis of MCI in elderly Chinese individuals.

Methods:

186 MCI subjects and 153 subjects with normal cognitive function were evaluated consecutively in this study. Neutrophil (NEUT) count and Lymphocyte (LYM) count were measured in fasting blood samples. The NLR was calculated by dividing the absolute NEUT count by the absolute LYM count. Multivariable logistic regression was used to evaluate the potential association between NLR and MCI. NLR for predicting MCI was analyzed using Receiver Operating Characteristic (ROC) curve analysis.

Results:

The NLR of MCI group was significantly higher than that of subjects with normal cognitive function (2.39 ± 0.55 vs. 1.94 ± 0.51, P < 0.001). Logistic regression analysis showed that higher NLR was an independent risk factor for MCI (OR: 4.549, 95% CI: 2.623-7.889, P < 0.001). ROC analysis suggested that the optimum NLR cut-off point for MCI was 2.07 with 73.66% sensitivity, 69.28% specificity, 74.48% Positive Predictive Values (PPV) and 68.36% negative predictive values (NPV). Subjects with NLR ≥ 2.07 showed higher risk relative to NLR < 2.07 (OR: 5.933, 95% CI: 3.467-10.155, P < 0.001).

Conclusion:

The elevated NLR is significantly associated with increased risk of MCI. In particular, NLR level higher than the threshold of 2.07 was significantly associated with the probability of MCI.

Blood Biomarkers of Parenchymal Damage in Ischemic Stroke Patients Treated With Revascularization Therapies

Purpose

Postischemic reperfusion injury may exacerbate cerebral damage and capillary dysfunction, leading to brain edema (BE), hemorrhagic transformation (HT), necrosis, and injury from free radicals with subsequent infarct growth (IG). Several plasmatic biomarkers involved in the ischemic cascade have been studied in relation to radiological and clinical outcomes of reperfusion injury in ischemic stroke with heterogeneous results. This article provides a brief overview of the contribution of circulating biomarkers to the pathophysiology of parenchymal damage in ischemic stroke patients treated with revascularization therapies.

Methods

We included full reports with measurements of plasma markers in patients with acute ischemic stroke treated with revascularization therapies.

Findings

Our research included a large number of observational studies investigating a possible role of circulating biomarkers in the development of parenchymal damage after acute stroke treatments. To make the results clearer, we divided the review in 4 sections, exploring the relation of different biomarkers with each of the indicators of parenchymal damage (HT, BE, IG, recanalization).

Discussion and conclusion

Definite conclusions are difficult to draw because of heterogeneity across studies. However, our review seems to confirm an association between some circulating biomarkers (particularly matrix metalloproteinase-9) and occurrence of parenchymal damage in ischemic stroke patients treated with revascularization therapies.

Neutrophil-lymphocyte ratio predicts post-thrombolysis early neurological deterioration in acute ischemic stroke patients

BACKGROUND AND PURPOSE

Intravenous thrombolysis (IVT) has become the standard treatment for acute ischemic stroke within 4.5 hr after symptoms onset. However, a fraction of patients would develop early neurological deterioration (END) after IVT. The aim of our study was to explore the utility of neutrophil-lymphocyte ratio (NLR) in predicting END.

METHODS

From October 2016 to March 2018, 342 consecutive patients with thrombolytic therapy were prospectively enrolled in this study. Blood cell counts were sampled in stroke emergency room before IVT. END was defined as a National Institutes of Health Stroke Scale score increase of ≥4 points within 24 hr after IVT. Multiple regression analysis was used to investigate the potential risk factors of END. We also performed receiver operating characteristic curve analysis and nomogram analysis to assess the overall discriminative ability of the NLR in predicting END.

RESULTS

Of the 342 patients, 86 (25.1%) participants were identified with END. Univariate logistic regression analysis demonstrated that patients with NLR in the third tertile, compared with the first tertile, were more likely to have END (odds ratio, 9.783; 95% confidence interval [CI], 4.847-19.764; p = .001). The association remained significant even after controlled for potential confounders. Also, a cutoff value of 4.43 for NLR was detected in predicting post-thrombolysis END with a sensitivity of 70.9% and a specificity of 79.3% (area under curve, 0.779; 95% CI, 0.731-0.822). Furthermore, our established nomogram indicated that higher NLR was an indicator of post-thrombolysis END (c-index was 0.789, p < .001).

CONCLUSIONS

This study showed that elevated level of NLR may predict post-thrombolysis END in ischemic stroke patients.

Neutrophil-to-lymphocyte ratio predicts hemorrhagic transformation in ischemic stroke: A meta-analysis

INTRODUCTION

The neutrophil-to-lymphocyte ratio (NLR) has been shown to be a marker associated with inflammation and is independently associated with the adverse clinical outcomes of symptomatic intracranial hemorrhage, cancer, and cardiovascular disease. Hemorrhagic transformation (HT) is a serious complication of ischemic cerebral infarction and can be intensified by therapeutic interventions for acute ischemic stroke (AIS). The purpose of our research was to explore the predictive effect of NLR for HT in patients with AIS and to determine the best predictive value.

METHODS

PubMed, Web of Science, EMBASE, MEDLINE, Cochrane, and Google Scholar were searched. The primary endpoint was HT, and subgroup analysis was performed. Review Manager software version 5.3 was used to statistically analyze the outcomes.

RESULTS

A total of seven studies including 3,726 patients met the inclusion criteria. The pooled odds ratio (OR) value of the high NLR that predicted HT in AIS patients was 1.53 (95% CI, 1.21-1.92; p = .0003). In addition, 1.10 (95% CI, 1.05-1.15; p < .0001) was the pooled OR of the high NLR associated with increased 3-month mortality in patients with AIS. In the subgroup analysis with an NLR cutoff value of 7.5-11, the correlation between NLR above the cutoff value and the rate of HT in patients with AIS was statistically significant (OR, 7.93; 95% CI, 2.25-27.95; p = .001).

CONCLUSION

A high NLR can predict HT and 3-month mortality in patients with AIS. Regardless of the country of origin and the sampling time, an NLR with a cutoff value of 7.5-11 was independently associated with HT in AIS patients.

Neutrophil to lymphocyte ratio predicts poor outcomes after acute ischemic stroke: A cohort study and systematic review

BACKGROUND AND PURPOSE

The relationship between neutrophil to lymphocyte ratio (NLR) and prognosis after acute ischemic stroke (AIS) remains controversial. The aim of this cohort study and systematic review was to ascertain the association of admission NLR with major clinical poor outcomes after AIS.

METHODS

We analyzed data from Chengdu stroke registry and performed a systematic review for previous literature. The outcomes were hemorrhagic transformation (HT), parenchymal hematoma (PH), symptomatic intracranial hemorrhage (sICH), 3-month death or disability (modified Rankin Scale≥3), and 3-month death. Odds ratios (ORs) and 95% confidence intervals (CIs) of NLR as a continuous and categorical variable and poor outcomes were pooled separately. We also calculated the predictive accuracy of admission NLR in different outcomes.

RESULTS

We included 808 patients from registry database and 9563 patients from previous studies. Our registry data showed that NLR ≥5 was associated with HT (OR 2.03, 95%CI 1.19-3.46), PH (OR 2.54, 95%CI 1.20-5.35) and 3-month death (OR 5.55, 95%CI 1.41-21.89); meta-analysis with our data and other observational studies indicated that higher NLR was associated with HT (OR 1.99, 95% CI 1.45-2.73), sICH (OR 2.22, 95% CI 1.60-3.09), 3-month death or disability (OR 1.68, 95% CI 1.18-2.38), and 3-month death (OR 2.79, 95% CI 1.57, 4.94). NLR had the highest predictive accuracy for 3-month death.

CONCLUSIONS

Higher NLR is positively associated with the risk of HT and 3-month death after stroke. Considering the limited predictive ability of a single biomarker, more studies should validate the role of NLR in prognostic models.

Association of Neutrophil-to-Lymphocyte Ratio and Lymphocyte-to-Monocyte Ratio with Treatment Modalities of Acute Ischaemic Stroke: A Pilot Study

Background and Objectives: Ischaemic stroke (IS) is the leading cause of death and disability worldwide. All stages of cerebral ischaemia, but especially acute phase, are associated with inflammatory response. Recent studies showed that neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR) may be used to assess inflammation in IS. To test whether there is a relationship between these parameters and type of stroke treatment, we analysed NLR and LMR in IS patients treated with three different modalities. Materials and Methods: The study included 58 adults with acute IS. A total of 28 patients received intravenous thrombolysis. In another 10 patients, the thrombolytic therapy was followed by thrombectomy and 20 patients did not undergo causal treatment. Blood samples were obtained within 24 h of the stroke diagnosis to calculate NLR and LMR. Next, NLR and LMR of the study subgroups were compared. Results: Our study revealed that NLR was significantly higher in patients treated with thrombectomy following thrombolysis, compared to no causal treatment. Statistical analysis demonstrated that patients with high National Institutes of Health Stroke Scale (NIHSS) scores presented higher NLR than in those with low NIHSS scores. Additionally, patients with high-sensitivity C-reactive protein (hs-CRP) ≥ 3 mg/L presented with significantly higher NLR and significantly lower LMR than the group of patients with lower hs-CRP (<3 mg/L). Conclusions: The main finding of this pilot study was that NLR in IS patients treated using thrombectomy following thrombolysis was markedly higher than that in other treatment groups, which was associated with increased severity of the disease in these patients. Therefore, patients with higher NLR may be expected to have more severe stroke. The link between stroke severity and NLR deserves further study.