Role of the Neutrophil to Lymphocyte Ratio in Guillain Barré Syndrome: A Systematic Review and Meta-Analysis

The neutrophil-to-lymphocyte ratio (NLR) levels predicting the surgical site infection in spinal surgery: a systematic review

Background

Surgical site infection (SSI) is a prevalent complication in spinal surgery, associated with significant morbidity, prolonged hospital stays, and increased healthcare costs. The early detection of SSI can lead to timely intervention. Among available diagnostic methods, the neutrophil-to-lymphocyte ratio (NLR) has emerged as a simple, accessible marker with potential predictive value for SSIs. This systematic review aims to evaluate the diagnostic role of NLR, in the early detection of SSIs following spinal surgery.

Methods

Following PRISMA guidelines, we conducted a comprehensive literature search in MEDLINE, Web of Science, Embase, and Scopus databases for studies examining the utility of NLR in predicting SSIs in all types of spinal surgery patients. Ultimately, 7 studies met the inclusion criteria; all retrospective in design, with sample sizes ranging from 77 to 384. Studies focused on NLR values measured at different postoperative days, solely or along with some integrating additional markers, including C-reactive protein (CRP) and body mass index (BMI), into predictive models.

Results

Our study confirmed that NLR serves as a significant predictor of SSIs post-spinal surgery. Analyses of included studies revealed variable optimal NLR cutoff values, ranging from 3.21 to 4.91, dependent on postoperative day and surgery type. The highest predictive accuracy was observed when NLR was combined with CRP and lymphocyte percentage, enhancing early SSI detection. However, the variability in cutoff values and measurement timing across studies suggests limitations due to heterogeneity in study designs and patient populations, indicating the need for further research to establish standardized protocols.

Conclusions

NLR could be of value for early SSI detection in spinal surgery, with its diagnostic accuracy potentially improved by combining it with other markers. However, variability in cutoff values and timing across studies suggests the need for further research to standardize these parameters. Establishing consistent protocols could improve SSI detection, enabling faster interventions and potentially enhancing patient outcomes in spinal surgery.

Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is a rare immune-mediated polyradiculoneuropathy. Patients typically develop rapidly progressive weakness and sensory deficits that can result in complete paralysis requiring mechanical ventilation. GBS is usually a monophasic disease in which an aberrant immune response to an infection or other trigger damages the peripheral nerves. For example, in patients with preceding Campylobacter jejuni infection, molecular mimicry causes a cross-reactive antibody response to nerve gangliosides. Diagnosis is based on clinical features, supported by cerebrospinal fluid analysis and nerve conduction studies. Effective treatments include plasma exchange and intravenous immunoglobulins. However, ~20% of patients who received treatment are unable to walk after 6 months and ~5% die as a consequence of GBS. Important knowledge gaps in GBS include its pathogenesis, especially after viral infections. In addition, there is a lack of specific biomarkers to improve the diagnosis, monitor the disease activity, and predict the clinical course and outcome of GBS. Major challenges for the future include finding more effective and personalized treatments, which are affordable in low-income and middle-income countries, and preparation for outbreaks of infections as potential triggers for GBS.

Risk factors of disease severity and mechanical ventilation requirement in childhood Guillain-Barré Syndrome

BACKGROUND

This study aimed to investigate the risk factors associated with the severity of the disease, the need for mechanical ventilation (MV) and poor prognosis in the early stages of Guillain-Barré Syndrome (GBS).

METHODS

Data of children who met GBS diagnostic criteria were evaluated retrospectively. The sample was divided into three binary subgroups according to severe GBS (Hughes Functional Grading Scale [HFGS] ≥ 4 at admission), mechanical ventilation (MV) requirement, and poor prognosis (inability to walk independently, HFGS ≥ 3 after six months). Various clinical, laboratory and electrophysiological parameters were compared between these subgroups.

RESULTS

The mean age of 63 children with GBS was 91.55±49.09 months. 13 (20.6%) patients required MV and 4 (6.3%) patients died. Associated risk factors for the need for MV in severe GBS were found to be autonomic dysfunction, bulbar palsy, sensory impairment, lowest total Medical Research Council (MRC) scale for muscle strength score at admission, high modified Erasmus GBS respiratory failure score (mEGRIS), high neutrophil-lymphocyte ratios (NLR) and high systemic immune-inflammation index (SII) values (p<0.001, p=0.003, p=0.033, p<0.001, p<0.001, p=0.037 and p=0.042, respectively). The lowest total MRC scale for muscle strength score at admission was a significant indicator of poor prognosis (p<0.001).

CONCLUSIONS

Autonomic dysfunction, bulbar palsy, sensory impairment, lowest total MRC scale for muscle strength score at admission, high mEGRIS score, high NLR and SII values are potential risk factors for the need for MV in children with severe GBS. The lowest total MRC scale for muscle strength score at admission was associated with poor prognosis.

Neutrophil to lymphocyte ratio and systemic immune-inflammatory index as markers of response to autologous hematopoietic stem cell transplantation in persons with multiple sclerosis

INTRODUCTION

Biomarkers that help to evaluate the immune system and could be useful in multiple sclerosis (MS) are the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and systemic immune-inflammatory index (SII). The objective of this work is to evaluate the significance of the SII index, PLR, and NLR before and after transplantation in individuals with MS who underwent autologous hematopoietic stem cell transplant (aHSCT) at a single institution.

METHODS

Patients with MS who received an aHSCT between 2017 and 2022 were included in the study. NLR, PLR, and SII index were calculated prior to the transplant and 100 days after, and evaluation of the expanded disability status scale (EDSS) was done before the transplant and 12 months after. The cohort was divided into two groups: aHSCT responders (R) and nonresponders (NR).

RESULTS

Fifty-eight individuals were examined: 37 patients in the responders group R group and 21 in NR group. There was no statistically significant difference in the SII, NLR, and PLR prior to the transplant, however at 100 days post-HSCT, NLR in the R group was 1.8 versus 3.1 in the NR group (p = 0.003), PLR was 194 versus 295, respectively (p = 0.024), meanwhile SII index was 489.5 versus 729.3 (p < 0.001).

CONCLUSION

High NLR and SII index values after the aHSCT were associated with a worsening in the EDSS score. However, since this is the first ever study that compared NLR and SII index with the aHSCT response in persons with MS, further studies must be performed to corroborate this information.

A study on the role of serum uric acid in differentiating acute inflammatory demyelinating polyneuropathy from acute-onset chronic inflammatory demyelinating polyneuropathy

BACKGROUND AND PURPOSE

Clinical symptoms and laboratory indices for acute inflammatory demyelinating polyneuropathy (AIDP), a variant of Guillain-Barré syndrome, and acute-onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) were analyzed to identify factors that could contribute to early differential diagnosis.

METHODS

A retrospective chart review was performed on 44 AIDP and 44 A-CIDP patients looking for any demographic characteristics, clinical manifestations or laboratory parameters that might differentiate AIDP from acutely presenting CIDP.

RESULTS

In Guillain-Barré syndrome patients (N = 63), 69.84% (N = 44) were classified as having AIDP, 19.05% (N = 12) were found to have acute motor axonal neuropathy, 6.35% (N = 4) were found to have acute motor and sensory axonal neuropathy, and 4.76% (N = 3) were found to have Miller Fisher syndrome. Serum uric acid (UA) was higher in A-CIDP patients (329.55 ± 72.23 μmol/L) than in AIDP patients (221.08 ± 71.32 μmol/L) (p = 0.000). Receiver operating characteristic analyses indicated that the optimal UA cutoff was 283.50 μmol/L. Above this level, patients were more likely to present A-CIDP than AIDP (specificity 81.80%, sensitivity 81.80%). During the follow-up process, serum samples were effectively collected from 19 AIDP patients during the rehabilitation phase and 28 A-CIDP patients during the remission stage, and it was found that UA levels were significantly increased in A-CIDP (remission) (298.9 ± 90.39 μmol/L) compared with AIDP (rehabilitation) (220.1 ± 108.2 μmol/L, p = 0.009).

CONCLUSION

These results suggest that serum UA level can help to differentiate AIDP from A-CIDP with high specificity and sensitivity, which is helpful for early diagnosis and guidance of treatment.

The clinical significance of systemic immune-inflammation index and platelet/neutrophil to lymphocyte ratio in Guillain-Barré syndrome

OBJECTIVE

Systemic immune-inflammation index (SII) and platelet/neutrophil to lymphocyte ratio (P/NLR) are two novel hematological inflammatory indices, this study invested the role of SII and P/NLR in Guillain-Barré syndrome (GBS).

METHODS

A total of 115 GBS patients and 120 healthy controls were enrolled in this retrospective study, SII and P/NLR were calculated from the value of complete blood counts. The Hughes Functional Grading Scale (HFGS) score on admission and at discharge was used to evaluate the severity and short-term outcome of GBS. The level of SII and P/NLR was compared between GBS patients and healthy controls, and the correlation between SII, P/NLR, and GBS's severity as well as poor short-term outcome was analyzed.

RESULTS

Increased SII (p < 0.001) and decreased P/NLR (p < 0.001) were observed in patients with GBS and the level of SII (p = 0.689) and P/NLR (p = 0.879) was not different between GBS subtypes. Patients with severe GBS and poor short-term outcomes had higher levels of SII and lower levels of P/NLR (p < 0.05), SII was positively correlated and P/NLR was negatively correlated with the HFGS score on admission and at discharge (p < 0.05). To predict severe GBS, the optimal cutoff value of SII was 620.87 (AUC0.633, sensitivity 60.8 % and specificity 60.9 %, p = 0.014), the optimal cutoff value of P/NLR was 53.11 (AUC0.635, sensitivity 45.1 %, specificity 82.8 %, p = 0.013). The SII level of 620.87 was found to be optimal predictive cutoff value for the poor short-term outcome of GBS (AUC 0.728, sensitivity of 82.6 %, specificity of 59.8 %, p = 0.001), the P/NLR level of 62.80 was found to be optimal predictive cutoff value for the poor short-term outcome of GBS (AUC 0.669, sensitivity 60.9 %, specificity 71.7 %, p = 0.012). Both SII>620.87 (p = 0.005) and P/NLR<53.11 (p = 0.002) were independent risk factors for severe GBS, and SII>620.87 (p = 0.035) was independently associated with the poor short-term outcome of GBS.

CONCLUSION

SII and P/NLR may be useful biomarkers to reflect GBS patients' severity and short-term outcome.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are early predictors of bronchopulmonary dysplasia

To determine whether neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are correlated with bronchopulmonary dysplasia (BPD) on the first day of prematurity and to help with early warning, identification, and intervention in the development of BPD. From January 2017 to June 2022, newborns who were diagnosed with BPD conducted a retrospective cohort study. Complete blood cells were measured within the first 24 hours of life in preterm neonates of 32 gestational weeks with BPD as the observation group and non-BPD infants as the control group. In all groups, the NLR and PLR levels were measured. Both univariate and multivariate logistic regression analyses were used to evaluate the data. In this research 76 cases of non-BPD and 48 cases of BPD were used as controls. Compared with the non-BPD group, the NLR and PLR levels were considerably higher in the BPD group. Logistic regression analysis suggested that NLR and PLR were independent risk factors for BPD (OR [odds ratio]: 3.786; 95% CI [confidence interval]: 1.75-8.16; P < .05; OR: 3.391; 95% CI: 1.85-28.78; P < .05). The findings may demonstrate that higher NLR and PLR are independently and significantly associated with the development of BPD.

Neutrophil biology in injuries and diseases of the central and peripheral nervous systems

The role of inflammation in nervous system injury and disease is attracting increased attention. Much of that research has focused on microglia in the central nervous system (CNS) and macrophages in the peripheral nervous system (PNS). Much less attention has been paid to the roles played by neutrophils. Neutrophils are part of the granulocyte subtype of myeloid cells. These cells, like macrophages, originate and differentiate in the bone marrow from which they enter the circulation. After tissue damage or infection, neutrophils are the first immune cells to infiltrate into tissues and are directed there by specific chemokines, which act on chemokine receptors on neutrophils. We have reviewed here the basic biology of these cells, including their differentiation, the types of granules they contain, the chemokines that act on them, the subpopulations of neutrophils that exist, and their functions. We also discuss tools available for identification and further study of neutrophils. We then turn to a review of what is known about the role of neutrophils in CNS and PNS diseases and injury, including stroke, Alzheimer's disease, multiple sclerosis, amyotrophic lateral sclerosis, spinal cord and traumatic brain injuries, CNS and PNS axon regeneration, and neuropathic pain. While in the past studies have focused on neutrophils deleterious effects, we will highlight new findings about their benefits. Studies on their actions should lead to identification of ways to modify neutrophil effects to improve health.

Comparative Analysis of Hematological and Immunological Parameters in Patients with Primary Sjögren's Syndrome and Peripheral Neuropathy

BACKGROUND

Primary Sjögren syndrome (pSS) is a multisystem disorder of autoimmune etiology, frequently involving peripheral nerves. Early detection of peripheral neuropathy (PN) manifestations might improve prognosis and disease control. The purpose of the study was to evaluate the predictive potential of hematological and immunological parameters associated with PN development in pSS patients.

METHODS

This single-center retrospective study included patients with pSS who were divided into two groups, according to the occurrence of neurological manifestations throughout the follow-up period.

RESULTS

From the total of 121 pSS patients included in the study, 31 (25.61%) developed neurological manifestations (PN+ group) during the follow-up period. At the moment of pSS diagnosis, 80.64% of PN+ patients exhibited increased disease activity, with ESSDAI scores above 14 (p = 0.001), and significantly higher values for VASp score (p = 0.001), with a mean value of 4.90 ± 2.45, compared to 1.27 ± 1.32 in the PN- group. The hematological assessment at the moment of pSS diagnosis revealed that neutrophils and neutrophil-to-lymphocyte ratio (NLR) were significantly higher in the PN+ group (p = 0.001), while lymphocytes, monocytes and monocyte-to-lymphocyte ratio (MLR) were significantly lower (p = 0.025, p = 0.13 and p = 0.003, respectively). Immuno-inflammatory parameters-gammaglobulins, complement fractions C3, C4, total proteins and vitamin D were significantly lower in the PN+ patients' group. In multivariate analysis, the independent predictive character for PN development in pSS patients was confirmed for NLR (95% CI 0.033 to 0.263, p = 0.012), MLR (95% CI -1.289 to -0.194, p = 0.008), gammaglobulins (95% CI -0.426 to -0.088, p < 0.003), complement fraction C4 (95% CI -0.018 to -0.001, p < 0.030) and vitamin D (95% CI -0.017 to -0.003, p < 0.009).

CONCLUSIONS

Readily available and frequently used hematological and immunological markers, such as NLR, MLR, gammaglobulins, C4 and vitamin D could be helpful in predicting the neurological involvement in pSS patients. These biological parameters might become useful tools for clinicians to monitor disease progression and identify potentially severe extraglandular manifestations in pSS patients.

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.

Low Lymphocyte-to-Monocyte Ratio as a Possible Predictor of an Unfavourable Clinical Outcome in Patients with Acute Ischemic Stroke after Mechanical Thrombectomy

Background

Although considerable progress has been made in the treatment of acute ischemic stroke (AIS), the clinical outcome of patients is still significantly influenced by the inflammatory response that follows stroke-induced brain injury. The aim of this study was to evaluate the potential use of complete blood count parameters, including indices and ratios, for predicting the clinical outcome in AIS patients undergoing mechanical thrombectomy (MT).

Methods

This single-centre retrospective study is consisted of 179 patients. Patient data including demographic characteristics, risk factors, clinical data, laboratory parameters on admission, and clinical outcome were collected. Based on the clinical outcome assessed at 3 months after MT by the modified Rankin Scale (mRS), patients were divided into two groups: the favourable group (mRS 0-2) and unfavourable group (mRS 3-6). Stepwise multivariate logistic regression analysis was used to detect an independent predictor of the unfavourable clinical outcome.

Results

An unfavourable clinical outcome was detected after 3 months in 101 patients (54.4%). Multivariate logistic regression analysis confirmed that the lymphocyte-to-monocyte ratio (LMR) was an independent predictor of unfavourable clinical outcome at 3 months (odds ratio = 0.761, 95% confidence interval 0.625-0.928, and P = 0.007). The value of 3.27 was chosen to be the optimal cut-off value of LMR. This value could predict the unfavourable clinical outcome with a 74.0% sensitivity and a 54.4% specificity.

Conclusion

The LMR at the time of hospital admission is a predictor of an unfavourable clinical outcome at 3 months in AIS patients after MT.