Neutrophil-Lymphocyte Ratio and Perihematomal Edema Growth in Intracerebral Hemorrhage

Association Between Neutrophil-Lymphocyte Ratio and 30-Day Infection and Thrombotic Outcomes After Intraventricular Hemorrhage: A CLEAR III Analysis

BACKGROUND

Serum neutrophil-lymphocyte ratio (NLR) is a surrogate marker for the inflammatory response after intracerebral hemorrhage (ICH) and is associated with perihematomal edema and long-term functional outcomes. Whether NLR is associated with short-term ICH complications is poorly understood. We hypothesized that NLR is associated with 30-day infection and thrombotic events after ICH.

METHODS

We performed a post hoc exploratory analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial. The study exposure was the serum NLR obtained at baseline and on days 3 and 5. The coprimary outcomes, ascertained at 30 days, were any infection and a thrombotic event, defined as composite of cerebral infarction, myocardial infarction, or venous thromboembolism; both infection and thrombotic event were determined through adjudicated adverse event reporting. Binary logistic regression was used to study the relationship between NLR and outcomes, after adjustment for demographics, ICH severity and location, and treatment randomization.

RESULTS

Among the 500 patients enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial, we included 303 (60.6%) without missing data on differential white blood cell counts at baseline. There were no differences in demographics, comorbidities, or ICH severity between patients with and without data on NLR. In adjusted logistic regression models, NLR ascertained at baseline (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.07, p = 0.03) and NLR ascertained at day 3 were associated with infection (OR 1.15; 95% CI 1.05-1.20, p = 0.001) but not with thrombotic events. Conversely, NLR at day 5 was associated with thrombotic events (OR 1.07, 95% CI 1.01-1.13, p = 0.03) but not with infection (OR 1.13; 95% CI 0.76-1.70, p = 0.56). NLR at baseline was not associated with either outcome.

CONCLUSIONS

Serum NLR ascertained at baseline and on day 3 after randomization was associated with 30-day infection, whereas NLR obtained on day 5 was associated with thrombotic events after ICH, suggesting that NLR could be a potential early biomarker for ICH-related complications.

Prediction of early neurological deterioration in acute ischemic stroke patients treated with intravenous thrombolysis

A proportion of acute ischemic stroke (AIS) patients suffer from early neurological deterioration (END) within 24 hours following intravenous thrombolysis (IVT), which greatly increases the risk of poor prognosis of these patients. Therefore, we aimed to explore the predictors of early neurological deterioration of ischemic origin (ENDi) in AIS patients after IVT and develop a nomogram prediction model. This study collected 244 AIS patients with post-thrombolysis ENDi as the derivation cohort and 155 patients as the validation cohort. To establish a nomogram prediction model, risk factors were identified by multivariate logistic regression analysis. The results showed that neutrophil to lymphocyte ratio (NLR) (OR 2.616, 95% CI 1.640-4.175, P < 0.001), mean platelet volume (MPV) (OR 3.334, 95% CI 1.351-8.299, P = 0.009), body mass index (BMI) (OR 1.979, 95% CI 1.285-3.048, P = 0.002) and atrial fibrillation (AF) (OR 8.012, 95% CI 1.341-47.873, P = 0.023) were significantly associated with ENDi. The area under the curve of the prediction model constructed from the above four factors was 0.981 (95% CI 0.961-1.000) and the calibration curve was close to the ideal diagonal line. Therefore, this nomogram prediction model exhibited good discrimination and calibration power and might be a reliable and easy-to-use tool to predict post-thrombolysis ENDi in AIS patients.

Association between circulating inflammatory biomarkers and functional outcome or perihaematomal oedema after ICH: a systematic review & meta-analysis

Background

Currently, there are no specific medical treatments for intracerebral haemorrhage (ICH), but the inflammatory response may provide a potential route to treatment. Given the known effects of acute brain injury on peripheral immunity, we hypothesised that inflammatory biomarkers in peripheral blood may be associated with clinical outcome following ICH, as well as perihaematomal oedema (PHO), which is an imaging marker of the neuroinflammatory response.

Methods

We searched OVID Medline and EMBASE on 07 April 2021 for studies of humans with ICH measuring an inflammatory biomarker in peripheral blood and PHO or clinical outcome. Risk of bias was assessed both by using a scale comprising features of the Newcastle-Ottawa Assessment Scale, STROBE-ME and REMARK guidelines, and for studies included in meta-analysis, also by the QUIPS tool.We used random effects meta-analysis to pool standardised mean differences (SMD) if ≥1 study quantified the association between identical biomarkers and measures of PHO or functional outcome.

Results

Of 8,615 publications, 16 examined associations between 21 inflammatory biomarkers and PHO (n=1,299 participants), and 93 studies examined associations between ≥1 biomarker and clinical outcome (n=17,702 participants). Overall, 20 studies of nine biomarkers (n=3,199) met criteria for meta-analysis of associations between inflammatory biomarkers and clinical outcome. Death or dependency (modified Rankin Scale (mRS) 3‒6) 90 days after ICH was associated with higher levels of fibrinogen (SMD 0.32; 95%CI [0.04, 0.61]; p=0.025), and high mobility group box protein 1 (HMGB1) (SMD 1.67; 95%CI [0.05, 3.30]; p=0.04). Higher WBC was associated with death or dependency at 90 days (pooled SMD 0.27; 95% CI [0.11, 0.44]; p=0.001; but the association was no longer significant when the analysis was restricted to studies with a low risk of bias (pooled SMD 0.22; 95% CI -0.04-0.48). Higher CRP seemed to be associated with death or dependency at 90 days (pooled SMD 0.80; 95% CI [0.44, 1.17]; p<0.0001) but this association was no longer significant when adjusted OR were pooled (OR 0.99 (95% CI 0.98-1.01)).

Conclusions

Higher circulating levels of, fibrinogen and HMGB1 are associated with poorer outcomes after ICH. This study highlights the clinical importance of the inflammatory response to ICH and identifies additional research needs in determining if these associations are mediated via PHO and are potential therapeutic targets.

Registration

PROSPERO ( CRD42019132628; 28/05/2019).

Predictive value of admission red cell distribution width-to-platelet ratio for 30-day death in patients with spontaneous intracerebral hemorrhage: an analysis of the MIMIC database

Aim

Prognostic assessment plays an important role in the effective management of patients with spontaneous intracerebral hemorrhage (ICH). The study aimed to investigate whether elevated red cell distribution width-to-platelet ratio (RPR) at admission was related to 30-day death in patients with spontaneous intracerebral hemorrhage (ICH).

Methods

This retrospective cohort study included 2,823 adult patients with ICH from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC) III and IV databases between 2001 and 2019. The Cox proportional hazard model was utilized to evaluate the relationship between RPR levels and 30-day death risk. The area under receiver-operating characteristic curve (AUC) was used to assess the predictive ability of RPR for 30-day death in patients with ICH.

Results

At the end of the 30-day follow-up, 799 (28.30%) patients died, and the median RPR level was 0.066 (0.053, 0.087). After adjusting for confounders, the tertile 3 of RPR levels [hazard ratio (HR) = 1.37, 95% confidence interval (CI): 1.15-1.64] were associated with a higher risk of 30-day death in patients with ICH compared with tertile 1. In the stratified analyses, elevated RPR levels were found to be associated with an increased risk of 30-day death in patients aged <65 years (HR = 1.77, 95%CI: 1.29-2.43), aged ≥65 years (HR = 1.30, 95%CI: 1.05-1.61), with Glasgow Coma Score (GCS) <14 (HR = 1.65, 95%CI: 1.27-2.14), with Charlson comorbidity index (CCI) ≥4 (HR = 1.45, 95%CI: 1.17-1.80), with (HR = 1.66, 95%CI: 1.13-2.43) or without sepsis (HR = 1.32, 95%CI: 1.08-1.61), and female patients (HR = 1.75, 95%CI: 1.35-2.26) but not in male patients (P = 0.139) and patients with GCS ≥14 (P = 0.058) or CCI <4 (P = 0.188). The AUC for RPR to predict 30-day death in patients with ICH was 0.795 (95%CI: 0.763-0.828) in the testing set, indicating a good predictive ability.

Conclusion

Elevated RPR levels were correlated with an increased risk of 30-day death in patients with ICH, and RPP levels showed good predictive ability for 30-day death.

Blood-Based Biomarkers in Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is one of the most lethal subtypes of stroke, associated with high morbidity and mortality. Prevention of hematoma growth and perihematomal edema expansion are promising therapeutic targets currently under investigation. Despite recent improvements in the management of ICH, the ideal treatments are still to be determined. Early stratification and triage of ICH patients enable the adjustment of the standard of care in keeping with the personalized medicine principles. In recent years, research efforts have been concentrated on the development and validation of blood-based biomarkers. The benefit of looking for blood candidate markers is obvious because of their acceptance in terms of sample collection by the general population compared to any other body fluid. Given their ease of accessibility in clinical practice, blood-based biomarkers have been widely used as potential diagnostic, predictive, and prognostic markers. This review identifies some relevant and potentially promising blood biomarkers for ICH. These blood-based markers are summarized by their roles in clinical practice. Well-designed and large-scale studies are required to validate the use of all these biomarkers in the future.

The effect of neutrophil-to-lymphocyte ratio and systemic inflammatory response on perihematomal edema after intracerebral hemorrhage

BACKGROUND

Perihematomal edema (PHE) is a marker of secondary brain injury in patients with intracerebral hemorrhage (ICH) and is associated with increased inflammatory markers and neurological disability. This study aims to assess the effect of the neutrophile-to-lymphocyte ratio (NLR) and systemic inflammatory response syndrome (SIRS) on PHE measurements and functional status in patients with ICH.

METHODS

We included 215 patients with primary ICH and the primary outcomes were absolute and relative PHE, and edema extension distance (EED). A favorable functional outcome was defined as a modified Rankin Scale (mRS) score 0-2 measured 3 months after ICH.

RESULTS

Median age was 73.0 years (interquartile range 66-80) and 54.4% patients were males. Fifty-nine patients were functionally independent at 90 days (mRS 0 to 2). NLR and SIRS were not predictors of absolute, relative PHE, and EED when adjusted for multiple confounders. However, admission NLR was independently associated with an unfavorable functional outcome at 90 days (aOR = 0.38; 95% CI 0.17-0.87; p = 0.021).

CONCLUSIONS

NLR and SIRS are not independent predictors of absolute and relative PHE measurements following ICH. Nevertheless, NLR predicts long-term disability in ICH patients. Further research is needed to understand the mechanisms by which inflammation causes neurological injury in ICH.

Neutrophil percentage to albumin ratio is associated with stroke-associated pneumonia and poor outcome in patients with spontaneous intracerebral hemorrhage

Background

The purpose of this study was to investigate the diagnostic performance of the neutrophil percentage-to-albumin ratio (NPAR) for predicting stroke-associated pneumonia (SAP) and functional outcome in patients with intracerebral hemorrhage (ICH).

Methods

We analyzed our prospective database of consecutive ICH patients who were admitted to the First Affiliated Hospital of Chongqing Medical University from January 2016 to September 2021. We included subjects with a baseline computed tomography available and a complete NPAR count performed within 6h of onset. The patients' demographic and radiological characteristics were analyzed. Good outcome was defined as a modifed Rankin Scale score of 0-3 at 90 days. Poor outcome was defined as a modifed Rankin Scale score of 4-6 at 90 days. Multivariable logistic regression models were used to investigate the association between NPAR, SAP, and functional outcome. Receiver operating characteristic (ROC) curve analysis was conducted to identify the optimal cutoff of NPAR to discriminate between good and poor outcomes in ICH patients.

Results

A total of 918 patients with ICH confirmed by non-contrast computed tomography were included. Of those, 316 (34.4%) had SAP, and 258 (28.1%) had poor outcomes. Multivariate regression analysis showed that higher NPAR on admission was an independent predictor of SAP (adjusted odds ratio: 2.45; 95% confidence interval, 1.56-3.84; P<0.001) and was associated with increased risk of poor outcome (adjusted odd ratio:1.72; 95% confidence interval, 1.03-2.90; P=0.040) in patients with ICH. In ROC analysis, an NPAR of 2 was identified as the optimal cutoff value to discriminate between good and poor functional outcomes.

Conclusion

Higher NPAR is independently associated with SAP and poor functional outcome in patients with ICH. Our findings suggest that early prediction of SAP is feasible by using a simple biomarker NPAR.

Combination of Hematoma Volume and Perihematoma Radiomics Analysis on Baseline CT Scan Predicts the Growth of Perihematomal Edema

PURPOSE

The aim is to explore the potential value of CT-based radiomics in predicting perihematomal edema (PHE) volumes after acute intracerebral hemorrhage (ICH) from admission to 24 h.

METHODS

A total of 231 patients newly diagnosed with acute ICH at two institutes were analyzed retrospectively. The patients were randomly divided into training (N = 117) and internal validation cohort (N = 45) from institute 1 with a ratio of 7:3. According to radiomics features extracted from baseline CT, the radiomics signatures were constructed. Multiple logistic regression analysis was used for clinical radiological factors and then the nomogram model was generated to predict the extent of PHE according to the optimal radiomics signature and the clinical radiological factors. The receiver operating characteristic (ROC) curve was used to evaluate the discrimination performance. The calibration curve and Hosmer-Lemeshow test were used to evaluate the consistency between the predicted and actual probability. The support vector regression (SVR) model was constructed to predict the overall value of follow-up PHE. The performance of the models was evaluated on the internal and independent validation cohorts.

RESULTS

The perihematoma 5 mm radiomics signature (AUC: 0.875) showed good ability to discriminate the small relative PHE(rPHE) from large rPHE volumes, comparing to intrahematoma radiomics signature (AUC: 0.711) or perihematoma 10 mm radiomics signature (AUC: 0.692) on the training cohort. The AUC of the combined nomogram model was 0.922 for the training cohort, 0.945 and 0.902 for the internal and independent validation cohorts, respectively. The calibration curves and Hosmer-Lemeshow test of the nomogram model suggested that the predictive performance and actual outcome were in favorable agreement. The SVR model also predicted the overall value of follow-up rPHE (root mean squared error, 0.60 and 0.45; Pearson correlation coefficient, 0.73 and 0.68; P < 0.001).

CONCLUSION

Among patients with acute ICH, the established nomogram and SVR model with favorable performance can offer a noninvasive tool for the prediction of PHE after ICH.

Neutrophil/lymphocyte ratio as a predictor of severe postoperative edema and ecchymosis in open rhinoplasty surgery

Purpose: This study investigated the relationship between preoperative neutrophil-to-lymphocyte ratio (NLR) and severe postoperative edema and ecchymosis after open rhinoplasty. Materials and Methods: The study was carried out retrospectively in 165 ASA I-II patients aged 18-45 years who underwent open rhinoplasty in the Department of Plastic and Reconstructive Surgery. The patients were grouped based on their scores on the edema and ecchymosis scales. The degree of edema and ecchymosis was considered “minimal” (Group M) in those scoring 0-2 points and “severe” (Group S) in those scoring 3-4 points. Periorbital edema and ecchymosis of the patients in both groups were scored based on the digital photographs taken on the 1st postoperative day. Results: There was no significant difference in the demographic and clinical characteristics of the patients grouped according to the degree of edema and ecchymosis. The optimal cut-off value of NLR was 2.1 (AUC = 0.747, Sensitivity = 0.666, Specificity = 0.707) for edema and 1.5 (AUC = 0.747, Sensitivity = 0.869, Specificity = 0.470) for ecchymosis. Multivariable analyzes for the development of edema and ecchymosis identified NLR (4.67 [2.38-9.40] and 6.54 [3.02-15.08, respectively) as a statistically significant independent prognostic factor. Conclusion: This study identified preoperative NLR as a predictor value of severe postoperative edema and ecchymosis after open rhinoplasty.

Simvastatin Upregulates Lipoxin A4 and Accelerates Neuroinflammation Resolution After Intracerebral Hemorrhage

BACKGROUND

Previous studies have demonstrated that statins can relieve inflammatory brain injury after intracerebral hemorrhage (ICH), but the mechanisms remain poorly characterized. This study aims to test whether simvastatin exerts an anti-inflammatory effect by regulating the proresolving mediators.

METHODS

First, male Sprague-Dawley rats had an injection of 200 μL autologous blood. Then, rats were randomly divided into groups treated with simvastatin (i.p. 2 mg/kg) or vehicle. Next, all rats underwent pro-resolving mediator lipoxin A4 (LXA4) level detection, flow cytometric, immunofluorescence, brain edema measurement, neurological scoring and western blot analysis.

RESULTS

We found that simvastatin significantly increased the plasma level of LXA4, an endogenous formyl-peptide receptor 2 (FPR2) agonist, in the early stage of ICH. Consistent with the effect of simvastatin, exogenous LXA4 administration also promoted apoptosis of the circulating neutrophils, reduced neutrophils brain infiltration, and ameliorated inflammatory brain injury after ICH. In addition, similar to simvastatin, exogenous LXA4 markedly decreased the level of phosphorylated p38 mitogen-activated protein kinase (MAPK) and the apoptosis-related proteins myeloid cell leukemia 1(Mcl-1)/Bax ratio (a decreased ratio represents the induction of apoptosis) in circulating neutrophils isolated from ICH rats. Notably, all of the aforementioned effects of simvastatin on ICH were significantly abolished by Boc-2, a selective antagonist of FPR2. Moreover, simvastatin led to a similar Mcl-1/Bax ratio reduction as SB203580 (a p38 MAPK inhibitor), but it was abolished by P79350 (a p38 MAPK agonist).

CONCLUSION

Collectively, these results suggest that simvastatin ameliorates ICH-mediated inflammatory brain injury, possibly by upregulating the level of pro-resolving mediator LXA4 and further stimulating the FPR2/p38 MAPK signaling pathway.

Radiomics features from perihematomal edema for prediction of prognosis in the patients with basal ganglia hemorrhage

Objective

We developed and validated a clinical-radiomics nomogram to predict the prognosis of basal ganglia hemorrhage patients.

Methods

Retrospective analyses were conducted in 197 patients with basal ganglia hemorrhage (training cohort: n = 136, test cohort: n = 61) who were admitted to The First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital) and underwent computed tomography (CT) scan. According to different prognoses, patients with basal ganglia hemorrhage were divided into two groups. Independent clinical risk factors were derived with univariate and multivariate regression analysis. Radiomics signatures were obtained using least absolute shrinkage and selection operator. A radiomics score (Rad-score) was generated by 12 radiomics signatures of perihematomal edema (PHE) from CT images that were correlated with the prognosis of basal ganglia hemorrhage patients. A clinical-radiomics nomogram was conducted by combing the Rad-score and clinical risk factors using logistic regression analysis. The prediction performance of the nomogram was tested in the training cohort and verified in the test cohort.

Results

The clinical model conducted by four clinical risk factors and 12 radiomcis features were used to establish the Rad-score. The clinical-radiomics nomogram outperformed the clinical model in the training cohort [area under the curve (AUC), 0.92 vs. 0.85] and the test cohort (AUC, 0.91 vs 0.85). The clinical-radiomics nomogram showed good calibration and clinical benefit in both the training and test cohorts.

Conclusion

Radiomics features of PHE in patients with basal ganglia hemorrhage could contribute to the outcome prediction. The clinical-radiomics nomogram may help first-line clinicians to make individual clinical treatment decisions for patients with basal ganglia hemorrhage.

The correlation of temporal changes of neutrophil-lymphocyte ratio with seizure severity and the following seizure tendency in patients with epilepsy

Background

Changes in the neutrophil-lymphocyte ratio (NLR) has been reported to be associated with epilepsy. Here we aim to investigate the correlation of temporal changes of NLR level with seizure severity and the follow-up seizure attacks in patients with epilepsy (PWE).

Methods

We performed a retrospective analysis of the laboratory data including leukocyte count and NLR within 24 h of acute seizure and during the follow-up period of 5–14 days after acute seizure (NLR1, NLR2, respectively) in 115 PWE, and 98 healthy individuals were included as controls in this study. The correlation of laboratory data with seizure types, etiology of epilepsy, anti-seizure drugs (ASDs), seizure severity, and the follow-up seizure attacks in PWE was studied.

Results

Leukocyte count (P < 0.001) and NLR level (P < 0.001) were found significantly different between PWE and controls. On the other hand, a multivariable logistic regression analysis showed that NLR1 level (OR = 2.992, P = 0.001) and admission leukocyte (OR = 2.307, P = 0.002) were both independently associated with acute epileptic seizures. Especially, higher NLR1 level was significantly associated with status epileptics (P = 0.013) and recurrent seizures after admission (P < 0.001). Furthermore, the multivariable logistic regression analysis indicated that higher NLR1 was a predictor for the tendency of the following recurrent seizure attacks (OR = 1.144, P = 0.002). NLR2 was inversely correlated with ASDs taken (P = 0.011). Levels of NLR1 (r = 0.441, P < 0.001) and NLR2 (r = 0.241, P = 0.009) were both positively correlated with seizure severity.

Conclusions

Seizures were correlated with the alterations of systemic inflammation reflected by leukocyte and NLR. NLR1 and admission leukocyte were both independently associated with acute epileptic seizures. Higher NLR1 was associated with status epilepticus and independently predicted the tendency of the following epileptic seizures. NLR2 was significantly associated with ASDs taken. Besides, NLR may be used as a biomarker for seizure severity.

Neutrophil-lymphocyte ratio as a predictor of outcome following traumatic brain injury: Systematic review and meta-analysis

Objectives

The neutrophil-to-lymphocyte ratio (NLR) is a simple and routinely performed hematological parameter; however, studies on NLR as a prognostic tool in traumatic brain injury (TBI) have yielded contradictory results.

Materials and Methods

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items in the Systematic Review and Meta-Analysis guidelines 2020. Electronic databases of PubMed, Cochrane Library, Web of Science, and Scopus were searched. The population consisted of TBI patients in the absence of moderate and severe extracranial injury. Day 1 NLR was taken for the analysis. The outcomes evaluated were mortality and the Glasgow Outcome Scale (GOS). No restrictions were placed on the language, year and country of publication, and duration of follow-up. Animal studies were excluded from the study. Studies, where inadequate data were reported for the outcomes, were included in the qualitative synthesis but excluded from the quantitative synthesis. Study quality was evaluated using the Newcastle-Ottawa scale (NOS). The risk of bias was estimated using the Cochrane RoBANS risk of bias tool.

Results

We retrieved 7213 citations using the search strategy and 2097 citations were excluded based on the screening of the title and abstract. Full text was retrieved for 40 articles and subjected to the eligibility criteria, of which 28 were excluded from the study. Twelve studies were eligible for the synthesis of the systematic review while seven studies qualified for the meta-analysis. The median score of the articles was 8/9 as per NOS. The risk of selection bias was low in all the studies while the risk of detection bias was high in all except one study. Ten studies were conducted on adult patients, while two studies reported pediatric TBI. A meta-analysis for GOS showed that high NLR predicted unfavorable outcomes at ≥6 months with a mean difference of -5.18 (95% confidence interval: -10.04, -0.32); P = 0.04; heterogeneity (I2), being 98%. The effect estimates for NLR and mortality were a mean difference of -3.22 (95% confidence interval: -7.12, 0.68), P = 0.11, and an I2 of 85%. Meta-analysis for Area under the curve (AUC) receiver operating characteristic of the included studies showed good predictive power of NLR in predicting outcomes following TBI with AUC 0.706 (95% CI: 0.582-0.829).

Conclusion

A higher admission NLR predicts an increased mortality risk and unfavorable outcomes following TBI. However, future research will likely address the existing gaps.

Changes in Cerebral Blood Flow and Diffusion-Weighted Imaging Lesions After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a common subtype of stroke and places a great burden on the family and society with a high mortality and disability rate and a poor prognosis. Many findings from imaging and pathologic studies have suggested that cerebral ischemic lesions visualized on diffusion-weighted imaging (DWI) in patients with ICH are not rare and are generally considered to be associated with poor outcome, increased risk of recurrent (ischemic and hemorrhagic) stroke, cognitive impairment, and death. In this review, we describe the changes in cerebral blood flow (CBF) and DWI lesions after ICH and discuss the risk factors and possible mechanisms related to the occurrence of DWI lesions, such as cerebral microangiopathy, cerebral atherosclerosis, aggressive early blood pressure lowering, hyperglycemia, and inflammatory response. We also point out that a better understanding of cerebral DWI lesions will be a key step toward potential therapeutic interventions to improve long-term recovery for patients with ICH.

Molecular, Pathological, Clinical, and Therapeutic Aspects of Perihematomal Edema in Different Stages of Intracerebral Hemorrhage

Acute intracerebral hemorrhage (ICH) is a devastating type of stroke worldwide. Neuronal destruction involved in the brain damage process caused by ICH includes a primary injury formed by the mass effect of the hematoma and a secondary injury induced by the degradation products of a blood clot. Additionally, factors in the coagulation cascade and complement activation process also contribute to secondary brain injury by promoting the disruption of the blood-brain barrier and neuronal cell degeneration by enhancing the inflammatory response, oxidative stress, etc. Although treatment options for direct damage are limited, various strategies have been proposed to treat secondary injury post-ICH. Perihematomal edema (PHE) is a potential surrogate marker for secondary injury and may contribute to poor outcomes after ICH. Therefore, it is essential to investigate the underlying pathological mechanism, evolution, and potential therapeutic strategies to treat PHE. Here, we review the pathophysiology and imaging characteristics of PHE at different stages after acute ICH. As illustrated in preclinical and clinical studies, we discussed the merits and limitations of varying PHE quantification protocols, including absolute PHE volume, relative PHE volume, and extension distance calculated with images and other techniques. Importantly, this review summarizes the factors that affect PHE by focusing on traditional variables, the cerebral venous drainage system, and the brain lymphatic drainage system. Finally, to facilitate translational research, we analyze why the relationship between PHE and the functional outcome of ICH is currently controversial. We also emphasize promising therapeutic approaches that modulate multiple targets to alleviate PHE and promote neurologic recovery after acute ICH.

Preoperative neutrophil-to-lymphocyte ratio (preNLR) for the assessment of tumor characteristics in lung adenocarcinoma patients with brain metastasis

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A relationship between preoperative Neutrophil-to-Lymphocyte ratio (preNLR) and brain metastasis characteristics such as tumor location and peritumoral brain edema is proposed.

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The corresponding spearman correlations of peritumoral brain edema and preoperative NLR between different tumor location was performed.

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A prognostic nomogram, that provide survival predictions for brain metastasis on lung adenocarcinoma (LUAD) patients has been established.

Objectives

Brain metastases from lung adenocarcinoma cause significant patient mortality. This study aims to evaluate the role of preoperative Neutrophil-to-Lymphocyte ratio (preNLR) in predicting the survival and prognosis of Lung adenocarcinoma (LUAD) patients with brain metastasis (BM) and provide more references for predicting peritumoral edema.

Methods

We retrospectively reviewed 125 LUAD-BM patients who had undergone surgical resection from December 2015 to December 2020. The clinical characteristic, demographic, MRI data, and preNLR within 24–48 h before craniotomy were collected. Patients were divided into two groups based on preNLR (high NLR and low NLR), with cutoff values determined by receiver operating characteristic (ROC) analysis. Association between preoperative NLR and clinical features was determined by using Pearson chi-squared tests. Uni- and multivariate analyzes were performed to compare the overall survival (OS) of clinical features.

Results

The patients were divided into NLR-low (64 patients) and NLR-high (61 patients) groups based on receiver operating characteristic analysis of NLR area. According to correlation analysis, a high preNLR (NLR≥2.8) is associated with the both supra- and infratentorial location involved (P = 0.017) and a greater incidence of severe peritumoral edema (P = 0.038). By multivariable analysis, age ≥ 65 years (P = 0.011), KPS < 70 (P = 0.043), elevated preNLR (P = 0.013), extracerebral metastases (P = 0.003), EGFR/ALK+ (P = 0.037), postoperative radiotherapy (P = 0.017) and targeted therapy (P = 0.007) were independent prognostic factors. OS nomogram was constructed based on cox model and model performance was examined (AUC = 0.935).

Conclusions

PreNLR may serve as a prognosis indicator in LUAD patients with brain metastasis, and high preNLR tends to be positively associate with multiple locations and severe peritumoral edema.

The effectiveness of ARISCAT Risk Index, other scoring systems, and parameters in predicting pulmonary complications after thoracic surgery

The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) risk index, which is frequently used in nonthoracic surgery, may not be sufficient to predict postoperative pulmonary complications (PPCs). We aimed to evaluate the effectiveness of the ARISCAT risk index, ASA, preoperative albumin level, neutrophil/lymphocyte ratio (NLR), and other parameters in predicting PPCs after thoracic surgery. Patients undergoing elective thoracic surgery with 1-lung ventilation (OLV) were prospectively analyzed. Demographic data, ARISCAT score, ASA, Nutritional Risk Score-2002, NLR, white blood cell counts, albumin, hemoglobin levels, intraoperative complications, postoperative average visual analogue scale (VAS) score for pain at the 24th-hour, the length of stay in the postoperative intensive care unit, chest tube removal time, postoperative complications, and discharge time were recorded. Patients were assessed for morbidity and mortality on the 90th-day. 120 patients' data were analyzed. PPCs developed in 26 patients. The development of PPCs was statistically significant in patients with high ARISCAT scores (P = .002), high ARISCAT grades (P = .009), and ASA III (P = .002). The albumin level was statistically significantly lower in patients who had mortality within 3 months (P = .007). When scoring systems and laboratory parameters were evaluated together, patients with high ARISCAT grade, Albumin < 35g/L, and ASA III had significantly higher development of PPCs (P = .004). ARISCAT risk index and ASA were found to be significant in predicting PPCs after thoracic surgery. They were also valuable when evaluated in combination with preoperative albumin levels. Additionally; age, male gender, duration of surgery, and duration of OLV were also found to be associated with PPCs.

Comparing hematoma characteristics in primary intracerebral hemorrhage versus intracerebral hemorrhage caused by structural vascular lesions

Intracerebral hemorrhage (ICH) caused by structural vascular lesions is associated with better outcomes than primary ICH, but this relationship is poorly understood. We tested the hypothesis that ICH from a vascular lesion has more benign hematoma characteristics compared to primary ICH. We performed a retrospective study using data from our medical center. The SMASH-U criteria were used to adjudicate the etiology of ICH. The co-primary outcomes were admission parenchymal hematoma volume and hematoma expansion at 24 h. Linear and logistic regression analyses were performed to test associations. A total of 231 patients were included of whom 42 (18%) had a vascular lesion. Compared to primary ICH patients, those with structural vascular lesions were younger (49 vs. 68 years, p < 0.001), less likely to have hypertension (29% vs. 74%, p < 0.001), had lower mean admission systolic blood pressure (140 ± 23 vs. 164 ± 35, p < 0.001), less frequently had IVH (26% vs. 44%, p = 0.03), and had mostly lobar or infratentorial hemorrhages. The median admission hematoma volume was smaller with vascular lesions (5.9 vs. 9.7 mL, p = 0.01). In regression models, ICH from a vascular lesion was associated with smaller admission hematoma volume (beta, -0.67, 95% CI, -1.29 to -0.05, p = 0.03), but no association with hematoma expansion was detected when assessed as a continuous (OR, 0.93; 95% CI, -4.46 to 6.30, p = 0.73) or dichotomous exposure (OR, 1.86; 95% CI, 0.40 to 8.51, p = 0.42). In a single-center cohort, patients with ICH from vascular lesions had smaller hematoma volumes than patients with primary ICH.

Baseline neutrophil-lymphocyte ratio can be associated with hematoma expansion in patients with intracerebral hemorrhage: a retrospective observational study

Background

Hematoma expansion can be related to increased mortality and poor clinical outcomes in patients with intracerebral hemorrhage (ICH). So, early identification and prevention of hematoma expansion can be considered as an important therapeutic aim. This study aimed to evaluate the hypothesis that the neutrophil to lymphocyte ratio (NLR) is associated with hematoma expansion in ICH patients.

Methods

We retrospectively evaluated the clinical data of a total of 221 patients with ICH who were treated in our department between April 2018 and April 2021. The demographic, clinical, radiological, and laboratory test data including the NLR upon admission were investigated. A binary logistic regression analysis was used to assess the independent associations between different variables and hematoma expansion.

Results

A total of 221 patients with ICH were included. There were 122 (55.2%) males and 99 (44.8%) females. The mean age (years) at admission was 66.43 ± 8.28.

The hematoma expansion occurred in 57 (25.8%) cases. The results of the multivariate analysis showed that hematoma volume at baseline (OR, 3.12; 95% CI 1.78–5.02; P < 0.001), admission systolic blood pressure (OR, 2.87; 95% CI 1.79–4.34; P = 0.013), Glasgow Coma Scale (GCS) (OR, 1.94; 95% CI 1.45–2.93; P = 0.020), and NLR (OR, 1.74; 95% CI 1.16–2.60; P = 0.032) were correlated with hematoma expansion in these patients.

Conclusions

Our findings suggest that NLR can be a predictor of hematoma expansion in patients with ICH. This cost-effective and easily available biomarker could be used to early prediction of hematoma expansion in these patients.

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.

Credibility of the Neutrophil-to-Lymphocyte Count Ratio in Severe Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality worldwide. The consequences of a TBI generate the activation and accumulation of inflammatory cells. The peak number of neutrophils entering into an injured brain is observed after 24 h; however, cells infiltrate within 5 min of closed brain injury. Neutrophils release toxic molecules including free radicals, proinflammatory cytokines, and proteases that advance secondary damage. Regulatory T cells impair T cell infiltration into the central nervous system and elevate reactive astrogliosis and interferon-γ gene expression, probably inducing the process of healing. Therefore, the neutrophil-to-lymphocyte ratio (NLR) may be a low-cost, objective, and available predictor of inflammation as well as a marker of secondary injury associated with neutrophil activation. Recent studies have documented that an NLR value on admission might be effective for predicting outcome and mortality in severe brain injury patients.

Early neutrophil-to-lymphocyte ratio is a prognostic marker in acute minor stroke or transient ischemic attack

Intravenous injection of alteplase is recommended for patients with minor disabling and not non-disabling ischemic stroke symptoms within 4.5 h of ischemic stroke symptom onset. However, it is hard for clinicians to distinguish which type of minor ischemic stroke is disabled at an early stage. In this study, we aimed to demonstrate early neutrophil-to-lymphocyte ratio is a prognostic marker in acute minor stroke or transient ischemic attack. 196 patients diagnosed with acute minor stroke or transient ischemic attack within 24 h of symptom onset were enrolled. Patients were divided into three groups according to the neutrophil-to-lymphocyte ratio value (< 2, 2-3, > 3). Clinical, neuroradiological, laboratory and follow-up data were collected from electronic database. Functional outcome was assessed by modified Rankin Scale. Neutrophil-to-lymphocyte ratio associated with functional outcome of 90 days was evaluated by logistic regression analysis, and we used receiver operating characteristic curve analysis to detect the overall predictive accuracy of this marker. Early neutrophil-to-lymphocyte ratio was associated with an increased risk of short-term functional outcome (OR 4.502, 95% CI 1.533-13.046, P = 0.006). The optimal cutoff value of neutrophil-to-lymphocyte ratio for prediction of short-term unfavorable outcome was 2.94 with a sensitivity of 69.6% and a specificity of 77.1% (area under the curve: 0.767, 95% CI 0.691-0.843). Early neutrophil-to-lymphocyte ratio is associated with short-term unfavorable functional outcome in patients with acute minor stroke or transient ischemic attack. Early neutrophil-to-lymphocyte ratio is beneficial for clinicians to distinguish minor disabling ischemic stroke at an early stage.

Perihematomal Edema After Intracerebral Hemorrhage: An Update on Pathogenesis, Risk Factors, and Therapeutic Advances

Intracerebral hemorrhage (ICH) has one of the worst prognoses among patients with stroke. Surgical measures have been adopted to relieve the mass effect of the hematoma, and developing targeted therapy against secondary brain injury (SBI) after ICH is equally essential. Numerous preclinical and clinical studies have demonstrated that perihematomal edema (PHE) is a quantifiable marker of SBI after ICH and is associated with a poor prognosis. Thus, PHE has been considered a promising therapeutic target for ICH. However, the findings derived from existing studies on PHE are disparate and unclear. Therefore, it is necessary to classify, compare, and summarize the existing studies on PHE. In this review, we describe the growth characteristics and relevant underlying mechanism of PHE, analyze the contributions of different risk factors to PHE, present the potential impact of PHE on patient outcomes, and discuss the currently available therapeutic strategies.

Central Nervous System Tissue Regeneration after Intracerebral Hemorrhage: The Next Frontier

Despite marked advances in surgical techniques and understanding of secondary brain injury mechanisms, the prognosis of intracerebral hemorrhage (ICH) remains devastating. Harnessing and promoting the regenerative potential of the central nervous system may improve the outcomes of patients with hemorrhagic stroke, but approaches are still in their infancy. In this review, we discuss the regenerative phenomena occurring in animal models and human ICH, provide results related to cellular and molecular mechanisms of the repair process including by microglia, and review potential methods to promote tissue regeneration in ICH. We aim to stimulate research involving tissue restoration after ICH.

CSF and serum inflammatory response and association with outcomes in spontaneous intracerebral hemorrhage with intraventricular extension: an analysis of the CLEAR-III Trial

Background

Intracerebral hemorrhage (ICH) results in a cascade of inflammatory cell activation with recruitment of peripheral leukocytes to the brain parenchyma and surrounding the hematoma. We hypothesized that in patients with ICH and intraventricular hemorrhage (IVH), a robust cerebrospinal fluid (CSF) inflammatory response occurs with leukocyte subtypes being affected by alteplase treatment and contributing to outcomes.

Methods

Serum and CSF cell counts from patients in the phase 3 Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III) trial were analyzed. CSF leukocytes were corrected for the presence of red blood cells. Trends in cell counts were plotted chronologically. Associations were evaluated between serum and CSF leukocyte subtypes and adjudicated functional outcome (modified Rankin Scale; mRS) at 30 and 180 days and bacterial infection according to treatment with intraventricular alteplase versus saline.

Results

A total of 279 and 292 patients had ≥3 differential cell counts from serum and CSF, respectively. CSF leukocyte subtypes evolved during IVH resolution with a significantly augmented inflammatory response for all subtypes in alteplase- compared to saline-treated patients. CSF leukocyte subtypes were not associated with detrimental effect on functional outcomes in the full cohort, but all were associated with poor 30-day outcome in saline-treated patients with IVH volume ≥20 mL. Higher serum lymphocytes were associated with good functional outcomes (mRS 0–3) in the entire cohort and saline-treated but not alteplase-treated group. Conversely, increased serum neutrophil-to-lymphocyte ratio (NLR) in the entire cohort and saline group was associated with worse functional outcomes. Higher median serum lymphocytes were associated with the absence of infection at 7 days.

Conclusions

Aseptic CSF inflammation after IVH involves all leukocyte subtypes. Serum lymphocytes may be associated with better outcomes by mitigating infection. Alteplase augments the inflammatory response without affecting outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-021-02224-w.

Early Predictors of the Increase in Perihematomal Edema Volume After Intracerebral Hemorrhage: A Retrospective Analysis From the Risa-MIS-ICH Study

Background and Purpose: Perihematomal edema (PHE) is associated with poor functional outcomes after intracerebral hemorrhage (ICH). Early identification of risk factors associated with PHE growth may allow for targeted therapeutic interventions. Methods: We used data contained in the risk stratification and minimally invasive surgery in acute intracerebral hemorrhage (Risa-MIS-ICH) patients: a prospective multicenter cohort study. Patients' clinical, laboratory, and radiological data within 24 h of admission were obtained from their medical records. The absolute increase in PHE volume from baseline to day 3 was defined as iPHE volume. Poor outcome was defined as modified Rankin Scale (mRS) of 4 to 6 at 90 days. Binary logistic regression was used to assess the relationship between iPHE volume and poor outcome. The receiver operating characteristic curve was used to find the best cutoff. Linear regression was used to identify variables associated with iPHE volume (ClinicalTrials.gov Identifier: NCT03862729). Results: One hundred ninety-seven patients were included in this study. iPHE volume was significantly associated with poor outcome [P = 0.003, odds ratio (OR) 1.049, 95% confidence interval (CI) 1.016-1.082] after adjustment for hematoma volume. The best cutoff point of iPHE volume was 7.98 mL with a specificity of 71.4% and a sensitivity of 47.5%. Diabetes mellitus (P = 0.043, β = 7.66 95% CI 0.26-15.07), black hole sign (P = 0.002, β = 18.93 95% CI 6.84-31.02), and initial ICH volume (P = 0.018, β = 0.20 95% CI 0.03-0.37) were significantly associated with iPHE volume. After adjusting for hematoma expansion, the black hole sign could still independently predict the increase of PHE (P < 0.001, β = 21.62 95% CI 10.10-33.15). Conclusions: An increase of PHE volume >7.98 mL from baseline to day 3 may lead to poor outcome. Patients with diabetes mellitus, black hole sign, and large initial hematoma volume result in more PHE growth, which should garner attention in the treatment.

Brain injury instructs bone marrow cellular lineage destination to reduce neuroinflammation

Acute brain injury mobilizes circulating leukocytes to transmigrate into the perivascular space and brain parenchyma. This process amplifies neural injury. Bone marrow hematopoiesis replenishes the exhausted peripheral leukocyte pools. However, it is not known whether brain injury influences the development of bone marrow lineages and how altered hematopoietic cell lineages affect neurological outcome. Here, we showed that bone marrow hematopoietic stem cells (HSCs) can be swiftly skewed toward the myeloid lineage in patients with intracerebral hemorrhage (ICH) and experimental ICH models. Lineage tracing revealed a predominantly augmented hematopoiesis of Ly6C^low monocytes infiltrating the ICH brain, where they generated alternatively activated macrophages and suppressed neuroinflammation and brain injury. The ICH brain uses β3-adrenergic innervation that involves cell division cycle 42 to promote bone marrow hematopoiesis of Ly6C^low monocytes, which could be further potentiated by the U.S. Food and Drug Administration-approved β3-adrenergic agonist mirabegron. Our results suggest that brain injury modulates HSC lineage development to curb distal brain inflammation, implicating the bone marrow as a unique niche for self-protective neuroimmune interaction that might be exploited to obtain therapeutic effects.

Neutrophil Counts as Promising Marker for Predicting In-Hospital Mortality in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND AND PURPOSE

Systemic inflammation is recognized as a hallmark of stroke. We aimed to evaluate the prognostic value of various inflammatory factors using blood at admission in patients with aneurysmal subarachnoid hemorrhage.

METHODS

In a multicenter observational study of patients with aneurysmal subarachnoid hemorrhage, the counts of neutrophil, platelet, and lymphocyte were collected on admission. Patients were stratified based on neutrophil counts with propensity score matching to minimize confounding. We calculated the adjusted odds ratios with 95% CIs for the primary outcome of in-hospital mortality and hospital-acquired infections.

RESULTS

A total of 6041 patients were included in this study and 344(5.7%) of them died in hospital. Propensity score matching analyses indicated that compared with the lower neutrophil counts, higher neutrophil counts were associated with increased risk of in-hospital mortality (odds ratio, 1.53 [95% CI, 1.14-2.06]), hospital-acquired infections (odds ratio, 1.61 [95% CI, 1.38-1.79]), and delayed neurological ischemic deficits (odds ratio, 1.52 [95% CI, 1.09-1.97]). Moreover, out of all the inflammatory factors studied, neutrophil counts demonstrated the highest correlation with in-hospital mortality and hospital-acquired infections.

CONCLUSIONS

Among patients with aneurysmal subarachnoid hemorrhage, high neutrophil counts at admission were associated with increased mortality and hospital-acquired infections. The neutrophil count is a simple, useful marker with prognostic value in patients with aneurysmal subarachnoid hemorrhage.

Systemic Inflammatory Response Syndrome is Associated with Hematoma Expansion in Intracerebral Hemorrhage

OBJECTIVES

Systemic inflammatory response syndrome (SIRS) and hematoma expansion are independently associated with worse outcomes after intracerebral hemorrhage (ICH), but the relationship between SIRS and hematoma expansion remains unclear.

MATERIALS AND METHODS

We performed a retrospective review of patients admitted to our hospital from 2013 to 2020 with primary spontaneous ICH with at least two head CTs within the first 24 hours. The relationship between SIRS and hematoma expansion, defined as ≥6 mL or ≥33% growth between the first and second scan, was assessed using univariable and multivariable regression analysis. We assessed the relationship of hematoma expansion and SIRS on discharge mRS using mediation analysis.

RESULTS

Of 149 patients with ICH, 83 (56%; mean age 67±16; 41% female) met inclusion criteria. Of those, 44 (53%) had SIRS. Admission systolic blood pressure (SBP), temperature, antiplatelet use, platelet count, initial hematoma volume and rates of infection did not differ between groups (all p>0.05). Hematoma expansion occurred in 15/83 (18%) patients, 12 (80%) of whom also had SIRS. SIRS was significantly associated with hematoma expansion (OR 4.5, 95% CI 1.16 - 17.39, p= 0.02) on univariable analysis. The association remained statistically significant after adjusting for admission SBP and initial hematoma volume (OR 5.72, 95% CI 1.40 - 23.41, p= 0.02). There was a significant indirect effect of SIRS on discharge mRS through hematoma expansion. A significantly greater percentage of patients with SIRS had mRS 4-6 at discharge (59 vs 33%, p=0.02).

CONCLUSION

SIRS is associated with hematoma expansion of ICH within the first 24 hours, and hematoma expansion mediates the effect of SIRS on poor outcome.

The Role of the Blood Neutrophil-to-Lymphocyte Ratio in Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is an important type of stroke with the highest rates of mortality and disability. Recent evidence indicates that neuroinflammation plays a critical role in both early brain injury and delayed neural deterioration after aSAH, contributing to unfavorable outcomes. The neutrophil-to-lymphocyte ratio (NLR) is a peripheral biomarker that conveys information about the inflammatory burden in terms of both innate and adaptive immunity. This review summarizes relevant studies that associate the NLR with aSAH to evaluate whether the NLR can predict outcomes and serve as an effective biomarker for clinical management. We found that increased NLR is valuable in predicting the clinical outcome of aSAH patients and is related to the risk of complications such as delayed cerebral ischemia (DCI) or rebleeding. Combined with other indicators, the NLR provides improved accuracy for predicting prognosis to stratify patients into different risk categories. The underlying pathophysiology is highlighted to identify new potential targets for neuroprotection and to develop novel therapeutic strategies.

Systemic inflammation status at admission affects the outcome of intracerebral hemorrhage by increasing perihematomal edema but not the hematoma growth

Acute stress and inflammation responses are associated with worse outcomes in intracerebral hemorrhage (ICH) but the precise mechanisms involved are unclear. We evaluated the effect of neutrophil-to-lymphocyte ratio (NLR) in ICH outcome, with focus on hematoma expansion and early cerebral edema. In a retrospective study, we included all patients with primary ICH admitted to our center within 24-h from symptom onset from January 2014 to February 2015. We retrieved demographic and medical history data, Glasgow Coma Scale scores, blood cell counts, glucose, and C-reactive protein, and calculated NLR. We obtained hematoma volumes by computerized planimetry. Outcomes included independence at 90 days (modified Rankin scale 0-2), mortality at 30 days, significant hematoma expansion (> 33% or > 6 mL) and early cerebral edema causing significant midline shift (> 2.5 mm) at 24 h. We included 135 patients. NLR independently associated with independence at 90 days (adjusted odds ratio (aOR) 0.79, 95% CI 0.67-0.93, p = 0.006) significant cerebral edema (aOR 1.08, 95%CI 1.01-1.15, p = 0.016) but not hematoma expansion (aOR 0.99, 95%CI 0.94-1.04, p = 0.736). The severity of midline shift was positively correlated with NLR (adjusted beta = 0.08, 95% CI 0.05-0.11, p < 0.001). In ICH, an immediate and intense systemic inflammatory response reduces the likelihood of a better functional outcome at 90 days, which is more likely to be explained by perihematomal edema growth than due to a significant hematoma expansion. These findings could have implications in new treatment strategies and trial designs, which endpoints tend to target exclusively hematoma enlargement.

Intracerebral Hemorrhage and Diabetes Mellitus: Blood-Brain Barrier Disruption, Pathophysiology, and Cognitive Impairments

There is a surge in diabetes incidence with an estimated 463 million individuals been diagnosed worldwide. Diabetes Mellitus (DM) is a major stroke-related comorbid condition that increases the susceptibility of disabling post-stroke outcomes. Although less common, intracerebral hemorrhage (ICH) is the most dramatic subtype of stroke that is associated with higher mortality, particularly in DM population. Previous studies have focused mainly on the impact of DM on ischemic stroke. Few studies have focused on impact of DM on ICH and discussed the blood-brain barrier disruption, brain edema, and hematoma formation. However, more recently, investigating the role of oxidative damage and reactive oxygen species (ROS) production in preclinical studies involving DM-ICH animal models has gained attention. But, little is known about the correlation between neuroinflammatory processes, glial cells activation, and peripheral immune cell invasion with DM-ICH injury. DM and ICH patients experience impaired abilities in multiple cognitive domains by relatively comparable mechanisms, which could get exacerbated in the setting of comorbidities. In this review, we discuss both the pathology of DM as a comorbid condition for ICH and the potential molecular therapeutic targets for the clinical management of the ICH and its recovery.

Clinical application values of neutrophil-to-lymphocyte ratio in intracranial aneurysms

Inflammation plays an important role in the pathogenesis and growth of intracranial aneurysms (IAs). We investigated the clinical value of the neutrophil-to-lymphocyte ratio (NLR) as a marker of systemic subclinical inflammation in patients with IAs.

Consecutive patients with IAs who underwent endovascular treatment (EVT) were enrolled in the study. The evaluation indicators were aneurysm size and rupture, a poor outcome at 3 to 6 months, and delayed cerebral ischemia (DCI) during hospitalization.

In total, 532 patients with IAs underwent EVT (mean age, 54.0 years; 62.4% female). Among patients with ruptured IAs, those with a higher NLR had an increased risk of a poor outcome at 3 to 6 months and DCI during hospitalization than those with a lower NLR. A higher NLR was significantly more strongly associated with the size of unruptured aneurysms and aneurysm rupture than a lower NLR. The NLR and C-reactive protein concentration showed similar predictive ability for aneurysm size and treatment prognosis. The NLR was lower at discharge than admission for patients with ruptured IAs and DCI.

An elevated NLR was significantly associated with the size of unruptured IAs, an increased risk of a poor outcome, and DCI in patients with ruptured IAs.

Neutrophil-to-Lymphocyte Ratio on Admission is an Independent Risk Factor for the Severity of Neurological Impairment at Disease Onset in Patients with a First Episode of Neuromyelitis Optica Spectrum Disorder

PURPOSE

To investigate the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the severity of neurological impairment at disease onset in patients with a first episode of neuromyelitis optica spectrum disorder (NMOSD).

PATIENTS AND METHODS

This retrospective study included 259 patients with newly diagnosed NMOSD who were hospitalized at our institution between January 2013 and January 2020 (NMOSD group) and 169 healthy control subjects who underwent a physical examination at our hospital during the same period (control group). The clinical data collected included general information, past medical history, biochemical test results, imaging findings, NLR, AQP-4 antibody status, and initial Expanded Disability Status Scale score. A logistic regression model was used to analyze NLR as an independent risk factor for the severity of neurological impairment at disease onset in the NMOSD group. Receiver-operating characteristic curve analysis was used to evaluate the ability of the NLR to predict the severity of neurological impairment at disease onset in the NMOSD group and to determine its critical value.

RESULTS

The NLR was significantly higher in the NMOSD group than in the control group (P<0.001). In the NMOSD group, neurological impairment at disease onset was more severe in those with a high NLR than in those with a low NLR (P<0.001). At onset of disease, patients with severe neurological impairment had a more significant increase in NLR than those with mild-to-moderate neurological impairment (P<0.001). Both univariate (OR 1.180, 95% CI 1.046-1.331, P=0.007) and multivariate (OR 1.146, 95% CI 1.003-1.308, P=0.044) logistic regression analyses showed that the NLR was positively correlated with the severity of neurological impairment at onset of disease in the NMOSD group. The area under the receiver-operating characteristic curve was 0.687.

CONCLUSION

The NLR is an independent risk factor for the severity of neurological impairment at disease onset in patients with a first episode of NMOSD.

miR-7-5p Affects Brain Edema After Intracerebral Hemorrhage and Its Possible Mechanism

Objective: To explore the relationship between miR-7-5p and brain edema after intracerebral hemorrhage and the role of butylphthalide (NBP) in brain edema after intracerebral hemorrhage. Method: Routine blood testing, C-reactive protein results, and computed tomography data were collected 1, 7, and 14 days after intracerebral hemorrhage in six patients. Levels of MMP-9, ZO-1, occludin, IL-6, TNF-α, and miR-7-5p were detected in each patient's serum. Sixty male Sprague-Dawley rats were randomly divided into sham operation, intracerebral hemorrhage, and NBP treatment groups. Dry-wet weight was used to assess brain edema, and Evans blue staining was used to assess the permeability of the blood-brain barrier. Expression levels of IL-6, TNF-α, ZO-1 and occludin, PI3K, AKT, p-AKT, AQP4, and miR-7-5p were analyzed in the rat brains. Result: The blood neutrophil-lymphocyte ratio (NLR) on day 1 was associated with the area of brain edema on day 7. The expression of miR-7-5p decreased after intracerebral hemorrhage, and as a result, the inhibition of the PI3K/AKT pathway was weakened. The decreased inhibition of the PI3K/AKT pathway resulted in an increase in AQP4 expression, which further aggravated brain edema. NBP can upregulate the expression of miR-7-5p, affecting these pathways to reduce brain edema. Conclusion: After intracerebral hemorrhage, miR-7-5p expression in brain tissue is reduced, which may increase the expression of AQP4 by activating the PI3K/AKT pathway. NBP can inhibit this process and reduce brain edema.

Potential therapeutic targets for intracerebral hemorrhage-associated inflammation: An update

Intracerebral hemorrhage (ICH) is a subtype of stroke with high mortality and disability but no specific or effective treatment. In the last two decades, much has been learned about the pathologic mechanisms of ICH. It is now known that after ICH onset, immune and inflammatory responses contribute to blood-brain barrier disruption, edema development, and cell death processes, jointly resulting in secondary brain injury. However, the translation of potential therapies from preclinical to clinical success has been disappointing. With the development of new laboratory technology, recent progress has been made in the understanding of ICH pathomechanisms, and promising therapeutic targets have been identified. This review provides an update of recent progress on ICH and describes the prospects for further preclinical studies in this field. Our goal is to discuss new therapeutic targets and directions for the treatment of ICH and promote the effective transformation from preclinical to clinical trials.

Higher Monocyte Count is Associated with 30-Day Case Fatality in Intracerebral Hemorrhage

BACKGROUND

Previous studies have suggested that elevated neutrophils, monocytes, and neutrophil-to-lymphocyte ratio (NLR) may be associated with poor outcomes in intracerebral hemorrhage (ICH). We sought to determine whether white blood cell (WBC) types were independently associated with poor outcome in ICH in a large cohort.

METHODS

We performed a retrospective study of primary ICH at two academic centers. Cases were identified via ICD-9 code and verified via physician review. We included only those patients with WBC types obtained within 24 h of ICH onset.

RESULTS

We identified 593 patients with primary ICH and WBC differentials in the first 24 h. Independent factors (OR, 95% CI) associated with 30-day case fatality were age > 80 (2.4 (1.4, 4.2)), p = 0.0023; NIHSS greater than median (3.9 (2.4, 6.3)), p < 0.0001; ICH volume quartiles (Q1: ref, Q2: 1.5 (0.7, 3.0), Q3: 3.2 (1.6, 6.6), Q4: 11.9 (5.3, 26.4)), p < 0.0001; non-lobar location (3.3 (1.9, 5.9)), p ≤ 0.0001; IVH (2.3 (1.4, 3.6)), p = 0.0005, monocytes greater than median (1.6 (1.0, 2.4)), p = 0.0457, and anticoagulant use (3.2 (1.8, 5.6)), p < 0.0001. Elevated NLR was not associated with higher case fatality.

CONCLUSIONS

We found that elevated monocytes were independently associated with 30-day case fatality. Future studies will investigate whether there are subgroups of ICH patients, including those with particular blood or imaging biomarkers, in which WBC types might help predict poor outcome and provide targets for intervention.

Antihyperthermic treatment decreases perihematomal hypodensity

OBJECTIVE

To investigate the effect on perihematomal hypodensity and outcome of a decrease in body temperature in the first 24 hours in patients with intracerebral hemorrhage (ICH).

METHODS

In this retrospective study on a prospectively registered database, among the 1,100 patients, 795 met all the inclusion criteria. Temperature variations in the first 24 hours and perihematomal hypodensity (PHHD) were recorded. Patients ≥37.5°C were treated with antihyperthermic drugs for at least 48 hours. The main objective was to determine the association among temperature variation, PHHD, and outcome at 3 months.

RESULTS

The decrease in temperature in the first 24 hours increased the possibility of good outcome 11-fold. Temperature decrease, lower PHHD volume, and a good outcome were observed in 31.8% of the patients who received antihyperthermic treatment.

CONCLUSION

The administration of early antihyperthermic treatment in patients with spontaneous ICH with a basal axillary temperature ≥37.5°C resulted in good outcome in a third of the treated patients.

Early elevated neutrophil-to-lymphocyte ratio associated with remote diffusion-weighted imaging lesions in acute intracerebral hemorrhage

AIMS

To explore the relationship between the circulating neutrophil-to-lymphocyte ratio (NLR) and the remote diffusion-weighted imaging lesions (R-DWILs) after spontaneous intracerebral hemorrhage (ICH).

METHODS

Consecutive patients with spontaneous ICH were prospectively collected from November 2016 to May 2018 and retrospectively analyzed. We included subjects who presented within 24 hours after symptom onset and were free of detectable infections on admission or in hospital. Blood samples were obtained at 24-48 hours after ICH ictus, while all complete MRI scans were performed at 5-8 days. R-DWILs were defined as focal hyperintensities remote from the site of the ICH or the peri-hematoma regions. NLR was calculated by dividing the absolute neutrophil counts by the absolute lymphocyte counts. Multivariate binary logistic regression models were generated to evaluate the relationship between NLR and R-DWILs.

RESULTS

One hundred sixty-three subjects met eligibility criteria (age 62.3 ± 13.6 years, 60.7% males), of whom 31(19.0%) experienced R-DWILs. Higher circulating NLR was documented in patients with R-DWILs. With the best cutoff value of 6.01, elevated NLR was independently associated with the presence of R-DWILs (OR = 3.170, 95% CI 1.306-7.697, P = .011) in the bivariate logistic regression analysis with adjustment for age, sex, atrial fibrillation, previous ischemic stroke/TIA, SBP on admission, hematoma volume, and IVH.

CONCLUSIONS

This study provides significant evidence of the association between circulating NLR and R-DWILs in spontaneous ICH patients. Patients with NLR > 6.01 at 24-48 hours after ICH ictus should be paid more attention to when evaluating R-DWILs.

Perihematomal Edema After Intracerebral Hemorrhage in Patients With Active Malignancy

Background and Purpose- Patients with active malignancy are at risk for intracerebral hemorrhage (ICH). We aimed to characterize perihematomal edema (PHE) and hematoma volumes after spontaneous nontraumatic ICH in patients with cancer without central nervous system involvement. Methods- Patients with active malignancy who developed ICH were retrospectively identified through automated searches of institutional databases. Control patients were identified with ICH and without active cancer. Demographic and cancer-specific data were obtained by chart review. Hematoma and PHE volumes were determined using semiautomated methodology. Univariate and multivariate linear regression models were created to assess which variables were associated with hematoma and PHE expansion. Results- Patients with cancer (N=80) and controls (N=136) had similar demographics (all P>0.20), although hypertension was more prevalent among controls (P=0.004). Most patients with cancer had received recent chemotherapy (n=45, 56%) and had recurrence of malignancy (n=43, 54%). Patients with cancer were thrombocytopenic (median platelet count 90 000 [interquartile range, 17 500-211 500]), and most had undergone blood product transfusion (n=41, 51%), predominantly platelets (n=38, 48%). Thirty-day mortality was 36% (n=29). Patients with cancer had significantly increased PHE volumes (23.67 versus 8.61 mL; P=1.88×10^-9) and PHE-to-ICH volume ratios (2.26 versus 0.99; P=2.20×10^-16). In multivariate analyses, variables associated with PHE growth among patients with cancer were ICH volume (β=1.29 [95% CI, 1.58-1.30] P=1.30×10^-5) and platelet transfusion (β=15.67 [95% CI, 3.61-27.74] P=0.014). Variables associated with 30-day mortality were ICH volume (odds ratio, 1.06 [95% CI, 1.03-1.10] P=6.76×10^-5), PHE volume (odds ratio, 1.07 [95% CI, 1.04-1.09] P=7.40×10^-6), PHE growth (odds ratio, 1.05 [95% CI, 1.01-1.10] P=0.01), and platelet transfusion (odds ratio, 1.48 [95% CI, 1.22-1.79] P=0.0001). Conclusions- Patients with active cancer who develop ICH have increased PHE volumes. PHE growth was independent of thrombocytopenia but associated with blood product transfusion. Thirty-day mortality was associated with PHE and ICH volumes and blood product transfusion.

Association between neutrophil to lymphocyte ratio and blood glucose level at admission in patients with spontaneous intracerebral hemorrhage

Previous studies indicated that both inflammatory responses and hyperglycemia are involved in the similar pathophysiological mechanisms after onset of intracerebral hemorrhage (ICH). However the relationship between hyperglycemia and inflammation remains unknown. We aim to evaluate the associations of hyperglycemia with inflammation and neutrophil to lymphocyte ratio (NLR) in patients with ICH. Patients with acute ICH were retrospectively enrolled. Clinical characteristics and imaging features were obtained. The associations between outcome and laboratory biomarkers were assessed by multivariable logistic regression analysis. Spearman analysis and multiple linear regression analysis were performed to estimate the association of NLR and serum glucose. 175 patients were enrolled. Poor outcome occurred in 86 patients at 30 days. Elevated blood glucose level (BGL) and NLR were strongly associated with outcome in patients with ICH. Moreover, combined NLR-BGL exhibited a better predictive accuracy compared with the peripheral leukocyte counts. Furthermore, there was a robust association between BGL and NLR. We first demonstrated both of NLR and BGL were independently associated with each other. Our results indicate that inflammatory responses and the pathological process of hyperglycemia may influence each other by several complex pathological mechanisms and have a mutual promoting effect to secondary brain injury.

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.

The intracerebral hemorrhage blood transcriptome in humans differs from the ischemic stroke and vascular risk factor control blood transcriptomes

Understanding how the blood transcriptome of human intracerebral hemorrhage (ICH) differs from ischemic stroke (IS) and matched controls (CTRL) will improve understanding of immune and coagulation pathways in both disorders. This study examined RNA from 99 human whole-blood samples using GeneChip® HTA 2.0 arrays to assess differentially expressed transcripts of alternatively spliced genes between ICH, IS and CTRL. We used a mixed regression model with FDR-corrected p(Dx) < 0.2 and p < 0.005 and |FC| > 1.2 for individual comparisons. For time-dependent analyses, subjects were divided into four time-points: 0(CTRL), <24 h, 24-48 h, >48 h; 489 transcripts were differentially expressed between ICH and CTRL, and 63 between IS and CTRL. ICH had differentially expressed T-cell receptor and CD36 genes, and iNOS, TLR, macrophage, and T-helper pathways. IS had more non-coding RNA. ICH and IS both had angiogenesis, CTLA4 in T lymphocytes, CD28 in T helper cells, NFAT regulation of immune response, and glucocorticoid receptor signaling pathways. Self-organizing maps revealed 4357 transcripts changing expression over time in ICH, and 1136 in IS. Understanding ICH and IS transcriptomes will be useful for biomarker development, treatment and prevention strategies, and for evaluating how well animal models recapitulate human ICH and IS.

Predictive ability of admission neutrophil to lymphocyte ratio on short-term outcome in patients with spontaneous cerebellar hemorrhage

As one of the prototypical intracranial hemorrhage (ICH), spontaneous cerebellar hemorrhage (SCH) is treated with different strategies by comparing with supratentorial hemorrhage (SH). Additionally, SCH patients usually suffer from worse prognosis than patients with other types of ICH. It is well documented that the unique anatomic structures of posterior cranial fossa lead to a higher risk for brainstem compression and/or brain edema in SCH patients. Recently, neutrophil to lymphocyte ratio (NLR) was reported to possess an excellent predictive ability for the prognosis of patients with ICH, and most of those cases are SH. Thus, the potential association between NLR and the prognosis of SCH patients remains to be elucidated. Here, we aim to assess the predictive role of admission NLR and other available inflammatory parameters for the outcomes of patients with SCH.All patients with acute SCH admitting to West China Hospital from February 2010 to October 2017 were retrospectively enrolled. According to the absolute neutrophil count, absolute lymphocyte count, white blood count and absolute monocyte count extracted from electronic medical records, NLR was calculated. The multivariable logistic regression analysis was applied to analyze the associations between disease outcome and laboratory biomarkers. The comparisons of predictive powers of each biomarker were assessed by receiver operating curves (ROCs). The spearman analyses and multiple linear analyses were also conducted to identify the independent predictors for admission NLR.Admission NLR independently associated with 30-day status (odds ratio [OR] 1.785, 95% confidence interval [CI] 1.463-2.666, P <.01) and exhibited a better predictive value (AUC 0.751, 95% CI 0.659-0.830, P <.001) with the best predictive cutoff point of 7.04 in 62 patients with unfavorable outcomes. Moreover, absolute neutrophil count, absolute lymphocyte count, presence of intraventricular hemorrhage (IVH) and Glasgow coma scale (GCS) score were also correlated with admission NLR, respectively.Admission NLR is a potential marker to independently predict the 30 days functional outcome of SCH patients. Based on our results, systemic inflammation in admission might be considered as an important player in participating the pathological process of patients with SCH.

Systemic inflammation in hemorrhagic strokes - A novel neurological sign and therapeutic target?

Growing evidences suggest that stroke is a systemic disease affecting many organ systems beyond the brain. Stroke-related systemic inflammatory response and immune dysregulations may play an important role in brain injury, recovery, and stroke outcome. The two main phenomena in stroke-related peripheral immune dysregulations are systemic inflammation and post-stroke immunosuppression. There is emerging evidence suggesting that the spleen contracts following ischemic stroke, activates peripheral immune response and this may further potentiate brain injury. Whether similar brain-immune crosstalk occurs in hemorrhagic strokes such as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is not established. In this review, we systematically examined animal and human evidence to date on peripheral immune responses associated with hemorrhagic strokes. Specifically, we reviewed the impact of clinical systemic inflammatory response syndrome (SIRS), inflammation- and immune-associated biomarkers, the brain-spleen interaction, and cellular mediators of peripheral immune responses to ICH and SAH including regulatory T cells (Tregs). While there is growing data suggesting that peripheral immune dysregulation following hemorrhagic strokes may be important in brain injury pathogenesis and outcome, details of this brain-immune system cross-talk remain insufficiently understood. This is an important unmet scientific need that may lead to novel therapeutic strategies in this highly morbid condition.

Perihematomal edema: Implications for intracerebral hemorrhage research and therapeutic advances

In humans, perihematomal edema (PHE) is considered to be a radiological marker of secondary injury following intracerebral hemorrhage (ICH). There is also evidence that PHE might contribute to poor outcome in ICH patients. Given the rising interest in secondary injury after ICH as a therapeutic target, PHE is becoming increasingly used as a proof-of-concept surrogate measure to assess the potential efficacy of various therapeutic interventions in clinical trials. We review the pathophysiology of PHE and its evolution, its prognostic significance and relationship to clinical outcomes, and variabilities in its detection and measurement methodologies to determine the advantages versus shortcomings of using PHE as a translational target or radiological marker to examine the efficacy of interventions aiming to mitigate secondary injury in ICH.

Simvastatin Reduces Neutrophils Infiltration Into Brain Parenchyma After Intracerebral Hemorrhage via Regulating Peripheral Neutrophils Apoptosis

Statins, known for their lipid-lowering effects, also have immunomodulatory properties. This study aims to examine whether systematic simvastatin administration could decrease polymorphonuclear neutrophils (PMNs) infiltration into brain tissue, as well as alleviate neuroinflammation in a rat model of intracerebral hemorrhage (ICH). The ICH model was induced in adult male Sprague-Dawley rats by an injection of autologous blood. Animals randomly received simvastatin (i.p. 2 mg/kg) or vehicle daily from 5 days before ICH until sacrificed. Routine blood counts, brain water content, neurological scoring, immunofluorescence and RT-PCR were conducted to evaluate the anti-inflammatory effect of simvastatin following ICH. Furthermore, flow cytometric and western blotting analysis were implemented for elucidating the mechanisms involved in simvastatin-induced reduction of neutrophil brain-invading. Elevated PMNs count and neutrophil-to-lymphocyte ratio in circulation were detected in rat model of ICH, which was reversed by using simvastatin. Simvastatin effectively alleviated PMNs infiltration and proinflammatory factors release in perihematomal area, as well as attenuated ICH-induced brain edema and neurological deficits. Simvastatin significantly downregulated the expression of antiapoptotic protein-Mcl-1 while increased the level of proapoptotic protein-Bax and cleaved caspase 3 in PMNs. Simvastatin treatment significantly alleviated PMNs brain-infiltrating and subsequent neuroinflammatory reaction after ICH, in part by accelerating peripheral PMNs apoptosis through disorganized the expression of apoptotic related proteins. Our data provided new evidence for simvastatin application on patients with ICH.

Predictive value of lymphocyte to monocyte ratio and monocyte to high-density lipoprotein ratio for acute deep vein thrombosis after total joint arthroplasty: a retrospective study

Background

Deep vein thrombosis (DVT) is one of the most dangerous complications of total joint arthroplasty (TJA). Systemic inflammation has proved to have a great contribution to thrombosis and has been considered as a risk factor for DVT recently. The lymphocyte to monocyte ratio (LMR) and monocyte to high-density lipoprotein (HDL) ratio (MHR) are two biomarkers used widely for systemic inflammation. This study aims to find out the potential predictive value of LMR and MHR for DVT after TJA.

Methods

A total of 853 patients who underwent primary TJA were finally included in this retrospective study. Acute DVT after TJA was evaluated by venography. Preoperative and postoperative LMR and MHR were calculated according to the blood routine test and blood biochemistry test. The association between LMR or MHR and DVT and their predictive value were evaluated by multiple logistic regression analysis and ROC curve respectively.

Results

Totally, 126 patients (14.8%) were diagnosed with DVT by venography. Patients with DVT had a significantly higher level of preoperative MHR (P < 0.001) and postoperative MHR (P < 0.001), along with a significantly lower level of preoperative LMR (P < 0.001) and postoperative LMR (P < 0.001). Multiple logistic regression indicated that BMI (OR = 1.10, P = 0.001), preoperative LMR (OR = 0.72, P<0.001), and postoperative LMR (OR = 0.32, P < 0.001) were independent risk factors for DVT. Besides, BMI (OR = 1.17, P = 0.001), female (OR = 4.6, P = 0.004), preoperative MHR (OR = 10.43, P = 0.008), postoperative Hb (OR = 0.96, P = 0.002), and postoperative LMR were independently associated with symptomatic DVT. The ROC curve suggested that the postoperative LMR had a potential to predict DVT after TJA.

Conclusion

In summary, the present study found out a significant association of perioperative LMR or MHR with DVT after TJA. Moreover, the postoperative LMR had a potential to predict DVT accurately.