The association between platelet/lymphocyte ratio, neutrophil/lymphocyte ratio, and carotid artery stenosis and stroke following carotid endarterectomy

The association between neutrophil to lymphocyte ratio and covert brain infarction after carotid endarterectomy: a single center retrospective study

BACKGROUND

Neutrophil to lymphocyte ratio (NLR) is a biomarker which is related with inflammation and atherosclerosis. Higher NLR is associated with vulnerability of carotid atherosclerotic plaques. Covert brain infarction (CBI) following carotid endarterectomy (CEA) indicates poor prognosis in cognization. In this study, we aimed to investigate the relationship between NLR and CBI in patients who accepted CEA.

METHODS

In this observational and retrospective cohort study, 333 patients who underwent CEA due to severe carotid artery stenosis were enrolled. NLR was acquired from routine blood tests upon admission. Postoperative CBI was detected on magnetic resonance imaging. Logistic regression analysis was used to examine the association between NLR and CBI.

RESULTS

Patients with CBI had higher NLR (CBI patients: 2.45[1.76-3.58] vs. non-CBI patients: 2.31[1.82-2.88]; P = 0.05). NLR is a strong independent factor predicting the risk of CBI following CEA (odds ratio [OR], 1.740; 95% confidence interval [CI]: 1.325-2.286; P < 0.001). Furthermore, the predictive risk value by NLR is not affected by other related factors.

CONCLUSIONS

NLR is associated with the risk of CBI in patients underwent CEA. NLR is a convenient and low-cost biomarker that can be used for risk stratification management of perioperative carotid stenosis patients.

Systemic immune-inflammation index for predicting poor outcome after carotid endarterectomy: A novel hematological marker

OBJECTIVE

To investigate the predictive role of systemic immune-inflammation index (SII) on postoperative poor outcome in patients undergoing carotid endarterectomy (CEA).

METHODS

A total of 347 patients undergoing elective isolated CEA between March 2010 and April 2022 were included in this multicenter retrospective observational cohort and risk-prediction study and were divided into two groups as poor outcome group (n = 23) and favorable outcome group (n = 324). Poor outcome was defined as the presence of at least one of the complications within 30 days of surgery including stroke, myocardial infarction, and death. The patients' baseline clinical characteristics, comorbidities, and hematological indices were derived from the complete blood count (CBC) analysis, and perioperative data, outcomes, and complications were screened, recorded, and then compared between the groups. Multivariate logistic regression and receiver-operating characteristic (ROC) curve analyses were conducted following univariate analyses to detect the independent predictors of poor outcome as well as the cutoff values with sensitivity and specificity rates.

RESULTS

A total of 23 patients out of 347 (6.6%) manifested poor outcome; and stroke, myocardial infarction, and death occurred in 13, 3, and 7 cases, respectively. There were no significant differences between the groups in terms of basic clinical characteristics, comorbidities, and perioperative data, except for lengths of intensive care unit and hospital stays. Although the median values of PLT, PLR, NLR, and SII of the poor outcome group were found to be significantly higher than the favorable outcome group in univariate analysis, only SII was detected to be a significant and independent predictor of poor outcome in multivariate logistic regression analysis (OR = 1.0008; 95% CI: 1.0004-1.0012; p = 0.002). ROC curve analysis revealed that SII of 1356 × 103/mm3 constituted the cutoff value for predicting poor outcome with 78.3% sensitivity and 64.5% specificity (AUC = 0.746; 95% CI: 0.64-0.851).

CONCLUSIONS

Our study revealed for the first time in the literature that SII significantly predicted poor outcome after CEA.

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

Background

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

Methods

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

Results

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

Conclusion

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

Association between platelet lymphocyte ratio and neutrophil lymphocyte ratio and clinical outcomes following carotid endarterectomy

Background

Approximately 30% of stroke cases result from carotid disease. Although several risk factors for complications after carotid endarterectomy have been identified, the existence of a biomarker that can estimate postoperative risk in these patients has not yet been proven.

Objectives

This study aimed to investigate correlations between the platelet-lymphocyte ratio (PLR) and the neutrophil-lymphocyte ratio (NLR) and postoperative clinical outcomes in patients undergoing carotid endarterectomy.

Methods

A retrospective study was conducted, including 374 patients who underwent carotid endarterectomy between 2002 and 2019 due to moderate to high extracranial internal carotid artery stenosis. Their platelet-lymphocyte ratio and neutrophil-lymphocyte ratios were obtained from the same blood samples.

Results

There was a statistically significant correlation between the PLR and the occurrence of restenosis (p < 0.01) and acute myocardial infarction (AMI) after endarterectomy (p = 0.03). Additionally, there was a statistically significant correlation between the PLR and the combined outcomes stroke and/or AMI and/or death (p = 0.03) and stroke and/or AMI and/or death and/or restenosis (p < 0.01). However, there were no significant correlations between NLR and these outcomes (p = 0.05, p = 0.16).

Conclusions

The platelet-lymphocyte ratio proved to be a useful test for predicting occurrence of strokes, acute myocardial infarctions, and deaths during the postoperative period after carotid endarterectomy. It was also associated with the risk of postoperative restenosis.

Carotid Plaque Features and Inflammatory Biomarkers as Predictors of Restenosis and Mortality Following Carotid Endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is the first-line surgical intervention for cases of severe carotid stenoses. Unfortunately, the restenosis rate is high after CEA. This study aims to demonstrate the predictive role of carotid plaque features and inflammatory biomarkers (monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), Systemic Inflammation Response Index (SIRI), and Aggregate Index of Systemic Inflammation (AISI)) in carotid restenosis and mortality at 12 months following CEA.

METHODS

The present study was designed as an observational, analytical, retrospective cohort study and included all patients over 18 years of age with a minimum of 70% carotid stenosis and surgical indications for CEA admitted to the Vascular Surgery Clinic, Emergency County Hospital of Targu Mures, Romania between 2018 and 2021.

RESULTS

According to our results, the high pre-operative values of inflammatory biomarkers-MLR (OR: 10.37 and OR: 6.11; p < 0.001), NLR (OR: 34.22 and OR: 37.62; p < 0.001), PLR (OR: 12.02 and OR: 16.06; p < 0.001), SII (OR: 18.11 and OR: 31.70; p < 0.001), SIRI (OR: 16.64 and OR: 9.89; p < 0.001), and AISI (OR: 16.80 and OR: 8.24; p < 0.001)-are strong independent factors predicting the risk of 12-month restenosis and mortality following CEA. Moreover, unstable plaque (OR: 2.83, p < 0.001 and OR: 2.40, p = 0.04) and MI (OR: 3.16, p < 0.001 and OR: 2.83, p = 0.005) were independent predictors of all outcomes. Furthermore, AH (OR: 2.30; p = 0.006), AF (OR: 1.74; p = 0.02), tobacco (OR: 2.25; p < 0.001), obesity (OR: 1.90; p = 0.02), and thrombotic plaques (OR: 2.77; p < 0.001) were all independent predictors of restenosis, but not for mortality in all patients. In contrast, antiplatelet (OR: 0.46; p = 0.004), statin (OR: 0.59; p = 0.04), and ezetimibe (OR:0.45; p = 0.03) therapy were protective factors against restenosis, but not for mortality.

CONCLUSIONS

Our data revealed that higher preoperative inflammatory biomarker values highly predict 12-month restenosis and mortality following CEA. Furthermore, age above 70, unstable plaque, cardiovascular disease, and dyslipidemia were risk factors for all outcomes. Additionally, AH, AF, smoking, and obesity were all independent predictors of restenosis but not of mortality in all patients. Antiplatelet and statin medication, on the other hand, were protective against restenosis but not against mortality.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Predictive Value of Complete Blood Count-Derived Inflammatory Markers for 5-Year Survival After Carotid Endarterectomy: Implications for Practice

Complete blood count inflammatory markers (CBC-IMs) have been associated with cardiovascular diseases and mortality. We aimed to evaluate the relationship between preoperative CBC-IMs and 5-year survival after carotid endarterectomy (CEA). Retrospective analysis of 411 consecutive patients who underwent CEA between 2004 and 2018 was done. CBC-IM included the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte (LMR) ratio, and systemic immune-inflammation index (SII). Survival rate at 5 years was 79.8%. Age (hazard ratio (HR) = 1.05, P = .003), hemoglobin (HR = 0.78, P < .001), heart failure (HR = 2.91, P = .005), American Society of Anesthesiologists (ASA)-IV score (HR = 2.41, P = .043), and active neoplastic disease (HR = 2.61, P = .028) were independently related to survival. The discrimination of this model (C-statistic) was 0.698. Spline analysis showed a linear relationship between survival and NLR (P < .001), PLR (P < .001), and SII (P < .001). After adjusting for the baseline predictive score, there was a significant relationship between survival and NLR (HR = 1.191, P = .001), PLR (HR = 1.004, P = .017), and SII (HR = 1.001, P < .001). The addition of NLR, PLR, and SII to the survival model improved the continuous net reclassification index (c-NRI) by 0.29 (P = .028), 0.347 (P = .008), and 0.481 (P < .001), respectively, but not the C-statistic. CBC-IMs show a linear and independent relationship with 5-year survival after CEA and may moderately contribute to patient selection for this preventive intervention.

Blood Cell Count Indexes of Systemic Inflammation in Carotid Artery Disease: Current Evidence and Future Perspectives

Carotid artery disease is commonly encountered in clinical practice and accounts for approximately 30% of ischemic strokes in the general population. Numerous biomarkers have been investigated as predictors of the onset and progression of carotid disease, the occurrence of cerebrovascular complications, and overall prognosis. Among them, blood cell count (BCC) indexes of systemic inflammation might be particularly useful, from a pathophysiological and clinical point of view, given the inflammatory nature of the atherosclerotic process. The aim of this review is to discuss the available evidence regarding the role of common BCC indexes, such as the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV), platelet distribution width (PDW), and red cell distribution width (RDW), in the diagnosis and risk stratification of carotid artery disease, and their potential clinical applications.

Circulatory markers of immunity and carotid atherosclerotic plaque

BACKGROUND AND AIMS

We aimed to determine the association of circulatory markers of innate and adaptive immunity with carotid atherosclerotic plaque characteristics.

METHODS

In 1602 participants from the population-based Rotterdam Study with subclinicalcarotid atherosclerosis, blood sampling was performed to determine granulocyte, platelet, monocyte (innate immunity) and lymphocyte (adaptive immunity) counts, from which the granulocyte-to-lymphocyte ratio [GLR], platelet-to-lymphocyte ratio [PLR], monocyte-to-lymphocyte ratio [MLR] and systemic immune-inflammation index [SII] were calculated. All participants underwent carotid MRI for evaluation of plaque characteristics. Plaque size (stenosis >30%, maximum plaque thickness) and plaque composition (presence of intraplaque hemorrhage [IPH], lipid-rich necrotic core [LRNC], and calcification) were assessed. Using linear and logistic regression models, the association of innate and adaptive immunity markers with plaque size and plaque components, adjusting for relevant confounders, was assessed.

RESULTS

Higher levels of granulocytes were significantly associated with larger plaque thickness (mean difference [Ln (mm)] per Ln increase granulocyte count [95% CI]: 0.06 [0.02; 0.10]). Conversely, more lymphocytes related with smaller maximum plaque thickness (mean difference [Ln (mm)] per Ln increase lymphocyte count: 0.09 [-0.14;-0.04]) and a lower prevalence of IPH (odds ratio per Ln increase lymphocyte count: 0.60 [0.37; 0.97]). Moreover, all ratio measures were associated with larger plaque thickness, of which the MLR also associated with more frequent LRNC (odds ratio per Ln increase MLR: 1.26 [1.02; 1.56]).

CONCLUSIONS

The innate immunity links to larger plaques, whilst the adaptive immunity seems to relate to smaller plaques and a lower frequency of IPH. These results suggest that an imbalance in innate and adaptive immunity may play a role in the vulnerability of carotid atherosclerotic plaques.

Association of Inflammatory Markers with Multisite Artery Disease in Patients with Peripheral Arterial Disease

INTRODUCTION

Chronic inflammation plays a considerable role in atherosclerosis and may occur simultaneously in different arteries. This condition is referred to as multisite arterial disease (MSAD). We aimed to investigate the association between inflammatory markers and MSAD.

METHODS

In this cross-sectional study we included 526 patients with peripheral artery disease (PAD). Patients with PAD were evaluated by conventional or computed tomography angiography for the presence of coronary artery disease (CAD) and those with at least 30% stenosis were included in the study. Patients were divided into two groups: either MSAD+(PAD and CAD), Group 1) or MSAD- (only PAD without CAD, Group 2). Inflammatory markers were compared between the two groups.

RESULTS

Among all patients, 293 had MSAD while 233 had only PAD. The MSAD+group had higher neutrophil-to-lymphocyte ratio (NLR) and platelet-to-neutrophil ratio (PLR) (5.08±0.19, 4.67±0.51, and 207.1±6.23, 169.3±10.8, respectively, p<0.001). In multivariate analysis, HT [odds ratio (OR): 2.40 (1.61-3.59)); p<0.002], male gender [OR: 2.03 (1.29-3.17); p=0.002], DM [OR:1.56 (1.03-2.36); P=0.035], NLR [OR: 1,08 (1.02-1.16); p=0.021, and PLR [OR:1.05 (1.03-1.08); p<0.001] were found to be associated with MSAD.

CONCLUSION

NLR and PLR are correlated with MSAD and may indicate the extent of atherosclerosis.

Prognostic value of systemic immune-inflammation index in acute/subacute patients with cerebral venous sinus thrombosis

Objective

To evaluate the prognosis values of systemic immune–inflammation index (SII) in non-chronic cerebral venous sinus thrombosis (CVST).

Methods

patients with CVST, admitted to the First Affiliated Hospital of Zhengzhou University, were retrospectively identified from January 2013 to December 2018. We selected patients in acute/subacute phase from database. Functional outcomes of patients were evaluated with the modified Rankin Scale (mRS)—mRS 3–6 as poor outcomes and mRS 6 as death. The overall survival time was defined as the date of onset to the date of death or last follow-up date. Survival analysis was described by the Kaplan-Meier curve and Cox regression analysis. Multivariate logistic regression analysis assessed the relationship between SII and poor functional outcome. The area under the Receiver Operating Curve curve (AUC) was estimated to evaluate the ability of SII in prediction.

Results

A total of 270 patients were included and their duration of follow-up was 22 months (6–66 months), of whom 31 patients had poor outcomes and 24 patients dead. Cox regression analysis showed that SII (HR=1.304, 95% CI: 1.101 to 1.703, p=0.001) was a predictor of death in non-chronic CVST. Patients with higher SII presented lower survival rates (p=0.003). The AUC of SII was 0.792 (95% CI: 0.695 to 0.888, p=0.040) with a sensitivity of 69.6% and specificity of 80.1%. Subgroups analysis demonstrated that SII was an important predictor of poor outcomes in male (OR=1.303, 95% CI: 1.102 to 1.501, p=0.011) and pregnancy/puerperium female (OR=1.407, 95% CI: 1.204 to 1.703, p=0.034).

Conclusions

SII was a potential predictor in the poor prognosis of patients with acute/subacute CVST, especially in male and pregnancy/puerperium female.

Higher Platelet-to-Lymphocyte Ratio Is Associated With Worse Outcomes After Intravenous Thrombolysis in Acute Ischaemic Stroke

Objective: The platelet-to-lymphocyte ratio (PLR) is a new marker of atherosclerotic inflammation and has been identified as a predictive factor in cardiovascular diseases, but its significance in patients with acute ischaemic stroke (AIS) who have undergone intravenous thrombolysis (IVT) is still unknown.

Methods: Consecutive patients who were treated with IVT using recombinant tissue plasminogen activator (rtPA) for AIS were included from May 2012 to August 2018. The PLR was calculated according to platelet and lymphocyte counts within 24 h after thrombolysis therapy. Functional outcomes were assessed by the modified Rankin Scale (mRS) at 3 months after thrombolysis. Stroke severity was assessed by National Institutes of Health Stroke Scale (NIHSS) scores. The primary endpoint was an unfavorable outcome (mRS > 2), and the secondary endpoint was death at 3 months.

Results: A total of 286 patients were included in the study. The median age was 69.5 (59.0–80.0) years, and 59.1% of patients were men. A total of 120 (42.0%) patients had an unfavorable outcome, and 38 (13.2%) died. Patients with an unfavorable outcome had significantly higher PLR values compared with those with a favorable outcome [172.5 (105.3–239.0) vs. 139 (97.0–194.5), P = 0.008], and the PLR values of the patients who died at 3 months were higher than those of the surviving patients [189.5 (127.5–289.0) vs. 142.0 (98.0–215.5), P = 0.006]. After adjustment for other variables, the PLR was independently associated with the two endpoints: unfavorable outcome (OR 2.220, 95% CI 1.245–3.957, P = 0.007) and death (OR 2.825, 95% CI 1.050–7.601, P = 0.040) at 3 months after thrombolysis. In addition, PLR was correlated with the NIHSS score (R = 0.230, P < 0.001).

Conclusions: Higher PLR levels were independently associated with an unfavorable outcome and death at 3 months in AIS patients treated with IVT.