Clinical Significance of Baseline Neutrophil-to-Lymphocyte Ratio in Patients With Ischemic Stroke or Hemorrhagic Stroke: An Updated Meta-Analysis

The neutrophil-to-lymphocyte ratio is associated with functional outcome among single small subcortical infarction: Mediating effects of white matter hyperintensities

BACKGROUND

Increasing evidence indicated that neutrophil-to-lymphocyte ratio (NLR) was correlated with unfavorable functional outcome in ischemic stroke. However, limited studies have explored the relationship between NLR and single small subcortical infarction (SSSI). This study aims to investigate the link between NLR and functional outcome in patients with SSSI and assess whether white matter hyperintensities (WMH) mediates the relationship between NLR and unfavorable functional prognosis.

METHODS

This research analyzed data from patients with SSSI in a Chinese cohort study. The primary outcome was unfavorable functional outcome (modified Rankin Scale score of 2-6) at 90 days after ischemic stroke onset, and the secondary outcome was unfavorable functional outcome at discharge. The relationship between NLR and functional outcome was analyzed using restricted cubic spline (RCS) and multivariable logistic regression. A mediation analysis was conducted to examine the link between NLR and unfavorable functional outcome mediated by WMH.

RESULTS

Among the 513 patients with SSSI included in the study, unfavorable functional outcome was seen in 145 (28.3%) patients at the 90-day follow-up and 156 patients (30.4%) at discharge. After controlling for confounding variables, elevated NLR levels were found to be linked with unfavorable functional outcome both at 90 days and at discharge. Mediation analyses indicated that overall WMH significantly mediated the relationship between NLR and unfavorable functional outcome at 90 days and discharge, with mediation proportions of 29.6% and 24.2%, respectively. Periventricular WMH accounted for 36.4% and 32.1% of the mediation effects, respectively.

CONCLUSION

Elevated NLR independently increased the risk of unfavorable functional outcome in individuals with SSSI. In patients with SSSI, WMH partially mediated the relationship between NLR and unfavorable functional outcome.

A Systematic Review on the Role of Neutrophil to Lymphocyte Ratio in Limb Ischemia

BACKGROUND

Limb ischemia is a severe vascular condition that can lead to critical complications, endangering both limbs and lives. The goal of this research was to explore the role of neutrophil to lymphocyte ratio (NLR) in limb ischemia.

METHODS

From inception to June 8, 2022, PubMed/MEDLINE, Institute for Scientific Information Web of Science, and Scopus were searched for articles comparing NLR in limb ischemia to healthy individuals.

RESULTS

Finally, a total of 23 studies were included in the review. There was a direct link between NLR and critical limb ischemia (CLI) development in peripheral arterial disease patients. Elevated NLR levels predict a higher risk of CLI among peripheral arterial disease patients. Also, it was concluded that NLR is a dependable predictor of survival in patients with limb ischemia, and higher NLR readings are linked to decreased survival rates. Moreover, the risk of amputation is related to the level of NLR in CLI patients. However, based on the data, NLR is not a reliable indicator of sarcopenia in CLI patients. More research is needed to determine the relationship between NLR and response to treatment in CLI patients. Also, we recommend investigating the effect of each treatment on NLR level in these patients.

CONCLUSIONS

Our results provide evidence that NLR level is associated with risk of amputation and mortality in patients with limb ischemia. It is a promising biomarker that can be easily incorporated into clinical practice to assist in the prediction and prevention of CLI.

The comparison of the risk of neurological deterioration and clinical outcomes in different atherosclerotic stroke patterns

This study aims to compare the incidences of neurological deterioration (ND) and poor outcome (a modified Ranking scale > 2 points at discharge) among patients with different atherosclerotic stroke patterns. A total of 688 participants were categorized into 4 groups according to atherosclerotic stroke pattern: multiple small infarcts (MSI), single subcortical infarction (SSI), borderzone infarct (BZI) and large infarct groups. Among the 4 groups, MSI group had the lowest incidences of ND and poor outcome (13.5% and 16.2%, respectively). In multivariable analyses, for BZI patients, the risks of ND [odds ratio (OR) = 3.90, 95% confidence interval (CI) = 2.10-7.22, p < 0.001] and poor outcome (OR = 3.45, 95% CI = 1.67-7.14, p = 0.001) both significantly increased compared to MSI, both of which were the highest among the 4 stroke patterns. The neutrophil to lymphocyte ratio in BZI and large infarct groups were higher than in MSI and SSI groups [3.35 (2.28, 5.04) and 3.36 (2.53, 4.94) vs. 2.64 (1.89, 4.06) and 2.71 (1.93, 3.91), p < 0.001]. BZI group had the highest risks of ND and poor outcome among atherosclerotic stroke patients. BZI and large infarct patients had stronger poststroke inflammation than MSI and SSI patients.

Impact of Neutrophil-to-Lymphocyte Ratio on Stroke Severity and Clinical Outcome in Anterior Circulation Large Vessel Occlusion Stroke

Background: The prognostic value of the neutrophil-lymphocyte ratio (NLR) in ischemic stroke remains debated due to cohort variability and treatment heterogeneity across studies. This study evaluates the relationship between admission NLR, stroke severity and 90-day outcomes in patients with anterior circulation large vessel occlusion (LVO) undergoing early, successful revascularization. Methods: A retrospective multicenter study was conducted with 1082 patients treated with mechanical thrombectomy for acute ischemic stroke. The relationship between admission NLR, baseline National Institutes of Health Stroke Scale (NIHSS), 24 h NIHSS and 90-day modified Rankin Scale (mRS) outcomes was analyzed using logistic regression. Results: Admission NLR correlated weakly but significantly with both baseline (p = 0.018) and 24 h (p = 0.005) NIHSS scores, reflecting stroke severity. However, multivariate analysis showed that higher 24 h NIHSS scores (OR 0.831, p = 0.000) and prolonged puncture-to-recanalization times (OR 0.981, p = 0.000) were independent predictors of poor 90-day outcomes, whereas NLR was not (p = 0.557). Conclusions: Admission NLR is associated with stroke severity but does not independently predict clinical outcomes at 90 days in patients achieving early and successful revascularization. These findings underscore the critical role of inflammation in the acute phase of stroke but suggest that its prognostic value for long-term outcomes is limited in this context.

Diagnostic Value of Inflammatory Biomarkers in Intracranial Venous Thrombosis: A Multi-model Predictive Analysis

OBJECTIVE

Cerebral venous thrombosis (CVT) is a rare but significant condition, primarily affecting young adults, especially women. The diagnosis of CVT is challenging due to its nonspecific clinical presentation. Inflammatory biomarkers, such as the systemic immune-inflammatory index (SII), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR), may aid in early diagnosis. This study aimed to explore the role of these biomarkers and assess machine learning models for improving diagnostic accuracy.

METHODS

This study included 100 CVT patients and 50 controls. Data collected included demographic information, biochemical markers, and clinical symptoms. Traditional statistical methods and machine learning models, including decision trees, random forests, AdaBoost, k-nearest neighbors, support vector machines (SVM), and artificial neural networks (ANN), were used to evaluate the diagnostic value of biomarkers.

RESULTS

The SII and NLR levels were significantly higher in CVT patients. The ANN model based on SII and PLR achieved the best diagnostic performance, with an area under the curve (AUC) of 0.94, showing high accuracy and reliability.

CONCLUSION

Inflammatory biomarkers, particularly SII, have significant predictive value in CVT diagnosis. Machine learning models, especially ANN, show promise in improving diagnostic accuracy. Future studies with larger sample sizes are needed to validate these findings further.

Prediction of the outcome of intracerebral hemorrhage by blood neutrophil to lymphocyte ratio: a prospective observational study

Introduction

Intracerebral haemorrhage (ICH) is defined as bleeding within the brain parenchyma. Neutrophil lymphocyte ratio (NLR) is a dynamic parameter that can be affected by an underlying condition like microangiopathy (e.g. hemorrhagic stroke). The NLR value at the time of stress (e.g. ICH) could be a predictor among various other factors on the outcome of the disease. The aim of this study is to see if NLR could be a predictor of the outcome of the ICH.

Methods

This is a prospective observational study conducted in the Department of Neurosurgery and Department of Neurology, from March 2020 to February 2021. The ICH cases presented to the emergency department within 24 h of symptoms were included. The baseline haematological and biochemical investigations were sent and the noncontrast computed tomography (NCCT) head was done for the diagnosis of ICH. The NLR was measured. The ICH volume was calculated by ABC/2. Follow-up of the patient to measure outcome was done with a modified Rankin scale (mRS) on 30 days. Student's t-test was used to correlate NLR-mRS. Fischer's exact test was used for a categorical association of NLR to mRS.

Results

A total of 89 patients with ICH were enrolled in this study. In this study, 62.92% of patients had good outcomes (NLR of 4.88±3.06), whereas 37.08% of patients had bad outcomes (NLR of 9.09± 4.92). Statistically, higher NLR was significantly predictive of poorer outcomes.

Conclusions

ICH causes stress in the body, which alters the value of NLR. Components of NLR are altered after haemorrhage due to a change in homeostasis of brain parenchyma. The NLR value obtained at the time of emergency department visits may help to predict the 30 days outcome of ICH.

Value of the red blood cell distribution width (RDW) and neutrophil lymphocyte ratio (NLR) in the prediction of functional recovery and 3-month mortality following endovascular treatment for acute anterior circulation ischemic stroke

Objectives

The red blood cell distribution width (RDW) and neutrophil to lymphocyte ratio (NLR) have been linked to poor prognosis in patients with ischaemic stroke. However, no study has yet evaluated the prognostic role of RDW and NLR, or their combined effect on reperfusion in patients with endovascularly-treated acute ischaemic stroke. This study therefore aimed to analyse the impact of RDW and NLR on poor functional outcomes and failed reperfusion following endovascular treatment in patients with acute anterior circulation ischaemic stroke.

Methods

A total of 275 patients with acute anterior circulation ischaemic stroke treated endovascularly between 2015 and 2018 were enrolled in this study. The relationships between RDW, NLR, and poor outcomes were analysed using univariate and multivariate logistic regression models and receiver operating characteristic (ROC) curve analysis. The Youden Index was applied to determine the cut-off value.

Results

Multivariate logistic regression analysis identified RDW (p = 0.015) and NLR (p = 0.015) as independent predictors of mortality at the 3rd month. ROC curve analysis of RDW revealed a cutoff value of 14.25 (p = 0.009) for poor clinical outcomes (modified Rankin scale [mRS] 3-6). Similarly, a cutoff value of 14.25 was found for mortality prediction (p = 0.003). The cutoff value for poor clinical outcome (mRS 3-6) in the NLR was determined as 5.93 (p = 0.003), whereas the cutoff value for mortality was set at 5.17 (p = 0.028). RDW also predicted failed reperfusion, with a cutoff value of 17.75 (p = 0.048).

Conclusions

High RDW and NLR upon admission were identified as independent indicators of mortality in endovascularly treated acute anterior circulation ischemic stroke patients. Furthermore, the RDW could potentially predict failed reperfusion.

Neutrophil to lymphocyte ratio and five-year mortality in patients with acute ischemic stroke

Background

Previous studies linked neutrophil to lymphocyte ratio (NLR) with short-term mortality after acute ischemic stroke (AIS), but its relationship with long-term mortality remains unclear. This study investigates the association between NLR and five-year mortality in AIS patients.

Method

We analyzed 416 AIS patients from April 2012 to January 2016 at Zhangjiagang TCM Hospital. Admission NLR was divided into quartiles: Q1 (<2.00), Q2 (2.00-3.05), Q3 (3.06-5.46), and Q4 (≥5.46). We assessed 5-year all-cause and vascular mortality using Kaplan-Meier, Cox regression, and receiver operating characteristic (ROC) curve analyses.

Results

Over five years, 134 (32.2 %) all-cause deaths and 114 (27.4 %) vascular deaths occurred. Elevated NLR was significantly associated with increased risks of all-cause and vascular mortality. Multivariate Cox analysis identified stroke history (HR: 1.57, 95 % CI 1.08-2.30), baseline National Institutes of Health Stroke Scale (NIHSS) score (HR: 1.09, 95 % CI 1.05-1.12), and NLR (HR: 1.09, 95 % CI 1.05-1.12) as independent risk factors for all-cause mortality. These factors also predicted 5-year vascular mortality: stroke history (HR: 1.65, 95 % CI 1.10-2.49), NIHSS score (HR: 1.10, 95 % CI 1.06-1.13), and NLR (HR: 1.08, 95 % CI 1.05-1.10). NLR quartiles were significantly linked to both outcomes: all-cause mortality HRs were Q2 (1.87, 95 % CI 1.00-3.51), Q3 (2.40, 95 % CI 1.31-4.39), Q4 (2.77, 95 % CI 1.47-5.24), P for trend = 0.001; vascular mortality HRs were Q2 (1.76, 95 % CI 0.88-3.55), Q3 (2.34, 95 % CI 1.14-4.40), Q4 (2.57, 95 % CI 1.28-5.16), P for trend = 0.002. Kaplan-Meier survival analysis revealed significantly higher mortality rates in higher NLR quartiles (log-rank p < 0.001). ROC analysis identified optimal NLR cutoff values of 3.42 for predicting 5-year all-cause mortality (AUC 0.689) and 3.51 for vascular-cause mortality (AUC 0.700), with moderate sensitivity and specificity.

Conclusions

Higher NLR at admission was linked with five-year all-cause mortality and mortality attributed explicitly to vascular causes in AIS patients.

Evaluation of Naples Score for Long-Term Mortality in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

The Naples score (NS), which is a composite of cardiovascular adverse event predictors including neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, albumin, and total cholesterol, has emerged as a prognostic risk score in cancer patients. We aimed to investigate the predictive value of NS for long-term mortality in ST-segment elevation myocardial infarction patients (STEMI). A total of 1889 STEMI patients were enrolled in this study. The median duration of the study was 43 months (IQR: 32-78). Patients were divided into 2 groups according to NS as group 1 and group 2. We created 3 models as a baseline model, model 1 (baseline + NS in continuous), and model 2 (baseline + NS as categorical). Group 2 patients had higher long-term mortality rates than group 1 patients. The NS was independently associated with long-term mortality and adding NS to a baseline model improved the model performance for prediction and discrimination of long-term mortality. Decision curve analysis demonstrated that model 1 had a better net benefit probability for detecting mortality compared with the baseline model. NS had the highest contributive significant effect in the prediction model. An easily accessible and calculable NS might be used for risk stratification of long-term mortality in STEMI patients undergoing primary percutaneous coronary intervention.

Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, Systemic Immune Inflammation Index and Efficacy of Remote Ischemic Conditioning in Acute Ischemic Stroke: A Post Hoc Exploratory Analysis of the RICAMIS Study

Background

We conducted a post-hoc analysis of the RICAMIS trial to investigate the effect of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune inflammation index (SII) on the efficacy of remote ischemic conditioning treatment.

Methods

In this post-hoc analysis, NLR, PLR, and SII were measured before randomization. Patients were divided into two groups based on their cut-off values: high vs low NLR, high vs low PLR, and high vs low SII groups. Each group was further subdivided into RIC and control groups. The primary endpoint was a poor outcome (mRS 2-6 at 90 days). Differences in the primary endpoint between the RIC and control subgroups were compared, and the interactions of treatment assignment with NLR, PLR, and SII were evaluated.

Results

A total of 1679 patients were included in the final analysis. Compared with the control group, RIC significantly improved functional outcomes regardless of the inflammation status. The improved probability of poor outcome in the RIC vs control group was numerically greater in the high vs low inflammation group (NLR, 7.8% vs 5.1%; PLR, 7% vs 6.5%; SII, 9% vs 5.3%). However, we did not find an interaction effect of an intervention (RIC or control) with different NLR, PLR, or SII on clinical outcomes (P > 0.05). In addition, the NLR and SII were independently associated with functional outcomes in all patients, regardless of whether they received RIC.

Conclusion

Inflammation may not affect the efficacy of RIC in patients with acute moderate ischemic stroke, although a lower probability of poor outcome at 90 days was identified in patients with a high vs low inflammatory status.

Coronary heart disease increases the risk of perioperative ischemic stroke after noncardiac surgery: A retrospective cohort study

OBJECTIVE

To investigate the association between coronary heart disease (CHD) and the risk of perioperative ischemic stroke in patients undergoing noncardiac surgery.

METHODS

This retrospective study evaluated the incidence of ischemic stroke within 30 days after a noncardiac surgery. A cohort of 221,541 patients who underwent noncardiac surgery between January 2008 and August 2019 was segregated according to whether they were diagnosed with CHD. Primary, sensitivity, and subgroup logistic regression analyses were conducted to confirm that CHD is an independent risk factor for perioperative ischemic stroke. Propensity score matching analysis was used to account for the potential residual confounding effect of covariates.

RESULTS

Among the 221,541 included patients undergoing noncardiac surgery, 484 patients (0.22%) experienced perioperative ischemic stroke. The risk of perioperative ischemic stroke was higher in patients with CHD (0.7%) compared to patients without CHD (0.2%), and multivariate logistic regression analysis showed that CHD was associated with a significantly increased risk of perioperative ischemic stroke (odds ratio (OR), 3.7943; 95% confidence interval (CI) 2.865-4.934; p < 0.001). In a subset of patients selected by propensity score matching (PSM) in which all covariates between the two groups were well balanced, the association between CHD and increased risk of perioperative ischemic stroke remained significantly significant (OR 1.8150; 95% CI, 1.254-2.619; p = 0.001). In the subgroup analysis stratified by age, preoperative β-blockers, and fibrinogen-to-albumin ratio (FAR), the association between CHD and perioperative ischemic stroke was stable (p for interaction >0.05). Subgroup analyses also showed that CHD was significantly increased the risk of perioperative ischemic stroke in the preoperative mean arterial pressure (MAP) ≥94.2 mmHg subgroups (p for interaction <0.001).

CONCLUSION

CHD is significantly associated with an increased risk of perioperative ischemic stroke and is an independent risk factor for perioperative ischemic stroke after noncardiac surgery. Strict control of preoperative blood pressure may reduce the risk of perioperative ischemic stroke for patients with CHD undergoing noncardiac surgery.

Association of early seizures after ischemic stroke with diffusion-weighted imaging-alberta stroke program early CT score (DWI-ASPECTS) and neutrophil-to-lymphocyte ratio

BACKGROUND

Post-stroke seizure (PSS) is a common considerable complication of acute ischemic stroke (AIS). Early risk assessment can clinical practitioners to plan effective prevention and management. We aimed to determine whether assessing Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS), and neutrophil indices allows for identifying patients at risk of PSS.

METHODS

This prospective study included AIS patients with cortical involvement admitted to a single academic center between January 2020 to October 2023. For all included subjects, DWI-Brain MRI, blood neutrophils, and platelet counts were obtained and the DWI-ASPECTS score was calculated. Then, the patients were followed up for 6 months in terms of PSS occurrence. Based on the occurrence of PSS, patients were divided into two groups of PSS and non-PSS. For analysis, imaging and laboratory data were compared between two groups. Logistic regression was applied to determine the relationship between DWI-ASPECTS and neutrophil indices, with early PSS. Finally, the sensitivity and specificity of these variables for PSS were estimated.

RESULTS

A total of 309 were included in the final statistical analysis. DWI-ASPECT and neutrophil-to-lymphocyte ratio (NLR) were significantly associated with early PSS with OR of 0.74 and OR of 1.13, respectively (P < 0.05). Further analysis showed that, a combination of DWI-ASPECTS, NLR had an area under the curve (AUC) of 0.72 for predicting the occurrence of early PSS.

CONCLUSION

DWI-ASPECTS and NLR are associated with the occurrence of early PSS after cortical ischemic stroke. A combination of these predictors had higher sensitivity and specificity for PSS rather than each factor alone. These findings may be helpful for determining the risk of PSS if validated in future studies.

The prognostic value of combined uric acid and neutrophil-to-lymphocyte ratio in acute ischemic stroke patients treated with intravenous thrombolysis

BACKGROUND

Serum uric acid (UA) and the neutrophil-to-lymphocyte ratio (NLR) have been reported to be associated with outcomes in acute ischemic stroke (AIS). However, whether UA is related to the prognosis of AIS patients undergoing intravenous thrombolysis (IVT) remains inconclusive. We sought to explore the combined effect of UA and NLR on the prognosis of AIS treated with IVT.

METHODS

A total of 555 AIS patients receiving IVT treatment were enrolled. Patients were categorized into four groups according to the levels of UA and NLR: LNNU (low NLR and normal UA), LNHU (low NLR and high UA), HNNU (high NLR and normal UA), and HNHU (high NLR and high UA). Multivariable logistic regression analysis was used to evaluate the value of serum UA level and NLR in predicting prognosis. The primary outcomes were major disability (modified Rankin scale (mRS) score 3-5) and death within 3 months.

RESULTS

After multivariate adjustment, a high NLR (≥ 3.94) increased the risk of 3-month death or major disability (OR, 2.23; 95% CI, 1.42 to 3.55, p < 0.001). However, there was no statistically significant association between a high UA level (≥ 313.00 µmol/L) and clinical outcome. HNHU was associated with a 5.09-fold increase in the risk of death (OR, 5.09; 95% CI, 1.31-19.83; P value = 0.019) and a 1.98-fold increase in the risk of major disability (OR, 1.98; 95% CI 1.07-3.68; P value = 0.030) in comparison to LNNU.

CONCLUSIONS

High serum UA levels combined with high NLR were independently associated with 3-month death and major disability in AIS patients after IVT.

The Role of Neutrophils in Multiple Sclerosis and Ischemic Stroke

Inflammation plays an important role in numerous central nervous system (CNS) disorders. Its role is ambiguous-it can induce detrimental effects, as well as repair and recovery. In response to injury or infection, resident CNS cells secrete numerous factors that alter blood-brain barrier (BBB) function and recruit immune cells into the brain, like neutrophils. Their role in the pathophysiology of CNS diseases, like multiple sclerosis (MS) and stroke, is highly recognized. Neutrophils alter BBB permeability and attract other immune cells into the CNS. Previously, neutrophils were considered a homogenous population. Nowadays, it is known that various subtypes of these cells exist, which reveal proinflammatory or immunosuppressive functions. The primary goal of this review was to discuss the current knowledge regarding the important role of neutrophils in MS and stroke development and progression. As the pathogenesis of these two disorders is completely different, it gives the opportunity to get insight into diverse mechanisms of neutrophil involvement in brain pathology. Our understanding of the role of neutrophils in CNS diseases is still evolving as new aspects of their activity are being unraveled. Neutrophil plasticity adds another level to their functional complexity and their importance for CNS pathophysiology.

How well does peripheral blood neutrophil-to-lymphocyte ratio predict the severity and prognosis of hemorrhagic Stroke

OBJECTIVE

We explored the blood neutrophil-to-lymphocyte ratio (NLR) as a prognostic marker and its relation with mortality and Modified Rankin Scale (mRS) score at discharge and at 3 months following ICH and also compared NLR with intracerebral hemorrhage (ICH) score, Sequential Organ Failure Assessment (SOFA) score and National Institutes of Health Stroke Scale (NIHSS) score.

METHODS

The investigators calculated the NIHSS score, SOFA score, ICH score and NLR of 90 adult patients within 3 days of onset of stroke with evidence of hemorrhagic stroke in brain imaging and correlated it with in-hospital mortality, 3-month mortality and mRS at 3 months following stroke using regression analysis.

RESULTS

Out of 90 individuals, there were 54 (60%) males and 36 (40%) females. The mRS score at 3 months significantly related to the admission NLR ratio >7 and SOFA score. Similarly, the in-hospital death and 3-month mortality was related to the admission NLR ratio >7 and ICH score. However, at a cut off value of NLR>3 for assessing the prognosis of the patients, we did not get significant results for mRS at 3 months following stroke and for in-hospital and 3-month mortality.

CONCLUSION

A high NLR ratio >7 predicted worse outcomes in terms of mortality and morbidity at 3-months following haemorrhagic stroke. Hence, like ICH score, NLR can predict 3-month mortality following an acute haemorrhagic stroke and can also predict morbidity following 3 months of brain haemorrhage.

Peripheral blood cell count ratios as a predictor of poor functional outcome in patients with acute ischemic stroke

BACKGROUND AND AIMS

Acute ischemic stroke (AIS) is a leading cause of death and long-term disability worldwide. Thromboinflammation plays an important role in the pathophysiology of stroke. The peripheral blood cell count ratios (PBCCR): neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR), are global inflammatory indicators with prognostic value for the clinical outcome after stroke. We aimed to determine the relationship between NLR, PLR, or LMR and the functional outcome three months post-stroke.

METHODS

A prospective, hospital-based study, including 141 participants with AIS, was conducted at a referral stroke center in North-Eastern Bulgaria. The PBCCRs were obtained during the first 24 hours after stroke onset. Stroke severity was measured using the NIHSS scale, and functional outcome was assessed with the modified Rankin Scale (mRS) at discharge and 3 months post-stroke.

RESULTS

We found significantly lower total lymphocyte counts, and higher NLR, PLR, and C-reactive protein in the poor-outcome group (mRS>3) three months post-stroke. A positive correlation was found between the NIHSS score and mRS score on discharge, NLR, and PLR with the worse outcome on the third month. The receiver operating characteristic (ROC) curves showed the predictability of NLR (AUC, 0.626, 95%CI: 0.524-0.724, p = 0.018), and for PLR- (AUC, 0.613, 95%CI: 0.510-0.716, p = 0.031). The optimal cutoff value for NLR was 2.68 (sensitivity 77.8% and specificity 60.4%), and for PLR - 122.6 (sensitivity 77.8% and specificity 61.5%).

CONCLUSION

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are simple, widely available, and cost-effective biomarkers with high prognostic value for the clinical outcome three months post-stroke.

Prognostic Role of Neutrophil to Lymphocyte Ratio in Allergic Rhinitis: A Systematic Review and Meta-analysis

One of the crucial triggers of allergic diseases is an inflammatory reaction and neutrophil to lymphocyte ratio (NLR) is one of the systemic inflammation biomarkers. Our review aimed to evaluate role of NLR in predicting severity and comorbidities of allergic rhinitis (AR). We systematically searched Scopus, Web of Science, and PubMed to find relevant studies. Standardized mean difference (SMD) with a 95% confidence interval (CI) was reported. Due to the high levels of heterogeneity, the random-effects model was used to generate pooled effects. Eleven articles were included in the systematic review, among which ten were included in meta-analysis including 1122 healthy controls and 1423 patients with AR. We found that patients with AR had a significantly higher level of NLR than healthy controls (SMD = 0.19, 95%CI = 0.03-0.36, P = 0.03). In addition, patients with moderate to severe AR had significantly higher levels of NLR compared to those with mild AR (SMD = 0.41, 95%CI = 0.20-0.63, P < 0.001). Interestingly, it was found that NLR could associate with some comorbidities of AR, like asthma. Our results confirmed that NLR could assist clinicians in predicting the severity and comorbidities of AR.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04148-8.

Prognostic performance of neutrophil/lymphocyte ratio and platelet/lymphocyte ratio for mortality in patients with acute stroke

OBJECTIVE

To evaluate the prognostic performance of the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) for mortality in patients with acute stroke treated at a Peruvian hospital.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care hospital.

PATIENTS

Patients aged ≥18 years with a diagnosis of acute stroke and admitted to the hospital from May 2019 to June 2021.

INTERVENTIONS

None.

MAIN VARIABLES OF INTERESTS

Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and mortality.

RESULTS

A total of 165 patients were included. The mean age was 66.1±14.2 years, and 59.4% were male. Only NLR had a performance superior to 0.7 (AUC: 0.75; 95%CI: 0.65-0.85), and its elevated levels were associated with an increased risk of mortality (aRR: 3.66; 95%CI: 1.77-8.85) after adjusting for confounders.

CONCLUSION

The neutrophil-to-lymphocyte ratio has an acceptable prognostic performance for mortality in patients with acute stroke. Its use may be considered to stratify patients' risk and to consider timely alternative care and management.

Neutrophil-to-lymphocyte ratio is associated with stroke progression and functional outcome in patients with ischemic stroke

OBJECTIVE

The objective of the present research was to examine the correlation between the neutrophil-to-lymphocyte ratio (NLR) and stroke progression (SP) as well as the functional outcome following an ischemic stroke (IS).

METHODS

The current study was conducted as prospective observational research. A cohort of 341 participants diagnosed with IS was included in the study from March 2019 to August 2021. This study's primary measure of interest was the occurrence of SP within the initial week following hospital admission. The secondary outcome was functional status 3 months after IS as measured by a modified Rankin scale score. The association between NLR with SP, and poor functional outcomes was examined using multivariate logistic regression. The predictive value of NLR for SP and poor functional outcomes was evaluated using the receiver operating characteristic (ROC) curve.

RESULTS

Among the 341 enrolled patients, 56 (16.4%) had SP, and 285 (83.6%) had no SP. The results of the multivariate logistic regression analysis demonstrated that the existence of diabetes mellitus and the NLR were independently associated with SP and poor functional outcomes. The area under the ROC curve of NLR in predicting poor functional outcome was 0.6117 (95% confidence interval, .5341-.6893, p = .0032), and the optimal cut-off point was 4.2139. The sensitivity and specificity of NLR in predicting poor functional outcomes were 52.7% and 72.0%, respectively.

CONCLUSION

Patients with acute IS exhibited a very high incidence of SP. NLR may be a valuable prognostic indicator in clinical practice because it was independently associated with SP and a poor functional outcome.

The thrombus proteome in stroke reveals a key role of the innate immune system and new insights associated with its etiology, severity, and prognosis

BACKGROUND

Nowadays little is known about the molecular profile of the occluding thrombus of patients with ischemic stroke.

OBJECTIVES

To analyze the proteomic profile of thrombi in patients who experienced an ischemic stroke in order to gain insights into disease pathogenesis.

METHODS

Thrombi from an exploratory cohort of patients who experienced a stroke were obtained by thrombectomy and analyzed by sequential window acquisition of all theoretical spectra-mass spectrometry. Unsupervised k-means clustering analysis was performed to stratify patients who experienced a stroke. The proteomic profile was associated with both the neurological function (National Institute of Health Stroke Scale [NIHSS]) and the cerebral involvement (Alberta Stroke Program Early CT Score [ASPECTS]) prior to thrombectomy and the clinical status of patients at 3 months using the modified Rankin Scale. In an independent cohort of 210 patients who experienced a stroke, the potential role of neutrophils in stroke severity was interrogated.

RESULTS

Proteomic analysis identified 580 proteins in thrombi, which were stratified into 4 groups: hemostasis, proteasome and neurological diseases, structural proteins, and innate immune system and neutrophils. The thrombus proteome identified 3 clusters of patients with distinctive severity, prognosis, and etiology of the stroke. A protein signature clearly distinguished atherothrombotic and cardioembolic strokes. Several proteins were significantly correlated with the severity of the stroke (NIHSS and ASPECTS). Functional proteomic analysis highlighted the prominent role of neutrophils in stroke severity. This was in line with the association of neutrophil activation markers and count with NIHSS, ASPECTS, and the modified Rankin Scale score 90 days after the event.

CONCLUSION

The use of sequential window acquisition of all theoretical spectra-mass spectrometry in thrombi from patients who experienced an ischemic stroke has provided new insights into pathways and players involved in its etiology, severity, and prognosis. The prominent role of the innate immune system identified might pave the way for the development of new biomarkers and therapeutic approaches in this disease.

Neutrophil to lymphocyte ratio in parkinson's disease: a systematic review and meta-analysis

BACKGROUND

The goal of this research was to explore the role of Neutrophil to lymphocyte ratio (NLR) in Parkinson's disease (PD).

METHODS

From inception to 4 June 2023, PubMed, Web of Science, and ProQuest were searched for papers comparing NLR in PD to healthy individuals. Standardized mean difference (SMD) with a confidence interval (CI) of 95% were calculated.

RESULTS

A random-effect model revealed that PD patients had elevated NLR values compared to healthy individuals (SMD = 0.81, 95% CI = 0.47 to 1.14, P < 0.001). The results of subgroup analysis were as follows: (1) study design: We observed that patients with PD had higher levels of NLR than healthy controls in either retrospective (SMD = 1.12, 95% CI = 0.58 to 1.66, P < 0.001) or prospective (SMD = 0.43, 95% CI = 0.18 to 0.68, P = 0.001) studies. (2) Ethnicity: We noticed that individuals with PD had higher levels of NLR than healthy controls, whether they were East Asian (SMD = 0.93, 95% CI = 0.22 to 1.63, P = 0.010) or Caucasian (SMD = 0.75, 95% CI = 0.40 to 1.10, P < 0.001).The pooled sensitivity of NLR in the prediction of PD was 0.67 (95% CI = 0.61-0.73), and the pooled specificity was 0.66 (95% CI, 0.61-0.70).

CONCLUSIONS

Increased levels of NLR is highly related with the presence of PD. Further research is needed to determine the potential clinical benefits of this simple and low-cost biomarker in the PD diagnosis.

Applicability of the low-grade inflammation score in predicting 90-day functional outcomes after acute ischemic stroke

BACKGROUND AND PURPOSE

The low-grade inflammation (LGI) score, a novel indicator of chronic LGI, combines C-reactive protein (CRP), leukocyte counts, the neutrophil/lymphocyte ratio (NLR), and the platelet (PLT) count to predict outcomes of patients with various conditions, such as cardiovascular diseases, cancers, and neurodegenerative diseases. However, few studies have examined the role of the LGI score in predicting functional outcomes of patients with ischemic stroke. The present study aimed to evaluate the association between the LGI score and functional outcomes of patients with ischemic stroke.

METHODS

A total of 1,215 patients were screened in the present study, and 876 patients were finally included in this retrospective observational study based on the inclusion and exclusion criteria. Blood tests were conducted within 24 h of admission. Severity of ischemic stroke was assessed using the NIHSS score with severe stroke denoted by NIHSS > 5. Early neurological deterioration (END) was defined as an increment in the total NIHSS score of ≥ 2 points within 7 days after admission. Patient outcomes were assessed on day 90 after stroke onset using the modified Rankin Scale (mRS).

RESULTS

The LGI score was positively correlated with baseline and the day 7 NIHSS scores (R2 = 0.119, p < 0.001;R2 = 0.123, p < 0.001). Multivariate regression analysis showed that the LGI score was an independent predictor of stroke severity and END. In the crude model, the LGI score in the fourth quartile was associated with a higher risk of poor outcomes on day 90 compared with the LGI score in the first quartile (OR = 5.02, 95% CI: 3.09-8.14, p for trend < 0.001). After adjusting for potential confounders, the LGI score in the fourth quartile was independently associated with poor outcomes on day 90 (OR = 2.65, 95% CI: 1.47-4.76, p for trend = 0.001). Finally, the ROC curve analysis showed an AUC of 0.682 for poor outcomes on day 90 after stroke onset.

CONCLUSION

The LGI score is strongly correlated with the severity of acute ischemic stroke and that the LGI score might be a good predictor for poor outcomes on day 90 in patients with acute ischemic stroke.

The role of neutrophil percentage to albumin ratio in predicting 1-year mortality in elderly patients with hip fracture and external validation

Objectives

This study aimed to investigate the association between the neutrophil percentage to albumin ratio (NPAR) on the day of admission and mortality 1 year after surgery in elderly patients with hip fractures.

Methods

Clinical characteristics and blood markers of inflammation were retrospectively collected from October 2016 to January 2022 in elderly patients with hip fractures at two different regional tertiary medical centers. It is divided into a training set and an external validation set. Multivariate Nomogram models such as NPAR were constructed using the least absolute shrinkage and selection operator (LASSO) regression results and multi-factor logistic regression analysis. In addition, multivariate Cox regression analysis and Kaplan-Meier survival curves were used to explore the relationship between NPAR values and mortality within 1 year in elderly patients with hip fractures. The predictive performance of the Nomogram was evaluated using the concordance index (C Index) and receiver operating characteristic curve (ROC) and validated by Bootstrap, Hosmer-Lemesow goodness of fit test, calibration curve, decision curve, and clinical impact curve analysis.

Results

The study included data from 1179 (mean age, 80.34 ± 8.06 years; 61.4[52.1%] male) patients from the Guangzhou Red Cross Hospital affiliated with Jinan University and 476 (mean age, 81.18 ± 8.33 years; 233 [48.9%] male) patients from the Xiaogan Central Hospital affiliated with Wuhan University of Science and Technology. The results showed that NPAR has good sensitivity and specificity in assessing patients' prognosis 1 year after surgery. Multivariate logistic regression models based on influencing factors such as NPAR have good discrimination and calibration ability (AUC=0.942, 95% CI:0.927-0.955; Hosmer-Lemeshow test: P >0.05). Kaplan-Meier survival curves for the training and validation sets showed that patients in the high NPAR group had a higher mortality rate at 1 year compared to the low NPAR group (P< 0.001). Multivariate Cox regression showed that high NPAR values were an independent risk factor for death within 1 year in elderly hip fracture patients (P< 0.001, HR =2.38,95%CI:1.84-3.08).

Conclusion

Our study showed that NPAR levels were significantly higher in patients who died within 1 year after surgery in both the training and validation sets. NPAR has good clinical value in assessing 1-year postoperative prognosis in elderly patients with hip fractures.

Association between inflammatory biomarkers and venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a common thrombotic vascular disease that has a significant impact on people's well-being and quality of life. A plethora of clinical studies explore the relationship between inflammatory biomarkers and VTE but yield conflicting results. This article proposed to pool these studies to draw a more convincing conclusion.

METHODS

We searched several databases for studies before April 2023. Available data was processed using Stata software (version 15.0 SE) and R (version 4.1.2). This meta-analysis has been registered in PROSPERO (CRD42022321815). The VTE in this review encompassed pulmonary embolism, deep vein thrombosis, and cerebral venous thrombosis.

RESULTS

A total of 25 articles were finally involved in this study. Our results revealed that higher levels of high-sensitivity C-reactive protein (hs-CRP, MD, 0.63, 95%CI, 0.21-1.05) and C-reactive protein (CRP)> 3ug/ml (OR, 1.52, 95%CI, 1.18-1.96) might be regarded as risk factors for future VTE occurrence. The elevated levels of monocyte (MD, 0.03, 95%CI, 0.00-0.05), hs-CRP (0.85, 0.61-1.08), CRP (0.66, 0.20-1.13) and IL-6 (0.47, 0.25-0.70) might represent the previous VTE; a series of markers such as white blood cell (1.43, 0.88-1.98), neutrophil (1.79, 1.02-2.56), monocyte (0.17, 0.14-0.21), hs-CRP (3.72, 1.45-5.99), IL-6 (5.99, 4.52-7.46), platelet-lymphocyte ratio (33.1, 24.45-41.78) and neutrophil-lymphocyte ratio (1.34, 0.95-1.73) increased during the acute phase of VTE.

CONCLUSIONS

In general, activated inflammatory biomarkers might not only be correlated with an increased risk of VTE, but may also give a hint of the occurrence of VTE in clinical settings.

A Nomogram for Predicting the Recurrence of Acute Non-Cardioembolic Ischemic Stroke: A Retrospective Hospital-Based Cohort Analysis

Non-cardioembolic ischemic stroke (IS) is the predominant subtype of IS. This study aimed to construct a nomogram for recurrence risks in patients with non-cardioembolic IS in order to maximize clinical benefits. From April 2015 to December 2019, data from consecutive patients who were diagnosed with non-cardioembolic IS were collected from Lanzhou University Second Hospital. The least absolute shrinkage and selection operator (LASSO) regression analysis was used to optimize variable selection. Multivariable Cox regression analyses were used to identify the independent risk factors. A nomogram model was constructed using the "rms" package in R software via multifactor Cox regression. The accuracy of the model was evaluated using the receiver operating characteristic (ROC), calibration curve, and decision curve analyses (DCA). A total of 729 non-cardioembolic IS patients were enrolled, including 498 (68.3%) male patients and 231 (31.7%) female patients. Among them, there were 137 patients (18.8%) with recurrence. The patients were randomly divided into training and testing sets. The Kaplan-Meier survival analysis of the training and testing sets consistently revealed that the recurrence rates in the high-risk group were significantly higher than those in the low-risk group (p < 0.01). Moreover, the receiver operating characteristic curve analysis of the risk score demonstrated that the area under the curve was 0.778 and 0.760 in the training and testing sets, respectively. The nomogram comprised independent risk factors, including age, diabetes, platelet-lymphocyte ratio, leukoencephalopathy, neutrophil, monocytes, total protein, platelet, albumin, indirect bilirubin, and high-density lipoprotein. The C-index of the nomogram was 0.752 (95% CI: 0.705~0.799) in the training set and 0.749 (95% CI: 0.663~0.835) in the testing set. The nomogram model can be used as an effective tool for carrying out individualized recurrence predictions for non-cardioembolic IS.

Meta-analysis of differences in neutrophil to lymphocyte ratio between hypertensive and non-hypertensive individuals

This study systematically reviewed the evidence regarding differences in the neutrophil to lymphocyte ratio (NLR) level between hypertensive and normotensive individuals as well as between patients with dipper and non-dipper hypertension (HTN). PubMed, Scopus, and Web of Science databases were systematically searched up to 20 December 2021. This was done without any limitation with regard to date, publication, or language. Pooled weighted mean differences (WMD) with 95% confidence intervals (95% CI) were reported. We assessed the quality of studies based on the Newcastle-Ottawa Scale (NOS). In total, 21 studies were included in our study. There was a significant increase in NLR levels for the hypertensive group in comparison to the control group (WMD = 0.40, 95%CI = 0.22-0.57, P < 0.0001). In addition, the NLR levels were higher in the non-dipper than in the dipper group (WMD = 0.58, 95%CI = 0.19-0.97, P = 0.003). Our findings showed that hypertensive patients had higher level of NLR than normotensive individuals.

The prognostic values of neutrophil to lymphocyte ratio in traumatically injured patients upon admission: A mini-Review

Subsequent to trauma and systemic inflammatory response syndrome, the typical reaction is an enhancement of the total white blood cell count. Neutrophils are abundant circulating leukocytes in humans that play a crucial role in initial immune response against invading microbes through phagocytosis and exerting inflammatory mediators. However, lymphocytes are the main cellular compartments of the immune system that are negatively affected in the setting of trauma. The neutrophil to lymphocyte ratio (NLR), which can be easily measured in daily clinical practices, is an alternative marker of inflammation before any clinical findings can be observed. Therefore, in this mini-review study, we briefly discussed recent evidence on NLR variations at the time of hospitalization and its prognostic values in trauma patients. Most investigations declared high values of NLR potentially have a poor prognosis in traumatically ill patients on admission and contribute to coagulopathy, increased hospitalization and mortality. Moreover, given that various cut-off points have been considered for the NLR value, receiving a unique one and linking with subsequent outcomes of the disease should be in ongoing researches.

Relationship Between Pain and Disability Among Stroke Patients

Background

Stroke is prevalent in Iran, and its complications can decline patients' quality of life and psychological state.

Objectives

This study aimed to investigate the relationship between pain following stroke (PFS) and disability in stroke patients.

Methods

The current case-control study was conducted on 184 stroke patients (92 cases and 92 controls). Data collection tools included a demographic questionnaire, the Visual Analog Scale (VAS), and the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire. Based on the medical files of all patients with stroke, eligible ones were invited to participate in the study via phone calls. The collected data were then analyzed.

Results

The disability rate was higher in the case group of patients with a history of hemorrhagic stroke, smoking, stroke, and diabetes (P < 0.05). The mean ± SD age was 72.45 (11.54). Also, the level of disability in patients increased with age (P = 0.000). The mean ± SD disability score was 78.63 (6.92) in patients with PFS and 54.9 (10.87) in patients without PFS. Also, R = 0.795 and R2= 0.631 indicated the significance of disability severity in patients with PFS.

Conclusions

The prevalence of disability was higher in patients with higher PFS levels. Hence, drug interventions or rehabilitation programs can be used to reduce the disability of stroke patients.

Escalating Bi-Directional Feedback Loops between Proinflammatory Microglia and Mitochondria in Ageing and Post-Diagnosis of Parkinson's Disease

Parkinson's disease (PD) is a chronic and progressive age-related neurodegenerative disease affecting up to 3% of the global population over 65 years of age. Currently, the underlying physiological aetiology of PD is unknown. However, the diagnosed disorder shares many common non-motor symptoms associated with ageing-related neurodegenerative disease progression, such as neuroinflammation, microglial activation, neuronal mitochondrial impairment, and chronic autonomic nervous system dysfunction. Clinical PD has been linked to many interrelated biological and molecular processes, such as escalating proinflammatory immune responses, mitochondrial impairment, lower adenosine triphosphate (ATP) availability, increasing release of neurotoxic reactive oxygen species (ROS), impaired blood brain barrier integrity, chronic activation of microglia, and damage to dopaminergic neurons consistently associated with motor and cognitive decline. Prodromal PD has also been associated with orthostatic hypotension and many other age-related impairments, such as sleep disruption, impaired gut microbiome, and constipation. Thus, this review aimed to present evidence linking mitochondrial dysfunction, including elevated oxidative stress, ROS, and impaired cellular energy production, with the overactivation and escalation of a microglial-mediated proinflammatory immune response as naturally occurring and damaging interlinked bidirectional and self-perpetuating cycles that share common pathological processes in ageing and PD. We propose that both chronic inflammation, microglial activation, and neuronal mitochondrial impairment should be considered as concurrently influencing each other along a continuum rather than as separate and isolated linear metabolic events that affect specific aspects of neural processing and brain function.

Assessment of immune cell profiles among post-menopausal women in the Women's Health Initiative using DNA methylation-based methods

BACKGROUND

Over the past decade, DNA methylation (DNAm)-based deconvolution methods that leverage cell-specific DNAm markers of immune cell types have been developed to provide accurate estimates of the proportions of leukocytes in peripheral blood. Immune cell phenotyping using DNAm markers, termed immunomethylomics or methylation cytometry, offers a solution for determining the body's immune cell landscape that does not require fresh blood and is scalable to large sample sizes. Despite significant advances in DNAm-based deconvolution, references at the population level are needed for clinical and research interpretation of these additional immune layers. Here we aim to provide some references for immune populations in a group of multi-ethnic post-menopausal American women.

RESULTS

We applied DNAm-based deconvolution to a large sample of post-menopausal women enrolled in the Women's Health Initiative (baseline, N = 58) or the ancillary Long Life Study (WHI-LLS, N = 1237) to determine the reference ranges of 58 immune parameters, including proportions and absolute counts for 19 leukocyte subsets and 20 derived cell ratios. Participants were 50-94 years old at the time of blood draw, and N = 898 (69.3%) self-identified as White. Using linear regression models, we observed significant associations between age at blood draw and absolute counts and proportions of naïve B, memory CD4+, naïve CD4+, naïve CD8+, memory CD8+ memory, neutrophils, and natural killer cells. We also assessed the same immune profiles in a subset of paired longitudinal samples collected 14-18 years apart across N = 52 participants. Our results demonstrate high inter-individual variability in rates of change of leukocyte subsets over this time. And, when conducting paired t tests to test the difference in counts and proportions between the baseline visit and LLS visit, there were significant changes in naïve B, memory CD4+, naïve CD4+, naïve CD8+, memory CD8+ cells and neutrophils, similar to the results seen when analyzing the association with age in the entire cohort.

CONCLUSIONS

Here, we show that derived cell counts largely reflect the immune profile associated with proportions and that these novel methods replicate the known immune profiles associated with age. Further, we demonstrate the value this methylation cytometry approach can add as a potential application in epidemiological studies.

Neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio, and platelet-lymphocyte ratio in stroke-associated pneumonia: a systematic review and meta-analysis

BACKGROUND

Predicting stroke-associated pneumonia (SAP) is crucial for intensifying preventive measures and decreasing morbidity and mortality. This meta-analysis aims to evaluate the association between baseline neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), and platelet-lymphocyte ratio (PLR) with SAP and to determine the strength of the association.

METHODS

The Web of Science, SCOPUS, and PUBMED databases were searched to find eligible studies. The standardized mean difference (SMD) and 95% confidence interval (CI) were used to evaluate the differences in NLR, MLR, and PLR levels between SAP and non-SAP patients. The meta-analysis was conducted using the software "Review Manager" (RevMan, version 5.4.1, September 2020). The random-effect model was used for the pooling analysis if there was substantial heterogeneity. Otherwise, the fixed-effect model was adopted.

RESULTS

Twelve studies comprising 6302 stroke patients were included. The pooled analyses revealed that patients with SAP had significantly higher levels of NLR, MLR, and PLR than the non-SAP group. The SMD, 95% CI, p-value, and I² for them were respectively reported as (0.88, 0.70-1.07, .00001, 77%); (0.94, 0.43-1.46, .0003, 93%); and (0.61, 0.47-0.75, .001, 0%). Subgroup analysis of NLR studies showed no significant differences in the effect size index between the severity of the stroke, the sample size, and the period between the stroke onset and the blood sampling.

CONCLUSION

This systematic review and meta-analysis suggest that an elevated NLR, MLR, and PLR were associated with SAP, indicating that they could be promising blood-based biomarkers for predicting SAP. Large-scale prospective studies from various ethnicities are recommended to validate this association before they can be applied in clinical practice.

The Negative Prognostic Role of Inflammatory Biomarkers in Patients With Chronic Cerebrospinal Venous Insufficiency

BACKGROUND

The pathologic consequences of inflammatory responses in chronic cerebrospinal venous insufficiency (CCSVI) remains poorly understood. Hence, this study was aimed to evaluate the peripheral inflammatory biomarkers in patients with intracranial and extracranial CCSVI pathology. In addition, the relationship between inflammatory cytokine profile and CCSVI prognosis was also evaluated.

METHODS

Patients diagnosed with CCSVI between July 2017 and July 2019 were included and subsequently divided into 3 groups based on the location of stenosis. The inflammatory biomarker assay included neutrophil-to-lymphocyte ratios (NLRs), platelet-to-lymphocyte ratios (PLRs), red blood cell distribution widths (RDW), C-reactive protein (CRP) levels, interleukin-6 (IL-6) levels, and neuron-specific enolase levels. Clinical outcomes were assessed using the modified Rankin Scale and Patient Global Impression of Change score. Univariate and multivariate regression analyses were performed to identify significant prognostic factors for poorer outcomes. Finally, we established a nomogram based on the multivariate regression analysis.

RESULTS

We enrolled 248 patients in total, including 102 males and 146 females, with an average age of 57.85±12.28 years. Compared with patients with internal jugular vein stenosis, cerebral venous sinus stenosis (CVSS) patients were mostly younger and had been suffering from headaches and severe papilledema. Higher levels of NLR, RDW, and CRP were also observed in the CVSS group. Multivariate analysis indicated that NLR, PLR, and IL-6 were the independent prognostic factors for poor CCSVI outcomes.

CONCLUSIONS

The clinical presentations and increases in NLR, PLR, IL-6, and CRP levels could be distinctly marked in patients with CVSS-related CCSVI than that in internal jugular vein stenosis-related CCSVI, indicating poor prognostic outcomes in these patients. A proinflammatory state might be associated with CCSVI pathology.

Leukocyte indicators and variations predict worse outcomes after intravenous thrombolysis in patients with acute ischemic stroke

Leukocytes are systematic inflammation indicators related to stroke prognosis and can exhibit large dynamic waves before and after recombinant tissue plasminogen activator (r-tPA) therapy. However, additional evidence is needed to determine the prognostic significance of various leukocytes including both static and dynamic data among patients who underwent r-tPA therapy. A total of 251 patients treated with r-tPA were included; their leukocyte data were collected at two time points, and patients were followed up for three months. Analysis revealed the following findings. (i) Patients with hemorrhagic transformation (HT) and unfavorable outcomes had a higher level of leukocytes after r-tPA therapy (leukocyte count (adjusted OR (aOR) 1.191 for HT and 1.184 for unfavorable outcomes), neutrophil count (aOR 1.215 and 1.214), neutrophil-to-lymphocyte ratio (NLR; aOR 1.084 and 1.091)) and larger dynamic leukocyte changes. (ii)Among all leukocytes, the NLR after r-tPA administration demonstrated the strongest correlation with HT and unfavorable outcomes. (iii) Patients with an NLR ≥ 3.322 had a 3.492-fold increased risk for HT, and those with an NLR ≥ 5.511 had a 3.024-fold increased risk for functional outcomes. Overall, this study shows that leukocytes, especially leukocyte count, neutrophil count and the NLR, are independently associated with HT and functional outcomes in stroke patients.

Twenty-eight-day in-hospital mortality prediction for elderly patients with ischemic stroke in the intensive care unit: Interpretable machine learning models

Background

Risk stratification of elderly patients with ischemic stroke (IS) who are admitted to the intensive care unit (ICU) remains a challenging task. This study aims to establish and validate predictive models that are based on novel machine learning (ML) algorithms for 28-day in-hospital mortality in elderly patients with IS who were admitted to the ICU.

Methods

Data of elderly patients with IS were extracted from the electronic intensive care unit (eICU) Collaborative Research Database (eICU-CRD) records of those elderly patients admitted between 2014 and 2015. All selected participants were randomly divided into two sets: a training set and a validation set in the ratio of 8:2. ML algorithms, such as Naïve Bayes (NB), eXtreme Gradient Boosting (xgboost), and logistic regression (LR), were applied for model construction utilizing 10-fold cross-validation. The performance of models was measured by the area under the receiver operating characteristic curve (AUC) analysis and accuracy. The present study uses interpretable ML methods to provide insight into the model's prediction and outcome using the SHapley Additive exPlanations (SHAP) method.

Results

As regards the population demographics and clinical characteristics, the analysis in the present study included 1,236 elderly patients with IS in the ICU, of whom 164 (13.3%) died during hospitalization. As regards feature selection, a total of eight features were selected for model construction. In the training set, both the xgboost and NB models showed specificity values of 0.989 and 0.767, respectively. In the internal validation set, the xgboost model identified patients who died with an AUC value of 0.733 better than the LR model which identified patients who died with an AUC value of 0.627 or the NB model 0.672.

Conclusion

The xgboost model shows the best predictive performance that predicts mortality in elderly patients with IS in the ICU. By making the ML model explainable, physicians would be able to understand better the reasoning behind the outcome.

Admission neutrophil-to-lymphocyte ratio to predict 30-day mortality in severe spontaneous basal ganglia hemorrhage

Background

Spontaneous intracerebral hemorrhage (ICH) usually occurs in the basal ganglia and is highly lethal and disabling. The aim of this study was to evaluate the predictors of 30-day mortality in patients with severe spontaneous basal ganglia hemorrhage.

Methods

This retrospective study included patients with severe basal ganglia intracerebral hemorrhage treated in the Third Affiliated Hospital of Soochow University from 2012 to 2018. Demographic, clinical, laboratory and neuroradiological data were collected. The short-term prognosis was evaluated and divided into death within 30-days and survival over 30-days. We studied the factors affecting the prognosis of patients with severe intracerebral hemorrhage, analyzed the parameters related to neutrophil-to-lymphocyte (NLR) at admission, and evaluated the predictive effect of NLR on 30-day mortality.

Results

A total of 105 patients was included in this retrospective study. The 30-day death group had a larger hematoma, a higher probability of ventricular hemorrhage, a higher ICH score and a lower Glasgow Coma Scale (GCS) score on admission. Meanwhile, the patients in the death group had higher White blood cells (WBC) counts, neutrophil counts, NLRs and C-reactive protein (CRP) levels. The risk factors for 30-day death were related to the ICH volume, GCS score, ICH score, WBC count, neutrophil count, NLR and CRP. The univariate receiver operating characteristic (ROC) curve of the risk factors showed that the NLR had the best prediction performance. Mathematical predictive models for ICH patients showed that the model with NLR had better prediction accuracy.

Conclusions

The NLR is expected to be a potential biomarker for predicting the prognosis of patients with severe basal ganglia hemorrhage.

Leukocyte Count and Neutrophil-To-Lymphocyte Ratio as Simple Hematologic Predictors of Stroke Severity and Functional Outcome in Acute Ischemic Stroke Patients

Background:

It has long been recognized that inflammation plays a critical role in the pathogenesis of ischemic stroke. However, whether leukocyte count and neutrophil-to-lymphocyte ratio are related to stroke severity and functional outcome is uncertain.

Objective:

This clinical study aimed to evaluate the association of leukocyte count and neutrophil-to-lymphocyte ratio with stroke severity and functional outcome in acute ischemic stroke patients.

Methods:

This hospital-based, retrospective observational study included 112 subjects with acute ischemic stroke. All subjects had their demographic, clinical, and laboratory data obtained. The leukocyte count and neutrophil-to-lymphocyte ratio were evaluated by stroke severity on admission and 3-month functional outcome. The severity of stroke at admission was measured using the National Institutes of Health Stroke Scale (NIHSS), whereas the Barthel Index was used to measure 3-month functional outcome (BI). We conducted a regression analysis, adjusting for any confounding variables.

Results:

Higher leukocyte count was significantly associated with increased risk of stroke severity (odds ratio [OR] 1.391, 95% confidence intervals [CI], 1.121-1.725, p: 0.003) and unfavorable functional outcome (OR 1.434, 95% CI, 1.068-1.925, p: 0.017). Higher neutrophil-to-lymphocyte ratio was not significantly associated with increased risk of stroke severity (OR 1.181, 95% CI, 0.947-1.474, p: 0.140) and unfavorable functional outcome (OR 1.246, 95% CI, 0.905-1.716, p: 0.177).

Conclusion:

Our study indicates that leukocyte count is an independent predictor of stroke severity on admission and unfavorable functional outcome.

An Elevated Neutrophil-to-Lymphocyte Ratio Predicts In-Hospital Mortality in Stroke Patients: A Prospective Cohort Study

Introduction Cerebrovascular accidents or strokes are a major cause of mortality and morbidity in today's world. Post-stroke disabilities like paralysis, dementia, etc., can affect the quality of life of patients as well as their families. A combined increase in neutrophils and a decrease in lymphocytes during inflammation in stroke manifests as an elevated neutrophil-to-lymphocyte ratio (NLR), thereby indicating the severity of neural damage. Aim We aimed to determine if an elevated NLR observed on the day of hospital admission can predict a higher risk of in-hospital mortality in stroke patients. Confirmatory results could aid in developing risk stratification for management, ultimately improving clinical and functional outcomes. Materials and methods Sixty stroke patients were monitored throughout their hospital stay in this prospective cohort study. NLR was calculated at admission using routine complete blood counts. The data were analyzed using SPSS Software v23.0 (IBM Corp., Armonk, NY). An unpaired t-test was used to compare the means between the two groups. Categorical data were analyzed using the chi-square test. The receiver operating curve (ROC) was plotted and used to ascertain if a cut-off value of NLR could be obtained to predict in-hospital mortality in stroke patients. P values <0.05 were considered statistically significant. Results About 23.3% (n=14) of the patients died during their hospital stay, with no significant differences between the survivor and death cohorts in terms of comorbidities like diabetes and hypertension. The mean NLR calculated within 24 hours of hospital admission in patients who died (NLR=8.47 (standard deviation (SD)=4.67)) was significantly higher (p=0.009) than in those who survived (NLR=5.84 (SD=2.62)). Upon ROC analysis, patients with NLR >6.03 on the day of admission demonstrated a higher risk of in-hospital mortality (p=0.015 (95% CI: 0.577-0.855)). An area under the curve (AUC) of 0.72 with a sensitivity of 92.86% and a specificity of 54.35% was obtained. Conclusions Elevated NLR (cut-off >6.03) obtained within 24 hours of hospital admission is an indicator of a higher risk of in-hospital mortality in stroke patients. Hence, patients presenting with a high NLR at admission can be prioritized for personalized targeted treatment, potentially reducing mortality and post-stroke complications.

The neutrophil-to-lymphocyte ratio is an important indicator correlated to early neurological deterioration in single subcortical infarct patients with diabetes

Background and purpose

This study aimed to investigate the relationship between neutrophil-to-lymphocyte ratio (NLR) and early neurological deterioration (END) among cases suffering from single subcortical infarction (SSI) and diabetes.

Methods

We collected the data of patients with SSI admitted to our hospital between January 2019 and December 2020 retrospectively. A score of ≥2 elevations in overall National Institutes of Health Stroke Scale (NIHSS) score or ≥1 increase in motor NIHSS score in 5-day post-admission was considered END. Furthermore, logistic regression was used to analyze the relationship between NLR and END among SSI cases.

Results

Altogether, we enrolled 235 consecutive SSI cases, of which 53 (22.5%) were diagnosed with END, while 93 (39.5%) were diabetic. In patients with diabetes, the value of NLR increased markedly among the patients with END (median, 3.59; IQR, 2.18–4.84) compared to patients without END (median, 2.64; IQR, 1.89–3.18; P = 0.032). Meanwhile, in patients without diabetes, NLR was not significantly associated with END. In the multivariate analysis, NLR values were positively related to END (adjusted odds ratio (OR), 1.768; 95% CI, 1.166–2.682, P = 0.007) upon adjusting age, SSI type, lesion diameter, initial NIHSS, fasting blood glucose (FBG), 2-h postprandial blood glucose (2hPBG), and estimated glomerular filtration rate (eGFR). The subgroup analysis showed that the relationship between NLR and END was more pronounced in the branch atheromatous disease (BAD) (adjusted OR, 1.819; 95% CI, 1.049–3.153, P = 0.033) and anterior SSI subgroups (adjusted OR, 2.102; 95% CI, 1.095–4.037, P = 0.026).

Conclusion

NLR value was significantly related to END among SSI patients with diabetes and was recognized as an independent factor in predicting the risk of END.

Postoperative neutrophil-lymphocyte ratio predicts unfavorable outcome of acute ischemic stroke patients who achieve complete reperfusion after thrombectomy

Purpose

Only approximately half of anterior circulation large vessel occlusion (LVO) patients receiving endovascular treatment (EVT) have a favorable outcome. The aim of this study was to explore the association of dynamic inflammatory markers (i.e., neutrophil to lymphocyte ratios, NLR, measured at different times after EVT) as well as other potential influencing factors with unfavorable outcome among acute ischemic stroke (AIS) patients who achieved complete reperfusion after EVT.

Methods

Patients treated with EVT for LVO between January 2019 to December 2021 were prospectively enrolled. Complete reperfusion was defined as modified thrombolysis in cerebral infarction (mTICI) grade 3. A modified Rankin scale at 90 days (mRS90) of 3-6 was defined as unfavorable outcome (i.e., futile reperfusion). A logistic regression analysis was performed with unfavorable outcome as a dependent variable. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) were then used to determine the diagnostic values of NLR and other relevant factors.

Results

170 patients with complete reperfusion (mTICI 3) were included in this study. Unfavorable outcome was observed in 70 (41.2%). Higher NLR within 24h (p=0.017) and at 3-7d (p=0.008) after EVT were an independent risk factors for unfavorable outcome at 3 months. In addition, older age, higher NIHSS scores, poor collaterals, and general anesthesia were independent predictors of unfavorable outcomes. When accounting for NLR, the diagnostic efficiency improved compared to conventional characteristics.

Conclusion

Our findings suggest that advanced age, increased stroke severity, poor collaterals, general anesthesia, and NLR are independent predictors for an unfavorable clinical outcome following complete reperfusion after EVT. Neuroinflammation may merit particular attention in future studies.

Stroke and Emerging Blood Biomarkers: A Clinical Prospective

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

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

In this study, we conducted a systematic review and meta-analysis regarding the role of the neutrophil to lymphocyte ratio (NLR) in Guillain Barré syndrome (GBS). The most recent update to the search was on July 18, 2022, through the databases of Web of Science, PubMed, Embase, and Scopus. The Newcastle-Ottawa scale was used for quality assessment of included studies. Finally, 14 studies were included in the review, and among them, ten studies were included in the meta-analysis. Our results showed that NLR levels were significantly increased in the patients with GBS compared with healthy controls (SMD = 1.05; 95%CI = 0.59 to 1.50, P < 0.001). After treatment, NLR levels were decreased to the extent that they became similar to healthy controls (SMD = -0.03, 95%CI = -0.29 to 0.22, P = 0.204). Moreover, NLR was a stable predictor of outcome or response to treatment in such patients (SMD = 1.01, 95%CI = 0.65 to 1.37, P < 0.001); the higher the NLR, the worse the outcome. In addition, patients who underwent mechanical ventilation had higher levels of NLR compared to those who did not (SMD = 0.93, 95%CI = 0.05 to 1.82, P = 0.03). However, NLR levels were not different among distinct GBS subtypes, so it could not distinguish among them. In conclusion, our analysis indicates that the NLR levels are highly elevated in patients with GBS. Therefore, the NLR has the potential to be used as a biomarker to inform diagnosis, prognosis, or treatment responses in GBS, and future studies are warranted.

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

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

Neutrophil-to-Lymphocyte Ratio and Early Neurological Deterioration in Stroke Patients: A Systematic Review and Meta-Analysis

In light of the growing emphasis on classifying stroke patients for different levels of monitoring intensity and emergency treatments, we conducted a systematic review of a wide range of clinical studies, according to the preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines, with no restrictions on the language or publication date, to analyze the potential of the neutrophil-to-lymphocyte ratio (NLR) as an early neurological deterioration (END) risk predictor. A comprehensive search was carried out in PubMed, Scopus, and Web of Science databases from the inception to March 13, 2022. Nine articles were included in our study. Stroke patients with END had significantly higher NLR levels than the those without END (SMD = 0.73; CI 95% = 0.42-1.05, P value < 0.001). In the subgroup analysis, according to ethnicity, East Asian patients with END had elevated levels of NLR compared to those without END (SMD = 0.79; CI 95% = 0.52-1.06, P value < 0.001). However, the difference in the Caucasian group was not significant (SMD = 0.60; CI 95% = -0.50-1.70, P value = 0.28). In the subgroup analysis according to the type of stroke, the NLR levels in patients with hemorrhagic stroke who developed END were similar to those without END (SMD = 0.84, CI 95% = -0.10-1.77, P value = 0.07). Vice versa, in the ischemic stroke group, patients with END had elevated levels of NLR compared to those without END (SMD = 0.67, CI 95% = 0.38-0.96, P value < 0.001). NLR is a unique inflammatory biomarker whose increase in END suggests an immune system dysfunction in the pathogenesis of the disease.

Stroke-induced changes to immune function and their relevance to increased risk of severe COVID-19 disease

As the COVID-19 pandemic moves towards endemic disease, it remains of key importance to identify groups of individuals vulnerable to severe infection and understand the biological factors that mediate this risk. Stroke patients are at increased risk of developing severe COVID-19, likely due to stroke-induced alterations to systemic immune function. Furthermore, immune responses associated with severe COVID-19 in patients without a history of stroke parallel many of the immune alterations induced by stroke, possibly resulting in a compounding effect that contributes to worsened disease severity. In this review, we discuss the changes to systemic immune function that likely contribute to augmented COVID-19 severity in patients with a history of stroke and the effects of COVID-19 on the immune system that may exacerbate these effects.

Clinical Characteristics and Prognosis of Antibody-Negative Autoimmune Encephalitis in Children: A Single-Center Retrospective Study

BACKGROUND

Autoimmune encephalitis (AE) is a group of immune-mediated brain diseases. However, new diagnostic criteria for AE in children indicate that partial pediatric patients with AE may be diagnosed without evidence of positive autoantibodies. Therefore, the clinical characteristics and prognosis of children with antibody-negative but probable AE require further investigation.

METHODS

Forty-one children with AE admitted to our hospital from April 2014 to January 2021 were retrospectively enrolled in this study. Children were divided into two groups according to positive or negative antibody tests. Clinical characteristics, cerebrospinal fluid, video electroencephalography, brain magnetic resonance imaging, and prognosis were analyzed, and the correlation between modified Rankin scale (mRS) and neutrophil-to-lymphocyte ratio (NLR) was examined.

RESULTS

Of 41 children, 16 cases tested positive for autoantibodies. The main features were psychiatric symptoms, cognitive disturbances, speech disturbances, movement disorders, and seizures. All the children were given a combination of intravenous methylprednisolone pulses with intravenous immunoglobulin therapy; 26 cases (63%) had a good outcome, and 15 cases (37%) had a poor outcome. Antibody-positive and antibody-negative but probable AE were analyzed by univariate analysis and showed lower lymphocyte counts and higher NLR and mRS scores in the antibody-negative group (P < 0.05). The Spearman rank correlation analysis showed a positive correlation between NLR level and mRS scores (P < 0.05).

CONCLUSIONS

Antibody-negative but possible AE is frequent in children who may have a more severe neurological impairment and higher NLR than antibody-positive AE. Aggressive immunotherapy in antibody-negative AE is essential to achieve a good prognosis.

Vitamin D serum level predicts stroke clinical severity, functional independence, and disability—A retrospective cohort study

Background

Stroke is a leading cause of mortality and disability and one of the most common neurological conditions globally. Many studies focused on vitamin D as a stroke risk factor, but only a few focused on its serum level as a predictor of stroke initial clinical severity and recovery with inconsistent results. The purpose of this study was to assess the relationship between serum vitamin D levels and stroke clinical severity at admission and functional independence and disability at discharge in Saudi Arabia.

Methodology

A retrospective cohort study of adult ischemic stroke patients who had their vitamin D tested and admitted within 7 days of exhibiting stroke symptoms at King Abdulaziz Medical City (KAMC) Jeddah, Saudi Arabia. Based on vitamin D level, the patients were categorized into normal [25(OH)D serum level ≥ 75 nmol/L], insufficient [25(OH)D serum level is 50–75 nmol/L], and deficient [25(OH)D serum level ≤ 50 nmol/L]. The primary outcome was to assess the vitamin D serum level of ischemic stroke patients’ clinical severity at admission and functional independence at discharge. The National Institute of Health Stroke Scale (NIHSS) was used to assess the clinical severity, whereas the modified Rankin scale (mRS) was used to assess functional independence and disability.

Results

The study included 294 stroke patients, out of 774, who were selected based on the inclusion and exclusion criteria. The mean age of the participants was 68.2 ± 13.4 years, and 49.3% were male. The patients’ distribution among the three groups based on their vitamin D levels is: normal (n = 35, 11.9%), insufficient (n = 66, 22.5%), and deficient (n = 196, 65.6%). After adjusting for potential covariates, regression analysis found a significant inverse relationship of NIHSS based on 25(OH)D serum level (beta coefficient: −0.04, SE: 0.01, p = 0.003). Patients with deficient serum vitamin D level also had significantly higher odds of worse functional independence in mRS score [OR: 2.41, 95%CI: (1.13–5.16), p = 0.023] when compared to participants with normal vitamin D level.

Conclusion

Low vitamin D levels were associated with higher severity of stroke at admission and poor functional independence and disability at discharge in patients with acute ischemic stroke. Further randomized clinical and interventional studies are required to confirm our findings.

High Neutrophil-Lymphocyte Ratio and Low Lymphocyte-Monocyte Ratio Combination after Thrombolysis Is a Potential Predictor of Poor Functional Outcome of Acute Ischemic Stroke

(1) Background: Ischemic stroke is one of the leading causes of death and disability. An inflammatory response is observed in multiple stages of cerebral ischemia, particularly in the acute phase. Recent publications revealed that the neutrophil−lymphocyte ratio (NLR) and lymphocyte−monocyte ratio (LMR) may be used to predict long-term prognosis in acute ischemic stroke (AIS) after thrombolysis. To test whether there is a relationship between the combination of these parameters and long-term prognosis, we analyzed the NLR−LMR combination in AIS patients treated with intravenous recombinant tissue plasminogen activator (rtPA); (2) Methods: The study included 285 adults with a diagnosis of AIS and rtPA treatment within a 4.5 h time window. Blood samples were obtained at admission and 24 h after thrombolysis to calculate pre- and post-thrombolysis NLR and LMR. Clinical data, including NIHSS was registered on admission and day 1. The long-term outcome was defined 90 days post-event by the modified Rankin Scale (mRS). Therapy-associated intracranial hemorrhage (ICH) was classified according to ECASS II. Receiver operating characteristic curve (ROC) analysis was performed to determine optimal cutoffs of NLR and LMR as predictors of therapy outcomes; (3) Results: Patients were stratified by cutoffs of 5.73 for NLR and 2.08 for LMR. The multivariate logistic regression model, including all possible confounders, displayed no significant association between NLR or LMR with 3-months functional prognosis. The combination of high NLR−low LMR vs. low NRL−high LMR as obtained 24 h after thrombolysis was found to be an independent predictor of poor 3-months functional outcome (mRS ≥ 2; OR 3.407, 95% CI 1.449 to 8.011, p = 0.005). The proportion of patients between low NLR−high LMR and high NLR−low LMR groups from admission to day 1 showed no significant change in the good outcome group. On the other hand, in the poor outcome group (mRS ≥ 2), low NLR−high LMR and high NLR−low LMR groups displayed a significant shift in patient proportions from 67% and 21% at admission (p = 0.001) to 36% and 49% at 24 h after thrombolysis (p < 0.001), respectively; (4) Conclusions: Our study demonstrated for the first time that a high NLR−low LMR combination as observed at 24 h after thrombolysis can serve as an independent predictor of 3-months poor outcome in AIS patients. This simple and readily available data may help clinicians to improve the prognostic estimation of patients and may provide guidance in selecting patients for personalized and intensified care post-thrombolysis.

Neutrophil-to-lymphocyte ratio as a predictor for cardiovascular diseases: a cohort study in Tianjin, China

Based on a cohort in Tianjin, China, we explore the relationship between neutrophils-to-lymphocyte ratio (NLR) and the risk of cardiovascular diseases (CVDs). From January 2010 to December 2019, 4667 eligible participants aged more than 40 years old, CVDs-free, and registered in two community health service centers were recruited and followed up. The values of NLR collected at baseline were included in Cox proportional hazards model to evaluate its association with the incidence risk of CVDs. Hazard ratio (HR) and 95% confidence interval (CI) were calculated before and after adjustment for potential confounding factors selected by LASSO regression. During a total of 13,691 person-years of follow-up among all participants (median, 2.0 years; interquartile range, 1.7-2.5), 150 (3.42%) newly diagnosed CVDs events occurred, with the incidence density of CVDs of 10.96/1000 person-year. The incidence density in subgroups categorized by tertiles of baseline NLR was 8.08/1000, 11.74/1000, and 13.24/1000, respectively (p trend = 0.019). COX models revealed that after adjustment for potential confounders, NLR (as a continuous variable) was significantly related to the risk of total CVDs (HR 1.10, 95% CI: 1.04, 1.17), myocardial infarction (HR 1.12, 95% CI: 1.05, 1.20), and ischemic stroke (HR 1.21, 95% CI: 1.10, 1.33). When NLR was categorized into tertiles, participants in the top tertile had a significantly higher risk of CVDs (HR 1.61, 95% CI: 1.06, 2.44) and myocardial infarction (HR 1.88, 95% CI: 1.09, 3.27) relative to those in the bottom tertile.

Systemic White Blood Cell Count as a Biomarker for Malignant Cerebral Edema in Large Vessel Ischemic MCA Stroke

OBJECTIVES

Large middle cerebral artery (MCA) strokes remain a major cause for mortality and morbidity all over the world, and therefore early identification of patients with the highest risk for malignant cerebral edema is crucial for early intervention. Neutrophils to lymphocytes ratio (NLR) and peripheral total white blood cell (WBC) count are inflammatory markers done routinely for all patients, and this study evaluated the use of NLR and elevated white blood cell count within the first 24 h of MCA ischemic stroke onset, with the absence of significant hemorrhagic transformation, to predict malignant cerebral edema.

MATERIALS AND METHODS

A total of 156 patients with large MCA strokes were included. We collected demographic, clinical, radiological data, and NLR and WBCs within the first 24 h from admission.We excluded patients who had any underlying infections diagnosed 7 days before or within 72 h after admission. We used a body temp of 38 C or more, abnormal CXR or abnormal urine analysis within the first 72 h to exclude patients with possible infections.We excluded immune-compromised patients and patients on steroid therapy. We compared the NLR and WBC count in patients who developed malignant cerebral edema versus the patients who did not. NLR > 3.5 and < 3.5 was used for comparison. We then conducted multivariate logistic regression models to explore the relationship between cerebral edema, WBCs and NLR count simultaneously.

RESULTS

NLR, WBC, radiological involvement of more than 50% of MCA territory infarction on presentation, hyperdense MCA sign, and NIH stroke scale were all significantly higher in patients with malignant cerebral edema within the first 24 h. Using univariate logistic regression, NLR performs better than WBC when predicting the occurrence of malignant cerebral edema (AUC = 0.74 vs. 0.62). However, NIH stroke scale scores, and radiological involvement of more than 50% of MCA territory infarction on the first 24 h of presentation on CT scan both showed better discriminative performance for malignant cerebral edema than NLR (AUC = 0.84 and 0.76, respectively). When combined, NLR > 3.5 paired with the NIH stroke scale score had the best predictive performance (AUC = 0.87).

CONCLUSION

NLR > 3.5 can be used for early prognostication in patients with large vessel MCA ischemic strokes with no significant hemorrhagic transformation within the first 24 h regardless if they had reperfusion therapy or not. Combining NLR of > 3.5 in addition to high NIHSS provided the best predictive model in our study. Further studies are needed to further develop the best predictive model in diverse populations.