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

Analysis of the correlation between neutrophil percentage-to-albumin ratio, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio with short-term prognosis in acute ischemic stroke patients undergoing intravenous thrombolysis

Introduction

The purpose of this study was to evaluate the association between four easy-to-measure inflammatory markers and the 90-day outcomes with acute ischemic stroke (AIS) patients who received intravenous thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA). These included the neutrophil percentage-to-albumin ratio (NPAR), the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), and the combined NPAR+NLR index.

Methods

This study enrolled 151 AIS patients who were treated with rt-PA (0.9 mg/kg). Clinical data were collected and NPAR, NLR, PLR were calculated from the admission blood work. The patients were followed up for 90 days after stroke onset and subsequently categorized into two groups based on the modified Rankin Scale (mRS): a favorable outcome group (111 patients, mRS ≤ 2) and a poor outcome group (40 patients, mRS > 2).

Results

In this study, we foud elevated level of albumin and lymphocyte counts are protective factors for short-term prognosis. Age, neutrophil percentage, NPAR, NLR, PLR, NIHSS score, and fasting blood glucose (FBG) are associated with poor short-term prognosis. Among these, age, NPAR, NLR, and NIHSS score are independent risk factors for poor short-term prognosis.

Discussion

NPAR, NLR, PLR, and the combined NPAR+NLR index may have predictive value for poor short-term outcomes in AIS patients following thrombolysis. NPAR demonstrates the highest predictive capability, in the following order: NPAR > NPAR+NLR > NLR > PLR.

Segmented neutrophil-to-monocyte ratio and systemic immune-inflammation index associated with the severity and functional prognosis of acute ischemic stroke

PURPOSE/AIM OF THE STUDY

To identify the inflammation indexes associated with the severity and functional prognosis in ischemic stroke.

MATERIAL AND METHODS

A prospective study was conducted with ischemic stroke cases included in the i-ReNe clinical registry. Patients were divided into groups according to the severity on admission measured by the National Institutes of Health Stroke Scale (NIHSS) and the functional prognosis at 30 and 90 days of discharge measured by the modified Rankin Scale (mRS).

RESULTS

We included 145 patients with a mean age of 61.5 ± 12.75, 97 (66.9%) were men. The leukocyte and neutrophil counts, Neutrophil-to-Lymphocyte ratio (NLR), Derived Neutrophil-to-Lymphocyte ratio (dNLR), Platelet-to-Lymphocyte ratio (PLR), Segmented Neutrophil-to-Monocyte ratio (SeMo ratio), and Systemic Immune-inflammation index (SII) were higher in moderate-to-severe stroke (NIHSS ≥6). NLR, PLR, SeMo ratio, and SII were higher in the group with severe disability and death at 30 days (mRS ≥4). In the multiple logistic regression analyses, SeMo ratio >14.966 and SII >623.723 were associated with moderate-to-severe stroke (NIHSS ≥6). In addition, SeMo ratio >7.845 was associated with severe disability and death at 30 days (mRS ≥4).

CONCLUSIONS

Systemic inflammation indexes could be rapid and low-cost markers used in the initial evaluation of ischemic stroke, whose values could help to stratify patients according to their severity and functional prognosis. This is the first study to establish a relationship between ischemic stroke and the SeMo ratio.

The Effect of Systemic Inflammatory Response on Mechanical Thrombectomy is Partly Mediated by Pre-thrombectomy Cerebral Edema in Acute Stroke Patients

OBJECTIVE

To explore the effect of baseline Systemic Inflammatory Response reflected by platelet-to-lymphocyte ratio (PLR) and pre-thrombectomy cerebral edema reflected by Net Water Uptake (NWU) on futile recanalization in patients with Acute Ischemic Stroke (AIS) after successful thrombectomy, and to investigate the potential mediating role of baseline cerebral edema.

METHODS

134 Patients with anterior circulation ischemic stroke receiving successful thrombectomy were retrospectively studied. Their demographic and clinical characteristics were collected at admission, and the NWU was quantitatively calculated based on baseline computed tomography (CT). The predictive value of PLR for futile recanalization and the relationship between PLR, NWU, and futile recanalization using mediation analysis were explored. Patients were followed up for 90 days and were divided into a futile recanalization group and a favorable prognosis group [90-day modified Rankin Scale score of 0-2].

RESULTS

High baseline PLR, NWU, no first-pass reperfusion, and large baseline ischemic core volume were independent predictors of futile recanalization after successful thrombectomy in patients with AIS. Mediation analysis results indicate that PLR may partially mediate the occurrence of futile recanalization through NWU.

CONCLUSION

Baseline PLR and NWU were independent predictors of futile recanalization, and higher PLR and NWU values were associated with a higher likelihood of futile recanalization. The findings suggest that early cerebral edema reflected by a high NWU value may be a mediator of PLR-affecting prognosis.

Impact of a New Preoperative Immune-Nutrition Protocol Using Zinc on Hospital Outcomes of Children with Hirschsprung's Disease: A Novel Randomized Controlled Trial

Purpose

Research proved the beneficial effect of Zinc on human health and Gastrointestinal tract inflammatory diseases. We propose that zinc would be of value in children with Hirschsprung's disease (HD) undergoing elective pull-through surgery. This study was carried out to determine the influence of preoperative zinc intake on postoperative outcomes, especially the hospital length of stay in patients diagnosed with HD as a primary outcome. Other outcomes include identification of the nutritional and inflammatory status including the nutritional and inflammatory markers in children with HD with possible impacts on hospital outcomes.

Methods

This is a randomized interventional control study that was applied to 50 children diagnosed with HD who underwent elective pull-through surgery. We randomly allocated 25 diagnosed with HD who underwent elective pull-through surgery. We randomly allocated 25 patients to zinc treatment.

Results

The results demonstrated that the interventional group had a lower incidence of complications (20%) when compared to the control group (64%), with a significant p-value of 0.002. In addition, less incidence of Hirschsprung's associated enterocolitis (HAEC) (12% vs. 40%) and skin excoriation (8% vs. 32%) were documented in the interventional group compared to the controls respectively.

Conclusion

Pre-operative zinc supplementation may have a beneficial impact on HD children undergoing elective pull-through surgery as regards outcomes such as HAEC and skin excoriation.

Evaluation of systemic immune-inflammation index and systemic inflammation response index in the differentiation of acute Ischemic stroke and transient Ischemic attack

Objective

The aim of this study was to examine the levels of hematologic parameters in acute ischemic stroke (AIS) and transient ischemic attack (TIA) and to evaluate the use of Neutrophil/Lymphocyte ratio (NLR), Systemic Immune-Inflammation Index (SII), and systemic inflammation response index (SIRI) in the differentiation of AIS and TIA.

Materials and Methods

Data and hematological results of patients admitted to the emergency department and diagnosed with AIS and TIA were compared retrospectively.

Results

The study included 36 TIA patients (M/F = 15/21) with a mean age of 64.52 ± 15.597 years and 74 AIS patients (M/F = 35/39) with a mean age of 71.91 ± 13.86 years. Laboratory data showed that lymphocyte count (p = 0.022) and hemoglobin level (p = 0.017) were significantly higher in AIS patients. In addition, monocyte count (p = 0.001), neutrophil/lymphocyte ratio (NLR) (p < 0.001), CRP level (p = 0.007), and SII (p = 0.001) and SIRI values (< 0.001) were significantly increased in AIS patients compared to TIA patients.

Conclusion

The results obtained in the present study show that hematologic inflammatory parameters are increased in AIS. NLR, SII and SIRI may provide insight in the differential diagnosis of AIS and TIA.

Safety of alteplase intravenous thrombolysis and influencing factors of clinical outcome in elderly patients with acute ischemic stroke

OBJECTIVE

To explore the safety of intravenous thrombolysis with alteplase (rt-PA) in the treatment of acute ischemic stroke (AIS) in the elderly (≥ 80 years old) and with analyze the influencing factors of its clinical outcome.

METHODS

A total of 144 elderly patients (≥ 80 years old) with AIS who were admitted to our hospital from April 2018 to October 2019 were divided into the elderly thrombolytic group (n = 55) and the elderly non-thrombolytic group (n = 89) according to their different treatment methods, and 166 non-elderly AIS thrombolytic patients in the same period were selected as the non-elderly thrombolytic group. Routine antiplatelet therapy or anticoagulant therapy was given to the elderly non-thrombolytic group, while intravenous thrombolysis with rt-PA was given to the elderly thrombolytic group and the non-elderly thrombolytic group. The changes in National Institutes of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), and intracranial hemorrhage transformation within 7 days, mortality within 3 months were used to evaluate the prognosis and safety of patients in each group. Binary Logistic regression was used to analyze the independent factors affecting the long-term prognosis of thrombolytic therapy for AIS in the elderly.

RESULTS

After the treatment, the short-term prognosis and the long-term prognosis improvement rates in the non-elderly thrombolytic group and the elderly thrombolytic group were higher than that in the elderly non-thrombolytic group (P < 0.05). There was no statistical difference in mortality between the elderly thrombolytic group and the elderly non-thrombolytic group or in intracranial hemorrhage transformation among the different groups (P > 0.05). Binary logistic regression analysis showed that NIHSS score before treatment was an independent risk factor affecting the long-term prognosis of elderly AIS patients after thrombolysis (P < 0.05).

CONCLUSION

Elderly AIS patients after rt-PA thrombolysis therapy can improve the short-term, long-term prognosis. The risk of intracranial hemorrhage transformation and death is not higher than that of elderly non thrombolytic patients, indicating that rt-PA treatment is safe for elderly AIS patients. The NIHSS score before treatment was an independent risk factor affecting the long-term prognosis of elderly AIS patients after thrombolytic therapy.

Association between neutrophil-to-lymphocyte ratio and short-term all-cause mortality in patients with cerebrovascular disease admitted to the intensive care unit-a study based on the MIMIC-IV database

BACKGROUND

Inflammation plays a crucial role in cerebrovascular disease (CVD) progression. Neutrophil-to-lymphocyte ratio (NLR) is an important inflammatory marker, though its diagnostic role in CVD is still under investigation. This study evaluates the relationship between NLR and short-term all-cause mortality in patients with CVD admitted to the intensive care unit (ICU).

METHODS

We conducted a retrospective study using data from the Medical Information Mart for Intensive Care (MIMIC-IV) (v2.2) database, including 4,327 adult ICU-admitted CVD patients. NLR values at admission were analyzed alongside various mortality variables. Multivariate Cox proportional hazards regression models and Kaplan-Meier (K-M) survival curves assessed the relationship between NLR and short-term all-cause mortality. Predictive power, sensitivity, specificity, and area under the curve (AUC) of NLR for short-term mortality were investigated using Receiver Operating Characteristic (ROC) analysis. Additionally, restricted cubic spline (RCS) curves and subgroup analyses were conducted.

RESULTS

Among the 4,327 patients, 3,600 survived (survival group) and 727 died (non-survival group) within 28 days of admission (mortality rate: 16.8%). A multivariate Cox regression analysis identified NLR as an independent predictor of 28-day all-cause mortality (hazard ratio: 1.013; 95% confidence interval: 1.0086-1.0188; p < 0.001). The predictive model, incorporating NLR, age, gender, BMI, Charlson comorbidity index (CCI), WBC counts, Platelet, INR, and CRP, achieved an AUC of 0.686 (95% confidence interval: 0.665-0.70). While platelet-to-lymphocyte ratio was also analyzed, its predictive efficiency was less pronounced compared to NLR. A best NLR threshold of 6.19 was determined, distinguishing survivors from non-survivors. Kaplan-Meier survival curves showed that patients with NLR ≥ 6.19 had significantly lower survival rates at 7-, 14-, 21-, and 28-days. Subgroup analyses indicated that NLR did not significantly interact with most subgroups.

CONCLUSION

NLR may serve as an independent predictor for short-term all-cause mortality in ICU-admitted CVD patients, enhancing our understanding of the association between inflammatory biomarkers and CVD prognosis.

Systemic immune-inflammation index predicts short-term mortality in acute ischemic stroke with severe stenosis of internal carotid artery associated pneumonia

BACKGROUND

We aimed to investigate the relationship between systemic immune-inflammation index (SII) and short-term mortality in acute ischemic stroke (AIS) with internal carotid artery (ICA) severe stenosis and stroke associated pneumonia (SAP) patients.

METHODS

Information on general demographic, laboratory data, CT angiography, magnetic resonance angiography, or digital subtraction angiography were obtained. The predictive power was evaluated by assessing the area under the receiver operating characteristic (ROC) curve. The logistic regression was performed to assess the association of SII and short-term mortality in severe stenosis ICA-AIS and SAP patients.

RESULT

Among 342 patients with severe stenosis ICA-AIS and SAP, death occurred in 66 patients during 120 days follow-up. Multivariate regression analyses indicated that increased SII predicts higher mortality in 120 days follow-up, and the risk of short-term mortality in SII > 666.31 × 109/L group is increased 4.671-fold. Patients with SII > 666.31 × 109/L had higher proportion of male, hypertension, smoking, higher admission NIHSS score, higher systolic blood pressure, and higher proportion of 120 days mortality. Higher SII predicted a worse 120 days mortality was worked out by Kaplan-Meier methods.

CONCLUSION

An elevated SII was remarkably associated with 120 days mortality in severe stenosis ICA-AIS and SAP patients.

Dynamic changes of systemic inflammation response index and systemic immune-inflammation index are associated with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

OBJECTIVES

Delayed cerebral ischemia (DCI) is a factor contributing to poor outcome of aneurysmal subarachnoid hemorrhage (aSAH). Serial inflammatory response is known to affect the occurrence of DCI. The aim of this study was to evaluate associations of dynamic changes of various inflammatory markers with occurrence of DCI after aSAH.

METHODS

A total of 279 patients with interventional treatment for aSAH were enrolled, and dichotomized according to the occurrence of DCI. Various inflammatory markers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and their dynamic changes were analyzed at four different time points. Receiver operating characteristic (ROC) curve analysis with area under the curve (AUC) and univariate, multivariate Cox regression analyses with hazard ratio (HR) and 95 % confidence interval (CI) were performed to identify predictors for DCI.

RESULTS

Differences of SII and SIRI values between DCI (+) and DCI (-) group were significantly higher at 5-7 days than at other time points (P < 0.001 and P < 0.001, respectively). SII and SIRI had higher predicting values for DCI occurrence than other inflammatory markers (AUC: 0.862, 95 % CI: 0.786-0.928; P < 0.001 and AUC: 0.851, 95 % CI: 0.769-0.913; P < 0.001, respectively). SII at 5-7 days (HR: 1.74, 95 % CI: 1.38-3.22, P = 0.020) and SIRI at 5-7 days (HR: 1.62, 95 % CI: 1.28-2.84, P = 0.035) were associated with occurrence of DCI.

CONCLUSIONS

Dynamic changes of SII and SII might be predictors of DCI occurrence in patients with aSAH.

Inflammatory biomarkers are correlated with thrombus burden in cerebral venous sinus thrombosis

BACKGROUND

 Increasing evidence suggests that inflammatory biomarkers play a significant role in cerebral venous sinus thrombosis (CVST). The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) are related to thrombotic conditions and indicators of systemic inflammation.

OBJECTIVE

 To analyze the correlation between inflammatory biomarkers and the extent of thrombus, determined by the CVST-Score.

METHODS

 A total of 40 patients with CVST (24 female subjects; 60%) and 40 age- and sex-matched healthy controls were retrospectively evaluated. Inflammatory biomarkers, including C-reactive protein (CRP), PLR, NLR, MLR, and the CVST-Score, were recorded to assess the relationship between biomarkers and thrombus burden. The patients were grouped according to symptom duration (group 1: 0-3 days; group 2: 4-7 days; and group 3: 8-30 days) to compare biomarker levels.

RESULTS

 The CRP, NLR, and PLR were significantly higher in the CVST group (p < 0.001; p = 0.003; p = 0.014 respectively). The NLR and PLR presented a significant positive correlation with the CVST-Score (p = 0.003, r = 0.464; p = 0.040, r = 0.326 respectively). The NLR was significantly higher in group 1 compared with groups 2 and 3 (p = 0.016 and p = 0.014 respectively). In group 1, there was a stronger positive correlation between the CVST-Score and the NLR (p = 0.026, r = 0.591) and the PLR (p = 0.012, r = 0.648). The multiple linear regression analysis revealed that the NLR is a key factor in predicting the CVST-Score (p = 0.019).

CONCLUSION

 The NLR and PLR are associated with thrombus burden in CVST, especially in patients admitted to the hospital in the early stages. The NLR is an independent factor to predict the thrombus burden in CVST.

Higher fibrinogen and neutrophil-to-lymphocyte ratio are associated with the early poor response to intravenous thrombolysis in acute ischemic stroke

Background

Inflammation and platelet activation play pivotal roles in acute ischemic stroke (AIS) pathogenesis. Early response to thrombolysis is a vital indicator for the long-term prognosis of AIS. However, the correlation between fibrinogen or the neutrophil-to-lymphocyte ratio (NLR) and the early response to intravenous thrombolysis in patients with AIS remains unclear.

Methods

AIS patients undergoing intravenous thrombolysis were enrolled between January 2018 and May 2023. Blood cell counts were sampled before thrombolysis. A good response was defined as a National Institutes of Health Stroke Scale (NIHSS) score decreased ≥4 or complete recovery 24 h after thrombolysis treatment. A poor response was defined as any increase in the NIHSS score or a decrease in the NIHSS score <4 at the 24 h after thrombolysis treatment compared with that at admission. Logistic regression analysis was performed to explore the relationship of the fibrinogen level and NLR with a poor thrombolysis response. Receiver operating characteristic (ROC) analysis was used to assess the ability of the fibrinogen level and NLR to discriminate poor responders.

Results

Among 700 recruited patients, 268 (38.29%) were diagnosed with a good response, and 432 (61.71%) were diagnosed with a poor response to intravenous thrombolysis. A binary logistic regression model indicated that an elevated fibrinogen level (odds ratio [OR], 1.693; 95% confidence interval [CI] 1.325-2.122, P < 0.001) and NLR (OR, 1.253; 95% CI, 1.210-2.005, P = 0.001) were independent factors for a poor response. The area under the curve (AUC) values for the fibrinogen level, NLR and fibrinogen level combined with the NLR for a poor response were 0.708, 0.605, and 0.728, respectively.

Conclusions

Our research indicates that the levels of fibrinogen and NLR at admission can be used as a prognostic factor to predict early poor response to intravenous thrombolysis.

Supra-Blan2 t score as a multisystem-based risk score to predict poor 3-month outcome in acute ischemic stroke patients with intravenous thrombolysis

AIM

To develop and validate a novel weighted score integrating multisystem laboratory and clinical variables to predict poor 3-month outcome (mRS score of 3-6) in acute ischemic stroke (AIS) patients with intravenous thrombolysis (IVT) therapy.

METHODS

We retrospectively analyzed data from Trial of Revascularization Treatment for Acute Ischemic Stroke study. The Supra-Blan2 t score was derived using the data on age, the National Institutes of Health Stroke Scale score, history of atrial fibrillation, blood sugar level, neutrophil count, direct bilirubin level, platelet-lymphocyte ratio, and TnI level in the derivation cohort of 433 patients, and validated in a cohort of 525 patients. Furthermore, we compared the performance of the Supra-Blan2 t score with DRAGON, TURN, and SPAN-100 scores.

RESULTS

The discrimination capacity in the derivation and validation cohorts was good for poor 3-month outcome (the area under the curve was 0.821 and 0.843, respectively). The cumulative incidence of poor 3-month outcome significantly increased across risk categories in the derivation (low-risk, 9.2%; medium-risk, 17.4%; and high-risk, 58.8%) and validation cohorts (12.7%, 36.5%, and 73.6%, respectively). The performance of the Supra-Blan2 t score was similar to or superior to DRAGON, TURN, and SPAN-100 scores.

CONCLUSION

The Supra-Blan2 t score, based on easily available multisystem laboratory and clinical variables, reliably predicted poor 3-month functional outcome in AIS patients treated with IVT therapy featuring good calibration and discrimination.

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 at admission is a risk factor for in-hospital gastrointestinal bleeding in acute ischemic stroke patients after dual antiplatelet therapy: A case control study

BACKGROUND

Gastrointestinal bleeding is a clinically important complication in acute ischemic stroke patients after dual antiplatelet therapy. The present study was to explore the association between neutrophil-to-lymphocyte ratio (NLR) and in-hospital gastrointestinal bleeding in acute ischemic stroke (AIS) patients who had received dual antiplatelet therapy.

METHODS

This restrospective study enrolled AIS patients who had received dual antiplatelet therapy in our hospital from January 2019 to December 2021. Patients were divided into a bleeding group and a non-bleeding group according to whether they had in-hospital gastrointestinal bleeding. Propensity score matching was used to match the confounding variables between the two groups. Multivariate logistic regression was performed to evaluate the association between NLR and in-hospital gastrointestinal bleeding. Receiver operating characteristic (ROC) curve was used to test the prediction ability of NLR.

RESULTS

A total of 1130 patients were enrolled in this study. Before matching, there were 51 patients in the bleeding group, 1079 patients in the non-bleeding group. After matching, 49 pairs of patients were successfully matched. Multivariate regression revealed that NLR was an independent predictor of in-hospital gastrointestinal bleeding in AIS patients who had received dual antiplatelet therapy. The area under curve (AUC) of NLR in predicting in-hospital gastrointestinal bleeding was 0.908, the sensitivity and specificity were 0.878 and 0.857 respectively.

CONCLUSIONS

NLR at admission is a useful predictor of in-hospital gastrointestinal bleeding in acute ischemic stroke patients after dual antiplatelet therapy. Still, more prospective studies with larger sample size are needed to validate the result.

Pan-Immune-Inflammatory Value Predicts the 3 Months Outcome in Acute Ischemic Stroke Patients after Intravenous Thrombolysis

BACKGROUND AND PURPOSE

Immune and inflammatory response plays a central role in the clinical outcomes of stroke. This study is aimed to explore the clinical significance of the new inflammation index named pan-immune-inflammation value (PIV) in patients with acute ischemic stroke (AIS) after intravenous thrombolysis therapy (IVT).

METHODS

Data were collected from 717 patients who received IVT at the First Affiliated Hospital of Soochow University. Baseline data were collected before intravenous thrombolysis. Multivariate logistic regression analysis was used to assess the association between PIV and 3 months clinical outcome after intravenous thrombolysis. We also used receiver operating characteristic (ROC) curves analysis to assess the discriminative ability of PIV, platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), and systemic immune-inflammation index (SII) in predicting 3 months poor outcome.

RESULTS

Of 717 patients, 182 (25.4%) patients had poor outcomes at 3 months. Patients with 3 months of poor outcome had significantly higher PIV levels compared to those with favorable outcomes [316.32 (187.42-585.67) vs. 223.80 (131.76-394.97), p < 0.001)]. After adjusting for potential confounders, the risk of 3 months of poor outcome was significantly higher among patients whose PIV fell in the third quartile (244.21-434.49) and the fourth quartile (> 434.49) than those in the first quartile (< 139.93) (OR = 1.905, 95% CI: 1.040-3.489; OR = 2.229, 95%CI: 1.229-4.044). The area under the ROC curve of PIV to predict 3 months of poor outcome was 0.607 (95%CI: 0.560-0.654; p < 0.001). The optimal cut-off values of PIV were 283.84 (59% sensitivity and 62% specificity).

CONCLUSION

The higher levels of PIV were independently associated with 3 months of poor outcomes in AIS patients receiving IVT. PIV like other inflammatory factors (PLR, NLR, and SII), can also predict adverse outcomes after IVT in AIS patients.

Association of platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio with outcomes in stroke patients achieving successful recanalization by endovascular thrombectomy

Objective

Serum inflammatory biomarkers play crucial roles in the development of acute ischemic stroke (AIS). In this study, we explored the association between inflammatory biomarkers including platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and monocyte-to-lymphocyte ratio (MLR), and clinical outcomes in AIS patients who achieved successful recanalization.

Methods

Patients with AIS who underwent endovascular thrombectomy (EVT) and achieved a modified thrombolysis in the cerebral infarction scale of 2b or 3 were screened from a prospective cohort at our institution between January 2013 and June 2021. Data on blood parameters and other baseline characteristics were collected. The functional outcome was an unfavorable outcome defined by a modified Rankin Scale of 3-6 at the 3-month follow up. Other clinical outcomes included symptomatic intracranial hemorrhage (sICH) and 3-month mortality. Multivariable logistic regression analysis was performed to evaluate the effects of PLR, NLR, and MLR on clinical outcomes.

Results

A total of 796 patients were enrolled, of which 89 (11.2%) developed sICH, 465 (58.4%) had unfavorable outcomes at 3 months, and 168 (12.1%) died at the 3-month follow up. After adjusting for confounding variables, a higher NLR (OR, 1.076; 95% confidence interval [CI], 1.037-1.117; p < 0.001) and PLR (OR, 1.001; 95%CI, 1.000-1.003; p = 0.045) were significantly associated with unfavorable outcomes, the area under the receiver operating characteristic curve of NLR and PLR was 0.622 and 0.564, respectively. However, NLR, PLR, and MLR were not independently associated with sICH and 3-month mortality (all adjusted p > 0.05).

Conclusion

Overall, our results indicate that higher PLR and NLR were independently associated with unfavorable functional outcomes in AIS patients with successful recanalization after EVT; however, the underlying mechanisms are yet to be elucidated.

Emerging Treatment Strategies for Cerebral Ischemia-Reperfusion Injury

Cerebral ischemia-reperfusion injury (CI/RI) injury is a common feature of ischemic stroke which occurs when the blood supply is restored after a period of ischemia in the brain. Reduced blood-flow to the brain during CI/RI compromises neuronal cell health as a result of mitochondrial dysfunction, oxidative stress, cytokine production, inflammation and tissue damage. Reperfusion therapy during CI/RI can restore the blood flow to ischemic regions of brain which are not yet infarcted. The long-term goal of CI/RI therapy is to reduce stroke-related neuronal cell death, disability and mortality. A range of drug and interventional therapies have emerged that can alleviate CI/RI mediated oxidative stress, inflammation and apoptosis in the brain. Herein, we review recent studies on CI/RI interventions for which a mechanism of action has been described and the potential of these therapeutic modalities for future use in the clinic.

The efficacy and safety of intravenous tirofiban in the treatment of acute ischemic stroke patients with early neurological deterioration

WHAT IS KNOWN AND OBJECTIVE

Many patients with acute ischemic stroke (AIS) develop early neurological deterioration (END), leading to disabilities or death. Thus, this study aimed to investigate the efficacy and safety of intravenous tirofiban in treating patients with AIS and END who missed the thrombolysis time window.

METHODS

A total of 123 AIS-END patients participated in the study between January 2021 and December 2021. Patients were randomized into the tirofiban group (n = 63) and the control group (n = 60) based on whether a tirofiban injection was administered. The National Institute of Health Stroke Scale (NIHSS) was used to assess neurological function at the 48th hour and on the 7th day after intervention, and the modified Rankin Scale (mRS) was used to assess neurological recovery 90 days after AIS. Adverse reactions during the intervention were recorded for safety analysis.

RESULTS AND DISCUSSION

The 7th day NIHSS and 90th day post-AIS mRS scores of the tirofiban group were significantly lower than those of the control group (p < 0.05), while the 90th day good prognosis (mRS ≤ 2) rate of the tirofiban group was significantly higher (84.13% vs. 65.00%, p < 0.05). Logistic regression demonstrated a protective effect of tirofiban for good prognosis in AIS patients with END (OR = 4.675, 95% CI [1.012-21.605], p < 0.05). No cases of intracranial haemorrhage transformation or death were observed during the treatment in either group.

WHAT IS NEW AND CONCLUSION

Tirofiban injection exhibited a high safety profile and significantly improved the prognosis of AIS-END patients who missed the intravenous thrombolysis time window.

Platelet-to-lymphocyte ratio at 24h after thrombolysis is a prognostic marker in acute ischemic stroke patients

Background

The changes in the platelet-to-lymphocyte ratio (PLR) before and after recombinant tissue plasminogen activator (rtPA) treatment and the time point at which the PLR is a potentially valuable prognostic predictor in patients wit ischemic stroke remain largely unknown. Therefore, the purpose of this study was to explore the characteristics of the PLR and evaluate their effects on clinical outcomes before and 24 h after rtPA treatment.

Methods

This study included 741 consecutive patients with acute ischemic stroke who underwent intravenous thrombolysis with rtPA. We collected data on demographics, vascular risk factors, medication history, and other clinical information pertaining to all patients. Specifically, blood samples for PLR measurement were collected on admission and 24 h after stroke. The outcome was assessed by using the Modified Rankin Scale (mRS) at 3 months and whether death occurred within 3 months or not. Univariate and multivariate logistic regression analysis was used to assess the association of the PLR with the risks of poor outcome (mRS>2) and death. An individualized prediction model was established to predict poor outcome.

Results

Of the 741 patients, 255 (34.4%) had poor outcome, and 43 (5.8%) died. The PLR significantly increased 24 h after rtPA in patients with poor outcome and death. Logistic analysis revealed that higher PLR 24 h after rtPA was independently associated with increased risks of poor outcome and death. However, the PLR on admission was not associated with the risks of poor outcome and death. The individualized prediction model for poor outcome based on the 24-h PLR exhibited favorable discrimination (areas under the curves of the training and validation groups: 0.743 and 0.729, respectively), calibration (P > 0.05), and clinical usefulness.

Conclusions

We found the PLR to be a variable that potentially predicts the risks of poor outcome and death in patients with acute ischemic stroke 24 h after rtPA; however, it cannot make the same prediction on admission.

Neutrophil-to-Lymphocyte ratio on admission predicts gastrointestinal bleeding in acute basal ganglia hemorrhage

Background

Gastrointestinal bleeding (GIB) is a potential contributing factor for poor prognosis of spontaneous basal ganglia hemorrhage (BGH). This study aimed to investigate the predictive value of new inflammatory biomarkers including neutrophil to lymphocytes (NLR) on admission and construct a nomogram for rapidly predicting GIB in acute BGH.

Methods

The retrospective study included all patients with acute BGH admitted from the emergency department in Huashan Hospital from July 2017 to January 2019. Multivariate analysis was conducted to evaluate the correlation between factors within 24 h and the occurrence of GIB within 7 days after BGH. The receiver operating characteristic (ROC) curve was performed to estimate the prediction ability of inflammatory biomarkers. A nomogram based on significant predictors was validated by ROC curve and calibration curve.

Results

A total of 122 patients were enrolled in this study, and the incidence of GIB was 23.0%. Patients with GIB had larger hematoma volume (≥30 ml), lower Glasgow Coma Scale (GCS) score (≤8) and increased inflammatory biomarkers on admission. ROC curve revealed that NLR had a high predictive value to the complication (area under the curve = 0.87). According to multivariate analysis, NLR, GCS score, and hematoma volume were main factors for nomogram, with good calibration and discrimination.

Conclusions

Neutrophil‐to‐lymphocyte ratio and GCS score within 24 h after the onset of acute BGH are the independent risk factors for GIB. The nomogram developed by these predictors may assist surgeons in rapidly assessing and preventing of GIB for BGH patients in earlier stage.

Prognostic Role of the Platelet-Lymphocyte Ratio in Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy: A Meta-Analysis

Background

Both inflammation and thrombotic/hemostatic mechanisms may play a role in acute ischemic stroke (AIS) pathogenesis, and a biomarker, such as the platelet-to-lymphocyte ratio (PLR), considering both mechanisms may be of clinical utility.

Objectives

This meta-analysis sought to examine the effect of PLR on functional outcomes, early neurological changes, bleeding complications, mortality, and adverse outcomes in AIS patients treated with reperfusion therapy (RT).

Design

Systematic Review and Meta-Analysis.

Data Sources and Methods

Individual studies were retrieved from the PubMed/Medline, EMBASE and Cochrane databases. References thereof were also consulted. Data were extracted using a standardised data sheet, and systematic reviews and meta-analyses on the association of admission (pre-RT) or delayed (post-RT) PLR with defined clinical and safety outcomes were conducted. In the case of multiple delayed PLR timepoints, the timepoint closest to 24 hours was selected.

Results

Eighteen studies (n=4878) were identified for the systematic review, of which 14 (n=4413) were included in the meta-analyses. PLR collected at admission was significantly negatively associated with 90-day good functional outcomes (SMD=-.32; 95% CI = -.58 to -.05; P=.020; z=-2.328), as was PLR collected at delayed timepoints (SMD=-.43; 95% CI = -.54 to -.32; P<.0001; z=-7.454). PLR at delayed timepoints was also significantly negatively associated with ENI (SMD=-.18; 95% CI = -.29 to -.08; P=.001. Conversely, the study suggested that a higher PLR at delayed timepoints may be associated with radiological bleeding and mortality. The results varied based on the type of RT administered.

Conclusions

A higher PLR is associated with worse outcomes after stroke in terms of morbidity, mortality, and safety outcomes after stroke.

Prediction of Early Mortality Among Children With Moderate or Severe Traumatic Brain Injury Based on a Nomogram Integrating Radiological and Inflammation-Based Biomarkers

Inflammation-based scores have been increasingly used for prognosis prediction in neurological diseases. This study aimed to investigate the predictive value of inflammation-based scores combined with radiological characteristics in children with moderate or severe traumatic brain injury (MS-TBI). A total of 104 pediatric patients with MS-TBI were retrospectively enrolled and randomly divided into training and validation cohorts at a 7:3 ratio. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of prognosis in pediatric patients with MS-TBI. A prognostic nomogram was constructed, and its predictive performance was validated in both the training and validation cohorts. Sex, admission platelet-to-lymphocyte ratio, and basal cistern status from initial CT findings were identified as independent prognostic predictors for children with MS-TBI in multivariate logistic analysis. Based on these findings, a nomogram was then developed and its concordance index values were 0.918 [95% confidence interval (CI): 0.837-0.999] in the training cohort and 0.86 (95% CI: 0.70-1.00) in the validation cohort, which significantly outperformed those of the Rotterdam, Marshall, and Helsinki CT scores. The proposed nomogram, based on routine complete blood count and initial CT scan findings, can contribute to individualized prognosis prediction and clinical decision-making in children with MS-TBI.

Clinical Value of the Prognostic Nutrition Index in the Assessment of Prognosis in Critically Ill Patients with Stroke: A Retrospective Analysis

Purpose

The purpose of study was to evaluate the association between prognostic nutritional index (PNI) and all-cause mortality of critically ill patients with stroke.

Methods

Clinical data derived from Multiparameter Intelligent Monitoring in Intensive Care were analyzed. The primary endpoint was 30-day all-cause mortality; secondary endpoints were 90-day mortality and one-year cause mortality. The potential prognostic roles of PNI were analyzed by Cox proportional hazard models. The independent prognostic roles of PNI in the cases were analyzed by smooth curve fitting.

Results

Concerning 30-day mortality, the HR (95% CI) for a high PNI (≥39.7) was 0.700 (0.544, 0.900; P = 0.00539), compared to a low PNI (<39.7). After adjusting for multiple confounders, the HR (95% CI) for a high PNI (≥39.7) was 0.732 (0.547, 0.978; P = 0.03514), compared to a low PNI (<39.7). Regarding 90-day and one-year mortality, a similar trend was observed. In addition, a nonlinear association between PNI and 30-day mortality was found. Using recursive algorithm and two-piecewise linear regression model, inflection point (IP) was calculated, which was 49.4. On the right side of the IP, there was a positive relationship between PNI and 30-day mortality, and the effect size, 95% CI, and P value were 1.04 (1.01, 1.07), P = 0.0429, respectively. On the left of the IP, the effect size, 95% CI, and P value were 0.97 (0.96, 0.99) and 0.0011, respectively.

Conclusions

The PNI was an independent predicting factor of 30-day, 90-day, and 1-year mortality of the critically ill patients with stroke. In addition, there was a U-shaped relationship between PNI and all-cause mortality of stroke patients. PNI was a risk factor for the outcome of stroke when PNI was >49.4, while PNI was a protective factor for outcome of stroke when PNI was <49.4.

Predictive Value of the Systemic Immune Inflammation Index for Adverse Outcomes in Patients With Acute Ischemic Stroke

Background and Purpose

The systemic immune-inflammation index, a new index based on platelets, neutrophils and lymphocytes, has been shown to be associated with outcomes of patients with venous sinus thrombosis and cancer. However, its application in acute ischemic stroke has rarely been reported. Therefore, we examined the relationship between systemic immune-inflammation index levels at hospital admission and the outcomes of patients 3 months after onset, and plotted a nomogram to predict the probability of adverse outcomes in patients with acute ischemic stroke.

Methods

We retrospectively analyzed a total of 208 patients with acute ischemic stroke who were admitted between January 2020 and December 2020, and recorded the modified Rankin score 3 months later. A modified Rankin score ≥ 3 was defined as an adverse outcome. Age, sex, NIHSS score, SII, hypertension and coronary heart disease were included in the binary logistic regression, and the nomogram was plotted with a regression equation.

Results

Receiver operating characteristic (ROC) curve analysis indicated that the best cutoff value of the systemic immune-inflammation index was 802.8, with a sensitivity of 70.9% and specificity of 58.2% (area under the curve: 0.657, 95% confidence interval: 0.572–0.742). The nomogram had a C index of 0.802. The average error of the calibration curves of the training set and the validation set was 0.021 and 0.034, respectively.

Conclusion

The systemic immune-inflammation index is associated with short-term adverse outcomes in patients with acute ischemic stroke, and the nomograms can predict the risk of adverse outcomes in patients with acute ischemic stroke.

Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, and Monocyte-to-Lymphocyte Ratio in Depression: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Research on neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) in depression is still emerging and has increased 3-fold since the first meta-analysis. An updated meta-analysis with sufficient studies can provide more evidence for a potential relationship between NLR, PLR, MLR, and depression.

METHODS

We identified 18 studies from the PubMed, EMBASE, Cochrane library, and Web of Science databases. Meta-analyses were performed to generate pooled standardized mean differences (SMDs) and 95% confidence intervals (CIs) between patients with depression and controls. Sensitivity analysis, subgroup analysis, meta-regression, and publication bias were conducted.

RESULTS

A total of 18 studies including 2,264 depressed patients and 2,415 controls were included. Depressed patients had significantly higher NLR and PLR compared with controls (SMD = 0.33, 95% CI: 0.15-0.52, p < 0.001 and SMD = 0.24, 95% CI: 0.02-0.46, p < 0.05, respectively). MLR was slightly higher in depressed individuals compared to controls (SMD = 0.15, 95% CI: -0.26 to 0.55, p > 0.05), despite the absence of significance. Sensitivity analysis removing one study responsible for heterogeneity showed a higher and significant effect (SMD = 0.32, 95% CI: 0.20-0.44) of MLR. Three subgroup analyses of NLR, PLR, MLR, and depression revealed obvious differences in the inflammatory ratios between depressed patients and controls in China and the matched age and gender subgroup. Individuals with post-stroke depression (PSD) had higher NLR and MLR values as compared to non-PSD patients (SMD = 0.51, 95% CI: 0.36-0.67, p < 0.001 and SMD = 0.46, 95% CI: 0.12-0.79, p < 0.01, respectively). Meta-regression analyses showed that male proportion in the case group influenced the heterogeneity among studies that measured NLR values (p < 0.05).

CONCLUSIONS

Higher inflammatory ratios, especially NLR, were significantly associated with an increased risk of depression. In the subgroup of China and matched age and gender, NLR, PLR, and MLR were all elevated in depressed patients vs. controls. Individuals with PSD had higher NLR and MLR values as compared to non-PSD patients. Gender differences may have an effect on NLR values in patients with depression.

Increased Platelet-to-Lymphocyte Ratio is an Independent Predictor of Hemorrhagic Transformation and In-Hospital Mortality Among Acute Ischemic Stroke with Large-Artery Atherosclerosis Patients

Background

The platelet-to-lymphocyte ratio (PLR) is an inflammation marker of acute ischemic stroke, but its significance in patients with hemorrhage transformation (HT) after acute ischemic stroke with large-artery atherosclerosis (AIS-LAA) is unclear, and we also identified the relationship between PLR and in-hospital mortality of HT after AIS-LAA.

Methods

This was a retrospective analysis of patients with AIS-LAA. The PLR was calculated according to platelet and lymphocyte counts on admission. HT was defined on follow-up magnetic resonance imaging or computed tomography when neurologic deterioration worsened during hospitalization. The univariate analysis and multivariate logistic regression were performed to assess the association of PLR, HT and in-hospital mortality of HT after AIS-LAA.

Results

We included 328 Chinese AIS-LAA patients (mean age 67.2±11.1 years; 70.4% male). HT occurred in 38 patients (11.6%). After multivariate regression analyses, NRL (odds ratio [OR] 1.354, 95% confidence interval [CI] 1.176–1.559, P<0.001) and PLR (odds ratio [OR] 3.869, 95% confidence interval [CI] 2.233–5.702, P<0.001) were independently associated with HT after AIS-LAA. The area under the ROC curve (AUC) value of PLR (0.72, 95% CI (0.64–0.80), P<0.001) tested a greater discriminatory ability compared with neutrophil-lymphocyte ratio (NLR) (0.67, 95% CI (0.58–0.76), P<0.001). Meanwhile, PLR was found to be significantly related to HT after AIS-LAA, including in subtypes of artery-to-artery embolization (aOR 1.699, 95% CI 1.298–3.215, P<0.001), in-situ thrombosis (aOR4.499, 95% CI 1.344–9.054, P<0.001) and branch atheromatous disease (aOR3.239, 95% CI 1.098–8.354, P<0.001). Increased PLR predicts high in-hospital mortality of HT after AIS-LAA (OR 1.041, 95% CI (1.006–1.077), P=0.020; aOR 1.053, 95% CI (1.004–1.104), P=0.034).

Conclusion

High PLR is associated with greater risk of HT in AIS-LAA patients, including in artery-to-artery embolization, in-situ thrombosis and branch atheromatous disease. Meanwhile, increased PLR predicts high in-hospital mortality of HT after AIS-LAA.

Acute Inflammation in Cerebrovascular Disease: A Critical Reappraisal with Focus on Human Studies

Recent attention has been focused on the field of inflammatory biomarkers associated with vascular disorders, regarding diagnosis, prognosis, and possible therapeutical targets. In this study, we aimed to perform a comprehensive review of the literature regarding the use of inflammatory biomarkers in stroke patients. We searched studies that evaluated inflammation biomarkers associated with Cerebrovascular Disease (CVD), namely, ischemic Stroke (IS), Intracerebral Hemorrhage (ICH) and Cerebral Venous Thrombosis (CVT). As of today, neutrophil–lymphocyte ratio (NLR) seems the be the most widely studied and accepted biomarker for cerebrovascular disease due to its easy access and availability. Although demonstrated as a prognostic risk factor, in IS, ICH and CVT, its diagnostic role is still under investigation. Several other prognostic factors could be used or even combined together into a diagnostic or prognostic index. Multiple inflammatory biomarkers appear to be involved in IS, ICH, and CVT. Blood inflammatory cells, easily measured and accessible at admission may provide information regarding accurate diagnosis and prognosis. Although not yet a reality, increasing evidence exists to suggest that these may become potential therapeutic targets, likely influencing or mitigating complications of CVD and improving prognosis. Nevertheless, further larger, well-designed randomized clinical trials are still needed to follow up this hypothesis.

Inflammatory Biomarkers and Intracranial Hemorrhage after Endovascular Thrombectomy

BACKGROUND

Intracranial hemorrhage after endovascular thrombectomy is associated with poorer prognosis compared with those who do not develop the complication. Our study aims to determine predictors of post-EVT hemorrhage - more specifically, inflammatory biomarkers present in baseline serology.

METHODS

We performed a retrospective review of consecutive patients treated with EVT for acute large vessel ischemic stroke. The primary outcome of the study is the presence of ICH on the post-EVT scan. We used four definitions: the SITS-MOST criteria, the NINDS criteria, asymptomatic hemorrhage, and overall hemorrhage. We identified nonredundant predictors of outcome using backward elimination based on Akaike Information Criteria. We then assessed prediction accuracy using area under the receiver operating curve. Then we implemented variable importance ranking from logistic regression models using the drop in Naegelkerke R2 with the exclusion of each predictor.

RESULTS

Our study demonstrates a 6.3% SITS (16/252) and 10.0% NINDS (25/252) sICH rate, as well as a 19.4% asymptomatic (49/252) and 29.4% (74/252) overall hemorrhage rate. Serologic markers that demonstrated association with post-EVT hemorrhage were: low lymphocyte count (SITS), high neutrophil count (NINDS, overall hemorrhage), low platelet to lymphocyte ratio (NINDS), and low total WBC (NINDS, asymptomatic hemorrhage).

CONCLUSION

Higher neutrophil counts, low WBC counts, low lymphocyte counts, and low platelet to lymphoycyte ratio were baseline serology biomarkers that were associated with post-EVT hemorrhage. Our findings, particularly the association of diabetes mellitus and high neutrophil, support experimental data on the role of thromboinflammation in hemorrhagic transformation of large vessel occlusions.

The Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Predict Reperfusion and Prognosis after Endovascular Treatment of Acute Ischemic Stroke

Background: Studies assessing the prognostic effect of inflammatory markers of blood cells on the outcomes of patients with acute ischemic stroke treated with endovascular treatment (EVT) are sparse. We evaluated whether the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) affect reperfusion status in patients receiving EVT. Methods: Using a multicenter registry database, 282 patients treated with EVT were enrolled in this study. The primary outcome measure was unsuccessful reperfusion rate after EVT defined by thrombolysis in cerebral infarction grades 0–2a. Logistic regression analysis was performed to analyze the association between NLR/PLR and unsuccessful reperfusion rate after EVT. Results: Both NLR and PLR were higher in the unsuccessful reperfusion group than in the successful reperfusion group (p < 0.001). Multivariate analysis showed that both NLR and PLR were significantly associated with unsuccessful reperfusion (adjusted odds ratio (95% confidence interval): 1.11 (1.04–1.19), PLR: 1.004 (1.001–1.01)). The receiver operating characteristic curve showed that the predictive ability of both NLR and PLR was close to good (area under the curve (AUC) of NLR: 0.63, 95% CI (0.54–0.72), p < 0.001; AUC of PLR: 0.65, 95% CI (0.57–0.73), p < 0.001). The cutoff values of NLR and PLR were 6.2 and 103.6 for unsuccessful reperfusion, respectively. Conclusion: Higher NLR and PLR were associated with unsuccessful reperfusion after EVT. The combined application of both biomarkers could be useful for predicting outcomes after EVT.

Red cell index: A novel biomarker for 3-month mortality in acute ischemic stroke patients treated with intravenous thrombolysis

BACKGROUND

The red cell index (RCI) was described as a biomarker for evaluating respiratory function in previous studies, but the relationship between RCI and stroke, remained a mystery. The present study aimed to probe the association between RCI at 24-hr and 3-month mortality and functional outcomes among acute ischemic stroke (AIS) patients treated with recombinant tissue plasminogen activator (r-tPA).

METHODS

A total of 217 AIS patients between January 2016 and January 2019 were recruited in this retrospective study. AIS patients were grouped in terms of RCI tertiles. Predictive factors were confirmed via multivariate logistic regression analysis. The receiver operating characteristic (ROC) was used to assess the ability of RCI in predicting mortality. In addition, the risk of 3-month all-cause mortality was evaluated by Cox proportional hazard model.

RESULTS

We grouped AIS patients into tertiles with the purpose of comparing clinical factors and RCI levels. Multivariate logistic regression analysis presented that RCI (odds ratio [OR] = 1.443, 95% confidence interval [CI] [1.167-1.786], p = 0.001) was an independent biomarker for 3-month all-cause mortality. The best cutoff value of RCI was 2.41 (area under the curve [AUC] = 0.639, 95% CI [0.501-0.778], p = .032), with a sensitivity of 40.9% and a specificity of 89.7%. Cox survival analysis demonstrated a positive significant correlation between RCI (hazard ratio [HR] = 1.332, 95% CI [1.148-1.545], p < .001) and mortality risk.

CONCLUSION

RCI, a potential predictor, was significantly associated with 3-month mortality in AIS patients with r-tPA.

Evaluation of hematological parameters as an indicator of disease severity in Covid-19 patients: Pakistan's experience

BACKGROUND

The severity of COVID-19 could be evaluated by examining several blood parameters mainly white blood cell (WBC) count, granulocytes, platelet, and novel hemocytometric markers neutrophils to lymphocyte ratio (NLR), platelet-to-lymphocyte (PLR), and lymphocyte to monocyte ratio (LMR). The current study was conducted to investigate alteration in blood parameters and their association with the severity and mortality of COVID-19 patients.

METHODOLOGY

An observational cross-sectional study was conducted retrospectively, a total of 101 COVID-19 positive patients were examined: 52 were mild, 24 were moderate, 09 were severe, and 16 were critically diseased patients. We also recorded 16 deaths associated with the critical group. The overall mean age observed in our study was 48.94 years, where the mean age for critical individuals was 62.12 ± 14.35 years.

RESULTS

A significant association between the disease severity and elevation in blood parameters were observed. The WBC's and granulocyte count were significantly increased (p value <0.001) while the mean platelet count (165.0 × 109 /L) and red blood cell volume distribution width (RDW) were decreased in the critical group (57.86%) compared to mild group's patients (177.3%) (p = 0.83). The lymphocytes count was decreased in critical patients (1.40 × 109 /L) compared to mild patients (1.92 × 109 /L) (p = 0.28). A significant association was observed in platelet-lymphocyte ratio (p < 0.001), Neutrophil-Lymphocyte ratio (p = <0.001), and Lymphocyte-Monocyte ratio (0.011).

CONCLUSION

These blood parameters could be used as a suitable biomarker for the prognosis and severity of COVID-19. Evaluating novel hemograms NLR, PLR, and LMR can aid clinicians to identify potentially severe cases at early stages, initiate effective management in time, and conduct early triage which may reduce the overall mortality of COVID-19 patients.

Systemic Inflammation Response Index and Systemic Immune-inflammation Index for Predicting the Prognosis of Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVES

Inflammatory response plays a pivotal role in the progress of aneurysmal subarachnoid hemorrhage (aSAH). As novel inflammatory markers, systemic inflammation response index (SIRI) and systemic immune-inflammation (SII) index could reflect clinical outcomes of patients with various diseases. The aim of this study was to ascertain whether initial SIRI and SII index were associated with prognosis of aSAH patients.

METHODS

A total of 680 patients with aSAH were enrolled. Their prognosis was evaluated with modified Rankin Scale (mRS) at 3 months, and unfavorable clinical outcome was defined as mRS score of 3-6. Receiver operating characteristic (ROC) curve analysis was performed to identify cutoff values of SIRI and SII index for predicting clinical outcomes. Univariate and multivariate regression analyses were performed to explore relationships of SIRI and SII index with prognosis of patients.

RESULTS

Optimal cutoff values of SIRI and SII index to discriminate between favorable and unfavorable clinical outcomes were 3.2 × 10⁹/L and 960 × 10⁹/L, respectively (P < 0.001 and 0.004, respectively). In multivariate analysis, SIRI value ≥ 3.2 × 10⁹/L (odds ratio [OR]: 1.82, 95% CI: 1.46-3.24; P = 0.021) and SII index value ≥ 960 × 10⁹/L (OR: 1.68, 95% CI: 1.24-2.74; P = 0.040) were independent predicting factors for poor prognosis after aSAH.

CONCLUSIONS

SIRI and SII index values are associated with clinical outcomes of patients with aSAH. Elevated SIRI and SII index could be independent predicting factors for a poor prognosis after aSAH.

Systemic Immune-Inflammation Index Predicts 3-Month Functional Outcome in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Background and Purpose

Systemic immune-inflammation index (SII), a novel inflammation index derived from counts of circulating platelets, neutrophils and lymphocytes, has been studied in developing incident cancer. However, the clinical value of SII in acute ischemic stroke (AIS) patients had not been further investigated. Therefore, we aimed to explore the association between SII and severity of stroke as well as 3-month outcome of AIS patients.

Methods

A total of 216 AIS patients receiving intravenous thrombolysis (IVT) and 875 healthy controls (HCs) were retrospectively recruited. Blood samples were collected within 24h after admission. Severity of stroke was assessed by the National Institute of Health stroke scale (NIHSS) scores on admission and poor 3-month functional outcome was defined as Modified Rankin Scale (mRS) > 2.

Results

SII levels in AIS patients were higher than in HCs. The cut-off value of SII is 545.14×10⁹/L. Patients with SII > 545.14×10⁹/L had higher NIHSS scores (median: 5 vs 9, p < 0.001), a positive correlation between SII and NIHSS was observed (rs = 0.305, p < 0.001). Multivariate logistic regression analyses showed that high SII was one of the independent risk factors for poor prognosis at 3 months of AIS patients (OR = 3.953, 95% CI = 1.702-9.179, p = 0.001). The addition of SII to the conventional prognostic model improved the reclassification (but not discrimination) of the functional outcome (net reclassification index 39.3%, p = 0.007).

Conclusion

SII is correlated with stroke severity at admission and can be a novel prognostic biomarker for AIS patients treated with IVT.

Eosinophil-to-Monocyte Ratio is a Potential Predictor of Prognosis in Acute Ischemic Stroke Patients After Intravenous Thrombolysis

Background

Eosinophil and monocyte have been demonstrated separately to be independent predictors of acute ischemic stroke (AIS). This study aimed to evaluate the association between eosinophil-to-monocyte ratio (EMR) and 3-month clinical outcome after treatment with recombinant tissue plasminogen activator (rt-PA) for AIS patients. Simultaneously, we made a simple comparison with other prognostic indicators, such as 24h neutrophil-to-lymphocyte ratio (NLR) and 24h platelet-to-lymphocyte ratio (PLR) to investigate the prognostic value of EMR.

Methods and Results

A total of 280 AIS patients receiving intravenous thrombolysis were retrospectively recruited for this study. Complete blood count evaluations for EMR were conducted on 24 hours admission. The poor outcome at 3-month was defined as the modified Rankin Scale (mRS) of 3–6 and the mRS score for death was 6. The EMR levels in patients with AIS were lower than those in the healthy controls and showed a negative correlation with the NIHSS score. At the 3-month follow-up, multivariate logistic regression analysis indicated an association among EMR, poor outcome and mortality. In addition, EMR had a higher predictive ability than popular biomarkers like NLR and PLR for 3-month mortality.

Conclusion

The lower levels of EMR were independently associated with poor outcome and dead status in AIS patients.

Predictors of death within 6 months of stroke onset: A model with Barthel index, platelet/lymphocyte ratio and serum albumin

AIMS

To develop and internally validate a nomogram to predict the risk of death within 6 months of onset of stroke in Chinese. Identifying risk factors with potentially direct effects on the nomogram will improve the quality of risk assessment and help nurses implement preventive measures based on patient-specific risk factors.

DESIGN

A retrospective study.

METHODS

We performed a least absolute shrinkage and selection operator (LASSO) regression modelling and multivariate logistic regression analysis to establish a prediction model of death risk in stroke patients within 6 months of onset. LASSO and time-dependent Cox regression models were further used to analyse the 6-month survival of stroke patients. Data were collected from 21 October 2013-6 May 2019.

RESULTS

The independent predictors of the nomogram were Barthel index (odds ratio (OR) = 0.980, 95% confidence interval (CI) = 0.961-0.998, p = .03), platelet/lymphocyte ratio (OR = 1.005, 95% CI = 1.000-1.010, p = .04) and serum albumin (OR = 0.854, 95% CI = 0.774-0.931, p < .01). This model showed good discrimination and consistency, and its discrimination evaluation C-statistic was 0.879 in the training set and 0.891 in the internal validation set. The DCA indicated that the nomogram had a higher overall net benefit over most of the threshold probability range. The time-dependent Cox regression model established the impact of the time effect of the age variable on survival time.

CONCLUSIONS

Our results identified three predictors of death within 6 months of stroke in Chinese. These predictors can be used as risk assessment indicators to help caregivers performing clinical nursing work, and in clinical practice, it is suggested that nurses should evaluate the self-care ability of stroke patients in detail. The constructed nomogram can help identify patients at high risk of death within 6 months, so that intervention can be performed as early as possible.

An Effective Machine Learning Approach for Identifying Non-Severe and Severe Coronavirus Disease 2019 Patients in a Rural Chinese Population: The Wenzhou Retrospective Study

This paper has proposed an effective intelligent prediction model that can well discriminate and specify the severity of Coronavirus Disease 2019 (COVID-19) infection in clinical diagnosis and provide a criterion for clinicians to weigh scientific and rational medical decision-making. With indicators as the age and gender of the patients and 26 blood routine indexes, a severity prediction framework for COVID-19 is proposed based on machine learning techniques. The framework consists mainly of a random forest and a support vector machine (SVM) model optimized by a slime mould algorithm (SMA). When the random forest was used to identify the key factors, SMA was employed to train an optimal SVM model. Based on the COVID-19 data, comparative experiments were conducted between RF-SMA-SVM and several well-known machine learning algorithms performed. The results indicate that the proposed RF-SMA-SVM not only achieves better classification performance and higher stability on four metrics, but also screens out the main factors that distinguish severe COVID-19 patients from non-severe ones. Therefore, there is a conclusion that the RF-SMA-SVM model can provide an effective auxiliary diagnosis scheme for the clinical diagnosis of COVID-19 infection.

The association of neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, and lymphocyte to monocyte ratio with post-thrombolysis early neurological outcomes in patients with acute ischemic stroke

Background and purpose

To investigate the association of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and lymphocyte to monocyte ratio (LMR) with post-thrombolysis early neurological outcomes including early neurological improvement (ENI) and early neurological deterioration (END) in patients with acute ischemic stroke (AIS).

Methods

AIS patients undergoing intravenous thrombolysis were enrolled from April 2016 to September 2019. Blood cell counts were sampled before thrombolysis. Post-thrombolysis END was defined as the National Institutes of Health Stroke Scale (NIHSS) score increase of ≥ 4 within 24 h after thrombolysis. Post-thrombolysis ENI was defined as NIHSS score decrease of ≥ 4 or complete recovery within 24 h. Multinomial logistic regression analysis was performed to explore the relationship of NLR, PLR, and LMR to post-thrombolysis END and ENI. We also used receiver operating characteristic curve analysis to assess the discriminative ability of three ratios in predicting END and ENI.

Results

Among 1060 recruited patients, a total of 193 (18.2%) were diagnosed with END and 398 (37.5%) were diagnosed with ENI. Multinomial logistic model indicated that NLR (odds ratio [OR], 1.385; 95% confidence interval [CI] 1.238–1.551, P = 0.001), PLR (OR, 1.013; 95% CI 1.009–1.016, P = 0.001), and LMR (OR, 0.680; 95% CI 0.560–0.825, P = 0.001) were independent factors for post-thrombolysis END. Moreover, NLR (OR, 0.713; 95% CI 0.643–0.791, P = 0.001) served as an independent factor for post-thrombolysis ENI. Area under curve (AUC) of NLR, PLR, and LMR to discriminate END were 0.763, 0.703, and 0.551, respectively. AUC of NLR, PLR, and LMR to discriminate ENI were 0.695, 0.530, and 0.547, respectively.

Conclusions

NLR, PLR, and LMR were associated with post-thrombolysis END. NLR and PLR may predict post-thrombolysis END. NLR was related to post-thrombolysis ENI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-021-02090-6.

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

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

Clinical Relevance of Changes in Peripheral Blood Cells After Intracranial Aneurysm Rupture

BACKGROUND

The rupture of an intracranial aneurysm (IA) causes a systemic response that involves an immune/inflammatory reaction. We sought to characterize the systemic response to IA rupture.

METHODS

We included 19 patients in the acute phase of IA rupture and 20 control subjects. Flow cytometry was used to analyze alterations in the level of mononuclear leukocytes. Cell-related parameters, including the neutrophil-to-lymphocyte ratio (NL-R), lymphocyte-to-monocyte ratio (LM-R), platelet-to-lymphocyte ratio (PL-R), and systemic immune-inflammation index (SII), were calculated, and the relationship between the analyzed hematological parameters and clinical status was investigated.

RESULTS

Patients with ruptured IAs presented with significantly higher white blood cells (WBC) and neutrophil counts but lower lymphocyte counts than control subjects. NL-R and SII values were higher and the LM-R was lower in the acute phase after IA rupture. Analyzing the severity of clinical status and the outcome of patients with subarachnoid hemorrhage, we found that patients with poor clinical status, as measured by the Glasgow Coma Scale (GCS) and the Hunt and Hess scale, had significantly lower lymphocyte counts and higher NL-R, PL-R and SII values than those with good clinical status. Additionally, patients with lower GCS scores presented a lower proportion of CD3+CD4-CD8- cells. Worse outcomes assessed at discharge were associated with lower lymphocyte counts but higher PL-R values.

CONCLUSIONS

The current study pointed to the significance of systemic immune and inflammatory responses after IA rupture and the potential clinical utility of hematological parameters, which can be easily calculated. In particular, the role of DN T cells and the significance of the SII as a marker related to clinical status should be further investigated.

The inflammatory markers and prognosis of cervicocephalic artery dissection: a stroke center study from a tertiary hospital

OBJECTIVE

Cervicocephalic artery dissection (CeAD) is the most common cause of ischemic stroke in young adults. Although the exact cause is unknown, inflammation is thought to have a role. Here, we investigated the relationship between CeAD and inflammation.

METHODS

Patients diagnosed with CeAD in our stroke center were evaluated retrospectively, and their demographic and clinical features were recorded. The C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell, neutrophil and lymphocyte counts, platelet/lymphocyte ratio (PLR), and neutrophil/lymphocyte ratio (NLR) were recorded on admission. Modified Rankin scores (mRS) were noted on admission and at 6 months to evaluate the dependency status and functional outcome of each patient.

RESULTS

Of the 95 patients in the study, 70 (73.7%) were male, and the mean age was 44.4 ± 9.8 years. Patients with high WBC count, ESR, PLR, and NLR frequently had mRS scores of 3-6 at admission; these differences were significant (p = 0.04, p = 0.02, p = 0.04, and p = 0.02, respectively). At 6 months, patients with high CRP and ESR at admission also had significantly poorer prognoses (p < 0.001, p = 0.002, respectively). PLR and NLR values were higher in patients with mRS of 3-6. But there were no significant differences between the good and poor prognosis groups regarding PLR and NLR (p = 0.22, p = 0.05, respectively).

CONCLUSION

Inflammation may have a role in the prognosis of CeAD, and inflammatory markers can be evaluated as auxiliary tests for determining prognosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prognostic significance of plasma IL-2 and sIL-2Rα in patients with first-ever ischaemic stroke

Background

An imbalance between circulating neuroprotective and neurotoxic T cell subsets leads to poor prognosis in acute ischaemic stroke (AIS). Preclinical studies have indicated that the soluble form of the interleukin-2 receptor α (sIL-2Rα)-IL-2 complex regulates T cell differentiation. However, the association between sIL-2Rα levels and AIS remains unclear.

Methods

A total of 201 first-ever AIS patients within 24 h after stroke onset and 76 control subjects were recruited. The National Institutes of Health Stroke Scale (NIHSS) score and 3-month functional outcome (modified Rankin Scale [mRS] score) at admission were assessed. Plasma sIL-2Rα and IL-2 levels at admission were measured. Prognostic significance was identified by using univariate and multivariate logistic regression analyses.

Results

Patients with poor functional outcomes at 3 months had significantly higher levels of sIL-2Rα and lower levels of IL-2 than patients with good outcomes. Moreover, sIL-2Rα levels showed a strong positive correlation with NIHSS and mRS scores (p < 0.0001), whereas IL-2 levels were negatively correlated with mRS scores (p < 0.01). Univariate analyses showed that higher sIL-2Rα and IL-2 levels were associated with an increased and reduced risk of unfavourable outcomes, respectively. After adjusting for confounding variables, the sIL-2Rα level remained independently associated with an increased risk of an unfavourable outcome, and adding sIL-2Rα levels to the conventional risk factor model significantly improved risk reclassification (net reclassification improvement 17.56%, p = 0.003; integrated discrimination improvement 5.78%, p = 0.0003).

Conclusions

sIL-2Rα levels represent a novel, independent prognostic marker that can improve the currently used risk stratification of AIS patients. Our findings also highlight that elevated plasma sIL-2Rα and IL-2 levels manifested opposite correlations with functional outcome, underlining the importance of IL-2/IL-2R autocrine loops in AIS.