Could Neutrophil-to-Lymphocyte Ratio (NLR) Serve as a Potential Marker for Delirium Prediction in Patients with Acute Ischemic Stroke? A Prospective Observational Study

Abstract

Delirium is an acute brain disorder that commonly occurs in patients with acute ischemic stroke (AIS). Pathomechanism of delirium is related to the neuroinflammatory process and oxidative stress. Search for readily available diagnostic marker that will aid clinicians in early identification of delirium is ongoing. The aim of this study was to investigate whether neutrophil-to-lymphocyte ratio (NLR) could serve as a potential marker for delirium prediction in patients with AIS and to find an easy diagnostic tool using laboratory and clinical parameters to predict delirium. Prospective observational study (NCT03944694) included patients with AIS admitted to the neurology department of a district general hospital. All patients were screened for delirium using CAM-ICU (Confusion Assessment Method for Intensive Care Unit). Demographic and medical history data and admission lab results, including differential white blood cell analysis, were collected from all patients. We included 1001 patients in the final analysis. The mean age of the sample was 71 years, and 52% of patients were males. The incidence of early-onset delirium was 17.2%. The NLR was elevated in delirious patients (6.39 ± 8.60 vs. 4.61 ± 5.61, p < 0.001). The best cut-off value of NLR to predict delirium using the receiver operating characteristics (ROC) was determined at 4.86. Multivariable logistic regression analysis showed that the odds ratio (OR) for developing delirium with NLR > 4.86 (adjusted for age, sex, body mass index (BMI), comorbidities, and baseline neurology) was 1.875 (95% CI 1.314–2.675, p = 0.001). As a result of different combinations of markers and clinical parameters based on logistic regression, a formula—DELirium in Acute Ischemic Stroke (DELIAS score)—was obtained with the area under the ROC curve of 0.801 (p < 0.001). After regression of the cut-off points of the obtained curve, a significant correlation of the DELIAS score was observed with the occurrence of early-onset delirium (OR = 8.976, p < 0.001) and with delirium until the fifth day after AIS (OR = 7.744, p < 0.001). In conclusion, NLR can be regarded as a potential marker for prediction of early-onset delirium after AIS. On the basis of combined laboratory and clinical parameters, the DELIAS score was calculated, which gave the highest predictive value for delirium in the analyzed group of patients after ischemic stroke. However, further studies are needed to validate these findings.

May Neutrophil to Lymphocyte Ratio Serve a Role in the Prediction of Clinical Features of Migraine?

“…Episodic and chronic migraine various inflammatory biomarkers and migraines have been investigated by several researchers [3,19,20]. Many researchers have investigated the relationships between the features of headaches and inflammation using hematologic parameters [3,6,10,13,[21][22][23]. The main goal of these studies is to evaluate the inflammatory processes using hematological markers and to investigate the association of these markers with clinical parameters of headaches, and their utility in discriminating headache syndromes from other diseases [10,24].…”

“…However, even when WBC is within normal limits, an increased neutrophil to lymphocyte ratio (NLR) may indicate inflammation and inflammation-related pathologies [4]. The NLR has been used in the evaluation and prognostication of various diseases, including coronary artery diseases, malignancies, rheumatologic diseases, and neurological diseases [5][6][7][8][9][10][11][12]. Few studies have investigated the value of this marker in the evaluation of migraineurs [8,10,13].…”

Current Evidence Regarding Biomarkers Used to Aid Postoperative Delirium Diagnosis in the Field of Cardiac Surgery—Review

“…A study based on the white cells-derived markers (NLR, PLR, and PWR) seems promising, and thanks to their effectiveness and the ease of obtaining the results, they may become a helpful factor in the diagnosis and monitoring of delirium after cardiac surgery [ 61 ]. It has also been proposed to use NLR as a potential marker for delirium prediction in patients with other medical problems (i.e., acute ischemic stroke) [ 115 ].…”

Neutrophil-lymphocyte Ratio as a Predictor of Delirium in Older Hospitalized Patients: A Prospective Cohort Study

“…Egberts et al [42] found that in a cohort of acutely ill elderly patients, a raised NLR was an independent predictor of delirium. Additionally, Kotfits et al [43] stated that an increased NLR is significantly associated with increased risk of delirium in patients with acute ischemic stroke. The results of our study are consistent with these increase its permeability, cytokines then migrate across the BBB and activate microglia which will produce reactive oxygen species, the accumulation of cytokines and reactive oxygen species in brain may lead to the process of oxidization and inflammation and eventually result in neurodegeneration [7,46].…”