The predictive role of the neutrophil–lymphocyte ratio in the prognosis of adult patients with stroke

Wan, Jinzhao; Wang, Xiaoxiong; Zhen, Yunbo; Chen, Xin; Yao, Penglei; Liu, Wenwu; Lu, Enzhou; Du, Yiqun; Liu, Huailei

doi:10.1186/s41016-020-00201-5

Cited by 15 publications

(14 citation statements)

References 38 publications

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“…In the advent of precision medicine nowadays, clinical practice is shifting towards accurate and specific disease characterization, as well as quantifying disease progression and response to therapy, for which biomarkers play critically important role (96). The neutrophil to lymphocyte ratio is a cheap, readily available and easy to interpret immune marker which may provide a diagnostic clue particularly for clinical outcomes post stroke (97–99).…”

Section: Resultsmentioning

confidence: 99%

Scoping Review of Existing Stroke Guidelines; Argument for a Value-Added Change

Wijeratne

Sales

Jakovljević

et al. 2021

Preprint

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Background and Purpose: Stroke represents one of the most important causes of morbidity (eighty million patients with disabling of ongoing effects of stroke at a given time, globally) and mortality (the second leading cause of death) worldwide. Innovative systems biology-based approach is likely to increase the understanding of the underpinning of acute stroke promise to enhance stroke prevention, acute treatment, and neurorehabilitation. Recent growing body of evidence with shared pathobiology with COVID-19 and the critically important role of inflammation in the context of stroke points to far-reaching consequences of acute stroke, just as in the case of COVID-19 ( post-acute event issues as well as long term issues ). So far, stroke typically defined by late-appearing disease manifestation by the range of stroke subtypes as defined by the WHO or American Stroke Association. This definition neglects the underlying pathobiological mechanisms such as low-grade chronic inflammation and already compromised vascular system. Diseases such as stroke is hardly a simple result of a single problem, but rather a complex cascade of pathobiological processes and interactions in a complex biochemical environment. The evidence of changes in innate immunity and adaptive immunity during the index event of acute stroke and recovery over next 3-12 months can be easily elicited with simple bedside blood tests such as neutrophil-lymphocyte ratio (NLR) with well over 300 published papers including several systematic reviews and meta-analyses confirming this. Global standard operating procedures (SOP) of stroke care dictated by the national and international stroke guidelines at present. It is imperative to explore the evidence of systems biology approach in current stroke guidelines. This is likely to be a key turning point in managing stroke across the continuum (prevention, management of acute event and rehabilitation). Methods: We systematically searched for guideline recommendation on the day-to-day use of peripheral inflammatory markers such as NLR published in the English language between January 1, 2005, and December 2020. Any other evidence of systems biology-based approach or recommendation was explored within the selected guidelines for this scoping review. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 4 authors to determine clinical scenarios explained/given, scientific evidence used, and recommendations presented in the context of systems biology. Results: The scoping review found 3,830 (3830) titles with 119 guidelines from 46 countries included for this review (Figure 1; PRISMA diagram). Stroke-related organizations wrote Sixty-five per cent of the guidelines while national ministries wrote a fewer number of guidelines. We were primarily interested in recommendations for acute management in AIS published in the English language. Fifteen eligible guidelines were identified from 15 different countries/regions. None of the guidelines recommended the routine use of peripheral markers of inflammation, such as NLR, among their acute assessment and management recommendations. None of the existing guidelines explored the systems biology approach to one of the most complex diseases affecting the human brain, stroke. Conclusions: This systematic review has identified a significant evidence-practice gap in all existing national stroke guidelines published in English medium as of October 2020. These guidelines included the only current living stroke guidelines, Stroke Guidelines from Australia with a real opportunity to modernize the living stroke guidelines with systems biology approach and provide 2020 vision towards better stroke care globally. Investigation of complex disease such as stroke is best served through a systems biology approach. One of the easiest places to start is simple blood tests such as total white cell count and NLR. Systems biology approach point us towards simple tools such immune-inflammatory index (SII), Sunshine Prognostic Score (SPS) which should pave the way for the stroke physician community address the challenges in systems biology approach in stroke care. These challenges include translating bench research to the bedside, managing big data ( continuous pulse, blood pressure, sleep, Oxygen saturation, progressive changes in NLR, SII, SPS, etc.). Working with an interdisciplinary team is also provide a distinct advantage.

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Section: Resultsmentioning

confidence: 99%

Scoping Review of Existing Stroke Guidelines; Argument for a Value-Added Change

Wijeratne

Sales

Jakovljević

et al. 2021

Preprint

View full text Add to dashboard Cite

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“…As a combination of the above two distinct inflammatory markers, NLR is considered as a comprehensive marker of systemic inflammation in acute ischemic stroke patients. Increasing evidence suggests that NLR is an independent predictor of poor prognosis, early neurological deterioration, and mortality after ischemic stroke ( 9 , 30 , 31 ). In general population, the normal range of NLR has been suggested to be between 0.78 and 3.53 ( 32 ).…”

Section: Discussionmentioning

confidence: 99%

High Neutrophil–Lymphocyte Ratio Predicts Post-stroke Cognitive Impairment in Acute Ischemic Stroke Patients

et al. 2021

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Background and Aims: Systemic inflammation is associated with an increased risk of cognitive impairment and dementia, but the associations between them in stroke patients are less clear. We examined the impact of systemic inflammation represented as the neutrophil-lymphocyte ratio (NLR) on the development of post-stroke cognitive impairment (PSCI) and domain-specific cognitive outcomes 3-month after ischemic stroke.Methods: Using prospective stroke registry data, we consecutively enrolled 345 participants with ischemic stroke whose cognitive functions were evaluated 3-month after stroke. Their cognition was assessed with the Korean version of the Vascular Cognitive Impairment Harmonization Standards and the Korean-Mini Mental Status Examination. PSCI was defined as a z-score of < -2 standard deviations for age, sex, and education adjusted means in at least one cognitive domain. The participants were categorized into five groups according to the quintiles of NLR (lowest NLR, Q1). The cross-sectional association between NLR and PSCI was assessed using multiple logistic regression, adjusting for age, sex, education, vascular risk factors, and stroke type.Results: A total of 345 patients were enrolled. The mean age was 63.0 years and the median NIHSS score and NLR were 2 [1–4] and 2.26 [1.65–2.91], respectively. PSCI was identified in 71 (20.6%) patients. NLR was a significant predictor for PSCI both as a continuous variable (adjusted OR, 1.14; 95% CI, 1.00–1.31) and as a categorical variable (Q5, adjusted OR, 3.26; 95% CI, 1.17–9.08). Patients in the Q5 group (NLR ≥ 3.80) showed significantly worse performance in global cognition and in visuospatial and memory domains.Conclusions: NLR in the acute stage of ischemic stroke was independently associated with PSCI at 3 months after stroke, and high NLR was specifically associated with cognitive dysfunction in the memory and visuospatial domains. Thus, systemic inflammation may be a modifiable risk factor that may influence cognitive outcomes after stroke.

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“…APACHE score [26,60] Serum hemoglobin [61] Serum neutrophil to lymphocyte ratio [62,63] Cerebral perfusion pressure and partial pressure of oxygen in interstitial brain tissue (PbtO2) [64] Serum iron/ferritin/transferrin [65] Chronic kidney disease [66] Imaging Variables IVH expansion [50,51,67] Peak PHE [68] Spot sign/island sign/black hole sign/blend sign [69] Non contrast CT-Hypodensities on CT [69,70]…”

Section: Physiologic Variablesmentioning

confidence: 99%

Prognostication after intracerebral hemorrhage: a review

Witsch

Siegerink

Nolte

et al. 2021

Neurol. Res. Pract.

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Background Approximately half of patients with spontaneous intracerebral hemorrhage (ICH) die within 1 year. Prognostication in this context is of great importance, to guide goals of care discussions, clinical decision-making, and risk stratification. However, available prognostic scores are hardly used in clinical practice. The purpose of this review article is to identify existing outcome prediction scores for spontaneous intracerebral hemorrhage (ICH) discuss their shortcomings, and to suggest how to create and validate more useful scores. Main text Through a literature review this article identifies existing ICH outcome prediction models. Using the Essen-ICH-score as an example, we demonstrate a complete score validation including discrimination, calibration and net benefit calculations. Score performance is illustrated in the Erlangen UKER-ICH-cohort (NCT03183167). We identified 19 prediction scores, half of which used mortality as endpoint, the remainder used disability, typically the dichotomized modified Rankin score assessed at variable time points after the index ICH. Complete score validation by our criteria was only available for the max-ICH score. Our validation of the Essen-ICH-score regarding prediction of unfavorable outcome showed good discrimination (area under the curve 0.87), fair calibration (calibration intercept 1.0, slope 0.84), and an overall net benefit of using the score as a decision tool. We discuss methodological pitfalls of prediction scores, e.g. the withdrawal of care (WOC) bias, physiological predictor variables that are often neglected by authors of clinical scores, and incomplete score validation. Future scores need to integrate new predictor variables, patient-reported outcome measures, and reduce the WOC bias. Validation needs to be standardized and thorough. Lastly, we discuss the integration of current ICH scoring systems in clinical practice with the awareness of their shortcomings. Conclusion Presently available prognostic scores for ICH do not fulfill essential quality standards. Novel prognostic scores need to be developed to inform the design of research studies and improve clinical care in patients with ICH.

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The predictive role of the neutrophil–lymphocyte ratio in the prognosis of adult patients with stroke

Cited by 15 publications

References 38 publications

Scoping Review of Existing Stroke Guidelines; Argument for a Value-Added Change

Scoping Review of Existing Stroke Guidelines; Argument for a Value-Added Change

High Neutrophil–Lymphocyte Ratio Predicts Post-stroke Cognitive Impairment in Acute Ischemic Stroke Patients

Prognostication after intracerebral hemorrhage: a review

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