Introduction
While the relationship between high Neutrophil-to-Lymphocyte Ratio (NLR) and Early Neurological Deterioration (END) in acute strokes has not been well-documented, this study aims to investigate potential connections. Specifically, we focus on patients suffering from acute infarctions within the anterior circulation.
Methods
Patients
This analysis included a cohort of consecutive patients who experienced their first-ever acute ischemic stroke and were admitted to Jinling Hospital within 24 hours of symptom onset. A diagnosis of acute ischemic stroke was confirmed through observation of new focal neurological deficits, supported by relevant lesions visible on diffusion-weighted imaging (DWI) or computed tomography (CT). Only subjects with anterior circulation infarctions were considered eligible for inclusion in this study.
We excluded patients based on specific criteria: those diagnosed with infections within 72 hours before or after admission, individuals currently using corticosteroids or any other immunosuppressive medications, patients with a history of cancer or immune system disorders, and those with incomplete medical records.
Demographic and Clinical Data Collection
Baseline demographic data, such as age and sex, as well as a comprehensive range of vascular risk factors—hypertension, diabetes mellitus, hypercholesterolemia, atrial fibrillation, cigarette smoking, alcohol consumption, coronary heart disease, and previous myocardial infarction—were meticulously collected. Additionally, vital signs, including blood pressure at the time of admission, were recorded alongside the duration of hospitalization and the timeline from ischemic onset to hospital admission.
Laboratory parameters were analyzed from fasting blood samples collected during the first 24 hours after hospital admission. Key laboratory metrics comprised total white blood cell counts, subtypes, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, creatinine, serum glucose, albumin, and hematocrit levels. The NLR was specifically calculated as the ratio of neutrophil count to lymphocyte count. The etiological classification of stroke was guided by the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.
The National Institutes of Health Stroke Scale (NIHSS) scores were evaluated by seasoned neurologists immediately upon admission, again at 72 hours, and at patient discharge. Functional disabilities were assessed using the modified Rankin Scale (mRS) at the time of discharge.
Treatment and Neurological Assessment
Patients who received treatment with tissue plasminogen activator (tPA) or underwent endovascular therapy were excluded from our study. Treatment protocols adhered strictly to established guidelines, and participants were subject to a range of additional care plans aimed at managing cardiovascular risk factors as appropriate. END was conditionally defined as an increase of ≥2 points in the NIHSS score within the first 72 hours post-admission.
Ethics Statement and Patient Consents
This study received ethical approval from the Clinical Trials Ethics Committee of Jinling Hospital, with all conducted procedures aligned with the guidelines of the Declaration of Helsinki. Informed consent was duly obtained from each participant or their authorized representatives.
Statistical Analysis
Continuous data were represented as mean ± standard deviation (SD) or median values along with interquartile ranges (IQR). Evaluations were made using Student’s t-test or Mann–Whitney U-test as appropriate, while categorical data were conveyed in terms of frequencies and percentages, undergoing assessment through chi-square test or Fisher’s exact test. A stepwise forward conditional process was implemented within a multiple logistic regression model to investigate the correlation between END and other covariates. Outcomes were articulated as odds ratios (OR) with corresponding 95% confidence intervals (CI). Receiver Operating Characteristic (ROC) curve analysis was employed to determine the optimal cut-off values for NLR predictive of END, with a two-sided P value considered statistically significant.
Results
A total of 228 consecutive patients were included in the analysis. The mean age of the participants was 61 years, with approximately 67% being male. Among the cohort, 64 individuals (28.1%) experienced episodes of END within the first 72 hours post-admission. Tragically, two patients who experienced END succumbed during hospitalization. The median difference between NIHSS scores at admission and at 72 hours for the END group was 2 (IQR, 2 to 3).
Demographic and clinical characteristics of patients who experienced END compared to those who did not are summarized in Table 1. END correlated significantly with several variables, including systolic blood pressure, HDL-cholesterol levels, serum glucose, and NLR, as well as stroke severity at admission. Notably, patients experiencing END had significantly higher NIHSS scores at admission than those who did not (median NIHSS score of 5 vs 4; p=0.011).
The data showed elevated NLR in patients with END (median NLR 3.8 vs. 2.4; p=0.006) and a marked decrease in lymphocyte counts (mean lymphocyte counts 1.6 vs. 1.9; p=0.006) when juxtaposed against subjects without END.
Table 1 Demographic Information and Clinical Characteristics
Age, sex, and variables deemed statistically significant (p<0.05) were analyzed, with NIHSS scores at admission categorized as dichotomous variables.
Results of multivariate logistic regression analysis demonstrated that an NLR >2.65 (OR, 4.019; 95% CI, 1.937–8.337; p=0.038) and elevated serum glucose levels upon admission (OR, 1.178; 95% CI, 1.021–1.359; p=0.025) emerged as independent predictors of END. Patients exhibiting an NLR greater than 2.65 had nearly four times the likelihood of developing END compared to those with an NLR of 2.65 or lower. ROC curve analysis determined that the optimal NLR cut-off value to predict END was established at 2.68, demonstrating a sensitivity of 75% and specificity of 60.98% (area under the ROC curve, 0.72; 95% CI, 0.657–0.777; P <0.001).
Table 2 Logistic Regression Model to Predict END
Figure 1 Receiver Operating Curves (ROC) of Neutrophil Lymphocyte Ratio (NLR) to Predict Early Neurological Deterioration (END) in Patients with Anterior Circulation Stroke
Analysis of the study population revealed a division into two groups based on NLR median (2.65), which demonstrated that patients classified in the high NLR subgroup (NLR>2.65) had prolonged hospitalization durations (median length of stays 12 days vs. 4 days; p<0.001) (refer to Table 3).
Table 3 Short-Term Outcome Characteristics
Discussion
This study does present several notable limitations. Initially, the specific threshold for an increase in NIHSS scores to evaluate END remains a topic of discussion. Previous studies have suggested variations in defining END as an increase of ≥2 or even 4 points in NIHSS scores at 48-120 hours post-admission. In our analysis, we accepted an increase of ≥2 points in the NIHSS score after 72 hours of hospitalization as our definition for END. This divergence in defining END may yield inconsistent results across studies.
Secondly, data collection was conducted retrospectively from a stroke registry, where the limited sample size may introduce biases. Conclusively, several potential predictors for END remain unexplored within this study, such as the size of infarcted cerebral areas. Therefore, further investigations with larger samples and multi-center studies are essential to deepen our understanding of the relationship between NLR and END.
In conclusion, our findings indicate that higher NLR at admission significantly correlates with the incidence of END in patients suffering from acute ischemic strokes involving anterior circulation lesions. Given its cost-effectiveness and ease of acquisition, the NLR could be a practical clinical marker for evaluating the risk of END post-acute infarction.
Funding
This research was backed by the Science Foundation of Kangda College of Nanjing Medical University (KD2022KYJJZD080) and the Science Foundation of Nanjing Medical University (NMUB20220160).
Disclosure
A portion of the data has been previously presented as an abstract during the Poster Presentations at the Asia Pacific Stroke Conference 2017. This study can also be accessed on ResearchSquare.
References
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The Curious Case of NLR and Early Neurological Deterioration
Well, ladies and gentlemen, what do we have here? A fascinating study boldly strutting its way into the academic limelight, examining whether the neutrophil-lymphocyte ratio (NLR) can predict early neurological deterioration (END) in patients who have just experienced an acute ischemic stroke in the anterior circulation. It’s like watching a medical drama unfold! The stakes are high, the implications are serious, and frankly, I can’t help but be captivated.
Introduction
Strokes! Just when you think they couldn’t be more dramatic, along come the findings of a study conducted at Jinling Hospital, where scientists, or shall I say “mad researchers,” are peeling back the layers of how inflammatory markers (in this case, NLR) might be heralding some pretty grim news for stroke patients.
Methods
First off, let’s talk about the patient base. A total of 228 unlucky souls who were admitted within 24 hours post-stroke get invited for the party. Ah, but there are a few uninvited guests – cancers, infections, and the folks currently flirting with corticosteroids were shown the door. It’s only a select crowd! Now, the researchers pull out their lab coats and collect a myriad of demographic and clinical data, from age to vital signs, and of course, our star performer: NLR! Talk about a health data buffet. We also learn what the heck END is. A nifty little spike in the NIHSS score after three days. You know, the sort of thing that gets you a ticket to the after-party… in the ICU.
Results
After this rigorous collection of data, what do they find? Well, brace yourselves:
- About 28.1% of those studied had a spot on the END list.
- NLR levels are higher in those with END, with a median NLR of 3.8 compared to 2.4 in the non-END group.
- Patients with a NLR above 2.65 had nearly four times the likelihood of deteriorating. Yes, you read that right — almost four times!
Ringing endorsement for NLR as a **clinically useful biometric.** Researchers, in true dramatic flair, used ROC analysis to determine that a nifty cut-off of 2.68 packed a punch with a sensitivity of 75% and specificity of 60.98% — not bad at all.
Discussion
Now folks, this study isn’t without its share of limitations—like any good plot twist! Definitions vary on what constitutes END, and, let’s face it, they only had 228 patients, so bias could very well be crashing the party. “EXCUSE ME! We’re trying to do science here!” is probably on repeat in their heads.
But if you’re still with me, let’s consider the implications. The NLR — a simple, cheap test — could unveil the hidden struggles of stroke patients. It’s set to shake up how we assess risks during acute strokes, potentially changing patient management from an ignorable statistic into a critical alarm bell!
Conclusion
In conclusion, this study boldly declares that NLR at admission may serve as a handy dandy predictor for END among patients suffering from acute ischemic strokes due to anterior circulation issues. So, the next time you’re at a cocktail party and the topic of systemic inflammation arises, you can just paint an impressively dramatic scene of NLRs, strokes, and potential patient outcomes — who knows, it might just be the best way to spice up your social life!
Funding and Disclosure
All in all, this study was backed by the Science Foundation of Kangda College of Nanjing Medical University, and the authors graciously reported no conflicts of interest. Who knew stroke science could be so thrilling? That’s science, folks — always keeping us on our toes!
References
Many esteemed references will back up this enlightening whirlwind of information, but since we’re all about keeping it concise, we’ll save the deep dive for a rainy day (or perhaps just for the keen-eyed among you). If you’re interested, I can definitely help track those down!
What is the significance of the neutrophil-lymphocyte ratio (NLR) in predicting early neurological deterioration (END) in acute ischemic stroke patients?
The Curious Case of NLR and Early Neurological Deterioration
Well, ladies and gentlemen, what do we have here? A fascinating study boldly strutting its way into the academic limelight, examining whether the neutrophil-lymphocyte ratio (NLR) can predict early neurological deterioration (END) in patients who have just experienced an acute ischemic stroke in the anterior circulation. It’s like watching a medical drama unfold! The stakes are high, the implications are serious, and frankly, I can’t help but be captivated.
Introduction
Strokes! Just when you think they couldn’t be more dramatic, along come the findings of a study conducted at Jinling Hospital, where scientists, or shall I say “mad researchers,” are peeling back the layers of how inflammatory markers (in this case, NLR) might be heralding some pretty grim news for stroke patients.
Methods
First off, let’s talk about the patient base. A total of 228 unlucky souls who were admitted within 24 hours post-stroke get invited for the party. Ah, but there are a few uninvited guests – cancers, infections, and the folks currently flirting with corticosteroids were shown the door. It’s only a select crowd! Now, the researchers pull out their lab coats and collect a myriad of demographic and clinical data, from age to vital signs, and of course, our star performer: NLR! Talk about a health data buffet. We also learn what the heck END is. A nifty little spike in the NIHSS score after three days. You know, the sort of thing that gets you a ticket to the after-party… in the ICU.
Results
After this rigorous collection of data, what do they find? Well, brace yourselves:
- About 28.1% of those studied had a spot on the END list.
- NLR levels are higher in those with END, with a median NLR of 3.8 compared to 2.4 in the non-END group.
- Patients with a NLR above 2.65 had nearly four times the likelihood of deteriorating. Yes, you read that right — almost four times!
Ringing endorsement for NLR as a **clinically useful biometric.** Researchers, in true dramatic flair, used ROC analysis to determine that a nifty cut-off of 2.68 packed a punch with a sensitivity of 75% and specificity of 60.98% — not bad at all.
Conclusion
This study opens a heartfelt dialogue in the medical community about the role of inflammatory markers in predicting stroke outcomes. With NLR shining as a star player, the quest for effective, early predictive tools that can really make a difference expands its horizons. As we continue to peel back the layers of stroke research, may we find more pearls of wisdom that enhance patient care and outcomes!