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Nguyen A, Nguyen A, Hsu TI, Lew HD, Gupta N, Nguyen B, Mandavalli A, Diaz MJ, Lucke-Wold B. Neutrophil to Lymphocyte Ratio as a Predictor of Postoperative Outcomes in Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Diseases 2023; 11:diseases11010051. [PMID: 36975600 PMCID: PMC10047119 DOI: 10.3390/diseases11010051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/05/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
(1) Introduction: Traumatic brain injury (TBI) is a leading cause of injury and mortality worldwide, carrying an estimated cost of $38 billion in the United States alone. Neutrophil to lymphocyte ratio (NLR) has been investigated as a standardized biomarker that can be used to predict outcomes of TBI. The aim of this review was to determine the prognostic utility of NLR among patients admitted for TBI. (2) Methods: A literature search was conducted in PubMed, Scopus, and Web of Science in November 2022 to retrieve articles regarding the use of neutrophil to lymphocyte ratio (NLR) as a prognostic measure in traumatic brain injury (TBI) patients. Inclusion criteria included studies reporting outcomes of TBI patients with associated NLR values. Exclusion criteria were studies reporting only non-primary data, those insufficiently disaggregated to extract NLR data, and non-English or cadaveric studies. The Newcastle-Ottawa Scale was utilized to assess for the presence of bias in included studies. (3) Results: Following the final study selection 19 articles were included for quantitative and qualitative analysis. The average age was 46.25 years. Of the 7750 patients, 73% were male. Average GCS at presentation was 10.51. There was no significant difference in the NLR between surgical vs. non-surgical cohorts (SMD 2.41 95% CI −1.82 to 6.63, p = 0.264). There was no significant difference in the NLR between bleeding vs. non-bleeding cohorts (SMD 4.84 95% CI −0.26 to 9.93, p = 0.0627). There was a significant increase in the NLR between favorable vs. non-favorable cohorts (SMD 1.31 95% CI 0.33 to 2.29, p = 0.0090). (4) Conclusions: Our study found that NLR was only significantly predictive for adverse outcomes in TBI patients and not surgical treatment or intracranial hemorrhage, making it nonetheless an affordable alternative for physicians to assess patient prognosis.
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Affiliation(s)
- Andrew Nguyen
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
| | - Alexander Nguyen
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
| | - Timothy I. Hsu
- School of Medicine, University of California, Irvine, CA 92617, USA
| | - Harrison D. Lew
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
| | - Nithin Gupta
- School of Medicine, Campbell University, Lillington, NC 27546, USA
| | - Brandon Nguyen
- Alix School of Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Akhil Mandavalli
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
| | - Michael J. Diaz
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
- Correspondence:
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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Ghozy S, El-Qushayri AE, Varney J, Kacimi SEO, Bahbah EI, Morra ME, Shah J, Kallmes KM, Abbas AS, Elfil M, Alghamdi BS, Ashraf G, Alhabbab R, Dmytriw AA. The prognostic value of neutrophil-to-lymphocyte ratio in patients with traumatic brain injury: A systematic review. Front Neurol 2022; 13:1021877. [PMID: 36353130 PMCID: PMC9638118 DOI: 10.3389/fneur.2022.1021877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/30/2022] [Indexed: 11/26/2022] Open
Abstract
Traumatic brain injury (TBI) places a heavy load on healthcare systems worldwide. Despite significant advancements in care, the TBI-related mortality is 30–50% and in most cases involves adolescents or young adults. Previous literature has suggested that neutrophil-to-lymphocyte ratio (NLR) may serve as a sensitive biomarker in predicting clinical outcomes following TBI. With conclusive evidence in this regard lacking, this study aimed to systematically review all original studies reporting the effectiveness of NLR as a predictor of TBI outcomes. A systematic search of eight databases was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement (PRISMA) recommendations. The risk of bias was assessed using the Quality in Prognostic Studies (QUIPS) tool. Eight studies were ultimately included in the study. In most of the studies interrogated, severity outcomes were successfully predicted by NLR in both univariate and multivariate prediction models, in different follow-up durations up to 6 months. A high NLR at 24 and 48 h after TBI in pediatric patients was associated with worse clinical outcomes. On pooling the NLR values within studies assessing its association with the outcome severity (favorable or not), patients with favorable outcomes had 37% lower NLR values than those with unfavorable ones (RoM= 0.63; 95% CI = 0.44–0.88; p = 0.007). However, there were considerable heterogeneity in effect estimates (I2 = 99%; p < 0.001). Moreover, NLR was a useful indicator of mortality at both 6-month and 1-year intervals. In conjunction with clinical and radiographic parameters, NLR might be a useful, inexpensive marker in predicting clinical outcomes in patients with TBI. However, the considerable heterogeneity in current literature keeps it under investigation with further studies are warranted to confirm the reliability of NLR in predicting TBI outcomes.
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Affiliation(s)
- Sherief Ghozy
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, United States
- Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC Program), Oxford University, Oxford, United Kingdom
- *Correspondence: Sherief Ghozy
| | | | - Joseph Varney
- School of Medicine, American University of the Caribbean, Philipsburg, Sint Maarten
| | | | | | | | - Jaffer Shah
- Drexel University College of Medicine, Drexel University, Philadelphia, PA, United States
| | - Kevin M. Kallmes
- Nested Knowledge, Saint Paul, MN, United States
- Superior Medical Experts, Saint Paul, MN, United States
| | | | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Badrah S. Alghamdi
- Neuroscience Unit, Department of Physiology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Pre-Clinical Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ghulam Ashraf
- Department of Medical Laboratory Sciences, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
- Ghulam Ashraf
| | - Rowa Alhabbab
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Adam A. Dmytriw
- Neurointerventional Program, Departments of Medical Imaging and Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
- Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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High Neutrophil-to-Lymphocyte Ratio Facilitates Cancer Growth-Currently Marketed Drugs Tadalafil, Isotretinoin, Colchicine, and Omega-3 to Reduce It: The TICO Regimen. Cancers (Basel) 2022; 14:cancers14194965. [PMID: 36230888 PMCID: PMC9564173 DOI: 10.3390/cancers14194965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/03/2022] [Accepted: 10/03/2022] [Indexed: 11/22/2022] Open
Abstract
Simple Summary Several elements that are composed of, or related to, neutrophils, have been shown to inhibit strong immune responses to cancer and promote cancers’ growth. This paper presents the collected data showing these elements and how their coordinated actions as an ensemble facilitate growth in the common cancers. The paper goes on to present a drug regimen, TICO, designed to reduce the cancer growth enhancing effects of the neutrophil related elements. TICO uses four already marketed, readily available generic drugs, repurposed to inhibit neutrophil centered growth facilitation of cancer. Abstract This paper presents remarkably uniform data showing that higher NLR is a robust prognostic indicator of shorter overall survival across the common metastatic cancers. Myeloid derived suppressor cells, the NLRP3 inflammasome, neutrophil extracellular traps, and absolute neutrophil count tend to all be directly related to the NLR. They, individually and as an ensemble, contribute to cancer growth and metastasis. The multidrug regimen presented in this paper, TICO, was designed to decrease the NLR with potential to also reduce the other neutrophil related elements favoring malignant growth. TICO is comprised of already marketed generic drugs: the phosphodiesterase 5 inhibitor tadalafil, used to treat inadequate erections; isotretinoin, the retinoid used for acne treatment; colchicine, a standard gout (podagra) treatment; and the common fish oil supplement omega-3 polyunsaturated fatty acids. These individually impose low side effect burdens. The drugs of TICO are old, cheap, well known, and available worldwide. They all have evidence of lowering the NLR or the growth contributing elements related to the NLR when clinically used in general medicine as reviewed in this paper.
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Mishra RK, Galwankar S, Gerber J, Jain A, Yunus M, Cincu R, Moscote-Salazar LR, Quiñones-Ossa GA, Agrawal A. Neutrophil-lymphocyte ratio as a predictor of outcome following traumatic brain injury: Systematic review and meta-analysis. J Neurosci Rural Pract 2022; 13:618-635. [PMID: 36743744 PMCID: PMC9893942 DOI: 10.25259/jnrp-2022-4-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022] Open
Abstract
Objectives The neutrophil-to-lymphocyte ratio (NLR) is a simple and routinely performed hematological parameter; however, studies on NLR as a prognostic tool in traumatic brain injury (TBI) have yielded contradictory results. Materials and Methods This systematic review and meta-analysis was conducted according to the Preferred Reporting Items in the Systematic Review and Meta-Analysis guidelines 2020. Electronic databases of PubMed, Cochrane Library, Web of Science, and Scopus were searched. The population consisted of TBI patients in the absence of moderate and severe extracranial injury. Day 1 NLR was taken for the analysis. The outcomes evaluated were mortality and the Glasgow Outcome Scale (GOS). No restrictions were placed on the language, year and country of publication, and duration of follow-up. Animal studies were excluded from the study. Studies, where inadequate data were reported for the outcomes, were included in the qualitative synthesis but excluded from the quantitative synthesis. Study quality was evaluated using the Newcastle-Ottawa scale (NOS). The risk of bias was estimated using the Cochrane RoBANS risk of bias tool. Results We retrieved 7213 citations using the search strategy and 2097 citations were excluded based on the screening of the title and abstract. Full text was retrieved for 40 articles and subjected to the eligibility criteria, of which 28 were excluded from the study. Twelve studies were eligible for the synthesis of the systematic review while seven studies qualified for the meta-analysis. The median score of the articles was 8/9 as per NOS. The risk of selection bias was low in all the studies while the risk of detection bias was high in all except one study. Ten studies were conducted on adult patients, while two studies reported pediatric TBI. A meta-analysis for GOS showed that high NLR predicted unfavorable outcomes at ≥6 months with a mean difference of -5.18 (95% confidence interval: -10.04, -0.32); P = 0.04; heterogeneity (I2), being 98%. The effect estimates for NLR and mortality were a mean difference of -3.22 (95% confidence interval: -7.12, 0.68), P = 0.11, and an I2 of 85%. Meta-analysis for Area under the curve (AUC) receiver operating characteristic of the included studies showed good predictive power of NLR in predicting outcomes following TBI with AUC 0.706 (95% CI: 0.582-0.829). Conclusion A higher admission NLR predicts an increased mortality risk and unfavorable outcomes following TBI. However, future research will likely address the existing gaps.
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Affiliation(s)
- Rakesh Kumar Mishra
- Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Sagar Galwankar
- Department of Global Health, University of South Florida, Tampa, Florida, United States
| | - Joel Gerber
- Department of Emergency Medicine, University of South Florida, Tampa, Florida, United States
| | - Anuj Jain
- Department of Anesthesia, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Md. Yunus
- Department of Trauma and Emergency Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Rafael Cincu
- Department of Neurosurgery, Valencia General Hospital, Valencia, Spain
| | | | | | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Marchese P, Lardone C, Canepele A, Biondi S, Roggi C, Massart F, Bonuccelli A, Peroni D, Giotta Lucifero A, Luzzi S, Foiadelli T, Orsini A. Pediatric traumatic brain injury: a new relation between outcome and neutrophil-to-lymphocite ratio. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 92:e2021417. [PMID: 35441607 PMCID: PMC9179059 DOI: 10.23750/abm.v92is4.12666] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/27/2022] [Indexed: 11/23/2022]
Abstract
Leading causes of death in industrialized countries are traumatic injuries and acquired disability, and entry to the emergency department in childhood. TBI (traumatic brain injury) may involve the onset of both primary lesions and a complex immune response (sterile immune reaction to brain injury), which, in addition to neuro-protective effects, can mediate secondary neurological injury. The neutrophil-to-lymphocyte ratio (NLR), as a circulating inflammatory marker, has been related to outcomes in adult patients with non-neurologic diseases (such as gut tumours) or neurologic diseases (such as stroke or brain tumours), and to the prognosis of traumatic brain injury in adolescents and adults. However, the potential role of NLR in predicting outcomes in paediatric head trauma is not clearly defined. The aim of this retrospective observational study is to evaluate the association between clinical features predictive of intracranial and extracranial lesions in TBI and NLR and to establish whether an elevation of NLR is indirectly associated with adverse outcomes in pediatric patients with TBI. We analysed a sample of 219 pediatric patients, between 2-18 years old, after a TBI, and evaluated if differences in NLR were associated with neurological signs or positive CT in pediatric patients. We then compared the NLR values between healthy subjects and patients with TBI. (www.actabiomedica.it)
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Affiliation(s)
| | | | | | | | | | | | | | - Diego Peroni
- Department of Pediatrics, University of Pisa, Italy.
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Thomas Foiadelli
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy.
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Siwicka-Gieroba D, Dabrowski W. Credibility of the Neutrophil-to-Lymphocyte Count Ratio in Severe Traumatic Brain Injury. Life (Basel) 2021; 11:life11121352. [PMID: 34947883 PMCID: PMC8706648 DOI: 10.3390/life11121352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 02/07/2023] Open
Abstract
Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality worldwide. The consequences of a TBI generate the activation and accumulation of inflammatory cells. The peak number of neutrophils entering into an injured brain is observed after 24 h; however, cells infiltrate within 5 min of closed brain injury. Neutrophils release toxic molecules including free radicals, proinflammatory cytokines, and proteases that advance secondary damage. Regulatory T cells impair T cell infiltration into the central nervous system and elevate reactive astrogliosis and interferon-γ gene expression, probably inducing the process of healing. Therefore, the neutrophil-to-lymphocyte ratio (NLR) may be a low-cost, objective, and available predictor of inflammation as well as a marker of secondary injury associated with neutrophil activation. Recent studies have documented that an NLR value on admission might be effective for predicting outcome and mortality in severe brain injury patients.
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Xie QJ, Huang W, Shen L, Wang MH, Liu KF, Liu F. Combination of Neutrophil-to-Lymphocyte Ratio and Admission Glasgow Coma Scale Score Is Independent Predictor of Clinical Outcome in Diffuse Axonal Injury. World Neurosurg 2021; 152:e118-e127. [PMID: 34033962 DOI: 10.1016/j.wneu.2021.05.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND The neutrophil-to-lymphocyte ratio (NLR) is an independent predictor of clinical outcome of different diseases, such as acute ischemic stroke, intracerebral hemorrhage, malignant tumor, and traumatic brain injury. However, the prognostic value of NLR plus admission Glasgow Coma Scale score (NLR-GCS) is still unclear in patients with diffuse axonal injury (DAI). Therefore this study assessed the relationship between the NLR-GCS and 6-month outcome of DAI patients. METHODS The clinical characteristics of DAI patients admitted to our department between January 2014 and January 2020 were retrospectively analyzed. The candidate risk factors were screened by using univariate analysis, and the independence of resultant risk factors was evaluated by the binary logistic regression analysis and least absolute shrinkage and selection operator regression analysis. The predictive value of NLR-GCS in an unfavorable outcome was assessed by the receiver operating characteristics curve analysis. RESULTS A total of 93 DAI patients were included. Binary logistic regression analysis and least absolute shrinkage and selection operator regression analysis showed the level of NLR on admission was an independent risk factor of unfavorable outcomes in DAI patients. The ROC curve analysis showed that the predictive capacity of the combination of NLR and admission GCS score and combination of NLR and coma duration outperformed NLR, admission GCS score, and coma duration alone. CONCLUSIONS The higher NLR level on admission is independently associated with unfavorable outcomes of DAI patients at 6 months. Furthermore, the combination of NLR and admission GCS score provides the superior predictive capacity to either NLR or GCS alone.
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Affiliation(s)
- Qi-Jun Xie
- Department of Neurosurgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Wu Huang
- Department of Neurosurgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Liang Shen
- Department of Neurosurgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Ming-Hai Wang
- Department of Neurosurgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Ke-Feng Liu
- Department of Neurosurgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Fang Liu
- Department of Neurosurgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China.
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Alexiou GA, Lianos GD, Tzima A, Sotiropoulos A, Nasios A, Metaxas D, Zigouris A, RN JZ, Mitsis M, Voulgaris S. Neutrophil to lymphocyte ratio as a predictive biomarker for computed tomography scan use in mild traumatic brain injury. Biomark Med 2020; 14:1085-1090. [DOI: 10.2217/bmm-2020-0150] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Aim: Traumatic brain injury (TBI) is a serious health concern. We set out to investigate the role of neutrophil-to-lymphocytes ratio (NLR) at admission for predicting the need for computed tomography (CT) in mild-TBI. Materials & methods: A retrospective study of adult patients who presented with mild-TBI Results: One hundred and thirty patients met the inclusion criteria. Seventy-four patients had positive CT-findings. The mean NLR-levels at presentations were 5.6 ± 4.8. Patients with positive CT-findings had significant higher NLR-levels. Receiver operating characteristic curve analysis was conducted and the threshold of NLR-levels for detecting the cases with positive CT-findings was 2.5, with 78.1% sensitivity and 63% specificity Conclusion: To the best of our knowledge no previous study has assessed the value of NLR-levels for predicting the need for CT in mild-TBI.
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Affiliation(s)
- George A Alexiou
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Georgios D Lianos
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece
| | - Aggeliki Tzima
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | | | - Anastasios Nasios
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Dimitris Metaxas
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Andreas Zigouris
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Jolanda Zika RN
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
| | - Michail Mitsis
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece
| | - Spyridon Voulgaris
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece
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