Novel peripheral blood cell ratios: Effective 3-month post-mechanical thrombectomy prognostic biomarkers for acute ischemic stroke patients

Nomogram model for decompressing craniectomy after mechanical thrombectomy in patients with acute ischemic stroke

The most common treatment method for patients with acute ischemic stroke with large vessel occlusion is mechanical thrombectomy. However, complications such as cerebral edema and hemorrhage transformation after MT can affect patient prognoses, while decompression craniectomy considerably improves patient prognoses. The aim of this study was to identify clinical indicators, such as the neutrophil/high-density lipoprotein cholesterol ratio, to predict DC. A retrospective analysis was conducted in AIS-LVO patients who received MT at Huizhou Central People's Hospital and the Affiliated Hospital of Guilin Medical University. The patients were randomly divided into training, internal validation group and external validation group sets to generate and validate a nomogram model. Multivariate binary logistic analyses indicated that SBP > 178.5 mmHg, WBC > 12.05*109/L, PT > 14.54 s, and NHR > 8.874*109/mmol were independent risk factors for DC after MT in patients with AIS-LVO. In the training set, the area under the curve indicated good accuracy. Calibration curve results showed the average error in the training set was 0.038, and 0.036 in the validation set, showing good model fit. NHR was an independent risk factor for DC treatment after MT in AIS-LVO patients. A nomogram based on NHR accurately predicted if DC treatment was required after MT in patients with AIS-LVO.

Value of the red blood cell distribution width (RDW) and neutrophil lymphocyte ratio (NLR) in the prediction of functional recovery and 3-month mortality following endovascular treatment for acute anterior circulation ischemic stroke

Objectives

The red blood cell distribution width (RDW) and neutrophil to lymphocyte ratio (NLR) have been linked to poor prognosis in patients with ischaemic stroke. However, no study has yet evaluated the prognostic role of RDW and NLR, or their combined effect on reperfusion in patients with endovascularly-treated acute ischaemic stroke. This study therefore aimed to analyse the impact of RDW and NLR on poor functional outcomes and failed reperfusion following endovascular treatment in patients with acute anterior circulation ischaemic stroke.

Methods

A total of 275 patients with acute anterior circulation ischaemic stroke treated endovascularly between 2015 and 2018 were enrolled in this study. The relationships between RDW, NLR, and poor outcomes were analysed using univariate and multivariate logistic regression models and receiver operating characteristic (ROC) curve analysis. The Youden Index was applied to determine the cut-off value.

Results

Multivariate logistic regression analysis identified RDW (p = 0.015) and NLR (p = 0.015) as independent predictors of mortality at the 3rd month. ROC curve analysis of RDW revealed a cutoff value of 14.25 (p = 0.009) for poor clinical outcomes (modified Rankin scale [mRS] 3-6). Similarly, a cutoff value of 14.25 was found for mortality prediction (p = 0.003). The cutoff value for poor clinical outcome (mRS 3-6) in the NLR was determined as 5.93 (p = 0.003), whereas the cutoff value for mortality was set at 5.17 (p = 0.028). RDW also predicted failed reperfusion, with a cutoff value of 17.75 (p = 0.048).

Conclusions

High RDW and NLR upon admission were identified as independent indicators of mortality in endovascularly treated acute anterior circulation ischemic stroke patients. Furthermore, the RDW could potentially predict failed reperfusion.

Inflammatory biomarkers may be associated with poor outcomes after mechanical thrombectomy

BACKGROUND

Mechanical thrombectomy (MT) has become the mainstay of treatment for acute ischemic stroke (AIS) recently. This case-control study aimed to identify the pivotal role of inflammation in the prognosis of AIS patients after MT.

METHODS

Altogether, 70 AIS patients who underwent MT were retrospectively recruited for this study. Receiver operating characteristic analysis was performed to demonstrate the sensitivity and specificity of the inflammatory variables for predicting prognosis. A meta-analysis was performed to pool the published results together. Stata software was used for analysis.

RESULTS

There was no differences in pre-MT inflammatory biomarkers between patients who survived and those who died, as well as patients with modified Rankin Scale (mRS) 0-2 and mRS ≥ 3. In contrast, post-MT C-reactive protein (CRP) levels might be a potential parameter to predict death after thrombectomy [area under the curve (AUC), 95%confidence interval (CI), 0.737, 0.587-0.887; p = 0.005; optimal cutoff value = 4.565]. Moreover, post-MT monocyte count might be an appropriate parameter to predict poor long-term prognosis after thrombectomy (AUC, 95%CI, 0.704, 0.575-0.833; p = 0.017; optimal cutoff value = 0.345). A meta-analysis revealed that the pre-MT inflammatory indices, including white blood cell count (weighted mean difference, 95%CI, 1.32, 1.01-1.63), neutrophil count (1.23, 0.95-1.51), monocyte count (0.05, 0.02-0.09), neuthrophil-to-lymphocyte ratio (2.42, 1.98-2.87) and platelet-to-lymphocyte ratio (24.65, 7.99-41.32), were higher in patients with 3-month mRS ≥ 3, and the lymphocyte count (-0.31,-0.43 to -0.18) was lower in this cohort.

CONCLUSIONS

Inflammatory indices were significantly associated with the prognosis of patients undergoing MT, especially post-MT CRP and monocyte count, which can predict long-term outcomes.

Red blood cell distribution width to platelet ratio predicts early neurological deterioration in acute ischemic stroke patients receiving intravenous thrombolysis

BACKGROUND

Inflammation plays a prominent role in the pathogenesis and progression of acute ischemic stroke (AIS). The red blood cell distribution width to platelet ratio (RPR) has been demonstrated as a novel biomarker to indicate the severity of inflammatory reaction. This study aimed to explore the association between RPR before intravenous thrombolysis and early neurological deterioration (END) after thrombolysis in AIS patients.

METHODS

AIS patients accepting intravenous thrombolysis were recruited continuously. Postthrombolysis END was defined as death or an increase in the National Institute of Health Stroke Scale (NIHSS) score ≥4 points within 24 h after intravenous thrombolysis compared to the NIHSS score before intravenous thrombolysis. We constructed univariate and multivariate logistic regression analyses to investigate the relationship of RPR before intravenous thrombolysis to postthrombolysis END. Moreover, a receiver operating characteristic (ROC) curve was applied to examine the discriminative utility of RPR before intravenous thrombolysis in predicting postthrombolysis END.

RESULTS

A total of 235 AIS patients were included, and 31 (13.19%) subjects underwent postthrombolysis END. The univariate logistic regression analysis demonstrated that RPR before intravenous thrombolysis was significantly related to postthrombolysis END (odds ratio [OR], 2.162; 95% confidence interval [CI], 1.605-2.912; P < 0.001). After adjusting for potential confounding variables with P < 0.15 in the univariate logistic regression analysis, the difference remained statistically significant (OR, 2.031; 95% CI, 1.436-2.873; P < 0.001). Furthermore, an optimal cutoff value of 7.66 for RPR before intravenous thrombolysis in predicting postthrombolysis END was observed in the ROC curve analysis, and the sensitivity and specificity were calculated as 61.3% and 81.9%, respectively (area under the curve [AUC], 0.772; 95% CI, 0.684-0.860; P < 0.001).

CONCLUSIONS

RPR before intravenous thrombolysis might be an independent risk factor for postthrombolysis END in AIS patients. Elevated levels of RPR before intravenous thrombolysis may predict postthrombolysis END.

Monocyte to HDL and Neutrophil to HDL Ratios as Potential Ischemic Stroke Prognostic Biomarkers

Ischemic stroke (IS) exhibits significant heterogeneity in terms of etiology and pathophysiology. Several recent studies highlight the significance of inflammation in the onset and progression of IS. White blood cell subtypes, such as neutrophils and monocytes, participate in the inflammatory response in various ways. On the other hand, high-density lipoproteins (HDL) exhibit substantial anti-inflammatory and antioxidant actions. Consequently, novel inflammatory blood biomarkers have emerged, such as neutrophil to HDL ratio (NHR) and monocyte to HDL ratio (MHR). Literature research of two databases (MEDLINE and Scopus) was conducted to identify all relevant studies published between 1 January 2012 and 30 November 2022 dealing with NHR and MHR as biomarkers for IS prognosis. Only full-text articles published in the English language were included. Thirteen articles have been traced and are included in the present review. Our findings highlight the utility of NHR and MHR as novel stroke prognostic biomarkers, the widespread application, and the calculation of which, along with their inexpensive cost, make their clinical application extremely promising.

Diagnostic value and mechanism of plasma S100A1 protein in acute ischemic stroke: a prospective and observational study

Background

Plasma S100A1 protein is a novel inflammatory biomarker associated with acute myocardial infarction and neurodegenerative disease's pathophysiological mechanisms. This study aimed to determine the levels of this protein in patients with acute ischemic stroke early in the disease progression and to investigate its role in the pathogenesis of acute ischemic stroke.

Methods

A total of 192 participants from hospital stroke centers were collected for the study. Clinically pertinent data were recorded. The volume of the cerebral infarction was calculated according to the Pullicino formula. Multivariate logistic regression analysis was used to select independent influences. ROC curve was used to analyze the diagnostic value of AIS and TIA. The correlation between S100A1, NF-κB p65, and IL-6 levels and cerebral infarction volume was detected by Pearson correlation analysis.

Results

There were statistically significant differences in S100A1, NF-κB p65, and IL-6 among the AIS,TIA, and PE groups (S100A1, [230.96 ± 39.37] vs [185.85 ± 43.24] vs [181.47 ± 27.39], P < 0.001; NF-κB p65, [3.99 ± 0.65] vs [3.58 ± 0.74] vs [3.51 ± 0.99], P = 0.001; IL-6, [13.32 ± 1.57] vs [11.61 ± 1.67] vs [11.42 ± 2.34], P < 0.001). Multivariate logistic regression analysis showed that S100A1 might be an independent predictive factor for the diagnosis of disease (P < 0.001). The AUC of S100A1 for diagnosis of AIS was 0.818 (P < 0.001, 95% CI [0.749-0.887], cut off 181.03, Jmax 0.578, Se 95.0%, Sp 62.7%). The AUC of S100A1 for diagnosis of TIA was 0.720 (P = 0.001, 95% CI [0.592-0.848], cut off 150.14, Jmax 0.442, Se 50.0%, Sp 94.2%). There were statistically significant differences in S100A1, NF-κB p65, and IL-6 among the SCI,MCI, and LCI groups (S100A1, [223.98 ± 40.21] vs [225.42 ± 30.92] vs [254.25 ± 37.07], P = 0.001; NF-κB p65, [3.88 ± 0.66] vs [3.85 ± 0.64] vs [4.41 ± 0.45], P < 0.001; IL-6, [13.27 ± 1.65] vs [12.77 ± 1.31] vs [14.00 ± 1.40], P = 0.007). Plasma S100A1, NF-κB p65, and IL-6 were significantly different from cerebral infarction volume (S100A1, r = 0.259, P = 0.002; NF-κB p65, r = 0.316, P < 0.001; IL-6, r = 0.177, P = 0.036). There was a positive correlation between plasma S100A1 and IL-6 with statistical significance (R = 0.353, P < 0.001). There was no significant positive correlation between plasma S100A1 and NF-κB p65 (R < 0.3), but there was statistical significance (R = 0.290, P < 0.001). There was a positive correlation between IL-6 and NF-κB p65 with statistical significance (R = 0.313, P < 0.001).

Conclusion

S100A1 might have a better diagnostic efficacy for AIS and TIA. S100A1 was associated with infarct volume in AIS, and its level reflected the severity of acute cerebral infarction to a certain extent. There was a correlation between S100A1 and IL-6 and NF-κB p65, and it was reasonable to speculate that this protein might mediate the inflammatory response through the NF-κB pathway during the pathophysiology of AIS.

Prognostic role of dynamic neutrophil-to-lymphocyte ratio in acute ischemic stroke after reperfusion therapy: A meta-analysis

Background

The prognostic role of the neutrophil-to-lymphocyte ratio (NLR), an inflammatory marker, in acute ischemic stroke (AIS) after reperfusion therapy remains controversial. Therefore, this meta-analysis sought to assess the correlation between the dynamic NLR and the clinical outcomes of patients with AIS after reperfusion therapy.

Methods

PubMed, Web of Science, and Embase databases were searched to identify relevant literature from their inception to 27 October 2022. The clinical outcomes of interest included poor functional outcome (PFO) at 3 months, symptomatic intracerebral hemorrhage (sICH), and 3-month mortality. The NLR on admission (pre-treatment) and post-treatment was collected. The PFO was defined as a modified Rankin scale (mRS) of >2.

Results

A total of 17,232 patients in 52 studies were included in the meta-analysis. The admission NLR was higher in the 3-month PFO (standardized mean difference [SMD] = 0.46, 95% confidence interval [CI] = 0.35-0.57), sICH (SMD = 0.57, 95% CI = 0.30-0.85), and mortality at 3 months (SMD = 0.60, 95% CI = 0.34-0.87). An elevated admission NLR was associated with an increased risk of 3-month PFO (odds ratio [OR] = 1.13, 95% CI = 1.09-1.17), sICH (OR = 1.11, 95% CI = 1.06-1.16), and mortality at 3 months (OR = 1.13, 95% CI = 1.07-1.20). The post-treatment NLR was significantly higher in the 3-month PFO (SMD = 0.80, 95% CI = 0.62-0.99), sICH (SMD = 1.54, 95% CI = 0.97-2.10), and mortality at 3 months (SMD = 1.00, 95% CI = 0.31-1.69). An elevated post-treatment NLR was significantly associated with an increased risk of 3-month PFO (OR = 1.25, 95% CI = 1.16-1.35), sICH (OR = 1.14, 95% CI = 1.01-1.29), and mortality at 3 months (OR = 1.28, 95% CI = 1.09-1.50).

Conclusion

The admission and post-treatment NLR can be used as cost-effective and easily available biomarkers to predict the 3-month PFO, sICH, and mortality at 3 months in patients with AIS treated with reperfusion therapy. The post-treatment NLR provides better predictive power than the admission NLR.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022366394.

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.

Monocytohigh-density lipoprotein ratio has a high predictive value for the diagnosis of multiple system atrophy and the differentiation from Parkinson’s disease

Background and purpose

Inflammation is closely related to the pathogenesis of multiple system atrophy (MSA). As markers of inflammation, the monocyte to high-density lipoprotein ratio (MHR), neutrophil to lymphocyte ratio (NLR), and red cell distribution width to platelet ratio (RPR) have been proven to be associated with a large variety of diseases. The aim of this study was to explore the association between inflammatory markers (MHR, NLR, and RPR) and MSA, and the difference between MSA and Parkinson’s disease (PD) was further compared by these inflammatory markers.

Materials and methods

This study was divided into three groups: 47 patients with MSA, 125 patients with PD, and 124 healthy controls. The corresponding laboratory indicators of subjects were collected and analyzed to obtain MHR, NLR, and RPR values.

Results

Compared with healthy controls, the MHR, NLR, and RPR were higher in the MSA group (P < 0.05), and the MHR was higher in the MSA group than in the PD group (P < 0.001). Multivariate logistic regression analysis showed that MHR*10 (corrected OR = 1.312, 95% CI 1.093–1.575) and RPR*100 (corrected OR = 1.262, 95% CI 1.055–1.509) were positively correlated with the risk of MSA. The receiver operating characteristic (ROC) curve indicated that the areas under the curve (AUCs) of the MHR, NLR, and RPR for predicting MSA were 0.651 (95% CI 0.562–0.74; P < 0.05), 0.6 (95% CI 0.501–0.699; P < 0.05), and 0.612 (95% CI 0.516–0.708; P < 0.05), respectively. The AUC of MSA and PD predicted by the MHR was 0.727 (P < 0.001). When the cut-off value was 0.38, the sensitivity and specificity were 60 and 77%, respectively. Spearman correlation analysis showed that the MHR was significantly and positively correlated with the course of MSA cerebellar type (MSA-C) patients.

Conclusion

There may be peripheral inflammation in patients with MSA. Compared with NLR and RPR, MHR has higher predictive value for the diagnosis and differential diagnosis of MSA.

Role of Neutrophil-Lymphocyte Ratio in the Prognosis of Acute Ischaemic Stroke After Reperfusion Therapy: A Systematic Review and Meta-analysis

Background

Inflammation may mediate response to acute reperfusion therapy (RT) in acute cerebral ischaemia. Neutrophil-lymphocyte ratio (NLR), an inflammatory biomarker, may play an important role in acute ischaemic stroke (AIS) prognostication.

Objective

This meta-analysis sought to examine the effect of NLR on functional outcomes, mortality and adverse outcomes in AIS patients receiving RT.

Methods

Individual studies were retrieved from PubMed/Medline, EMBASE and Cochrane databases. Data were extracted using a standardised data sheet and meta-analysis on association of admission (pre-RT) or delayed (post-RT) NLR with clinical/safety outcomes after RT was conducted.

Results

Thirty-five studies (n = 10 308) were identified for the systematic review with 27 (n = 8537) included in the meta-analyses. Lower admission NLR was associated with good functional outcomes (GFOs), defined as 3-month modified Rankin scale (mRS) 0–2 (SMD = −.46; 95% CI = −.62 to −.29; P < .0001), mRS 0–1 (SMD = −.44; 95% CI = −.66 to −.22; P < .0001) and early neurological improvement (ENI) (SMD = −.55; 95 %CI = −.84 to −.25; P < .0001). Lower delayed admission NLR was also associated with GFOs (SMD = −.80; 95%CI = −.91 to −.68; P < .0001). Higher admission NLR was significantly associated with mortality (SMD = .49; 95%CI = .12 to .85; P = .009), intracerebral haemorrhage (ICH) (SMD = .34; 95% CI = .09 to .59; P = .007), symptomatic ICH (sICH) (SMD = .48; 95% CI = .07 to .90; P = .022) and stroke-associated infection or pneumonia (SMD = .85; 95% CI = .50, 1.19; P < .0001). Higher delayed NLR was significantly associated with sICH (SMD = 1.40; 95% CI = .60 to 2.19; P = .001), ICH (SMD = .94; 95% CI = .41 to 1.46; P < .0001) and mortality (SMD = 1.12; 95% CI = .57 to 1.67; P < .0001). There were variations in outcomes across RT groups.

Conclusion

Higher admission or delayed NLR is significantly associated with worse morbidity, mortality and safety outcomes in AIS patients receiving RT.

Monocyte/High-Density Lipoprotein Ratio Predicts the Prognosis of Large Artery Atherosclerosis Ischemic Stroke

Objective: Monocyte to high-density lipoprotein ratio is considered as a new inflammatory marker and has been used to predict the severity of coronary heart disease and the incidence of adverse cardiovascular events (ACEs). However, there is a lack of data relative to large artery atherosclerosis (LAA) ischemic stroke. We investigated whether the monocyte to high-density lipoprotein (HDL) ratio (MHR) is related to the 3-month functional prognosis of LAA ischemic stroke.

Materials and Methods: A retrospective analysis was conducted on 316 LAA ischemic stroke patients. The 3-month functional outcome was divided into good and poor according to the modified Rankin Scale (mRS) score. Multivariate logistic regression analysis was performed to evaluate the correlation between MHR and prognosis of ischemic stroke.

Results: The MHR level of poor functional outcome group was higher than that of the good functional outcome group [0.44 (0.3, 0.55) vs. 0.38 (0.27, 0.5), P = 0.025]. Logistic stepwise multiple regression revealed that MHR [odds ratio (OR) 9.464, 95%CI 2.257–39.678, P = 0.002] was an independent risk factor for the 3-month poor outcome of LAA ischemic stroke. Compared to the lower MHR tertile, the upper MHR tertile had a 3.03-fold increase (95% CI 1.475–6.225, P = 0.003) in the odds of poor functional outcome after adjustment for potential confounders. Moreover, a multivariable-adjusted restricted cubic spline (RCS) showed a positive close to a linear pattern of this association.

Conclusion: Elevated MHR was independently associated with an increased risk of poor 3-month functional outcome of patients with LAA ischemic stroke.