The Predictive Role of Postoperative Neutrophil to Lymphocyte Ratio for 30-Day Mortality After Intracerebral Hematoma Evacuation

Neutrophil-to-lymphocyte ratio, white blood cell, and C-reactive protein predicts poor outcome and increased mortality in intracerebral hemorrhage patients: a meta-analysis

Objective

Inflammation participates in the pathology and progression of secondary brain injury after intracerebral hemorrhage (ICH). This meta-analysis intended to explore the prognostic role of inflammatory indexes, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), white blood cell (WBC), and C-reactive protein (CRP) in ICH patients.

Methods

Embase, PubMed, Web of Science, and Cochrane Library were searched until June 2023. Two outcomes, including poor outcome and mortality were extracted and measured. Odds ratio (OR) and 95% confidence interval (CI) were presented for outcome assessment.

Results

Forty-six studies with 25,928 patients were included in this meta-analysis. The high level of NLR [OR (95% CI): 1.20 (1.13-1.27), p < 0.001], WBC [OR (95% CI): 1.11 (1.02-1.21), p = 0.013], and CRP [OR (95% CI): 1.29 (1.08-1.54), p = 0.005] were related to poor outcome in ICH patients. Additionally, the high level of NLR [OR (95% CI): 1.06 (1.02-1.10), p = 0.001], WBC [OR (95% CI): 1.39 (1.16-1.66), p < 0.001], and CRP [OR (95% CI): 1.02 (1.01-1.04), p = 0.009] were correlated with increased mortality in ICH patients. Nevertheless, PLR was not associated with poor outcome [OR (95% CI): 1.00 (0.99-1.01), p = 0.749] or mortality [OR (95% CI): 1.00 (0.99-1.01), p = 0.750] in ICH patients. The total score of risk of bias assessed by Newcastle-Ottawa Scale criteria ranged from 7-9, which indicated the low risk of bias in the included studies. Publication bias was low, and stability assessed by sensitivity analysis was good.

Conclusion

This meta-analysis summarizes that the high level of NLR, WBC, and CRP estimates poor outcome and higher mortality in ICH patients.

The trend of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in spontaneous intracerebral hemorrhage and the predictive value of short-term postoperative prognosis in patients

Background

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) play an important role in the inflammatory response in various diseases, but the role in the course of spontaneous intracerebral hemorrhage (ICH) is unclear.

Methods

This study retrospectively collected baseline characteristics and laboratory findings, including NLR and PLR at different time points, from spontaneous ICH patients undergoing surgery between January 2016 and June 2021. Patients were scored using the modified Rankin Scale (mRS) to evaluate their functional status at 30 days post-operation. Patients with mRS score ≥3 were defined as poor functional status, and mRS score <3 was defined as good functional status. The NLR and PLR were calculated at admission, 48 h after surgery and 3-7 days after surgery, respectively, and their trends were observed by connecting the NLR and PLR at different time points. Multivariate logistic regression analysis was used to identify independent risk factors affecting the prognosis of ICH patients at 30 days after surgery.

Results

A total of 101 patients were included in this study, and 59 patients had a poor outcome at 30 days after surgery. NLR and PLR gradually increased and then decreased, peaking at 48 h after surgery. Univariate analysis demonstrated that admission Glasgow Coma Scale (GCS) score, interval from onset to admission, hematoma location, NLR within 48 h after surgery and PLR within 48 h after surgery were associated with poor 30-day prognosis. In multivariate logistic regression analysis, NLR within 48 h after surgery (OR, 1.147; 95% CI, 1.005, 1.308; P, 0.042) was an independent risk factor for 30-day after surgery prognosis in spontaneous ICH patients.

Conclusion

In the course of spontaneous intracerebral hemorrhage, NLR and PLR initially increased and subsequently decreased, reaching their peak values at 48 h after surgery. High NLR within 48 h after surgery was an independent risk factor for poor prognosis 30 days after surgery in spontaneous ICH patients.

Neutrophil-lymphocyte ratio as a predictor of outcome following traumatic brain injury: Systematic review and meta-analysis

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.

The predictive value of neutrophil to lymphocyte ratio on 30-day outcomes in spontaneous intracerebral hemorrhage patients after surgical treatment: A retrospective analysis of 128 patients

Objective

The purpose of this study was to explore the predictive value of the neutrophil-to-lymphocyte ratio (NLR) on 30-day outcomes in patients with spontaneous intracerebral hemorrhage (ICH) after surgical treatment.

Methods

This retrospective study utilized data from patients with ICH who underwent craniotomy or minimally invasive puncture and drainage (MIPD) between January 2015 and June 2021. The patients meeting the inclusion criteria were divided into two groups according to 30-day outcomes, namely, the favorable outcome group and the poor outcome group. Sex, age, time from onset to admission, vital signs at admission, admission Glasgow Coma Scale (GCS) score, diabetes mellitus, hypertension, hematoma volume, hematoma location, surgical approach, and NLR at different time points were all recorded and analyzed.

Results

A total of 128 patients were finally enrolled in this study, including 32 and 96 patients in the favorable outcome group and the poor outcome group, respectively. During the course of ICH, the changing trend of NLR was to increase first and then decrease and peaked within 48 h after surgery. In the univariate analysis, systolic blood pressure, admission GCS score, hematoma volume, surgical approach, and NLR within 48 h after surgery were statistically significant. In the multivariable analysis, NLR within 48 h after surgery (odds ratio [OR] = 1.342, p < 0.001) was an independent risk factor of the 30-day outcomes in patients with ICH after surgical treatment. The receiver operating characteristic (ROC) analysis showed that the best predictive cut-off value for NLR within 48 h after surgery was 12.35 [sensitivity 82.9%, specificity 81.8%, and area under the curve (AUC) 0.877] and 14.46 (sensitivity 55.1%, specificity 87.5%, and area under the curve 0.731) for the MIPD group and the craniotomy group, respectively.

Conclusions

In the process of ICH, the value of NLR was increased first and then decreased and peaked within 48 h after surgery. NLR within 48 h after surgery was an independent risk factor of the 30-day outcomes in patients with ICH. The peak NLR >12.35 or 14.46 in patients receiving MIPD or craniotomy reflected a poor prognosis, respectively.

"Rogue" [DEspR+CD11b+] neutrophil subset correlates with severity in spontaneous intracerebral hemorrhage

Objective

Cumulative clinical, cellular, and molecular evidence reinforces the role of neutrophils in secondary brain injury in spontaneous intracerebral hemorrhage (sICH). However, since generalized neutrophil inhibition is detrimental, identification of targetable "rogue" neutrophil subsets associated with sICH severity is key.

Methods

In a pilot prospective observational study of consented patients with sICH, we immunotyped whole blood to assess circulating neutrophil markers (~day 3 after ICH symptoms onset): (a) DEspR±CD11b± neutrophils by flow cytometry, (b) DEspR±CD11b± neutrophil extracellular trap (NET)-forming neutrophils by immunofluorescence cytology, and (c) neutrophil-lymphocyte ratio (NLR). Using Spearman rank correlation (r) with Bonferroni correction, we assessed the association of neutrophil markers with same-day clinical and neuroimaging parameters of sICH severity, index ICH score, 90-day modified Rankin Scale (mRS) score, and potential interrelationships. As comparators, we assessed same-day plasma biomarkers elevated in sICH: interleukin-6/IL-6, myeloperoxidase/MPO, soluble-terminal complement complex/sC5b-9, endothelin-1/ET-1, and mitochondrial/nuclear DNA ratio (mt/nDNA ratio).

Results

We detected strong correlations [r(n = 13) > 0.71, power > 0.8, Bonferroni corrected p B < 0.05] for all three neutrophil markers with 90-day mRS score, differentially for DEspR+CD11b+ neutrophil counts, and NLR with perihematomal edema (PHE) volume and for DEspR+CD11b+ NET-forming neutrophil counts with intraparenchymal hemorrhage (IPH)-volume. Only DEspR+CD11b+ neutrophil counts show a strong correlation with index ICH score, same-day Glasgow Coma Scale (GCS) score, and NLR and NET-forming neutrophil counts. The sum of the ICH score and three neutrophil markers exhibited the highest correlation: [r(n = 13) 0.94, p B = 10-5]. In contrast, plasma biomarkers tested were elevated except for MPO but exhibited no correlations in this pilot study.

Conclusion

Strong correlation with multiple sICH severity measures, NET formation, and NLR identifies DEspR+CD11b+ neutrophils as a putative "rogue" neutrophil subset in sICH. The even stronger correlation of the sum of three neutrophil markers and the index ICH score with 90-day mRS outcome reinforces early neutrophil-mediated secondary brain injury as a key determinant of outcome in patients with sICH. Altogether, data provide a basis for the formal study of the DEspR+CD11b+ neutrophil subset as a potential actionable biomarker for neutrophil-driven secondary brain injury in sICH. Data also show ex vivo analysis of patients with sICH neutrophils as a translational milestone to refine hypotheses between preclinical and clinical studies.

Prognostic Role of the Neutrophil-to-Lymphocyte Ratio in Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

The neutrophil-to-lymphocyte ratio (NLR) plays an important role in the progression of intracerebral hemorrhage (ICH). An increasing number of studies have reported that a high NLR is correlated with poor clinical outcomes among patients with ICH. Here, we conducted a systematic review and meta-analysis to evaluate the prognostic value of NLR in the setting of ICH. We performed a comprehensive search of electronic literature databases to identify all relevant studies evaluating the prognostic role of NLR in patients with ICH. Two researchers independently screened the studies and extracted relevant data. We extracted, pooled, and weighted odds ratio (OR) and 95% confidence interval (CI) values using a generic inverse-variance method, and then evaluated the heterogeneity among studies using Q test and I² statistic. Finally, we selected a total of 26 studies including 7,317 patients for the current study. Overall, our results indicated that a high NLR was significantly associated with a poor outcome (OR, 1.32; 95% CI, 1.19–1.46; P < 0.00001), mortality (OR, 1.05; 95% CI, 1.01–1.09; P = 0.02), and neurological deterioration (OR, 1.65; 95% CI, 1.08–2.52; P = 0.02). We did not observe a significant association between NLR and hematoma expansion (OR, 1.04; 95% CI, 0.99–1.08; P = 0.09). Our study indicated that a high NLR is significantly associated with poor clinical outcomes in patients with ICH. As NLR is a simple and easily available biomarker, future studies should focus on exploring its application in the prognostic evaluation of patients with ICH.

A simple lectin-based biochip might display the potential clinical value of glycomics in patients with spontaneous intracerebral hemorrhage

Background

Intracerebral hemorrhage (ICH) is a cerebrovascular disease with extremely high disability and mortality rates. Glycans play critical roles in biological processes. However, whether glycans can serve as potential biomarkers for determining clinical diagnosis and prognosis in ICH remains determined.

Methods

In this study, we established a lectin-biochip to measure serum glycans levels in ICH patients (n=48) and healthy controls (n=16). An enzyme-linked immunosorbent assay (ELISA) was carried out to determine serum levels of IL-10 and TNF-α in the patients. Correlation analyses of the serum glycan and cytokine levels and the clinicopathological parameters of patients were performed.

Results

The biochip-based data revealed that the serum levels of α-Man/α-Glc (ConA), Galβ3GalNAc (PNA), GalNAc (VVA), Fucα6GlcNAc (AAL), α-Fuc (LTL), and Galβ3GalNAc-Ser/Thr (AIL) significantly increased in the super-acute phase of ICH in comparison with healthy controls. Clinicopathological analysis indicated the serum levels of ConA, VVA, and LTL had significant associations with the National Institute of Health Stroke Scale (NIHSS), and serum VVA levels had a significant association with the Mini-Mental State Examination (MMSE) at day 90 after ICH. Correlation coefficient analysis revealed significant correlations between TNF-α and ConA (P<0.001) as well as between IL-10 and ConA (P<0.001), PNA (P=0.02), VVA (P<0.001), and MAL (P=0.04), respectively.

Conclusions

We established a proof-of-concept platform for detecting serum glycomics and highlighted their potential value in diagnosing and predicting ICH patients' outcomes.

Early Serum Biomarkers for Intensive Care Unit Treatment within the First 24 Hours in Patients with Intracerebral Hemorrhage

BACKGROUND

 The prognostic significance of serum biomarkers in patients with intracerebral hemorrhage (ICH) is not well investigated concerning inhospital mortality (IHM) and cardiopulmonary events within the first 24 hours of intensive care unit (ICU) treatment. The influence of troponin I (TNI) value and cortisol value (CV) on cardiopulmonary events within the first 24 hours of ICU treatment was reported in subarachnoid hemorrhage patients, but not in ICH patients up to now. The aim of this study was to investigate the role of early serum biomarkers on IHM and TNI value and CV on cardiopulmonary events within the first 24 hours of ICU treatment.

PATIENTS AND METHODS

 A total of 329 patients with spontaneous ICH were retrospectively analyzed. Blood samples were taken on admission to measure serum biomarkers. The TNI value and CV were defined as biomarkers for cardiopulmonary stress. Demographic data, cardiopulmonary parameters, including norepinephrine application rate (NAR) in microgram per kilogram per minute and inspiratory oxygen fraction (FiO₂) within the first 24 hours, and treatment regime were analyzed concerning their impact on ICU treatment and in hospital outcome. Binary logistic analysis was used to identify independent prognostic factors for IHM.

RESULTS

 Patients with initially nonelevated CVs required higher NAR (p = 0.01) and FiO₂ (p = 0.046) within the first 24 hours of ICU treatment. Lower cholinesterase level (p = 0.004), higher NAR (p = 0.002), advanced age (p < 0.0001), larger ICH volume (p < 0.0001), presence of intraventricular hemorrhage (p = 0.007) and hydrocephalus (p = 0.009), raised level of C-reactive protein (p = 0.024), serum lactate (p = 0.003), and blood glucose (p = 0.05) on admission were significantly associated with IHM. In a multivariate model, age (odds ratio [OR]: 1.055; 95% confidence interval [CI]: 1.026-1.085; p < 0.0001), ICH volume (OR: 1.016; CI: 1.008-1.025; p < 0.0001), and Glasgow Coma Scale (GCS) score (OR: 0.680; CI: 0.605-0.764; p < 0.0001) on admission as well as requiring NAR (OR: 1.171; CI: 1.026-1.337; p = 0.02) and FiO₂ (OR: 0.951; CI: 0.921-0.983, p = 0.003) within the first 24 hours were independent predictors of IHM.

CONCLUSION

 Higher levels of C-reactive protein, serum lactate, blood glucose, and lower cholinesterase level on admission were significantly associated with IHM. Patients with initially nonelevated CVs required higher NAR and FiO₂ within the first 24 hours of ICU treatment. Furthermore, requiring an NAR > 0.5 µg/kg/min or an FiO₂ > 0.21 were identified as additional independent predictors for IHM. These results could be helpful to improve ICU treatment in ICH patients.