High neutrophil percentage and neutrophil-lymphocyte ratio in acute phase of ischemic stroke predict cognitive impairment: A single-center retrospective study in China

Peripheral immunity is associated with cognitive impairment after acute minor ischemic stroke and transient ischemic attack

Immunoinflammation is associated with the development of post-stroke cognitive impairment (PSCI), however, peripheral immunity has not been fully explored. We aimed to investigate the association between PSCI and peripheral immune indicators, including neutrophil, lymphocyte, and mononuclear percentages and counts; the systemic immune inflammation index; platelet-to-lymphocyte ratio; neutrophil-to-lymphocyte ratio (NLR); and lymphocyte-to-monocyte ratio. A total of 224 patients with acute minor ischemic stroke or transient ischemic attack with 6-12 months of follow-up were included. PSCI was defined as a Montreal Cognitive Assessment score < 22 during the follow-up period. We performed logistic regression, subgroup analyses based on age and sex, and further established predictive models. We found that increased innate immunity indicators (neutrophils, neutrophil percentage) increased the risk of PSCI, whereas increased adaptive immunity indicator (lymphocytes) were protective against PSCI, especially in patients aged 50-65 years. Neutrophil percentage and NLR improved the predictive efficacy of the models that included demographic, clinical, and imaging information, with the area under the curve increased from 0.765 to 0.804 and 0.803 (P = 0.042 and 0.049, respectively). We conducted a comprehensive analysis of peripheral immunity in PSCI, providing a novel perspective on the early detection, etiology, and treatment of PSCI.

Infection, Inflammation, and Poststroke Cognitive Impairment

BACKGROUND

Infection and inflammation are dementia risk factors in population-based cohorts; however, studies in stroke are scarce. We determined the prevalence of infection after stroke and routinely measured inflammatory biomarkers during hospitalization and their associations with acute and 6-month cognitive impairment.

METHODS AND RESULTS

A prospective stroke cohort completed the Oxford Cognitive Screen at ≤2 weeks and 6 months after stroke. Infection, inflammatory markers (C-reactive protein, white cell count, and neutrophil/lymphocyte ratio), and systemic inflammatory response syndrome were ascertained throughout admission with electronic patient records supplemented by hand searches. Associations with acute and 6-month global and domain-specific cognitive impairment were analyzed using multivariable regression, adjusting for demographic/vascular factors and stroke severity. Among 255 patients (mean age, 73.9 [SD, 12.6] years; 46.3% women; mean education, 12.6 [SD, 3.7] years; median National Institutes of Health Stroke Scale score 5 [range, minimum-maximum, 0-30]), infection was present in 90 patients (35.3%) at mean 4.4 (SD, 6.9) days after stroke, consisting predominantly of pneumonia (47/90; 52%) and urinary tract infection (39/90; 43%). Admission white cell count was elevated in 25.1% (n=64; mean, 9.5×109/L [SD, 3.2×109/L]), C-reactive protein in 41.2% (n=105; mean, 27.5 [SD, 50.9 mg/L]), neutrophil/lymphocyte ratio in 55.7% (n=97; mean, 5.5 [SD, 4.5]), and systemic inflammatory response syndrome in 26.6% (n=53 [45.2%] positive during hospitalization). Infection was associated with acute and 6-month poststroke cognitive impairment (P<0.05adj) with stronger associations acutely for severe infection (infection+systemic inflammatory response syndrome; P=0.03adj). Acute language, executive function and attention domain impairments, and 6-month number processing impairment were associated with infection (P<0.05adj). No significant relationships were found for any biomarker and cognitive impairment.

CONCLUSIONS

Infection and elevations in routinely measured inflammatory biomarkers are common following stroke; however, only infection is associated with poststroke cognitive impairment, suggesting that increases in these biomarkers may be nonspecific. Infection may present a tractable target for reducing poststroke cognitive impairment.

Electroencephalographic power spectrum changes in cerebral small vessel disease combined with cognitive dysfunction and its relationship with neutrophil/lymphocyte ratio and its clinical value - a pilot study

Objective

The study aimed to explore the changes in the electrical power spectrum of the brain and its correlation with neutrophil/lymphocyte ratio (NLR) in patients with cognitively impaired cerebral small vessel disease (CSVD) and to explore its clinical application.

Methods

A total of 61 patients with CSVD who attended the People's Hospital of Shaanxi Province from September 2021 to September 2022 were divided into the group with cognitive impairment (cerebral small vascular with cognitive impairment, CSVCI group, n = 29) and the group without cognitive impairment (CSVD group, n = 32) based on the Montreal Cognitive Assessment Scale (MoCA) score, while 20 healthy subjects were recruited as the control group (healthy control, HC group). EEG was performed in the three groups, and the difference in whole brain quantitative EEG power spectral density (PSD) was calculated and compared between the three groups.

Results

The PSD values in the δ and θ bands of the CSVCI group were higher than those of the CSVD group, while the PSD values in the α band were lower than those of the CSVD and HC groups. In addition, PSD values in the δ-band in the CSVD group were lower than those in the HC group (all p < 0.05). Multifactorial logistic regression showed that reduced α-band global average PSD and low years of education were independent risk factors for cognitive impairment in patients with CSVD (p < 0.05). In patients with cerebral small-vessel disease, α-band PSD was positively and δ-band PSD negatively correlated with MoCA score, and paraventricular, deep white matter, and total Fazekas scores were negatively correlated with MoCA score. Furthermore, θ-band PSD is positively correlated with NLR (all p < 0.05).

Conclusion

EEG activity was slowed down in patients with CSVD with cognitive impairment. The α-band global mean PSD values independently affected the occurrence of cognitive impairment in CSVD patients beyond the Fazekas score. NLR may be one of the mechanisms leading to the slowing down of the EEG, which can be used as an objective indicator for the early prediction of cognitive impairment but still needs to be clarified by further studies.

Prediction of poststroke cognitive impairment based on the systemic inflammatory response index

BACKGROUND

Poststroke cognitive impairment (PSCI) is a prevalent complication among stroke survivors. Although the systemic inflammatory response index (SIRI) has been shown to be a reliable predictor of a variety of inflammatory diseases, the association between the SIRI and PSCI is still unclear. Therefore, the purpose of this study was to investigate the relationship between SIRI and PSCI, and to design a nomogram to predict the risk of PSCI in acute ischemic stroke (AIS) patients.

METHODS

A total of 1342 patients with AIS were included in the study. Using the Mini-Mental State Examination scale, patients were separated into PSCI and non-PSCI groups within 2 weeks of stroke. Clinical data and SIRI values were compared between the groups. We developed the optimal nomogram for predicting PSCI using multivariate logistic regression. Finally, the nomogram was validated using the receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA).

RESULTS

In total, 690 (51.4%) patients were diagnosed with PSCI. After adjusting for potential confounders, the SIRI (OR = 1.226, OR: 1.095-1.373, p < .001) was shown to be an independent risk factor for PSCI in the logistic regression analysis. The nomogram based on patient gender, age, admission National Institutes of Health Stroke Scale scores, education, diabetes mellitus, and SIRI had good discriminative ability with an area under the curve (AUC) of 0.716. The calibration curve and Hosmer-Lemeshow test revealed excellent predictive accuracy for the nomogram. Finally, the DCA showed the good clinical utility of the model.

CONCLUSION

Increased SIRI on admission is correlated with PSCI, and the nomogram built with SIRI as one of the predictors can help identify PSCI early.

Association between the neutrophil-to-lymphocyte ratio and cognitive impairment: a meta-analysis of observational studies

Background

Systemic inflammation is one of the underlying mechanisms of cognitive impairment. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a systemic inflammation indicator. This meta-analysis aimed to evaluate the association between high NLR and cognitive impairment (CI) risk.

Method

A comprehensive systematic search was conducted to identify eligible studies published until May 30, 2023. The reference group comprised patients with the lowest NLR level, whereas the exposure group comprised those with the highest NLR level. The main outcome was to examine the relationship between NLR and CI risk. The secondary outcome included the association between patient characteristics or comorbidities and CI risk.

Results

This meta-analysis included 11 studies published between 2018 and 2023, involving 10,357 patients. Patients with CI had a higher NLR than those without (mean difference=0.35, 95% confidence interval [CI]: 0.26-0.44, p < 00001, I2 = 86%). Consistently, pooled results revealed an association between high NLR and CI risk (odds ratio [OR]=2.53, 95% CI:1.67-3.82, p<0.0001, I2 = 84%). Furthermore, aging (mean difference =4.31 years, 95% CI:2.83-5.8, p < 0.00001, I2 = 92%), diabetes (OR=1.59, 95% CI:1.35-1.88, p < 0.00001, I2 = 66%), and hypertension (OR=1.36, 95% CI:1.19-1.57, p < 0.00001, I2 = 0%) were significant risk factors for CI. However, no significant associations were observed between CI and male gender (OR = 0.84, 95% CI:0.64-1.11, p = 0.22, I2 = 81%), body mass index (mean = -0.32 kg/m2, 95% CI: -0.82, 0.18, p = 0.2, I2 = 82%), alcohol consumption (OR = 1.11, 95% CI:0.95-1.3, p = 1.35, I2 = 0%), and smoking (OR = 0.99, 95% CI:0.87-1.13, p = 0.86, I2 = 0%). Meta-regression found that diabetes and hypertension, but not age, significantly moderated the association between NLR and CI.

Conclusion

This meta-analysis showed a significant association between high NLR and increased CI risk. Moreover, meta-regression identified diabetes and hypertension, but not age, as significant moderating factors in the relationship between NLR and CI. To validate and strengthen these findings, further large-scale studies are required.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023430384, identifier CRD42023430384.

Neutrophil to high-density lipoprotein cholesterol ratio, a novel risk factor associated with acute ischemic stroke

To investigate the relationship between neutrophil to high-density lipoprotein cholesterol ratio (NHR) and Acute Ischemic Stroke (AIS), and provide a new direction for the diagnosis and prevention of AIS. A total of 158 patients with AIS and 162 healthy individuals were recruited. Demographic, clinical, and laboratory data of participants were obtained and the multivariable logistic regression analysis was employed to assess risk factors for AIS. The receiver operating characteristic (ROC) curve was plotted to analyze the diagnostic value of NHR for AIS. The spearman correlation analysis was used to estimate the correlation between NHR and national institute of health stroke scale (NIHSS) score. The age, White blood cell, MONO (monocyte), NEUT (neutrophil), creatinine, TG (triglyceride), NHR, neutrophil to lymphocyte ratio and MONO to high-density lipoprotein cholesterol ratio were remarkably greater and HDL-C (high-density lipoprotein cholesterol) was dramatically lower in the case group compared with in the control group (P < .05). The multivariable logistic regression analysis revealed that age [OR = 1.095, 95% CI (1.056, 1.135)], TG [OR = 6.188, 95% CI (2.900, 13.206)] and NHR [OR = 11.394, 95% CI (1.196, 108.585)] were independent risk factors for AIS (P < .05). The areas under the curve (AUCs) for the prediction of AIS by the age, TG and NHR were 0.694, 0.686, 0.782, respectively, the specificity were 56.8%, 88.3%, 87.0%, and the sensitivity were 75.3%, 44.3%, 56.3%, respectively (P < .05). In addition, spearman correlation analysis indicated that there was a positive correlation between NHR and NIHSS score (R = 0.558, P < .05). The level of NHR was higher in patients with a NIHSS score of above 5 points compared with those with a NIHSS score of 5 points or lower (P < .0001). The age, TG, and NHR were independent risk factors for AIS, and the level of NHR was positively correlated with severity of AIS.

The Managing Cancer and Living Meaningfully (CALM) Intervention Alleviates Chemotherapy-Related Cognitive Impairment in Patients with Breast Cancer by Modulating Pan-Immune-Inflammation Values

Background:

The number of patients with breast cancer is increasing worldwide, resulting in a growing number of patients with chemotherapy-related cognitive impairment (CRCI), which seriously affects their quality of life. CRCI is associated with inflammatory factors and systemic inflammatory markers such as pan-immune-inflammation value (PIV) and monocyte-to-lymphocyte ratio (MLR), which can reflect the level of inflammation in the body. While the Managing Cancer and Living Meaningfully (CALM) intervention has been demonstrated to alleviate CRCI in patients with breast cancer, the specific mechanism remains unclear.

Objective:

This study evaluated the impact of the CALM intervention on systemic inflammation.

Methods:

Ninety patients with breast cancer with CRCI were enrolled and randomized into care as usual (CAU) and CALM intervention groups. All patients were assessed using the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog), Mini-Mental State Exam (MMSE), and Functional Assessment of Cancer Therapy-Breast (FACT-B) before and after the CAU/CALM intervention. The blood levels of inflammatory markers were also analyzed before and after the intervention.

Results:

Compared to the CAU group, the CALM group showed significantly improved cognitive function and significantly decreased PIV ( P < .05). PIV was significantly negatively correlated with FACT-Cog ( P < .05). The levels of other inflammatory markers, including MLR, neutrophil-to-lymphocyte ratio (NLR), granulocyte-to-lymphocyte ratio (GLR), and systemic immune-inflammation index (SII), were also reduced in the CALM group.

Conclusion:

PIV is an important marker of inflammation. The CALM intervention may improve the cognitive function of patients by regulating the systemic inflammation marker PIV through the neuroimmune axis.