Peripheral Blood Neutrophil-to-lymphocyte Ratio as a Predictor of Functional Outcomes in Patients with Hemorrhagic Stroke
Sethu Babu, Mathew Pulicken, Arun K Thazhathuveedu
Functional outcomes, Hemorrhagic stroke, Intracranial hemorrhage, Modified Rankin scale, Neutrophil-to-lymphocyte ratio, The ICH score
Citation Information :
Babu S, Pulicken M, Thazhathuveedu AK. Peripheral Blood Neutrophil-to-lymphocyte Ratio as a Predictor of Functional Outcomes in Patients with Hemorrhagic Stroke. Indian J Crit Care Med 2022; 26 (1):18-22.
Background: Peripheral blood neutrophil-to-lymphocyte ratio (NLR) has recently emerged as a prognostic biomarker in many disease states. The aim of this study was to evaluate the diagnostic utility of NLR to predict poor functional outcomes in patients with hemorrhagic stroke and to compare it with the intracranial hemorrhage (ICH) score.
Materials and methods: Patients who presented to the emergency department with clinical features suggestive of stroke were evaluated with computed tomography (CT) brain to identify ICH. The ICH scores and NLR were estimated at the time of admission. Modified Rankin Scale (mRS) score equal to or greater than 3 at 90 days was used to define poor functional outcomes (major disability or death). Receiver operating characteristic (ROC) curve was plotted with NLR and the ICH score to analyze and compare their discriminative ability to predict poor functional outcomes.
Results: A total of 158 patients were recruited for the study. One hundred and seven patients were found to have poor functional outcomes as per their mRS score at 90 days. The mean NLR and the ICH scores at presentation were significantly higher for the poor outcome group (6.57 and 2.83) compared to the good outcome group (2.75 and 1.49). The ROC analysis revealed that both NLR and the ICH scores were good predictors of functional outcomes at 90 days with area under the curve (AUC) of 0.814 and 0.819, respectively. The sensitivity and specificity of NLR were 84 and 66.3% and those of the ICH score were 66.7 and 78.3% to predict poor functional outcomes.
Conclusion: In patients with hemorrhagic stroke, NLR at admission is a good predictor of functional outcomes at 90 days. When compared to the ICH score, NLR is more sensitive but less specific in predicting poor functional outcomes.
Ikram MA, Wieberdink RG, Koudstaal PJ. International epidemiology of intracerebral hemorrhage. Curr Atheroscler Rep 2012;14(4):300–306. DOI: 10.1007/s11883-012-0252-1.
An SJ, Kim TJ, Yoon BW. Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: an update. J Stroke 2017;19(1):3. DOI: 10.5853/jos.2016.00864.
Paramanathan A, Saxena A, Morris DL. A systematic review and meta-analysis on the impact of pre-operative neutrophil lymphocyte ratio on long term outcomes after curative intent resection of solid tumours. Surg Oncol 2014;23(1):31–39. DOI: 10.1016/j.suronc.2013.12.001.
Liu X, Shen Y, Wang H, Ge Q, Fei A, Pan S. Prognostic significance of neutrophil-to-lymphocyte ratio in patients with sepsis: a prospective observational study. Mediators Inflamm 2016;2016:8191254. DOI: 10.1155/2016/8191254.
Yang Z, Zhang Z, Lin F, Ren Y, Liu D, Zhong R, et al. Comparisons of neutrophil-, monocyte-, eosinophil-, and basophil-lymphocyte ratios among various systemic autoimmune rheumatic diseases. Apmis 2017;125(10):863–871. DOI: 10.1111/apm.12722.
Song SY, Zhao XX, Rajah G, Hua C, Kang RJ, Han YP, et al. Clinical significance of baseline neutrophil-to-lymphocyte ratio in patients with ischemic stroke or hemorrhagic stroke: an updated meta-analysis. Front Neurol 2019;10:1032. DOI: 10.3389/fneur.2019.01032.
Lattanzi S, Cagnetti C, Provinciali L, Silvestrini M. Neutrophil-to-lymphocyte ratio predicts the outcome of acute intracerebral hemorrhage. Stroke 2016;47(6):1654–1657. DOI: 10.1161/STROKEAHA.116.013627.
Giede-Jeppe A, Bobinger T, Gerner ST, Sembill JA, Sprügel MI, Beuscher VD, et al. Neutrophil-to-lymphocyte ratio is an independent predictor for in-hospital mortality in spontaneous intracerebral hemorrhage. Cerebrovasc Dis 2017;44(1–2):26–34. DOI: 10.1159/000468996.
Sun Y, You S, Zhong C, Huang Z, Hu L, Zhang X, et al. Neutrophil to lymphocyte ratio and the hematoma volume and stroke severity in acute intracerebral hemorrhage patients. Am J Emerg Med 2017;35(3):429–433. DOI: 10.1016/j.ajem.2016.11.037.
Hemphill III JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001;32(4):891–897. DOI: 10.1161/01.str.32.4.891.
Quinn TJ, Dawson J, Walters M. Dr John Rankin; his life, legacy and the 50th anniversary of the Rankin Stroke Scale. Scott Med J 2008;53(1):44–47. DOI: 10.1258/RSMSMJ.53.1.44.
Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, Van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988;19(5):604–607. DOI: 10.1161/01.str.19.5.604.
Broderick JP, Adeoye O, Elm J. Evolution of the modified Rankin scale and its use in future stroke trials. Stroke 2017;48(7):2007–2012. DOI: 10.1161/STROKEAHA.117.017866.
Gao SQ, Huang LD, Dai RJ, Chen DD, Hu WJ, Shan YF. Neutrophil-lymphocyte ratio: a controversial marker in predicting Crohn's disease severity. Int J Clin Exp Pathol 2015;8(11):14779. PMID: 26823804. PMCID: PMC4713590.
Islas-Vazquez L, Aguilar-Cazares D, Galicia-Velasco M, Rumbo-Nava U, Meneses-Flores M, Luna-Rivero C, et al. IL-6, NLR, and SII markers and their relation with alterations in CD8+ T-lymphocyte subpopulations in patients treated for lung adenocarcinoma. Biology 2020;9(11):376. DOI: 10.3390/biology9110376.
Kulaksizoglu B, Kulaksizoglu S. Relationship between neutrophil/lymphocyte ratio with oxidative stress and psychopathology in patients with schizophrenia. Neuropsychiatr Dis Treat 2016;12:1999. DOI: 10.2147/NDT.S110484.
Tekinarslan İ, Güler S, Utku U. Spontaneous intracerebral hemorrhage: etiology and yearly prognostic factors. Turk J Neurol 2012;18(3):88–95. DOI: 10.4274/Tnd.45220.