Abstract
Introduction: Stroke represents a significant global health care challenge, ranking as the second most common cause of mortality and disability worldwide. Inflammatory process plays an important role in pathophysiology of acute ischemic stroke. These inflammatory responses increase the brain damage and cause neurological deterioration. Neutrophils and lymphocytes serve as pivotal mediators of inflammatory response.
Aims and Objectives: This study aims to evaluate the association between the Neutrophils to lymphocyte ratio (NLR) with the initial severity of stroke and the short-term functional outcome using the NIHSS and BARTHEL index respectively.
Materials and Methods: We conducted an observational cross-sectional study on 80 patients admitted at Father Muller Medical College Hospital, which is a tertiary care centre in Mangalore between May 2023 to April 2024. Diagnosis of stroke was based on clinical evaluation and Radiological imaging. Peripheral blood samples were collected for complete blood count within 24 hours of stroke onset. The NLR was determined by dividing the absolute neutrophil count (ANC) to the absolute lymphocyte count (ALC). This was then correlated with the NIHSS and the BARTHEL index.
Results: This study included 80 patients, with the mean age of 65.1 years. Majority of the patients were in the age group 51-70years (55%). The mean NLR was found to be 13.39. The mean NIHSS and BARTHEL index was 11.08 and 63.69 respectively. The NLR showed significant correlation with the initial stroke severity and the short-term functional outcomes. For the purpose of correlation NLR was divided into three groups i.e. >3, 3-5 and >5. Patients with higher NLR (>5) were more likely to have a severe stroke and greater dependency. Conversely, those with lower NLR (<3) had a minor stroke and slight dependency. 80% of the patients with severe stroke had a NLR above 5, while 82% of the patients with minor stroke had a NLR below 3 (p value <0.001). This study also found a strong correlation between NIHSS and the BARTHEL index - patients with lower NIHSS and NLR were found to have a better short term function outcome.
Conclusion: NLR was found to be significantly associated with the initial severity of stroke and the short-term functional outcome. Because of its high specificity, low cost, routine use NLR can be used for the prediction of severity of stroke and patients can be prioritised for specialised treatment thus reducing the mortality rates.
References
- Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurology. 2019; 48:439-58.
- Stroke, Cerebrovascular accident [Internet]. Health topics. 2013. Available at: http://www.who.int/topics/cerebrovascular_accident /en. Accessed 28 November 2019.
- Buckley BM. Healthy ageing: ageing safely. European Heart Journal Supplements. 2001:3(N): N6-10.
- Chamorro A, Hallenbeck J. The harms and benefits of inflammatory and immune responses in vascular disease. Stroke. 2006; 37:291-293.
- Worthmann H, Tryc AB, Deb M, et al. Linking infection and inflammation in acute ischemic stroke. Ann N Y Acad Sci. 2010; 1207:116-122.
- Buck BH, Liebeskind DS, Saver JL, et al. Early neutrophilia is associated with volume of ischemic tissue in acute stroke. Stroke. 2008; 39:355-360.
- Kim J, Song TJ, Park JH, et al. Different prognostic value of white blood cell subtypes in patients with acute cerebral infarction. Atherosclerosis. 20102; 222:464-467.
- Furlan JC, Vergouwen MD, Fang J, Silver FL. White blood cell count is an independent predictor of outcomes after acute ischaemic stroke. Eur J Neurol. 2014; 21:215-222.
- Imtiaz F, Shafique K, Mirza SS, Ayoob Z, Vart P, Rao S Neutrophil lymphocyte ratio as a measure of systemic inflammation in prevalent chronic diseases in Asian population. Int Arch Med. 2012; 5:2.
- Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ. Neutrophil lymphocyte ratio as a prognostic factor in colorectal cancer. J Surg Oncol. 2005; 91:181-184.
- Tamhane UU, Aneja S, Montgomery D, Rogers EK, Eagle KA, Gurm HS. Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. Am J Cardiol. 2008; 102:653-657.
- Tokgoz S, Kayrak M, Akpinar Z, Seyithanoglu A, Gungy F, Yuruten B. Neutrophil lymphocyte ratio as a predictor of stroke. J Stroke Cerebrovasc Dis. 2013; 22:1169-1174.
- Celikbilek A, Ismailogullari S, Zararsiz G. Neutrophil to lymphocyte ratio predicts poor prognosis in ischemic cerebrovascular disease. J Clin Lab Anal. 2014; 28:27-31.
- Goldstein LB, Jones MR, Matchar DB, et al. Improving the reliability of stroke subgroup classification using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria editorial comment: classifying the mechanisms of ischemic stroke. Stroke. 2001; 32:1091-1097.
- Cucchira BL, Kasner SE, wolk DA. Early impairment in consciousness predicts mortality after hemispheric ischemic stroke. Crit care Med. 2004:32(1):241-5.
- Haumer M, Amighi J, Exner M, et al. Association of neutrophils and future cardiovascular events in patients with peripheral artery disease. J Vasc Surg 2005; 41:610-617.
- Nam KW, Kim TJ, LEE JS, KWON JS, High Neutrophil-to-Lymphocyte Ratio Predicts Stroke-Associated Pneumonia. Stroke 2018; 49:1886-1892
- Desai S, Jadhav A. Neutrophil-to-lymphocyte ratio predicts large vessel occlusion stroke (4221). Neurology. 2020;94(15 Supplement):4221.
- Shah D, Rajan R, Batra A, Anand I, Saraf A, Sethi P. Evaluation of Neutrophil-to-Lymphocyte Ratio Among Ischemic Stroke Subtypes and Stroke Severity. Journal of Stroke Medicine. 2022;5(1):40-47
- Lavanya D, Yogitha C, Kumar A, Somapur D. Relationship between neutrophil lymphocyte ratio and prognosis in acute ischemic stroke. Journal of Medical Science and Clinical Research. 2018;6(11).
Corresponding Author
Dr Aaron Jovin Mathias
Father Muller Medical College
DOI: https://dx.doi.org/10.18535/jmscr/v12i09.02
