Top

BMC Neurology

Published in:

Open Access 01-12-2020 | Stroke | Research article

Increased neutrophil-to-lymphocyte ratio predicts the development of post-stroke infections in patients with acute ischemic stroke

Authors: Lanying He, Jian Wang, Feng Wang, Lili Zhang, Lijuan Zhang, Wang Zhao

Published in: BMC Neurology | Issue 1/2020

Abstract

Background

Infections could increase the risk of poor outcome in patients with acute ischemic stroke (AIS). The peripheral neutrophil-to-lymphocyte ratio (NLR) is an important indicator of inflammation. The purpose of our study was to investigate the association increased NLR with post stroke infections (PSI) in AIS.

Methods

In this study, we included 606 consecutive patients with AIS within 24 h. The NLR was calculated by dividing absolute neutrophil counts by absolute lymphocyte counts. Receiver operating characteristic (ROC) curve was performed to identify the optimal cut point of NLR for PSI. The relationship between NLR and PSI was analyzed by multivariable analysis.

Results

We assessed 606 consecutive patients with AIS. ROC curve analysis showed that the optimal cut point of NLR for PSI was NLR ≥ 5.79. Compared with no PSI, patients with PSI have higher NLR, older age, higher NIHSS, higher PCT, higher percentage of nasogastric tube feeding and indwelling urinary catheter (P < 0.05). Multivariable analysis showed that NLR ≥ 5.79 [adjusted odds ratio (aOR),4.52; 95% confidence interval (CI),3.02–6.76; P < 0.001], older age (aOR,1.03; 95% CI, 1.00–1.05; P = 0.009), higher admission NIHSS (aOR,1.13; 95%CI, 1.07–1.18; P < 0.001), indwelling urinary catheter (aOR1.83; 95%CI, 1.08–3.10; P = 0.026], and nasogastric tube feeding (aOR2.52; 95%CI, 1.38–4.59; P = 0.003) were associated with increased risk of PSI.

Conclusions

Higher NLR can predict PSI in AIS patients. The NLR may help to select high-risk patients to start intervention in time.

Smith CJ, Bray BD, Hoffman A, Meisel A, Heuschmann PU, Wolfe CD, Tyrrell PJ, Rudd AG, Intercollegiate Stroke Working Party Group. Can a novel clinical risk score improve pneumonia prediction in acute stroke care? A UK multicenter cohort study. J Am Heart Assoc. 2015;4(1):e001307. https://doi.org/10.1161/JAHA.114.001307.

Ji R, Shen H, Pan Y, Wang P, Liu G, Wang Y, China National Stroke Registry Investigators. Novel risk score to predict pneumonia after acute ischemic stroke. Stroke. 2013;44(5):1303–09. https://doi.org/10.1161/STROKEAHA.111.000598.

Finlayson O, Kapral M, Hall R, Asllani E, Selchen D, Saposnik G, Canadian stroke network; stroke outcome research Canada (SORCan) working group. Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology. 2011;77(14):1338–45. https://doi.org/10.1212/WNL.0b013e31823152b1.

Meisel A, Smith CJ. Stroke: preventive antibiotics for stroke associated pneumonia. Nat Rev Neurol. 2015;11(12):672–3. https://doi.org/10.1038/nrneurol.2015.220.

Westendorp WF, Nederkoorn PJ, Vermeij JD, Dijkgraaf MG, van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMC Neurol. 2011;11:110. https://doi.org/10.1186/1471-2377-11-110.

Ionita CC, Siddiqui AH, Levy EI, Hopkins LN, Snyder KV, Gibbons KJ. Acute ischemic stroke and infections. J Stroke Cerebrovasc Dis. 2011;20(1):1–9. https://doi.org/10.1016/j.jstrokecerebrovasdis.2009.09.011.

Vermeij JD, Westendorp WF, van de Beek D, Nederkoorn PJ. Post-stroke infections and preventive antibiotics in stroke: update of clinical evidence. Int J Stroke. 2018;13(9):913–20. https://doi.org/10.1177/1747493018798557.

Hoffmann S, Harms H, Ulm L, Nabavi DG, Mackert BM, Schmehl I, Jungehulsing GJ, Montaner J, Bustamante A, Hermans M, Hamilton F, Göhler J, Malzahn U, Malsch C, Heuschmann PU, Meisel C, Meisel a; PREDICT investigators. Stroke-induced immunodepression and dysphagia independently PREDICT stroke-associated pneumonia—the PREDICT study. J Cereb Blood Flow Metab. 2017;37(12):3671–82. https://doi.org/10.1177/0271678X16671964.

Meisel C, Schwab JM, Prass K, Meisel A, Dirnagl U. Central nervous system injury-induced immune deficiency syndrome. Nat Rev Neurosci. 2005;6(10):775–86. https://doi.org/10.1038/nrn1765.

10.

Dirnagl U, Klehmet J, Braun JS, Harms H, Meisel C, Ziemssen T, Prass K, Meisel A.. Stroke-induced immunodepression: experimental evidence and clinical relevance. Stroke. 2007;38(2):770–3. https:// doi.https://doi.org/10.1161/01.STR.0000251441.89665.bc.

11.

Curbelo J, Luquero Bueno S, Galván-Román JM, Ortega-Gómez M, Rajas O, Fernández-Jiménez G, Vega-Piris L, Rodríguez-Salvanes F, Arnalich B, Díaz A, Costa R, de la Fuente H, Lancho Á, Suárez C, Ancochea J, Aspa J. Inflammation biomarkers in blood as mortality predictors in community-acquired pneumonia admitted patients: importance of comparison with neutrophil count percentage or neutrophil-lymphocyte ratio. PLoS One. 2017;12(3):e0173947. https://doi.org/10.1371/journal.pone.0173947.

12.

de Jager CP, Wever PC, Gemen EF, Kusters R, van Gageldonk-Lafeber AB, van der Poll T, Laheij RJ.. The neutrophil-lymphocyte count ratio in patients with community-acquired pneumonia. PLoS One. 2012;7(10):e46561. https://doi.org/10.1371/journal.pone.0046561.

13.

Berhane M, Melku M, Amsalu A, Enawgaw B, Getaneh Z, Asrie F. The role of neutrophil to lymphocyte count ratio in the differential diagnosis of pulmonary tuberculosis and bacterial community-acquired pneumonia: a cross-sectional study at ayder and mekelle hospitals, Ethiopia. Clin Lab. 2019;65(4). https://doi.org/10.7754/Clin.Lab.2018.180833.

14.

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. Mediat Inflamm. 2016;2016:8191254. https://doi.org/10.1155/2016/8191254.

15.

Wang L, Song Q, Wang C, Wu S, Deng L, Li Y, Zheng L, Liu M Neutrophil to lymphocyte ratio predicts poor outcomes after acute ischemic stroke: A cohort study and systematic review J Neurol Sci 2019;406:116445. https://doi.org/10.1016/j.jns.2019.116445.

16.

Semerano A, Strambo D, Martino G, Comi G, Filippi M, Roveri L, Bacigaluppi M. Leukocyte counts and ratios are predictive of stroke outcome and hemorrhagic complications independently of infections. Front Neurol. 2020;11:201. https://doi.org/10.3389/fneur.2020.00201.

17.

Aly M, Abdalla RN, Batra A, Shaibani A, Hurley MC, Jahromi BS, Potts MB, Ansari SA. Follow-up neutrophil-lymphocyte ratio after stroke thrombectomy is an independent biomarker of clinical outcome. J Neurointerv Surg. 2020:neurintsurg-2020-016342. https://doi.org/10.1136/neurintsurg-2020-016342.

18.

Cheng Y, Ying A, Lin Y, Yu J, Luo J, Zeng Y, Lin Y. Neutrophil-to-lymphocyte ratio, hyperglycemia, and outcomes in ischemic stroke patients treated with intravenous thrombolysis. Brain Behav. 2020;22:e01741. https://doi.org/10.1002/brb3.1741.

19.

Ying A, Cheng Y, Lin Y, Yu J, Wu X, Lin Y. Dynamic increase in neutrophil levels predicts parenchymal hemorrhage and function outcome of ischemic stroke with r-tPA thrombolysis. Neurol Sci. 2020;41(8):2215–2223. https://doi.org/10.1007/s10072-020-04324-6.

20.

Lux D, Alakbarzade V, Bridge L, Clark CN, Clarke B, Zhang L, Khan U, Pereira AC. The association of neutrophil-lymphocyte ratio and lymphocyte-monocyte ratio with 3-month clinical outcome after mechanical thrombectomy following stroke. J Neuroinflammation. 2020;17(1):60. https://doi.org/10.1186/s12974-020-01739-y.

21.

Hu Y, Huang K, Ji Z, Wang S, Bai M, Pan S, Lin Z, Wu Y. High neutrophil-to-lymphocyte ratio is associated with poor clinical outcome in patients with critically ill stroke. Minerva Anestesiol. 2020. https://doi.org/10.23736/S0375-9393.20.14310-4. Online ahead of print.

22.

Nam KW, Kim TJ, Lee JS, Kwon HM, Lee YS, Ko SB, Yoon BW. High neutrophil-to-lymphocyte ratio predicts stroke-associated pneumonia. Stroke. 2018;49(8):1886–1892. https://doi.org/10.1161/STROKEAHA.118.021228.

23.

Wang L, Guo W, Wang C, Yang X, Hao Z, Wu S, Zhang S, Wu B, Liu M. Dynamic change of neutrophil to lymphocyte ratios and infection in patients with acute ischemic stroke. Curr Neurovasc Res. 2020. https://doi.org/10.2174/1567202617666200408091131.

24.

Yang Y, Shi YZ, Zhang N, Wang S, Ungvari GS, Ng CH, Wang YL, Zhao XQ, Wang YJ, Wang CX, Xiang YT. The disability rate of 5-year post-stroke and its correlation factors: a National Survey in China. PLoS One. 2016;11(11):e0165341. https://doi.org/10.1371/journal.pone.0165341.

25.

Hannawi Y, Hannawi B, Rao CP, Suarez JI, Bershad EM. Strokeassociated pneumonia: major advances and obstacles. Cerebrovasc Dis. 2013;35(5):430–43. https://doi.org/10.1159/000350199.

26.

Vermeij FH, Scholte op Reimer WJ, de Man P, van Oostenbrugge RJ, Franke CL, de Jong G, de Kort PL, Dippel DW; Netherlands Stroke Survey Investigators. Stroke-associated infection is an independent risk factor for poor outcome after acute ischemic stroke: data from the Netherlands Stroke Survey. Cerebrovasc Dis. 2009;27(5):465–471. https://doi.org/10.1159/000210093.

27.

Yeh SJ, Huang KY, Wang TG, Chen YC, Chen CH, Tang SC, Tsai LK, Yip PK, Jeng JS. Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit. J Neurol Sci. 2011; 306(1–2):38–41. https://doi.org/10.1016/j.jns.2011.04.001.

28.

Saposnik G, Hill MD, O’Donnell M, Fang J, Hachinski V and Kapral MK. Variables associated with 7-day, 30-day, and 1-year fatality after ischemic stroke. Stroke. 2008;39(8):2318–24. https://doi.org/10.1161/STROKEAHA.107.510362.

29.

Khoury T, Mari A, Nseir W, Kadah A, Sbeit W, Mahamid M. Neutrophil-to-lymphocyte ratio is independently associated with inflammatory activity and fibrosis grade in nonalcoholic fatty liver disease. Eur J Gastroenterol Hepatol. 2019;31(9):1110–5. https://doi.org/10.1097/MEG.0000000000001393.

30.

Song M, Liu Y, Lu Z, Luo H, Peng H, Chen P. Prognostic factors for ARDS: clinical, physiological and atypical immunodeficiency. BMC Pulm Med. 2020;20(1):102. https://doi.org/10.1186/s12890-020-1131-0.

31.

Feliciano EMC, Kroenke CH, Meyerhardt JA, Prado CM, Bradshaw PT, Kwan ML, Xiao J, Alexeeff S, Corley D, Weltzien E, Castillo AL, Caan BJ. Association of Systemic Inflammation and Sarcopenia with Survival in nonmetastatic colorectal Cancer: results from the C SCANS study. JAMA Oncol. 2017;3(12):e172319. https://doi.org/10.1001/jamaoncol.2017.2319.

32.

Selvaggio S, Abate A, Brugaletta G, Musso C, Di Guardo M, Di Guardo C, Vicari ESD, Romano M, Luca S, Signorelli SS. Platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio and monocyte-to-HDL cholesterol ratio as markers of peripheral artery disease in elderly patients. Int J Mol Med. 2020;46(3):1210–16. https://doi.org/10.3892/ijmm.2020.4644.

33.

Tao C, Wang J, Hu X, Ma J, Li H, You C. Clinical value of neutrophil to lymphocyte and platelet to lymphocyte ratio after aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2017;26(3):393–401. https://doi.org/10.1007/s12028-016-0332-0.

34.

Gokhan S, Ozhasenekler A, Mansur Durgun H, Akil E, Ustundag M, Orak M. Neutrophil lymphocyte ratios in stroke subtypes and transient ischemic attack. Eur Rev Med Pharmacol Sci. 2013;17(5):653–7. PMID:23543449.PubMed

35.

Jones KA, Maltby S, Plank MW, Kluge M, Nilsson M, Foster PS, Walker FR. Peripheral immune cells infiltrate into sites of secondary neurodegeneration after ischemic stroke. Brain Behav Immun. 2018;67:299–307. https://doi.org/10.1016/j.bbi.2017.09.006.

36.

Brooks SD, Spears C, Cummings C, VanGilder RL, Stinehart KR, Gutmann L, Domico J, Culp S, Carpenter J, Rai A, Barr TL. Admission neutrophil-lymphocyte ratio predicts 90 day outcome after endovascular stroke therapy. J NeuroIntervent Surg. 2014;6(8):578–83. https://doi.org/10.1136/neurintsurg-2013-010780.

37.

Saliba W, Barnett-Griness O, Elias M, Rennert G. Neutrophil to lymphocyte ratio and risk of a first episode of stroke in patients with atrial fibrillation: a cohort study. J Thromb Haemost. 2015;13(11):1971–9. https://doi.org/10.1111/jth.13006.

38.

Li L, Zhang LH, Xu WP, Hu JM. Risk assessment of ischemic stroke associated pneumonia. World J Emerg Med. 2014;5(3):209–13. https://doi.org/10.5847/wjem.j.1920-8642.2014.03.009.

39.

Anrather J, Iadecola C. Inflammation and stroke: an overview. Neurotherapeutics. 2016;13(4):661–70. https://doi.org/10.1007/s13311-016-0483-x.

40.

Lattanzi S, Brigo F, Trinka E, Cagnetti C, Di Napoli M, Silvestrini M. Neutrophil-to-lymphocyte ratio in acute cerebral hemorrhage: a system review. Transl Stroke Res. 2019;10(2):137–45. https://doi.org/10.1007/s12975-018-0649-4.

41.

Macrez R, Ali C, Toutirais O, Le Mauff B, Defer G, Dirnagl U, Vivien D. Stroke and the immune system: from pathophysiology to new therapeutic strategies. Lancet Neurol. 2011;10(5):471–80. https://doi.org/10.1016/S1474-4422(11)70066-7.

42.

de Jager CP, Wever PC, Gemen EF, Kusters R, van Gageldonk Lafeber AB, van der Poll T, Laheij RJ. The neutrophil-lymphocyte count ratio in patients with community-acquired pneumonia. PLoS One. 2012;7(10):e46561. https://doi.org/10.1371/journal.pone.0046561.

43.

Shim R, Wong CH. Ischemia, immunosuppression and infection tackling the predicaments of post-stroke complications. Int J Mol Sci. 2016;17(1):64. https://doi.org/10.3390/ijms17010064.

44.

Prass K, Meisel C, Höflich C, Braun J, Halle E, Wolf T, Ruscher K, Victorov IV, Priller J, Dirnagl U, Volk HD, Meisel A. Stroke induced immunodeficiency promotes spontaneous bacterial infections and is mediated by sympathetic activation reversal by poststroke T helper cell type 1-like immunostimulation. J Exp Med. 2003;198(5):725–36. https://doi.org/10.1084/jem.20021098.

45.

Walter U, Knoblich R, Steinhagen V, Donat M, Benecke R, Kloth A. Predictors of pneumonia in acute stroke patients admitted to a neurological intensive care unit. J Neurol. 2007;254(10):1323–9. https://doi.org/10.1007/s00415-007-0520-0.

Title: Increased neutrophil-to-lymphocyte ratio predicts the development of post-stroke infections in patients with acute ischemic stroke
Authors: Lanying He
Jian Wang
Feng Wang
Lili Zhang
Lijuan Zhang
Wang Zhao
Publication date: 01-12-2020
Publisher: BioMed Central
Keywords: Stroke
Thrombectomy
Published in: BMC Neurology / Issue 1/2020
Electronic ISSN: 1471-2377
DOI: https://doi.org/10.1186/s12883-020-01914-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Increased neutrophil-to-lymphocyte ratio predicts the development of post-stroke infections in patients with acute ischemic stroke

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2020

Study protocol: improving cognition in people with progressive multiple sclerosis: a multi-arm, randomized, blinded, sham-controlled trial of cognitive rehabilitation and aerobic exercise (COGEx)

Bilateral thalamic lesions in a patient with probable acute disseminating encephalomyelitis: a case report

Comparison of clinical outcomes in patients who underwent Gamma Knife radiosurgery for parasellar meningiomas with or without prior surgery

A systematic review and meta-analysis to evaluate the diagnostic accuracy of recognition of stroke in the emergency department (ROSIER) scale

Factors affecting prehospital delay in rural and urban patients with stroke: a prospective survey-based study in Southwest Germany

Chinese families with autosomal recessive hereditary spastic paraplegia caused by mutations in SPG11