What the fuck is the use of predicting poor outcome? I'd fire the lot of you.
Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Stroke: A Systematic Review and Meta-Analysis
Wenxia Li
Miaomiao Hou1†, 
Xinyi Li- 1Shanxi Academy of Medical Sciences, Shanxi Bethune Hospital, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- 2Shanxi Medical University, Taiyuan, China
Background: Stroke has become a major problem around the world, which is one of the main causes of long-term disability. Therefore, it is important to seek a biomarker to predict the prognosis of patients with stroke. This meta-analysis aims to clarify the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the prognosis of stroke patients.
Methods: This study was pre-registered in PROSPERO (CRD42020186544). We performed systematic research in PubMed, Web of Science, and EMBASE databases for studies investigating the prognostic value of NLR. Based on the enrolled studies, patients were divided into the low-NLR cohort and the high-NLR cohort. Odds ratios (ORs) with 95% confidence intervals (CIs) were extracted and analyzed by the Review Manager 5.3 and Stata 12.0 software. Heterogeneity was estimated by using Cochran's Q test and I2 value. Sensitivity analyses and subgroup analyses were also performed to explore the potential sources of heterogeneity. Publication bias was assessed with funnel plots and assessed by Egger's tests.
Results: Forty-one studies with 27,124 patients were included. In the overall analysis, elevated NLR was associated with an increased mortality in acute ischemic stroke (AIS) patients (OR = 1.12, 95% CI = 1.07–1.16) and in acute hemorrhagic stroke (AHS) patients (OR = 1.23, 95% CI = 1.09–1.39), poorer outcomes in AIS patients (OR = 1.29, 95% CI = 1.16–1.44), and in AHS patients (OR = 1.11, 95% CI = 1.03–1.20). While in terms of hemorrhagic transformation (HT), elevated NLR was associated with an increased incidence of HT in AIS patients (OR = 1.15, 95% CI = 1.08–1.23).
Conclusions: This study demonstrated that elevated NLR was significantly associated with poor prognosis of stroke patients. High NLR is associated with a 1.1- to 1.3-fold increased risk of poor outcomes of AIS/AHS patients. NLR could be helpful as a potential prognostic biomarker to guide clinical decision making.
Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020186544.
Introduction
With almost 6 million deaths and more than 10% of all mortality every year, stroke has become one of the predominant threats to human health (1). There are two types of strokes, one is ischemic stroke, which accounts for 85% of all acute stroke, and the other is hemorrhagic stroke. According to previous reports, about 40% of all stroke deaths are attributable to hemorrhagic stroke (2). Currently, the major treatment for acute ischemic stroke is reperfusion therapy, which includes intravenous tissue plasminogen activator and endovascular therapy (EVT) (3). Exploring the key factors that affect the prognosis of stroke patients is crucial for clinicians to design appropriate treatments to improve the clinical efficacy and prognosis to stroke patients.
As we all know, there are two important pathophysiological mechanisms of stroke including oxidative stress and inflammation. After stroke, the inflammatory response is activated and plays a significant role in secondary brain injury (4). In recent years, the immunity has emerged as a new breakthrough target in the treatment strategy for acute stroke. Meanwhile, it is non-displaceable in predicting a poor prognosis (5). However, it is a complex process that can induce the activation and immunosuppression of a variety of inflammatory cells. Previous studies have found the different roles of neutrophils and lymphocytes in the progression and prognosis after stroke. Neutrophils could re-infiltrate the ischemic site in the first few hours after stroke, and then release chemical mediators related to increased tissue damage and poor neurological prognosis (6). At the same time, stroke could trigger a special immunosuppressive state (4), such as the activation of neutrophils, which leads to a decrease in lymphocytes (7), and certain types of lymphocytes are considered to be important brain protective immune regulators; the decrease of these lymphocytes may lead to deterioration of nerve function (8). Recently, the neutrophil-to-lymphocyte ratio (NLR) has become a powerful predictor of death in patients with cardiovascular disease or peripheral arterial occlusive disease. Previous studies reported a correlation between stroke severity and NLR determined at admission. Several studies suggested that the initial NLR was associated with mortality and infarct size in ischemic stroke patients.
However, the value of NLR in predicting the poor prognosis of stroke patients is still controversial. Some studies showed that NLR had no obvious effect on mortality (9, 10), while some studies demonstrated that a high NLR was an independent predictor of poor clinical outcomes in patients with stroke (11, 12). Thus, the aim of this study was to perform a meta-analysis to clear the relationship between NLR and the prognosis in patients with stroke.
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