Journal of the Neurological Sciences 387 (2018) 115–118

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Journal of the Neurological Sciences

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Neutrophil to lymphocyte ratio and early clinical outcomes in patients with T

acute ischemic stroke
Sungwook Yua,b,c, Hisatomi Arimab, Carin Bertmarc, Stephen Clarkec, Geoffrey Herkesc,
⁎
Martin Krausec,
a
Department of Neurology, Korea University College of Medicine, Seoul, Republic of Korea
b
The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
c
Department of Neurology, Royal North Shore Hospital, St Leonards and University of Sydney, Sydney, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The neutrophil to lymphocyte ratio (NLR) is closely linked to mortality in patients with cardio-
Neutrophil vascular disease. We investigated whether NLR is associated with early clinical outcomes in patients with acute
Lymphocyte ischemic stroke.
Leukocyte Methods: We collated data from a tertiary hospital's stroke registry including admitted patients with a first-ever
Outcomes
acute ischemic stroke within 72 h of onset. White blood cell counts and peripheral differential counts were
Ischemic stroke
measured on admission. Early clinical outcomes were in-hospital mortality and disability at discharge assessed
by the modified Rankin scale (mRS).
Results: Among 1131 stroke patients, 454 patients were included and classified into tertile groups based on NLR
on admission. Patients in higher tertiles of NLR were likely to have severe neurologic deficit at discharge. Higher
NLR tertiles were associated with an unfavourable shift of mRS score (p < .0001). This association remained
significant after adjustment for clinical and laboratory variables including age, sex, hypertension, hypercho-
lesterolemia, atrial fibrillation, stroke severity, and glucose level (p = .032 for trend). However, risk of death or
major disability (score of 3–6 on mRS) and in-hospital mortality were not significantly different across NLR
tertile groups.
Conclusions: In patients with acute ischemic stroke, NLR was predictive of short-term functional outcome.

1. Introduction
Inflammation after stroke contributes to brain injury [1–3] and a
number of inflammatory biomarkers have been investigated in stroke
patients [4]. Elevated peripheral leukocyte count has been shown to be
associated with mortality or poor clinical outcome in patients with
acute ischemic stroke [5–8] or with higher risks of stroke in patients
with symptomatic intracranial atherosclerotic disease [9]. However,
post-stroke immunologic response is a complex process inducing acti-
vation of diverse inflammatory cells and immunodepression [2,3].
Neutrophils and lymphocytes among subtypes of leukocytes might have
different effects on clinical outcomes since a prior study suggested an
inverse association between lymphocyte counts within three days of
stroke onset and functional outcome at three months [10].
Recently, neutrophil to lymphocyte ratio (NLR) has emerged as a
strong predictor of mortality in patients with cardiovascular disease
[11,12] or peripheral arterial occlusive disease [13]. Previous studies in
stroke patients also proposed the prognostic value of NLR for prediction
of mortality [12,14–17]. Furthermore, higher NLR has been shown to
be independently associated with worse outcome at 3 months in is-
chemic stroke patients treated with thrombolytic therapy [18,19].
However, this relationship has been investigated in a relatively narrow
range of stroke patients and the literature on the association between
NLR and functional outcomes is limited.
We undertook this study to evaluate whether NLR was associated
with short-term clinical outcome in patients with acute ischemic stroke.
2. Materials and methods
2.1. Study design
We included consecutive patients with stroke or transient ischemic
attack who were admitted to Royal North Shore Hospital (RNSH), a
tertiary hospital in Sydney, Australia, and registered in the hospital's

⁎
Corresponding author at: Department of Neurology, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia.
E-mail address: martin.krause@sydney.edu.au (M. Krause).

https://doi.org/10.1016/j.jns.2018.02.002
Received 17 June 2017; Received in revised form 28 January 2018; Accepted 1 February 2018
Available online 02 February 2018
0022-510X/ © 2018 Published by Elsevier B.V.
S. Yu et al.
stroke registry database from January 2009 to March 2013. Patients
who were older than 18 years and were admitted to the hospital within
72 h of onset due to a first-ever acute ischemic stroke were selected.
Patients were excluded if they had a transient ischemic attack, throm-
bolysis therapy, an in-hospital stroke, a history of steroids or im-
munosuppressive agents, an infection history within one week before
admission, and the occurrence of infection during hospitalization.
Infection including pneumonia and urinary tract infection was defined
by typical symptoms with supported evidence from physical examina-
tion, blood or urinary tests, imaging etc. This study was approved by
the Institutional Review Board with a waiver of patients' informed
consent due to the retrospective study design.
Ischemic stroke was diagnosed by the World Health Organization's
definition [20] and confirmed by computerized tomography or mag-
netic resonance imaging. Baseline demographics were collated from the
stroke registry database including vascular risk factors, e.g. hyperten-
sion, diabetes, hypercholesterolemia, atrial fibrillation, ischemic heart
diseases, smoking status and alcohol consumption. Information on
previous medication was obtained including antiplatelet agents, antic-
oagulants, and lipid lowering agents.
Stroke severity was assessed by the Scandinavian Stroke Scale (SSS)
on admission and categorised into four groups with very severe (score
of 0 to 14 points), severe (15 to 29 points), moderate (30 to 44 points),
and mild (45 to 58 points) deficit [21]. We assessed disability at dis-
charge by the modified Rankin scale (mRS) and in-hospital mortality as
clinical outcomes.
2.2. Neutrophil to lymphocyte ratio
Blood samples were collected on admission and white blood cell
counts and peripheral differential counts were measured. NLR was
calculated by neutrophil count divided by lymphocyte count. All pa-
tients were grouped into tertiles according to their NLR on admission.
2.3. Statistical analysis
Data were presented as number (%), mean (standard deviation) or
median (interquartile range [IQR]) as appropriate. Baseline demo-
graphic and laboratory data were compared across NLR tertile groups
using Fisher's exact test for categorical variables and Kruskal-Wallis test
for continuous variables. Correlation between two variables was as-
sessed by Pearson or Spearman correlation test. Clinical Outcomes were
mRS distribution at discharge, in-hospital mortality and death or major
disability (mRS 3–6) at discharge. We used binomial and multinomial
logistic regression to investigate the association between NLR and
clinical outcomes. To adjust for other potential confounding variables,
multivariable analyses including age, sex, and other variables, that
were significant in univariable analyses with P < .05, were performed.
P value < .05 for two-sided hypothesis testing was considered as sta-
tistically significant. Statistical analyses were conducted using SAS
version 9.3 (SAS Institute, Cary, North Carolina, USA).
3. Results
3.1. Baseline characteristics
Among 1131 consecutive stroke patients, 626 had the first ever is-
chemic stroke. Of 626 patients, 172 were excluded due to age under
18 years (n = 3), thrombolysis treatment (n = 38), onset to admission
time over 72 h (n = 49), unknown onset time (n = 16), and occurrence
of infection during hospitalization (n = 66). Finally, 454 patients were
included in this study. Number of patients who were admitted within
24 h after stroke onset was 376 (82.8%).
Baseline clinical characteristics are presented in Table 1. Median
(IQR) age of included patients was 72.4 years (62.1–82.6) and 201
(44.3%) were male. Median (IQR) score of SSS on admission was 54
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Journal of the Neurological Sciences 387 (2018) 115–118
(44–56). Median duration of hospitalization was 5.5 days (3.3–9.0).
Dyslipidemia was more frequently observed in patients with the highest
NLR tertile. Other stroke risk factors were not different across NLR
tertile groups. Patients in higher tertiles of NLR were more likely to
have severe neurologic deficit. (Table 1) Median SSS scores from the
lowest to the highest tertiles of NLR were 56 (50–58), 55 (46–56), and
50 (32–56), respectively. Moreover, patients in higher NLR tertiles
stayed longer at hospital. Duration of hospitalization was significantly
correlated to the severity of neurologic deficit assessed by SSS
(r = −0.40, p < .0001). Time intervals from stroke onset to admission
or to blood sampling were not different among the tertile groups. WBC
and neutrophils counts increased in higher NLR tertile groups. How-
ever, lymphocytes and eosinophils counts decreased as the NLR in-
creased. Elevated levels of glucose were found in the higher tertile
groups.
3.2. Clinical outcomes
During hospitalization, 98 (21.6%) patients had unfavourable out-
comes: 78 patients with major disability (mRs 3–5) and 20 patients who
died in hospital (4.4%). Higher tertiles of NLR were significantly as-
sociated with unfavourable shift of mRS scores in multinomial logistic
regression analysis (p < .0001) (Table 2). The highest tertile group
had 2.68 fold-increased risks of unfavourable shift of mRS compared to
the lowest tertile group of NLR. [95% confidence interval (CI)
1.77–4.06]. In univariable analysis, age, sex, hypertension, smoking,
hypercholesterolemia, atrial fibrillation, glucose level, and SSS score
were confounding variables significantly associated with unfavourable
shift of mRS. After adjustments for clinical and laboratory variables that
had significant association with outcomes, the association between
tertiles of NLR and unfavourable shift of mRS remained significant
(p < .032).
Risk of death or major disability (mRS 3–6) significantly increased
in higher tertiles of NLR (p = .0002 for trend). However, the associa-
tion was no longer significant after adjustment of confounding variables
as outlined above. There was a trend towards increased in-hospital
mortality in the higher NLR, but this association did not reach statistical
significance.
4. Discussion
In patients with acute first-ever ischemic stroke, higher NLR within
3 days after the stroke onset was an independent predictor for un-
favourable functional outcomes at discharge. NLR on admission, how-
ever, was not significantly associated with increased in-hospital mor-
tality after adjustment for other potential predictors. These results
suggest that NLR on admission after acute ischemic stroke is a simple
and useful hematologic biomarker to estimate short-term functional
outcomes.
Post-stroke inflammation causes a deleterious effect on brain injury
while it might play a different role in tissue repair and regeneration in a
time-dependent way [2]. Neutrophils are a major subtype of leukocytes
to respond early after stroke and represent active inflammatory reaction
[2,22]. Subsets of lymphocyte, specific T cell lymphocytes, might have
a regulatory function in inflammation inducing neuroprotection [1–3].
It has been well known that stroke-induced systemic immunosuppres-
sion, e.g. lymphopenia, could increase susceptibility to infection in-
cluding pneumonia and urinary tract infections [3,23], which cause a
harmful effect on clinical outcomes. In acute ischemic stroke patients,
total WBC and neutrophil counts within three days after symptom onset
had a positive correlation with stroke severity and infarct volume,
while higher lymphocyte counts was associated with early improve-
ment during the first week after admission and good functional out-
come at three months [10,24]. Therefore, higher NLR could be a more
sensitive marker indicating higher level of post-stroke inflammation
[25].
S. Yu et al. Journal of the Neurological Sciences 387 (2018) 115–118

Table 1
Baseline characteristics according to tertiles of neutrophil to lymphocyte ratio.

Neutrophil to lymphocyte ratio

1st 2nd 3rd

All ≤2.36 2.37–4.10 4.12≤

(n = 454) (n = 151) (n = 152) (n = 151) P value

Demographic
Age (years) 70.0 ± 16.0 68.1 ± 17.1 69.8 ± 15.2 72.0 ± 15.6 0.084
Male 253 (55.7) 80 (53.0) 89 (58.6) 84 (55.6) 0.621

Medical history
Hypertension 256 (56.4) 82 (54.3) 88 (57.9) 86 (57.0) 0.808
Diabetes mellitus 90 (19.8) 27 (17.9) 32 (21.1) 31 (20.5) 0.759
Smoking 54 (11.9) 17 (11.3) 18 (11.8) 19 (12.6) 0.939
Hypercholesterolemia 257 (25.6) 103 (68.2) 83 (54.6) 71 (47.0) 0.0008
Atrial fibrillation 137 (30.2) 40 (26.5) 42 (27.6) 55 (36.4) 0.120
Ischemic heart diseases 75 (16.5) 21 (13.9) 23 (15.1) 31 (20.5) 0.257

Medication history
Anticoagulation agent 51 (11.2) 9 (6.0) 17 (11.2) 25 (16.6) 0.014
Antiplatelet agent 137 (30.2) 43 (28.5) 54 (35.5) 40 (26.5) 0.197
Lipid lowering agent 147 (32.4) 48 (31.8) 48 (31.6) 51 (33.8) 0.904

Clinical features
Fever 123 (26.4) 38 (25.2) 43 (28.3) 39 (25.8) 0.810

Laboratory findings
Hemoglobin (g/dL) 13.8 ± 1.6 14.1 ± 1.5 13.8 ± 1.5 13.7 ± 1.8 0.144
Platelet count (×109/L) 226.0 ± 84.1 219.0 ± 69.8 235.1 ± 107.1 223.8 ± 69.5 0.387
White blood cell count (×109/L) 8.3 ± 2.6 7.3 ± 2.0 7.9 ± 2.2 9.7 ± 2.9 < 0.0001
Neutrophils 5.7 ± 2.5 4.1 ± 1.1 5.3 ± 1.6 7.8 ± 2.8 < 0.0001
Lymphocytes 1.7 ± 0.9 2.4 ± 1.0 1.7 ± 0.5 1.1 ± 0.4 < 0.0001
Monocytes 0.6 ± 0.2 0.6 ± 0.2 0.6 ± 0.2 0.6 ± 0.2 0.661
Eosinophils 0.1 ± 0.2 0.2 ± 0.2 0.2 ± 0.2 0.1 ± 0.1 < 0.0001
Glucose (mmol/L) 7.0 ± 3.1 6.7 ± 3.0 6.9 ± 2.6 7.3 ± 3.7 0.016
Creatinine (μmol/L) 87.8 ± 30.0 87.3 ± 24.5 86.5 ± 24.9 89.6 ± 38.6 0.810
SSS score 54 (44–56) 56 (50–58) 55 (46–56) 50 (32–56) < 0.0001
SSS score category
Mild (45–58) 337 (74.2) 125 (82.8) 121 (79.6) 91 (60.3) 0.0004
Moderate (30–44) 54 (11.9) 11(7.3) 16 (10.5) 27 (17.9)
Severe (15–29) 32 (7.1) 9 (6.0) 6 (4.0) 17 (11.3)
Very severe (0–14) 31 (6.8) 6 (4.0) 9 (5.9) 16 (10.6)
Onset to admission time (hours) 14.3 ± 20.8 14.4 ± 21.4 16.7 ± 23.2 11.8 ± 17.3 0.315
Onset to sampling time (hours) 19.0 ± 25.1 19.4 ± 24.2 22.3 ± 29.5 15.4 ± 20.3 0.599
Hospitalization (days) 5.5 (3.3–9.0) 4.7 (2.6–6.5) 5.3 (3.3–9.3) 7.3 (3.6–10.6) < 0.0001

Number is expressed as number (%) or mean (standard deviation) or median (interquartile range) as appropriate. Scandinavian Stroke Scale (SSS).

Previous reports have demonstrated that NLR was related to infarct
volume and stroke severity [14,15]. Moreover, NLR has been reported
to have a predictive value associated with mortality or functional out-
comes in patients with acute stroke. Higher NLR on admission was
consistently found to be related to mortality within 60 days after acute
ischemic stroke [14–17]. Recently, increased NLR was identified as an
independent factor for symptomatic intracerebral hemorrhage or poor
outcome at 3 months in acute ischemic patients who were treated with
IV recombinant tissue plasminogen activator or endovascular therapy
[18,19]. In line with previous studies, this study demonstrated the
predictive value of NLR in association with unfavourable outcome at
discharge. However, we did not find the association of higher NLR with
mortality. This might be due to a low mortality rate (< 5%) in this
study in contrast to the higher mortality rate of 13% to 28% [14–17] in
the previous studies. This difference is likely to be caused by the large
proportion of patients (over 70%) with mild stroke in our study and
specific target groups with atherothrombotic stroke [16] or supra-
tentorial ischemic stroke [14,15] in the previous studies. The popula-
tion in the present study including consecutive ischemic patients had a
wide range of stroke patients. Thus, the results of this study may be
clinically more relevant and provide an evidence to extend predictive
value of NLR for clinical outcomes in patients with acute ischemic
stroke.
There were limitations in this study. This was a retrospective study
in a single university hospital with a relatively small sample size.
Information on post-stroke complications including cerebral edema and
hemorrhagic transformation was not collected, which might be poten-
tial imaging parameters to affect functional outcomes. We included
patients within 72 h after stroke onset. Although most of the study
population (82.8%) had the time from stroke onset to admission < 24
h, a relatively longer inclusion time window might have affected the
findings of this study. Variation in length of hospital stay may also have
affected the results of this study despite the short-term clinical out-
comes and adjustment of the severity of stroke. In addition, the statis-
tical power of the present analysis may have been somewhat limited
because of low mortality rate. We did not measure the change of NLR
during hospitalization. Change of NLR over time may provide valuable
information for understanding the underlying mechanism of post-stroke
immunologic response and its clinical implications.
The strength of NLR is the fact that it is easy and simple to be
evaluated on admission. NLR might reflect post-stroke immunologic
imbalance after stroke more accurately than total WBC or neutrophil
counts. Our results suggest that, in patients with acute ischemic stroke,
NLR on admission could be useful in prediction of short-term clinical
outcomes.

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S. Yu et al. Journal of the Neurological Sciences 387 (2018) 115–118

Table 2
Risks of clinical outcomes according to tertiles of neutrophil to lymphocyte ratio.

Neutrophil/lymphocyte ratio

1st 2nd 3rd

≤2.36 2.37–4.10 4.12≤

(n = 151) (n = 152) (n = 151) P trend

⁎
Score on the modified Rankin scale (mRS)
n (%)
0: No symptoms at all 74 (49.0) 71 (46.7) 38 (25.2)
1: No substantive disability despite symptoms 35 (23.2) 35 (23.0) 40 (26.5)
2: Slight disability 21 (13.9) 17 (11.2) 25 (16.6)
3: Moderate disability requiring some help 9 (6.0) 15 (9.9) 18 (11.9)
4: Moderate–severe disability requiring assistance with daily living 5 (3.3) 3 (2.0) 7 (4.6)
5: Severe disability, bedbound and incontinent 3 (2.0) 5 (3.3) 13 (8.6)
6: Death 4 (2.7) 6 (4.0) 10 (6.6)
Crude OR (95%CI) 1 (reference) 1.14 (0.75–1.74) 2.68 (1.77–4.06) < 0.0001
Adjusted OR (95%CI) 1 (reference) 1.23 (0.69–2.20) 1.87 (1.05–3.34) 0.032

Death or major disability (mRS 3–6)

n (%) 21 (13.9) 29 (19.1) 48 (31.8)
Crude OR (95%CI) 1 (reference) 1.46 (0.79–2.70) 2.89 (1.62–5.12) 0.0002
Adjusted OR (95%CI) 1 (reference) 1.56 (0.55–4.48) 1.26 (0.44–3.60) 0.701

Death
n (%) 4 (2.7) 6 (4.0) 10 (6.6)
Crude OR (95%CI) 1 (reference) 1.51 (0.42–5.46) 2.61 (0.80–8.50) 0.098
Adjusted OR (95%CI) 1 (reference) 1.71 (0.10–28.67) 0.87 (0.06–12.72) 0.740

OR, odds ratio; 95%CI, 95% confidence interval.

Adjustments were made for age, sex, hypertension, smoking, hypercholesterolemia, atrial fibrillation, glucose level, and Scandinavian Stroke Scale score.
⁎
The difference in the modified Rankin scale scores was determined using ordinal logistic regression models.

Conflict of interest 26–34.

None to declare.
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