Neutrophil-to-lymphocyte ratio as an independent predictor for unfavorable functional outcome in aneurysmal subarachnoid hemorrhage
Neutrophil-to-lymphocyte ratio as an independent predictor for unfavorable functional outcome in aneurysmal subarachnoid hemorrhage
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DOI：
10.3171/2018.9.jns181975
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发表时间：
2020-02-01
影响因子：
4.1
通讯作者：
Gerner, Stefan T.
中科院分区：
文献类型：
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作者：
Giede-Jeppe, Antje;Reichl, Jonathan;Gerner, Stefan T.
目的脑卒中相关的免疫抑制和炎症反应越来越被认为是脑卒中后感染的触发因素，从而可能影响脑卒中的预后。几项研究表明，嗜中性粒细胞与淋巴细胞比率（NLR）升高是缺血性卒中或脑出血患者不良结局的重要预测因素。到目前为止，在蛛网膜下腔出血患者中，NLR和结局之间的关系还没有充分确定。作者试图调查NLR入院和功能结果之间的关联在蛛网膜下腔出血（aSAHholding. METHODS），这项观察性研究包括所有连续aSAH患者承认德国三级中心超过5年的时间（2008-2012）。从机构数据库中检索有关患者人口统计学和临床、实验室和住院测量的数据，以及神经放射学数据。在3个月和12个月时使用改良兰金量表（mRS）评分评估功能结局，并将其分为有利（mRS评分0-2）和不利（mRS评分3-6）。在3个月时，对具有有利和不利结果的aSAH患者的放射学和实验室特征进行比较。此外，还进行了多变量分析，以研究与有利结局独立相关的参数。进行受试者工作特征（ROC）曲线分析，以确定NLR的最佳截止值，以区分这些患者的有利和不利结局。为了解释基线特征的不平衡，进行了倾向评分匹配，以评估NLR对结局测量的影响。3个月时预后不良的患者年龄较大，入院时临床状态较差（格拉斯哥昏迷评分和Hunt和Hess分级），蛛网膜下腔和脑室内出血量较大（改良Fisher评分和Graeb评分），感染并发症（肺炎和败血症）发生率较高。根据mRS评分，在结局不利的患者中观察到入院时NLR显著更高（mRS评分0-2的中位数[IQR] NLR 5.8 [3.0-10.0] vs mRS评分3-6的NLR 8.3 [4.5-12.6]; p < 0.001）。调整后，入院时NLR仍然是SAH患者不良结局的重要预测因素（OR [95% CI] 1.014 [1.001-1.027]; p = 0.028）。在ROC分析中，NLR 7.05被确定为区分有利和不利结局的最佳临界值（曲线下面积= 0.614，p < 0.001，约登指数= 0.211; mRS评分3-6：NLR >= 7.05的94/153 [61.4%] vs NLR < 7.05的67/166 [40.4%]; p < 0.001）。使用2个倾向评分匹配队列对NLR水平≥ 7.05 vs < 7.05的患者进行亚组分析（每组n = 133例），显示NLR ≥ 7.05的患者中3个月时功能结局不良的患者比例增加（3个月时mRS评分3-6分：NLR ≥ 7.05 82/133 [61.7%] vs NLR < 7.05 62/133 [46.6%]; p = 0.014），但3个月时的死亡率没有差异（NLR >= 7.05 37/133 [27.8%] vs NLR < 7.05 27/133 [ 20.3%]; p = 0.131）.结论在aSAH患者中，NLR是与不良功能结局相关的独立参数。NLR对功能结局的影响是否与预先存在的合并症有关，或在卒中相关免疫抑制的背景下代表独立的因果关系，应在未来的研究中进行调查。
OBJECTIVE Stroke-associated immunosuppression and inflammation are increasingly recognized as factors triggering infections and thus potentially influencing outcome after stroke. Several studies have demonstrated that elevated neutrophil-to-lymphocyte ratio (NLR) is a significant predictor of adverse outcomes for patients with ischemic stroke or intracerebral hemorrhage. Thus far, in patients with subarachnoid hemorrhage the association between NLR and outcome is insufficiently established. The authors sought to investigate the association between NLR on admission and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH).METHODS This observational study included all consecutive aSAH patients admitted to a German tertiary center over a 5-year period (2008-2012). Data regarding patient demographics and clinical, laboratory, and in-hospital measures, as well as neuroradiological data, were retrieved from institutional databases. Functional outcome was assessed at 3 and 12 months using the modified Rankin Scale (mRS) score and categorized into favorable (mRS score 0-2) and unfavorable (mRS score 3-6). Patients' radiological and laboratory characteristics were compared between aSAH patients with favorable and those with unfavorable outcome at 3 months. In addition, multivariate analysis was conducted to investigate parameters independently associated with favorable outcome. Receiver operating characteristic (ROC) curve analysis was undertaken to identify the best cutoff for NLR to discriminate between favorable and unfavorable outcome in these patients. To account for imbalances in baseline characteristics, propensity score matching was carried out to assess the influence of NLR on outcome measures.RESULTS Overall, 319 patients with aSAH were included. Patients with unfavorable outcome at 3 months were older, had worse clinical status on admission (Glasgow Coma Scale score and Hunt and Hess grade), greater amount of subarachnoidal and intraventricular hemorrhage (modified Fisher Scale grade and Graeb score), and higher rates of infectious complications (pneumonia and sepsis). A significantly higher NLR on admission was observed in patients with unfavorable outcome according to mRS score (median [IQR] NLR 5.8 [3.0-10.0] for mRS score 0-2 vs NLR 8.3 [4.5-12.6] for mRS score 3-6; p < 0.001). After adjustments, NLR on admission remained a significant predictor for unfavorable outcome in SAH patients (OR [95% CI] 1.014 [1.001-1.027]; p = 0.028). In ROC analysis, an NLR of 7.05 was identified as the best cutoff value to discriminate between favorable and unfavorable outcome (area under the curve = 0.614, p < 0.001, Youden's index = 0.211; mRS score 3-6: 94/153 [61.4%] for NLR >= 7.05 vs 67/166 [40.4%] for NLR < 7.05; p < 0.001). Subanalysis of patients with NLR levels >= 7.05 vs < 7.05, performed using 2 propensity score-matched cohorts (n = 133 patients in each group), revealed an increased proportion of patients with unfavorable functional outcome at 3 months in patients with NLR >= 7.05 (mRS score 3-6 at 3 months: NLR >= 7.05 82/133 [61.7%] vs NLR < 7.05 62/133 [46.6%]; p = 0.014), yet without differences in mortality at 3 months (NLR >= 7.05 37/133 [27.8%] vs NLR < 7.05 27/133 [ 20.3%]; p = 0.131).CONCLUSIONS Among aSAH patients, NLR represents an independent parameter associated with unfavorable functional outcome. Whether the impact of NLR on functional outcome is related to preexisting comorbidities or represents independent causal relationships in the context of stroke-associated immunosuppression should be investigated in future studies.