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Original research
Admission neutrophil–lymphocyte ratio predicts delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage
  1. Fawaz Al-Mufti1,2,
  2. Krishna Amuluru3,
  3. Nitesh Damodara4,
  4. Vincent Dodson4,
  5. David Roh5,
  6. Sachin Agarwal5,
  7. Philip M Meyers6,
  8. E Sander Connolly Jr7,
  9. Michael J Schmidt8,
  10. Jan Claassen5,
  11. Soojin Park5
  1. 1 Department of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
  2. 2 Department of Neurology and Neurosurgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
  3. 3 Department of Interventional Neuroradiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  4. 4 Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
  5. 5 Department of Neurology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
  6. 6 Department of Radiology and Neurological Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
  7. 7 Department of Neurosurgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
  8. 8 Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York, USA
  1. Correspondence to Dr. Fawaz Al-Mufti; fawazalmufti{at}


Background Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) has a multifactorial pathophysiology, with immune dysregulation being an important component. The neutrophil–lymphocyte ratio (NLR) is an established prognostic marker in patients with cancer, cardiac disease, and sepsis.

Objective To determine whether there is a relationship between NLR and DCI in patients with aSAH.

Methods We evaluated 1067 patients with aSAH between 2006 and 2015 enrolled in a single-center, prospective, observational cohort study. Admission white blood cell differentials (NLR) were analyzed using a cut-off point of ≥5.9. DCI from cerebral vasospasm was defined as the occurrence of focal neurological impairment, or a decrease in at least two points on the Glasgow Coma Scale, which was not apparent immediately after aneurysm occlusion, and could not be attributed to other causes. Cerebral infarct was defined as a new infarct on CT that was not visible on the admission or immediate postoperative scan, when the cause was thought to be vasospasm by the research team. Logistic regression models were generated.

Results We found that 768 (72%) patients had an admission NLR ≥5.9. In a multivariable model, elevated NLR was associated with poor admission Hunt-Hess grade (OR=1.6, 95% CI 1.2 to 2.6, p=0.005), Caucasian ethnicity (OR=2.6, 95% CI 1.9 to 3.7, p<0.001), anterior aneurysm location (OR=1.7, 95% CI 1.2 to 2.4, p=0.004), loss of consciousness at ictus (OR=1.4, 95% CI 1.0 to 2.0, p=0.055), and thick SAH (modified Fisher grade ≥3) (OR=1.8, 95% CI 1.3 to 2.4, p<0.001). Admission NLR predicted development of delayed cerebral ischemia (DCI) (OR=1.7; 95% CI 1.1 to 2.5, p=0.008) after controlling for known predictors such as age, poor admission clinical grade, thick SAH blood, and elevated admission mean arterial pressure.

Conclusions This study provides further evidence of the association between inflammation and DCI. Admission NLR is a readily available and convenient biomarker that may be a clinically useful tool for prognostication when evaluating aSAH.

  • inflammatory response
  • subarachnoid
  • hemorrhage
  • aneurysm

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  • Contributors FA-M and KA conceived the idea for the study. FA-M developed the theory and performed the computations. FA-M, ND, and VD performed the statistical analyses and drafted the manuscript. DR, SA, PMM, ESC, MJS, JC, and SP verified the analytical methods and contributed to the interpretation of results. All authors provided critical feedback and helped to shape the research, analysis, and manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.