Neutrophil–Lymphocyte ratio is associated with poor clinical outcome after mechanical thrombectomy in stroke in patients with COVID-19

Fawaz Al-Mufti, Priyank Khandelwal, Tolga Sursal, Jared B. Cooper, Eric Feldstein, Krishna Amuluru, Jayaji M. Moré, Ambooj Tiwari, Amit Singla, Adam A. Dmytriw, Mariangela Piano, Luca Quilici, Guglielmo Pero, Leonardo Renieri, Nicola Limbucci, Mario Martínez-Galdámez, Miguel Schüller-Arteaga, Jorge Galván, Juan Francisco Arenillas-Lara, Zafar HashimSanjeev Nayak, Keith Desousa, Hai Sun, Pankaj K. Agarwalla, J. Sudipta Roychowdhury, Emad Nourollahzadeh, Tannavi Prakash, Andrew R. Xavier, J. Diego Lozano, Gaurav Gupta, Dileep R. Yavagal, Mohammad Elghanem, Chirag D. Gandhi, Stephan A. Mayer

Research output: Contribution to journalArticlepeer-review


Background: The neutrophil–lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19. Objective: We sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke. Methods: We analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated. Results: Incidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27–87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p =.003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2–38.6, p =.03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2–52.4, p =.03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p =.043, TICI p =.070). Conclusions: We show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.

Original languageEnglish (US)
Pages (from-to)386-392
Number of pages7
JournalInterventional Neuroradiology
Issue number4
StatePublished - Aug 2023

All Science Journal Classification (ASJC) codes

  • Radiology Nuclear Medicine and imaging
  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine


  • Neutrophil lymphocyte ratio
  • acute ischemic stroke
  • large vessel occlusion


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