Original Contributions| Volume 54, ISSUE 5, P607-614, May 2018

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Utility of Neutrophil-to-Lymphocyte Ratio (NLR) as a Predictor of Acute Infarction in New-Onset Acute Vertigo Patients Without Neurologic and Computed Tomography Abnormalities

Published:February 01, 2018DOI:



      Neutrophil-to-lymphocyte ratio (NLR) has been used as a predictive marker for various conditions. However, there are no previous studies about NLR as a prognostic marker for acute infarction.


      To evaluate the potential utility of NLR as a predictor of acute infarction in acute vertigo patients without neurologic and computed tomography (CT) abnormalities.


      We conducted a prospective, observational study in the Emergency Department (ED) between January 2015 and December 2016. All patients underwent physical examination, laboratory tests, CT, and magnetic resonance imaging (MRI). Results of the initial and follow-up MRI with clinical progress note were considered as the reference standard. Statistically, multivariate logistic regression analysis and receiver operating characteristic (ROC) curve were used.


      Thirty-five (25.9%) patients were diagnosed with acute infarction and 100 (74.1%) patients were diagnosed with peripheral vertigo. Horizontal nystagmus (p = 0.03; odds ratio 0.22) and NLR (p = 0.03; odds ratio 5.4) were significant factors for the differential diagnosis of acute infarction and peripheral vertigo. NLR > 2.8 showed the greatest area under the ROC curve (AUC; 0.819), optimal sensitivity (85.7%), and specificity (78.0%). NLR > 1.4 showed the highest sensitivity (97.1%) and relatively low specificity (41%). The absence of horizontal nystagmus increased the specificity (81.0%) and AUC (0.844).


      A combination of NLR > 2.8 and the absence of horizontal nystagmus is sufficiently specific for acute infarction in an ED patient with acute vertigo; thus, further testing with MRI is indicated. NLR < 2.8 by itself or combined with the presence of horizontal nystagmus is not sufficiently sensitive to rule out the need for further testing.


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        • Cheung C.S.
        • Mak P.S.
        • Manley K.V.
        • et al.
        Predictors of important neurological causes of dizziness among patients presenting to the emergency department.
        Emerg Med J. 2010; 27: 517-521
        • Karatas M.
        Central vertigo and dizziness: epidemiology, differential diagnosis, and common causes.
        Neurologist. 2008; 14: 355-364
        • Kerber K.A.
        • Brown D.L.
        • Lisabeth L.D.
        • Smith M.A.
        • Morgenstern L.B.
        Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study.
        Stroke. 2006; 37: 2484-2487
        • Edlow J.A.
        A new approach to the diagnosis of acute dizziness in adult patients.
        Emerg Med Clin North Am. 2016; 34: 717-742
        • Savitz S.I.
        • Caplan L.R.
        • Edlow J.A.
        Pitfalls in the diagnosis of cerebellar infarction.
        Acad Emerg Med. 2007; 14: 63-68
        • Hwang D.Y.
        • Silva G.S.
        • Furie K.L.
        • Greer D.M.
        Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct.
        J Emerg Med. 2012; 42: 559-565
        • Kabra R.
        • Robbie H.
        • Connor S.E.
        Diagnostic yield and impact of MRI for acute ischaemic stroke in patients presenting with dizziness and vertigo.
        Clin Radiol. 2015; 70: 736-742
        • Lawhn-Heath C.
        • Buckle C.
        • Christoforidis G.
        • Straus C.
        Utility of head CT in the evaluation of vertigo/dizziness in the emergency department.
        Emerg Radiol. 2013; 20: 45-49
        • Kartal A.G.
        • Yılmaz S.
        • Yaka E.
        • et al.
        Diagnostic value of S100B protein in the differential diagnosis of acute vertigo in the emergency department.
        Acad Emerg Med. 2014; 21: 736-741
        • Nelson J.A.
        • Viirre E.
        The clinical differentiation of cerebellar infarction from common vertigo syndromes.
        West J Emerg Med. 2009; 10: 273-277
        • Edlow J.A.
        • Newman-Toker D.
        Using the physical examination to diagnose patients with acute dizziness and vertigo.
        J Emerg Med. 2016; 50: 617-628
        • Lee H.
        Isolated vascular vertigo.
        J Stroke. 2014; 16: 124-130
        • Kerber K.A.
        • Newman-Toker D.E.
        Misdiagnosing dizzy patients: common pitfalls in clinical practice.
        Neurol Clin. 2015; 33: 565-575
        • Vanni S.
        • Nazerian P.
        • Casati C.
        • et al.
        Can emergency physicians accurately and reliably assess acute vertigo in the emergency department?.
        Emerg Med Australas. 2015; 27: 126-131
        • Abraha H.D.
        • Butterworth J.
        • Bath P.M.
        • Wassif W.S.
        • Garthwaite J.
        • Sherwood R.A.
        Serum S100 protein, relationship to clinical outcome in acute stroke.
        Ann Clin Biochem. 1997; 34: 546-550
        • Wunderlich M.T.
        • Wallesch C.W.
        • Goertler M.
        Release of neurobiochemical markers of brain damage is related to the neurovascular status on admission and the site of arterial occlusion in acute ischemic stroke.
        J Neurol Sci. 2004; 227: 49-53
        • Zahorec R.
        Ratio of neutrophil to lymphocyte counts—rapid and simple parameter of systemic inflammation and stress in critically ill.
        Bratisl Lek Listy. 2001; 102 ([in English, Slovak]): 5-14
        • Hwang S.Y.
        • Shin T.G.
        • Jo I.J.
        • et al.
        Neutrophil-to-lymphocyte ratio as a prognostic marker in critically-ill septic patients.
        Am J Emerg Med. 2017; 35: 234-239
        • Xue J.
        • Huang W.
        • Chen X.
        • et al.
        Neutrophil-to-lymphocyte ratio is a prognostic marker in acute ischemic stroke.
        J Stroke Cerebrovasc Dis. 2017; 26: 650-657
        • Choi K.D.
        • Lee H.
        • Kim J.S.
        Vertigo in brainstem and cerebellar strokes.
        Curr Opin Neurol. 2013; 26: 90-95
        • Newman-Toker D.E.
        • Hsieh Y.H.
        • Camargo Jr., C.A.
        • Pelletier A.J.
        • Butchy G.T.
        • Edlow J.A.
        Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample.
        Mayo Clin Proc. 2008; 83: 765-775
        • Kim H.A.
        • Lee H.
        Isolated vestibular nucleus infarction mimicking acute peripheral vestibulopathy.
        Stroke. 2010; 41: 1558-1560
        • Stanton V.A.
        • Hsieh Y.H.
        • Camargo Jr., C.A.
        • et al.
        Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians.
        Mayo Clin Proc. 2007; 82: 1319-1328
        • Kerber K.A.
        • Meurer W.J.
        • West B.T.
        • Fendrick A.M.
        Dizziness presentations in U.S. emergency departments, 1995–2004.
        Acad Emerg Med. 2008; 15: 744-750
        • Grad A.
        • Baloh R.W.
        Vertigo of vascular origin. Clinical and electronystagmographic features in 84 cases.
        Arch Neurol. 1989; 46: 281-284
        • Gul U.
        • Kayani A.M.
        • Munir R.
        • Hussain S.
        Neutrophil lymphocyte ratio: a prognostic marker in acute ST elevation myocardial infarction.
        J Coll Physicians Surg Pak. 2017; 27: 4-7
        • Kundi H.
        • Balun A.
        • Cicekcioglu H.
        • et al.
        The relation between platelet-to-lymphocyte ratio and pulmonary embolism severity index in acute pulmonary embolism.
        Heart Lung. 2015; 44: 340-343
        • Ruhnau J.
        • Schulze J.
        • Dressel A.
        • Vogelgesang A.
        Thrombosis, neuroinflammation, and poststroke infection: the multifaceted role of neutrophils in stroke.
        J Immunol Res. 2017; 2017: 5140679
        • Buck B.H.
        • Liebeskind D.S.
        • Saver J.L.
        Early neutrophilia is associated with volume of ischemic tissue in acute stroke.
        Stroke. 2008; 39: 355-360
        • Frangogiannis N.G.
        • Smith C.W.
        • Entman M.L.
        The inflammatory response in myocardial infarction.
        Cardiovasc Res. 2002; 53: 31-47
        • Schwartz M.
        • Moalem G.
        Beneficial immune activity after CNS injury: prospects for vaccination.
        J Neuroimmunol. 2001; 113: 185-192
        • Härtl R.
        • Schürer L.
        • Schmid-Schönbein G.W.
        • del Zoppo G.J.
        Experimental antileukocyte interventions in cerebral ischemia.
        J Cereb Blood Flow Metab. 1996; 16: 1108-1119