Background: The prognostic value of the neutrophil–lymphocyte ratio (NLR) in ischemic stroke remains debated due to cohort variability and treatment heterogeneity across studies. This study evaluates the relationship between admission NLR, stroke severity and 90-day outcomes in patients with anterior circulation large vessel occlusion (LVO) undergoing early, successful revascularization. Methods: A retrospective multicenter study was conducted with 1082 patients treated with mechanical thrombectomy for acute ischemic stroke. The relationship between admission NLR, baseline National Institutes of Health Stroke Scale (NIHSS), 24 h NIHSS and 90-day modified Rankin Scale (mRS) outcomes was analyzed using logistic regression. Results: Admission NLR correlated weakly but significantly with both baseline (p = 0.018) and 24 h (p = 0.005) NIHSS scores, reflecting stroke severity. However, multivariate analysis showed that higher 24 h NIHSS scores (OR 0.831, p = 0.000) and prolonged puncture-to-recanalization times (OR 0.981, p = 0.000) were independent predictors of poor 90-day outcomes, whereas NLR was not (p = 0.557). Conclusions: Admission NLR is associated with stroke severity but does not independently predict clinical outcomes at 90 days in patients achieving early and successful revascularization. These findings underscore the critical role of inflammation in the acute phase of stroke but suggest that its prognostic value for long-term outcomes is limited in this context.

The red blood cell distribution width (RDW) and neutrophil to lymphocyte ratio (NLR) have been linked to poor prognosis in patients with ischaemic stroke. However, no study has yet evaluated the prognostic role of RDW and NLR, or their combined effect on reperfusion in patients with endovascularly-treated acute ischaemic stroke. This study therefore aimed to analyse the impact of RDW and NLR on poor functional outcomes and failed reperfusion following endovascular treatment in patients with acute anterior circulation ischaemic stroke. A total of 275 patients with acute anterior circulation ischaemic stroke treated endovascularly between 2015 and 2018 were enrolled in this study. The relationships between RDW, NLR, and poor outcomes were analysed using univariate and multivariate logistic regression models and receiver operating characteristic (ROC) curve analysis. The Youden Index was applied to determine the cut-off value. Multivariate logistic regression analysis identified RDW (p = 0.015) and NLR (p = 0.015) as independent predictors of mortality at the 3rd month. ROC curve analysis of RDW revealed a cutoff value of 14.25 (p = 0.009) for poor clinical outcomes (modified Rankin scale [mRS] 3-6). Similarly, a cutoff value of 14.25 was found for mortality prediction (p = 0.003). The cutoff value for poor clinical outcome (mRS 3-6) in the NLR was determined as 5.93 (p = 0.003), whereas the cutoff value for mortality was set at 5.17 (p = 0.028). RDW also predicted failed reperfusion, with a cutoff value of 17.75 (p = 0.048). High RDW and NLR upon admission were identified as independent indicators of mortality in endovascularly treated acute anterior circulation ischemic stroke patients. Furthermore, the RDW could potentially predict failed reperfusion.

A 72-year-old male patient presented with a decreased level of consciousness. He had no known history of systemic disease. He also had a painful vesicular rash on the scalp three weeks prior that had resolved. His neurological examination, during which he could not respond to verbal stimuli, revealed that his four extremities responded to painful stimuli and that the plantar reflex was downgoing bilaterally. His body temperature was 37.3°C. Diffusion-weighted magnetic resonance imaging (MRI) revealed infarcted areas, indicating diffusion restriction in both suprathalamic regions ( Figures 1 and 2). A lumbar puncture was performed. No cells were observed upon direct examination of the cerebrospinal fluid. The microprotein levels were high at 65.4 mg/dL. Polymerase chain reaction (PCR) for varicella zoster virus (VZV) DNA was positive. Serum VZV IgG >1500 mIU/mL was positive, and serum VZV IgM was 2.2 mIU/mL was negative. The patient was given 10 mg/kg acyclovir three times daily for 21 days and 60 mg/kg methylprednisolone for 14 days. The patient began to respond significantly to verbal stimuli in the fourth month of hospitalization. VZV can spread centrally from the peripheral nerves, causing neurovascular disorders ranging from ischemic stroke-related large-vessel vasculopathy to arterial dissection and subarachnoid hemorrhage¹ 1. Nagel MA, Gilden D. Update on varicella zoster virus vasculopathy. Curr Infect Dis Rep. 2014;16(6):1-8. . VZV vasculopathy is often chronic and long-lasting. Clinical improvement is possible with antiviral therapy² 2. Nagel MA, Cohrs RJ, Mahalingam R, Wellish MC, Forghani B, Schiller A, et al. The varicella zoster virus vasculopathies. Neurology. 2008;70(11):853-60. . Given that VZV is a treatable cause of stroke, its etiology should be investigated even if the rash is not described.

Background: Medium vessel occlusions (MeVOs) are an increasingly recognized but heterogeneous target for endovascular therapy (EVT). This study aims to compare primary MeVO, rescue MeVO, and large vessel occlusion (LVO) thrombectomy cases to identify which MeVO subtypes derive a meaningful benefit from EVT under appropriate safety conditions. Methods: We retrospectively analyzed a multicenter registry of patients undergoing EVT for acute ischemic stroke. MeVO was defined as the occlusion of the A1-A3, M2-M3, P1-P3, fetal PCA, or PICA segments and classified as primary or rescue. Clinical outcomes were assessed by NIHSS score at baseline, discharge, and 90 days; functional outcome by the modified Rankin scale (mRS); and reperfusion by modified thrombolysis in cerebral infarction (mTICI). Safety endpoints included intracranial hemorrhage and mortality. Results: Among 603 EVT patients, 202 (33.5%) had MeVO. Compared to LVO, MeVO patients were older and had more prior strokes but achieved similar reperfusion and safety outcomes. At 90 days, mRS distribution differed, with MeVO showing more mRS 2 and LVO more mRS 1, while higher-disability strata were comparable. Within MeVO, 119 (58.9%) were primary and 83 (41.1%) rescue occlusions. Rescue MeVO patients presented with higher baseline severity (NIHSS score of 19 vs. 18) and, despite similar reperfusion, experienced worse 90-day outcomes and higher mortality (21.7% vs. 0.8%). Conclusions: EVT for primary MeVO is feasible, effective, and safe, whereas rescue MeVO is associated with poor functional outcomes and markedly higher mortality. These findings highlight rescue MeVO as a distinct phenotype and support a selective approach prioritizing disabling syndromes, proximal/dominant branch occlusions, and IVT non-response.

Although the underlying cause of ischemic stroke is vascular occlusion, the post-stroke pathophysiology remains unclear. Therefore, numerous biomarkers have been investigated for both diagnostic and prognostic purposes. In our study, the diagnostic value of the parameters NLR, PLR, RDW-CV, RDW-SD, HIF-1, and DEC-1 was comprehensively evaluated. NLR, Blood samples from patients with ischemic stroke and healthy controls were analyzed for NLR, PLR, RDW-CV, RDW-SD, HIF-1, and DEC-1 levels. Demographic and clinical characteristics of both patient and control groups were recorded. The relationship between HIF-DEC measurements and laboratory parameters was subsequently assessed. For statistical analysis, the Mann-Whitney U test was used for comparisons between groups, and the Chi-Square test was applied for categorical variables. RDW-SD values were found to be higher in patients diagnosed with cerebrovascular accident (CVA) while DEC levels were lower in the stroke group. Although no significant correlation was observed between HIF levels and other parameters in either the CVA or control groups, there was a weak inverse correlation found between DEC and NLR (r:-0.258), and between DEC and RDW-CV (r:-0.268), and a weak linear correlation between DEC and RDW (r:0.319) in the whole group. No significant correlations were found between DEC and other measurements within either the control or CVA groups individually. Our study may indicate that pathways increasing the levels of DEC-1, which acts on the PI3K/Akt pathway, could lead the development of new therapeutic strategies for ischemic stroke.