ORIGINAL ARTICLE www.ijcmr.

com Section: Medicine

The Prognostic Role of Lymphocytes with Respect to Mortality in

Stroke Patients
Manoj Mathur1, Isha Gupta2

was associated with increased risk for developing adverse

ABSTRACT outcome in terms of morbidity and mortality in cardiovascular
Introduction: The secondary neuroinflammatory response diseases particularly MI.2 Studies have clearly demonstrated
after an episode of acute stroke can have grave impact on a negative correlation between lymphocyte counts and
the prognosis of the stroke whether ischemic or hemorrhagic severity of coronary atherosclerosis.3 Physiologic stress
stroke. Physiological stress during an episode of acute during acute stroke leads to high level of cortisol which
stroke leads to high levels of cortisol and catecholamines leads to lower lymphocyte counts.4 Moreover, acute stressful
due to sympathetic nervous system activation which causes
conditions cause activation of sympathetic nervous system
a decrease in the circulating lymphocyte levels leading to
which causes redistribution of lymphocytes to lymphatic
lymphopenia. This may have an impact on the outcome of the
stroke patients.
organs and also promotes apoptosis of lymphocytes leading
Materials and methods: A total of 100 adult patients, 50 to lymphopenia.
each with onset ischemic and hemorrhagic stroke (as per CT/ Several studies have shown that a low lymphocyte count is
MRI diagnosis) were enrolled in the study within 48 hours correlated with poor clinical neurological outcome, plays a
of onset. Those with prior history of stroke were excluded. negative role in long-term functional recovery and can even
Demographic, clinical and hematological assessment was be associated with higher mortality.5,6
done. Patients were followed up till discharge/death. Data was This study aimed to highlight the importance of lymphopenia
analyzed using SPSS 21.0 and its association with poor outcome especially mortality in
Result: Out of the 100 patients of stroke analysed , 41 patients stroke patients, both ischemic and hemorrhagic.
expired and 59 survived during the course of the study. It was Aims and Objective –
observed that the mean lymphocytes % in those who expired
To assess the prognostic role of lymphocytes with respect to
was 11.34 (SD – 7.62) while in those who survived was 14.28
mortality in stroke patients, both ischemic and hemorrhagic
(SD – 6.43) i.e. the lymphocytes % in those who expired was
significantly lower than in those who survived the stroke (p stroke.
value – 0.04). MATERIAL AND METHODS
Conclusion: It was concluded that lymphopenia was
significantly associated with poor neurological outcome i.e.
It was a Prospective Cohort (Observational) Study, carried
mortality in patients of stroke , both ischemic and hemorrhagic. out at the Department of Medicine, SRN Hospital, Motilal
It can be considered as a prognostic marker in patients of Nehru Medical College, Prayagraj. The study population
stroke, however further studies with larger sample size are included a total of 100 Adult patients (Age > 18 years),
needed to explore the role of lymphocytes as a prognostic with signs and symptoms suggestive of stroke attending the
marker in stroke patients. medicine department of SRN hospital. (50 each with onset
ischemic and hemorrhagic stroke)
Keywords: Lymphocytes, Mortality, Stroke
Ethical clearance from ethics committee was taken. Patients/
primary legal caregivers of the patients falling in sampling
frame were invited to participate in study and were explained
INTRODUCTION about the procedures involved. Only those subjects providing
an informed consent were enrolled in the study.
Stroke, both ischemic and hemorrhagic are one of the most
After enrolment, demographic, clinical and hematological
common and devastating disorders. Stroke is the second most
assessment was done. Patients were followed up till
common cause of death worldwide. It is also a leading cause
discharge/death.
of serious long-term disability. Ischemic stroke comprises of
about 85% of all strokes while hemorrhagic stroke are about
Professor, Department of Internal Medicine, 2Junior Resident 3rd
1
15%, however both these stroke lead to severe neurological Year, Department of Internal Medicine, Motilal Nehru Medical
and functional impairement.1 College and Swaroop Rani Nehru Hospital, Prayagraj
Lymphocytes are blood cells responsible for cellular and
humoral immunity in the body that have shown to modulate Corresponding author: Isha Gupta, Flat UG01, C block, Tulsiani
the immunologic response in our body. Lymphocytes Enclave, George Town, Lowther Road, opposite Bhola Hospital,
modulate the mononuclear cell phenotype and induce Prayagraj, Uttar Pradesh, Pin - 211002, India
tissue inhibitor of metalloproteinase-1 expression that have How to cite this article: Manoj Mathur, Isha Gupta. The
key role in tissue healing. Experimental models have also prognostic role of lymphocytes with respect to mortality in stroke
revealed that lymphocytes exert anti-inflammatory response patients. International Journal of Contemporary Medical Research
in atherosclerosis development. Recently, lymphopenia 2023;10(1):A4-A6.

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Section: Medicine International Journal of Contemporary Medical Research
Volume 10 | Issue 1 | January 2023 | ISSN (Online): 2393-915X; (Print): 2454-7379
Mathur, et al. The Prognostic Role of Lymphocytes with Respect to Mortality

SN Parameter Expired (n=41) Survival (n=59) Statistical significance

Mean SD Mean SD t ‘p’
1. Hb (g/dl) 13.06 2.13 12.07 1.70 2.58 0.011
2. TLC (‘000/cumm) 13.98 4.78 10.83 3.60 3.65 <0.001
3. Neutrophils (%) 81.90 13.71 79.04 8.30 1.30 0.196
4. Lymphocytes (%) 11.34 7.62 14.28 6.43 -2.09 0.040
5. Monocytes (%) 5.04 2.38 6.45 2.55 -2.79 0.006
6. PC (lakhs/cumm) 1.50 0.86 1.60 0.73 -0.64 0.525
7. MPV(fl) 10.11 1.34 10.19 1.60 -0.28 0.777
8. PDW 15.71 3.02 15.57 3.05 0.22 0.824
9. PCT 0.13 0.07 0.15 0.06 -1.52 0.133
10. PLR 0.22 0.21 0.14 0.09 2.43 0.017
11. RDW 14.40 3.86 13.68 1.86 1.23 0.221
Table-1: Association of Hematological Parameters with mortality

Figure-1: Comparison of mean age of ischemic and hemorrhagic

stroke patients Figure-3: Association of Hematological Parameters with mortality

brain tumour and haemorrhagic transformation of a cerebral

infarct
RESULTS
The present study was carried out to study the prognostic role
of lymphocytes with respect to mortality in stroke patients,
both ischemic and hemorrhagic.
For this purpose, a total of 100 stroke patients (50 each of
ischemic and hemorrhagic type) were enrolled in the study.
Fig 1 and 2 shows the age and gender profile of patients
enrolled in the study respectively.
Figure-2: Comparison of Sex profile of ischemic and hemorrhagic Overall age of patients ranged from 30 to 95 years. Mean age
stroke patients of patients was 63.50±13.32 years.
Overall, majority of patients were males (68%). Almost one-
Data was analyzed using IBM Statistical Package for Social third (32%) were females. The sex-ratio was 2.13.
Sciences, 21.0. Table 1 shows that out of the total 100 stroke patients
analyzed, 41 expired while 59 survived during the course
Inclusion criteria
of the study. Mean hemoglobin, TLC level and PLR were
MRI/CT confirmed cases of new onset cerebrovascular
significantly higher of those who expired as compared to
accidents (both ischemic and haemorrhagic stroke).
those who survived. Mean lymphocyte as well as monocyte
Presenting to the Medicine department within 48 hrs of
counts were significantly lower among those who expired as
onset.
compared to those who survived.
Both genders, age > 18 years.
The mean lymphocytes % in those who expired was 11.34
Exclusion criteria (SD – 7.62) while in those who survived was 14.28 (SD –
Patients with prior history of stroke. 6.43) i.e. there was significant lymphopenia in those who
Patients with intracerebral hemorrhage due to bleeding from expired than in those who survived the stroke (p value –

International Journal of Contemporary Medical Research Section: Medicine A5

ISSN (Online): 2393-915X; (Print): 2454-7379 | Volume 10 | Issue 1 | January 2023 |
Mathur, et al. The Prognostic Role of Lymphocytes with Respect to Mortality

0.04). 3. Cho KI, Ann SH, Singh GB, Her AY, Shin ES. Combined
Statistically, there was no significant difference between Usefulness of the Platelet-to-Lymphocyte Ratio and the
two groups with respect to mean neutrophils, platelet count, Neutrophil-to-Lymphocyte Ratio in Predicting the Long-
MPV, PDW, PCT and RDW Term Adverse Events in Patients Who Have Undergone
Percutaneous Coronary Intervention with a Drug-
Discussion –
Eluting Stent. PLoS One. 2015 Jul 24;10(7):e0133934.
In our study, out of 100 stroke patients studied, 41 expired
4. Hu G, Sarti C, Jousilahti P, Peltonen M, Qiao
while 59 survived during the course of the study. It was Q, Antikainen R, et al. The impact of history of
observed that there was significant lymphopenia in those hypertension and type 2 diabetes at baseline on the
who expired than in those who survived the stroke (p value incidence of stroke and stroke mortality. Stroke 2005;
– 0.04). 36:2538-43.
These findings corroborated with the study findings of Juli 5. Zhang J, Ren Q, Song Y, et al. Prognostic role of
C et al. wherein they found that decreased lymphocyte count neutrophil–lymphocyte ratio in patients with acute
was associated with poor outcome(poor NIHSS score) in ischemic stroke. Medicine. 2017;96:45.
acute ischemic stroke patients.7 6. Bolayır A. The relationship between lymphocyte/
The similar findings were reproduced by Vogelgesang A et al. monocyte ratio and short-term mortality in acute
wherein they concluded that loss of CD4+ T lymphocytes led ischemic stroke patients. Cumhuriyet Tip Dergisi.
2018;40(2):128–134.
to stroke induced immunosuppression further contributing to
7. Juli C, Heryaman H, Nazir A, Ang ET, Defi IR,
a poor outcome in stroke patients. 8
Gamayani U, Atik N. The Lymphocyte Depletion in
Conclusion – The present study conducted on 100 stroke Patients with Acute Ischemic Stroke Associated with
patients including both ischemic as well as hemorrhagic Poor Neurologic Outcome. Int J Gen Med. 2021 May
stroke patients, we observed that lymphopenia was 14;14:1843-1851.
significantly associated with poor neurological outcome (in 8. Vogelgesang A, May VE, Grunwald U, Bakkeboe M,
terms of mortality). Thus, Lymphocyte count is a simple, Langner S, Wallaschofski H, et al. Functional status
cost effective and routinely available test which can be of peripheral blood T-cells in ischemic stroke patients.
considered as a prognostic marker in patients of stroke. This PLoS ONE. 2010;5(1).
study is amongst the very few studies of Indian subcontinent
wherein both ischemic and hemorrhagic strokes were Source of Support: Nil; Conflict of Interest: None
studied together and the prognostic role of lymphocytes was
Submitted: 22-11-2022; Accepted: 26-12-2022; Published: 30-01-2023
analyzed with respect to mortality.
Further studies with larger sample size are needed to explore
the role of lymphocytes as a prognostic marker in stroke
patients.
Limitation: Despite the best efforts, our study had few
limitations:
1. The sample size of our study was small involving only a
single centre patients of acute ischemic stroke and acute
haemorrhagic stroke which might not be representative
of the overall stroke population.
2. Owing to lack of long term follow up for our patients,
we cannot comment whether lymphocyte count is a
useful predictor of long-term prognostic outcome in
patients with stroke or not.
3. Our study was carried out in a tertiary care centre where
the cases are either serious or referred thus justifying the
higher than usual mortality of stroke in our study. Our
study may thus be biased towards more serious cases.
REFERENCES
1. Loscalzo J, Kasper DL, Longo DL, Fauci AS, Hauser
SL, Jameson JL, et al. chapter 426 Introduction to
Cerebrovascular Diseases. In: Harrison's® principles of
internal medicine. New York: McGraw Hill; 2022.
2. Azab B, Zaher M, Weiserbs KF, Torbey E, Lacossiere K,
Gaddam S, et al. Usefulness of neutrophil to lymphocyte
ratio in predicting short- and long-term mortality after
non-ST elevation myocardial infarction. The American
Journal of Cardiology 2010; 106:470-6.

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Section: Medicine International Journal of Contemporary Medical Research
Volume 10 | Issue 1 | January 2023 | ISSN (Online): 2393-915X; (Print): 2454-7379