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Background and PurposeFew data exist on the relationship between differential subpopulations of peripheral leukocytes
and early cerebral infarct size in ischemic stroke. Using diffusion-weighted MR imaging (DWI), we assessed the
relationship of early total and differential peripheral leukocyte counts and volume of ischemic tissue in acute stroke.
MethodsAll included patents had laboratory investigations and neuroimaging collected within 24 hours of stroke onset.
Total peripheral leukocyte counts and differential counts were analyzed individually and by quartiles. DWI lesions were
outlined using a semiautomated threshold technique. The relationship between leukocyte quartiles and DWI infarct
volumes was examined using multivariate quartile regression.
Results173 patients met study inclusion criteria. Median age was 73 years. Total leukocyte counts and DWI volumes
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showed a strong correlation (Spearman rho0.371, P000.1). Median DWI volumes (mL) for successive neutrophil
quartiles were: 1.3, 1.3, 3.2, and 20.4 (P for trend 0.001). Median DWI volumes (mL) for successive lymphocyte
quartiles were: 3.2, 8.1, 1.3, and 1.5 (P0.004). After multivariate analysis, larger DWI volume remained strongly
associated with higher total leukocyte and neutrophil counts (both probability values 0.001), but not with lymphocyte
count (P0.4971). Compared with the lowest quartiles, DWI volumes were 8.7 mL and 12.9 mL larger in the highest
quartiles of leukocyte and neutrophil counts, respectively.
ConclusionsHigher peripheral leukocyte and neutrophil counts, but not lymphocyte counts, are associated with larger
infarct volumes in acute ischemic stroke. Attenuating neutrophilic response early after ischemic stroke may be a viable
therapeutic strategy and warrants further study. (Stroke. 2008;39:355-360.)
Key Words: diffusion-weighted imaging inflammation ischemic leukocytosis
magnetic resonance imaging stroke
Received April 5, 2007; final revision received June 19, 2007; accepted July 4, 2007.
From the Division of Neurology (B.H.B.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; the Stroke Center and Department of
Neurology (B.H.B., D.S.L., J.L.S., O.Y.B., S.W.Y., S.S., L.K.A., D.K., T.R., B.O.), University of California, Los Angeles; the Department of Neurology
(O.Y.B.), Samsung Medical Center, Sungkyunkwan University, South Korea; the Stroke Center and Department of Radiology (J.P.V., N.S.), University
of California, Los Angeles; and the Department of Emergency Medicine (S.S.), University of California, Los Angeles.
Correspondence to Brian H. Buck MD, FRCPC, Division of Neurology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, room A421,
Toronto, Ontario, Canada M4N3M5. E-mail brianhbuck@gmail.com
2008 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.107.490128
355
356 Stroke February 2008
years, diagnosis of acute ischemic stroke, multimodal MRI per- Racial distribution was 66% white, 12% black, 13% Asian,
formed within 24 hours of last known well time, peripheral leukocyte and 0.6% other. Ethnic distribution was 9% Hispanic and
count and differential performed on admission blood work, and
91% not Hispanic. The median NIHSS on presentation was 4
admission during an 18-month period beginning January 1, 2004.
The study was approved by the hospital Institutional Review Board. (interquartile [IQR] range 2 to 12; full range 0 to 38) and the
meanSD time between last known well time and the MRI
MRI Methods and Image Analysis scan was 10.77.9 hours (range 0.7 to 24). Stroke subtypes
Patients were imaged before receiving any reperfusion therapy with classified using the modified TOAST criteria14 were: 41%
a 1.5-T Siemens Vision scanner (Siemens Medical System) using a cardioembolic, 17.4% large vessel atherothromboembolic,
protocol detailed previously,10 which included DWI, perfusion
25.4% small vessel occlusion, 13.3% stroke of undetermined
weighted imaging, gradient-recalled echo examination, and fluid
attenuated inversion recovery imaging (FLAIR). DWI was per- etiology, and 5.8% other etiology. On discharge, 94 (54.3%)
formed with 2 levels of diffusion sensitization (b0 and 1000 had poor outcome defined as discharge Rankin 2.
s/mm2) with the following parameters: 5 to 7 mm slice thickness, no Leukocyte count was measured at a meanSD of 9.67.3
gap, and 17 to 20 slices. DWI lesion volumes were measured with hours after stroke onset. The meanSD total peripheral
MIPAV software (Medical Image Processing, Analysis and Visual-
ization, version 3.0, National Institutes of Health, Bethesda, Md).
leukocyte, neutrophil, and lymphocyte counts were:
Raters outlined regions of acute diffusion abnormality on the 8.733.36, 6.173.15, and 1.830.83109cells/L, respec-
b1000 image, consulting apparent diffusion coefficient and FLAIR tively. The meanSD time between the MRI and leukocyte
sequences to distinguish acute from nonacute diffusion change. collection was 1.15.3 hours.
Acute diffusion lesions were defined on a slice-by-slice basis using Table 1 shows population demographic information, risk
a semiautomatic threshold approach by a rater blinded (BHB) to all
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Association of Total Leukocyte, Lymphocyte, and neutrophil count were similar to that of the total leukocyte
Neutrophil Quartiles With DWI Lesion Volume count. The volume in the highest quartile was significantly
The median (IQR) DWI lesion volumes by quartile of total larger than the lower 3 quartiles. DWI volumes in the lower
leukocyte count, neutrophil count, and lymphocyte count are 3 neutrophil quartiles did not differ significantly from each
shown in Table 2, including both univariate and adjusted other. The pattern for the lymphocyte count was different and
multivariate analyses. DWI volume was positively correlated showed the DWI lesion volume in the second quartile to be
with total leukocytes (Spearman rho0.371, P0.001) and significantly larger than the other 3 quartiles.
neutrophils (Spearman rho0.415, P0.001) but not lym- The multivariate estimated effect sizes of total leukocyte
phocytes. On bivariate median regression analysis, higher and neutrophil quartiles on DWI lesion volumes showed a
leukocyte quartiles were significantly associated with larger similar pattern to the bivariate analysis. Elevated leukocyte
DWI lesion volumes (Table 2). Patients in the highest and neutrophil count remained positively associated with
leukocyte quartile had significantly larger median lesion DWI lesion volumes. Figure 2 shows the multivariate ad-
volumes than the lower 3 quartiles. None of the 3 lower justed median DWI volumes, IQR, and 95% CI for each of
quartiles differed significantly from each other. the neutrophil quartiles. Pairwise comparison showed that the
Both neutrophil and lymphocyte counts were significantly difference in DWI volumes in the highest neutrophil quartile
associated with DWI lesion volume. The results for the was significantly larger than the lower 3 quartiles (P0.001).
358 Stroke February 2008
of increased DWI volume in the highest total leukocyte and matched stroke incidence by 2- to 3-fold, possibly as a result
neutrophil quartiles. Analysis of differential subpopulations of increased platelet leukocyte aggregation and platelet acti-
of peripheral leukocytes indicated that the total leukocyte vation.29 We attempted to control for clinically-manifest
effect was largely attributable to the positive association concurrent infection by adjusting for body temperature in the
between the neutrophil fraction and DWI volume because we multivariate analyses, and this did not affect the relationship
did not find any independent relationship between DWI noted between neutrophil counts and DWI lesion volume.
volumes and lymphocyte counts. This effect did not appear to Elevation in leukocyte counts and specifically the neutro-
be present across the full range of neutrophil counts, but phil population may have occurred after the onset of stroke,
rather there was a threshold between the third and fourth with greater inflammatory response contributing to greater
quartiles above which elevation in neutrophil counts was ischemic brain injury.30 The present finding that only the
associated with significantly larger infarct volumes. neutrophil quartile and not lymphocytes predicted DWI
These results are consistent with previous studies that have lesion volume is in keeping with the known temporal profile
reported a relationship between lesion size and elevated of inflammatory cell involvement in the hyperacute phases of
markers of systemic inflammatory response including WBC, stroke. Prior studies have shown that neutrophils are among
body temperature, C-reactive protein, and additional inflam- the earliest inflammatory cell type to show substantial up-
matory biomarkers.1,2,15,16 Studies that have correlated the regulation in gene expression6 and to infiltrate the ischemic
inflammatory cell response with infarct volumes have almost brain.7 Recruitment of neutrophils can be detected as early as
exclusively used CT or T2-weighted MRI.2,17 There have 5 hours after stroke onset and peaks at 24 hours.1
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been studies that have looked at inflammatory markers in It must also be acknowledged that the association of
relation to DWI lesion volumes in small numbers of pa- neutrophilia and lesion volume we detected may be an
tients.16,18 This study is distinct in that DWI MRI was used to epiphenomenon. Large infarcts may provoke a greater stress
determine volumes of ischemic tissue early after onset. DWI and inflammatory response as a secondary reaction to the
MRI demarcates brain tissue in which there has been a failure initial brain injury.
of cellular energy-dependent processes attributable to cere- This study has some limitations. This is a cross-sectional
bral hypoperfusion and predicts final infarct volume well, study, and the cause and effect relationship between total
albeit imperfectly.19,20 Our finding that total leukocyte and leukocyte and neutrophil quartiles and DWI lesion volume
neutrophil counts are associated with DWI lesion volumes cannot be determined. Serial measures of leukocytes and
suggests this inflammatory response occurs early, before the lesion volume during the first hours after stroke onset could
development of large volumes of infarcted or necrotic tissue. potentially better illuminate the potential role of inflamma-
Several mechanisms may contribute to the association tory cells in the propagation of ischemic injury, but are
between leukocyte count and DWI lesion volume. Athero- logistically challenging to accomplish. To control for premor-
sclerosis is increasingly being viewed as a chronic inflamma- bid infection we used body temperature. Systemic infection
tory disease,21 and one possibility is that an elevation in may occur without elevations in body temperature, and future
leukocyte count predates the stroke onset and reflects the studies should include additional biomarkers of inflammation
burden of atherosclerotic disease. Leukocytosis has been such as high sensitivity CRP. Initial DWI lesion volume was
associated with degree of atherosclerosis,22,23 is a risk factor
analyzed, not final T2-weighted lesion volume, as late T2
for cardiovascular events and stroke,24,25 is related to stroke
studies were not obtained routinely in these patients. How-
subtype,24 and consequently may affect DWI lesion volumes.
ever, multiple studies have demonstrated that early DWI lesion
Furthermore, there is evidence leukocytosis may be associ-
volumes correlate well with final T2 lesion volumes.31,32
ated with plaque destabilization and the induction of acute
In conclusion, in acute ischemic stroke early elevation of
thrombotic events.26,27 This study provides some support for
total leukocyte count and neutrophil count is associated with
an interplay of these mechanisms. We found a greater
larger volume of early ischemic tissue. Part of this effect is
proportion of patients with small vessel occlusion in the
attributable to an association of small vessel stroke mecha-
lowest (versus highest) total leukocyte quartiles, whereas the
nism with low leukocyte count, but even after adjustment for
upper 3 quartiles trended toward larger proportions of pa-
this and other factors, the association of inflammatory cells
tients with cardioembolic and large vessel atherosclerotic
and early lesion volume remains robust. To date, clinical
mechanisms. This finding accords with a population-based
trials of agents that modulate inflammation in acute stroke
study that found that stroke-free individuals with the highest
have been disappointing.33,34 Determining whether suppress-
quartile of leukocyte count have an overall increased risk of
ing the response of neutrophils can help reduce the propaga-
stroke compared with the lowest quartile, and the risk is more
tion of ischemic damage should continue to be an important
pronounced for atherosclerotic and cardioembolic subtypes.24
goal of future investigations.
However, because monocyte-macrophages and lymphocytes
are the major immune cells implicated in atherosclerotic
lesions,28 our finding that elevated neutrophils were corre- Sources of Funding
This work was supported in part by Heart and Stroke Foundation of
lated with larger DWI volumes cannot fully be explained by Canada fellowship award (to B.H.B.) and NIH/NINDS P50
an association with premorbid atherosclerotic burden. NS044378 (to J.L.S.).
Another possibility is that increased admission leukocyte
counts reflect the presence of premorbid infection. After Disclosures
infection the incidence of stroke exceeds the general age- None.
360 Stroke February 2008
References 17. Suzuki S, Kelley RE, Reyes-Iglesias Y, Alfonso VM, Dietrich WD.
1. Nilupul Perera M, Ma HK, Arakawa S, Howells DW, Markus R, Rowe CC, Cerebrospinal fluid and peripheral white blood cell response to acute
Donnan GA. Inflammation following stroke. J Clin Neurosci. 2006;13:18. cerebral ischemia. South Med J. 1995;88:819 824.
2. Audebert HJ, Rott MM, Eck T, Haberl RL. Systemic inflammatory 18. Montaner J, Rovira A, Molina CA, Arenillas JF, Ribo M, Chacon P,
response depends on initial stroke severity but is attenuated by successful Monasterio J, Alvarez-Sabin J. Plasmatic level of neuroinflammatory
thrombolysis. Stroke. 2004;35:2128 2133. markers predict the extent of diffusion-weighted image lesions in
3. Christensen H, Boysen G. C-reactive protein and white blood cell count hyperacute stroke. J Cereb Blood Flow Metab. 2003;23:14031407.
increases in the first 24 hours after acute stroke. Cerebrovasc Dis. 2004; 19. Kidwell CS, Alger JR, Saver JL. Beyond mismatch: Evolving paradigms
18:214 219. in imaging the ischemic penumbra with multimodal magnetic resonance
4. Pozzilli C, Lenzi GL, Argentino C, Bozzao L, Rasura M, Giubilei F, imaging. Stroke. 2003;34:2729 2735.
Fieschi C. Peripheral white blood cell count in cerebral ischemic 20. Kidwell CS, Saver JL, Starkman S, Duckwiler G, Jahan R, Vespa P,
infarction. Acta Neurol Scand. 1985;71:396 400. Villablanca JP, Liebeskind DS, Gobin YP, Vinuela F, Alger JR. Late
5. Wang Q, Tang XN, Yenari MA. The inflammatory response in stroke. secondary ischemic injury in patients receiving intraarterial thrombolysis.
J Neuroimmunol. 2007;184:53 68. Ann Neurol. 2002;52:698 703.
6. Tang Y, Xu H, Du X, Lit L, Walker W, Lu A, Ran R, Gregg JP, Reilly 21. Ross R. Atherosclerosisan inflammatory disease. N Engl J Med. 1999;
M, Pancioli A, Khoury JC, Sauerbeck LR, Carrozzella JA, Spilker J, 340:115126.
Clark J, Wagner KR, Jauch EC, Chang DJ, Verro P, Broderick JP, Sharp 22. Elkind MS, Cheng J, Boden-Albala B, Paik MC, Sacco RL. Elevated
FR. Gene expression in blood changes rapidly in neutrophils and white blood cell count and carotid plaque thickness: The northern man-
monocytes after ischemic stroke in humans: A microarray study. J Cereb hattan stroke study. Stroke. 2001;32:842 849.
Blood Flow Metab. 2006;26:1089 1102. 23. Loimaala A, Rontu R, Vuori I, Mercuri M, Lehtimaki T, Nenonen A,
7. Yamagami S, Tamura M, Hayashi M, Endo N, Tanabe H, Katsuura Y, Bond MG. Blood leukocyte count is a risk factor for intima-media
Komoriya K. Differential production of mcp-1 and cytokine-induced thickening and subclinical carotid atherosclerosis in middle-aged men.
neutrophil chemoattractant in the ischemic brain after transient focal Atherosclerosis. 2006;188:363369.
Downloaded from http://stroke.ahajournals.org/ by guest on April 28, 2017
ischemia in rats. J Leukoc Biol. 1999;65:744 749. 24. Elkind MSV, Sciacca RR, Boden-Albala B, Rundek T, Paik MC, Sacco
8. Akopov SE, Simonian NA, Grigorian GS. Dynamics of poly- RL. Relative elevation in baseline leukocyte count predicts first cerebral
morphonuclear leukocyte accumulation in acute cerebral infarction and infarction. Neurology. 2005;64:21212125.
their correlation with brain tissue damage. Stroke. 1996;27:1739 1743. 25. Madjid M, Awan I, Willerson JT, Casscells SW. Leukocyte count and
9. Jiang N, Moyle M, Soule HR, Rote WE, Chopp M. Neutrophil inhibitory coronary heart disease: Implications for risk assessment. J Am Coll
factor is neuroprotective after focal ischemia in rats. Ann Neurol. 1995; Cardiol. 2004;44:19451956.
38:935942. 26. Elkind MS. Inflammation, atherosclerosis, and stroke. Neurologist. 2006;
10. Liebeskind, Kidwell. Advanced MR imaging of acute stroke: The Uni- 12:140 148.
versity of California at Los Angeles endovascular therapy experience.
27. Stoll G, Bendszus M. Inflammation and atherosclerosis: Novel insights
Neuroimaging Clin N Am. 2005;15:455 466.
into plaque formation and destabilization. Stroke. 2006;37:19231932.
11. Koenker R, Hallock K. Quantile regression. J Econ Perspect. 2001;15:
28. Libby P, Ridker PM, Maseri A. Inflammation and atherosclerosis.
143156.
Circulation. 2002;105:11351143.
12. Frankel MR, Morgenstern LB, Kwiatkowski T, Lu M, Tilley BC,
29. Zeller JA, Lenz A, Eschenfelder CC, Zunker P, Deuschl G. Platelet-
Broderick JP, Libman R, Levine SR, Brott T. Predicting prognosis
leukocyte interaction and platelet activation in acute stroke with and
after stroke: A placebo group analysis from the National Institute of
Neurological Disorders and Stroke rt-PA Stroke trial. Neurology. without preceding infection. Arterioscler Thromb Vasc Biol. 2005;25:
2000;55:952959. 1519 1523.
13. Shook SJ, Gupta R, Vora NA, Tievsky AL, Katzan I, Krieger DW. Statin 30. Becker KJ. Targeting the central nervous system inflammatory response
use is independently associated with smaller infarct volume in nonlacunar in ischemic stroke. Curr Opin Neurol. 2001;14:349 353.
MCA territory stroke. J Neuroimaging. 2006;16:341346. 31. Schaefer PW, Hunter GJ, He J, Hamberg LM, Sorensen AG, Schwamm
14. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, LH, Koroshetz WJ, Gonzalez RG. Predicting cerebral ischemic infarct
Marsh EED. Classification of subtype of acute ischemic stroke. Defi- volume with diffusion and perfusion MR imaging. Am J Neuroradiol.
nitions for use in a multicenter clinical trial. Toast. Trial of org 10172 in 2002;23:17851794.
acute stroke treatment. Stroke. 1993;24:35 41. 32. Albers GW. Diffusion-weighted MRI for evaluation of acute stroke.
15. Smith CJ, Emsley HC, Gavin CM, Georgiou RF, Vail A, Barberan EM, Neurology. 1998;51:S47 49.
del Zoppo GJ, Hallenbeck JM, Rothwell NJ, Hopkins SJ, Tyrrell PJ. Peak 33. Krams M, Lees KR, Hacke W, Grieve AP, Orgogozo J-M, Ford GA.
plasma interleukin-6 and other peripheral markers of inflammation in the Acute stroke therapy by inhibition of neutrophils (ASTIN): An adaptive
first week of ischaemic stroke correlate with brain infarct volume, stroke dose-response study of UK-279,276 in acute ischemic stroke. Stroke.
severity and long-term outcome. BMC Neurol. 2004;4:2. 2003;34:25432548.
16. Winbeck K, Poppert H, Etgen T, Conrad B, Sander D. Prognostic rel- 34. Ovbiagele B, Kidwell CS, Starkman S, Saver JL. Neuroprotective agents
evance of early serial C-reactive protein measurements after first ische- for the treatment of acute ischemic stroke. Curr Neurol Neurosci Rep.
mic stroke. Stroke. 2002;33:2459 2464. 2003;3:9 20.
Early Neutrophilia Is Associated With Volume of Ischemic Tissue in Acute Stroke
Brian H. Buck, David S. Liebeskind, Jeffrey L. Saver, Oh Young Bang, Susan W. Yun, Sidney
Starkman, Latisha K. Ali, Doojin Kim, J. Pablo Villablanca, Noriko Salamon, Tannaz Razinia
and Bruce Ovbiagele
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