Acta Medica Mediterranea, 2016, 32: 97

THE PROGNOSTIC RELATIONSHIP BETWEEN COMPLETE BLOOD COUNT PARAMETERS AND

INFARCT-POSITIVE TRANSIENT ISCHEMIC ATTACK, INFARCT-NEGATIVE TRANSIENT ISCHEMIC
ATTACK, AND ISCHEMIC STROKE

ISHAK SAN1, FERHAT ICME2, YÜCEL YUZBASIOGLU2, YAVUZ OTAL2, SELÇUK COSKUN2, ALP SENER2, AHMET FATIH KAHRAMAN4,
ERKUT EROL3
1
Golbasi Hasvak State Hospital, Department of Emergency Medicine, Ankara - 2Atatürk Education and Research Hospital,
Department of Emergency Medicine, Ankara - 3Elaziğ Education and Research Hospital, Department of Emergency Medicine,
Elaziğ - 4Bozok University, Fakulty of Medicine, Department of Emergency Medicine, Zonguldak, Turkey

ABSTRACT

Introduction: Stroke is an important health problem that may lead to serious disabilities or even to death. In the present study
we aimed to investigate whether complete blood count parameters can aid in the detection and the differential diagnosis of infarct-
positive Transient Ischemic Attack (TIA), infarct-negative TIA, and ischemic stroke (IS) in patient followed up in the emergency depart-
ment.
Materials and methods: This study retrospectively reviewed the medical records of 252 patients meeting the medical history and
physical examination criteria for TIA (n=99) and IS (n=153) Neutrophil, lymphocyte, and platelet counts, platelet distribution width
(PDW), and mean platelet volume (MPV) levels obtained from the complete blood count taken at the time of emergency department
admission were recorded for both patient and control groups; platelet/lymphocyte ratio (PLR) and neutrophil/lymphocyte ratio (NLR)
were calculated from these parameters. The ischemic stroke, TIA, and control groups, as well as other subgroups were compared with
one another with respect to the complete blood count parameters.
Results: Neutrophil count, MPV, and NLR levels were higher in the IS group compared to the control group whereas IS group
had a lower lymphocyte count, platelet count, and a PDW level compared to the control group. TIA group had a higher neutrophil
count, NLR and PLR than the control group whereas lymphocyte count and PDW level were lower in the TIA group compared to the
control group. MPV level was higher in the IS and infarct-positive TIA patient group than both the control group and infarct-negative
TIA patient group.
Conclusion: Owing to high MPV levels in both infarct-positive TIA and IS, we suggest that MPV can be a good marker for
infarction. Furthermore, lower platelet count in the IS group and higher PLR in the TIA group can both be used in the differential dia-
gnosis of both conditions.

Key words: Cerebral infarction, transient ischemic attack, blood cell count parameters, diagnosis.
DOI:10.19193/0393-6384_2016_1_15

Received May 30, 2015; Accepted November 02, 2015

Introduction these patients and starting an appropriate treatment

Stroke is the third leading cause of death after
cardiovascular disorders and cancer while it ranks
first among disorders leading to disability world-
wide(1). transient ischemic attack (TIA) contributes
stroke incidence by carrying a stroke risk of 2-4%
during the first 48 hours, about 6% during the first
7 days, and 10-15% during the first 90 days(2,3,4). As
the incidence of the disorder is so high, it is vital to
make the diagnosis and differential diagnosis of
as rapid as possible to minimize stroke-related mor-
tality and morbidity. Although there currently exists
no test to make this distinction within a short time
period and with high accuracy, Leukocytes, neu-
trophil, platelet counts, platelet distribution width
(PDW), mean platelet volume (MPV), platelet/lym-
phocyte ratio (PLR) and neutrophil/lymphocyte
ratio (NLR) are believed to cause to inflammatory
tissue injury and/or to atherosclerotic complications
in acute stroke.
98
The debate, however, still continues on most
of these markers. This debate may also result from
more widespread utilization of modern brain imag-
ing techniques allowing accurate detection of cere-
bral infarction in a third of patients who are initially
thought to have TIA and who have a symptom
duration of less than 24 hours(5,6).
We aimed to investigate if some complete
blood count parameters would aid in the detection
and the differential diagnosis of infarct-positive
TIA, infarct-negative TIA, and ischemic stroke (IS)
in patient followed up in the emergency depart-
ment.
Materials and methods
After ethics committee approval, this study
retrospectively reviewed the medical records of 252
patients with the medical history and physical
examination, of which 99 met criteria for TIA and
153 met the criteria for IS suggested by the
American Heart Association (AHA) / American
Stroke Association (ASA) guidelines for stroke
(2014), who were admitted to Ankara Atatürk
Training and Research Hospital, Emergency
Department between 01/01/2013 and 31/01/2014
and underwent both brain tomography and brain
magnetic resonance imaging (MRI).
The study also included a control group con-
sisting of 60 healthy volunteers who had no sus-
pected stroke or transient ischemic attack, who did
not have any of the exclusion criteria, and who
gave consent for participating in the study.
The medical records were used to obtain and
record information about demographic properties
(age, sex) of the participants as well as neutrophil,
lymphocyte, and platelet count, PDW, and MPV in
the admission complete blood count test. The para-
meters obtained from complete blood count were
used to calculate PLR and NLR. The demographic
properties and complete blood count parameters
same as the patient group were also recorded for the
control group.
Patients diagnosed with TIA based on the
AHA/ASA guidelines for stroke (2014) were cate-
gorized into 2 groups as infarct-positive TIA and
infarct-negative TIA, depending whether there was
signs of cerebral infarction on MRI scans.
IS, TIA, control group, and other subgroups
were compared with one another with respect to the
aforementioned complete blood count parameters.
Blood samples of both the patient and control
Ishak San, Ferhat Icme et Al
groups were taken into ethylene daimine tetra acetic
acid (EDTA)-containing tubes and studied within 1
hour in a Roche Sysmex X-2100 branded device.
Exclusion criteria
• patients with stroke being intervened more
than 24 hours after the onset of stroke symptoms
• patients with stroke as a result of cerebral
infarction or bleeding secondary to trauma, tumor,
infection etc.
• patients with lacunar infarction, Water shed
infarction, venous infarction, or embolic infarction
on MRI
• all patients detected to have bleeding on
cerebral tomography or MRI
• patients with concomitant acute coronary
syndrome, pulmonary thromboembolism, acute
renal failure, or chronic renal failure
• patients with known thyroid disorders
• patients with known hematological disorders
• patients admitted to emergency department
in cardiopulmonary arrest
Statistical analysis
The normal distribution of the age and blood
parameters of the participants was tested with
Shapiro-Wilk test. Since the continuous variables
did not show normal distribution, they were pre-
sented as median (interquartile range-IQR); cate-
gorical variables such as the diagnostic groups were
presented as number and percentage.
Blood parameters were compared between the
patient and control groups with the Kruskal Wallis
test. A corrected p value was provided in paired
comparisons and the p values were shown in bold
in the statistically significant results.
The statistical analyses and calculations were
performed using IBM SPSS Statistics 21.0 (IBM
Corp. Released 2012. IBM SPSS Statistics for
Windows, Version 21.0. Armonk, NY: IBM Corp.)
software package. The statistical significance level
was set at p<0.05
Results
Of a total 312 subjects enrolled in the study,
157 (50.3%) were male and 155 (49.7%) were
female. There were no significant differences
between the groups with regard to sex distribution
(p ˃ 0.05). Of 312 subjects, 60 (19.2%) were in the
control group and 252 (80.8%) were in the patient
group (Table 1).
The prognostic relationship between complete blood count parameters and infarct-positive transient ischemic attack... 99

n (%)
The paired comparison of the control group
and TIA subgroups for the blood count parameters
Sex
revealed a significant difference only for the MPV
Male 157 (50.3) level between the infarct-positive and infarct-nega-
Female 155 (49.7) tive TIA subgroups (p=0.031, Table 3)
Control Group 60 (19.2)

Patient Group 252 (80.8)

IS Group 153 (60.7)

TIA Group 99 (39.3)

Infarct-positive 19 (19.2)

Infarct-negative 80 (80.8)

Table 1: Distribution according to sex and diagnosis of

individuals.
TIA:transient ischemic attack, IS: ischemic stroke

The mean age of the IS, TIA, and control

groups were 69.68, 64.49, and 70.25 years, respec-
tively. No significant difference was observed
between the control and patient groups with respect
to age (p ˃ 0.05).
The levels and the statistical comparisons of
the complete blood count parameters of the IS, TIA,
and control groups were shown in Table 2.

Table 3: Paired comparison of the TIA subgroups and

the control group with respect to blood parameters.
TIA:transient ischemic attack, MPV: mean platelet volume
PDW: platelet distribution width, NLR: neutrophil/lymphocyte
ratio, PLR: platelet/lymphocyte ratio

The comparison of the blood parameters of the

IS group with infarct-positive TIA and infarct-nega-
tive TIA groups revealed significant differences for
MPV levels (Table 4) whereas other parameters did
not significantly differ across the groups (p>0.05 ).

Table 2: Paired comparison of the patient and control

groups with respect to blood parameters. Table 4: Paired comparison of the IS group and the TIA
TIA:transient ischemic attack, IS: ischemic stroke, MPV: mean subgroups with respect to MPV.
platelet volume PDW: platelet distribution width, NLR: neu- TIA:transient ischemic attack, IS: ischemic stroke, MPV: mean
trophil/lymphocyte ratio, PLR: platelet/lymphocyte ratio platelet volume
100
Discussion
Although many contemporary studies have
shown a pathological thrombocyte activity in cere-
bral ischemic events, the relationship between the
diagnosis and prognosis of ischemic stroke and
thrombocyte count and MPV is still controver-
sial (7,8,9,10,11,12). Furthermore, there is an ongoing
debate whether increased MPV level is clinically
useful for the diagnosis of TIA and its differentia-
tion from IS(8,12,13).
Konstantopoulos et al. showed that thrombo-
cyte of patients with atherosclerotic stroke demon-
strated an enhanced aggregation compared to those
of healthy individuals(14). Another study valuing an
experimental model of median carotid arteria occlu-
sion showed that thrombocyte accumulation in the
ischemic zone may be a result of focal ischemia(15).
There is an ongoing debate about the impact of
increased MPV level on early diagnosis and prog-
nosis in both ischemic stroke and TIA.
Two studies by İçme et al. showed that MPV
may be beneficial for the diagnosis of ischemic
stroke whereas Maccaby et al. reported that MPV
had no diagnostic power(7,8). İçme et al. also report-
ed in another study that MPV had no diagnostic
utility in TIA, while Doğan et al. demonstrated that
MPV was diagnostic for TIA(8,13).
In our study, MPV was significantly higher in
the ischemic stroke group compared to both control
and TIA groups. Furthermore, the patients diag-
nosed with TIA and detected to have cerebral
infarction had significantly higher MPV levels than
the TIA group without infarction. These results sug-
gest that MPV may have a diagnostic utility in cere-
brovascular events directly related to infarction
such as ischemic stroke and infarct-positive TIA,
while it has no diagnostic ability in infarct-negative
TIA.
PDW refers to the distribution of the size of
platelets in circulating blood volume; together with
MPV, it is used to predict coagulation activity to a
better extent(16). Khan et al. found out that PDW
level was higher in patients suffering myocardial
infarction and unstable angina pectoris(17,18). In con-
trast, Ihara et al. reported that PDW was lower in
patients with angiographic coronary artery steno-
sis(19,20). İçme et al. found no significant alteration in
stroke, although we detected that PDW was signifi-
cantly lower in both stroke, TIA groups as well as
TIA subgroups(7,8). To our opinion, these contradic-
tory results likely suggest that further trials with
Ishak San, Ferhat Icme et Al
larger sample size are needed to explore the role of
PDW in this indication.
The acute phase response can emerge both
before ischemic stroke and after the development of
neurological deficit(21,22). Studies on animal models
have revealed that neutrophil invasion may play a
role in the progression of atherosclerotic plaque(23).
Neutrophils may facilitate plaque rupture by releas-
ing proteolytic enzymes, arachidonic acid deriva-
tives, and superoxide radicals(18). Therefore, a high
neutrophil count may indicate not only the severity
of the inflammatory milieu in patients with athero-
sclerosis, but also plaque instability. Furthermore,
high leukocyte and neutrophil counts have been
proposed to indicate the severity of clinical signs,
worse prognosis, mortality, and a larger infarct size
for acute ischemic stroke patients and patient with
TIA(8,24,25,26).
In a study comparing neutrophil count and
normal laboratory results of 1041 patients with TIA
and ischemic stroke, Ross et al. found a significant-
ly higher neutrophil count in TIA and ischemic
stroke groups(27). Another study emphasized that
neutrophil count may be diagnostic in TIA. There
are several studies implying that neutrophil and leu-
cocyte counts were neither diagnostic nor prognos-
tic(21). In our study both the ischemic stroke and TIA
groups had a significantly higher neutrophil count
compared to the control group.
Lymphocytes have a very important role in the
regulation of inflammatory response during various
stages of atherosclerotic process(28,29). A lower lym-
phocyte count has been associated to a poor prog-
nosis in acute MI and advanced stage heart fail-
ure(30,31). In addition, some studies have reported that
NLR is one of the strongest predictors of worse
prognosis in patients undergoing percutaneous
coronary intervention or coronary bypass
surgery(32,33). NLR has similarly been reported to
have a prognostic role in peripheral arterial dis-
ease (34) . A study on stroke reported that NLR
remained high within the first 24 hours after stroke
onset and it decreased by 7 days thereafter. In a
study by Gökhan et al., NLR was higher in TIA
compared to IS(35). We observed that lymphocyte
count was significantly lower in both stroke and
TIA and TIA subgroups compared to the control
group. NLR, on the other hand, was significantly
higher in all groups compared to the control group.
In addition to NLR, the PLR is regarded as
another marker of systemic inflammation(36). It has
been suggested to have a diagnostic value in partic-
The prognostic relationship between complete blood count parameters and infarct-positive transient ischemic attack...
ularly some cancer types including breast, pancreas,
and non-small cell lung cancer. While our study
demonstrated that PLR was higher in both the
stroke and TIA group than the control group, this
difference was only statistically significant in the
TIA group.
Conclusion
Complete blood count parameters have been
studied individually or collectively, and MPV has
been found as the most reliable marker among
them. We also suggest that MPV can be a good
marker of infarction as our study confirmed previ-
ous results in that it showed that MPV was higher
in both infarct-positive TIA and IS. Furthermore,
lower platelet count in IS and higher PLR in TIA
can be used for the differential diagnosis of both
conditions.
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