Objective To investigate the predictive value of preoperative neutrophil-to-lymphocyte ratio (NLR) for anterior circulation thrombectomy in elderly patients with wake-up stroke and its clinical significance for prognostic assessment.

Methods The clinical data of 115 elderly patients with wake-up stroke who underwent anterior circulation thrombectomy at the 7th Affiliated Hospital of Guangxi Medical University were retrospectively analyzed. The dependent variable was the 90-day Modified Rankin Scale (mRS) score, with good outcome defined as mRS score 0–2 and poor outcome defined as mRS score 3–5. Univariate and multivariate logistic regression analyses were conducted to analyze the associated factors. Additionally, the receiver operating characteristic (ROC) curve was employed to assess the predictive value of NLR in stroke thrombectomy.

Results In univariate analysis, preoperative NLR, age, baseline National Institutes of Health Stroke Scale (NIHSS) score, infarct volume and DSA-collateral circulation compensation were statistically significant differences (P ＜ 0.05). Multivariate logistic regression analysis showed that preoperative NLR and infarct volume were associated with poor outcomes after thrombectomy (P ＜ 0.05). The Youden index analysis showed that the cut-off values of NLR and infarct volume were 3.115 and 41.210 mL, respectively. The area under curve (AUC) of NLR and infarct volume were 0.653 (95%CI: 0.553–0.745, P ＜ 0.05) and 0.800 (95%CI: 0.553–0.745, P ＜ 0.05), respectively. The AUC of the combination of the two was 0.827 (95%CI: 0.748–0.907, P ＜ 0.01), the sensitivity was 83.0%, and the specificity was 75.0%.

Conclusion The combined application of preoperative NLR and infarct volume can accurately predict the adverse outcomes caused by pre-stroke thrombectomy in the elderly after awakening, which has important clinical value.