Non-HDL/HDL Cholesterol Ratio as a Protective Factor for Functional Recovery Following Intracerebral Hemorrhage: A Prospective Cohort Study

Purpose: Whether lipid profiles influence functional recovery after intracerebral hemorrhage (ICH) is unclear. This study investigated the association between the non-high-density lipoprotein to high-density lipoprotein cholesterol ratio (NHHR) and 90-day functional outcomes in patients with ICH. Patients and Methods: This single-center, prospective, observational cohort study enrolled 200 patients with acute ICH. Fasting blood samples were collected within 24 hours of admission for lipid profiling, and NHHR was calculated as (total cholesterol high-density lipoprotein cholesterol [HDL-C])/HDL-C. The primary outcome was functional status at 90 days, assessed using the modified Rankin Scale (mRS). Based on the mRS scores, patients were classified into two groups: favorable outcome (mRS ≤ 2, functional independence) and poor outcome (mRS > 2, functional dependence or death). Results: Of the 200 patients, 81 (40.5%) had poor outcomes at 90 days. The poor outcome group exhibited significantly lower baseline NHHR compared to the favorable outcome group (2.54 vs. 2.75, P = 0.002 ). After multivariable adjustment, a higher NHHR remained independently associated with reduced odds of poor outcome (adjusted odds ratio = 0.608; 95% confidence interval: 0.401– 0.921; P = 0.019 ). As a standalone predictor, NHHR exhibited high sensitivity (85.2%) but low specificity (39.5%) for predicting poor outcome, with an optimal cutoff of ≤ 3.185. Its discriminative ability was modest (area under the curve [AUC] = 0.590; 95% CI: 0.510– 0.670; P = 0.03 2). However, combining NHHR with the NIHSS score substantially improved prognostic performance (AUC = 0.863; 95% CI: 0.804– 0.923; P < 0.001), an effect that remained stable after internal validation (bootstrap-corrected AUC = 0.851; 95% CI: 0.789– 0.914). Conclusion: A higher baseline NHHR independently predicts favorable 90-day outcomes after ICH, supporting a “protective lipid paradox” distinct from ischemic stroke. As a simple and readily available biomarker, NHHR offers complementary prognostic information to established clinical scales and may aid early risk stratification.