BackgroundEarly detection and treatment of neuropathy in leprosy is important to prevent disabilities. A recent study showed that the Nerve Conduction Studies (NCS) and Warm Detection Thresholds (WDT) tests can detect leprosy neuropathy the earliest. These two tests are not practical under field conditions, however, because they require climate-controlled rooms and highly trained staff and are expensive. We assessed the usefulness of alternative test methods and their sensitivity and specificity to detect neuropathy at an early stage.MethodsThrough a literature search we identified five alternative devices that appeared user-friendly, more affordable, portable and/or battery-operated: the Neuropad®, Vibratip™, NC-Stat®DPNCheck™, NeuroQuick and the Thermal Sensibility Tester (TST), assessing respectively sweat function, vibration sensation, nerve conduction, cold sensation and warm sensation. In leprosy patients in Bangladesh, the posterior tibial and sural nerves that tested normal for the monofilament test and voluntary muscle test were assessed with the NCS and WDT as reference standard tests. The alternative devices were then tested on 94 nerves with abnormal WDT and/or NCS results and on 94 unaffected nerves. Sensitivity and specificity were the main outcomes.ResultsThe NeuroQuick and the TST showed very good sensitivity and specificity. On the sural nerve, the NeuroQuick had both a sensitivity and a specificity of 86%. The TST had a sensitivity of 83% and a specificity of 82%. Both the NC-Stat®DPNCheck™ and Vibratip™ had a high specificity (88% and 100%), but a low sensitivity (16% and 0%). On the posterior tibial nerve, the NeuroQuick and the TST also showed good sensitivity, but the sensitivity was lower than for the sural nerve. The Neuropad® had a sensitivity of 56% and a specificity of 61%.ConclusionsThe NeuroQuick and TST are good candidates for further field-testing for reliability and reproducibility. The feasibility of production on a larger scale should be examined.Electronic supplementary materialThe online version of this article (doi:10.1186/s40249-017-0330-2) contains supplementary material, which is available to authorized users.

To the Editor:We read with great interest the article published by Broocks et al 1 titled "Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake," which was recently published in Neurosurgery. The authors conducted a study in which they found that quantitative measurements of net water uptake (NWU) based on computed tomography (CT) are an important marker for the early prediction of malignant cerebral edema (MCE) in patients who suffered a posterior circulation infarction (POCI). During their analysis, they obtained a high predictive value with an area under the curve of 0.94, a sensitivity of 94.3%, and a specificity of 82.6%, concluding that this parameter could help to identify patients at risk of presenting with MCE earlier and thus to have strict control with more timely and precise therapeutic measures. We appreciate the attempt of Broocks et al 1 to find new diagnostic and predictive methods for the management of MCE in patients with POCI.Although POCI is rare (about 3% of all ischemic accidents), 2 MCE is a relatively frequent complication within this subgroup, with an incidence ranging from 10% to 54%. 3,4 For the management of this condition, decompressive craniectomy is the intervention of choice in those institutions that do not count on modern equipment, 5 and, therefore, the only available solution is a highly invasive intervention. For this reason, it is imperative to seek diagnostic tools for the timely prediction of this complication, which will facilitate its management and allow an increase in the survival of those affected. This is especially true in regions in which the health system lacks resources for the care, diagnosis, timely, and effective treatment of these pathologies, such as developing countries, where specialized stroke care units are scarce or nonexistent. Besides, this type of study supports the need to invest in infrastructure in the health area too, because of the benefits granted by having specialized units in the management of conditions that carry a high burden of morbidity and mortality, and that helps to carry out quality research.Since the arrival of the patient at the health institution, data such as the time elapsed since the beginning of the injury and high scores on the scale of strokes, and even a high hypodensity that occupies more than two-thirds of the territory of the involved artery in a CT, 4,6 are variables used for the prediction of MCE in patients with infarction of other brain zones, which could be applied and studied in patients with POCI, to evaluate whether these variables impact on the final results of a stroke, regardless of the established therapy.Another very interesting tool for the early prediction of MCE is the whole-brain CT perfusion (WB-CTP). Fabritius et al 2 in the

Background: Haematoma volume is a strong predictor of morbidity and mortality in a spontaneous intracerebral hematoma. Timing of surgery, amount of clot removal, GCS on admission, pupillary abnormality and amount of bone removal of such cases are strong variables. A large amount of blood is causing impending herniation which is life-threatening and should be addressed immediately to reverse the situation. Objective:The main goal of this study is to assess the predictive analysis in decompressive craniotomy for haemorrhagic stroke.Method: A total of 72 cases were included in this study. This retrospective study was conducted in three private hospitals from 2009 to 2018. Male: Female was 3:2. Surgical outcome predictors were analyzed by using different variables-the timing of surgery, amount of clot removal, GCS on admission, pupillary abnormality, age of the patients and amount of bone removal.Results: 8 patients died, 2 patients were in a vegetative state, 1 patient developed osteomyelitis in a bone flap and 1 had CSF leak and meningitis. Conclusion:Decompressive craniotomy for large intracerebral hematoma is lifesaving. Among the variables-the timing of surgery and the amount of bone removal are strong predictors of the outcome of the surgery. AbbreviationsOne can differentiate between two clinical settings that could be known as DC. For patients with elevated intracranial pressure due to brain swelling due to traumatic brain injury, cerebral infarction, subarachnoid haemorrhage (SAH), intracerebral hemorrhage (ICH) and for other purposes, decompressive craniectomy (DC) is often performed as a potentially life-saving procedure. The wi-

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