Letter: Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake

Abstract

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

In Reply: Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake

“…We would like to thank the authors for sharing their valuable insights and thoughts about our work in their letter to the editor. 1,2 We agree with the authors about the significant clinical relevance of improving strategies for the identification of posterior circulation stroke (PCS) patients at risk for developing malignant cerebellar edema (MCE). The management of PCS is challenging, and clinical diagnosis often demanding because of unspecific symptoms.…”