Intracranial Reserve in Ischemic Stroke: Is the Skull Half-Full or Half-Empty?
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LETTERS TO THE EDITOR
Intracranial Reserve in Ischemic Stroke: Is the Skull Half‑Full or Half‑Empty? William K. Diprose1* , James P. Diprose2, Michael T. M. Wang3 and P. Alan Barber1,3 © 2020 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
We read with interest the article “Quantitative serial CT imaging-derived features improve prediction of malignant cerebral edema after ischemic stroke” by Foroushani et al. [1]. The authors report that greater intracranial reserve is associated with reduced risk of malignant cerebral edema, as “it likely captures the space available to compensate for swelling and those with more reserve are able to tolerate larger strokes with more edema before deterioration” [1]. This suggests that greater intracranial reserve is a favorable biomarker in patients with large ischemic strokes; however, we would like to highlight that the opposite is true with regard to long-term functional outcome. Greater intracranial reserve is synonymous with more severe cerebral atrophy. So, as the authors point out, cerebral atrophy may protect from developing malignant cerebral edema in the early phase of ischemic stroke. However, cerebral atrophy also leads to a diminished capacity for recovery following ischemic insults and has been repeatedly shown to be a poor prognostic marker in patients undergoing endovascular thrombectomy for severe strokes [2–4]. Therefore, the interpretation of this biomarker depends considerably on the specific outcome one is trying to predict—early complications or longterm functional outcome? The skull is either half-full, or half-empty, depending on how you look at it.
*Correspondence: [email protected] 1 Department of Neurology, Auckland City Hospital, Level 8, Support Building, 2 Park Road, Grafton, Auckland 1023, New Zealand Full list of author information is available at the end of the article This comment refers to the article available at https://doi.org/10.1007/ s12028-020-01105-z, https://doi.org/10.1007/s12028-020-01056-5.
Author details 1 Department of Neurology, Auckland City Hospital, Level 8, Support Building, 2 Park Road, Grafton, Auckland 1023, New Zealand. 2 Independent Researcher, Auckland, New Zealand. 3 Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand. Funding None. Conflict of interest The authors declare that they have no conflict of interest.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Received: 6 August 2020 Accepted: 2 September 2020
References 1. Foroushani HM, Hamzehloo A, Kumar A, Chen Y, Heitsch L, Slowik A, et al. Quantitative serial CT imaging-derived features improve prediction of malignant cerebral edema after ischemic stroke. Neurocrit Care. 2020. https://doi.org/10.1007/s12028-020-01056-5. 2. Diprose WK, Diprose JP, Wang MTM, Tarr GP, McFetridge A, Barber PA. Automated measurement of cerebral atrophy and outcome in endovascular
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