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Comments on ‘Computed Tomographic Parameters Predicting Fatal Outcome in Large Middle Cerebral Artery Infarction’

With great interest, we read the paper by Barber et al. [1] reporting cranial computed tomography parameters predicting fatal outcome in large middle cerebral artery infarction. In this retrospective multicenter study, midline shift (MLS) as depicted on cranial computed tomography scans has been identified as an outcome predictor in patients suffering from space-occupying middle cerebral artery infarction. In our own studies on this subject [2, 3], where we determined the lateral displacement of the third ventricle as a measure for MLS by means of transcranial sonography, we found an MLS 62.5, 3.5, 4.0 and 5.0 mm at 16, 24, 32 and 40 h after stroke onset predicting death due to cerebral herniation with a specificity and a positive predictive value of 1.0, respectively. These data provide evidence that the time point of MLS measurement is of utmost importance for a precise prediction of fatal outcome in this context, since vasogenic brain edema and the resulting space-occupying effect develops in a highly dynamic fashion within the first days after stroke onset. On the other hand, it is well known from brain tumors that large space occupation may be tolerated surprisingly well if the process develops slow enough. Barber et al. [1] reported a pineal shift 62 mm and an anteroseptal shift 65 mm on ‘CT scans within 48 h’ to be predictive for a fatal outcome (RR 2.32 and 2.84, respectively). However, this poorly defined time point of MLS measurement can lead to misdiagnoses, since an anteroseptal shift of 4 mm at 16 h, for example, would be predictive for a nonfatal outcome according to the criteria provided by Barber et al. [1]. With respect to surgical intervention, it is important to predict deterioration as early as possible before clinical signs of herniation occur. We were therefore surprised that the issue of timing has not been taken into account in this otherwise important work. We agree with the authors that MLS quantification should play an important role in the decision making for decompressive hemicraniectomy in malignant middle cerebral artery infarction.