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The correspondence praises the clinical significance and the use of quantitative imaging and ROC analysis, while questioning validity due to only four CHS events and a small retrospective cohort. It highlights selection bias over 2011–2024, limited hemodynamic evaluation, and constrained CHS case definitions, urging larger prospective validation combining anatomical, hemodynamic, and clinical 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artery diameter asa predictor of cerebral hyperperfusion syndrome following revascularization surgery”  \nAsra Amjad, MBBSa , Tooba Khurshid, MBBSb , Raghabendra Kumar Mahato, MBBSc ,*, Umair Ali, Pharm Dd  \nTo the Editor,  \nSince cerebral hyperperfusion syndrome (CHS) is still a feared but poorly understood consequence, we applaud the authors for tackling this understudied but clinically significant concern in carotid surgery outcomes. The recent paper by M. Anan et al, which used real-world data to assess preoperative cervical internal carotid artery (ICA) diameter as a predictor of CHS after revascularization surgery, caught our attention. Their investigation, which was based on quantitative imaging, revealed an invisible correlation between postoperative CHS and the larger cervical ICA diameter and higher stenosis ratio. Furthermore, the receiver operating characteristic (ROC) analysis indicated great diagnostic accuracy, which offers useful information for formulating hypotheses. Additionally, enrolling patients for both carotid endarterectomy (CEA) and stenting maximizes the clinical validity of the outcomes by simulating real-world heterogeneity[1] . Although this contribution highlights a useful and quantifiable anatomical characteristic, its pathophysiological significance needs to be viewed within the larger clinical framework. The uncommon condition known as CHS typically develops as a side effect following carotid surgery. It is unclear exactly what causes CHS, although it appears to be linked to increased regional cerebral blood flow as a result of a loss of cerebrovascular autoregulation. Clinical symptoms of CHS include focal neurologic abnormalities, seizures, severe unilateral headaches, and the most severe type of intracerebral  \na Islamic International Medical College, Riphah International University, Rawalpindi, Pakistan, bDepartment of Medicine, Karachi Medical and Dental College, Karachi, Pakistan, cDepartment of Medicine, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal and dDepartment of Pharmacy, University of Swabi, Swabi, Pakistan  \nSponsorships or competing interests that may be relevant to content are disclosed at the end of this article.  \n*Corresponding author. Address: Department of Medicine, Gandaki Medical College Teaching Hospital and Research Center, Pokhara 33700, Nepal. Tel.: +[977-9745829807. E-mail:102raghabendrakumarmahato@gmail.com](977-9745829807. E-mail:102raghabendrakumarmahato@gmail.com)[ ](977-9745829807. E-mail:102raghabendrakumarmahato@gmail.com)(R. K. Mahato).  \nCopyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.  \nAnnals of Medicine & Surgery (2026) 88:1146–1147  \nReceived 22 November 2025; Accepted 30 November 2025  \nPublished online 12 December 2025  \n[http://dx.doi.org/10.1097/MS9.0000000000004566](http://dx.doi.org/10.1097/MS9.0000000000004566)  \nhemorrhage[2] . Therefore, even if the physical relationship is evident, the complex and dynamic nature of CHS development cannot be well captured by it. Nevertheless, a number of restrictions weaken the conclusions’ validity. Because there were only four CHS instances (5.1%) and a small sample size (n = 78) in this retrospective investigation, the ROC analysis (area under the curve ≈ 0.97) is more susceptible to instability andoverfitting[1] . Because it is a retrospective study, selection bias is a possibility. Patients receiving both CEA and CAS were included over an extended period of time (2011–2024), during which time perioperative care, imaging modalit","cbCaislZMqhtm9iP","https://ap.wps.com/l/cbCaislZMqhtm9iP","pdf",166104,"English","# Letter to the Editor\n## Praise for clinical significance and imaging-based analysis\n## Concerns about sample size, selection bias, and ROC stability\n## Missing hemodynamic factors and limitations of CHS case definition\n## Conclusion and need for prospective validation","[{\"question\":\"What question does the letter evaluate about the original research?\",\"answer\":\"It evaluates whether preoperative cervical internal carotid artery (ICA) diameter can act as a predictor for cerebral hyperperfusion syndrome (CHS) after revascularization surgery.\"},{\"question\":\"Which aspects of the study does the letter commend?\",\"answer\":\"The letter applauds tackling an understudied clinical issue and highlights the use of quantitative imaging, reported correlation patterns, and ROC analysis providing diagnostic accuracy information.\"},{\"question\":\"What main limitations does the letter raise?\",\"answer\":\"It cites very few CHS cases, small retrospective sample size, possible selection bias across 2011–2024, lack of evaluation of key hemodynamic parameters, and variability/constraints in CHS outcome definition.\"}]","Critical appraisal of “Evaluation of preoperative cervical internal carotid artery diameter asa predictor of cerebral hyperperfusion syndrome following revascularization surgery” - Letter to the Editor - Critical appraisal | PDF",1790673746]