HACE is usually taught as a dramatic neurological emergency:

ataxia, confusion, hallucinations, coma.

But those are late manifestations.

The breakdown begins much earlier:

reduced oxygen delivery,

mitochondrial redox failure,

declining ATP production,

blood-brain barrier dysfunction,

and progressive loss of insight.

That is why climbers with evolving HACE often still believe they are functioning normally.

In neuro ICUs, edema is treated by restoring oxygen delivery, controlling perfusion, reducing intracranial pressure, and correcting physiology upstream. Dexamethasone is not routinely used for most cerebral edema states because steroids do not restore oxidative phosphorylation, ATP production, mitochondrial function, or oxygen delivery.

At altitude, oxygen is the primary drug.

Everything else is downstream.

The most dangerous mistake on the mountain is waiting for obvious symptoms before acting.

If your team sees it before you do, believe them.

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