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The ischemic penumbra: the location rather than the volume of recovery determines outcome
1aCRICM - Centre de Recherche de l'Institut du Cerveau et de la Moelle épinière, UPMC Paris 6 bInserm, U975, CNRS, UMR 7225 cCOGIMAGE, UPMC Paris 6 dAPHP, Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France.
Purpose Of Review:
The clinical efficiency of thrombolysis is explained by the rescue of ischemic penumbra areas resulting from early arterial recanalization. The perfusion-diffusion weighted imaging mismatch is a commonly used MRI surrogate of the ischemic penumbra. However, the randomized trials testing the mismatch hypothesis have been negative. We will review the 'mismatch concept' and the recent studies that aim to localize the clinically eloquent areas of penumbra in middle cerebral artery (MCA) infarcts.
Recent Findings:
New methods of image analysis have shown that poor outcomes after MCA stroke are related to infarction of an extremely well localized area of the periventricular white matter and adjacent internal capsule, where projections and association tracts are crossing and converging. This area almost colocalizes with the area salvaged by early arterial recanalization and is located extremely close to the initial ischemic core.
Summary:
The location of the area that correlates with disability in MCA stroke patients and that is salvaged by early arterial recanalization is in the same specific region of the deep white matter, close to the initial ischemic core. These findings may have important implications for designing new recanalization trials and support the importance of basic research on white-matter neuroprotection.
Insights
Recanalization in middle cerebral artery (MCA) stroke salvages deep white matter, not just the ischemic penumbra. This specific area, near the core, correlates with patient disability and outcomes.
Area of Science:
- Neuroimaging
- Stroke Neurology
- Cerebrovascular Disease
Background:
- Thrombolysis efficacy in stroke relies on salvaging ischemic penumbra.
- Perfusion-diffusion MRI mismatch is a common surrogate for ischemic penumbra.
- Randomized trials have yielded negative results for the mismatch hypothesis.
Purpose of the Study:
- Review the 'mismatch concept' in stroke.
- Identify clinically eloquent penumbra areas in middle cerebral artery (MCA) infarcts.
- Analyze recent studies on MCA stroke outcomes.
Main Methods:
- Review of recent studies on MCA stroke.
- Analysis of neuroimaging data correlating outcomes with infarct location.
- Localization of salvaged areas by early arterial recanalization.
Main Results:
- Poor outcomes in MCA stroke are linked to infarction in a specific periventricular white matter and internal capsule area.
- This critical area is close to the initial ischemic core.
- The salvaged area by recanalization closely matches this disability-correlated region.
Conclusions:
- The area correlating with disability and salvaged by recanalization in MCA stroke is a specific deep white matter region.
- Findings emphasize the importance of this deep white matter area in stroke outcomes.
- Implications for designing new recanalization trials and neuroprotection research are highlighted.
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