WSC 2026 | Redefining the cerebral ischemic core-penumbra-oligemia continuum

Yeah, so essentially we’ve lived in a model of oligemia penumbra core or core penumbra oligemia for many years, which I think has practical advantages. It’s simple. Many of the maps that are created provide us with a penumbra volume and a core volume. And I think that’s worked quite well for lots of the decision-making in the field. The interesting thing is that as we have evolved CT perfusion, we’re really now able to truly quantify various degrees of perfusion abnormality and have the ability to potentially refine this. And so my goal of this with my colleague, Dr Umberto Pensato, who was the first author of this publication, was to challenge our stroke community to think more broadly about this issue because I do feel there are nuances that could impact patient management decisions ultimately. Yeah, so as it turns out, if you look at the core compartment, so the so-called core volume compartment, there’s quite a range of blood flow reductions. And there’s been important experiments over the years demonstrating that when you approach virtually zero flow or near zero flow, the risk of a rapid blood-brain barrier disruption is very high, especially with reperfusion. So in a large ischemic core, many patients do quite well. In fact, we have good evidence that EVT is beneficial in large core but there is a subpopulation of these patients where the blood flow is extremely low and the risk of blood-brain barrier disruption is much higher even fairly early and that’s the group that we need to explore more I really want to challenge the field to look at this so-called leaky core compartment, very low flow, and test it in the large core population to see if this is a group where you develop the negative consequences of malignant edema and hemorrhagic transformation that can negatively impact patients. We’ve proposed a broader thinking here around six compartments. I think the science now needs to explore this more and see if we can assign specific quantitative thresholds for each of these regions. I think we can do it, but it would require large data sets and multiple groups to begin to explore this. I’m most fascinated to then apply that to particular clinical situations where we may change our management as a result of this. But first, we need to zero in and define these specific thresholds. And they probably will vary over time from onset. It may be different at one hour than at six hours.

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