(Stroke. 1999;30:93-99.)
© 1999 American Heart Association, Inc.
Original Contributions |
Ischemic Core and Penumbra in Human Stroke
From the University of Calgary, Calgary, Alberta, Canada (A.M.K.), and the University of Pittsburgh, Pittsburgh, Pa (A.D.F., M.B.F., L.R.W., C.A.J., H.Y.).
Correspondence to Anthony M. Kaufmann, MD, MSc, FRCSC, Assistant Professor, Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, 12th Floor, Foothills Hospital, 1403 29th St NW, Calgary, Alberta, Canada T2N 2T9.
Background and Purpose—The ischemic core and penumbra have not been thoroughly characterized after acute cerebral thromboembolic occlusion in humans. Differentiation between areas of potentially viable and irreversibly injured ischemic tissue may facilitate assessment and treatment of stroke patients.
Methods—Cerebral blood flow (CBF) was measured in 20 patients
with acute middle cerebral artery (MCA) occlusion between 60 and 360
minutes after stroke onset, with the stable xenon computerized
tomography (CT) technique. Threshold displays were generated at a
single level, and the percentages of hemisphere with CBF 
6, 10, 11
to 20, 21 to 30, and >30 cm3 · 100
g-1 · min-1 were measured. The
corresponding images on 12 available follow-up CT scans were similarly
assessed to determine the area of final infarct. Comparisons were
analyzed with a paired Student's t test and
Pearson's correlation coefficient.
Results—Discrete and confluent areas of CBF 20
cm3 · 100 g-1 ·
min-1 were identified in all patients, ipsilateral to the
symptomatic MCA territory. The average area of CBF 20
cm3 · 100 g-1 ·
min-1 within the ipsilateral hemisphere was 66±17%
compared with 36±12% contralaterally (P<0.001). A
difference in the extent of low CBF was due primarily to areas with CBF
10 cm3 · 100 g-1 ·
min-1 (48±18% versus 16±7%, P<0.001).
The area of most severe ipsilateral ischemia (6
cm3 · 100 g-1 ·
min-1) best corresponded to the final area of infarction
(37±18% versus 40±24%; correlation coefficient, 0.866;
P<0.01). The acute ischemic core destined to
infarction was not surrounded by a widened rim of moderate
ischemia because the area with CBF 11 to 20
cm3 · 100 g-1 ·
min-1 was similar bilaterally (19±4% versus 20±7%,
P=0.792, thus not significant).
Conclusions—Our study in acute human stroke involving MCA
occlusion indicates that a severely ischemic core (CBF 6
cm3 · 100 g-1 ·
min-1), observed between 1 to 6 hours after stroke onset,
corresponds to the cerebral tissue destined to infarction. The
ischemic penumbra with flow values between 7 and 20
cm3 · 100 g-1 ·
min-1 surrounding the ischemic core is very
narrow. Therefore, strategies to improve the outcome of many patients
with acute MCA occlusion must either include interventions to reverse
the ischemic process within a few minutes of onset or increase
the cerebral tolerance of ischemia and thereby prolong the
potential therapeutic window.
Key Words: cerebral blood flow • cerebral infarction • cerebral ischemia • penumbra • tomography, emission computed
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