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Original research
Penumbra salvage in extensive stroke: exploring limits for reperfusion therapy
  1. Gabriel Broocks1,
  2. Lukas Meyer1,
  3. Matthias Bechstein1,
  4. Sarah Elsayed1,
  5. Gerhard Schön2,
  6. Helge Kniep1,
  7. Andre Kemmling3,
  8. Uta Hanning1,
  9. Jens Fiehler1,
  10. Rosalie V McDonough1,4
  1. 1Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  2. 2Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  3. 3Department of Neuroradiology, UKGM, Marburg, Germany
  4. 4Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Gabriel Broocks, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; g.broocks{at}


Background The effect of thrombectomy in patients presenting with extensive ischemic stroke at baseline is currently being investigated; it remains uncertain to what extent brain tissue may be saved by reperfusion in such patients. Penumbra salvage volume (PSV) has been described as a tool to measure the volume of rescued penumbra.

Objective To assess whether the effect of recanalization on PSV is dependent on the extent of early ischemic changes.

Methods Observational study of patients with anterior circulation ischemic stroke triaged by multimodal-CT undergoing thrombectomy. PSV was defined as the difference between baseline penumbra volume and net infarct growth to follow-up. The effect of vessel recanalization on PSV depending on the extent of early ischemic changes (defined using Alberta Stroke Program Early CT Score (ASPECTS) and core volumes based on relative cerebral blood flow) was determined using multivariable linear regression analysis, and the association with functional outcome at day 90 was tested using multivariable logistic regression.

Results 384 patients were included, of whom 292 (76%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction ≥2b). Successful recanalization was independently associated with 59 mL PSV (95% CI 29.8 to 88.8 mL) and was linked to increased penumbra salvage up to an ASPECTS of 3 and core volume up to 110 mL. Recanalization was associated with a higher probability of a modified Rankin Scale score of ≤2 up to a core volume of 100 mL.

Conclusions Recanalization was associated with significant penumbra salvage up to a lower ASPECTS margin of 3 and upper core volume margin of 110 mL. The clinical benefit of recanalization for patients with very large ischemic regions of >100 mL or ASPECTS <3 remains uncertain and requires prospective investigation.

  • Stroke
  • Thrombectomy
  • CT perfusion

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors GB, LM, AK, UH, JF, RVM contributed to the conception and design of the study. GB, SE, MB, HK, AK, UH, JF, RVM contributed to the acquisition and analysis of data. GB, MB, GS, AK, JF, RVM contributed to drafting a significant portion of the manuscript. GB is the author acting as guarantor of this study.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests Authors received research support from: JF: German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions- und Förderbank (IFB). AK: research collaboration agreement: Siemens Healthcare (company involved in CT/MRI distribution). All other authors reported no relationships with commercial firms whose products could be affected by the present study.

  • Provenance and peer review Not commissioned; externally peer reviewed.