W David Freeman, MD, FRSM, FNCS, FAAN

The 18th Annual Stroke & Cerebrovascular Disease Review is coming to The Ritz-Carlton Amelia Island this October 14-17.
This year’s curriculum map:
🧠 Large vessel occlusion dynamics — from MeVO/M2 to basilar
💊 ICH reversal timing — when the 4-hour clock matters
🔬 CREST-2 keynote — the investigators, in person @Demaerschalk @ThomasBrott
⚡ Status epilepticus /stroke mimics— beyond first-line, Rapid EEG
🫀 Occult AF detection & management
🏥 Prehospital stroke systems of care
🔄 Minimally invasive ICH surgery — ARCH trial update
🧬 Cerebral amyloid angiopathy — emerging therapeutics
🏥 Stroke Economics and Social Determinants of Health (SDOH)

Jointly accredited: CME / Pharmacy CE / Nursing CE. Built for the whole team — neurologists, neurosurgeons, APPs, nurses, pharmacists.
Registration details below. 👇🏽
Save the dates: October 14-17, 2026.
ce.mayo.edu/stroke2026
@tamrar1 @RabihTawkMD @wchrisfox
@ThienHuynh15
#StrokeAmeliaIsland #MayoCPD #Stroke #Neurology #CME #NeuroCriticalCare

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@SpaceX 🚀 🪼

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🧠 Beyond ischemia: Could a "mechanical penumbra" hold the key to saving brain tissue after intracerebral hemorrhage (ICH)?

While penumbral imaging revolutionized ischemic stroke care, acute ICH treatment has lacked a similar imaging-guided target for intervention. A paper in Neurology introduces a compelling framework for perihematomal tissue recovery.

Here is what you need to know:

🩸 1. Rethinking the Penumbra in ICH
Previous models focused on ischemic or metabolic penumbrae, but evidence demonstrates perihematomal blood flow is often oligemic due to reduced metabolic demand, rather than primary ischemia. Instead, physical compression by the hematoma exerts mass effect directly on surrounding tissue.

🏗️ 2. What is the Mechanical Penumbra?
It refers to perilesional white matter compressed by physical hematoma forces. These axons remain structurally intact but functionally impaired. If decompression occurs in a timely manner, tissue can recover—analogous to relieving a compressed peripheral nerve.

📐 3. Spatial and Temporal Gradients
- Core Axons: Irreversibly damaged axons closest to the hematoma.
- Penumbral Axons: Compressed, nonfunctioning, but salvageable white matter tracts.
- Time Window: Persistent compression leads to permanent axonal loss, whereas timely evacuation restores integrity.

🔬 4. Imaging the Target via DTI
Diffusion Tensor Imaging (DTI) and Fractional Anisotropy (FA) offer promising biomarkers to map axonal integrity. By evaluating spatial and temporal FA gradients around subcortical hemorrhages, clinicians could identify patients who stand to benefit most from surgical evacuation.

💡 Key Takeaway
Developing validated imaging biomarkers of the mechanical penumbra could transform ICH trials (such as REACH and MINUTE) and shift treatment toward precision surgical selection.

📚 Reference:
Koch S, Romano JG, Zhao W, Alkhachroum A. The mechanical penumbra in intracerebral hemorrhage. Neurology. 2026;107:e218592. doi:10.1212/WNL.0000000000218592

🔗 Article URL:
doi.org/10.1212/WNL.00…