Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 0 0 2026 05 31 1482 1482 Dennis Soedibjo Anesthesiology and Intensive Therapy Subdivision, Neuroanestheisology and Neuro Critical Care, Dr Hasan Sadikin Hospital, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia. Iwan Fuadi Anesthesiology and Intensive Therapy Subdivision, Neuroanestheisology and Neuro Critical Care, Dr Hasan Sadikin Hospital, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia. Radian Halimi Anesthesiology and Intensive Therapy Subdivision, Neuroanestheisology and Neuro Critical Care, Dr Hasan Sadikin Hospital, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia. Tatang Bisri Anesthesiology and Intensive Therapy Subdivision, Neuroanestheisology and Neuro Critical Care, Dr Hasan Sadikin Hospital, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia. 2025 11 11 2025 12 01 Background: Cerebral hypoperfusion is a major cause of brain ischemia, both global and focal. In focal ischemia, there are three main zones: the ischemic core, which undergoes permanent damage; the penumbra, which remains salvageable; and the area with normal perfusion. A decrease in blood flow and disruption of cerebral autoregulation can convert the penumbra into an infarct if reperfusion is not promptly achieved. The penlucida region represents tissue capable of spontaneous recovery without intervention, whereas the penumbra requires immediate action to preserve neuronal viability. Neuronal injury in ischemia primarily results from energy production failure due to impaired oxidative phosphorylation, increased intracellular calcium, excessive glutamate release, and the formation of free radicals that lead to excitotoxicity and cell death through necrosis and apoptosis. Resuscitation of the penumbra–penlucida area aims to restore perfusion and oxygenation before irreversible damage occurs through the application of the neuroanesthetic-based ABCDE principles (airway, breathing, circulation, disability, exposure). Maintaining airway patency, oxygenation, normocapnic ventilation, and adequate cerebral perfusion pressure (CPP) are key to preserving collateral blood flow. Hypotension, hypoxia, hyperthermia, hypoglycemia and hyperglycemia must be avoided as they accelerate infarct progression. Anesthetic agents play a protective role by reducing cerebral metabolism, although careful monitoring of blood pressure is still necessary to prevent relative hypotension. Thus, the application of neuroanesthetic principles in penumbra–penlucida resuscitation aims to maintain cerebral perfusion, oxygenation, and metabolic stability to prevent the transformation of reversible tissue into a permanent infarct. https://aacc.tums.ac.ir/index.php/aacc/article/view/1482