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Watershed cerebral infarction

Watershed cerebral infarctions occur at the border between cerebral vascular territories


Predisposing situations
  • prolonged hypotension: e.g cardiac surgery 5; commonly gives a bilateral pattern
  • severe carotid stenosis: lesions are usually unilateral and occur on the side of the stenosis 

Radiographic features

CT and MRI

Exact pattern depends on the bordering territories.

The best known pattern is that of cortical infarction between middle cerebral artery, anterior cerebral artery and posterior cerebral artery.

With an ACA-MCA watershed infarction hypo-attenuation/signal abnormality follows a linear band corresponding to margin of those territories (corona radiata/centrum semiovale).

The other (less well known) pattern is called the internal watershed, between "medullary arteries arising from the superficial pial plexus and deep penetrating arteries arising from the basal cerebral arteries" 1. The tissue at risk in this pattern is the white matter tracts of the corona radiata, and centrum semiovale. When internal infarction is confluent, then clinical outcome is poor, with only three of six patients achieved independence in one study.

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