Watershed cerebral infarction

Last revised by Avni K P Skandhan on 11 Feb 2022

Watershed cerebral infarctions, also known as border zone infarcts, occur at the border between cerebral vascular territories where the tissue is furthest from arterial supply and thus most vulnerable to reductions in perfusion. 

Watershed cerebral infarction accounts for 5-10% of all cerebral infarctions 8. They tend to occur in the elderly, who have a higher incidence of arterial stenosis and hypotensive episodes, as well as sources of microemboli. 

Although traditionally watershed infarction has been thought of as being due primarily to hypoperfusion, more recently there is mounting evidence that both episodes of hypoperfusion and/or microemboli from inflamed atherosclerotic plaques or other sources can be causative 3,5.

Episodes of systemic hypotension, particularly combined with severe inflow stenosis or occlusion (e.g. carotid stenosis), is the typical scenario in which a watershed infarction is encountered and classically affects the deep border zone (string of pearls sign) but can also involve the external border zone 3. The location of stenoses and anatomy of the circle of Willis will contribute to the location of infarcts. 

In contrast, clearance of the microemboli, which may form on the surface of inflamed plaques or are the result of an embolic shower (including fat embolism and air embolism 11,12), usually only affect the external (cortical) border zone presumably as the absence of abundant collateral supply makes these areas more likely to infarct from small occlusions 3,10

Thus, in the absence of significant inflow impairment, a border zone infarct in an isolated area is more likely to be secondary to microembolism.  

The exact pattern depends on the bordering territories, which are usually variable in different individuals. Imaging of watershed infarction should also aim to determine the presence and severity of arterial stenosis and occlusion.

These are usually wedge-shaped or gyriform:

  • ACA/MCA: in the frontal cortex, extending from the anterior horn to the cortex
  • MCA/PCA: in the parieto-occipital region, extending from the posterior horn to the cortex
  • parallel parafalcine stripes in the subcortical white matter at the vertex - this type is seen with profound diffuse hypoperfusion

Triple watershed zone: most vulnerable region where ACA, MCA, and PCA converge in the parieto-occipital region posterior to the lateral ventricles.

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Cases and figures

  • Case 1: internal watershed
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  • Case 2: ACA-MCA-PCA watershed
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  • Case 3
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  • Case 4
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  • Case 5: right ACA-MCA
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  • Case 6: watershed infarctions
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  • Case 7
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  • Case 8: internal watershed zone
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  • Case 9
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  • Case 10
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  • Case 11: due to massive pulmonary embolism
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  • Case 12: old MCA-PCA watershed infarct
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