Unilateral watershed infarction

Case contributed by Dr Samah Faiq Juma Al-Obaidi


Acute history of dysphasia. Known case of hypertension.

Patient Data

Age: 55 years old
Gender: Male

Multi planar brain MRI revealed scattered altered bright signal foci in the left cerebral hemisphere distributed in the centrum semiovale, subcortical white matter, insular cortex and periventricular region. all shows diffusion restriction. The T2 WI revealed absent signal void in the extra and intracranial segments of the left ICA which is confirmed by the cerebral MRA study. Infratentorial structures are unremarkable.

Case Discussion

Watershed infarcts occur at the border zones between major cerebral arterial territories as a result of hypo perfusion.

There are two patterns of border zone infarcts:

  1. Cortical border zone infarctions CWS
    Infarctions of the cortex and adjacent subcortical white matter located at the border zone of ACA/MCA and MCA/PCA. It may be embolic if isolated and less frequently due to hemodynamic compromise.

  2. Internal border zone infarctions IWS
    Infarctions of the deep white matter of the centrum semiovale and corona radiata at the border zone between lenticulostriate perforators and the deep penetrating cortical branches of the MCA or at the border zone of deep white matter branches of the MCA and the ACA. These are caused mainly by arterial stenosis or occlusion.

  • Bilateral watershed infarcts happen mainly due to severe systemic hypotensive crises.

  • On the basis of their radiological appearance, IWS infarcts have been divided into confluent and partial infarcts. Confluent infarcts correspond to large cigar-shaped infarcts alongside the lateral ventricle, whereas partial IWS infarcts may appear either as a single lesion or in a chain-like (or “rosary-like”) pattern in the CSO(centrum semi ovale). However, partial IWS infarcts sometimes are difficult to distinguish from lacunar, medullary, or striatocapsular infarcts, as well as from leukoariosis. The latter, however, affects in a diffuse way the Para ventricular white matter bilaterally as it represents chronic diffuse white matter ischemia. Partial IWS infarct and leukoariosis may, however, coexist, particularly in the elderly. Regarding medullary infarcts, they correspond to small, immediately subcortical infarcts caused by occlusion of medullary arteries arising from the pial plexus. They are generally smaller and more superficial than partial IWS infarcts, but IWS and white matter medullary infarcts have been sometimes lumped together as so-called subcortical white matter infarcts because of the difficulty in distinguishing between them.

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Case information

rID: 49164
Published: 21st Nov 2016
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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