Case Report

Internal Watershed Infarction as an Imaging and Clinical Challenge: a Case Report


We presented the case of a patient with internal watershed infarction with a nonspecific clinical presentation including hemiplegia, hemisensory deficit, and speech disturbance. Neuroimaging and ultrasound diagnostic procedure are important tools for diagnosis of these rare ischemic events that count for about 6% of all strokes.  Specific therapy is mandatory for the diagnosis of watershed infarction and different from the therapeutical measures than can be taken for embolic and atherothrombotic strokes. Our patient was a 69-year-old, right-handed Caucasian woman who presented to our facility with acute right side weakness and speech disturbance. He had hypothyroidism, permanent atrial fibrillation, diabetes mellitus and she was hypotensive. She reported dizziness few days before the accident. Imaging studies revealed internal watershed infarction. Therapeutic procedures were taken to restore low cerebral blood flow. Internal watershed infarction is rare (less than 10% of all strokes) but well recognized a clinical feature of stroke. Specific pathophysiology generally is connected with hypoperfusion and hemodynamic mechanisms. Specific therapy is mandatory for these conditions.

D'Amore C, Paciaroni M.: Boreder-zone and watershed infarcts.Front Neurol Neurosci. 2012;30:181-4. Epub 2012 Feb 14. Review

Bogousslavsky J, Regli F: Unilateral watershed cerebral infarcts. Neurology 1986;36(3):373–377.

Mangla R, Kolar B, Almast J, Ekholm SE: Border Zone Infarcts: Pathophysiologic and Imaging Characteristics

Torvik A: The pathogenesis of watershed infarcts in the brain. Stroke 1984;15(2):221–223.

Momjian-Mayor I,Baron JC:The pathophysiology of watershed infarction in internal carotid artery disease: review of cerebral perfusion studies. Stroke 2005;36(3):567–577.

Caplan LR,Hennerici M: Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 1998;55(11):1475–1482.

Belden JR, Caplan LR, Pessin MS, Kwan E: Mechanisms and clinical features of posterior border-zone infarcts. Neurology 1999;53(6):1312–1318.

Provenzale JM, Jahan R, Naidich TP, Fox AJ: Assessment of the patient with hyperacute stroke: imaging and therapy. Radiology 2003;229(2):347–359.

Amarenco P, Kase CS, Rosengart A, Pessin MS, Bousser MG, Caplan LR: Very small (border zone) cerebellar infarcts: distribution, causes, mechanisms and clinical features. Brain 1993;116(Pt 1): 161–186.

Bladin CF, Chambers BR. Frequency and pathogenesis of hemodynamic stroke. Stroke.

; 25: 2179–2182.

Howard R, Trend P, Russell RW. Clinical features of ischemia in cerebral arterial border zones after periods of reduced cerebral blood flow. Arch Neurol. 1987; 44: 934–940.

Adams JH, Brierley JB, Connor RC, Treip CS. The effects of systemic hypotension upon the human brain. Clinical and neuropathological observations in 11 cases. Brain. 1966; 89: 235–268

Mull M, Schwarz M, Thron A. Cerebral hemispheric low-flow infarcts in arterial occlusive disease. Lesion patterns and angiomorphological conditions., Stroke. 1997; 28: 118–123.

Pollanen MS, Deck JH. Directed embolization is an alternate cause of cerebral watershed infarction. Arch Pathol Lab Med. 1989; 113: 1139–1141.

Brierley JB, Excell BJ. The effects of profound systemic hypotension upon the brain of m. Rhesus: Physiological and pathological observations. Brain. 1966; 89: 269–298.

Bladin CF, Chambers BR. Clinical features, pathogenesis, and computed tomographic characteristics of internal watershed infarction. Stroke. 1993; 24: 1925–1932.

Lang EW, Daffertshofer M, Daffertshofer A, Wirth SB, Chesnut RM, Hennerici M. Variability of vascular territory in stroke. Pitfalls and failure of stroke pattern interpretation. Stroke. 1995; 26: 942–945.

Weiller C, Ringelstein EB, Reiche W, Buell U. Clinical and hemodynamic aspects of low-flow infarcts. Stroke. 1991; 22: 1117–1123.

Isaka Y, Nagano K, Narita M, Ashida K, Imaizumi M. High signal intensity on T2-weighted magnetic resonance imaging and cerebral hemodynamic reserve in carotid occlusive disease. Stroke. 1997; 28: 354–357.

Markus H. Transcranial doppler detection of circulating cerebral emboli. A review. Stroke. 1993; 24: 1246–1250.

Bozzao A, Floris R, Gaudiello F, Finocchi V, Fantozzi LM, Simonetti G. Hemodynamic modifications in patients with symptomatic unilateral stenosis of the internal carotid artery: evaluation with MR imaging perfusion sequences. AJNR Am J Neuroradiol. 2002; 23: 1342–1345.

Yamauchi H, Fukuyama H, Nagahama Y, Nabatame H, Ueno M, Nishizawa S, Konishi J, Shio H. Significance of increased oxygen extraction fraction in five-year prognosis of major cerebral arterial occlusive diseases. J Nucl Med. 1999; 40: 1992–1998.

IssueVol 54, No 3 (2016) QRcode
SectionCase Report(s)
Infraction Imaging Clinical

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How to Cite
Marčić M, Marčić L, Kolić K, Titilić M. Internal Watershed Infarction as an Imaging and Clinical Challenge: a Case Report. Acta Med Iran. 2016;54(3):222-225.