Autopsy and Case Reports
https://app.periodikos.com.br/journal/autopsy/article/doi/10.4322/acr.2023.448
Autopsy and Case Reports
Autopsy Case Report

Radiologic-pathologic autopsy correlation of an internal watershed infarct, a case report

Thomas Dimitrios Zaikos; David M. Yousem; Juan C. Troncoso; James Stephen Nix

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Abstract

Internal watershed infarcts (IWIs) occur at the junction of the deep and superficial perforating arterial branches of the cerebrum. Despite documentation in the radiology literature, IWIs are rarely encountered at the time of autopsy. Here, we report the case of a 59-year-old incarcerated male who was brought to the emergency department after being found unresponsive on the floor of his jail cell. Initial examination and imaging demonstrated right-sided hemiplegia, aphasia, right facial droop, and severe stenosis of the left middle cerebral artery, respectively. Repeat imaging 4 days after admission and 26 days before death demonstrated advanced stenosis of the intracranial, communicating segment of the right internal carotid artery, a large acute infarct in the right posterior cerebral artery territory, and bilateral deep white matter ischemic changes with a right-sided “rosary-like” pattern of injury that is typical of IWIs. Postmortem gross examination showed that the right deep white matter lesion had progressed to a confluent, “cigar-shaped” subacute IWI involving the right corona radiata. This is the first well-documented case of an IWI with radiologic imaging and photographic gross pathology correlation. This case uniquely highlights a rarely encountered lesion at the time of autopsy and provides an excellent visual representation of internal watershed neuroanatomy.

Keywords

Internal watershed, infarction, autopsy, neuropathology

References

1 Bladin CF, Chambers BR. Clinical features, pathogenesis, and computed tomographic characteristics of internal watershed infarction. Stroke. 1993;24(12):1925-32. http://dx.doi.org/10.1161/01.STR.24.12.1925. PMid:8248975.

2 Bogousslavsky J. The plurality of subcortical infarction. Stroke. 1992;23(5):629-31. http://dx.doi.org/10.1161/01.STR.23.5.629. PMid:1579957.

3 Van Den Bergh R. Centrifugal elements in the vascular pattern of the deep intracerebral blood supply. Angiology. 1969;20(2):88-94. http://dx.doi.org/10.1177/000331976902000205. PMid:4179336.

4 Moody DM, Bell MA, Challa VR. Features of the cerebral vascular pattern that predict vulnerability to perfusion or oxygenation deficiency: an anatomic study. AJNR Am J Neuroradiol. 1990;11(3):431-9. PMid:2112304.

5 Momjian-Mayor I, Baron JC. The pathophysiology of watershed infarction in internal carotid artery disease: review of cerebral perfusion studies. Stroke. 2005;36(3):567-77. http://dx.doi.org/10.1161/01.STR.0000155727.82242.e1. PMid:15692123.

6 Amano Y, Sano H, Fujimoto A, Kenmochi H, Sato H, Akamine S. Cortical and internal watershed infarcts might be key signs for predicting neurological deterioration in patients with internal carotid artery occlusion with mild symptoms. Cerebrovasc Dis Extra. 2020;10(2):76-83. http://dx.doi.org/10.1159/000508090. PMid:32726784.

7 Yong SW, Bang OY, Lee PH, Li WY. Internal and cortical border-zone infarction: clinical and diffusion-weighted imaging features. Stroke. 2006;37(3):841-6. http://dx.doi.org/10.1161/01.STR.0000202590.75972.39. PMid:16424374.

8 Rothstein A, Oldridge O, Schwennesen H, Do D, Cucchiara BL. Acute cerebrovascular events in hospitalized COVID-19 patients. Stroke. 2020;51(9):e219-22. http://dx.doi.org/10.1161/STROKEAHA.120.030995. PMid:32684145.

9 Sawlani V, Scotton S, Nader K, et al. COVID-19-related intracranial imaging findings: a large single-centre experience. Clin Radiol. 2021;76(2):108-16. http://dx.doi.org/10.1016/j.crad.2020.09.002. PMid:33023738.
 


Submitted date:
05/02/2023

Accepted date:
08/17/2023

Publication date:
10/23/2023

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