Background and Purpose: Hemodynamic patterns after borderzone (BZ) infarction are variable and dynamic. However, stroke mechanisms in different types of BZ infarctions have not been systematically studied by magnetic resonance angiography (MRA) and transcranial Doppler ultrasonography (TCD). Methods: Forty-nine patients who experienced a stroke limited to the territory of either the superficial or internal borderzone proved on MRI included in our registry, corresponding to 4% of 1,200 patients with ischemic stroke, were studied. All these patients underwent MRA, extracranial Doppler ultrasonography, TCD and other investigations from the standard protocol of our registry. Twenty of them (41%) had a posterior BZ infarct, 14 (29%) an anterior BZ infarct, 10 (20%) a subcortical BZ infarct and 5 (10%) bilateral BZ infarcts. Results: Unilateral internal carotid artery (ICA) tight stenosis or occlusion ipsilateral to the lesion was present in 14 patients (70%) with a posterior BZ infarct, in 72% of those with an anterior BZ infarct, in 80% of those with a subcortical BZ infarct and in 80% of those with bilateral BZ infarcts. TCD showed cross-filling of the middle cerebral artery via the anterior communicating artery in 5 patients (25%) with a posterior BZ infarct and 10% had an increased mean flow velocity (MFV) in the ipsilateral P1 posterior cerebral artery (PCA). In patients with an anterior BZ infarct, 3 (23%) had an MFV increase in the contralateral A1 anterior cerebral artery (ACA), and 2 (15%) had a higher MFV in the ipsilateral PCA. An elevated velocity at midline depths with reversed A1 ACA flow direction was seen in 2 patients (20%) with a subcortical infarct, and 1 patient (10%) had an MFV increase in the ipsilateral P1 PCA. Left ventricular systolic dysfunction (ejection fraction <40%) was present in 50% of patients with a posterior BZ infarct, in 36% of those with an anterior BZ infarct, in 20% of those with a subcortical BZ infarct and bilateral BZ infarcts each. Conclusion: The association of severe ICA stenosis or occlusion with cardiopathies and left ventricular dysfunction may play a critical role in those with BZ infarcts having inadequate collateral supply, while a cardioembolism or acute ICA dissection may also cause BZ infarction due to the rapidity of the occlusive process and the inability of the cerebral vasculature to recruit collateral pathways quickly enough.

Keywords:
Borderzone infarct, Occlusion, Doppler ultrasonography, Magnetic resonance angiography
1.
Zülch KJ: Über die Entstehung und Lokalisation der Hirninfarkte. Neurochirurgia (Stuttg) 1961;21:158–178.
2.
Adams JH, Brierly JB, Connor RCR, Treip C: The effects of systemic hypotension upon the human brain: Clinical and neuropathological observations in eleven cases. Brain 1966;89:235–268.
3.
Fisher CM, McQuillen JB: Bilateral cortical border zone infarction: A pseudo-brainstem stroke. Arch Neurol 1981;38:62–63.
4.
Torvik A: The pathogenesis of watershed infarcts in the brain. Stroke 1984;15:221–223.
5.
Bogousslavsky J, Regli F: Unilateral watershed cerebal infarcts. Neurology 1986;36:373–377.
6.
Angeloni U, Bozzao L, Fantozzi L, Bastianello S, Kushner M, Fieschi C: Internal border zone infarction following acute middle cerebral artery occlusion. Neurology 1990;40:1196–1198.
7.
Gandolfo C, Del Sette M, Finocchi C, Calautti C, Loeb C: Internal border zone in patients with ischemic stroke. Cerebrovasc Dis 1998;8:255–258.
8.
Graeber MC, Jordan JE, Mishra SK, Nadeau SE: Watershed infarction on computed tomographic scan. Arch Neurol 1992;49:311–313.
9.
Bladin CF, Chambers BR: Clinical features, pathogenesis, and computed tomographic characteristics of internal watershed infarction. Stroke 1993;24:1925–1932.
10.
Schneider M: Hypoxie und Anoxie. Therapiewoche 1956;6:217–221.
11.
Ringelstein EB, Zeumer H, Angelou D: The pathogenesis of strokes from internal carotid artery occlusion: Diagnostic and therapeutical implications. Stroke 1983;14:867–875.
12.
Schneider PA, Rossman ME, Bernstein EF, Torem S, Ringelstein EB, Otis SM: Effect of internal carotid artery occlusion in transcranial hemodynamics: Transcranial Doppler evaluation and clinical correlation. Stroke 1988;19:589–593.
13.
Powers WJ: Cerebral hemodynamics in ischemic cerebrovascular disease. Ann Neurol 1991;29:231–240.
14.
Akopov S, Whitman GT: Hemodynamic studies in early ischemic stroke. Serial transcranial Doppler and magnetic resonance angiography evaluation. Stroke 2002;33:1274–1279.
15.
Kumral E, Ozkaya B, Sagduyu A, Sirin H, Vardarli E, Pehlivan M: The Ege Stroke Registry: A hospital-based study in the Aegean Region, İzmir, Turkey. Cerebrovasc Dis 1988;8:278–288.
16.
Mounier-Vehier F, Leys D, Godefroy O, Rondepierre P, Marchau M Jr, Pruvo JP: Borderzone infarct subtypes: Preliminary study of the presumed mechanism. Eur Neurol 1994;34:11–15.
17.
Ringelstein EB, Stögbauer F: Borderzone infarcts; in Bogousslavsky J, Caplan LR (eds): Stroke Syndromes. Cambridge, Cambridge University Press, 2001, pp 564–582.
18.
American Society of Echocardiography Committee of Standards: Report of the American Society of Echocardiography Committee of nomenclature and standards in two-dimensional imaging. Circulation 1980;62:212.
19.
Alexandrov AV, Demchuck AM, Wein TH, Grotta JC: Yield of transcranial Doppler in acute cerebral ischemia. Stroke 1999;30:1604–1609.
20.
Demchuck AM, Christou I, Wein TH, Felberg RA, Malkoff M, Grotta JC, Alexandrov AV: Specific transcranial Doppler flow findings related to the presence and site of arterial occlusion. Stroke 2000;31:140–146.
21.
Leblanc R, Yamamoto YL, Tyler JL, Diksic M, Hakim A: Borderzone ischemia. Ann Neurol 1987;22:707–713.
22.
Romanl FCA, Abramowicz A: Changes in brain and pial vessels in arterial borderzones. Arch Neurol 1964;11:40–65.
23.
Ross Russell RW, Bharucha N: Recognition and prevention of borderzone cerebral ischaemia during cardiac surgery. Q J Med 1978;47:303–323.
24.
Torvik A, Skullerud K: Watershed infarcts in the brain caused by microemboli. Clin Neuropathol 1982;1:99–105.
25.
Katz SD, Marantz PR, Biasucci L, Jondeau G, Lee K, Brennan C, LeJemtel TH: Low incidence of stroke in ambulatory patients with heart failure: A prospective study. Am Heart J 1993;126:141–146.
26.
Kelly R, Staines A, MacWalter R, Stonebridge P, Tunstall-Pedoe H, Struthers AD: The prevalence of treatable left ventricular systolic dysfunction in patients who present with noncardiac vascular episodes: A case-control study. J Am Coll Cardiol 2002;39:219–224.
27.
Rodda RA, Path FRC: The arterial patterns associated with internal carotid artery disease and cerebal infarcts. Stroke 1986;17:69–75.
28.
Harrison MJG, Marshall J: The variable clinical and CT findings after carotid occlusion: The role of collateral blood supply. J Neurol Neurosurg Psychiatry 1988;51:269–272.
29.
Anzola GP, Gasparotti R, Magoni M, Prandini F: Transcranial Doppler sonography and magnetic resonance angiography in the assessment of collateral hemispheric flow in patients with carotid artery disease. Stroke 1995;26:214–217.
30.
Weiller C, Ringelstein EB, Reiche W, Buell U: Clinical and hemodynamic aspects of low-flow infarcts. Stroke 1991;22:1117–1123.
31.
Hendriksen J, Hartkamp MJ, Hillen B, Mali WPTM, van der Grond J: Collateral ability of the circle of Willis in patients with unilateral internal carotid artery occlusion: Border-zone infarcts and clinical symptoms. Stroke 2001;32:2768–2773.
32.
Razumovsky AY, Gillard JH, Bryan RN, Hanley DF, Oppenheimer SM: TCD, MRA, and MRI in acute cerebral ischemia. Acta Neurol Scand 1999;99:65–76.
33.
Caplan LR, Hennerici M: Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 1998;55:1475–1482.
34.
Weiller C, Müllges W, Ringelstein EB, Buell U, Reiche W: Patterns of brain infarctions in internal carotid artery dissections. Neurosurg Rev 1991;14:111–113.
35.
Decker K, Hipp E: Morphologie und Angiographie. Anat Anz 1963;105:100–116.
© 2004 S. Karger AG, Basel
2004
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.