The Pathophysiology of Watershed Infarction in Internal Carotid Artery Disease

医学 心脏病学 梗塞 冲程(发动机) 栓塞 颈内动脉 灌注扫描 颈动脉疾病 血流动力学 放射科 内科学 脑梗塞 灌注 缺血 心肌梗塞 颈动脉 颈动脉内膜切除术 工程类 机械工程
作者
Isabelle Momjian-Mayor,Jean-Claude Baron
出处
期刊:Stroke [Lippincott Williams & Wilkins]
卷期号:36 (3): 567-577 被引量:293
标识
DOI:10.1161/01.str.0000155727.82242.e1
摘要

Background and Purpose— In carotid disease, infarcts can occur in the cortical as well as internal watershed (WS), or both. Better understanding the pathophysiology of WS infarcts would guide treatment. Two distinct hypotheses, namely low-flow and micro-embolism, are equally supported by neuropathological and physiological studies. Here we review the evidence regarding the mechanisms for WS stroke in carotid disease and whether they differ between cortical and internal WS infarcts. Summary of Review— After a brief account of the anatomy of the WS and the cerebrovascular physiology in circumstances of low perfusion pressure, the literature concerning the mechanisms of WS infarction in carotid disease is reviewed and discussed with emphasis on imaging and ultrasound studies of the cerebral hemodynamics. Conclusion— The evidence strongly favors a hemodynamic mechanism for internal WS infarction, especially regarding the so-called rosary-like pattern in the centrum semiovale. However, the relationships between cortical WS infarction and hemodynamic compromise appear more complicated. Thus, although severe hemodynamic compromise appears to underlie combined cortical and internal WS infarction, artery-to-artery embolism may play an important role in isolated cortical WS infarcts. Based on the high prevalence of microembolic signals documented by ultrasound in symptomatic carotid disease, a recent hypothesis postulates that embolism and hypoperfusion play a synergetic role, according to which small embolic material prone to lodge in distal field arterioles would be more likely to result in cortical micro-infarcts when chronic hypoperfusion prevails. Future studies combining imaging of brain perfusion, diffusion-weighted imaging, and ultrasound detection of microembolic signals should help resolve these issues.
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