Diffuse Hypoperfusion Syndromes Cerebral and Spinal Cord

As discussed in the section on arterial anatomy, the midthoracic spinal cord is a border zone or watershed area that is susceptible to ischemia due to the unequal blood supply in this region. In situations of systemic hypoperfusion, there can be a spinal cord infarction. Conditions such as an aortic dissection can also cause a global decrease in spinal cord perfusion that results in gray matter infarction with relative sparing of the white matter tracts.

There can be border zone or watershed infarctions in the brain between the major arterial circulations. These conditions may occur with severe hypotension or in association with cardiac surgery. There are several described syndromes. y

If there is ischemia in the border zone territory of the anterior, middle, and posterior cerebral arteries, there may be bilateral parieto-occipital infarcts. There can be a variety of visual defects, including lower altitudinal visual field defects, optic ataxia, cortical blindness, disorders of ocular pursuit, and abnormalities in judging size, distance, and movement. If there is ischemia between the territories of the anterior and middle cerebral arteries bilaterally, a syndrome of bibrachial sensorimotor impairment can occur. Initially, there is weakness of the entire upper limbs, but later the weakness may be confined to the forearms and hands. Saccadic eye movements may be impaired due to involvement of the frontal eye fields. In ischemia to the border zone regions between the middle and posterior cerebral arteries, there can be bilateral parietotemporal infarctions. Patients have cortical blindness initially that may improve. However, there are a number of defects in higher cortical function, including dyslexia, dysgraphia, dyscalculia, and memory defects, that persist.

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