case_images: PMC10687791_01
case_images: Magnetic resonance imaging from hospital day 4. A - the acute large right posterior cerebral artery infraction is seen affecting the right medial temporal lobe and occipital lobe on the diffusion weighted imaging; B - at the upper border of the right parieto-occipital cortical infarction, one can see a string of bright areas in the deep centrum semiovale on the right side representing acute watershed infarction on this diffusion weighted image. Acute cortical strokes are seen in the left hemisphere; C - the fluid attenuated inversion recovery (FLAIR) scan confirms the deep watershed infarctions bilaterally, seen as higher signal intensity on this imaging. The visualization on FLAIR suggests the infarctions are over 6 hours old. Diffusion weighted imaging remain positive for 7-15 days.
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case_images: PMC10687791_01_autopsy-13-e2023448-g01.jpg
case_images: gf01
case_images: Four days later, the patient developed a new right hemispheric disease and was found to have a new large acute infarct of the right posterior cerebral artery territory (Figure 1). Bilateral deep white matter ischemic changes were also identified with a beaded, "rosary-like" pattern tracking along the internal watershed zone of the right corona radiata in extension from the adjacent PCA infarct (Figure 1).
case_images: A and B - gross and microscopic pathology of internal watershed infarct; A - a confluent, "cigar-shaped" lesion involving the right hemispheric deep white matter was identified at the time of brain cutting (red arrow). This lesion extended from the frontal pole to the parieto-occipital lobe.
case_images: autopsy-13-e2023448-g02.jpg
case_images: PMC10687791_01_autopsy-13-e2023448-g02.jpg
case_images: gf02
case_images: Adjacent to, but not contiguous with the large PCA infarct, was a separate, well-demarcated wedge/"cigar-shaped" lesion involving the right deep white matter, extending from the frontal pole to the parieto-occipital lobe (Figure 2).
case_images: Microphotographs of the Brain - A - low-magnification photograph of representative section of the lesion (asterisk) and overlying cortex (section taken from area of red box from panel A); B - representative histology of the interface between the lesion demonstrating a necrotic core with infiltrating macrophages (asterisk) and neovascularization (arrow) as well as adjacent reactive glial tissue (arrowheads) (A - H&E; B - H&E, 200x).
case_images: autopsy-13-e2023448-g03.jpg
case_images: PMC10687791_01_autopsy-13-e2023448-g03.jpg
case_images: gf03
case_images: Hematoxylin and eosin-stained tissue sections from this second lesion revealed a subacute infarct with central necrotic debris, neuronal loss, rarefaction, macrophage infiltration, neovascularization, axonal spheroids, and gliosis (Figure 3).