Grenzzoneninfarkte: Pathophysiologie und Kennzeichen in der Bildgebung^[1]

Zusammenfassung

Grenzzonen- oder Wasserscheideninfarkte sind ischämische Läsionen, die an charakteristischen Stellen zwischen den Versorgungsgebieten von 2 großen Arterien auftreten. Diese Läsionen machen etwa 10 % aller Hirninfarkte aus und sind in der Fachliteratur ausführlich beschrieben. Ihre Pathophysiologie ist noch nicht vollständig entschlüsselt, aber eine allgemein anerkannte Hypothese geht davon aus, dass eine verminderte Perfusion in den distalen Bereichen der Gefäßgebiete zu einer Infarktanfälligkeit führt. Es werden 2 Arten von Grenzzoneninfarkten unterschieden: äußere (kortikale) und innere (subkortikale). Um das jeweils beste bildgebende Verfahren für den Umgang mit solchen Infarkten auszuwählen, ist es wichtig, die zugrunde liegenden Kausalzusammenhänge zu verstehen. Innere Grenzzoneninfarkte werden hauptsächlich durch hämodynamische Beeinträchtigung verursacht, während man davon ausgeht, dass äußere Grenzzoneninfarkte eher das Resultat einer Embolie und nicht immer mit einer Hypoperfusion assoziiert sind. Es wurden verschiedene bildgebende Verfahren eingesetzt, um das Vorhandensein und das Ausmaß hämodynamischer Beeinträchtigung oder Minderperfusion in Assoziation mit Grenzzoneninfarkten zu bestimmen. Einige Befunde (wie multiple kleine innere Infarkte) haben sich als unabhängige Prädiktoren nachfolgender ischämischer Schlaganfälle erwiesen. Eine Kombination mehrerer moderner Techniken (z. B. Diffusions- und Perfusionsmagnetresonanztomografie und -computertomografie, Positronenemissionstomografie, transkranieller Doppler-Ultraschall) kann hilfreich sein, um den pathophysiologischen Prozess zu identifizieren, eine frühe klinische Diagnose zu stellen, über die Therapie zu entscheiden und eine Prognose über die Behandlungsergebnisse abzugeben.

Abstract

Border zone or watershed infarcts are ischemic lesions that occur in characteristic locations at the junction between two main arterial territories. These lesions constitute approximately 10 % of all brain infarcts and are well described in the literature. Their pathophysiology has not yet been fully elucidated, but a commonly accepted hypothesis holds that decreased perfusion in the distal regions of the vascular territories leaves them vulnerable to infarction. Two types of border zone infarcts are recognized: external (cortical) and internal (subcortical). To select the most appropriate methods for managing these infarcts, it is important to understand the underlying causal mechanisms. Internal border zone infarcts are caused mainly by hemodynamic compromise, whereas external border zone infarcts are believed to result from embolism but not always with associated hypoperfusion. Various imaging modalities have been used to determine the presence and extent of hemodynamic compromise or misery perfusion in association with border zone infarcts, and some findings (e. g., multiple small internal infarcts) have proved to be independent predictors of subsequent ischemic stroke. A combination of several advanced techniques (e. g., diffusion and perfusion magnetic resonance imaging and computed tomography, positron emission tomography, transcranial Doppler ultrasonography) can be useful for identifying the pathophysiologic process, making an early clinical diagnosis, guiding management, and predicting the outcome.

¹ © 2011 The Radiological Society of North America. All rights reserved. Originally puplished in English in RadioGraphics 2011; 31: 1201 – 1214. Online puplished in 10.1148 /rg.315105014. Translated and reprinted with permission of RSNA. RSNA is not responsible for any inaccuracy or error arising from the translation from English to German.

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