A 65-year-old hypertensive man presents with acute-onset bilateral arm and leg weakness, sparing the face, after a period of hypotension during cardiac surgery. MRI shows bilateral parasagittal cortical and subcortical T2 hyperintensity between the anterior cerebral and middle cerebral artery territories. What is this stroke pattern called?

• A Lacunar infarct
• B Top-of-the-basilar syndrome
• C Locked-in syndrome
• D Watershed (borderzone) infarct ✓

Explanation

Watershed infarcts occur in border zones between major arterial territories during systemic hypotension. The classic presentation is proximal limb weakness (man-in-the-barrel syndrome) with facial sparing. Lacunar infarcts are small deep infarcts. Top-of-the-basilar affects thalamus and occipital lobes. Locked-in syndrome is from ventral pontine lesion with preserved consciousness.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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