From the Guidelines
The prognosis for patients with bilateral watershed strokes is generally poor, with high morbidity and mortality rates, and significant long-term neurological deficits. The outcomes vary based on stroke severity, timing of treatment, and underlying causes, with many patients experiencing cognitive impairment, motor weakness, and speech difficulties 1. Mortality rates are relatively high, with approximately 20-40% of patients dying within the first year, and recovery is typically slow and incomplete, with most neurological improvement occurring within the first 3-6 months.
Key Factors Influencing Prognosis
- Stroke severity
- Timing of treatment
- Underlying causes, such as carotid stenosis or cardiac dysfunction
- Presence of comorbidities, such as hypertension, diabetes, or hyperlipidemia
Treatment and Management
Treatment focuses on managing the underlying cause, along with aggressive rehabilitation, including:
- Carotid endarterectomy or stenting for carotid stenosis
- Anticoagulation with medications like warfarin (target INR 2-3) or direct oral anticoagulants for cardiac issues
- Blood pressure management, typically maintaining systolic pressure between 120-140 mmHg
- Early intensive rehabilitation, including physical, occupational, and speech therapy, which significantly improves functional outcomes 1
Rehabilitation and Recovery
The provision of stroke rehabilitation services has received considerable attention in recent years, with a focus on tailoring services to ensure optimal recovery for patients, and addressing fiscal pressures on costly health services 1. Rehabilitation programs should consider lifestyle changes, depression, and caregiver burden as important issues to work on with the patient and caregivers. Early supported hospital discharge and home-based rehabilitation programs have been shown to be cost-effective, while home-based therapy in stable patients has been shown to produce comparable outcomes to conventional outpatient rehabilitation 1.
From the Research
Prognosis of Bilateral Watershed Stroke
The prognosis for a patient with bilateral watershed stroke is generally poor, with high mortality and morbidity rates.
- Bilateral watershed infarcts are associated with a higher risk of death and disability compared to other infarct patterns 2.
- A study found that patients with bilateral watershed infarcts after cardiac surgery were 17.3 times more likely to die and had poorer outcomes compared to those with other infarct patterns 2.
- The mechanism of bilateral watershed strokes may involve an intraoperative drop in blood pressure from a patient's baseline, which can lead to cerebral hypoperfusion and ischemia 2.
Clinical Characteristics and Diagnostic Algorithm
- Watershed strokes are ischemic strokes located in vulnerable border zones between brain tissue supplied by the anterior, posterior, and middle cerebral arteries 3.
- The diagnosis of watershed strokes requires prompt recognition and investigation of its etiology, and neurologists should use imaging techniques such as MRI to evaluate the extent of the infarct and guide therapeutic management 3.
- Bilateral watershed infarcts can be detected by diffusion-weighted imaging MRI, which is more sensitive than CT scans 2.
Treatment and Management
- The treatment of bilateral watershed strokes involves restoring blood flow to the affected areas and managing the underlying cause of the stroke 4.
- Surgery, such as transsphenoidal adenomectomy, may be considered in some cases to decompress the affected arteries and restore blood flow 4.
- Anticoagulation therapy, such as apixaban, may be used to prevent recurrent strokes in patients with atrial fibrillation and a history of stroke or transient ischemic attack 5, 6.