A 50-year-old woman developed multiorgan system failure secondary to sepsis. She became obtunded during a period of hypotension, and cranial CT demonstrated diffuse borderzone infarction. Brain autopsy revealed green pigmentation in areas of infarction due to vascular leakage of bilirubin at sites of blood–brain barrier disruption, mapping the borderzone regions and bilateral posterior anterior cerebral artery (ACA) territories with this endogenous label (total bilirubin at time of death was 24 mg/dL; direct bilirubin was 19 mg/dL; ACA infarction was not present on the initial CT, and was thought to be secondary to herniation) (figure). This brain–liver association evokes the first description of pathology in the borderzone regions in 1883 by Samuel-Jean Pozzi,1 who attributed the lesions to cortical “cirrhosis.”
Footnotes
Author contributions: Dr. Berkowitz drafted the initial manuscript and revised the manuscript. Dr. Sheu revised the manuscript and was involved in the preparation of the pathologic specimens. Dr. Rose revised the manuscript, prepared the figure, and was involved in the preparation of the pathologic specimens. Dr. Delalle revised the manuscript and was involved in the preparation of the pathologic specimens. Dr. Folkerth revised the manuscript and was involved in the preparation of the pathologic specimens.
Study funding: No targeted funding reported.
Disclosure: A. Berkowitz reports no relevant disclosures, but receives royalties from Clinical Pathophysiology Made Ridiculously Simple (Medmaster, Inc.) and The Improvising Mind (Oxford University Press). S. Sheu, M. Rose, I. Delalle, and R. Folkerth report no disclosures. Go to Neurology.org for full disclosures.
- © 2013 American Academy of Neurology
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