Bilirubin labeling of borderzone and anterior cerebral artery territory infarction.

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 anterior cerebral artery territories with this endogenous label (total bilirubin at time of death was 24 mg/dL; direct bilirubin 19 mg/dL) (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.”