arterial and venous supply of brain

ARTERIAL AND VENOUS SUPPLY OF BRAIN

Ariunjargal Buyanmunkh M,D

Артерийн анатоми

Аортын нумаас эхэлнэ:

Aortic arch

Innonimate artery

Left common carotid Left subclavian

Аортын нум:

3 . Innonimate artery 10. Left subclavian artery 15. Left common carotid artery

1.Innonimate artery • Brachiocephalic салаа • Аортын нумаас салаалах эхний судас

Innonimate artery

Right subclavian artery Right common carotid artery

Innonimate artery 4. Right subclavian artery 5. Right common carotid artery

1A.Right subclavian artery

Right subclavian artery

Right vertebral

artery

Internal mammary

artery Thyrocervic

al trunk Costocervic

al trunk

1A. Right Subclavian Artery :6. Right vertebral artery 9. Internal mammary artery 16. Thyrocervical trunk

16

Баруун Subclavian артерийн хэвийн бус хэлбэр

– Бүх тохиолдлын 0.5-1% – 1 биш 4 дэх судас болж аортын

нумаас салаалах – Нийт ийм хэлбэрийн

өөрчлөлттэй хүмүүсийн 10 %-д dysphagia lusoria буюу улаан хоолойн шахагдсанаас залгихад хүндрэл үүсдэг.

Right Vertebral Artery

• Баруун subclavian artery-н эхний салаа

1B. Right Common Carotid

2. Left common carotid • Аортын нумын гарах 2-р салаа

15.Left common carotid

Common carotid artery хүзүүний C3-C6 түвшинд external ба internal болж сална.

Variants -Bovine arch

Left Common Cartotid Artery хэлбэрүүд :

• LCCA – дутуу хөгжсөн эсвэл огт байхгүй байж болно – ECA ICA салаанууд шууд аортын нумаас салаалж болно.

3. Left subclavian artery

• Аортын нумын сүүлийн салаа

Left subclavian artery Left

vertebral artery

Internal mammary

Thyrocervical

trunk Costocervic

altrunk

Left vertebral artery

• Зүүн subclavian artery- н эхний салаа

11.Left vertebral artery 14.Left internal mammary

хэлбэрүүд • Left vertebral artery – шууд аортоос салаалж

болно.

MRA – aortic arch

RSCA

LSCA Innominate artery

LCCA

RCCA RVA

LVA

ECA-branches

External carotid artery

Anterior

Superior thyroidal

Lingual

Facial

Posterior

Occipital

Posterior auricular

Medial

Ascending pharyngeal

Terminal

Maxillary

Superficial temporal

ECA – branches

ECA – branches

Superior thyroid arteryLingual artery

Facial artery

Occipital artery

Posterior auricular artery

Ascending pharyngeal artery

Early arterial phase of CCA angiogram

ECA – branches

Late arterial phase of CCA angiogram

Posterior auricular artery Occipital artery

Facial artery

Lingual artery

Superficial temporal artery

Maxillary artery

Transverse facial

ECA – төгсгөлийн салаа

• Дотор мaxillary артери – Салаанууд – inferior

alveolar, middle meningeal, deep temporal , accessory meningeal , sphenopalatine , infraorbital , descending palatine, булчингийн салаанууд.

– Цусан хангамж – Дура хальс болон гавлын ялтас.

Superficial temporal artery

• Цусан хангамж –хуйх болон

чихний хэсгүүд. • салаанууд – transverse facial

artery

STA

Middle meningeal artery

hairpin turn of STA

ECA – MRA

Oblique view – MRA

Vertebral artery

Thyrocervical trunk

Facial artery Lingual artery

Superficialtemporal artery

Occipital artery

Maxillary artery

ECA – MRA

Straight AP view – MRA

Superficial temporal artery

Hairpin turn of STA

Maxillary artery

Facial artery Lingual artery

Vertebral artery

Middle meningeal artery

нүүрний салстын судаснууд- (нүүр улайх)

Oropharynx mucosal blush

High nasopharynx mucosal blush

Orbital mucosal blush

Nasal conchae septal blush

Palatal mucosal blush

Тархины гадна болон доторх судаснуудын холбоосууд

Maxillary artery

•Middle meningeal artery•Foramen rotundum artery•Accessory meningeal•Vidian artery •Ant / mid deep temporal

ICA •Ethmoidal br of opthalmic artery•Inferlolateral trunk of ICA •Inferolateral trunk •Intratemporal ICA•Opthalmic artery

•Occipital•Ascending pharyngeal artery •Ascending pharyngeal artery •Facial artery•Posterior auricular artery

•Vertebral•Vertebral C3 level •ICA (petrous and cavernous )•ICA (opthalmic artery)•ICA (stylomastoid artery)

Тархины гадна болон доторх судаснуудын холбоосууд

Internal carotid artery

Left CCA Right CCA

Internal carotid- carotid bulb

ECA

3-D CTA

Internal carotid artery

Cervical

Intraosseous / petrous

Lacerum

Cavernous

Intracranial / supraclinoid

Opthalmic

Communicating

ICA SEGMENTS

ICA

Carotid bulb

Petrous

Cavernous Supraclinoid

Cervical

Oblique Lateral

Cervical segment

• нарийсалгүй• Өргөсөлгүй • салаалалтгүй ICA

ICA

ECA

Variants – cervical segment

ICAECA

Petrous segment C2

Vertical

HorizontalGenu

Axial NECT inferior to superior ( bone window )

MRA

Petrous – салаанууд

Petrous segment of ICA

Intrapetrous

Vidian artery (artery of Pterygoid

canal )

Corticotympanic artery

Vidian canal

Foramen lacerum Vidian canal

Lacerum

Carotid angiogram

Cavernous ICA

C4 segments 1. Ascending (posterior vertical )2. Posterior genu 3. Horizontal 4. Anterior genu 5. Anterior vertical

Салаанууд Meningohypophyseal artery Inferolateral trunk Small capsular branches

Carotid angiogram

Axial CT Posterior genu as it courses anteromedially into the cavernous sinus

ICA courses along the bony grooves of carotid sulcus along the basisphenoid bone

• Throu cavernous sinus proper turns superiorly • Form grooves under anterior clinoid process • Anterior genu of ICA .• Curve upwards towards dural ring• Enter subarchnoid space

Posterior genu

Carotid sulcus

Anterior genu

MRA

CECT

C4 within cavernous sinus

Menigohypophyseal artery

•Posterior trunk•Arises at junction of c4 and c5•Supplies – •pituitary gland•tentorium (artery of Bernasconi and Cassinari )•cavernous sinus• clival dura• cn3 n 4 •High quality D/FSA•Enlarges to supply dural vascular malformation / neoplasm

Inferolateral trunk

•Lateral mainstream artery •Arises – inferolaterally from c4 segment •Supplies – •CN 3,4,6 •gasserian ganglion CN5 •cavernous sinus dura •Anastomose with br of internal maxillary artery . Collaterals b/w ECA N ICA •DSA – lateral view •Enlarged – vascular neoplasm / malformation / collaterals to ECA

Clinoid segment C5

Opthalmic segment C6

CECT Anterior clinoid process C6

Opthalmic artery Origin –• Intradural •Antero-superior ICA • Medial to anterior clinoid process

Course –Anterior throu optic canal

Below optic nerve

Crosses superomedially over the nerve Supply -globe Gives off ocular , lacrimal , muscular branches •Anastomose with ECA

Mid arterial phase DSA

Lateral view MRA

Lateral DSA

Superior hypophyseal trunk

superior hypophyseal aneurysm

Communicating C7

C7 segment branches

Posterior communicating artery Anterior choroidal artery

Lateral DSA

AChA

PCoA3D CTA

Posterior communicating artery

•салаанууд – anterior thalamoperforating arteries •Цусан хангамж – optic chiasma, pituitary stalk , thalamus , hypothalamus.

Lateral late arterial DSA

MRA

Хэлбэрүүд – PCoA 1. Дутуу хөгжил – 1/3 тохиолддог 2. Infundibuli хэсэгт тэлэгдэж

өргөсөх 6% д тохиолддог 3. PCoA хоёрчлогдох

PCoA fenestration

PCoA hypoplasia

Infundibular -PCoA

•Infundibular- тэлэгдэл • Should be 2мм –с илүүгүй

өргөнтэй, юүлүүр хэлбэртэй өргөсөл үүсдэг

Within suprasellar cistern under optic tract

Posteromedially around temporal lobe uncus

Cisternal Course :

Intraventricular course:

AChA angles sharply laterally

Enters choroidal fissure of temporal bone

Abrupt kink – plexal point

AChA-origin few mms above PCoA

Cisternal segment

Intraventricular segment

Anterior choroidal artery

Цжсан хангамж Choroidal plexus of lateral ventricle ( temporal horn and atrium )Optic tract and cerebral peduncle Uncal and parahippocampal gyri of temporal lobe .Thalamus and posterior limb of internal capsule.

AP mid arterial DSA

AP Late arterial DSA MRA lateral view

Choriodal blush

Terminal ICA

Anterior cerebral artery Middle cerebral artery

3D CTA MCA

ACA

ICA

3D CTA Mid arterial phase DSA

Circle of willis- circulus arteriosus

2ICAs

Horizontal segment A1 of

both ACAs2 Posterior

communicating arteries Anterior

communicating artery

Horizontal segment P1 of

both PCA s

Basilar artery

Холбогдсон артериудБайрлал- их тархины доод гадаргууд,Харааны мэдрэлийн зөрлөгийн орчимд

Anterior circulation

2 B/L ICAs

2ACAs

Unpaired ACoA anteriorly

Posterior circulation

Basilar bifurcation from merged VAs

2PCAs from BAs

B/L PCoAs

3DVRT CTA MRA

CT MRA

1. A12. P13. PCoA4. ACoA

Виллисын цагираг-г шинжлэх аргуудCerebral angiography- single injection

Contrast enhanced CT – maximum intensity projection

Invasive

MRA- time of flight sequence with multiple overlapping thin slab technique

Transcranial Doppler ultrasound

Non invasive

COW – салаанууд

• Medial lenticulostriate arteries• Recurrent artery of HeubnerACAs• Perforating branches – hypothalamus , optic chiasma ,

cingulate gyrus , corpus callosum , fornix • Large vessel – median artery of corpus callosum arises

from ACoA ACoA

• Anterior thalamoperforating arteries PCoA• Posterior thalamoperforating arteries • Thalamogeniculate arteries

Basilar artery, PCAs

Цусан хангамж- 1.Optic chiasma and tracts

Variants -COW Complete COW –only 20 –

25% Posterior circle anomalies –

50% anatomy specimens Common variants •Hypoplasia of 1 or both PCoA – 34%•Fetal origin of PCA from ICA

•Hypoplasia or absent A1 ACA segment. •Absent , duplicate or multichannel ACoA – 10-15%

Variants - COW

• Cerebral arteries • Vertebral artery • Basilar artery

CEREBRAL ARTERIESDistal ICA

Anterior cerebral artery

Middle cerebral artery

Basilar artery

Posterior cerebral artery

Anterior cerebral artery

A1 horizontal segment

• From ACA origin to ACoA junction.• Доод салаа нь - superior surface of optic

nerve and chaisma.• Дээд салаа нь – anterior hypothalamus ,

septum pellucidum , anterior commisure , fornix , anterior inferior portion of corpus straitum.

Medial lenticulostriate artery.

Recurrent Artery of Heubner

• Largest of the perforating branches.

• May arise from A1 or A2 segment.

• A1 – 44%• Proximal A2 – 50%• ACoA – less common • Derives its name from the

fact that it doubles back on its parent artery at an acute angle to join lenticulostriate vessel.

• Lies parallel to A1.

A2 segment- Interhemispheric segment From ACoA junction

Ascend in front of 3rd ventricle in cistern of lamina terminalis

br –Orbitofrontal, frontopolar

Curves around corpus callosum genu gives terminal branches

A2 terminal branches-

Pericollasal

Collasomarginal

Cortical A3 segment

• Supply the anterior 2/3rds of medial hemispheric surface + small superior area over the convexities.

• Callosomarginal a.– lies in cingulate gyrus supplies medial frontal lobe

Cortical branches – territories

Lateral DSA mid arterial phase

A1

A2

A3

orbitofrontal

CallosomarginalPericollasal

Medial lenticulostriate

Recurrent artery heubner

Pericollasal

A2

Orbitofrontal

Frontopolar

A3

Callosomarginal

AP DSA mid arterial

3D MRA

A2

Pericollasal

Callosomarginal

ACA– ACoA complex

• ACoA -Part of COW -not a true branch of ACA

• Branches – perforating • Supply –Lamina terminalis ,

Hypothalamus , Anterior commissure , Fornix, Septum pellucidum , Para olfactory gyrus , Subcellosal region , Anterior part of cingulate gyrus

Duplication ACA

Fenestration / duplication of ACA

Azygous ACA – solitary unpaired vessel

Single trunk from confluence of A1 segments of right n left ACAs- supplies both hemispheres .

Assc with lobar holoprosencephaly, saccular aneursym

• Normally A1 segment runs over the optic nerve.

• Here it runs below the optic nerve.

• Assc with aneurysms .

• Recognised before surgeries.

Infraoptic origin of ACA

Variable branches to C/L hemisphere.

Separate right n left ACA. 1 ACA is dominant than

other and it sends branches to other hemisphere.

Other ACA is hypoplastic – terminate as orbitofrontal or frontopolar branch.

Bihemispheric ACA

Middle cerebral artery

M1 horizontal

Origin -Laterally from ICA bifurcation

Till its bi/trifurcation at sylvian fissure.

Br – Lateral Lenticulostriate branch course

superiorlyAnterior temporal

artery Supplies-Lentiform nucleus

Part of IC , caudate nucleus

M2 insular

At its genu divides into branches

Loop over insula pass laterally to exit from

sylvian fissure

M3 opercular

Emerge from sylvian fissure

Ramify over hemispheric surfaceSupplies –cerebral cortex and white

matter

Cortical branches 1. Orbitofrontal artery (lateral

frontobasal )2. Prefrontal arteries 3. Precentral (prerolandic )4. Central sulcus (rolandic) 5. Postcentral sulcus (anterior

parietal) artery 6. Posterior parietal artery 7. Angular artery 8. Posterior temporal 9. Temporooccipital artery 10. Medial temporal

AP DSA mid arterial phase

AP DSA early arterial phase

Early arterial phase

Lateral DSA Mid arterial phase

Lateral

•M1 horizontal •MCA bifurcation •M2 insular •M3 opercular

CT

MRA

Lateral Lenticulostriate Artery

• Origin - M1 • Supplies – • Part of head and

body of caudate • Globus pallidus • Putamen • Posterior limb of

internal capsule

Sylvian segment territory

• Supplies • Inferolateral

frontal lobe • Insular cortex • Parietal lobe • Temporal lobe

Cortical segment territory

• Supplies – • Lateral

cerebrum • Insula • Ant- lateral

temporal lobe

Variants- MCA

• Less frequent • Fenestration and duplication • Single trunk • Accessory arteries

All uncommon ≤5 %

MCA fenestration

Accessory MCA

• It is either hypertrophied RA heubner or medial ACA perforator.• To be called accessory MCA it should have cortical branches.

PCA origin from bifurcation of basilar artery in interpeduncular cistern.Lies above occulomotar nerve. Circles midbrain above tentorium cerebelli.

Posterior cerebral artery

Posterior cerebral artery

P1 precommunicating / peduncular

•Basilar bifurcation extends laterally •Junction with PCoA•Br – •Post thalamoperforating-thalamus , midbrain •Medial posterior choroidal artery – anteromedially along roof of 3rd ventricle –tectal plate , midbrain , thalamus posterior , pineal gland , tele choroidae of 3rd ventricle.

P2 ambient / crural

•PCA- PCoA junction posterior •Above trochlear nerve and tentorial incisura •Br – •Thalamogeniculate arteries- MGB , pulvinar , brachium superior colliculus , crus cerebri , LGB •Lateral post choroidal artery – over pulvinar of thalamus – posterior thalamus , lateral ventricular choroid plexus

Inferior temporal artery • Undersurfac

e of temporal bone

• Anastamose -MCA

Parietooccipital artery• Posterior

1/3rd interhemispheric surface

• ACA Calcarine artery( P4 )• Visual cortex• Occipital

pole

Posterior pericollasal artery (splenial)• Splenium of

corpus callosum

• ACA

AP DSA

AP DSA mid arterial phase

Early arterial phase

Lateral DSA Mid arterial phase

MRA

CTA

Cortical territory

• Supply – • Medial +posterior

temporal lobe • Medial parietal

lobe • Occipital lobe

Variant – PCA • Fetal origin of PCA from ICA instead of basilar – 15- 20 %• Carotid basilar anastomosis – supply PCA via trigeminal artery or

other persistent channels

Vertebral artery V1 Courses –Cephalad to enter

transverse foramina at C6

Ascend directly to C2 (V2)

Turns laterally and superiorly thro C1 vertebral foramina

Looping posteriorly along atlas V3 extraspinal

Each VA passes superomedially thro foramen magnum

In Posterior fossa anterior to medulla (intradural )

VAs unite to form basilar artery

From subclavian arteriesLeft VA dominant 50%

Extracranial VA branches

1. V1-Small segmental spinal/ meningeal/ muscular branches.

2. V2- Anterior Meningeal artery , muscular branches.

3. V3 -Posterior Meningeal artery – Courses along posterior arch of

atlas. – Supplies falx cerebri – Variant – origin from ECA / PICA. – Greatly enlarged with vascular

malformations and neoplasms

Posterior meningeal artery

Intracranial VA branches

Vertebral artery

Anterior spinal artery

Medial medullary syndrome

Posterior inferior cerebellar artery

Arises from distal VA

Lateral medullary syndrome

Lateral DSA

AP DSA

V1- extraosseousV2 –foraminal V3 – extraspinal V4 – intradural

At c7 level At C6 level

At C1 C2 level At spinal cord and pons level

Posterior inferior cerebellar artery

• Front of medulla Anterior medullary segment

• Along side of medulla caudally to level of CN 9-11Lateral medullary segment

• Around inferior half of cerebellar tonsilTonsilomedullary segment

• Cleft btw tela choridae and inferior medullary velum rostrally and superior pole of tonsil caudally Telovelotonsillar segment

Cortical / hemispheric segment

Lateral DSA early arterial

Lateral DSA late arterial

Anterior medullary segment Posterior medullary segment Lateral medullary segment

• Choroid plexus of 4th ventricle.

• Posterolateral medulla. • Cerebellar tonsil. • Inferior vermis. • Posteroinferior cerebellar

hemisphere.

Supplies

PICA territory

Variants –

• Persistent vertebrobasilar anastamosis

• Left VA – aortic arch origin – 5%

• Hypolastic VA – 40 %

Hypoplastic VA

Hypoplastic VA terminating as PICA VA terminates in PICA – 1%

Duplicated VA

Orange arrow – duplicated VA Red – original VA from subclavian

VA duplication- ocassionally

Fenestrated VA

VA fenestration – occasionally

Extracranial PICA Extradural origin of PICAPICA from VA below foramen magnum

Basilar artery

Right and left VA s unite – BA

Course cephalad in front of pons

Pontine cistern in the space delineated by lateral margin of clivus and dorsum sellae

Terminates in interpeduncular cistern

Divides into PCAs

•Average length – 3 cm •Width 1.5- 4 mm •Diameter <4.5 mm

BA - Branches 1. AICA – Anterior Inferior

Cerebellar Artery – 1st major branch. – Posterior laterally in cerebellopontine

angle cistern toward the internal auditory canal. Here typically anteroinferior to facial and vestibulocochlear nerve.

– Few mms from origin AICA crossed by abducens nerve.

– Supplies- • Nerves • Inferolateral pons • Middle cerebellar peduncle • Flocculus • Anterolateral cerebelllar hemisphere

BA –branches 2. SCA- Superior Cerebellar Artery – – Arises from BA apex.– Posterolaterally around Pons and

mesencephalon below tentorial incisura and CNS 3 n 4.

– Supplies – • Superior surface of vermis n

cerebellar hemisphere. • Deep cerebellar white matter. • Dentate nucleus.

• Perforating branches – short n long segment

• BA – terminates into PCA s

AP DSA

MRA

Variants - Nonfused basilar

Variants -Basilar fenestration

Variants -AICA duplication

Variants -SCA origin from PCA / ICA directly

SCAs- can arise from P1 segment