arterial and venous supply of brain
TRANSCRIPT
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
