01/25/2018

7:30-9:30 Vascular Supply of the Brain and Spinal Cord

TTh Neuroanatomy
Anatomy Bldg Abad, M.D. - January 22, 2018

OUTLINE

I. Blood Supply of the Brain o ethmoidal cells

A. Anterior Circulation o nasal cavity
B. Posterior Circulation
C. Circle of Willis o dura of anterior cranial fossa
II. Blood Supply of the Spinal Cord o skin of the forehead
A. Arterial Supply
B. Venous Supply o root of nose and eyelids
III. Recombinant Tissue Plasminogen Activator o anastomose with the facial and internal maxillary arteries

BLOOD SUPPLY OF THE BRAIN (branches of external carotid artery)

The brain is supplied by two internal carotids and two vertebral MIDDLE CEREBRAL ARTERY
arteries. The four arteries lie within the subarachnoid space, and their • the largest of all cerebral arteries
branches anastomose on the inferior surface of the brain to form the • supplies the:
circle of Willis. o putamen
o globus pallidus
Anterior Circulation (Carotid System)
1. Internal Carotid Artery o caudate nucleus (striatum branches – source of HPN
2. Middle Cerebral Artery hematoma)

3. Anterior Cerebral Artery o external capsule

o claustrum
INTERNAL CAROTID ARTERY • branches of MCA:
 from Common Carotid Artery o Orbitofrontal

• it is found in the right of brachiocephalic trunk and left on aortic O Prerolandic

arch; division into internal and external carotid artery - level of thyroid o Rolandic
cartilage O Anterior parietal

• it passes through the carotid canal of petrous (temporal) bone in oPosterior parietal

the region of the medial end of the lateral cerebral sulcus *Angular artery – longest branch, reaches the occipital pole
It divides into:
○ anterior cerebral artery ANTERIOR CEREBRAL ARTERY

○ middle cerebral artery • supplies the:

o striate body
EXTERNAL CAROTID ARTERY o ventral anterior limb of internal capsule

• supplies the: o septal region

o neck o anterior commissure

o face o optic chiasm

o frontotemporal regions of the cranium • Striatum artery (recurrent artery) – longest of the branches

• small branches: • Major branches of the ACA at the interhemispheric cistern:

o floor of the middle ear o Orbital
o dura of clivus o Frontopolar
o semilunar ganglion of trigeminal nerve o Pericallosal

o pituitary gland o Callosomarginal

• ophthalmic arteries (subarachnoid space): o Parietal branches
o orbital structures

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 Posterior Circulation (Vertebral - Basilar System)
1. Posterior Cerebral Artery
2. Basilar Artery
3. Vertebral Artery

POSTERIOR CEREBRAL ARTERY

• Its terminal branches are occasionally an extension of the internal
carotid artery
• supplies the:
o midbrain
o rostral half of the pons
o thalamus
o choroid plexus of the third ventricle
• branches of the PCA (called Ammon’s horn arteries)
o Anterior temporal artery
o Posterior temporal artery
o Posterior occipital artery
o Calcarine artery
o Parieto-occipital artery
*these are vulnerable to compression during hippocampal herniation
Circle of Willis
Formed by the anastomoses between:
○ Two Internal Carotid Arteries
○ Two Vertebral Arteries
At subarachnoid space, beneath the optic nerve then optic chiasm
 Posterior Communicating artery
 Anterior Choroidal artery
 Anterior Cerebral artery
 Anterior Communicating artery

POSTERIOR COMMUNICATING ARTERY

(Distribution)
 Tuber cinerum, mamillary bodies
 Anterior third of the thalamus
 Subthalamus
 Part of the posterior limb of internal capsule
VERTEBRAL ARTERY
• first branch of subclavian artery ANTERIOR CHOROIDAL ARTERY
• traverses the upper six foramina of cervical vertebrae, enter the Supplies:
atlas and foramen magnum o Lateral geniculate body
• at the pontomedullary junction, the two vertebral arteries merge to o Choroid plexus of the inferior ventricular horn,
form the basilar artery o Optic tract,
o Uncus and hippocampal gyrus,
o Internal capsule,
o Midbrain

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  Anastomoses with the posterior choroidal artery (branch of o Anterior temporal artery
the posterior cerebral artery) o Posterior temporal artery
o Posterior occipital artery
Anterior Cerebral Artery o Calcarine artery
 Supplies: o Parieto-occipital artery
o Striate body
o Ventral limb of internal capsule Peripheral Anastomoses of Cerebral Arteries
o Septal region 1. Anterior and Posterior choroidal/ Ammon’s horn arteries
o Anterior commisure 2. Anterior and Middle Cerebral artery (at Precentral and
o Optic chiasm Central areas)
 Striatum artery(recurrent artery) – longest of the branches 3. Middle and Posterior cerebral arteries at precuneus
Five Major Branches at interhemispheric cistern:
1. Orbital
2. Frontopolar
3. Pericallosal
4. Callosomarginal
5. Parietal branches

Middle Cerebral Artery

 The largest of all cerebral arteries
 Supplies:
o Putamen
o Globus pallidus
o Caudate nucleus( striatum branches- source of
HPN hematoma) Signs and Syndromes of Cerebral Circulatory Deficiencies

o External capsule 1. Vertebrobasilar Insufficiency

o Claustrum 2. Internal Carotid Artery Deficiency

 Sub Branches: 3. Arterial Aneurysm

1. Orbitofrontal 4. Hypertensive Arterial Disease and Intracerebral Bleeding

2. Prerolandic
3. Rolandic Veins and Dural Sinuses

4. Anterior parietal 1. External Veins- Blood capillaries -> large dural sinuses ->

5. Posterior parietal internal jugular veins -> brachiocephalic vein -> superior

 Angular artery – longest branch, reaches the occipital lobe vena cava -> heart
o Remove blood from cortex, subcortical white

Posterior Cerebral Artery matter, pallidum, striata, thalamus

 Its terminal branches are occasionally an extension of the 2. Internal Veins

internal carotid artery o Drains blood from:

 Supplies:  white matter

o Midbrain  pallida

o Rostral half of pons  striata

o Thalamic  thalami

o Choroid plexus of the third ventricle

 Ammon’s horn arteries- branches of PCA
- These are vulnerable to compression during hippocampal
herniation

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 Symptomatology of Venous and Sinus Thrombosis could increase the amount of bleeding and possibly cause more
1. Acute Cerebral Venous Thrombosis damage to the brain. A CT scan or MRI of the head is done to confirm
Venous obstruction -> capillaries and venules become there is no bleeding in the brain before tPA is given.
engorged -> congestive hemorrhages in gray or white
matter When is tPA used?
BLOOD SUPPLY OF THE SPINAL CORD tPA has been approved to treat brain attacks in the first
Arterial Supply
three hours following the onset of symptoms. If given promptly, 1 in 3
Spinal arteries from the vertebral artery
patients who receive tPA resolve their symptoms or have major
1. Anterior Spinal Artery (1)
improvement in their stroke symptoms.
2. Posterior Spinal Arteries (2)
Radical arteries: segmental arteries from the vertebral, ascending
What are the risks of tPA?
cervical, intercostals and lumbar artery
Bleeding (hemorrhage), in the brain or in other parts of the
body, is the most common risk that can occur. In 6 out of 100 patients,
bleeding may occur into the brain and cause further injury. For 1 of
these 6 patients it may cause death or long term serious disability.

Should everyone receive tPA therapy?

Unfortunately the answer is no. Persons who cannot be
treated within three hours of their first symptom, patients with certain
medical conditions, and patients with certain types of strokes will not
qualify for this treatment.

Inclusion and Exclusion Criteria for Recombinant Tissue Plasminogen

Activator (IV rtPA)

IV rtPA Inclusion Criteria

Venous Supply  0 to 3‐Hour Time Window
1. Longitudinal veins  Ischemic stroke causing a measurable neurologic deficit
2. Radicular Veins  Onset time < 3 hours before initiating treatment
 Age ≥ 18 years
RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR
IV rtPA Exclusion Criteria,
What is tPA?
 0 to 3‐Hour Time Window
tPA is a medication that dissolves blood clots. It is called a
 Significant head trauma or stroke in prior 3 months
thrombolytic agent or more commonly referred to as the “clot
 Subarachnoid hemorrhage
buster.” It is an intravenous or IV medication usually given through a
 Arterial puncture at noncompressible site in prior 7 days
catheter inserted into a vein in the arm.
 History of prior intracranial brain hemorrhage
 Any CT finding suggestive of intracranial hemorrhage
What type of stroke is IV tPA used for?
 Intracranial neoplasm, arteriovenous malformation (AVM),
It was approved by the FDA in 1996 to treat ischemic type
or aneurysm
strokes. About 8 out of 10 brain attacks/strokes are ischemic. These
 Recent intracranial or intraspinal surgery
types of strokes are most often caused by blood clots that block the
 Blood pressure > 185/110 mm Hg
flow of blood to the brain causing tissue death. tPA is given to help
 Active internal bleeding
dissolve the clot quickly and restore the blood flow to the brain tissue.
 Bleeding diathesis (eg, platelet count < 100,000/mm3
The other common type of brain attack is called a hemorrhagic stroke.
 heparin administration within 48 hours resulting in
This brain attack/stroke is due to bleeding from a blood vessel into
abnormally elevated activated partial thromboplastin time
the brain. tPA is not used with this type of brain attack because it
(aPTT) greater than the upper limit of normal,

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  current use of anticoagulant with international normalized
ratio (INR) > 1.7 or prothrombin time (PT) > 15 seconds
 current use of direct thrombin inhibitor or factor Xa inhibitor
with elevated sensitive laboratory tests (eg, aPTT, INR,
platelet count, and ecarin clotting time [ECT], thrombin
time [TT], or appropriate factor Xa activity assays)
 Blood glucose < 50 mg/dL
 Multilobar brain infarction (> 1/3 cerebral hemisphere)

IV rtPA Relative Exclusion Criteria

(After careful consideration of anticipated risks and benefits, IV rtPA
may be administered in the following circumstances):
 Minor or rapidly improving neurologic symptomS
 Pregnancy
 Seizure at onset with postictal residual neurologic
impairments
 Major surgery or serious trauma within prior 14 days
 Gastrointestinal or urinary tract hemorrhage in prior 21 days
 Myocardial infarction in prior 3 months

SOURCES
MAM Trans
Dr. Abad’s Lecture
Clinical Neuroanatomy by Richard Snell
Jauch EC, Saver JL, Adams HP Jr, et al;
American Heart Association Stroke Council;
Council on Cardiovascular Nursing;
Council on Peripheral Vascular Disease;
Council on Clinical Cardiology.
Guidelines for the early management of patients with acute ischemic
stroke: A guideline for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2013;44(3):870
‐947

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