You are on page 1of 64

VASCULAR ANATOMY

and
CSF SPACES
OF THE BRAIN
SUYOGYA
-Resident,
Radiology

Highly vascular organ


High metabolic activity
15% of cardiac output
25% of total oxygen consumption
by the body
Two interconnected arterial
systems provide the blood supply
to the brain that form complex
anastomosis on the base of brain
(The circle of willis).
- A complete Circle of Willis is,
however, only seen in up to 24% of
individuals
- Variation of COW is rule; not an
exception. Absent Pcoa is the most
common variation.

Basic Neurovascular
histology:
Lack external elastic
lamina
Relatively deficient in
tunica media and
adventitia
Diseases of the cerebral
vasculature are different
from those of other
vascular distributions
due in large part to the
structural differences of
the cerebral arteries.

Internal carotid system (anterior circulation): Ipsilateral cerebral hemisphere, except for the medial
surface of the occipital lobe and the medial and inferior
surfaces of the temporal lobe.
Structures perfused by the anterior circulation include
evolutionarily younger parts of the brain including
the neocortex of the cerebral hemispheres.
These structures are highly sensitive to ischemia and
reperfusion hemorrhage if the occluded vessel is opened
later than 6 to 8 hours after symptom onset.

Vertebral-basilar system:
- Medial surface of the occipital lobe and the medial and
inferior surfaces of the temporal lobe.
- Brainstem and cerebellum.
- Structures perfused by the posterior circulation include the more
primitive brainstem and cerebellum, which may be more
resistant to ischemia and the clinical sequelae of infarction.
- Because of these, attempts to reperfuse the posterior circulation
during ischemic stroke are not as strictly limited by time from
symptom onset.
- Infarction in the posterior circulation can lead to the
locked-in syndrome.

SEGMENTS OF ICA:
C1 : cervical segment
- none
C2 : petrous segment
caroticotympanic artery
vidian artery

C6 : Supraclinoid segment

ophthalmic artery
superior hypophyseal
artery

C7 : communicating segment

posterior
communicating artery
anterior choroidal
artery
Cavernous segment:
meningohypophyseal
anterior cerebral
Three subsegments and two genu
The trunk
abducens nerve is inferolateral to ICA.artery
inferolateral trunk
middle cerebral artery
C5 : clinoid segment none

C3 : lacerum segment
- none
C4 : cavernous
segment

Aberrant
ICA
Congenital variant.
Cervical part of ICA is
lost, which is replaced
by enlarged
caroticotympanic
artery.
Radiologist failing to diagnose this condition may
lead to massive/fatal bleeding when operated or
biopsied.

AbICA hugs the cochlear promontory and crosses through


the middle ear cavity.

OPHTHALMIC ARTERY:
First intradural branch of
ICA
Aneurysms above the ICASAH- neurosurgical
intervention
Aneurysms below ICA- No
SAH- generally not treated
unless complications arise
like Carotid cavernous
fistula

ANTERIOR CEREBRAL ARTERY


Smaller of the two
terminal branches
Supplies most of the
medial surface of the
cerebral cortex, frontal
pole and anterior portions
of the corpus callosum
Branches
Superficial (cortical)
Deep (central, perforating).

ACA is divided into


three segments:
A1 : origin from the
ICA to the anterior
communicating
artery (ACOM).
A2 : from ACOM to
the origin of the
callosomarginal
artery
A3 : distal to the
origin of the
callosomarginal
artery (aka
pericallosal artery)

Heubner's artery:
Very closely related to AcoA.
Occlusion sometimes occurs during clipping of an
anterior commissure aneurysm resulting in an
ischemic
infarction
of the head
From
ICA bifurcation
to of the caudate that
manifests
in the days after the surgical procedure.
ACoA
Courses horizontally from
lateral to medial direction.
Perforating branches
( including the
recurrent artery of
Heubner and medial
lenticulostriate artery)
supply the anterior limb of
the internal capsule, the
inferior portions of head of
the caudate and anterior
globus pallidus.

A1 segment

A2 SEGMENT
ACoA junction to
bifurcation
Courses cephalad and
curves around the
genu of CC and gives
terminal branches
Branches
Rec artery of
Heubner
Orbitofrontal artery
Frontopolar artery

CORTICAL BRANCH AND VASCULAR


TERRITORY
Callosomarginal artery

One of the two terminal branches


In callosomarginal sulcus (while in the sulcus, it may
be lateral to the midline, should not be mistaken for a
true displacement by a mass)
Gives numerous branches (anterior, middle and
posterior internal frontal branches), and terminates in
the paracentral branch around the paracentral lobule

Pericallosal artery
Continuation of ACA over CC
Posteriorly anastomose with splenial artery of PCA

Territory: Anterior two-third of medial hemisphere


plus small superior area of cerebral convexity.

MIDDLE CEREBRAL
ARTERY
Larger of the two
terminal branches.
Supplies most of the
temporal lobe,
anterolateral frontal
lobe, and parietal lobe
Major segments
Horizontal/sphenoidal(
M1) segment
Insular( M2) segment
Opercular ( M3)
segment
Most frequently involved artery in ischemic stroke.
Cortical (M4)
Most commonly catheterized artery in the brain.

M1
SEGMENT

from the origin to


bifurcation/trifurcati
on
also known as
horizontal or
sphenoidal segment
Branches: lateral
lenticulostriate
arteries supplying
lentiform nucleus,
IC and caudate
nucleus.

Lenticulostriate arteries are end arties supplying the basal


ganglia and the internal capsule.
Lack of collaterals to these structures renders them particularly
vulnerable to reperfusion hemorrhage in the setting of ischemic
stroke

INSULAR( M2) SEGMENT


From bi(tri)furcation to circular
sulcus of insula where it makes
hairpin bend to continue as M3
M1 segments divides into
insular branches (superior and
inferior) in the sylvian fissure,
which can be site for embolus to
lodge
These insular branches loop
over the insula and pass laterally
to exit from the sylvian fissure.
Supply: temporal lobe and
insular cortex, parietal lobe
(sensory cortical areas),
inferlolateral frontal lobe

OPERCULAR (M3) SEGMENT


These are the MCA
branches as they
emerge from the
sylvian fissure.

Ramify over the


hemispheric
surface
Classically much of
the cerebral cortex
and white matter
are supplied by
MCA branches.

ANGIOGRAPHIC SYLVIAN POINT


Sylvian point:
The uppermost and most medial part of
the outer surface of the insula
Here, the last cortical MCA branch (the
angular artery) turns inferolaterally to exit
the sylvian fissure.
Represents the posterior limit of the
lateral cerebral sulcus.

Angiographic landmark for localizing supratentorial masses.

Sylvian triangle:
Anterosuperior point: Top of the most anterior identifiable opercular
branch
Posterosuperior point: Top of the most posterior identifiable
opercular branch
Anteroinferior point- Most anterior part of the trunk of MCA
Superior insular line- Join the Anterosuperior and Posterosuperior
point
Inferior insular line- Join the Posterosuperior and anteroinferior point
Anterior insular line- Join the Anterosuperior and anteroinferior point.

Vertebral and
basilar arteries
The VAs supply the posterior
circulation of the brainstem,
cerebellar hemispheres, and
posterior cerebral
hemispheres.
These arteries typically arise
from the SCAs bilaterally.
Anatomic segments:
Extraosseous segment (V1),
the foraminal segment (V2),
the extradural segment
(V3), and the intradural
segment
The larger (V4
of the two VAs is sometimes
denoted as dominant, making the most
common relationship a left dominant

Intraspinal branches of
vertebral artery:
1. Anterior spinal artery
2. Posterior spinal
artery
3. PICA
4. Medullary arteries

Basilar artery:

Formed at the pontomedullary junction.


Branches include:
1. Pontine arteries- paramedian, short
circumferential and long circumferential arteries
2. Labyrinthine arteries
3. Anterior inferior cerebellar artery
4. Superior cerebellar artery
5. Posterior cerebral artery.

Blood supply of Medulla


and Medullary syndromes

Lateral part of medulla of WallenburgBy PICA- Lateral medullary syndrome.


Medial part of medulla (Dejerine
Syndrome)- By ASA- Medial medullary
syndrome
PICA- Most common site of posterior

Blood supply of
pons and Pontine
syndrome:
1. Paramedian
branches
2. Short
circumferential
branches
3. Long
circumferential
branches
4. Enforcement from
the AICA and SCA.

Pontine syndromes continued


Lateral pontine
syndrome- Similar to
Lateral medullary
syndrome of
Wallenburg; AICA is
involved
Medial pontine
syndrome- Similar to
Medial medullary
syndrome

Posterior cerebral artery:


Formed by bifurcation of basilar artery on
the upper part of anterior surface of pons.
PCA divided four segments.
P1: extend from its origin from the basilar
artery to the junction with the P com
(within the interpeduncular cistern)
P2 From the Pcom to the posterior
aspect/dorsal aspect of the midbrain
(ambient segment)

P3 From the posterior aspect of the


midbrain to the calcarine fissure
(quadrigeminal segment)

P4 The terminal branches of the PCA distal


to the anterior limit of the calcarine fissure
(cortical segment)

Fetal origin of PCA and Artery of


Percheron:
Fetal origin of PCA:
Seen in 10-30% of cases.
Proximal PCA arises from
the ICA instead of from the
basilar bifurcation.
Usually there is hypoplasia
or absence of the P1
segment of the posterior
cerebral artery at the
same side. This variant is
seen in 15% to 25% of
cases.

Artery of Percheron:
Single dominant thalamoperforating artery arises
from the p1 segment and supplies the rostral
midbrain and bilateral medial thalami.

TERRITORIAL STROKES AND


VASCULAR ANATOMY

Territorial strokes are


used as a learning tool
to understand the
vascular anatomy of
brain.

Formation of CSF:
80%- Mostly from choroid plexuses of lateral ventricles, 3 rd
ventricle and 4th ventricle.
20%- From interstitial spaces of brain through ependymal
epithelium and from the blood capillaries of pia arachnoid.
Rate of CSF secretion- 0,3-0.4 ml/min
Total CSF volume is CSF 90-150. Intracranial = 125 ml
(Ventricles= 25 ml and cranial subarachnoid space=100 ml)
Normally 50% of the total volume of CSF is replaced every five to
six hours.

CSF Spaces
The brain is surrounded by cerebrospinal fluid (CSF)
within the sulci,fissuresandbasal cisterns. CSF is
also found centrally within theventricles.
The sulci, fissures, basal cisterns and ventricles together
form the 'CSF spaces', also known as the 'extra-axial
spaces'.

Circulation
Lateral ventricle foramen of monro
3rd ventricle Aqueduct of sylvius 4th
ventricle foramen of Magendie,
foramen of luschka SA spaces.
From 4th ventricle some CSF trickles down
to central canal of spinal cord.
Absorbed through arachnoid villi and
arachnoid granulations into venous
sinuses of dura mater

Arachnoid villi (pacchionian


bodies)
Small granular bodies
along venous sinuses
especially superior
sagittal sinus.
Represent invasion of
dura by arachnoid
membrane, covered by
endothelium of venous
sinuses.
Rarely seen in infants
(Upto 3 years)

Lateral Ventricle Curves through Each Cerebral Hemisphere

AC-shaped structure.
Curves from aninferior
hornthroughbodyin the parietal lobe
ending at the interventricular
foramen.
Two extensions: Posterior hornthat
extends backward into the occipital
lobe. Anterior hornthat extends
farther into the frontal lobe
The expanded area where the body
and the inferior and posterior horns
meet is called theatrium. Splenium
of corpus callosum arbitrarily
separates the body from trigone
Each lateral ventricle represents

Ventricles of brain
Series of communicating cavities lined by ependymal
epithelium and contain CSF.
Communicate with SA spaces around brain and around
spinal cord and with central canal of spinal cord.
Left lateral ventricle (1st ventricle)
Right lateral ventricle
Third ventricle
Fourth ventricle

Anterior horn boundaries:

Body of Lateral Ventricle

Posterior horn

Inferior horn

Dimensions:
Frontal horn of LV at the level of foramen Monro:
<40yrs: <12mm
>40yrs: <15mm

Ventriculohemispheric ratio:
<33% in adults
<40% in children.

Third ventricle
Interventricular foramina
communicating opening b/w lateral
ventricle and 3rd ventricle.
Lateral wall-Thalamus,
hypothalamus
Post wall indented by pineal gland
The lateral walls of the third
ventricle are joined by an
interthalamic adhesion, or massa
intermedia, a band of grey matter
that extends from one thalamus to
the other.

Width of 3rd
ventricle
<5mmchildren
<7mm-<60
Reasonable
as
yrs to use 7 mm
rd
an average
width
of
3
<9mm->60
ventricle during the second
decade yrs
and add 1 mm for

each decade upto 70 years.

Anterior wall Ant. Commissure, column of


fornix and lamina terminalis
Floor-optic chiasma, infundibulum, tuber cinereum,
mammillary bodies, posterior perforated substance

Roof-behind iv foramina composed largely of choroid plexu

The lamina terminalis forms the roof of the small virtual


cavity lying immediately below the ventricle, called the
cistern of the lamina terminalis.
This is important because it contains the anterior
communicating artery, and aneurysm formation at this site
may cause intraventricular hemorrhage through the thin
membrane of the lamina terminalis.

Choroid plexuses
Vascular plexus of piamater which
enters ventricles invaginating
ependymal wall modified as a
secretory epithelium and secretes
CSF.
Supplied by the Anterior and posterior
choroidal artery.
Situated in the body, inferior horn of lateral
ventricle, 3rd ventricle and 4th ventricle
The venous blood drains into the internal
cerebral veins great cerebral vein
Straight sinus.

4th ventricle
Rhomboid fossa
Situated b/w pons and upper half of medulla in front and
cerebellum behind.
Triangular in sagittal ; bean shaped in axial (Posterior
indentation formed by facial colliculus)
3 openings
Median aperture of Magendie-situated in lower part of roof
Lateral aperture of Luschka at the end of each lateral recess
Recesses: lateral, median dorsal and lateral dorsal

SUBARACHNOID CISTERNS
Large SA spaces at certain places.
Acts as the cushion around the medulla and other brain
structures.
Pulsations of arteries within the cistern helps to force
the CSF.
Cistern has density of CSF.

The parasellar cisterns


contain
a segment of the
oculomotor nerve
posterior communicating
and anterior choroidal
arteries
the basal vein.

Pontine cistern:
Pontine cistern:
The 5thcranialnerve, the
superior cerebellar artery,
the4th8thand 7thcranial
nerves, the loop of the
anterior-inferior cerebellar
artery
The 9th, 10thand
11thcranial nerves in close
relationship with the
posterior-inferior cerebellar
artery
The 12thcranial nerve and
the basilar artery.

Sylvian cistern
contains the M1 segment
of the middle cerebral
artery, the origin of the
lenticulostriate branches
and the first portion of the
basal vein.
Interpeduncular cistern:
Bifurcation of the basilar
artery and the apparent
origin of the 3rdcranial
nerve.

Ambient and quadrigeminal


cisterns or cistern of the
great cerebral vein:it is
located between the splenium
ofthecorpus callosumand the
cerebellum and contains the
great cerebral vein, thus the
name, the apparent origin of
the 4thcranial nerve, and the
pineal gland.

Retrothalamic cistern:
Also considered the "wings"
of the ambient cistern, are
the lateral extensions of
the ambient cisterns
located posterior to the
pulvinar nuclei

Cisterna Magnaor
cerebello-medullary
cistern:
It is the biggest of the
subarachnoid cisterns.
Located under the
cerebellum and behind the
medulla oblongata.
It communicates with the
fourth ventricle (via the
median aperture or
foramen of Magendie), the
medullary subarachnoid
space, and the pericerebellar subarachnoid
space.

THANK YOU

Questions
1. Segments of ACA
2. Segments of MCA
3. Segments of VA
4. Aberrant ICA
5. Artery of Percheron
6. Parts of lateral ventricle
7. Name of Ventral cisterns
8. Name of Dorsal cisterns
9. Name of communicating cisterns

You might also like