Cerebrovascular Organization

Diana Casper, Ph.D.
Director, Neurosurgery Lab
Montefiore Medical Center and the Albert 
Einstein College of Medicine
The Bronx, NY
   
 Why is it important to know the 
organization of the brain 
vasculature?

   
 Because….
• The brain is exquisitely sensitive to
changes in blood supply
• 2% of body weight, but 20% of oxygen
consumed
• Neurons are largely irreplaceable
• Half of all neurological problems have
vascular origins

   
 Stroke
Aneurism 
Arteriovenous Malformation 
­­can lead to:
 Hemorrhage and Infarction

   
  
From Haines Text  
 Stroke Statistics:  USA
• 500,000-700,000 new strokes per year
• Third highest cause of death
• Leading cause of adult disability (2/3 of
stroke survivors)
• Incidence increases with age
• African Americans>Hispanics> Whites
• $16,000,000,000 health cost
   
 Stroke Definitions
• Stroke:
–Acute disruption of blood flow to the brain leading to focal neurological deficits
–Two types: ischemic (blood supply cut off) and hemorrhagic (brain bleed)
• Sub-types of ischemic stroke
– thrombotic (50%): blood clot or atherosclerotic plaque forms within a vessel in the brain
– embolic (30%): deposition of an object loose (blood clot, air, bacteria, plaque) in the
bloodstream
– lacunar: very small brain blood vessel progressively narrows until completely occluded
– cryptogenic: mechanism unknown
• Causes of hemorrhagic stroke (about 20%)
– arteriovenous malformation (AVM)
– aneurism
– hypertension
• TIA (transient ischemic attack):
–Acute disruption of blood flow to the brain leading to focal neurological deficits
lasting less than 24 hours (usually 10 – 30 minutes)
   
 Lecture Overview

• Unique structure/function of brain vessels

• Sources of the major blood supply to CNS
• Major arteries and their perfusion domains
• Circle of Willis
• Venous system
• Summary

   
 Unique Features of the Cerebral Vasculature

• Blood brain barrier

• Glial end-feet wrap around vessels
–another layer of protection
• Veins are “valveless”
–what advantage does this serve?
• Some venous sinuses are lined by dura
• Pathology: breakdown of BBB with disease
–tumors, inflammation, Alzheimer’s disease
–this may provide a benefit to target drug delivery

   
 The Blood Brain Barrier
“collectively refers to the mechanisms that control the unique environment of the brain”
• tight junctions between endothelial cells limits
transport of substances to transcellular mechanisms
– diffusion (energy independent)
– faciliated
– transporters move molecules across cell
membranes
– e.g. peptides, amino acids, glucose
– passive
– depends on concentration gradient, size, charge,
and permeability of substance
– active transport (energy dependent)
– involves ATP
– can be coupled to another molecule (co-transport)
– endocytosis
– bulk phase (pinocytosis; fluid phase)--not much
– receptor-mediated (hormones, growth factors,
transferrin), involving coated pits, endosomes, and
is energy-dependent
– absorptive-mediated transport
Dr. Thomas P. Davis, – electrostatic interactions
• enzymes within endothelial cells that degrade
University of Arizona bioactive substances
College
  of Medicine   – neurotransmitter and neuropeptide metabolism
 Tight junctions

   
 Astrocytic End Feet

users.ahsc.arizona.edu
   
users.ahsc.arizona.edu/ davis/bbb.htm
 Circumventricular Organs (CVO’s)
• Midline structures around the 3rd and 4th ventricles
– permeable fenestrated capillaries (**exception: subcommisural organ).
– BBB surface area approximately 5000-fold greater than CVO’s
– recognized as important sites for communicating with CSF and
between brain and peripheral organs via blood-borne products

STRUCTURE LOCATION FUNCTION

median eminence base of the hypothalamus neuro-endocrine
neurohypophysis posterior pituitary oxytocin & ADH
organum vasculosum lamina terminalis LHRH and drinking behavior
subfornical organ third ventricle blood and body fluid pressure
subcommissural organ third ventricle water intake
area postrema floor of 4th ventricle vomiting response
pineal gland epithalamus melatonin, circadian rhythm
choroid plexus lateral, 3rd & 4th ventricles CSF production

   
 Blood­CSF Barrier
• choroid plexus--composed of
choroidal ependymal cells that
form tight junctions preventing
most macromolecules from
effectively passing into the CSF
from the blood. However, these
epithelial-like cells have shown a
low resistance as compared the
cerebral endothelial cells,
approximately 200 Ω ·cm2,
between blood and CSF. In
addition there are choroidal
fenestrated capillaries which are non-
continuous and have gaps between
the endothelial cells allowing the
free-movement of small molecules,
and ventricular ependyma.
• arachnoid membrane--a double layer
of ependymal cells that form the
subarachnoid space (CSF drainage).
Passage of substances from the blood
through the arachnoid membrane is
prevented by tight junctions between
ependymal cells, a largely passive
 http://users.ahsc.arizona.edu/davis/csfanatomy.htm
barrier.
 
 Brain Blood Supply
Two vascular systems supplied
by aortic arch
1. Internal carotid
system: aortic arch to
common carotid arteries
to internal carotid
arteries to anterior and
middle cerebral arteries
and anterior choroidal
arteries
2. Vertebral system: aortic
arch to left subclavian
artery and aortic arch to
innominate artery to right
subclavian artery to
vertebral arteries to
single basilar artery

   
Anatomy of brain 
vascular supply:

   
 Ascending vascular systems
• Note locations and relative
sizes of internal carotid and
vertebral arteries
• ICA parts:
– cervical--outside skull
– petrous--no branches
– cavernous--hypophysial and
meningeal branches
– cerebral--penetrates brain
anterior to (under) optic nerve:
branches are ophthalmic,
posterior communicating,
anterior choroidal, anterior
cerebral, and middle cerebral
arteries
   
 Blood Supply of the Brainstem

   
 Brainstem Arteries:  side view

   
 Brainstem blood supply, cont’d

   
 Cerebral Arteries along the floor of the 
cerebral vault

• internal carotid arteries (larger)

–left and right branches of the common carotid
arteries in the neck which enter the skull
(external carotids supply facial tissues)

• vertebral arteries (smaller)

– branch from the subclavian arteries which
primarily supply the shoulders, lateral chest and
arms
– both vertebral arteries fuse into the basilar
artery, which is located underneath, and primarily
supplies, the brainstem
• connections between internal carotid and
vertebral arteries through the circle of
Willis
–via bilateral posterior communicating arteries
   
–via midline anterior communicating artery
 Vertebral Arteries
• Origin: aortic arch gives rise to subclavian arteries which branch to give rise
to the vertebral arteries
• Pathway and Branches: runs rostrally along the medulla giving rise to 3
branches
–posterior spinal artery
• runs caudally along the dorsolateral aspect of the spinal cord and supplies the posterior 1/3 of
each half of the cord.
– anterior spinal artery
• joins the anterior spinal artery on the other side, forming a single anterior spinal artery that
runs caudally along the ventral midline of the spinal cord supplying the anterior 2/3 of the cord
• NOTE: spinal arteries are insufficient to supply more than cervical segments and are
reinforced caudally
– posterior inferior cerebellar artery (PICA).
• "PICA" supplies much of the inferior surface of the cerebellar hemispheres
• sends branches to other structures on its way to the cerebellum.• As it curves around the
brainstem, the artery supplies the choroid plexus of the 4th ventricle and much of the lateral
medulla
• Termination: vertebral arteries fuse at the pontomedullary junction to form the
midline
  basilar artery  
 Basilar Artery
• Origin:
–arises from the confluence of the two vertebral arteries at the pontine-
medullary junction on the midline
• Pathway: ascends in the central gutter (sulcus basilaris) inferior to the
pons
• Branches:
–anterior inferior cerebellar arteries "AICA"
–superior cerebellar arteries
–pontine branches
–internal auditory arteries (labyrinthine artery)
• Termination: bifurcates to form the posterior cerebral arteries
• Pathology:
–Thrombosis produces hypoxia and ischemia of the brainstem
• Poor prognoses, including paralysis of all extremities, heavy disturbances in
sensation, difficulty in swallowing and difficulty in respiration
   
 Branches of the Basilar Artery 
• anterior inferior cerebellar artery "AICA"
– arises just rostral to the formation point of the basilar artery
– supplies the ventral and lateral cerebellum
– supplies the caudal pons
• superior cerebellar arteries
– just inferior to the pituitary stalk and before bifurcation forming posterior cerebral
arteries
– this trunk divides into medial and lateral branches that supply:
• superior surface of the cerebellum
• caudal midbrain
• rostral pons
• pontine branches--supply the pons
• internal auditory artery (labyrinthine artery)
– often a branch of AICA
– travels with the facial and vestibulo-cochlear nerves, into the acoustic meatus
– supplies the middle ear
  – occlusion can lead to vertigo and ipsilateral
  deafness
Superior Cerebellar Artery
0

• Origin: basilar artery

• superior cerebellar artery
• superior cerebellar cortex
• superior cerebellar
peduncle
• deep cerebellar nuclei
• rostral pontine tegmentum
• inferior colliculus
 0

Basilar Artery
­ Circumferential Branches ­

• short branches
• lateral basilar pons
• long branches
• middle cerebellar
peduncle
• entire tegmentum
 Basilar Artery  0

­ Paramedian Pontine Branches ­

– medial basilar pons

– corticospinal fibers
– pontine nuclei
– floor of the 4th Ventricle
– medial tegmentum
Posterior Inferior 
Cerebellar Artery 0

PICA
– Origin: Vertebral artery
– PICA
posterior cerebellar lobe
inferior vermis
deep cerebellar nuclei
choroid plexus of 4th ventricle
medullary branches
dorsolateral medulla
 Anterior Cerebral Arteries
• Origin:
– internal carotid arteries (left and right)
• Pathway (A1-A5):
– part of circle of Willis (A1 segment)
– travel anteriorly over optic chiasm
– connected (A1/A2 junction) by anterior communicating artery (hot-spot for aneurisms)
– Bend, split into callosomarginal and pericallosal branches and travel along corpus
callosum as far as parieto-occipital sulcus
• Supply:
– A1: anterior hypothalamus and optic chiasm
– A2: surface and deeper aspects of frontal cortex (orbital, fronto-orbital, and fronto-polar
branches)
– A3-5: medial and superior aspects of frontal and parietal cortex (include 1° motor and
sensory) -- note that medial cortex serves lower extremities
– limbic structures (cingulate gyrus)
– anterior portions of basal ganglia (i.e. head of caudate) and internal capsule
– diencephalon (thalamus)
– anterior 4/5 of the corpus callosum
• Pathology:
–  occlusion may result in paralysis and sensory
  loss of the contralateral foot and leg
– urinary incontinence (bilateral damage)
 Anterior Cerebral Artery

   
 Middle Cerebral Artery
• Origin:
– internal carotid artery--usually the largest branch
• Pathway, Branches and Terminations:
– proceeds laterally through the medial portions of the sylvian cistern (M1)
• smaller branching vessels penetrate the cortex and perfuse deeper structures of the
diencephalon and telencephalon (lenticulostriate arteries)
• Variation: one branch from M1 and then smaller branches from this
– Bifurcates into superior and inferior branches that course into the lateral sulcus
• supplying the insular cortex (M2)
• opercula (M3)
– emerges from the lateral sulcus (M4) and spreads out to supply virtually the
entire lateral surface of the cerebral hemisphere
– also supplies the medial temporal surface and the temporal pole
• Pathology:
– major motor and somatosensory deficits (because it supplies pre- and post-
central gyri).
– If the left hemisphere is involved, language deficits are almost invariably found
   
 MCA: 
coronal and lateral views

   
 Anterior Choroidal Arteries
• Origin: internal carotid arteries
• Pathway: along optic tract
• Areas served:
– anterior hippocampus
– posterior limb of the internal capsule
• Pathology: anterior choroidal artery
syndrome
– visual deficits, weakness of opposite upper and
lower extremities

   
 Posterior Cerebral Arteries 
• Origin:
– Bifurcation of the basilar artery at the pons-midbrain junction
• Pathway (P1-P4), Branches, Terminations:
– pass laterally just rostral to the root of the occulomotor nerve
– curve around the midbrain and pass through the superior cistern
– superficial branches supply the medial and inferior surfaces of the
occipital and temporal lobes
– penetrating branches supply posterior corpus callosum, parts of the
thalamus, rostral midbrain and caudal diencephalon
– posterior choroidal arteries supply the choroid plexus of the 3rd
ventricle and the body of the 4th ventricle
• Pathology:
– Because the primary visual cortex is located in the occipital lobe,
occlusion of the posterior cerebral artery at its origin leads to visual
field deficits.
   
 Anterior and Posterior Cerebral 
Arteries: Medial View

   
 Cerebral Arteries: superior view

   
 Cerebral Arteries:
inferior view

   
 Cortical areas supplied by 
cerebral arteries
“Border zones” are particularly
susceptible to hypo-perfusion of distal
vascular beds due to hypotension or
“embolic showers” producing
“watershed infarcts”.

Anterior (ACA/MCA) watershed infarct

produces hemiparesis of contralateral
lower extremity, language deficits, ,
behavioral changes.

Posterior (MCA/PCA) watershed

infarct produces partial visual loss and
language problems.

From Wikipedia,  from Gray’s Anatomy
   
 Body parts affected in cerebral vessel 
disease can localize vascular lesion

  homunculus" from Penfield and Rasmussen:

"Motor   The Cerebral Cortex of Man (1950)
 Coronal View of Areas Supplied 
by Cerebral Arteries
1. anterior cerebral
2. middle cerebral 1
3. penetrating branches
of middle cerebral 3 2
4. anterior choroidal
54
5. posterior cerebral
5
   
 Circle of Willis
after Thomas Willis (1621-1673), an English physician
• Creates redundancies in the cerebral circulation
• A series of 1413 brains displays intact circle in 34.5%
• Five components and their origins:
– internal carotid arteries --arise from the common carotid arteries
– anterior cerebral arteries -- branch from the internal carotid artery
– anterior communicating artery -- connects the two anterior cerebral arteries and could be said to
arise from either one
– posterior communicating arteries -- branch from the internal carotid artery
– posterior cerebral arteries -- branch from the basilar artery
***NOTE: basilar artery and middle cerebral arteries are not considered part of the circle.
• Terminations
– central branches supply interior of the Circle of Willis (structures near interpeduncular fossa)
– cortical branches are named for the area they supply
• Anatomic variation (considerable)
– In one common variation the proximal part of the posterior cerebral artery is narrow and its ipsilateral
posterior communicating artery is large, so the internal carotid artery supplies the posterior cerebrum.
In another variation the anterior communicating artery is a large vessel, such that a single internal
carotid supplies both anterior cerebral arteries.
– Enlarges with aging and may explain why strokes affect children more severely than the elderly
   
 Collateral Circulation

   
   
 Structures included (excluded) in the 
Circle of Willis
http://www.bioengineering.canterbury.ac.nz/groups/brain.shtml

   
 0

Circle of Willis Cont.
• Posterior Cerebral arteries
• Posterior Communicating 
arteries
 Internal Carotid artery

• Middle Cerebral arteries
• Anterior Cerebral arteries
• Anterior Communicating 
artery
 Venous Drainage
• Superficial venous system
– on surface of the cerebrum, composed of dural venous sinuses
– some lined with dura mater as opposed to a traditional vein
– most prominent is the superior saggital sinus which flows in the saggital plane under the midline of the
cerebral vault, posteriorly and inferiorly to the torcula, forming the confluence of sinuses.
• Deep venous system
– composed of traditional veins inside the deep structures of the brain
– join behind the midbrain to form the Vein of Galen
– merges with the inferior saggital sinus to form the straight sinus which then joins the superficial venous
system mentioned above at the confluence of sinuses
• Confluence of sinuses
– where the superficial drainage joins with the sinus that primarily drains the deep venous system
– from here, two transverse sinuses bifurcate and travel laterally and inferiorly in an S-shaped curve that
form the sigmoid sinuses which go on to form the two jugular veins
– in the neck, the jugular veins parallel the upward course of the carotid arteries and drain blood into the
vena cava
• Cerebral veins are valveless.
• Major veins are interconnected by numerous functional anastomoses both within a group and
between the superficial and deep groups.
   
 Superior Venous Drainage

   
 Venous Anastomoses:
lateral view

   
 Venous System:
medial view
• Thalamostriate vein
(terminal vein) drains the
caudate nucleus (via the
transverse caudate veins)
and internal regions of the
hemisphere dorsal and
lateral to the caudate
nucleus.
• Join to form the great
cerebral vein (of Galen),
which is continuous with the
straight sinus
• AVM or aneurysm in
newborns gives rise to
bulging fontanelles,
progressive hydrocephalus
(due to occlusion of cerebral
aqueduct), and dilated veins
(telangiectasias) on the face
   
and scalp
 Venous System:
inferior view

   
 Venous Anastomoses: 
inferior view

   
 Basal Venous System
• Basal vein of Rosenthal
– from anterior cerebral vein on orbital cortex
– from in sylvian fissure as the deep middle cerebral vein
– proceeds around the medial edge of the temporal lobe
– joins the straight sinus
– receives blood from the midbrain and medial temporal lobe
• Transverse and sigmoid sinuses
– latter receives blood from petrosal sinus and connects with internal
jugular vein at the jugular foramen
• Cavernous sinus
– on either side of sphenoid bone
– cavernous part of internal carotid artery lies here
– associated with many cranial nerves (III, IV, VI, and V1 and V2), which
lie between the dura and the endothelial lining
– drains into the superior and inferior petrosal sinuses and the basilar
plexus on the ventral aspect of the brainstem
   
 Brainstem and Cerebellar Veins
• Brainstem
– drained by surface veins
– surface veins drain into larger veins or venous sinuses
– midbrain veins drain into vein of Rosenthal and basal vein
– pontine and medullary veins drain into petrosal sinuses and
cerebellar veins

• Cerebellum
– superior cerebellar veins enter the straight, transverse, or
superior petrosal sinuses
– inferior cerebellar surface is drained by inferior cerebellar
veins, which enter the inferior petrosal, transverse, or
   
straight sinuses
Pathology from Venous Occlusions
• Upstream consequences
– veins and sinuses are engorged
– edema in white matter
– possible hemorrhage
– increased intracranial pressure
• Symptoms
– vary according to region served

   
 Spinal Cord
• Arteries:
–anterior spinal artery
• central branches (motor); anterior 2/3 of cord
–posterior spinal arteries
• derived from PICA, posterior 1/3 of cord
• courses on surface medial to posterior root
–spinal branches of segmented arteries
• anterior and posterior radicular and medullary
arteries, the latter contribute to the arterial
vasocorona
• Veins: generally mirror arterial supply
–Anterior and posterior spinal veins
• Branch to form venous plexuses
• No valves--flow easily reversed
From “AnesthesiaUK” 
http://www.frca.co.uk/article
   
 Spinal Cord AVM

neuro.wehealny.org/ endo/cond_spinal­cord­malformations
   
 Redundancies and Anastomoses
• Interconnections (anastomoses) provide opportunities for
retrograde filling
– Extracerebral:
• aorta--supplies internal carotid and vertebral arteries
– in case of ICA occlusion there is enlargement of the branches of the subclavian
artery on the ipsilateral side and the vertebral artery takes over to perfuse the brain
• superior and inferior thyroid arteries
• deep cervical artery and descending branch of the occipital artery
• ophthalmic and external carotid arteries
– Intracerebral
• circle of Willis
– right/left and front/back communications
• Overlap:
– surface branches of anterior, middle, posterior cerebral arteries
• Both serve as safety mechanisms to achieve adequate perfusion
   
 Summary
• nervous system has a large requirement for vascular 
perfusion; interruptions have fatal consequences
• interconnections and redundancies decrease risk
• brain vessels differ from systemic vessels
• arterial supply of brain from two sources, and supply of 
spinal cord from brain and periphery
• venous drainage pools into large sinuses
• clinical presentation of CVA provides clues about location
   
 Blood Supply of Important Regions
Vu, D. (1998) Blood Supply of the CNS [Lecture Handout].   UNSW, 26 October 1998.

STRUCTURE BLOOD SUPPLY

Medulla •Anterior and posterior spinal arteries
· Vertebral arteries
· PICA
Pons · Paramedian branches of basilar artery
(pontine arteries)
· Short circumferential branches of basilar
artery
· Superior cerebellar artery and AICA
Midbrain · Paramedian branches of basilar artery
· Short circumferential branches of basilar
artery
· Posterior cerebral artery and superior
cerebellar artery (sup. & inf. colliculi)
Head of caudate and putamen · Anterolateral group
· Recurrent artery
Pallidum · Anterolateral group
· Anterior choroidal artery
· Posteromedial and posterolateral groups
· Anterior and posterior choroidal arteries
Thalamus · Posteromedial and posterolateral groups
· Anterior and posterior choroidal arteries
subthalamus · Posteromedial group
· Anterior choroidal artery
Internal capsule · Recurrent artery
· Anterolateral group
· Posterolateral group
· Anterior choroidal artery
   
 Suspect someone is having a 
stroke? Act F.A.S.T.
• FACE   Ask the person to smile. Does one side of 
the face droop?
• ARMS   Ask the person to raise both arms. Does 
one arm drift downward?
• SPEECH  Ask the person to repeat a simple 
sentence. Are the words slurred?  Can he/she 
repeat the sentence correctly?
• TIME   If the person shows any of these symptoms, 
time is important. Call 911 or get to the hospital fast. 
Brain cells are dying.
   
• 80 percent of strokes are preventable!!!

   
 THANK YOU