The proximal portions of the anterior, middle, and posterior cerebral arteries connected by the anterior and posterior

communicating arteries form a circle, the circle of Willis (Figure 274), around the infundibulum of the pituitary and the optic chiasm. The circle constitutes an important anastomotic channel between the internal carotid and the vertebral basilar systems. When either the internal carotid arteries (anterior circulation) or the vertebral basilar system (posterior circulation) becomes occluded, collateral circulation in the circle of Willis will provide blood to the area deprived of blood supply. The circle of Willis is complete in only 20 percent of individuals. In the majority of individuals, variation in size and/or origin of vessels is the rule. CONDUCTING AND PENETRATING VESSELS

The arteries of the brain fall into two general types. The conducting or superficial arteries are those which run in the pia arachnoid and include the internal carotid and vertebral basilar systems and their branches. These vessels receive autonomic nerves and function as pressure-equalization reservoirs to maintain an adequate perfusion pressure for the penetrating arteries. It is estimated that the drop in the pressure head from large vessels to the penetrating arterioles does not exceed 10 to 15 percent. The penetrating arterioles supply the cortex and white matter and are organized in vertical and horizontal patterns. These are presumed to be the primary sites of regional autoregulation and do not receive a significant neural supply.

COLLATERAL CIRCULATION
Anastomotic channels are present in all parts of both the arterial and venous circulations. Their main purpose is to ensure a continuing blood flow to the brain in case of a major occlusion of a feeding vessel. Some of these channels, however, are not very effective in collateral circulation because of their small caliber. The following are the major sites of collateral circulation. 1. 2. Extracranial anastomoses are found between cervical vessels, such as the vertebral and external carotids of the same side. Extracranial-intracranial anastomoses occur between branches of the external carotid and the ophthalmic artery. This is a major site of communication between extracranial and intracranial circulations. Thus, when the internal carotid is obstructed proximal to the origin of the ophthalmic artery, flow is reversed in the ophthalmic artery. Another site of extracranialintracranial anastomosis is through the rete mirabile, a group of small vessels that connect meningeal and ethmoidal branches of external carotid arteries with leptomeningeal branches of cerebral arteries. Intracranial anastomoses occur in the circle of Willis. Under normal conditions, there is very little side flow or flow from posterior to anterior segments in the circle of Willis. In the presence of major occlusion, however, the communications across the anterior or posterior communicating artery become a very important channel for collateral circulation. Other sites of intracranial anastomoses include those among the superior cerebellar, anterior inferior cerebellar, and posterior inferior cerebellar in the cerebellum.

3.

Arterial Supply of the Brain Characteristics of the Cerebral Arteries The circle of Willis (named after the English neuroanatomist Sir Thomas Willis) is a confluence (actually a hexagon) of vessels that gives rise to all of the major cerebral arteries. It is fed by the paired internal carotid arteries and the basilar artery. When the circle is complete, it contains a posterior communicating artery on each side and an anterior communicating artery. The circle of Willis shows many variations among individuals. The posterior communicating arteries may be large on one or both sides (embryonic type); the posterior cerebral artery may be thin in its first stretch (embryonic type); and the anterior communicating artery may be absent, double, or thin. Despite these variations, occlusion of each of the major cerebral arteries usually produces a characteristic clinical picture. The course of the large arteries (at least in their initial stretches) is largely ventral to the brain in a relatively small region. The arteries course in the subarachnoid space, often for a considerable distance, before entering the brain itself; rupture of a vessel (eg, from an aneurysm that has burst) tends to cause a subarachnoid hemorrhage. Each major artery supplies a certain territory, separated by border zones (watershed areas) from other territories; sudden occlusion in a vessel affects its territory immediately, sometimes irreversibly. Principal Arteries

The arterial blood for the brain enters the cranial cavity by way of two pairs of large vessels (Figs 121 and 122): the internal carotid arteries, which branch off the common carotids, and the vertebral arteries, which arise from the subclavian arteries. The vertebral arterial system supplies the brain stem, cerebellum, occipital lobe, and parts of the thalamus, and the carotids normally supply the remainder of the forebrain. The carotids are interconnected via the anterior cerebral arteries and the anterior communicating artery; the carotids are also connected to the posterior cerebral arteries of the vertebral system by way of two posterior communicating arteries, part of the circle of Willis. Vertebrobasilar Territory

After passing through the foramen magnum in the base of the skull, the two vertebral arteries form a single midline vessel, the basilar artery (Figs 122 and 123; see also Fig 710). This vessel terminates in the interpeduncular cistern in a bifurcation as the left and right posterior cerebral arteries. These may be thin, large, or asymmetric depending on retention of the embryonic pattern (in which the carotid supplies the posterior cerebral arteries). Several pairs of small circumferential arteries arise from the vertebral arteries and their fused continuation, the basilar artery. These are the posterior and anterior inferior cerebellar arteries, the superior cerebellar arteries, and several smaller branches, such as the pontine and internal auditory arteries. These vessels can show asymmetry and variability. The small penetrating arteries, which branch off the basilar artery, supply vital centers in the brain stem (Fig 12 4).

Carotid Territory The internal carotid artery passes through the carotid canal of the skull and then curves forward within the cavernous sinus and up and backward through the dura, forming the carotid siphon before reaching the brain (see Fig 121). The first branch is usually the ophthalmic artery. In addition to their links with the vertebral system, the carotids branch into a large middle and a smaller anterior cerebral artery on each side (Fig 125). The two anterior cerebral arteries usually meet over a short distance in midplane to form a short but functionally important anterior communicating artery. This vessel forms an anastomosis between the left and right hemispheres, which is especially important when one internal carotid becomes occluded. The anterior choroidal artery, directly off the internal carotid, carries blood to the choroid plexus of the lateral ventricles as well as to adjacent brain structures. Cortical Supply The middle cerebral artery supplies many deep structures and much of the lateral aspect of the cerebrum; it breaks up into several large branches that course in the depth of the lateral fissure, over the insula, before reaching the convexity of the hemisphere. The anterior cerebral artery and its branches course around the genu of the corpus callosum to supply the anterior frontal lobe and the medial aspect of the hemisphere; they extend quite far to the rear. The posterior cerebral artery curves around the brain stem, supplying mainly the occipital lobe and the choroid plexuses of the third and lateral ventricles and the lower surface of the temporal lobe (Figs 126 and 127). By comparing the territories irrigated by the anterior, middle, and posterior cerebral arteries on the one hand and the homunculus on the other, the student can predict the deficits caused by a stroke affecting the territories irrigated by each of these arteries (see Fig 126): In a stroke affecting the territory of the middle cerebral artery, weakness and sensory loss are most severe in the contralateral face and arm, but the leg may be only mildly affected or unaffected. In contrast, in a stroke affecting the territory irrigated by the anterior cerebral artery, weakness is most pronounced in the contralateral leg. Cerebral Blood Flow and Autoregulation

Many physiologic and pathologic factors can affect the blood flow in the arteries and veins of the brain. Under normal conditions of autonomic regulation, the pressure in the small cerebral arteries is maintained at 450 mm H2O. This ensures adequate perfusion of the cerebral capillary beds despite changes in systemic blood pressure. Increased activity in one cortical area is accompanied by a shift in blood volume to that area.

Arterial supply of the brain stem. A: Midbrain. The

basilar artery gives off paramedian branches that supply the oculomotor (III) nerve nucleus and the red nucleus (RN). A larger branch, the posterior cerebral artery, courses laterally around the midbrain, giving off a basal branch that supplies the cerebral peduncle (CP) and a dorsolateral branch supplying the spinothalamic tract (ST), medial lemniscus (ML), and superior cerebellar peduncle. The posterior cerebral artery continues (upper arrows) to supply the thalamus, occipital lobe, and medial temporal lobe. B: Pons. Paramedian branches of the basilar artery supply the abducens (VI) nucleus and the medial lemniscus (ML). The anterior inferior cerebellar artery gives off a basal branch to the descending motor pathways in the basis pontis (BP) and a dorsolateral branch to the trigeminal (V) nucleus, the vestibular (VIII) nucleus, and the spinothalamic tract (ST) before passing to the cerebellum (upper arrows). C: Medulla. Paramedian branches of the vertebral arteries supply descending motor pathways in the pyramid (P), the medial lemniscus (ML), and the hypoglossal (XII) nucleus. Another vertebral branch, the posterior inferior cerebellar artery, gives off a basal branch to the olivary nuclei (ON) and a dorsolateral branch that supplies the trigeminal (V) nucleus, the vestibular (VIII) nucleus, and the spinothalamic tract (ST) on its way to the cerebellum (upper arrows).

12.6 Arterial supply of the primary motor and sensory cortex (coronal view). Notice the location of the homunculus with respect to the territories of the cerebral arteries. 12.7 Arterial supply of the primary motor and sensory cortex (lateral view). Types of Channels The venous drainage of the brain and coverings includes the veins of the brain itself, the dural venous sinuses, the dura's meningeal veins, and the diploic veins between the tables of the skull (Figs 128, 129, and 1210). Emissary veins drain from the scalp, through the skull, into the larger meningeal veins and dural sinuses. Communication exists between most of these channels. Unlike systemic veins, cerebral veins have no valves and seldom accompany the corresponding cerebral arteries. Internal Drainage

The interior of the cerebrum drains into the single midline great cerebral vein (of Galen), which lies beneath the splenium of the corpus callosum. The internal cerebral veins (with their tributaries, the septal, thalamostriate, and choroidal veins) empty into this vein, as do the basal veins (of Rosenthal), which wind (one right and one left) around the side of the midbrain, draining the base of the forebrain. The precentral vein from the cerebellum and veins from the upper brain stem also empty into the great vein, which turns upward behind the splenium and joins the inferior sagittal sinus to form the straight sinus. The venous drainage of the base of the cerebrum is also into the deep middle cerebral vein (coursing in the lateral fissure) and then to the cavernous sinus. Cortical Veins Venous drainage of the brain surface is generally into the nearest large vein or sinus, from there to the confluence of the sinuses, and ultimately to the internal jugular vein (see Fig 128). The veins of the cerebral convex surfaces are divided into superior and inferior groups. The 6 to 12 superior cerebral veins run upward on the hemisphere's surface to the superior sagittal sinus, generally passing under any lateral lacunae. Most of the inferior cerebral veins end in the superficial middle cerebral vein. The inferior cerebral veins that do not end in this fashion terminate in the transverse sinus. Anastomotic veins can be found; these connect the deep middle cerebral vein with the superior sagittal sinus or transverse sinus. Venous Sinuses Venous channels lined by mesothelium lie between the inner and outer layers of the dura; they are called intradural (or dural) sinuses. Their tributaries come mostly from the neighboring brain substance. All sinuses ultimately drain into the internal jugular veins or pterygoid plexus. The sinuses may also communicate with extracranial veins via the emissary veins. These latter veins are important for two reasons: The blood can flow through them in either direction, and infections of the scalp may extend by this route into the intracranial structures. Of the venous sinuses, the following are considered most important: Superior sagittal sinus: between the falx and the inside of the skull cap. Inferior sagittal sinus: in the free edge of the falx. Straight sinus: in the seam between the falx and the tentorium. Transverse sinuses: between the tentorium and its attachment on the skull cap. Sigmoid sinuses: S-curved continuations of the transverse sinuses into the jugular veins; a transverse and a sigmoid sinus together form a lateral sinus. Sphenoparietal sinuses: drain the deep middle cerebral veins into the cavernous sinuses. Cavernous sinuses: on either side of the sella turcica. The cavernous sinuses receive drainage from multiple sources, including the ophthalmic and facial veins. Blood leaves the cavernous sinuses via the petrosal sinuses (see Fig 128). The cavernous sinuses are convoluted, with different chambers separated by fibrous trabeculae; thus, they have the appearance of a cavern. A number of important arteries and cranial nerves are embedded within the cavernous sinus and its walls. The internal carotid artery runs through the cavernous sinus (Fig 1211). In addition, the oculomotor, trochlear, and abducens nerves run through the cavernous sinus, as does the ophthalmic division of the trigeminal nerve, together with the trigeminal ganglion. Inferior petrosal sinuses: from the cavernous sinus to the jugular foramen. Superior petrosal sinus: from the cavernous sinus to the beginning of the sigmoid sinus.

Organization of veins and sinuses of the brain. Figure 1211 provides a frontal view, cut along the plane shown by the vertical line.

The cavernous sinus and associated structures. A: Relationship to skull and brain. B: The cavernous sinus wraps around the pituitary. Several important structures run through the cavernous sinus: the internal carotid artery; the oculomotor, trochlear, and abducens nerves; and the ophthalmic branch of the trigeminal nerve and trigeminal ganglion.

posterior lateral view.

Three-dimensional view of veins and sinuses of the brain, left

Magnetic resonance image of a midsagittal section through the head showing venous channels.
Structure Spinal Cord Medulla Level System P P S P P P P P P P P P P P P P A P P P A A A P Major artery Anterior spinal Posterior spinal Radicular arteries Anterior spinal Posterior spinal Vertebral Vertebral: PICA Basilar Basilar: AICA Basilar: SCA Vertebral: PICA Basilar: AICA Basilar: SCA Basilar Basilar: SCA Posterior cerebral PCom PCA: posterior choroidal PCA: thalamogeniculate PCA: thalamoperforating Anterior cerebral ACom PCom Posterior cerebral

Caudal Rostral

Pons Cerebellum Midbrain Thalamus

Caudal/middle Rostral Caudal Middle Rostral Caudal (inf colliculi) Rostral (sup colliculi)

Hypothalamus

subthalamus

Globus pallidus Striatum Septal nuclei Amygdala -Hippocampal formation Internal Capsule - Anterior limb Internal Capsule - Genu Internal Capsule Posterior limb IC - Retrolenticular Frontal lobe Pariertal lobe Occipital lobe Temproal lobe

Superior Middle, inferior Superior Inferior

Superior Middle Inferior inferior Superior Middle Inferior Superior Inferior

A A P P A A A A A A A A A A A A A A A A A A A A A A A P P

Anterior choroidal PCom Posterior choroidal PCA MCA: lenticulostriate Anterior choroidal MCA: lenticulostriate ACA: lenticulostriate ACA ACom Anterior choroidal Anterior choroidal PCA MCA ACA Internal capsule Anterior choroidal MCA ACA Anterior choroidal; ACA MCA Anterior choroidal Anterior choroidal ACA MCA ACA MCA PCA PCA

Tract Anterior spinothalamic tract Lateral spinothalamic tract Anterior spinocerebellar tract Posterior spinocerebellar tract Fasciculus cuneatus (info from upper limb) Fasciculus gracilis (info from lower limb)

Location Anterior funiculus Anterior & lateral funiculi Lateral funiculus

Function Pathway fro crude ouch and pressure sensation Pathway for pain, temp, tickle, itch and sexual sensation Pathway for unconscious coordination of motor activities (unconscious proprioception, automatic processes) to cerebellum Pathway for position sense (conscious proprioception) & fine cutaneous sensation (touch, vibration, fine pressure sense, two point discrimination)

Posterior funiculus

Neurons st 1 afferent neurons located in nd spinal ganglia; contain 2 neurons and cross in anterior commissure nd Projection (2 ) neurons receive st proprioceptive signals from 1 st afferent fibers originating at 1 neurons of spinal ganglia st Cell bodies of 1 neuron located in spinal ganglion; pass uncrossed to dorsal column nuclei

Tract Pyramidal tract

Anterior corticospinal tract Lateral corticospinal tract Rubrospinal tract Reticulospinal tract Vestibulospinal tract Tectospinal tract Olivospinal tract

Extrapyramidal motro system

Function most improtnat Originate in motor cortex pathway for Corticonuclear fibers to motor nuclei of cranial nerves voluntary motor Corticospinal fibers to motor cells in anterior horn of SC function Corticoreticular fibers to nuclei of reticular formation Pathway for autonomoic and learned moror processes (walking, running, cycling)