Lecture 11: Cerebrum: Neuroscience 1: Cerebral Circulation

AsturiaNOTES
Lecture 11: Cerebrum

Neuroscience 1: Cerebral Circulation
The brain is a highly metabolic organ. As such, it requires the following to maintain its function:
 15% of the total cardiac output
o The brain approximately receives 800mL of blood/minute
 This value increases with an increase in functional activity of a motor area
on vigorous exercise of the contralateral limb
 Cerebral blood flow is faster in the gray matter than in the white matter
1 Rate of blood flow to the gray matter: 70-80mL blood/100g of gray
matter/min
2 Rate of blood flow to the white matter: 30mL blood/100g of white
matter/min
a Why such a discrepancy? Remember that cell bodies
(neuron soma) are pooled in the gray matter, thus
metabolism is faster there. And faster metabolism
requires more glucose, more O 2. In the white matter are
just axons whose function demands fewer nutrients.
o Irreversible brain damage will occur if the cerebral blood flow drops to LESS
THAN 15mL of blood/100g of brain
 20% of the total O 2
o In the infant brain, the O2 extracted by the brain is about 50% to support brain
growth, development, and maturation
 25% of the total blood glucose
About 50% of intracranial problems are vascular in origin

 Patients coming into the clinic will be mostly complaining of vascular pathology
Two main sources of blood supply to the brain:

 Internal Carotid Artery (ICA)
o Gives rise to the Anterior Circulation which supplies 80% of the brain
 Vertebral Artery (or the Vertebrobasilar System)
o Gives rise to the Posterior Circulation which supplies 20% of the brain
SOURCES OF BLOOD SUPPLY

A. The Internal Carotid Artery System
 Main component: ICA
 Provides the anterior circulation of the brain
 Parts:
o Cervical Part (Pars cervicalis)
o Petrous Part (Pars petrosa)
o Cavernous Part (Pars cavernosa)
 Branches:
1 Inferior Hypophyseal Artery
2 Meningeal Artery
o Cerebral Part (Pars cisternalis)
 Branches:
1 Ophthalmic Artery
2 Posterior Communicating Artery
3 Anterior Choroidal Artery
AsturiaNOTES by RAsturiano UST-FMS A-2019: #TheElusiveDoktora Page 1 of 11

Nov 12, 2015. Lecturer: Dra. M.L.C. Joson—downloadable (for free!) at: www.theelusivedoktora.wordpress.com
AsturiaNOTES
4 Superior Hypophyseal Artery

5 Middle and Anterior Cerebral Artery (MCA, ACA)
 Anatomy of ICA:
o Arises at the bifurcation of the common carotid arteries in the neck. It will ascend in
front of the transverse processes of the upper 3 cervical vertebrae and enter the
base of the skull through the carotid canal.
 Within the cranium, the internal carotid artery lies in the cavernous sinus.
It then pierces the dura to begin its subarachnoid course.
1 Within the cavernous sinus, the ICA lies close to the medial wall
adjacent to the abducens nerve (CN 6)
a The other CNs in the cavernous sinus situated along the
lateral wall include the:
i Oculomotor (CN 3)
ii Trochlear (CN 4)
iii Maxillary Division of the Trigeminal Nerve (CN V 2)
o From its site of origin from the common carotid artery in the neck to its site of
bifurcation into the ACA and MCA, the internal carotid artery is divided into four
parts:
 Cervical part (pars cervicalis)—extends from the origin of the internal carotid
artery from the common carotid to the site where it enters the carotid
canal
 Petrous part (pars petrosa)—it is the part of the ICA as it courses through the
petrous portion of the temporal bone
 Cavernous part (pars cavernosa)—it is the part of the artery as it courses
through the cavernous sinus
 Cerebral part (pars cisternalis/supraclinoid part)—this segment extends from
the site of exit of the artery from the cavernous sinus to its bifurcation into
the ACA/MCA
1 Pars cavernosa + Pars cisternalis = Carotid Siphon
a Pars cavernosa and Pars cisternalis are S-shaped giving
rise to the siphon-shaped vessel
2 The major blood-supplying branches of the ICA arises at its cerebral
part
 Branches of ICA
o Ophthalmic Artery
 The ophthalmic artery is the first intracranial branch of the ICA as it
courses through the cavernous sinus
 Supplies the:
1 Optic Nerve
 Becomes the Central Retinal Artery
 Thus, interruption of the blood supply from the internal carotid system may
result in disturbances in visual acuity
 It has anastomotic connections with the branches of the external carotid
system
1 This anastomotic relationship is essential in establishing collateral
circulation when the internal carotid system is occluded in the neck

AsturiaNOTES
If the ophthalmic artery is occluded, the initial manifestation would be

monocular blindness
o Posterior Communicating Artery
 Important because it connects the Anterior Circulation to the Posterior
Circulation
Special note: Anterior choroidal artery + Superior hypophyseal artery + terminal branches of
ACA/MCA are located in the point where the ICA terminates to give rise to ACA and MCA
o Anterior Cerebral Artery (ACA)

 Origin: ICA
 Termination: At the parietooccipital sulcus
 Has five segments
1 Since ACA starts with A, the segment names start with letter „A‟ and
then a number = A1 as the first segment, and so on
2 The segments are so named in relation to the Corpus Callosum
3 A1—Pre-communicating segment
4 A2—Infracallosal segment
5 A3—Pre-callosal segment
6 A4—Supracallosal segment
7 A5—Post-callosal segment
8 A1-A2 are located basally
9 A3-A5 are located medially
 Supplies the medial and basal aspects of the cerebral hemispheres
 It extends to the anterior 2/3rds of the parietal lobe
 And the perforating branches of the ACA supply the:
1 Anterior caudate nucleus
2 Parts of the internal capsule
3 Putamen
4 Anterior hypothalamus
o Middle Cerebral Artery (MCA)
 Origin: ICA
 70% of the time, it is larger than the ACA
1 Why? Because it supplies more. More areas supplied = more blood
must come from it = the artery must be larger to accommodate more
blood
 MCA has 4 segments:
1 M1—Sphenoidal segment (medial portion of the Sylvian cistern)
a Most important and biggest segment
i Supplies most of the structures
b Branches off to become the Lenticulostriate Arteries
i Supply the adjacent medial/rostral aspects of
the temporal lobe
ii The lenticulostriate arteries are perforating
arteries
 Perforating arteries are designed to supply
deeper/inner structures of the brain

AsturiaNOTES

Lenticulostriate arteries supply the basal
ganglia
o The basal ganglia is the most
common location of bleeding in
intracerebral hemorrhages. And
when this happens, the artery of
interest is the lenticulostriate
arteries
c ICA and the point where it braches at the ventromedial
aspect of the insula (limen insulae)
d Bifurcates into superior and inferior trunk
i Aneurysm commonly arises at the bifurcation of
the M1
 Note: Aneurysms usually originate at
vascular locations which are high in
pressure/resistance
o And since there is a lot of blood flow
at the bifurcation of M1 (physio:
increased blood flow = increase in
pressure), it is an important site for
the origin of aneurysms
2 M2—Sylvian/Insular segment
3 M3—Opercular segment
4 M4—Terminal/Cortical segment
 MCA branches
1 Supply the convex/lateral areas of the brain
2 They also supply deep structures such as:
a Basal ganglia
b Putamen
c Parts of the globus pallidus
d Caudate nucleus
e Parts of the internal capsule
B. Vertebrobasilar system
 Main component: Basilar artery, Vertebral Artery
o Origin: Vertebral arteries (for BA), Subclavian Artery (VA)
 The union of the 2 distal parts of 2 vertebral arteries will give rise to the
Basilar Artery that will be seated in the Basilar Sulcus
 Provides the posterior circulation to the brain primarily supplying the brainstem area
Special note: When you hear the doctor saying, “There is a stroke involving the anterior
circulation,” the first thing that must come into your mind is ACA/MCA. But when the doctor
claimed that the stroke involved the posterior circulation, the first thing that must come into
your mind must be the vertebrobasilar system
o Segments of the Vertebral Artery
 4 segments
1 V1—Subclavian artery will course and insert into the transverse
foramen of the C6 (as entrance)

AsturiaNOTES
2V2—Will run inside and ascend the transverse foramina of C6-C2

3V3—Exit from C2 to atlantooccipital membrane (passes through
C1)
4 V4—Passes through the dura as it joins the BA (intracranial)
o The basilar artery does NOT have segments but it has branches:
 Anterior Inferior Cerebellar Artery (AICA)
1 Supplies the following:
a Ventral and lateral surfaces of the cerebellum
b Part of the pons
c Portion of the choroid plexus
2 Gives rise to: Labyrinthine Artery
 Pontine Arteries
1 Supplies the pons
2 Penetrate the pons immediately as paramedian branches
3 Branches:
a Short circumferential branches
b Long circumferential branches
 Superior Cerebellar Arteries (SCA)
1 Supply the superior surface of the cerebellum and its nuclei
2 Therefore, bulk of the cerebellum is supplied by the SCA
3 Branches: Medial and Lateral Branches
o The BA bifurcates to give rise to 2 Posterior Cerebral Arteries (PCA)
 The bifurcation is located at the interpeduncular cistern
 PCA has branches that supply the following:
1 Midbrain
2 Thalamus
3 Ventral/Medial surfaces of the temporal lobe and occipital
lobe as far as the parietooccipital sulcus
a Therefore, the parietooccpital sulcus serves to be an
important landmark in delineating the supply limit of
the ACA vs the PCA
i Anything anterior to the parietooccipital sulcus
is supplied by the ACA
ii Anything posterior to the parietooccipital
sulcus is supplied by the PCA
 Segments of PCA (four segments):
1 P1
a Between the basilar bifurcation and the PCom Artery
b Small perforating vessels and to quadrigeminal and
thalamoperforating arteris
2 P2
a Between the PCom Artery and the Inferior Temporal
Branches
b Medial and lateral posterior choroidal and
thalamogeniculate arteries as well as small perforating
branches to the midbrain

AsturiaNOTES
3 P3
a Gives rise to its temporal branches
4 P4
a Most important segment!!!
b Parietooccipital and calcarine arteries
c Calcarine Artery supplies the primary visual cortex
THE MOTOR HOMUNCULUS

 The motor homunculus is a topographical representation of the body parts in relation to its
motor innervation in the cortex.
 The more motor innervation a body part has, the bigger its representation in the motor
homunculus
 In the motor homunculus, the well-represented parts are the face and arm. Less
represented are the legs.
o Why?
 It has something to do with fine gross movement
1 The face and the Upper Extremity (UE) can do different kinds of
movement
2 While the Lower Extremity (LE) can only do so much
a Ex: You can play the guitar with your UE but almost
impossible with your LE
 In the motor homunculus:
o The MCA is linked to the UE
o The ACA is linked to the LE
Note: In the clinics, there is such a thing as differential weakness
 If a patient comes to you with a “generalized weakness”, you quantify what extremity is
weaker?
o Ex: If the patient has difficulty in walking but can still hold on to a pen or write, then
the vascular pathology is located in the ACA
THE CIRCLE OF WILLIS (CW)

 Described by Thomas Willis
 It is the main cerebral Circulation
 Has the anterior and posterior circulation connected by the posterior communicating
artery
 Contains the:
o ACA
o PCA
o MCA
o PComm
 It is located basally
o It co-exists with the following:
 Cranial Nerves
 Brainstem
 CW is a common site for aneurysm because of a lot of bifurcations and ramifications it has
o Rupture of aneurysm inside or near the CW leads to a catastrophic symptomatology
or scenario in the patient

AsturiaNOTES
Also, if the patient has CNS infection, the suppurations and exudates will be located
o
in the CW
 Why?
1 Because, again, the CW is basally located
a By gravity, the exudates have nowhere to go but basally
 The suppurations and exudates will cause irritation of the cranial nerves
and blood vessels leading to craniopathies
 Structures found inside the CW:
o Optic chiasm
o Optic tract
o Infundibulum
o Tuber cinereum
o Pituitary gland
o Mammillary bodies
o Hypothalamus
o Structures of the interpeduncular fossa
VEINS AND VENOUS SINUSES OF THE BRAIN

Generally speaking, the veins and the venous sinuses are harder to understand because veins
and venous sinuses of the brain come in various forms as there are congenital variants.
Unlike the arteries which are pretty much straightforward. But in this handout, I will discuss the
most usual pattern of venous blood flow.
 The venous drainage of the brain exits the skull through the Internal Jugular Vein
 There are 3 major venous sinuses
o Superior Sagittal Sinus (SSS)
 Will form the confluence of sinuses
o Inferior Sagittal Sinus (ISS)
 Internally and medially located
o Straight Sinus (SS)
o The sinuses are located within the dural complex
 Recall: Three meningeal layers (from outermost to innermost)
1 D—ura matter
2 A—arachnoid
3 P—ia matter
 Superficial Cerebral Veins
o AKA Cortical Veins
o Carry blood from the outer 1-2cm of the brain surface to large drainage channels
 Deep Cerebral Veins
o AKA Central Veins
o Drain blood from the inner regions of the brain:
 Hemispheric white matter
 Basal ganglia
 Corpus callosum
 Choroid plexus
 Few cortical areas as well
Note: The anastomotic veins connect the superficial veins to the deeper veins

AsturiaNOTES
 Drainages
o Blood from Cerebral and Emissary VeinsGreat Cerebral VeinSinus
RectusConfluence of SinusesTransverse SinusSigmoid Sinus IJV
o Blood from Cerebral and Emissary VeinsISSSRCoSTSSigSIJV
o Blood from Cerebral and Emissary VeinsOccipital SinusCoSTSSigSIJV
o Blood from Cerebral and Emissary VeinsSuperior Cerebral

VeinsSSSCoSTSSigSIJV
o Blood from Cerebral and Emissary VeinsInferior Cerebral

VeinsTSSigSIJV
o Blood from Cerebral and Emissary VeinsMiddle Cerebral VeinsCavernous

SinusSuperior Petrosal SinusSigSIJV
o Blood from Cerebral and Emissary VeinsMCVsCSInferior Petrosal

SinusIJV
Legends:
IJV=Internal Jugular Vein
ISS=Inferior Sagittal Sinus
SR=Sinus Rectus
CoS=Confluence of Sinuses
TS=Transverse Sinus
SigS=Sigmoid Sinus
SSS=Superior Sagittal Sinus
NEUROVASCULAR SYNDROMES
Cerebrovascular disorders include cerebral infarcts (most common) + cerebral
hemorrhages
A. Middle Cerebral Artery Syndrome

o Contralateral hemiplegia or hemiparesis affecting primarily FACE + UE
 Also affects LE but UE is more affected
o Contralateral sensory deficit which is more prominent in the FACE + UE
 Also affects LE but more of UE
o Contralateral visual field
o Contralateral conjugate gaze paralysis
 Involvement of the frontal eye field (Brodmann‟s area 8)
 Lesion at the Anterior Choroidal Artery
o Aphasia
 Happens especially if the left cerebral hemisphere is involved
 Can either be:
1 Expressive Aphasia—Broca‟s area is affected
2 Receptive Aphasia—Wernicke‟s area is affected
3 Global Aphasia—Both areas are affected

AsturiaNOTES
o Hemineglect of the contralateral half

 The weaker half (contralateral half) is neglected
1 Ex: You touch the patient in both arms with the same pressure. And
then, you ask the patient which arms you touched. The patient
answers that the arm you touch is the ipsilateral arm because the
contralateral arm is neglected
o Spatial Perception
 Happens if the right, non-dominant cerebral hemisphere is affected
 Characterized by:
1 Constructional apraxia—difficulty to build, assemble, or draw
objects
2 Topographagnosia
a AKA Topographical agnosia
b Difficulty in orienting one‟s self in one‟s surrounding
(Disorientation)
3 Dressing apraxia—difficulty in dressing up by one‟s self
o Gerstmann Syndrome
 Occurs in left-sided parietal lesion
 Characterized by:
1 Agraphia—difficulty to write
2 Acalculia—difficulty to do arithmetic
3 Agnosia (finger)—difficulty identifying one‟s fingers
4 Left-Right Disorientation
Note: Plegia vs. Paresis

 Plegia—very little to no movement at all
 Paresis—there is movement BUT the movement cannot go against gravity
o Cannot bring arms up
o Cannot flex arms
B. Anterior Cerebral Artery Syndrome

 Unilateral occlusion of the ACA is associated with the following:
o Contralateral hemiplegia or hemiparesis affecting primarily the LE
 It involves the UE but LE is weaker than UE
o Contralateral sensory deficits primarily affecting the LE
o Transcortical motor aphasia when the left dominant hemisphere is affected
 Area affected is in between the Broca‟s area and Wernicke‟s area
 Bilateral occlusion of the ACA is associated with the following:
o ACA bilateral occlusion is uncommon but it can happen
o Dementia-like symptoms
o Loss of initiative and spontaneity
o Profound apathy
o Memory and emotional disturbances
o Akinetic mutism
o Disturbance in gait and posture
o Grasp reflex
o Disorder of urinary sphincter control

AsturiaNOTES
 A frontal release sign—disorders that affect the frontal lobe

 The center for urinary control is located in the medial aspect of the frontal
lobe
C. Internal Carotid Artery Syndrome

 The internal carotid artery syndrome is a combination of the MCA/ACA syndromes +
transient monocular blindness
D. Posterior Cerebral Artery Syndrome

 Unilateral occlusion of the PCA is associated with:
o Contralateral hemianopia—loss of vision of the contralateral side
o Visual and color agnosia—impairment in recognition of visually presented objects
and color
o Contralateral sensory loss of all modalities with concomitant pain
(Thalamic syndrome)
o Pure alexia without agraphia with a left-sided lesion—Inability to read but
can write; occurs if left PCA is affected
E. Vertebral-Basilar Artery Syndrome

 Occlusion of the vertebral-basilar arterial system usually results in brainstem infarcts
o Bilateral long tract (sensory+motor) signs
o Crossed motor and sensory signs (if the occlusion is unilateral)
 Weakness of:
1 Right side of face
2 Left side of body or vice versa
 There is no crossed paralysis in if the cerebral hemisphere is affected
o Cerebellar signs
o Cranial nerve signs
o Alteration in state of consciousness (Stupor or coma)
o Disconjugate eye movements
F. Intracranial Hemorrhage Syndromes

 More appropriate name is Intracerebral Hemorrhage Syndromes
o Why?
 Because “intracranial” means anything inside the cranium—too broad and
non-specific
 Rupturing of blood vessels can be caused by the following:
o Spontaneous rupture (due to chronic hypertension)
o Congenital rupture (congenital saccular aneurysm)
o Aneurysm (arteriovenous malformation)
o Trauma
o Bleeding disorders
 Location of hemorrhages:
o Intracerebral—Hemorrhage within the brain parenchyma
o Intraventricular—Hemorrhage within the ventricular spaces
o Meningeal
 Subarachnoid hemorrhage—hemorrhage into the subarachnoid space

AsturiaNOTES
 Subdural hemorrhage—hemorrhage between dura and brain

1 AKA Subdural hematoma
 Epidural hemorrhage—hemorrhage between the dura and skull
1 AKA Epidural hematoma
-end-
References
1. Transcription notes by RAsturiano (A-2019) from the lecturer

2. Handout on Cerebral Circulation by Dr. M. Ostrea
Downloadable for free at: www.theelusivedoktora.wordpress.com

For any corrections you may find, content or otherwise, email me at:
ram.ustmedicine@gmail.com
-THANKS-
AsturiaNOTES
By RAsturiano
#TheElusiveDoktora


Lecture 11: Cerebrum: Neuroscience 1: Cerebral Circulation

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AsturiaNOTES

Lecture 11: Cerebrum

About 50% of intracranial problems are vascular in origin

Two main sources of blood supply to the brain:

SOURCES OF BLOOD SUPPLY

AsturiaNOTES by RAsturiano UST-FMS A-2019: #TheElusiveDoktora Page 1 of 11

4 Superior Hypophyseal Artery

AsturiaNOTES by RAsturiano UST-FMS A-2019: #TheElusiveDoktora Page 2 of 11

If the ophthalmic artery is occluded, the initial manifestation would be

o Anterior Cerebral Artery (ACA)

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AsturiaNOTES by RAsturiano UST-FMS A-2019: #TheElusiveDoktora Page 4 of 11

2V2—Will run inside and ascend the transverse foramina of C6-C2

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THE MOTOR HOMUNCULUS

THE CIRCLE OF WILLIS (CW)

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VEINS AND VENOUS SINUSES OF THE BRAIN

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o Blood from Cerebral and Emissary VeinsISSSRCoSTSSigSIJV

o Blood from Cerebral and Emissary VeinsOccipital SinusCoSTSSigSIJV

o Blood from Cerebral and Emissary VeinsSuperior Cerebral

o Blood from Cerebral and Emissary VeinsInferior Cerebral

o Blood from Cerebral and Emissary VeinsMiddle Cerebral VeinsCavernous

o Blood from Cerebral and Emissary VeinsMCVsCSInferior Petrosal

A. Middle Cerebral Artery Syndrome

AsturiaNOTES by RAsturiano UST-FMS A-2019: #TheElusiveDoktora Page 8 of 11

o Hemineglect of the contralateral half

Note: Plegia vs. Paresis

B. Anterior Cerebral Artery Syndrome

AsturiaNOTES by RAsturiano UST-FMS A-2019: #TheElusiveDoktora Page 9 of 11

 A frontal release sign—disorders that affect the frontal lobe

C. Internal Carotid Artery Syndrome

D. Posterior Cerebral Artery Syndrome

E. Vertebral-Basilar Artery Syndrome

F. Intracranial Hemorrhage Syndromes

AsturiaNOTES by RAsturiano UST-FMS A-2019: #TheElusiveDoktora Page 10 of 11

 Subdural hemorrhage—hemorrhage between dura and brain

1. Transcription notes by RAsturiano (A-2019) from the lecturer

Downloadable for free at: www.theelusivedoktora.wordpress.com

AsturiaNOTES by RAsturiano UST-FMS A-2019: #TheElusiveDoktora Page 11 of 11

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