The Brain

Sherwood: Human Physiology from Cells to System. 7th ed. p144

Cerebral Cortex

Sherwood: Human Physiology from Cells to System. 7th ed. p147

 The Metabolism of the Brain

• Can’t produce ATP without O2

• Uses only glucose.

Brain damage results if it’s

deprived of :
Uses 20% of the O2 and 50% of • O2 supply for > 4-5 min
the glucose consumed in the body • Glucose supply for > 10-15 min

Depends on a continuous,
adequate blood supply

Sherwood: Human Physiology from Cells to System. 7th ed. p141

THE ARTERIES
Blood Vessels to the Brain

Internal Anterior
carotid circulation
arteries

Vertebral Posterior
arteries circulation

Van De Graaff: Human Anatomy, 6th ed. p561

Common Carotid Artery

Internal carotid artery

passes through the
carotid canal

Internal carotid artery Brain

External carotid artery Head & neck

Bifurcation at the level

of the thyroid cartilage

Brachiocephalic trunk

Duus. Topical Diagnosis in Neurology. 4th ed. P419-20

Internal Carotid Artery (ICA)

Branches of ICA
• Anterior cerebral artery
• Middle cerebral artery
• Ophthalmic artery
• Posterior communicating artery
• Anterior choroidal artery
• Fine branches : tympanic cavity,
dura mater of the clivus,semilunar
ganglion, pituitary gland

Connected to the PCA at

the circle of Willis.

Van De Graaff: Human Anatomy, 6th ed. p563

 Anterior Cerebral Artery (ACA)
Goes above the optic chiasm to the medial
surface of the cerebral hemispheres.

It supplies :
• Paraseptal region
• Rostral portion of the basal ganglia &
diencephalon
• Anterior limb of the internal capsule
• Corpus callosum,
• Medial surfaces of the cerebral
hemispheres
• Leg areas of the primary sensory and motor
cortices
• Cingulate gyrus

Duus. Topical Diagnosis in Neurology. 4th ed. p424-7

Middle Cerebral Artery (MCA)

• The largest branch of the ICA

• After its origin from the ICA, it travels laterally
in the sylvian fissure.

Tree-like branches that bring blood to :

• Basal ganglia
• Anterior limb & genu of the internal capsule
• External capsule
• Claustrum
• Large areas of the frontal parietal, &
temporal lobes

CMSD 620 Neuroanatomy of Speech, Swallowing and Language

CSU, Chico, Patrick McCaffrey, Ph.D. Chapter 11 ,Blood Supply
Duus. Topical Diagnosis in Neurology. 4th ed. p425
 Other Branches of ICA
Ophthalmic artery • Eye • Nasal mucosa
• Eyelids • Root of the nose
• Sphenoid sinus • Dura mater of the anterior cranial fossa
• Ethmoid air cells • Skin of the forehead
Posterior • Join the ICA to the PCA
communicating artery • Tuber cinereum
• Mamillary body,
• Rostral thalamiic nuclei,
• Subthalamus
• Part of the internal capsule
Anterior choroidal • Choroid plexus of the • Hippocampus
artery temporal horn of the • Amygdala
lateral ventricle • Part of the basal ganglia
• Optic tract • Part of the internal capsule
• Uncus • Part of the pyramidal tract

Duus. Topical Diagnosis in Neurology. 4th ed. P422-3

Vertebral Artery

Enters through foramen magnum  dura

& arachnoid mater  subarachnoid space
 medulla oblongata

Passes – foramen transversarium C6-C1

Branch of 1st part of subclavian artery

Duus. Topical Diagnosis in Neurology. 4th ed. p429

 Basilar Artery

Divided into 2
Posterior Cerebral
Arteries (PCA)

Union of 2 vertebral
arteries

Vertebral a. &
basilar a. supply
the brainstem &
cerebellum
Duus. Topical Diagnosis in Neurology. 4th ed. p429
Arteries to Cerebellum
Superior • Rostral portion of the
Cerebellar cerebellar hemisphere
Artery (SCA) • Upper portion of the vermis

Anterior Inferior • Flocculus & the anterior

Cerebellar portion of the cerebellar
Artery (AICA) hemisphere.
• Labyrinthine artery 
inner ear

Posterior • Basal portion of the cerebellar

Inferior hemispheres,
Cerebellar • Lower portion of the vermis,
Artery • Part of the cerebellar nuclei,
(PICA) • The choroid plexus of the 4th
ventricle
• The dorsolateral portion of the
medulla

Duus. Topical Diagnosis in Neurology. 4th ed. p429

 Arteries to
Brainstem

Basilar artery
• The paramedian branches
• The short and long circumferential
branches

Duus. Topical Diagnosis in Neurology. 4th ed. p429

 Posterior Cerebral Artery (PCA)
Anterior Thalamoperforating Arteries

Rostral portion of the thalamus

Thalamogeniculate Arteries

Lateral portion of the thalamus

Lateral posterior choroidal arteries

• Geniculate bodies,
• Medial and posteromedial thalamic nuclei
• Pulvinar
• Choroid plexus of the lateral ventricle

Posterior Thalamoperforating Arteries Medial posterior choroidal arteries

• Basal & medial portions of the thalamus • Geniculate bodies,

• pulvinar • Medial and posteromedial thalamic nuclei
• Pulvinar
• Midbrain
Duus. Topical Diagnosis in Neurology. 4th ed. p431-2 • Choroid plexus of the 3rd ventricle
Cortical branches of the PCA
• Visual cortex of the calcarine
sulcus
• Occipital lobe
• Medial temporal lobe
 Collateral Circulation in the Brain
5 Leptomeningeal collaterals
between the ACA, MCA,
PCA

2 External carotid a. −
4 Circle of Willis superficial temporal a.
− angular a. − ICA

1 External carotid a. −
facial a. − angular a. −
ICA

Allowing brain areas to

3 External carotid a. − continue receiving
occipital a. − vertebral a.
adequate blood supply

Duus. Topical Diagnosis in Neurology. 4th ed. P433

 Circle of Willis
A point where the blood
carried by the internal
carotids and the basilar
system comes together

Anterior communicating
artery

Posterior communicating
artery

Sometimes, an
adjustment time is
required  Transient
ischemic attack (TIA)
CMSD 620 Neuroanatomy of Speech, Swallowing and Language
CSU, Chico, Patrick McCaffrey, Ph.D. Chapter 11 ,Blood Supply
Ischemic Syndromes in the
Anterior Circulation
Cerebral ischemia most commonly
arises in the territory of the ICA

Cardiogenic / arterioarterial emboli

arising in atherosclerotic plaques
at the bifurcation of the common
carotid artery

Duus. Topical Diagnosis in Neurology. 4th ed. P463

 Ischemic Syndromes in the
Anterior Circulation (2)
Bifurcation of ICA
• Extensive infarction in the
MCA’s territory
• Infarction in the ACA’s territory
• ↑intracranial pressure  fatal
MCA
• Contralateral brachiofacial
hemiparesis
• Contralateral hemihypesthesia
• Contralateral homonymous
hemianopsia
• Motor/sensory aphasia,
acalculia, agraphia, & motor
apraxia (dominant hemisphere)
• Constructive apraxia,
anosognosia (nondominant
hemisphere)
ACA
• Hemiparesis of the leg
• Very severe disturbance of drive
• Mental abnormalities
• Apraxia,
• Bladder dysfunction (incontinence)
• Pathological, “primitive” reflexes
(grasp, suck, & palmomental reflexes)
Ophtalmic a. Anterior choroidal a.
• Transient monocular • Contralateral hemiparesis
blindness • Contralateral hemihypesthesia
• Contralateral homonymous
hemianopsia
Duus. Topical Diagnosis in Neurology. 4th ed. P463-6
 Ischemic Syndromes in the
Posterior Circulation
• Usually embolic origin
• Brainstem infarction  cardiac / respiratory
distress
• Limited room in the posterior fossa for swollen
brain tissue  intracranial hypertension
• Compression of the aqueduct or 4th ventricle 
hydrocephalus

Duus. Topical Diagnosis in Neurology. 4th ed. P466-7

 Ischemic Syndromes in the
Posterior Circulation -- Cerebellum

SCA AICA PICA

• Severe ataxia • Ipsilateral • Wallenberg syndrome
• Astasia • hemiataxia • Hemiataxia,
• Abasia • Nystagmus • Dysmetria
• Sensory deficit in the ipsilateral half • 7th & 8th nerves impairment • Dysdiadochokinesia
of the face and the contralateral half • Labyrinthine a.  sudden
of the body deafness.
• trigeminal neuralgia

Duus. Topical Diagnosis in Neurology. 4th ed. P470-3

 Ischemic Syndromes in the
Posterior Circulation -- PCA
Medial & lateral posterior choroidal arteries Cortical branches
• Homonymous quadrantanopsia • Unilateral lesion  contralateral homonymous
• Hemisensory deficits hemianopsia
• Transcortical aphasia • Bilateral lesions  cortical blindness.
• Amnesia • Calcarine a.  scotoma
• Oculomotor dysfunction
Anterior thalamo- Posterior thalamo- Thalamogeniculate a.
perforating a. perforating a.
• Rest / intention tremor • Severe impairment • Transient contralateral hemiparesis,
• Choreoathetotic motor of consciousness • Persistent contralateral hemianesthesia for
restlessness with touch and proprioception (with lesser impairment
thalamic hand of pain and temperature sensation),
• Spontaneous pain,
• Mild hemiataxia
• Mild astereognosis,
• Contralateral choreoathetotic motor
restlessness.
Duus. Topical Diagnosis in Neurology. 4th ed. P467-70
 Ischemic Syndromes in the
Posterior Circulation -- Brainstem
Wallenberg syndrome Dejerine syndrome (Paramedian Millard Gubler or Foville syndrome
(PICA or vertebral a.) branches of the vertebral or basilar a.) (Circumferential branches of the basilar
a.)
• Vertigo • Ipsilateral flaccid 12th nerve palsy • Ipsilateral 6th nerve palsy (peripheral)
• Nystagmus • Contralateral hemiplegia with • 7th nerve palsy (nuclear);
• Nausea & vomiting Babinski’s sign • Contralateral hemiplegia;
• Dysarthra • Contralateral hypesthesia to touch and • Contralateral analgesia; thermanesthesia;
• Dysphonia pressure, impaired position sense & impairment of touch, position, & vibration
• Singultus • Nystagmus sense

Benedikt syndrome (interpeduncular branches of Weber syndrome (interpeduncular branches of the

the basilar a. & PCA) PCA & posterior choroidal a.)

• Ipsilateral 3rd nerve palsy • Ipsilateral 3rd nerve palsy

• Contralateral impairment of touch, position, &
vibration sense, two-point discrimination
• Contralateral hyperkinesia (tremor, chorea, athetosis)
• Contralateral rigidity
• Contralateral spastic hemiparesis;
• Contralateral parkinsonian rigidity;
• Contralateral dystaxia (corticopontine
• Possible interruption of the supranuclear nnervation
of 7th , 9th, 10th, 12th nerves

Duus. Topical Diagnosis in Neurology. 4th ed. P226-37

 Ischemic Syndromes in the
Posterior Circulation – Brainstem (2)
Syndrome of the caudal pontin
tegmentum (short and long
circumferential branches of basilar a,)
• Ipsilateral nuclear 6th & 7th nerve palsy
• Nystagmus
• Gaze paresis toward the side of the
lesion;
• Ipsilateral hemiataxia
• Ipsilateral asynergia
• Contralateral analgesia
• Contralateral thermanesthesia
• Contralateral hypesthesia
• Contralateral impairment of position &
vibration sense
• Ipsilateralpalatal & pharyngeal
myorhythmia
Duus. Topical Diagnosis in Neurology. 4th ed. P226-37
Syndrome of the oral pontine
tegmentum (long circumferen-
tial branches of the basilar a.
& SCA)
• Ipsilateral loss of facial
sensation
• Paralysis of the muscles of
mastication
• Hemiataxia
• Intention tremor
• Adiadochokinesia
• Contralateral impairment of all
sensory modalities
Syndrome of the midportion of
the basis pontis (paramedian &
short circumferential branches
of the basilar a.)
• Ipsilateral flaccid paresis of the
muscles of mastication
• Facial hypesthesia, analgesia,
and thermanesthesia;
• Ipsilateral hemiataxia
• Ipsilateral asynergia;
• Contralateral spastic
hemiparesis
THE VEINS
 Superficial Veins of the Brain
Blood from the brain parenchyma

Short cortical veins

•Superior anastomotic Superficial

vein of Trolard middle cerebral
• Dorsal superior cerebral vein
vein
•Inferior anastomotic vein
of Labbé

Cavernous
Superior sagittal sinus Sinus

Confluens sinuum, torcular

Herophili
Duus. Topical Diagnosis in Neurology. 4th ed. P435-6
 Deep Veins of the Brain
Venous blood from deep
regions of the brain

• Internal cerebral veins

• Basal veins of Rosenthal

Great vein of Galen

Sinus rectus

Confluens sinuum,
torcular Herophili
Duus. Topical Diagnosis in Neurology. 4th ed. P436-7
 Dural Sinuses
Superior sagittal sinus Sinus rectus

Confluens sinuum, torcular Herophili

Blood from basal Transverse sinus

regions of the brain
(mainly the temporal
lobe and the orbit)
Sigmoid sinus

Cavernous sinus Internal jugular vein

Variety of venous
channels (sigmoid
sinus. pterygoid
plexus, etc)

Duus. Topical Diagnosis in Neurology. 4th ed. P437-8

 Impaired Venous Drainage
from the Brain

↓ arteriovenous
pressure ↓ O2 &
↓perfusion
difference nutrients
across the
cerebral Infarction
Blocked ↑ the blood
capillaries of the
cerebral volume &
affected
vein venous
brain area
pressure ↑ transcapillary Vasogenic
pressure edema
gradient

Duus. Topical Diagnosis in Neurology. 4th ed. P473

 Impaired Venous Drainage
from the Brain (2)

Acute Venous Outflow Chronic Venous Outflow

Obstruction Obstruction
Etiology Thrombosis • Medication
• Bilateral stenosis of the
venous outflow channels
Manifstations • Headache • Headache
• Papilledema • Papilledema
• Epileptic seizures
• Focal neurological deficits
that progress over a few hours

Duus. Topical Diagnosis in Neurology. 4th ed. P478

 CEREBRAL
AUTOREGULATION
 Cerebral Autoregulation
The intrinsic capacity of the cerebral vasculature to maintain
.
constant blood flow in the face of varying cerebral perfusion
pressure Downey & Darling’s Physiological Basis of Rehabilitation Medicine. 3 ed. p27
rd

Metabolic • Balance between cerebral metabolism

regulation (demand) & O2 delivery

, Myogenic • Vascular smooth muscle in arterioles

regulation

Neurogenic • Sympathetic innervation

regulation
Paulson OB, Strandgaard S, Edvinsson L. Cerebral autoregulation.
Available at : http://www.ncbi.nlm.nih.gov/pubmed/2201348
 Cerebral Autoregulation (2)

Cerebral blood flow (CBF) MAP <50 mmHg  vasodilatation

remains constant Mean arterial
pressure (MAP) 50-150 mmHg MAP >150 mmHg  vasoconstriction

Hypoxemia/hypercapnia  vasodilatation
Arterial O2 & CO2 Continuing hypercapnia/hypocapnia 
concentration determine CBF Ph normalization by CSF bicarbonate
concentration  CBF return to normal

Downey & Darling’s Physiological Basis of Rehabilitation Medicine. 3rd ed. p28