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CNS Blood Supply

Nabeel Kouka, MD, DO, MBA
www.brain101.info

Spinal Cord

Vascular Supply

Arterial Supply
- Spinal Arteries Anterior (1) & Posterior (2) Spinal Artery from Vertebral artery - Radicular Arteries ----- Segmental arteries from Vertebral, Ascending Cervical, Intercostal and Lumbar Artery

Venous Drainage
- Longitudinal & Radicular Veins to Intervertebral veins ---- to Internal Vertebral Venous Plexus to external vertebral venous plexus ---- to segmental veins

5. Adamkiwicz artery

anterior spinal artery

segmental arteries

Blood Supply to the Spinal Cord and Brain Stem
The brain is one of the most metabolically active organs in the body, receiving 17% of the total cardiac output and about 20% of the oxygen available in the body.

The brain receives it¶s blood from two pairs of arteries, the carotid and vertebral. About 80% of the brain¶s blood supply comes from the carotid, and the remaining 20% from the vertebral.

The Vertebrobasilar System
The vertebral arteries originate from the subclavian artery, and ascend through the transverse foramen of the upper six cervical vertebra. At the upper margin of the Axis (C2) it moves outward and upward to the transverse foramen of the Atlas (C1). It then moves backwards along the articular process of atlas into a deep groove, passes beneath the atlanto-occipital ligament and enters the foramen magnum. The arteries then run forward and unite at the caudal border of the pons to form the basilar artery.

1.Blood Supply to the Spinal Cord and Brainstem The Spinal Cord receives its blood supply from two major sources. Branches of the vertebral arteries. the major source of blood supply. Pons and Midbrain areas receive their major sources of blood supply from several important branches of the Basilar artery . derives sporadically from segmental arteries The Medulla. 2. Multiple radicular arteries. via the anterior spinal and posterior spinal arteries.

posterior part of cerebellar hemisphere b. central nuclei of cerebellum d. medullary branches to dorsolateral medulla . choroid plexus of 4th ventricle e. the largest branch of the vertebral. Posterior Inferior Cerebellar Artery (PICA).Branches of the Vertebral Artery 1. Runs a course winding between the medulla and cerebellum Distribution: a. inferior vermis c. arises at the caudal end of the medulla on each side.

Runs down the ventral median fissure the length of the cord. . Distribution: a. formed from a Yshaped union of a branch from each vertebral artery.Branches of the Vertebral Artery 2. supplies the ventral 2/3 of the spinal cord. Anterior Spinal Artery.

originate from each vertebral artery or Posterior Inferior Cerebellar on each side of the Medulla. Posterior Spinal Arteries (2).Branches of the Vertebral Artery 3. Distribution: supplies the dorsal 1/3 of the cord of each side. . Descends along the dorsolateral sulcus.

medulla and cerebellum . This branch moves into the dura matter of the cranium 5. Bulbar branches.Branches of the Vertebral Artery 4. These branches head for the pons. Posterior meningeal. one or two branches that originate from the vertebral opposite the foramen magnum. composed of several smaller arteries which originate from the vertebral and it¶s branches.

Spinal Cord Blood Supply Ventral Dorsal .

. provides sulcal branches which penetrate the ventral median fissure and supply the ventral 2/3 of the spinal cord.Spinal Cord Blood Supply Anterior Spinal Artery. each descends along the dorsolateral surface of the spinal cord and supplies the dorsal 1/3. Posterior Spinal Arteries.

which divide into anterior and posterior radicular arteries as they move along ventral and dorsal roots to reach the spinal cord. Here they reinforce spinal arteries and anastomose with their branches. a series of circumferential anastomotic channels are formed around the spinal cord. called the arterial vasocorona. originating from segmental arteries at various levels. from which short branches penetrate and supply the lateral parts of the cord . From these varied sources of blood supply.Spinal Cord Blood Supply Radicular arteries.

Spinal Cord Blood Supply The radicular arteries provide the main blood supply to the cord at the thorasic. Usually located with the lower thorasic or upper lumbar spinal segment on the left side of the spinal cord . noticeably larger than the others. There are a greater number on the posterior (10-23) than anterior (6-10 only) side of the cord. or the artery of the lumbar enlargement. lumbar and sacral segments. One radicular artery. is called the artery of Adamkiewicz.

making these regions prone to ischemia after vascular occlusions. . The upper Thorasic (T1-T4) and first lumbar segments are the most vulnerable regions of the cord.Spinal Cord Blood Supply The spinal cord lacks adequate collateral supply in some areas.

First Lumbar arteries.Spinal Cord Blood Supply There are several arteries that reinforce the spinal cord blood supply and are termed segmental arteries 1. present in the mid-thorasic region 4. The Vertebral arteries. present in the lower cervical areas 3. present in the mid-lumbar regions . Posterior Intercostal. Ascending Cervical arteries. spinal branches which are present in the upper cervical (~C3-C5) levels 2.

. The posterior spinal veins run along the midline and the dorsal roots. These are drained by the anterior and posterior radicular veins.Spinal Cord Blood Supply The spinal veins arranged in an irregular pattern. These in turn empty into an epidural venous plexus which connects into an external vertebral venous plexus. the vertebral. The anterior spinal veins run along the midline and the ventral roots. intercostal and lumbar veins.

Spinal Cord Blood Supply Occlusion of the anterior spinal artery may lead to the anterior cord syndrome characterized by. 1. 2. due to damage to ventral gray matter and the ventral corticospinal tract. Loss of contralateral pain and temperature sensation. Loss of ipsilateral motor function. due to damage to the spinothalamic pathway . syndrome.

1. due to damage to corticospinal tract 2. vibratory sense.Spinal Cord Blood Supply Occlusion of the posterior spinal arteries may lead to the rare posterior cord syndrome characterized by. syndrome. Ipsilateral motor deficits. Ipsilateral loss of tactile discrimination. due to damage to the dorsal columns . position sense.

pons midbrain) receives the bulk of its blood supply from the vertebrobasilar system. all other branches supply the brain stem and cerebellum The posterior cerebral has only a small contribution. its main target being the posterior cerebral hemispheres .Blood Supply to the Brain Stem The brain stem (medulla. Except for the labyrynthine branch.

originates near the lower border of the Pons just past the union of the vertebral arteries. Anterior Inferior Cerebellar Arteries (AICA). Distribution: a.Branches of the Basilar Artery 1. also contributes to upper medulla and lower pontine areas . contributes to supply of central cerebellar nuclei c. supplies anterior inferior surface and underlying white matter of cerebellum b.

floor of fourth ventricle and pontine tegmentum .basal pons b. Pontine arteries. numerous smaller branches that can be subdivided into Paramedian and Circumferential pontine arteries. The Circumferential can be further subdivided into Long and Short pontine arteries. Distribution: a.lateral pons and middle cerebellar peduncle. circumferential pontine .Branches of the Basilar Artery 2. paramedian pontine .

cerebellar cortex. close to the Pons-Midbrain junction. Runs along dorsal surface of cerebellum Distribution: a. originates near the end of the Basilar artery. Superior Cerebellar arteries. white matter and central nuclei b. superior cerebellar peduncle and inferior colliculus .Branches of the Basilar Artery 3. Additional contribution to rostral pontine tegmentum.

some contribution to interpeduncular plexus . Posterior cerebral arteries. They appear as a bifurcation of the Basilar. just past the Superior Cerebellar arteries and the oculomotor nerve. mainly neocortex and diencephalon b. the terminal branches of the Basilar artery.Branches of the Basilar Artery 4. Curves around the midbrain and reaches the medial surface of the cerebral hemisphere beneath the splenium of the corpus callosum Distribution: a.

Supplies the region of the inner ear . may branch from the basilar.Branches of the Basilar Artery 5. but variable in its origin. Labyrynthine arteries.

2. sends blood to the paramedian region of the caudal medulla. bulbar branches supply areas of both the caudal and rostral medulla. . Posterior spinal artery. Anterior spinal artery.Blood Supply to the Medulla The Medulla is supplied by the. 3. along with dorsal areas of the inferior cerebellar peduncle. 1. Vertebral artery. Posterior inferior cerebellar artery. including the gracile and cuneate fasiculi and nuclei. supplies rostral areas. 4. supplies lateral medullary areas.

Blood Supply to the Medulla .

Blood Supply to the Medulla Occlusion of branches of the anterior spinal artery will produce a inferior alternating hemiplegia (aka medial medullary syndrome syndrome). An ipsilateral deviation and paralysis of the tongue. due to damage to the hypoglossal nucleus or nerve Occasionally. these symptoms will develop after occlusion of the vertebral artery before gives off its branches to the anterior spinal artery . 1. characterized by. A contralateral loss of position sense. A contralateral hemiplegia of the limbs. due to damage to the pyramids or the corticospinal fibers 2. vibratory sense and discriminative touch. due to damage to the medial leminiscus 3.

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spinal trigeminal tract and nucleus. portions of the inferior cerebellar peduncle .Blood Supply to the Medulla The posterior spinal arteries supply the gracile and cuneate fasiculi and nuclei.

hypoglossal nucleus (cranial nerve XII). spinal trigeminal tract.The vertebral arteries supply the pyramids at the level of the Pons. the medullary reticular formation. solitary motor nucleus dorsal motor nucleus of the Vagus (cranial nerve X). the inferior olive complex. spinothalamic tract spinocerebellar tract Blood Supply to the Medulla .

spinal trigeminal nucleus and tract. fibers from the nucleus ambiguous. dorsal motor nucleus of the Vagus (cranial nerve X) inferior cerebellar peduncle .Blood Supply to the Medulla The posterior inferior cerebellar arteries (PICA) supply spinothalamic tract.

1. Vertigo. due to damage to the descending hypothalamolspinal tract . A contralateral loss of pain and temperature sense.Blood Supply to the Medulla Occlusion of the posterior inferior cerebellar artery (or contributing vertebral) will produce a lateral medullary syndrome or Wallenberg¶s syndrome syndrome. nausea and vomiting. due to damage to the anterolateral system (spinothalamic tract) 2. Hornor¶s syndrome. (miosis [contraction of the pupil]. due to damage to the spinal trigeminal nucleus and tract 3. due to damage to the vestibular nuclei 4. decreased sweating). ptosis [sinking of the eyelid]. An ipsilateral loss of pain and temperature sense on the face. characterized by.

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supply anterolateral pons c. The Basilar artery.Blood Supply to the Pons The Pons is supplied by the. a. 1. contributions of this main artery can be further subdivided. long circumferential branches. paramedian branches. Some reinforcing contributions by the anterior inferior cerebellar and superior cerebellar arteries . to medial pontine region b. short circumferential branches. 2. run laterally over the anterior surface of the Pons to anastomose with branches of the anterior inferior cerebellar artery (AICA).

Distribution: a.Additional branches of the Basilar artery can be found branching off within the region of the Pons. also contributes to upper medulla and lower pontine areas Blood Supply to the Pons . contributes to supply of central cerebellar nuclei c. 1. Anterior Inferior Cerebellar Arteries (AICA). supplies anterior inferior surface and underlying white matter of cerebellum b. originates near the lower border of the Pons just past the union of the vertebral arteries.

Additional contribution to rostral pontine tegmentum.Blood Supply to the Pons 2. Runs along dorsal surface of cerebellum Distribution: a. superior cerebellar peduncle and inferior colliculus . cerebellar cortex. close to the Pons-Midbrain junction. Superior Cerebellar arteries. white matter and central nuclei b. originates near the end of the Basilar artery.

Remaining 9% were of duplicate origin Blood Supply to the Pons . common cochlear The labyrinthine has a variable origin. Superior cerebellar (25%) 4. (sample size of 238) the artery originated from. 1975. al. a. Supplies the region of the inner ear. according to a study done by Wende et. AICA (45%) 3. but variable in its origin. Labyrynthine arteries. anterior vestibular b. may branch from the basilar. Divides into two branches. PICA (5%) 5. 1.2. Basilar (16%) 2..

abducens nerve and nucleus (cranial nerve VI) . pontine reticular area. the medial leminiscus. and periaquaductal gray areas . this includes corticospinal fibers (basis pedunculi).Blood Supply to the Pons The paramedian branches of the Basilar artery supplies the paramedian regions of the Pons.

Blood Supply to the Pons The paramedian branches of the Basilar artery supply corticospinal fibers. periaquaductal gray areas . pontine reticular area. the medial leminiscus. abducens nerve and nucleus (cranial nerve VI) .

due to damage to the abducens nerve or tract (can cause diplopia ³double vision´) . Contralateral loss of tactile discrimination. Hemiplegia of the contralateral arm and leg. due to damage to the medial leminiscus 3. Ipsilateral lateral rectus muscle paralysis. vibratory and position sense. 1. due to damage to the corticospinal tracts 2.Blood Supply to the Pons Obstruction of the paramedian pontine arteries will produce a middle alternating hemiplegia (also termed medial pontine syndrome) which is characterized by.

pontocerebellar fibers.Blood Supply to the Pons The short circumferential branches supply. pontine nuclei. medial leminiscus the anterolateral system (spinothalamic fibers) .

middle and superior cerebellar peduncles. the anterolateral system (spinothalamic) pontine reticular nuclei. along with the anterior inferior cerebellar (caudally). hypothalamospinal fibers. and superior cerebellar artery (rostrally). facial motor nucleus (cranial nerve VII) trigeminal nucleus (cranial nerve V) spinal trigeminal nucleus and tract (cranial nerve V).Blood Supply to the Pons The long circumferential branches supply. . vestibular and cochlear nerves and nuclei.

Blood Supply to the Pons Occlusions of long branches circumferential branches of the basilar artery produce a lateral pontine syndrome. vomiting. nystagmus. due to damage to the anterolateral system (spinothalamic) 5. deafness. Contralateral loss of pain and temperature sense from the body. Ataxia. nausea. characterized by. Vertigo. due to damage to the spinal trigeminal nucleus and tract 4. due to damage to vestibular and cochlear nuclei and nerves 3. Ipsilateral pain and temperature deficits from face. tinitus. 1. due to damage to the facial and trigeminal motor nuclei (cranial nerves VII and V) . Ipsilateral paralysis of facial muscles and masticatory muscles. due to damage to the cerebral peduncles (middle and superior) 2.

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joins the posterior cerebral to form portions of the circle of Willis (arterial circle). forms a plexus with the posterior communicating arteries in the interpeduncular fossa. (some posterior choroidal) a branch of the posterior cerebral. derived from the internal carotid. Posterior cerebral artery. Posterior communicating artery. Contributes to the interpeduncular plexus 5. 3. 1. provides support for the tectum (superior and inferior colliculi) 4.Blood Supply to the Midbrain The major blood supply to the midbrain is derived from branches of the basilar artery. branches from this plexus supply a wide area if the midbrain 2. short circumferential and long circumferential . Quadrigeminal. Superior cerebellar artery. Branches of these arteries are best understood when grouped into paramedian. supplies dorsal areas around the central gray and inferior colliculus with support from branches of the posterior cerebral artery.

medial longitudinal fasiculus. this system supplies raphe region.Blood Supply to the Midbrain The paramedian arteries. form a plexus in the interpeduncular fossa. red nucleus substantia nigra crus cerebri . enter the through the posterior perforated substance. derived from the posterior communicating and posterior cerebral. oculomotor complex.

Contralateral hemiplegia of the limbs. caused by damage to the oculomotor nerve . and contralateral face and tongue due to damage to the descending motor tracts (crus cerebri). 2. 1.Blood Supply to the Midbrain Occlusion of midbrain paramedian branches produces a medial midbrain or superior alternating hemiplegia (or Weber¶s syndrome) characterized by. Ipsilateral deficits in eye motor activity.

this system supplies crus cerebri.Blood Supply to the Midbrain The short circumferential arteries originate from the interpeduncular plexus and portions of the posterior cerebral and superior cerebellar arteries. substantia nigra midbrain tegmentum .

one important branch.Blood Supply to the Midbrain The long circumferential branches originate mainly from the posterior cerebral artery. the quadrigeminal (collicular artery) supplies the superior and inferior colliculi. .

In addition to providing reinforement to the midbrain short and long circumferential arteries they move forward to supply portions of the diencephalon and the choroid plexus of the third and lateral ventricles .Blood Supply to the Midbrain The posterior choroidal arteries originate near the basilar bifurcation into the posterior cerebral arteries.

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due to failure of central control of respiration Infarcts within the ventral portion of the Pons can produce paralysis of all movements except the eyes. Patient is conscious but can communicate only with eyes. LOCKED-IN-SYNDROME .Other Clinical Points Substantial infarcts within the Pons are generally rapidly fatal.