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VASCULAR ANATOMY OF BRAIN

G PARTHASARATHY

• Anterior circulation - Internal carotid arteries • Posterior circulation - Vertebral and Basilar arteries • Meninges - External carotid arteries contribute

Internal carotid artery
• Common carotid artery bifurcates at level of upper border of thyroid cartilage (C3 – C4 disc level). • ICA lies posterior and lateral to ECA. • Divided into cervical, petrous, cavernous, supraclinoid segments.

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Cervical segment: no named branches arise.  Branches  Vidian artery (anastomoses with ECA)  Caroticotympanic artery (supplies middle ear) . Petrous segment:  Intraosseous  Begins at carotid canal. traverses foramen lacerum.

. ovale. Cavernous and supraclinoid segments – “Carotid siphon”.  Inferolateral trunk . 5th cranial nerves. Cavernous segment:  Branches  Posterior trunk (meningohypophyseal artery) .supplies pituitary.anastomoses with ECA branches through foramen rotundum. spinosum. tentorium. clival dura. .supplies 3rd. 4th.

 Posterior communicating artery – links ICA with Posterior cerebral artery (PCA can arise directly from ICA.  Branches  Ophthalmic artery – passes through optic canal into orbit. basal ganglia.  Anterior choroidal artery – supplies posterior internal capsule. medial temporal lobe. choroid plexus. . enters sub-arachnoid space near anterior clinoid process.“fetal arrangement”). Supraclinoid segment:  ICA pierces dura.

ICA segments in lateral angiogram .

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“azygos” anterior cerebral artery.gives off cortical branches.Terminal branches  Anterior cerebral artery:  Horizontal/Precommunicating A1 segment  Vertical/Postcommunicating A2 segment  Distal A3 segment. • Anatomical variations  Hypoplasia/aplasia of A1 segment  Fusion of A2 segments in midline. • Recurrent artery of Heubner arises from distal A1 or proximal A2. . • Perforating arteries arise from A1.medial lenticulostriate arteries.

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parietal branches (M4 segment). Opercular segment M3.  Horizontal segment M1. Cortical branches M4.  Branches  Perforating branches (M1 segment).  Temporal.medial and lateral lenticulostriate arteries supply basal ganglia and capsular region. frontal.supply most of the lateral surface except a narrow superomedial strip. angular. Middle cerebral artery:  Runs laterally in stem of lateral sulcus. Insular segment M2. .

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MRA showing MCA segments .

CTA .

• This point approximates the apex of insula.• Sylvian triangle – formed by the branches of MCA within sylvian fissure on outer surface of insula (form a loop) upon reaching the upper margin of insula. posterior limit of lateral sulcus. . • Serves as landmark for localising supratentorial masses. • Sylvian point – most medial point where the last cortical MCA branch (usually angular artery) turns inferiorly to exit sylvian fissure.

spinal branches. tonsillar. cerebellar branches.anterior and posterior spinal arteries .Vertebro – Basilar system  VA arises from first part of Subclavian artery.  Segments and branches:  Extaosseous V1 (origin → C6): segmental cervical muscular.gives off perforating medullary. choroid. .perforating branches to medulla.Posterior inferior cerebellar artery.  Foraminal V2 (C6 → C1): Anterior meningeal artery  Extraspinal V3 (C1 → foramen magnum): Posterior meningeal artery  Intradural V4 (intracranial): . .

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 Vertebral arteries fuse behind the clivus and in front of lower pons to form Basilar artery.  Superior cerebellar arteries.pass around brainstem to fan out over superior surface of cerebellar hemispheres. .  Branches:  Anterior inferior cerebellar arteries.  Posterior cerebral arteries – terminal BA branches.loops in the CP angle and gives off internal auditory arteries.

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.precommunicating  P2.anterior and posterior temporal arteries (P2).Posterior Cerebral Artery  Bifurcation of BA. Basilar tip aneurysms more common with caudal fusion.  Segments:  P1.posterior thalamoperforating areteries (P1).  Cortical branches.quadrigeminal  P4.either V-shaped (caudal fusion) or T-shaped (cranial fusion).calcarine  Branches:  Perforating branches.ambient  P3. thalamogeniculate arteries (P2).  Ventricular/ choroidal branches (P2).

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 Distal PCA divides into 2 terminal trunks o Medial branches. calcarine artery.lateral occipital artery. . • P1 segment hypoplastic or absent. not occlusion. • Absent PCA on vertebral angiogram usually due to “fetal” origin.medial occipital artery. • Injection of ipsilateral carotid artery confirms presence of fetal PCA. o Lateral branches. temporal arteries.  Fetal origin of PCA: • Large Posterior communicating artery gives direct origin to PCA.

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deep temporal arteries. • Occipital artery supplies dura through a petromastoid branch. • Maxillary artery gives off middle meningeal accessory meningeal.gives branches to dura mater of posterior cranial fossa. .External Carotid artery • Ascending pharyngeal artery.

Anastomotic pathways • The Circle of Willis • Extracranial – Intracranial anastomoses • Leptomeningeal collaterals .

 Anteriorly  Internal carotid arteries.precommunicating A1 segment  Anterior communicating artery  Posteriorly  Basilar artery. PcoAs course below optic tracts.Circle of Willis  Central arterial anastomotic ring of brain.lies above sella in suprasellar cistern. .distal part  Anterior cerebral arteries.distal part  Posterior cerebral arteries.precommunicating P1 segment  Posterior communicating arteries  A1 segments course above optic nerves.

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• Variations:  Absent or hypoplastic components (A1.optic tracts.PcoA).entire central base of brain (hypothalamus.midbrain).  Persistent caroticovertebral anastomoses (trigeminal.• CTA/ MRA best for imaging entire COW. cross-compression of contralateral carotid artery to visualize AcoA.  Fetal origin of PCA.thalamus.internal capsule. • DSA requires multiple views. hypoglossal). • Vascular territory. • Complete COW found only in 40% of people. .

.Intracranial anastomoses:  Between ECA and ICA: o Facial artery o Middle meningeal artery o Ophthalmic artery o Superficial temporal artery  Between ECA and Posterior circulation: o Occipital artery o Ascending pharyngeal artery o Vertebral artery  Leptomeningeal (pial) collaterals: • End-to-end anastomoses between distal branches of intracerebral arteries. Extracranial. • Provide collateral flow across watershed zones.

Dural venous sinuses • Endothelial lined trabeculated venous channels encased within dural reflections.coronal for superior sagittal sinus). . Communicate with extracranial veins directly. • Obtain source images for MR venogram perpendicular to main axis of dural sinus (eg. • Receive blood from superficial and deep veins. CTV excellent for general overview but DSA best for detailed dilineation. • Contain arachnoid granulations. villi – return CSF to venous circulation. • MRV.

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Vein of Trolard. tentorium.  Receives tributaries from falx.  Inferior sagittal sinus:  Smaller channel in inferior free margin of falx.  Joins with Vein of Galen to form straight sinus.terminates at venous sinus confluence.collects superficial cortical veins.  Important hemispheric tributary. and cerebral hemispheres.  Straight sinus:  Runs from falcotentorial apex posteroinferiorly to sinus confluence.  Receives tributaries from corpus callosum. Superior sagittal sinus:  Occupies upper convex attached margin of falx cerebri.  Originates from ascending frontal veins anteriorly. .

cerebellum. and transverse sinuses. left TS a continuation of straight sinus. .  Tributaries from tentorium. occipital lobes.  Extends from internal occipital protubertance to posteroinferior angle of parietal bone.  Transverse (lateral) sinuses:  Situated in the posterior part of attached margins of tentorium cerebelli. Venous sinus confluence (Torcular Herophili):  Formed from union of superior sagittal. straight.  Often asymmetric (R>L).  Often asymmetric.  Right TS usually continuation of superior sagittal sinus. Hypoplastic /atretic segment common. inferiof temporal. interconnections between TS highly variable.  Important tributary – Vein of Labbe.

 Communicate inferiorly with pterygoid venous plexus. medially with contralateral CS. Sigmoid sinuses:  Anteroinferior continuation of TSs. cranial nerves III. IV. posteriorly with superior/ inferior petrosal sinus. V1. VI. V2.  Tributaries include superior and inferior ophthalmic veins. trabeculated venous compartment along sides of sella turcica.  Inconstantly visualized at DSA.  Extends from superior orbital fissure anteriorly to clivus and petrous apex posteriorly.  Gentle S. .  Contains cavernous ICA. sphenoparietal sinus.  Cavernous sinuses:  Irregularly shaped.shaped inferior curve.  Terminate by becoming Internal jugular veins.

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 Basilar plexus of veins:  Lies over the clivus.  Inferior petrosal sinus:  Lie in petro-occipital fissure.  Drain CS into superior bulb of IJV.  Sphenoparietal sinuses:  Lie along posterior free margin of lesser wing of sphenoid bone.  Drain into anterior part of CS.  Connects the two inferior petrosal sinuses and communicates with internal vertebral venous plexus.  Drains cavernous sinus into TS. Superior petrosal sinus:  Lie in the anterior margin of attached margin of tentorium along upper border of petrous temporal bone.  May receive frontal trunk of middle meningeal vein. .

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• Jugular bulb flow often very asymmetric. turbulent (pseudolesion).Imaging pitfalls • TSs often asymmetric. TSs). . • Subacute clot hyperintense on T1WI. • Acute dural sinus/ cortical vein thrombi isointense with brain on T1WI. Should not be misdiagnosed as occlusion.should not be mistaken for enhancement. • Unopacified venous blood streaming into dural sinus on DSA should not be mistaken for filling defect (thrombus). hypoplastic/ atretic segments common. So T2*(GRE) or T1 C+ imaging very helpful. • “Giant” arachnoid granulations appear as round/ ovoid CSFequivalent filling defects in dural sinuses (esp.

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AP DSA. o Superior group: • 6-12 in number. drain superolateral surface of hemisphere. o Organized into superior. highly variable in number and configuration. middle and inferior groups. .Superficial cerebral veins o Located within subarachnoid space. • Terminate in superior sagittal sinus.step-ladder appearance. • Lateral DSA.arranged in spoke-like pattern.

• Middle group: • Superficial middle cerebral vein – drains the area around posterior ramus of lateral sulcus. • Terminates into CS or at times into sphenoparietal sinus. • Communicates with deep middle cerebral vein. • Inferior group: • Orbital veins terminate in Sup.SS. Tentorial veins terminate in CS. • Basal vein of Rosenthal: begins near anterior perforated substance, curves posteriorly around cerebral peduncles. Receives anterior cerebral veins, DMCV- drains into vein of Galen. • BVR- looks like “frog leg” on DSA AP view.

“Dots” of contrast at subependymal/ medullary vein junction define roof of lateral ventricle. o Medullary veins: • Small linear veins.Deep cerebral veins o Includes medullary. . course toward ventricles. originate 1-2 cm below cortex. • DSA. o Subependymal veins • Septal veins course posteriorly along septum pellucidum. subependymal and deep paramedian veins. • Thalamostriate veins course anteriorly between caudate and thalamus.

• DSA AP view.course posteriorly in tela choroidea of 3rd ventricle. BVRs to form great cerebral vein. characteristic “double curve” appearance. .terminate in rostral quadrigeminal cistern by uniting with each other.TSVs define size and configuration of lateral ventricle. • Deep paramedian veins: • Internal cerebral veins . .• TSV terminate at IV foramen by uniting with septal veins to form ICV.

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absent/hypoplastic straight sinus.SS at falcotentorial apex to form straight sinus.primitive median promesencephalic vein persists as outlet for diencephalic. .VofG forms a prominent arc curving around corpus callosum splenium.o Vein of Galen: • Short. choroidal venous drainage. . • Vein of Galen malformation: . • DSA. U-shaped midline vein formed by union of ICVs and BVRs. • Unites with inf.persisting falcine sinus +/.

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Vein of Galen malformation .

medulla.paired paramedian structures. superior vermian vein.Posterior fossa veins  Superior (Galenic) group:  Drains up into vein of Galen. curve posterosuperiorly under uvula of vermis.  T1 C+ MR: APMV enhancement along pontine/ medullary surface is normal. collects tributaries from cerebellum.  Posterior (tentorial) group:  Inferior vermian veins.  Includes precentral cerebellar vein. .prominent trunk in CPA. anterior pontomesencephalic vein.  Anterior (petrosal) group:  Petrosal vein. pons. Should not be mistaken for meningitis.

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