Curiculum vitae

Dr. An An, M. Sc., Sp.S

Lulus dokter FK UGM th 2001

Lulus Spesialis Saraf FK UGM th 2013
Lulus S2 Ilmu Kedokteran Klinik FK UGM th 2013
Staf Pengajar Neurologi FK UNTAN
Dokter Sp.S di SMF Saraf RSUD Dr.Soedarso & RS UNTAN
Dokter Sp.S di RS Promedika
Dokter Sp.S visiting di RS Mitra Medika
Praktek di Apotik Abadi Jl. Diponegoro no.27 Pontianak

CEREBRAL VASCULARIZATION
DAN
APLIKASI KLINIS NEUROLOGI

Arterial Blood Supply of the Brain

Derived from:
- Internal carotid artery:
to anterior 2/3 of the cerebral hemispheres
- Vertebral artery:
to the remaining posterior and medial regions of
the hemispheres, most of the diencephalon, brainstem,
cerebellum, and cervical spinal cord.
Arteries of the brain lie in the subarachnoid space

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Anastomosis
The carotid and vertebral-basilar are anatomically
interconnected with each other, and with their
counterparts in the opposite site, through the circle of
Willis.

These circle usually cannot carry enough blood flow

to maintain adequate cerebral circulation if either a
carotid or a vertebral artery is suddenly blocked.

Circulus arteriosus Willis

1.
2.
3.
4.
5.
6.

Basilar
Posterior cerebral
Posterior communicating
Internal carotid
Anterior cerebral
Anterior communicating

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Branches of Internal Carotid Artery

cavernous part

cerebral part

- cavernous
- hypophyseal
- meningeal

- ophthalmic

- anterior cerebral
- middle cerebral
- anterior choroid
to: globus pallidus, caudate
nucleus, amygdala,
hypothalamus, red nucleus,
substansia nigra, capsula interna
(post. limb), optic radiation,
hippocampus.
- posterior communicating

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Internal carotid artery in the cavernous sinus

Anterior Cerebral Artery

Areas supplied by anterior cerebral artery:

Septal area

Primary motor cortex for legs, foots, urinary bladder

Additional motor planning areas in the medial frontal lobe anterior

to precentral gyrus

Most of the corpus callosum except its posterior part

Middle Cerebral Artery

Central branches: Lenticulostriate artery
Through: anterior perforate substance
To:
lentiform nucleus, caudate nucleus and internal capsule
Cortical branches:
Superior branch to:

Primary motor cortex for face and arm

Brocas area
Frontal eye fields (for looking at eye movements to the
opposite site)
Primary somatosensory cortex for face & arm
Parts of lateral frontal & parietal lobe for 3-D visual
perceptions and for ability to interpret & express emotion

Middle Cerebral Artery

Cortical branches (cont.)
Inferior branches to
Wernicks area
Parts of posterior parietal lobe for 3-D visual
perceptions and for ability to interpret & express
emotion
Optic radiation particularly fibers that represent
information from the contralateral superior
quadrants of the visual field

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Outer surface of hemispherium showing areas

supplied by cerebral arteries

Medial surface

Branches of Vertebral & Basilar arteries

Vertebral:
- posterior & anterior spinal
- posterior inferior cerebellar

Basilar:
- pontine
- labyrinthine
- anterior inferior cerebellar
- superior cerebellar
- posterior cerebral
- posterior communicating

Areas supplied by vertebral-basilar

arteries
Rostral midbrain:
- Pyramidal tract (PT), superior cerebellar peduncle,
n. III nucleus, medial longitudinal fasciculus (MLF),
reticular formation (RF)
Mid pons:
- MLF, RF, PT, middle cerebellar peduncle (MCP),
trigeminal sensory & motor nuclei

Areas supplied by vertebral-basilar arteries

(cont.)
Caudal pons:
- n. VI nucleus, motor fibers n. VII, lateral gaze center, PT
- n. VII nucleus, MCP, descending tract nucleus n. V,
spinothalamic tract (ST), vestibular & cochlear nuclei

Rostral medulla:
- n. XII nucleus, PT, medial lemniscus
- nucleus ambiguus, n. IX & X, descending tract nucleus n.
V, ST, Vestibular nuclei, Inferior cerebellar peduncle

Structures supplied by posterior

cerebral artery
- Diencephalon
- Midbrain
- Optic radiation & striate cortex (primary visual
cortex)
- Splenium of the corpus callosum
- Hippocampal formation & the posterior of fornix
(important for new declarative memory)

Cerebral Blood flow

Every minute,
50 ml/100 g/min
- about 600-700 ml of blood flow through
the carotid arteries and their branches
- about 100-200 ml flow through the
vertebral-basilar system.

Cerebral Blood flow

Cerebral blood flow constant despite variation in blood
pressure (65-140 mm Hg).
Below this range cbf decrease
Above cbf increase

Control by sympathetic insubarachnoid space and by

adrenegic intrinsic inside the brain
CO2 and O2 also important
Intracranial pressure & cbf complex autoreg

Blood-Brain Barrier
Located at capillary endothel within brain, except
circumventric. system
Depends on the tight junction between endothel and a
relative lack of transport
Function
Protect brain from circulating substance
Selective transport of substances by specialized transport
system
Metabolism & modification of blood or brain borne substance

Atheromatous plaques
Atheromatous plaques tend to form at branchings and
curves of the cerebral arteries.
In the carotid circulation the most frequent sites:
- in the internal carotid artery at its origin
- in the stem MCA or its bifurcation into superior
and inferior divisions
- in the ACA as it curves backwards over the corpus
callosum.

Emboli
Emboli tend to enter the carotid circulation far more
frequently than they enter the vertebral circulation
Large emboli carried up the carotid tend to be swept into
the MCA --> prone to getting stuck at its branches in the
Sylvian fissure
Emboli can also lodge in one of the major cortical
branches of MCA as well as in the smaller branches

Lenticulostriate arteries
Small diameter arteries originate as right angle branches of
MCA.
Particularly susceptible to damage from hypertension.
Rupture of the artery produces an intracerebral hemorrhage,
initially centered in the region they supply
Occlusion produces a lacunar infarct.
--> leads to stereotyped stroke syndromes.

Lenticulostriate arteries
Hemorrhage:
- may remain localized to the putamen (and caudate)
- may involve neighboring structures (internal caps.etc)
- may rupture into ventricular system
Lacunar infarct:
- may have serious functional consequences if they involve
internal capsule
- may silent if they involve small region of white matter or
basal ganglia.

Stroke lakunar

Stroke infark

Ischemic
Injury
Apoptotic
Cell Death
Necrotic
Cell Death

Stroke infark

Stroke infark

Stroke

Paramedian vessels supplying the medial parts of the

brainstem are at risk for hypertensive damage,
particularly in the pons.
Large pontine hemorrhages involve the corticospinal
tract and reticular formation bilaterally.
Pontine lacunar infarcts may also damage the
corticospinal tracts.

Penetrating cerebellar vessels are also at risk for

hypertensive hemorrhage, with bleeding often occuring
near the dentate nucleus
--> deficits related to the cerebellum such as limb ataxia.
It may also affect brainstem function by compression or by
rupture into the fourth ventricle

APLIKASI KLINIS

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Middle Cerebral Artery

Largest branch of Internal
Carotid.
Supplies portion of frontal lobe
and lateral surface of Temporal
and Parietal lobes.
Primary Motor and Sensory
areas for face, throat , hand and
arm.
Dominant hemisphere, supplies
area controlling speech.
Is the Artery most often occluded
in stroke.
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Middle Cerebral Artery

The MCA proceeds laterally into the lateral
sulcus and spreads to supply virtually the entire
lateral surface of the cerebral hemiphere, where
most of the precentral and postcentral gyri are
located.
Included in this region are the motor speech of
area Broca and the sensory language area of
Wernickle.
MCA also supply the putamen, part of the
caudate nucleus, the outer globus pallidus, the
posterior limb of the internal capsule and the
corona radiata.

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Middle Cerebral Artery

Characterized by weakness of the contralateral
face with hemianopsia and a preference of the
eyes and head toward the side of the involved
hemispere
Aphasia in dominant hemisphere injury
Hemineglect
Involvement restricted to branches of the MCA
may produces fragment of this syndrome sparing
of leg strengh
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Middle Cerebral Artery superior

division

Weakness - upper and lower extremity (C)

Weakness - face - lower half (C)
Hemisensory loss - upper and lower extremity
(C)
Sensory loss - face - all modalities (C)
Hemineglect (ND)
Aphasia expressive (D)
(AHA Stroke Center, 2004)
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Middle Cerebral Artery inferior division

Visual loss - homonymous hemianopia (C)

Visual loss - upper quadrant anopsia (C)
Constructional apraxia (ND)
Aphasia receptive (D)

( AHA Stroke center, 2004)

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Anterior Cerebral Artery

The ACA follow the corpus callosum supplying
the anterior four fifths of the corpus callosum and
medial aspect of the frontal and parietal lobes.
Deep branches, arising near the circle of Willis,
supply the anterior limb of the internal capsule,
the inferior head of caudate nucleus and the
anterior part of the globus pallidus.

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Anterior Cerebral Artery

Much rarer
The classic presentation is proximal arm/leg
weakness with present of distal strength, the socalled man in a barrel
ACA occlusions cause contralateral motor and
somatosensory deficits, primarily of the lower
extremities.
In addition, apraxia, mental and personal
changes, primitiv reflexes and bowel and bladder
incontinence often ptresent

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Posterior Cerebral Artery

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Posterior Cerebral Artery

Involves the brainstem, cerebellum, thalamus &
occipital lobes
Present with bilateral limb weakness or sensory
disturbances, cranial nerve defisit, ataxia,
nausea, and vomiting or coma
occlusion of the basilar artery trunk : Present with
hemianopia, memory disturbance, mild
personality disturbance
Rarely; bilateral thalamus : a state of decreased
responsiveness and apathy without motor,
sensory or visual impairment

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Arterial Blood Supply of the spinal cord

1. Posterior & anterior spinal arteries
2. Spinal branches of vertebral, deep
cervical, intercostal and lumbar arteries

Blood supply of the

meninx
Blood Supply
anterior, middle & posterior meningeal
arteries

Blood supply to the cerebral hemisphere

Comes from cortical branches of the:

- ant.or, middle & post.or cerebral arteries
Subarachnoid vessels pass into subpial space --> enter
the cortex perpendicularly and divide: --> long &
short ramies
Long branches penetrate white matter 3-4 cm without
anastomosing --> terminal arteries
Short branches to cortex & makes anastomoses

Dural venous sinuses

Blood-filled spaces situated between
layers of dura mater:
Superior & inferior, straight, transverse,
sigmoid, and occipital sinuses
- Confluens of sinuses
- Cavernous sinuses
- Superior and inferior petrosal sinuses

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