BLOOD SUPPLY OF CNS

Arterial Supply
• The central nervous system,
like any system of the body,
requires constant oxygenation
and nourishment. The brain
has a particularly high oxygen
demand – at rest it represents
one fifth of the body’s total
oxygen consumption. It is also
very sensitive to oxygen
deprivation, with ischemic cell
death resulting within minutes.
• There are two paired arteries which are responsible for the blood
supply to the brain; the vertebral arteries, and the internal
carotid arteries. These arteries arise in the neck, and ascend to
the cranium.

• Within the cranial vault, the terminal branches of these arteries

form an anastomotic circle, called the Circle of Willis. From this
circle, branches arise which supply the majority of the cerebrum.

• Other parts of the CNS, such as the pons and spinal cord, are
supplied by smaller branches from the vertebral arteries.

• We shall now look at these individual components in more detail.

 Internal Carotid Arteries
• The internal carotid arteries (ICA) originate at the bifurcation of the left and
right common carotid arteries, at the level of the fourth cervical vertebrae
(C4).
• They move superiorly within the carotid sheath, and enter the brain via the
carotid canal of the temporal bone. They do not supply any branches to the
face or neck.
• Once in the cranial cavity, the internal carotids pass anteriorly through the
cavernous sinus. Distal to the cavernous sinus, each ICA gives rise to:

• Ophthalmic artery – supplies the structures of the orbit.

• Posterior communicating artery – acts as an anastomotic ‘connecting
vessel’ in the Circle of Willis (see ‘Circle of Willis’ below).
• Anterior choroidal artery – supplies structures in the brain important for
motor control and vision.
• Anterior cerebral artery – supplies part of the cerebrum.
• The internal carotids then continue as the middle cerebral artery, which
supplies the lateral portions of the cerebrum.
Vertebral Arteries
• The right and left vertebral arteries arise from the subclavian arteries,
medial to the anterior scalene muscle. They then ascend the posterior
aspect of the neck, through holes in the transverse processes of the
cervical vertebrae, known as foramen transversarium.

• The vertebral arteries enter the cranial cavity via the foramen
magnum. Within the cranial vault, some branches are given off:

• Meningeal branch – supplies the falx cerebelli, a sheet of dura mater.

• Anterior and posterior spinal arteries – supplies the spinal cord,
spanning its entire length.
• Posterior inferior cerebellar artery – supplies the cerebellum.
• After this, the two vertebral arteries converge to form the basilar
artery. Several branches from the basilar artery originate here, and go
onto supply the cerebellum and pons. The basilar artery terminates by
bifurcating into the posterior cerebral arteries.
Arterial Circle of Willis
• The terminal branches of the vertebral and internal carotid arteries all
anastomose to form a circular blood vessel, called the Circle of Willis.

• There are three main (paired) constituents of the Circle of Willis:

• Anterior cerebral arteries – terminal branches of the internal carotid

arteries.
• Internal carotid arteries – located immediately proximal to the origin of
the middle cerebral arteries.
• Posterior cerebral arteries – terminal branches of the vertebral arteries.
• To complete the circle, two ‘connecting vessels’ are also present:

• Anterior communicating artery – connects the two anterior cerebral

arteries.
• Posterior communicating artery – branch of the internal carotid, this
artery connects the ICA to the posterior cerebral artery.
Regional Blood Supply to the Cerebrum
• There are three cerebral arteries; anterior, middle and posterior. They
each supply a different portion of the cerebrum.

• The anterior cerebral arteries supply the anteromedial portion of the

cerebrum. The middle cerebral arteries are situated laterally, supplying the
majority of the lateral part of the brain. The posterior cerebral arteries
supply both the medial and lateral parts of the posterior cerebrum.
Arterial Supply to the Spinal Cord
• The spinal cord is primarily supplied by three longitudinal arteries, as it descends
from the brainstem to the conus medullaris. These are:

• Anterior spinal artery – formed from branches of the vertebral arteries, travelling in
the anterior median fissure. Gives rise to the sulcal arteries, which enter the spinal
cord.
• Two posterior spinal arteries – originate from the vertebral artery or the
posteroinferior cerebellar artery, anastomosing with one another in the pia mater.
• However, below the cervical level supply from these longitudinal arteries is
insufficient. There is support via anastomosis with the segmental medullary and
radicular arteries.
• The anterior and posterior segmental medullary arteries are derived from spinal
branches of a number of arteries, before entering the vertebral canal through the
intervertebral foramina.
• The great anterior segmental artery of Adamkiewicz reinforces circulation to the
inferior 2/3 of the spinal cord, and is found on the left in the majority of individuals.
• The radicular arteries supply (and follow the path of) the anterior and posterior
nerve roots. Some radicular arteries may also contribute to supplying the spinal
cord.
 Clinical Notes
Stroke
• The brain is particularly sensitive to oxygen starvation. A stroke is an
acute development of a neurological deficit, due to a disturbance in the
blood supply of the brain.
• There are four main causes of a cerebrovascular accident:

• Thrombosis – obstruction of a blood vessel by a locally forming clot.

• Embolism – obstruction of a blood vessel by an embolus formed
elsewhere.
• Hypoperfusion – lack of blood supply to the brain, due to systemically
low blood pressure (e.g shock).
• Haemorrhage – an accumulation of blood within the cranial cavity.
• Out of these four, the most common cause is embolism. In many
patients, the atherosclerotic embolus arises from the vessels of the
neck.
Intracerebral Aneurysms
• An aneurysm is a dilation of an artery, which is greater than 50% of the normal
diameter. They are most likely to occur to occur in the vessels contributing to the
Circle of Willis. They are particularly dangerous – producing few symptoms until
they rupture. Upon rupture, blood typically accumulates in the subarachnoid
space – with a subsequent increase in intracranial pressure.
• Once the artery wall has ruptured, it is a medical emergency, and the patient is
likely to die unless treated swiftly. Treatment of an intracerebral aneurysm is
surgical.

Spinal Cord Infarction

• Spinal cord infarction (also known as a spinal stroke) refers to the death of
nervous tissue, which results from an interruption of the arterial supply.
• Clinical signs of spinal cord infarction include muscle weakness and paralysis with
loss of reflexes. The most common causes of infarction are vertebral fractures or
dislocations, vasculitic disease, atheromatous disease, or external compression
(e.g. abdominal tumours).
• 95% of spinal cord ischaemic events are to the anterior aspect of the spinal cord,
with the posterior columns preserved. Treatment is by reversal of any known
cause.
 Venous Drainage
• The central nervous system consists of the cerebrum, cerebellum,
brainstem and spinal cord. Their venous drainage is complex, and rather
uniquely, does not follow the arterial supply.

• The cerebrum, cerebellum and brainstem are drained by numerous

veins, which empty into the dural venous sinuses. The spinal cord is
supplied by anterior and posterior spinal veins, which drain into the
internal and external vertebral plexuses.

• In this lecture, we shall consider the venous drainage of the central

nervous system. We will discuss the dural venous sinuses, cerebral
veins, spinal veins, and consider the clinical relevance of the described
anatomy.
Dural Venous Sinuses
• The dural venous sinuses lie between the periosteal and meningeal
layers of the dura mater. They are best thought of as collecting pools of
blood, which drain the central nervous system, the face, and the scalp.
All the dural venous sinuses ultimately drain into the internal jugular
vein. Unlike most veins of the body, the dural venous sinuses do not
have valves.
• There are eleven venous sinuses in total. The straight, superior, and
inferior sagittal sinuses are found in the falx cerebri of the dura mater.
They converge at the confluence of sinuses (overlying the internal
occipital protuberance). The straight sinus is a continuation of the great
cerebral vein and the inferior sagittal sinus.
• From the confluence, the transverse sinus continues bi-laterally and
curves into the sigmoid sinus to meet the opening of the internal
jugular vein.
• The cavernous sinus drains the ophthalmic veins and can be found on
either side of the sella turcica. From here, the blood returns to the
internal jugular vein via the superior or inferior petrosal sinuses.
 Clinical Notes
Cerebral Venous Sinus Thrombosis
• Cerebral venous sinus thrombosis (CVST) describes the presence of a
thrombus within one of the dural venous sinuses.
• The thrombus occludes venous return through the sinuses, and causes an
accumulation of deoxygenated blood within the brain parenchyma. This in
turn can lead to venous infarction. The situation is complicated by an
accumulation of cerebrospinal fluid, which can no longer drain through the
thrombosed venous sinus.
• Common clinical features are headache, nausea and vomiting, and
neurological defects.
• The definitive diagnosis is usually made by CT or MRI scan with contrast,
which demonstrates obstruction of the venous sinuses. Treatment is with
anticoagulation.
Veins of the Cerebrum
• The veins of cerebrum are responsible for carrying blood from the brain tissue, and
depositing it in the dural venous sinuses.
• They can be divided into superficial and deep groups, which are flamboyantly
arranged around the gyri and sulci of the brain. Upon exiting the cerebral
parenchyma, the veins run in the subarachnoid space and pierce the meninges to
drain into the dural venous sinuses.

 Superficial System
• The superficial system of veins is largely responsible for draining the cerebral cortex:
• Superior cerebral veins: Drain the superior surface, carrying blood to the superior
sagittal sinus.
• Superficial middle cerebral vein: Drains the lateral surface of each hemisphere,
carrying blood to the cavernous or sphenopalatine sinuses.
• Inferior cerebral veins: Drain the inferior aspect of each cerebral hemisphere,
depositing blood into cavernous and transverse sinuses.
• Superior anastamotic vein (Trolard): Connects the superficial middle cerebral vein to
the superior sagittal sinus.
• Inferior anastamotic vein (Labbé): Connects the superficial middle cerebral vein to
the transverse sinus.
 Deep System
• Subependymal veins – There are numerous subependymal
veins, which will not be described here in detail. These
receive blood from the medullary veins and carry it to the
dural venous sinuses. The great cerebral vein (vein of
Galen) is worthy of a mention; it is formed by the union of
two of the deep veins, and drains into the straight sinus.
• Medullary veins: Originate 1-2cm below the cortical grey
matter, and drain into subependymal veins. These drain
the deep areas of the brain.
Other Structures in the Central Nervous System
 Cerebellum
• There are two main veins responsible for the venous drainage of the cerebellum
– the superior and inferior cerebellar veins. They empty into the superior
petrosal, transverse and straight dural venous sinuses.

 Brainstem
• Venous drainage of the brainstem is carried out by numerous vessels – many of
which are beyond the scope of this article. Examples of veins that drain the
brainstem include the transverse pontine vein, anteromedian medullary vein,
and the anterior and posterior spinal veins.

 Spinal Cord
• The spinal cord is supplied by three anterior and three posterior spinal veins.
These veins are valveless, and form an anastamotic network along the surface
of the spinal cord. They also receive venous blood from the radicular veins.
• The spinal veins drain into the internal and external vertebral plexuses, which in
turn empty into the systemic segmental veins. The internal vertebral plexus also
empties into the dural venous sinuses superiorly.
 Cavernous Sinus
• The cavernous sinus is a paired dural venous sinus located within
the cranial cavity. It is divided by septa into small ‘caves’ – from
which it gets its name.
• Each cavernous sinus has a close anatomical relationship with
several key structures in the head, and is arguably the most
clinically important venous sinus.
Anatomical Location and Borders
• The cavernous sinuses are located within the middle cranial fossa, on
either side of the sella turcica of the sphenoid bone (which contains
the pituitary gland). They are enclosed by the endosteal and meningeal
layers of the dura mater.

• The borders of the cavernous sinus are as follows:

• Anterior – superior orbital fissure.

• Posterior – petrous part of the temporal bone.
• Medial – body of the sphenoid bone.
• Lateral – meningeal layer of the dura mater running from the roof to
the floor of the middle cranial fossa.
• Roof – meningeal layer of the dura mater that attaches to the anterior
and middle clinoid processes of the sphenoid bone.
• Floor – endosteal layer of dura mater that overlies the base of the
greater wing of the sphenoid bone.
 Contents
• Several important structures pass through the cavernous sinus to enter the
orbit. The can be sub-classified by whether they travel through the sinus
itself, or through its lateral wall:
Travels through cavernous sinus: Travels through lateral wall of cavernous
sinus:
• Abducens nerve (CN VI) • Oculomotor nerve (CN III)
• Carotid plexus (post-ganglionic • Trochlear nerve (CN IV)
sympathetic nerve fibres) • Ophthalmic (V1) and maxillary (V2)
• Internal carotid artery (cavernous branches of the trigeminal nerve
portion)

• The cavernous sinus is the only site in the body where an artery (internal
carotid) passes completely through a venous structure. This is thought to
allow for heat exchange between the warm arterial blood and cooler venous
circulation.
• A useful mnemonic to remember the contents and their relation to one
another is: O TOM CAT, where OTOM (oculomotor nerve, trochlear
nerve, ophthalmic branch, maxillary branch) refers to the lateral wall
contents from superior to inferior, and CAT (internal carotid artery,
abducens nerve, trochlear nerve) refers to the horizontal contents,
from medial to lateral.
Dural Venous Sinus System
• Each cavernous sinus receives venous drainage from:

• Ophthalmic veins (superior and inferior) – these enter the cavernous sinus via the
superior orbital fissure.
• Central vein of the retina – drains into the superior ophthalmic vein, or directly
into the cavernous sinus.
• Sphenoparietal sinus – empties into the anterior aspect of the cavernous sinus.
• Superficial middle cerebral vein – contributes to the venous drainage of the
cerebrum
• Pterygoid plexus – located within the infratemporal fossa.
• It is important to note that the superior ophthalmic vein forms an anastomosis
with the facial vein. Therefore, the ophthalmic veins represent a potential route
by which infection can spread from an extracranial to an intracranial site.

• The cavernous sinuses empty into the superior and inferior petrosal sinuses, and
ultimately, into the internal jugular vein. The left and right cavernous sinuses are
connected in the midline by the anterior and posterior intercavernous sinuses.
They travel through the sella turcica of the sphenoid bone.
 Clinical Notes
Cavernous Sinus Thrombosis
• Cavernous sinus thrombosis (CST) refers to the formation of a clot within
the cavernous sinus.

• This most common cause of CST is infection; which typically spreads from
an extracranial location such as the orbit, paranasal sinuses, or the ‘danger
zone’ of the face. Infection is able to spread in this manner due to the
anastomosis between the facial vein and superior ophthalmic veins.

• Common clinical features include headache, unilateral periorbital oedema,

proptosis (eye bulging), photophobia and cranial nerve palsies. The
abducens nerve (CN VI) is most commonly affected.

• Treatment is typically with antibiotic therapy. Where the cause is infection,

thrombosis of the cavernous sinus can rapidly progress to meningitis.