BLOOD SUPPLY OF BRAIN

BY
PROF. DR. ANSARI
(BDS-II SEMESTER RAKCODS)

Revisado por J. San, 2021

A 78 year old man was admitted from a residential home having collapsed
.
suddenly He was known to have been hypertensive and had been a smoker.

• On examination he had
dysphagia, right sided
hemiplegia, brisk right sided
reflexes and a right up going
plantar response. A clinical
diagnosis of a cerebral
ischemia was made.
• CT of the brain was
performed after 12 hours of
admission &shown below:-

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A 78 year old man was admitted from a residential home having collapsed
.
suddenly He was known to have been hypertensive and had been a smoker.

• On examination he had Areas of infarction

dysphagia, right sided
hemiplegia, brisk right sided
reflexes and a right up going
plantar response. A clinical
diagnosis of a cerebral
ischemia was made.
• CT of the brain was
performed after 12 hours of
admission &shown below:-

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 Circle of Willis
At the base of brain

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 Circle of Willis
At the base of brain

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 The objectives are
• Formation of circle of Willis/ Circulus Arteriosus

• Areas of cerebrum and cerebellum supplied by each

branch from vertebrobasilar arterial arcade.

• Venous drainage from cerebrum and cerebellum.

• Applied anatomy of vertebrobasilar insufficiency.

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The circle of Willis/Circulus arteriosus

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 The circulus arteriosus is formed
• Between branches of internal carotid arteries and
vertebral arteries.
• It is placed in the cisterna interpeduncularis, at the
base of the brain.
• The internal carotid arteries, right and left enters
the cranium passing through the internal carotid
foramina.
• The two vertebral arteries enter the cranium
through the foramen magnum.
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 The right sided arteries communicate with
the left sided
• By means of one anterior and two posterior
communicating arteries.
• The members of circle are:-
• (a) anterior cerebral
• (b) anterior communicating
• © Posterior communicating &
• (d) posterior cerebral
• There are two types of branches arising from the
circle.
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 The cortical branches
• Are superficial branches visible on the surfaces
of the brain and they supply the cortical gray
matter.
• The deep branches are central branches that
perforates the substance of brain and supply
the deep nuclei.
• These deep branches are end arteries, they
never form anatomosis with their neighbours.

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 The brain needs glucose and oxygen
• For its proper functioning. The astrocytes form the
blood brain barrier along with the endothelium of the
capillaries.
• Brain cannot sustain anoxia for more than few minutes,
there will be permanent damage to the neurons, if the
blood supply is not restored after few minutes & brain
death will occur.
• The medial surface of the cerebral hemisphere is
supplied by anterior cerebral artery, the branches cross
over the superior border and supply a fingers breadth
area on the superiolateral surface of hemisphere. 12
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 ACA
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 Obstruction of anterior cerebral artery
leads to paraplegia

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Personality dysfunction occur due to
infarction of both anterior cerebral arteries
• If both anterior cerebral arteries arise from one
stem major disturbances occur with infarction
occurring at the medial aspects of both cerebral
hemispheres resulting in aphasia, paraplegia,
incontinence and frontal lobe/personality
dysfunction.

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Occlusion of one anterior cerebral artery distal
to anterior communicating artery results in

– Contra lateral weakness and sensory loss, affecting mainly

distal contra lateral leg (foot/leg more affected than thigh).
– Mild or no involvement of upper extremity.
– Head and eyes may be deviated toward side of lesion
acutely.
– Urinary incontinence with contra lateral grasp reflex and
paratonic rigidity may be present.
– May produce transcortical motor aphasia if left side is
affected.
– Disturbances in gait and stance = gait apraxia.
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 MIDDLE CEREBRAL ARTERY (MCA):

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• Sensory and motor deficits on contralateral face
and arm > leg
• Head and eyes deviated toward side of infarct
• With left-side lesion (dominant hemisphere)—
global aphasia initially, then turns into Broca's
aphasia (motor speech disorder)
• Right side lesion (nondominant hemisphere)—
deficits on spatial perception, hemi-neglect,
constructional apraxia, dressing apraxia
• Muscle tone usually decreased initially and
gradually increases over days or weeks to spasticity
• Transient loss of consciousness is uncommon
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Wallenberg's syndrome also known as lateral medullary
syndrome, PICA syndrome, and vertebral artery syndrome.

– Ipsilateral side
• Horner's syndrome (ptosis, anhydrosis, and miosis)
• decrease in pain and temperature sensation on the
ipsilateral face
• cerebellar signs such as ataxia on ipsilateral extremities
(patient falls to side of lesion)
– Contralateral side
• Decreased pain and temperature on contralateral body
– Dysphagia, dysarthria, hoarseness, paralysis of vocal cord
– Vertigo; nausea and vomiting
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Hiccups 19
Medial Medullary Syndrome
• Typical syndrome:
– Ipsilateral hypoglossal palsy (with deviation toward the
side of the lesion)

– Contralateral hemiparesis.

– Contralateral lemniscal sensory loss

– (proprioception and position sense)

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 Occlusion of Posterior cerebral artery
• Visual field cuts (including cortical blindness when bilateral)
• May have prosopagnosia (can't read faces)
• palinopsia (abnormal recurring visual imagery)
• alexia (can't read)
• transcortical sensory aphasia (loss of power to comprehend
written or spoken words; patient can repeat)
• Structures supplied by the interpeduncular branches of the
PCA include the oculomotor cranial nerve (CN 3) and
trochlear (CN 4) nuclei and nerves
• Clinical syndromes caused by the occlusion of these branches
include oculomotor palsy with contralateral hemiplegia =
Weber's
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The superiolateral surface of cerebral
hemisphere is supplied by MCA

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 The posterior cerebral artery

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The cerebellum is supplied by three
cerebellar arteries-AICA/PICA/SCA

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 The central /straited branches
• These are central
Branches /
that dips inside
the substance of brain
&supply the deep
Nuclei.
They arise from
Circle of Willis.
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• By apoplexy is meant the rupture of a blood-vessel
with consequent extravasations of blood, either in or
on the brain.
• It may occur in any portion of the brain, and either
from the arteries of the base, or from the smaller
arteries of the cortex.
• The former is the more frequent. The arteries that
most often rupture are the branches of the middle
cerebral which enter the anterior perforated space,
especially its outer portion.
• One of the largest of these anterolateral arteries, as
has already been mentioned, known as the
lenticulostriate, has been called by Charcot the artery
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 HYPERTENSIVE HEMORRAGE IN THE BASAL GANGLIA & THALAMUS

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 Berry aneurysm

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 Large aneurysm at the cerebello-
pontine angle

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 Pontine hemorrhage

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 Pontine hemorrhage
• Patients with a large central hemorrhage present with a progressive
decrease in the level of consciousness rapidly leading to coma.
• Bilateral bulbar muscle weakness, "pinpoint" pupils, hyperthermia,
and hyperventilation are common associated findings.
• This presentation is seen most often in patients with uncontrolled
hypertension .
• . Contralateral hyperhidrosis in the subacute or late phase after
pontine hemorrhage may be seen.
• This is thought to be secondary to disruption of contralateral
inhibitory sweating pathway .
• Up to one third of patients may develop a severe headache before
the onset of focal signs .
• Vomiting may be seen in 20% of patients, and seizures (mostly flexor
spasms
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and not true convulsions) have been reported in 30% of 31
patients
 The venous drainage of brain
• Cerebral veins drain the surfaces of brain, they run
in the sulci and gyri and drains into near by dural
venous sinuses.
• Deep cerebral veins drain in to the straight sinus.
• The cerebellum is drained by cerebellar veins which
ends up into the near by dural venous sinuses.
• All dural sinuses emerges from the internal jugular
foramen and comes out as internal jugular vein.

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 Cavernous sinus

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 The dangerous area of face

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 Cavernous sinus thrombosis
• Clinical manifestations include dysfunction of
cranial nerves III, IV, V, and VI, marked
periorbital swelling, chemosis, fever, and
visual loss.

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 The dural venous sinuses

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