Declan O’Kane MD FRCP University of Hertfordshire

STROKE VASCULAR ANATOMY

Anatomy you need to know

 Extracranial anatomy of blood supply to brain

 Intracranial anatomy of blood supply to brain
 Vascular territories and Venous drainage
 Variants
Blood supply to brain

 We have four arteries which supply the brain

 R and L Internal carotid arteries
 R and L Vertebral arteries
 These all communicate
 Occlusion of one or two arteries may be silent
 Sometimes external carotid can provide
collateral flow
Definitions of Terms

Anterior circulation (2/3rds of perfusion)

 Is that region or volume of brain supplied
by the Internal carotid artery and its
branches
Posterior circulation (1/3rds of perfusion)
Is that region or volume of brain supplied
by the vertebral artery or its branches
 Carotid bifurcation

Surgeons differentiate
Internal Carotid artery and
External carotid artery
as External carotid artery
has branches in the neck
Internal carotid – clinical

 Carotid endarterectomy at bifurcation

 Close relation with cranial nerves VII, IX, X, XI
and XII
 Sympathetic fibres lie within the carotid
sheath (Horners)
 Can lead for example to post op hoarseness
and difficulty swallowing
 Diseases: Atheroma, Obstruction, Stenosis,
Dissection, Aneurysms can develop
ANT
POST

Lateral view of the carotid artery

Internal carotid artery

 Cervical segment extends from carotid bifurcation

to skull base
 Petrous segment as artery runs along petrous bone
and enters foramen lacerum heading cephalically
 Cavernous segment as it enters cavernous sinus,.
Look for classical sigmoid shape
 Supraclinoid: Turns forwards exits cavernous sinus
and gives off branches and splits into MCA/ACA
 Identify anterior exit of ophthalmic artery
 Posterior exit of posterior communicating
Things to note

 The carotid has multiple bends which helps

reduce the pulsatile flow to a more laminar
flow
 Intracranial vessels deficient in some elastic
lamina and more fragile than extracranial
vessels
Important Branches of ICA

 Ophthalmic artery passes forwards to the

eye. Occlusion does not always cause
blindness. Aneurysms seen here.
 Posterior communicating artery passes back
to connect anterior and posterior circulation.
Site of aneurysms
 Anterior choroidal artery passes back
 Middle cerebral artery passes laterally
 Anterior cerebral artery passes anteriorly
Ophthalmic artery
 1st branch of the ICA. Enters the orbit with the optic nerve and gives off a
branch the central artery to retina. The artery runs forward to supply the
eye and scalp around the eye as well as frontal and ethmoidal sinuses.
 Maxillary artery anastomoses provides some collateral flow if proximal
occlusion. Occlusion of the ophthalmic artery does not tend to cause
blindness and as there are collaterals
 Central artery to the retina: runs along the centre of the optic nerve
entering the eye to supply the inner retinal layers. Occlusion will cause
monocular blindness
 Posterior ciliary artery is the main source of blood supply to the optic
nerve head (ONH), and it also supplies the choroid up to the equator, the
retinal pigment epithelium. The blood supply in the ONH is segmental, so
that most of its ischemic lesions result in sectoral visual field defects.
There may be multiple (up to 5) PCAs. Vessel involved in Anterior
Ischaemic optic neuropathy and Giant cell arteritis.
Posterior communicating artery

 Joins anterior and posterior circulations

 Closely associated with IIIrd nerve which can
be compressed by an aneurysm of the
PCOMM
 Irrigates the ventral thalamus,
hypothalamus and tail of caudate
Anterior choroidal artery

 Arises from the ICA and Passes posteriorly

with branches to supply
 Posterior limb of internal capsule
 choroid plexus of lateral ventricle
 optic tract and lateral geniculate body
(hemianopia)
 area of midbrain and globus pallidus and
substantia nigra
Coronal view
Middle cerebral artery (1)

 M1 segment from the bifurcation of the internal

carotid passes laterally to the surface of the insula
where it bifurcates.
 Occlusion here may result in massive infarction
depending on collateral supply and whether it is
proximal or distal to lenticulostriate vessels.
 A clot may be seen in the artery "the hyperdense MCA
sign" in which a string of thrombus may be seen within
the M1 on Non contrast CT
 M2 segment within the sylvian fissure and branch. A
clot here may result in a "dot"sign on CT. The artery
branches into
Middle cerebral artery (3)

M1 gives off
 Lateral lenticulostriate arteries (Deep
penetrating vessels)
 Branch of at right angles to supply the Globus
pallidus and putamen, posterior limb of internal
capsule, head and tail of caudate, thalamus and
Meyer's loop which includes some of the optic
radiations can be caught
 Arterial occlusion typically may cause lacunar type
strokes and vulnerable to lipohyalinosis and
occlusion
Middle cerebral artery (2)

 M3 segments Upper division

 prefrontal (frontal cortex)
 precentral (primary motor and associated areas)
 central (pre/post central gyri)
 post central (primary sensory area)
 parietal (posterior parietal)
 M3 segments Lower division
 middle temporal (mid temporal cortex)
 temporoccipital (temporal and occipital cortex)
 angular (angular and associated gyri)
Anterior cerebral artery
 On Medial surface of cerebrum ACA Arches up and around and back over
the corpus callosum)
 A1 Segment - from the bifurcation of the internal carotid to the anterior
comm artery. Branches include
 Medial lenticulostriate artery : contributes to anteroinferior part including the
anterior limb of internal capsule and anterior portion of caudate and putamen
 Anterior communicating artery connects both ACA and is a common site of
aneurysms
 Recurrent artery of Heubner supplies head of caudate and anteroinferior internal
capsule
 A2 Pericallosal branch - is the continuation of A1 supplying medial
surface of cerebral cortex and corpus callosum after the Anterior
communicating branch
 Orbitofrontal
 Polar frontal
 Callosomarginal
Vertebral artery

 It supplies the Posterior circulation

 Arises from supraposterior segment of subclavian
arteries but in 6% L Vertebral comes off Aortic arch
 Artery lies in formina of lateral aspect of vertebra
C2-C6 where it is vulnerable to torsional and
extension flexion forces
 Enters foramen magnum in front of cord and
medulla and passes up to unites to form Basilar
artery. Basilar artery splits to form PCA
Vertebral artery

 Intracranial artery wall shows marked change,

with a reduction in the thickness of the adventitial
and medial layers, and a reduction of elastic fibres
in the media and external elastic lamina.
 Occasional asymmetry with a dominant and
atretic artery
 Redundancy as paired artery so stenosis or
occlusion of a single vertebral can be
accommodated by contralateral side if none of
the branches are compromised
Sections of VA

 V1 - origin to foramen transversarium (usually

C6)
 V2 - from the first foramen transversarium
(usually C6) to the foramen transversarium of
C2
 V3 - from C2 to the dura
 V4 - from the dura to their confluence to form
the basilar artery
The four parts of the vertebral artery.

Cloud G , and Markus H QJM 2003;96:27-54

Clinical of subclavian

 Proximal Subclavian stenosis can steal blood

from vertebral
 Atheroma at vertebral origin
Vertebral artery

 Numerous Spinal branches

 Anterior spinal artery – spinal cord
 Posterior inferior cerebellar artery –
posterolateral medulla and cerebellum
 Forms Basilar artery
Basilar artery

 Formed at lower aspect of pons from

vertebrals and lies in front of the brainstem
 Anterior inferior cerebellar artery
 Internal auditory artery
 Numerous perforating branches penetrate
basis pontis and supply pons
 Superior cerebellar artery
 Splits into R/L posterior cerebral artery
Basilar branches

 Supplies Pons with

 Paramedian perforators
 Short circumferential perforators
 Long circumferential perforators
Posterior cerebral arteries

 Formed at level of midbrain

 The arteries sweep laterally around the
midbrain and then posteriorly towards the
occipital cortex
 They are connected to the anterior circulation
via the posterior communicating artery
Venous anatomy
Venous Anatomy

 Superior sagittal sinus: Venous blood from the brain passes across
the subdural space in the bridging veins and emissary veins into the
superior sagittal sinus. The sinus also receives CSF through the
arachnoid villi.
 Transverse sinuses
 Cavernous sinus: contains various other structures including III, IV
and V1, V2 and VI and postganglionic sympathetic fibres and the
siphon part of the internal carotid artery
 Great cerebral vein drains deep cerebral structures into the Straight
sinus
 Ultimately all venous outflow is to the internal jugular vein to the SVC
and RA
Figure 2c. Normal sinovenous
anatomy.

Rodallec M H et al. Radiographics 2006;26:S5-S18

Figure 4. Normal sinovenous anatomy.

Rodallec M H et al. Radiographics 2006;26:S5-S18