CHAPTER

39

Anatomy and Physiology of the

Cerebrovascular System
Robert Egan

ARTERIAL SYSTEM OF THE BRAIN

Origin of the Cerebral Arterial Blood Supply from the Aortic
Arch
Internal Carotid Artery and Its Branches
Anterior Cerebral Artery, Anterior Communicating Artery, and
Their Branches
Vertebrobasilar Arterial System and Its Branches
Leptomeningeal Arterioles
Circle of Willis
Internal Carotid-Basilar Anastomoses
External Carotid Artery

VENOUS SYSTEM OF THE BRAIN

Veins of the Brain: Cerebral and Posterior Fossa Veins
Diploic Veins
Meningeal Veins
Dural Sinuses
Orbital Veins
Extracranial Cerebral Veins
COLLATERAL CIRCULATION TO THE BRAIN AND THE
ORBITS
Collateral Circulation Between Cerebral Vessels
PHYSIOLOGY OF CEREBRAL BLOOD FLOW
Autoregulation of Cerebral Blood Flow
Factors Other than Autoregulation Affecting Cerebral Blood Flow

ARTERIAL SYSTEM OF THE BRAIN

ORIGIN OF THE CEREBRAL ARTERIAL BLOOD
SUPPLY FROM THE AORTIC ARCH

origin of the cerebral vessels are occasionally seen (Fig.

39.2B).

The cerebral arterial blood supply is derived from the aortic arch through three major vessels: the innominate (brachiocephalic) artery, the left common carotid artery (CCA), and
the left subclavian artery (Fig. 39.1). The innominate artery
arises as the largest trunk of the aortic arch and branches
into the right CCA and the right subclavian artery. The right
CCA ascends to the upper level of the thyroid cartilage,
where it bifurcates into the right internal carotid artery
(ICA) and external carotid artery (ECA) (Fig. 39.1). The
left CCA arises from the apex of the aortic arch and divides
into the left ICA and ECA (Figs. 39.1 and 39.2A).
The left subclavian artery arises directly from the aortic
arch. The first branch of each subclavian artery is the vertebral artery (VA), although occasionally the left VA arises
directly from the aortic arch rather than from the left subclavian artery. The two VAs ascend from the base of the neck
through the foramina in the transverse processes of the upper
six vertebrae and wind behind the upper articular processes
of the atlas before entering the cranial cavity through the
foramen magnum (Fig. 39.1). Anomalous variations of the

INTERNAL CAROTID ARTERY AND ITS

BRANCHES
The cervical segment of the ICA begins at the level of
the bifurcation of the CCA. This segment runs inside the
carotid sheath and ascends behind the tonsillar fossa to the
base of the skull and enters the cranial cavity by passing
through the carotid canal. The next segment of the ICA lies
within the carotid canal of the petrous bone and is called
the petrous segment (Fig. 39.3). Two branches may arise
from the petrous segment of the ICA, the caroticotympanic
artery and the vidian (pterygoid) artery. The ICA then
exits from the petrous bone superiorly to enter the cavernous
sinus.
The cavernous segment of the ICA begins at the superior
margin of the retrolingual ligament at the posterior aspect
of the cavernous sinus. Within the sinus, the artery may turn
immediately and course anteriorly for several millimeters,
or it may continue superiorly for a few millimeters before
turning anteriorly (Fig. 39.3). It then abruptly bends back
1901

1902

CLINICAL NEURO-OPHTHALMOLOGY

Figure 39.1. Schematic drawing of the origin of the cerebral blood vessels from the aortic arch. Inset shows the main branches
of the external carotid artery.

superiorly and posteriorly, at which point it pierces a portion

of the dura mater called the proximal dural ring.
Three groups of branches arise from the cavernous segment of the ICA: the meningohypophyseal trunk, the artery
of the inferior cavernous sinus, and the capsular arteries
(16). The meningohypophyseal trunk (5) is the most
proximal branch and is almost always present and gives rise
to three smaller branches (Fig. 39.4): the tentorial artery
which supplies the intracavernous portions of the oculomotor and trochlear nerves (7,8); the inferior hypophyseal artery which supplies a large portion of the pituitary gland

(8,9); and the dorsal meningeal artery which supplies the

tip of the petrous bone, the upper clivus, and the abducens
nerve (7).
The artery of the inferior cavernous sinus originates
from the lateral aspect of the horizontal segment of the cavernous portion of the ICA distal to the origin of the meningohypophyseal trunk and supplies the cranial nerves within the
cavernous sinus (610). A superior branch may occasionally
give rise to the tentorial artery and a medial branch may
anastomose with the ophthalmic artery (OA). The posterior
ramus of the artery of the inferior cavernous sinus supplies

ANATOMY AND PHYSIOLOGY OF THE CEREBROVASCULAR SYSTEM

1903

B
Figure 39.2. A, Aortogram in an 8-year-old boy showing the normal anatomical configuration of the aortic arch and the
origin of the cerebral blood vessels. B, Aortogram in an 18-year-old woman with an anomalous origin of the right subclavian
artery, which arises posterolaterally to the left subclavian artery. The innominate artery branches into both the right CCA and
left CCA. (Courtesy of Raymond Tien, MD.)

Figure 39.3. The main segments of the ICA. A, Schematic drawing of the ICA, showing the major intracavernous and
intracranial branches. In this illustration, the artery is divided into only four segments: cervical, petrous, cavernous, and
supraclinoid. a, meningohypophyseal trunk; b, artery of the inferior cavernous sinus; c, capsular artery (of McConnell); d, OA;
e, PComA; f, anterior choroidal artery. B, cerebral arteriogram showing the same four segments (arrows) of the ICA as seen
in A. Cx, cervical segment; P, petrous segment; Cv, cavernous segment; S, supraclinoid segment. (A, From Day A. Arterial
distributions and variants. In: Wood J, ed. Cerebral Blood Flow: Physiologic and Clinical Aspects. New York: McGraw-Hill,
19871936.)

1904

CLINICAL NEURO-OPHTHALMOLOGY

Figure 39.4. Cerebral arteriogram, lateral view, shows the cavernous segment of the ICA (CvS) between arrowheads. Note an enlarged meningohypophyseal artery (arrow) arising from this segment. oa, ophthalmic artery.

the abducens nerve, the gasserian ganglion, and the motor

root of the trigeminal nerve (7).
The capsular arteries arise from the medial side of the
cavernous portion of the ICA between the artery and the
pituitary gland, distal to the point of origin of the artery of

the inferior cavernous sinus, and are present infrequently

(5).
The ICA pierces the dura medial to the anterior clinoid
process and exits the cavernous sinus just beneath and lateral
to the optic nerve. It continues posteriorly for a short distance
before curving superiorly and slightly anteriorly once again,
where it is just inferior and lateral to the intracranial portion
of the optic nerve and the anterior optic chiasm. The shape
formed by the cavernous and the proximal intracranial portions of the ICA together is a somewhat elongated S.
These two segments are thus often called the carotid siphon
(3,11). The clinoid segment is that region of the ICA that
has just exited the cavernous sinus and is located adjacent
or just inferior to the anterior clinoid process, in a region
that has also been called the paraclinoid area.
The ophthalmic segment of the ICA begins at the distal
dural ring and ends just proximal to the origin of the posterior
communicating artery (PComA). This segment gives rise to
the OA (see below) and to one or more superior hypophyseal
arteries that supply the infundibulum of the pituitary gland,
the intracranial portion of the ipsilateral optic nerve, and the
anteroventral portion of the optic chiasm (Figs. 39.439.8)
(12,13). The superior hypophyseal arteries may also supply
the ipsilateral optic tract (7) or the intracanalicular optic
nerve (14).

Figure 39.5. Inferior view of the perforating branches of the supraclinoid portion of the ICA. In this illustration, this portion
of the artery is divided into three smaller segments that are named for the main arterial branch that arises from them. The
ophthalmic segment (C4-Op.) is named for the OA (Ophth.A.), the communicating segment (C4-Co.) is named for the PComA
(P.Co.A.), and the choroidal segment (C4-Ch.), named for the anterior choroidal artery (A.Ch.A.) Note that the main perforating
branches that supply the optic nerves (O.N.) and the optic chiasm (O.Ch.) arise from the ophthalmic segment, whereas the
branches that supply the optic tracts (O.Tr.) arise from the communicating and choroidal segments. A.Co.A., anterior communicating artery; Sup.Hyp.A., superior hypophyseal artery; Ant.Perf. Subst., anterior perforated substance; Fr.Lobe, frontal lobe;
Gyr. Rectus, gyrus rectus; Olf. N., olfactory nerve; Mam.Bodies, mammillary bodies; Infund., infundibulum; Tuber. Cin., tuber
cinereum. (From Gibo H, Lenkey C, Rhoton AL Jr. Microsurgical anatomy of the supraclinoid portion of the internal carotid
artery. J Neurosurg 1981;55560574.)

ANATOMY AND PHYSIOLOGY OF THE CEREBROVASCULAR SYSTEM

Figure 39.6. Inferior view of the perforating branches of the supraclinoid

portion of the ICA. Note multiple branches to the posterior lobe of the
pituitary gland and to the tuber cinereum. These branches arise from the
ophthalmic (C4-Op.), communicating (C4-Co.), and choroidal (C4-Ch.)
segments of the artery. A.Ch.A., anterior choroidal artery; P.Co.A., PComA;
O.N., optic nerve; O.Tr., optic tract; III, oculomotor nerve; Cer. Ped., cerebral peduncle. (From Gibo H, Lenkey C, Rhoton AL Jr. Microsurgical
anatomy of the supraclinoid portion of the internal carotid artery. J Neurosurg 1981;55560574.)

Figure 39.7. Inferior view of the perforating branches of the supraclinoid

portion of the ICA. The anterior lobe of the pituitary is reflected backward
to show the numerous branches that originate from the ophthalmic segment
of the ICA (C4-Op.) and supply the optic chiasm (O.Ch.), distal portions
of the optic nerves (O.N.), and the infundibulum (Infund.) Among this
group of vessels are the paired superior hypophyseal arteries (Sup.Hyp.A.).
A.Ch.A., anterior choroidal artery; P.Co.A., PComA; Ophth.A., OA;
A.Co.A., AComA; C4-Co., communicating segment of the ICA; C4-Ch.,
choroidal segment of the ICA; O.Tr., optic tract; III, oculomotor nerve.
(From Gibo H, Lenkey C, Rhoton AL Jr. Microsurgical anatomy of the
supraclinoid portion of the internal carotid artery. J Neurosurg 1981;
55560574.)

1905

Figure 39.8. Cerebral angiogram, lateral ICA injection. The ICA is defined from the cervical portion to the distal bifurcation as well as the OA,
CRA, ACA, MCA, PCA, anterior choroidal artery, and PComA. AChA,
anterior choroidal artery. (Courtesy of Raymond Tien, MD.)

Ophthalmic Artery and Its Branches

The OA is the most proximal major intradural branch of
the ICA. It usually arises from the anterior wall of the ophthalmic segment of the artery as that vessel emerges from
the distal dural ring just beneath the ipsilateral optic nerve
(15,16) (Figs. 39.7 and 39.8). The origin of the OA is intradural in about 90% of persons, but about 10% of the time
the OA originates extradurally, from either the cavernous or
the clinoid segment of the ICA (17). Rarely, the OA originates either as two trunks, one from the ICA and the other
from the middle meningeal artery (the latter trunk being
more prominent), or as a single trunk from the middle meningeal artery (16).
When the OA arises from the ICA, it courses anterolaterally below the optic nerve and enters the optic canal. The
length of the intracranial segment of the OA is usually about
3 mm, but it may be as much as 7 mm. It infrequently gives
off intracranial perforating branches that run posteriorly to
supply the ventral aspect of the ipsilateral optic nerve, the
optic chiasm, and the pituitary stalk (7).
As the OA enters the optic canal, it pierces the dural sheath
of the optic nerve, usually inferolateral but sometimes directly below the nerve. Once it pierces the dura, the OA is
surrounded, or at least covered, by dura, and it is thus separated from the substance of the nerve throughout its course
within the optic canal until it emerges at the apex of the
orbit. The intraorbital portion of the OA may be divided
into three segments (Fig. 39.9) (18). The first part extends
from the sight of entry of the OA into the orbit to where the
artery crosses under or over the optic nerve. The second part
of the OA is the segment that crosses the nerve. In almost
all cases, the OA crosses the nerve from lateral to medial,
with the artery crossing beneath the nerve in about 80% of
persons and above the nerve in the remaining 20%. The third
part of the intraorbital portion of the OA, lying medial to

1906

CLINICAL NEURO-OPHTHALMOLOGY

Figure 39.9. Schematic drawing of the three segments of the intraorbital

OA. The first part extends from the point of entrance of the artery into the
orbit (T.R.) to the point at which the artery crosses over (left side) or under
(right side) the optic nerve (O.N.) The second part is the segment that
crosses the nerve. The third part of the OA extends from the point at which
the artery has crossed over or under the nerve to its termination. (From
Hayreh S, Dass R. The ophthalmic artery. II: Intra-orbital course. Br J
Ophthalmol 1962;46165185.)

the nerve, extends from the point at which the artery has
crossed under or over the optic nerve to its termination.
The course of the OA within the orbit is quite variable,
as are its branches (1921). Major variations depend on
whether the artery has crossed over or under the optic nerve
(Fig. 39.10) (19). When the OA crosses over the nerve, its
first major branch is usually the central retinal artery (CRA),
followed by the lateral posterior ciliary artery, lacrimal artery, various muscular arteries, medial posterior ciliary arteries, posterior ethmoid artery, supraorbital artery, anterior
ethmoid artery, and medial palpebral artery. When the OA
crosses beneath the optic nerve, it usually sends small perforating branches to the optic nerve, followed by the lateral
posterior ciliary artery, the CRA, medial muscular arteries,
medial posterior ciliary artery, lacrimal artery, posterior ethmoid artery, supraorbital artery, anterior ethmoid artery, and
medial palpebral arteries. Whether it has crossed over or
under the optic nerve, the OA terminates by bifurcating into
a supratrochlear (or frontal) artery and a dorsal nasal (or
nasal) artery.
The number of posterior ciliary arteries varies. There are
usually two or three major trunks that immediately subdivide
into many small, tortuous branches that pierce the sclera
medially, laterally, and superiorly adjacent to the optic nerve
where they form an anastomotic ring, the circle of Zinn and
Haller (19,2123). These branches are called short posterior ciliary arteries, and they often give rise to one or more
cilioretinal arteries that supply the retina in the region of

Figure 39.10. Branches of the OA. A, Pattern of

branches when the artery crosses beneath the nerve. B,
Pattern of branches when the artery crosses over the nerve.
1, anterior ethmoid artery; 2, areolar branch; 3, CRA; 4,
collateral branch; 5, dorsal nasal branch; 6, ICA; 7, lacrimal artery; 8, lateral posterior ciliary artery; 9, muscular
artery (a, branch to lateral rectus; b, branch to levator palpebrae superioris; c, branch to medial rectus; d, branch to
superior oblique; e, branch to superior rectus); 10, medial
posterior ciliary artery; 11, medial palpebral artery; 12,
OA; 13, posterior ethmoid artery; 14, supraorbital artery;
15, supratrochlear artery; O.N., optic nerve; S.O.F., superior orbital fissure; T.R., tendinous ring. (From Hayreh S.
The ophthalmic artery. III: Branches. Br J Ophthalmol
1962;46212247.)

ANATOMY AND PHYSIOLOGY OF THE CEREBROVASCULAR SYSTEM

1907

Figure 39.11. (A,B) Ophthalmoscopic appearance of cilioretinal artery (arrow). Note that it arises separately from the rest
of the retinal arteries.

the optic disc (Fig. 39.11) (24,25). Cilioretinal arteries are

present in about 50% of normal patients (26). Between two
and four posterior ciliary arteries pierce the sclera medially
and laterally somewhat farther from the optic nerve and pass
around the globe within the sclera. These vessels are called
long posterior ciliary arteries (Fig. 39.10) (27). They supply internal structures of the anterior portion of the eye.
The CRA has a tortuous course along the inferior surface
of the optic nerve before it pierces the optic nerve sheath
1015 mm posterior to the globe (Fig. 39.12) (28). The CRA
may also be demonstrated angiographically (Fig. 39.8). The
artery runs within the subarachnoid space of the optic nerve
for 13 mm; it then gives off numerous branches that anastomose with surface branches of the pial vascular network
surrounding the nerve (21). These branches and the branches
passing anteriorly from the short posterior ciliary arteries
constitute a dense vascular network. Within the optic nerve,
the CRA gives off numerous branches that supply the axial
portion of the nerve (Fig. 39.12). As these branches pass
peripherally, becoming smaller in caliber until they become
capillaries, they often anastomose with penetrating branches
of the pial vascular network. The CRA passes though the
retrolaminar and laminar portions of the optic nerve to reach
the prelaminar portion of the nerve, where it gives off its
terminal branches that supply the inner layers of the retina
(Fig. 39.13) (29).
A number of branches of the OA anastomose with small
arteries that originate from larger branches of the external
carotid artery, thus forming an important collateral circulation to the eye and orbit. The main arteries that anastomose
in this manner are the anterior and posterior ethmoid arteries
and the lacrimal artery. This anastomotic network is proba-

bly responsible for maintenance of the blood supply to the

eye when the optic nerve is removed to treat a meningioma
or glioma. The OA may also be an important collateral pathway in patients with occlusive disease of the ipsilateral ICA
and may contribute to cerebral perfusion in such cases (30).
Two major branches arise from the most distal segment
or communicating segment of the ICA: the PComA and the
anterior choroidal artery. These arteries and their branches
are discussed below. In addition, the communicating segment of the ICA gives rise to numerous small perforating
vessels that supply the ipsilateral optic tract, the premammillary portion of the floor of the third ventricle, the optic chiasm, the pituitary stalk, the uncus, and the anterior and posterior perforated substance (Fig. 39.7) (12,31).
Posterior Communicating Artery and Its Branches
The PComA arises from the posterior wall of the communicating segment of the ICA, 615 mm distal to the origin
of the OA (Figs. 39.3, 39.539.8, and 39.14) (32). This vessel then passes posteromedially below the tuber cinereum
and above the sella turcica and oculomotor nerve to join the
posterior cerebral artery (PCA). During embryogenesis, the
PComA continues as the PCA, but by birth the PCA usually
arises from the basilar artery (BA); the PComA is one of
the components of the Circle of Willis (Fig. 39.14). In about
1320% of persons, however, the PComA remains the origin
of the PCA (fetal configuration) (33,34). Functionally via
angiography, the PCA may receive part of its blood supply
more commonly from both the PComA and the BA (35).
Magnetic resonance angiography (MRA) has documented a
completely intact Circle of Willis in up to 42% of 150 volun-

1908

CLINICAL NEURO-OPHTHALMOLOGY

Figure 39.12. Schematic drawing of the CRA and its relationship to the rest of the arteries that supply the optic nerve. The
CRA pierces the dura of the nerve about 1015 mm posterior to the globe. It sends branches to the pial vascular network and
then travels within the nerve to the globe. Within the nerve, the artery gives off numerous branches that supply the axial portion
of the nerve and anastomose with penetrating branches of the pial vessel network. The CRA gives off terminal branches that
supply the inner layers of the retina. (From Hogan M, Alvarado J, Weddell J. Histology of the Human Eye. An Atlas and
Textbook. Philadelphia: WB Saunders, 1971534.)

teers (36). When the PComA is small or of normal size,

it courses posteromedially to join the PCA medial to the
oculomotor nerve. In the fetal configuration, however, it
passes posterolaterally above or lateral to the oculomotor
nerve. The PComA ranges in length from 522 mm, with
the majority of PComAs being 1216 mm long (37,38).
Between 4 and 14 perforating arteries originate from the
PComA (32,33,38). These branches supply the ipsilateral
optic tract, the pituitary stalk, the optic chiasm, parts of the
thalamus, hypothalamus, subthalamus, and internal capsule
(3840). The largest and most constant branch that arises
from the PComA is the premammillary or anterior thalamoperforating artery (33,39,41). This artery enters the

floor of the 3rd ventricle anterior to or beside the mammillary bodies.

Anterior Choroidal Artery and Its Branches
The anterior choroidal artery is the most distal major
artery that arises from the ICA prior to its bifurcation. It
arises from the posterior wall of the distal portion of the
communicating segment of the ICA, 7.524 mm distal to
the origin of the OA and 2.510 mm proximal to the terminal
bifurcation of the ICA (Figs. 39.3, 39.539.8, and 39.15)
(32,37,40). In about 25% of persons, however, it originates
from the middle cerebral artery (MCA), PCA, or PComA

Figure 39.13. Ophthalmoscopic appearance of the terminal branches of the

CRA. The artery usually gives off four main branches: superior temporal
(ST), superior nasal (SN), inferior temporal (IT), and inferior nasal (IN). A
single trunk may give rise to the superior vessels, inferior vessels, or both
sets of vessels. In this eye, the superior retinal arteries arise as separate vessels,
whereas the inferior retinal arteries arise from a single trunk.

Figure 39.14. The PComA and the Circle of Willis. A, Each PComA (P.Co.A.) arises from the posterior wall of the supraclinoid
portion of the ipsilateral ICA, passes posteromedially, and joins the ipsilateral PCA (P.C.A.) A prominent premammillary artery
(Premam.A.) originates from each PComA. This vessel supplies the mammillary bodies and the floor of the 3rd ventricle. Also
shown in this photograph are the other arteries that make up the Circle of Willis. A.C.A., A-2, second portion of the ACA;
C.A., ICA; O.N., optic nerve; P.Ch.A., posterior choroidal artery; S.C.A., SCA; Th.Pe.A., posterior thalamoperforating artery;
III, oculomotor nerve. B, Schematic drawing of the the relationships of the arteries that comprise the Circle of Willis. The
supraclinoid portion of the ICA (I.C.A.) is shown with three of its major branches: the PComA (P.Com.A.), the MCA (M.C.A.),
and the ACA (A.C.A.). Two segments of the ACA are shown: the A-1 segment (A.C.A.(A1), the portion between the ICA
and the AComA (A.Com.A.); and the A-2 segment (A.C.A.(A2)), a 5-mm segment distal to the AComA that extends to the
genu of the corpus callosum. The distal end of the BA is shown with its two most distal branches: the superior cerebellar
artery (S.C.A.) and the PCA (P.C.A.). Two segments of the PCA are shown. The P-1 segment (P.C.A.(P1)) of the PCA begins
at its origin from the BA and ends where the artery joins with the PComA. The P-2 segment (P.C.A.(P2)) is the portion of the
vessel distal to the PComA. (A, From Rhoton AL Jr, Hardy DG, Chambers SM. Microsurgical anatomy and dissection of the
sphenoid bone, cavernous sinus and sellar region. Surg Neurol 1979;1263104. B, From Day A. Arterial distributions and
variants. In: Wood J, ed, Cerebral Blood Flow: Physiologic and Clinical Aspects. New York: McGraw-Hill, 19871936.)

1909

1910

CLINICAL NEURO-OPHTHALMOLOGY

Figure 39.15. Cerebral arteriogram showing course of anterior choroidal artery. A, Lateral view shows anterior choroidal
artery (arrow) arising from ICA and extending posteriorly. The artery is not obscured because the MCA is occluded. Note
course of distal segment of pericallosal artery around the splenium of the corpus callosum (arrowheads). B, Anteroposterior
view. Note the proximity of the anterior choroidal artery (arrows) to lenticulostriate arteries (black arrowhead) that arise from
a single trunk (white arrowhead).

(42). It courses posteriorly below the optic tract but above

the PComA, eventually terminating after passing through
the choroidal fissure to reach the choroid plexus in the temporal horn and trigone (atrium) of the lateral ventricle
(32,43). The anterior choroidal artery provides the main
blood supply to the ipsilateral optic tract. It also sends
branches to the hilum and anterolateral aspect of the ipsilateral lateral geniculate body, and to the cerebral peduncle,
thalamus, hippocampus, anterior part of the optic radiations,
uncus, and temporal lobe (4446).
Terminal Branches of the ICA: Anterior and Middle
Cerebral Arteries
After giving off the anterior choroidal artery, the ICA
terminates as a bifurcation producing two major arteries: the
anterior cerebral artery (ACA) and the middle cerebral artery
(MCA). These arteries and their branches supply major areas
of the brain, including portions of the ocular motor and visual
sensory pathways (Figs. 39.3A and 39.16).
ANTERIOR CEREBRAL ARTERY, ANTERIOR
COMMUNICATING ARTERY, AND THEIR
BRANCHES
Anterior Cerebral Artery and Its Branches
The ACA originates as the medial and smaller of the two
terminal branches of the ICA (Figs. 39.3, 39.539.8, and
39.1439.17). It courses anteromedially to the hemispheric
fissure, passing over the optic chiasm or the distal portion
of the optic nerves and below the medial olfactory stria (Figs.

39.14 and 39.17). In the interhemispheric fissure, it is joined

to the opposite ACA by the anterior communicating artery
(AComA) (Figs. 39.5, 39.7, 39.14, and 39.1839.20). The
segment of the ACA between the ICA and AComA is called
the A-1 or precommunicating segment. The segment of the
ACA distal to the AComA is usually separated into four
smaller segments designated A-2 to A-5 (47).
The length of the A-1 segment of the ACA ranges from
722 mm, but it is usually 1215 mm long (37,47,48). This
segment, particularly its proximal portion, gives rise to a
large number of branches that terminate in the distal portion
of the optic nerve, the optic chiasm, and the proximal portion
of the optic tract (Figs. 39.14A, 39.19, and 39.20) (47,48).
The recurrent artery of Heubner may occasionally arise from
the distal portion of this segment (48).
The portion of the ACA distal to its junction with the
AComA ascends between the cerebral hemispheres in the
longitudinal fissure, makes a smooth curve around the genu
of the corpus callosum, and passes posteriorly over the body
of the corpus callosum to the splenium (Figs. 39.16 and
39.17) (47). The A-2 segment is about 5 mm long and extends from the AComA junction to the genu of the corpus
callosum. The remaining three segments are often referred
to together as the pericallosal artery (Fig. 39.17). The most
distal segments of the ACA anastomose with distal segments
of the PCA in the anterior calcarine cortex. This part of
the distal ACA supplies calcarine cortex referable to the
monocular temporal visual field known as the temporal crescent and may be spared in PCA infarction.
The first major branch of the distal ACA is the recurrent