Section I / General

CASE 1  AQUEDUCTAL STENOSIS

A middle-aged woman complains of headache of several
months’ duration; over time she exhibits mental slowing, pap-
illedema with non-specific abducens palsies, spasticity with
pyramidal tract signs and limb ataxia. She has a history of
presumed viral meningoencephalitis years before but has oth-
erwise been well.
Imaging demonstrates symmetric enlargement of the lateral
and third ventricles (Fig. 5.9). The aqueduct is not visualized,
and the fourth ventricle and cisterna magna are normal. A
diagnosis of aqueductal stenosis is made, and ventricular
shunting results in remarkable clinical improvement.
Discussion: Aqueductal stenosis may be congenital or
acquired later in life, presumably as a result of viral or bacterial
infection with ependymitis and subsequent occlusion of the
aqueduct. It is often asymptomatic until adulthood, ultimately
presenting with a non-specific syndrome of hydrocephalus
involving primarily the anterior ventricular system, as visual-
ized in this case with appropriate neuroimaging.
Differential diagnoses include hydrocephalus secondary to
choroid plexus papilloma with overproduction of CSF, pine-
aloma, invasive tumour of the brain stem or cerebellum,
intraventricular tumour such as ependymoma of the fourth
ventricle, chronic basilar meningitis obliterating the foramina
of Luschka and Magendie, Arnold–Chiari malformation and
Dandy–Walker syndrome with enlargement of the fourth Fig. 5.9  MRI of aqueductal stenosis (dashed arrow) with marked ventricular
ventricle. The syndrome of so-called normal-pressure hydro- enlargement. There is an incidental empty sella turcica as well (solid arrow).
cephalus is evidenced classically by progressive memory
deficits and dementia; ataxia; pyramidal tract signs, especially secondary to prior trauma, meningitis, or subarachnoid haem-
in the legs; and urinary tract dysfunction. CSF pressure is orrhage, and neuroimaging is diagnostic in the majority of
normal, and there is no papilledema. This disorder is most cases, many of which respond dramatically to ventricular
likely due to obliteration of the cerebral subarachnoid space shunting.

fourth ventricle develops as a thin sheet in which the pia mater is in direct
contact with the ependymal lining of the ventricle. This thin sheet forms
the tela choroidea of the fourth ventricle, lying between the cerebellum
and the inferior part of the roof of the ventricle. The choroid plexus of
the fourth ventricle is T-shaped, having vertical and horizontal limbs, but
this form varies widely. The vertical (longitudinal) limb is double, flanks the
midline and is adherent to the roof of the ventricle. The limbs fuse at the
superior margin of the median aperture (foramen of Magendie) and are
often prolonged on the ventral aspect of the cerebellar vermis. The hori-
zontal limbs of the plexus project into the lateral recesses of the ventricle.
Small tufts of plexus pass through the lateral apertures (foramina of Luschka)
and emerge, still covered by ependyma, in the subarachnoid space of the
cerebellopontine angle.
The blood supply of the choroid plexus in the tela choroidea of the lateral
and third ventricles is usually via a single vessel from the anterior choroidal
branch of the internal carotid artery and several choroidal branches of the
posterior cerebral artery. The two sets of vessels anastomose to some extent.
Capillaries drain into a rich venous plexus served by a single choroidal vein.
The blood supply of the fourth ventricular choroid plexus is from the inferior
cerebellar arteries.

CASE 2  CHOROID PLEXUS PAPILLOMA

A 14-month-old boy exhibits progressive enlargement of the
head, with bulging fontanelles, spreading of the cranial sutures
and dilatation of the draining craniocerebral veins. No focal
signs are observed, but he demonstrates progressive motor
(and cognitive) retardation, spasticity, visual failure with optic
atrophy and ataxia, along with occasional seizures.
Imaging demonstrates generalized ventricular dilatation. A
large non-invasive tumour mass occupies the choroid plexus
on one side.
Discussion: This infant has a tumour involving the choroid
plexus, which is responsible for the overproduction of CSF
(approaching 2 liters/day in some cases). Most tumours here
are benign papillomas, but they are occasionally malignant,
with parenchymal invasion.
When presented with an infant with progressive hydro-
cephalus, as in this case, other diagnoses to consider include
aqueductal stenosis (either congenital atresia of the aqueduct
of Sylvius or acquired secondary to chronic infection such as
tuberculous meningitis with granular ependymitis); obstruc-
tion of draining cerebral veins secondary to vascular events
such as infantile subarachnoid haemorrhage or preterm intra-
cerebral haemorrhage, especially in low-birth-weight infants;
and colloid cysts of the third ventricle.
Neuroimaging is diagnostic under these circumstances.

88
 Chapter 5 / Ventricular System and Cerebrospinal Fluid

Anterior thalamic tubercle

Taenia chorioidea 3rd ventricle Lamina affixa

Chapter 5
Habenular commissure
Stria terminalis
Habenular trigone
Stria medullaris Pineal
Superior colliculus Brachium of superior colliculus
Medial geniculate body
Pulvinar
Brachium of inferior colliculus
Lateral geniculate

Cerebral peduncle Brachium conjunctivum

(superior cerebellar peduncle)
Inferior colliculus
Brachium pontis
Trochlear nerve (middle cerebellar peduncle)
Anterior medullary velum Lateral aperture of fourth ventricle
Median sulcus Trigeminal nerve
Medial eminence
Facial nerve
Superior fovea Vestibulocochlear nerve
Facial colliculus Glossopharyngeal nerve
Vestibular area
Vagus nerve

Hypoglossal trigone
Taenia of fourth ventricle
Area postrema
Gracile tubercle
Cuneate tubercle
Accessory nerve (cranial part)

Obex Accessory nerve (spinal part)

Posterior intermediate sulcus Fasciculus cuneatus

Posterior median fissure Fasciculus gracilis

Fig. 5.10  Dorsal aspect of the brain stem. The floor of the fourth ventricle has been exposed by cutting the cerebellar peduncles and removing the cerebellum.
(By permission from Mettler, F.A. 1948. Neuroanatomy, 2nd ed. CV Mosby, St. Louis.)

Cerebrospinal Fluid
Composition and Secretion
CSF is a clear, colourless liquid. In normal individuals, CSF contains a very small
amount of protein and differs from blood in its electrolyte content. It is not
simply an ultrafiltrate of blood but is actively secreted by the choroid plexus
epithelium. Choroid plexus epithelial cells have the characteristics of trans-
port and secretory cells. Their apical surfaces, from which CSF is secreted,
possess microvilli, and their basal surfaces exhibit interdigitations and folding.
There are tight junctions at the apical ends of the epithelial cells, which are
permeable to low-molecular-weight substances. Fenestrated capillaries in the
stroma of the choroid plexus lie just beneath the epithelial cells. A blood–CSF
barrier is sited at the choroid plexus epithelium.
Circulation and Drainage
Most of the CSF is secreted by the choroid plexuses in the lateral, third and
fourth ventricles. However, there is also a small contribution from the epen-
dymal lining of the ventricles and from the extracellular fluid from brain
parenchyma.
The total CSF volume is approximately 150 ml, of which 125 ml is intracra-
nial. The ventricles contain approximately 25 ml (almost all of which is in the
lateral ventricles), and the remaining 100 ml is located in the cranial subarach-
noid space. CSF is secreted at a rate of 0.35 to 0.40 ml per minute, which
means that normally, about 50% of the total volume of CSF is replaced every
5 to 6 hours. An effective means of removal from the cranial cavity is thus
essential. CSF flows from the lateral ventricles to the third ventricle and then
through the cerebral aqueduct to the fourth ventricle. Mixing of CSF from
different choroidal sources occurs and is probably assisted by cilia on the
ependymal cells lining the ventricles and by arterial pulsations. CSF leaves
the fourth ventricle through the medial and lateral apertures to enter the
subarachnoid space of the cisterna magna and subarachnoid cisterns over the
front of the pons, respectively. The movement of CSF in the extraaxial space
is complex and is characterized by a fast-flow component and a much slower
bulk-flow component. During systole, the major arteries lying in the basal
cisterns and other extraaxial intracranial spaces dilate significantly and exert
pressure effects on the CSF, which cause rapid CSF flow around the brain out
of the cranial cavity and into the upper cervical spine. The pressure wave that
causes this outflow of CSF is dispersed through the spinal CSF space, which
acts as a capacitance vessel. As the blood within the major arteries passes
into the brain in late systole and diastole, CSF reenters the skull from the
spine. This CSF flow occurs at rapid rates and is repeated during every heart
cycle. In addition, there is a slow bulk flow of CSF, with a time course mea-
sured in hours, which results in circulation of CSF over the cerebral surface in
a superolateral direction. CSF is absorbed into the venous system through
arachnoid villi associated with the major dural venous sinuses, predominantly
the superior sagittal sinus.
Hydrocephalus
Obstruction of the circulation of CSF leads to the accumulation of fluid
(hydrocephalus), which causes compression of the brain (Fig. 5.13). Within
the brain, critical points at which obstruction may occur correspond to
the narrow foramina and passages of the ventricular system. Thus, obstruction
of the interventricular foramen, as with an intraventricular tumour, causes
enlargement of one or both lateral ventricles. Obstruction of the cerebral
aqueduct, which may be congenital, due to atresia of the aqueduct, or
acquired, as in ependymitis accompanying chronic infection (e.g. tuberculous
meningitis), leads to enlargement of both lateral ventricles and the third
ventricle. Obstruction or congenital absence of the apertures of the fourth
ventricle leads to enlargement of the entire ventricular system. Obstruction
or restriction of CSF circulation can also occur within the subarachnoid space

89
Section I / General

Pineal gland
Pulvinar
Medial geniculate body

Colliculi

Inferior quadrigeminal brachium

Trochlear nerve

Lingula

Superior cerebellar peduncle

Superior medullary velum Middle cerebellar peduncle

Superior fovea
Dentate nucleus
Facial colliculus
Striae medullaris

Vestibular area
Inferior cerebellar peduncle

Inferior fovea
Hypoglossal triangle

Vagal triangle

Funiculus separans and area postrema Obex

Cuneate tubercle
Gracile tubercle

Posterior median sulcus

Fig. 5.11  Dorsal aspect of the brain stem, including the floor of the fourth ventricle.

Subfornical organ Organum vasculosum

Pineal

Area
postrema

Median eminence

Neurohypophysis
Fig. 5.12  Median sagittal section of the brain indicating the locations of the
circumventricular organs.

Fig. 5.13  MRI scan shows an enhancing mass, which is a meningioma growing
from the meninges at the edge of the foramen magnum. The tumour is benign
but is compressing the brain stem and causing secondary hydrocephalus.
(Courtesy of Professor Alan Jackson, Department of Neuroradiology, University
of Manchester, United Kingdom.)

90

CASE 3  TUBERCULOUS MENINGITIS WITH
OBSTRUCTIVE HYDROCEPHALUS
A 16-year-old boy experiences increasing bifrontal headaches
for 6 weeks and then develops recurrent vomiting, diplopia
and an unsteady gait. Shortly before hospitalization he
becomes confused, then stuporous. At the time of admission
to the hospital, he exhibits a stiff neck with signs of meningeal
irritation, mild facial diplegia, bilateral sixth nerve palsies and
papilledema. Cerebellar function cannot be assessed. Reflexes
are exaggerated throughout; the plantar responses are silent.
He has a low-grade fever, and chest X-ray demonstrates
several lesions in both lung fields, consistent with a diagnosis
of tuberculosis. Magnetic resonance imaging (MRI) of the head
shows enlargement of the lateral third ventricles, along with
contrast enhancement of the basal meninges. Spinal fluid is
under increased pressure and has a cloudy, opalescent appear-
ance. The CSF clots on standing and contains 125 leukocytes
as a result of meningeal adhesions caused by meningitis. When this occurs at
the level of the tentorial notch, passage of CSF from the posterior fossa to
its sites of reabsorption is restricted.
References
McKinley, M.J., McAllen, R.M., Davern, P., Giles, M.E., Penschow, J., Sunn, N., Uschakov, A., Oldfield,
B.J., 2003. The sensory circumventricular organs of the mammalian brain. Adv. Anat. Embryol.
Cell Biol. 172, III–XII, 1–122.
Mercier, F., Kitasako, J.T., Hatton, G.I., 2002. Anatomy of the brain neurogenic zones revisited:
fractones and the ?broblast/macrophage network. J. Comp. Neurol. 451, 170–188. Describes
the structure and ultrastructure of the basal laminae and subependymal layer.
Chapter 5 / Ventricular System and Cerebrospinal Fluid
per cubic millimetre, predominantly lymphocytes; it has a
Chapter 5
protein content of 400 mg% and a sugar content of less than
20 mg%. Within 48 hours, his CSF polymerase chain reaction
(PCR) is reported as consistent with tuberculosis, and the CSF
culture subsequently yields acid-fast organisms.
Discussion: This is the typical appearance and course of
tuberculous meningitis; the CSF findings themselves are
characteristic of a subacute to chronic bacterial meningitis.
Tuberculous meningitis must be differentiated from other
chronic meningitides, such as syphilitic or cryptococcal.
Some viral infections, in particular herpes and mumps, may
produce a similar set of changes within the spinal fluid.
Metastatic leptomeningeal invasion and sarcoid must also
be considered in the differential diagnosis. Bacteriological
studies are diagnostic.
Paulson, O.B., 2002. Blood–brain barrier, brain metabolism and cerebral blood flow. Eur.
Neuropsychopharmacol. 12, 495–501.
Russell, D.S., 1949. Observations on the pathology of hydrocephalus. Medical Research Council.
Strazielle, N., Ghersi-Egea, J.F., 2000. Choroid plexus in the central nervous system: biology and
physiopathology. J. Neuropathol. Exp. Neurol. 59, 561–574. Describes choroid plexus func-
tions in brain development, transfer of neurohumoral information, brain–
immune system interactions, brain aging and cerebral pharmacotoxicology.
Wolburg, H., Lippoldt, A., 2002. Tight junctions of the blood–brain barrier: development, composi-
tion and regulation. Vascul. Pharmacol. 38, 323–337. Reviews the molecular properties of
the tight junctions between endothelial cells that constitute the blood–brain
barrier.
91
 Vascular Supply of the
Brain and Spinal Cord
The brain is a highly vascular organ and its profuse blood supply is character-
ized by a densely branching arterial network (Fig. 6.1). It has high metabolic
activity due in part to the energy requirements of constant neural activity. It
demands about 15% of the cardiac output and uses 25% of the total oxygen
consumed by the body. The brain is supplied by two internal carotid arteries
and two vertebral arteries that form a complex anastomosis (circulus arterio-
sus, or the circle of Willis) on the base of the brain. Vessels diverge from this
anastomosis to supply the various cerebral regions. In general, the internal
carotid arteries and the vessels arising from them supply the forebrain, with
the exception of the occipital lobe of the cerebral hemisphere; the vertebral
arteries and their branches supply the occipital lobe, the brain stem and the
cerebellum. Venous blood from the brain drains into sinuses within the dura
mater. Acute interruption of the blood supply to the brain for more than a
few minutes causes permanent neurological damage. Such ischaemic strokes
along with intracranial haemorrhages are major sources of morbidity and
mortality.
ARTERIAL SUPPLY OF THE BRAIN
The arterial supply of the brain is derived from the internal carotid and ver-
tebral arteries, which lie, together with their proximal branches, within the
subarachnoid space at the base of the brain.
Internal Carotid Artery
The internal carotid arteries and their major branches (sometimes referred to
as the internal carotid system) essentially supply blood to the forebrain, with
the exception of the occipital lobe.
The internal carotid artery (Figs 6.2, 6.3) arises from the bifurcation of the
common carotid artery, ascends in the neck and enters the carotid canal of
the temporal bone. Its subsequent course is said to have petrous, cavernous
and cranial parts.
Petrous Part
The petrous part of the internal carotid artery ascends in the carotid canal
and curves anteromedially and then superomedially above the cartilage filling
the foramen lacerum, to enter the cranial cavity. It lies at first anterior to the
cochlea and tympanic cavity and is separated from the latter and the pharyn-
gotympanic tube by a thin, bony lamella that is cribriform in the young and
partly absorbed in old age. Further anteriorly it is separated from the trigemi-
nal ganglion by the thin roof of the carotid canal, although this is often
deficient. The artery is surrounded by a venous plexus and the carotid auto-
nomic plexus, which is derived from the internal carotid branch of the supe-
rior cervical ganglion. The petrous part of the artery gives rise to two branches.
The caroticotympanic artery is a small, occasionally double vessel that enters
the tympanic cavity by a foramen in the carotid canal and anastomoses with
the anterior tympanic branch of the maxillary artery and the stylomastoid
artery. The pterygoid artery is inconsistent. When present, it enters the ptery-
goid canal with the nerve of the same name and anastomoses with a (recur-
rent) branch of the greater palatine artery.
Cavernous Part
The cavernous part of the internal carotid artery ascends to the posterior
clinoid process. It turns anteriorly to the side of the sphenoid within the
cavernous sinus and then curves up medial to the anterior clinoid process to
emerge through the dural roof of the sinus. Occasionally, the two clinoid
processes form a bony ring around the artery, which is also surrounded by a
sympathetic plexus. The oculomotor, trochlear, ophthalmic and abducens
nerves are lateral to it.
This part of the artery gives off a number of small vessels. Cavernous
branches supply the trigeminal ganglion, the walls of the cavernous and infe-
rior petrosal sinuses and the nerves contained therein. A minute meningeal
branch passes over the lesser sphenoid wing to supply the dura mater and
bone in the anterior cranial fossa and also anastomoses with a meningeal
Chapter 6
branch of the posterior ethmoidal artery. Numerous small hypophysial
branches supply the neurohypophysis and are of particular importance
because they form the pituitary portal system.
Cerebral Part
After piercing the dura mater, the internal carotid artery turns back below the
optic nerve to run between the optic and oculomotor nerves. It reaches the
anterior perforated substance at the medial end of the lateral cerebral fissure
and terminates by dividing into large anterior and middle cerebral arteries.
Several preterminal vessels leave the cerebral portion of the internal
carotid. The ophthalmic artery arises from the internal carotid as it leaves the
cavernous sinus, often at the point of piercing the dura, and enters the orbit
through the optic canal. The posterior communicating artery (Figs 6.4–6.6)
runs back from the internal carotid above the oculomotor nerve and anasto-
moses with the posterior cerebral artery (which is a terminal branch of the
basilar artery), thereby contributing to the circulus arteriosus around the
interpeduncular fossa. The posterior communicating artery is usually very
small. Sometimes, however, it is so large that the posterior cerebral artery is
supplied via the posterior communicating artery rather than the basilar artery
(‘fetal posterior communicating artery’). It is often larger on one side. Small
branches from its posterior half pierce the posterior perforated substance,
together with branches from the posterior cerebral artery. Collectively, they
supply the medial thalamic surface and walls of the third ventricle. The ante-
rior choroidal artery leaves the internal carotid near its posterior communi-
cating branch and passes back above the medial part of the uncus. It crosses
the optic tract to reach and supply the crus cerebri of the midbrain; it then
turns laterally, recrosses the optic tract and gains the lateral side of the lateral
geniculate body, which it supplies with several branches. It finally enters the
inferior horn of the lateral ventricle via the choroid fissure and ends in the
choroid plexus. This small but important vessel also contributes to the blood
supply of the globus pallidus, caudate nucleus, amygdala, hypothalamus, tuber
cinereum, red nucleus, substantia nigra, posterior limb of the internal capsule,
optic radiation, optic tract, hippocampus and fimbria of the fornix.
Anterior Cerebral Artery
The anterior cerebral artery is the smaller of the two terminal branches of the
internal carotid artery (see Figs 6.5, 6.6).
The surgical nomenclature divides the vessel into three parts: A1, from the
termination of the internal carotid artery to the junction with the anterior
communicating artery; A2, from the junction with the anterior communicating
artery to the origin of the callosomarginal artery; A3, distal to the origin of
the callosomarginal artery. This segment is also known as the pericallosal
artery.
The anterior cerebral artery starts at the medial end of the stem of the
lateral cerebral fissure and passes anteromedially above the optic nerve to
the great longitudinal fissure, where it connects with its fellow by a short
transverse anterior communicating artery. The anterior communicating artery
is approximately 4 mm long and may be double. It gives off numerous antero-
medial central branches that supply the optic chiasma, lamina terminalis,
hypothalamus, para-olfactory areas, anterior columns of the fornix and cin-
gulate gyrus.
The two anterior cerebral arteries travel together in the great longitudinal
fissure. They pass around the curve of the genu of the corpus callosum (Fig.
6.7) and then along its upper surface to its posterior end, where they anasto-
mose with posterior cerebral arteries. They give off cortical and central
branches.
The cortical branches of the anterior cerebral artery are named by distribu-
tion. Two or three orbital branches ramify on the orbital surface of the frontal
lobe and supply the olfactory cortex, gyrus rectus and medial orbital gyrus.
Frontal branches supply the corpus callosum, cingulate gyrus, medial frontal
gyrus and paracentral lobule. Parietal branches supply the precuneus, and the
frontal and parietal branches both send twigs over the superomedial border
93
Section I / General

Middle cerebral artery

Ipsilateral anterior cerebral artery Contralateral anterior cerebral

artery cross-filling via anterior
communicating artery
Fig. 6.3  Internal carotid arteriogram. This image is a Towne’s projection obtained
by intra-arterial digital subtraction angiography. (Courtesy of Professor P. D.
Fig. 6.1  Resin cast of the arterial supply of the brain. (Photograph by Sarah-Jane
Griffiths, Academic Unit of Radiology, University of Sheffield.)
Smith.)

terminalis. Collectively, they supply the rostrum of the corpus callosum, the
septum pellucidum, the anterior part of the putamen, the head of the caudate
nucleus and adjacent parts of the internal capsule. Immediately proximal or
distal to its junction with the anterior communicating artery, the anterior
cerebral artery gives rise to the medial striate artery, which supplies the
anterior part of the head of the caudate nucleus and adjacent regions of the
putamen and internal capsule.

Middle Cerebral Artery

The middle cerebral artery is the larger terminal branch of the internal carotid.
The surgical nomenclature identifies four subdivisions: M1, from the termi-
nation of the internal carotid artery to the bi- or trifurcation (also known as
the sphenoidal segment); M2, the segment running in the lateral (Sylvian)
fissure (also known as the insular segment); M3, coming out of the lateral
fissure (also known as the operator segment); and M4, the cortical portions.
The middle cerebral artery runs first in the lateral cerebral fissure, then
posterosuperiorly on the insula; it divides into branches distributed to this
and the adjacent lateral cerebral surface (see Figs 6.5, 6.6, 6.8). Like the anterior
cerebral artery, it has cortical and central branches.
Cortical branches send orbital vessels to the inferior frontal gyrus and the
lateral orbital surface of the frontal lobe. Frontal branches supply the precen-
tral, middle and inferior frontal gyri. Two parietal branches are distributed to
the postcentral gyrus, the lower part of the superior parietal lobule and the
whole inferior parietal lobule. Two or three temporal branches supply the
lateral surface of the temporal lobe. Cortical branches of the middle cerebral
artery, therefore, supply the motor and somatosensory cortices representing
Ophthalmic artery Intracavernous portion Anterior choroidal artery the whole body, with the exception of the lower limb, the auditory area and
of internal carotid artery the insula.
Intrapetrous portion of (carotid siphon) Posterior communicating Small central branches of the middle cerebral artery—the lateral striate or
internal carotid artery artery
lenticulostriate arteries—arise at its commencement and enter the anterior
Fig. 6.2  Internal carotid arteriogram. This image is a lateral projection obtained perforated substance together with the medial striate artery. Lateral striate
by intra-arterial digital subtraction angiography. (Courtesy of Professor P. D. arteries ascend in the external capsule over the lower lateral aspect of the
Griffiths, Academic Unit of Radiology, University of Sheffield.) lentiform complex; they then turn medially, traverse the lentiform complex
and the internal capsule and extend as far as the caudate nucleus.
of the hemisphere to supply a strip of territory on the superolateral surface
(Fig. 6.8). Cortical branches of the anterior cerebral artery, therefore, supply Vertebral Artery
the areas of the motor and somatosensory cortices that represent the lower The vertebral arteries and their major branches (sometimes referred to as the
limb. vertebrobasilar system) essentially supply blood to the upper spinal cord,
Central branches of the anterior cerebral artery arise from its proximal brain stem, cerebellum and occipital lobe of the cerebrum (Figs 6.9, 6.10). In
portion and enter the anterior perforated substance (see Fig. 6.6) and lamina addition, other branches have a wider distribution.

94

Optic nerves
Middle cerebral
artery
Right internal
carotid artery
Superior
cerebellar artery
Posterior
cerebral artery
Labyrinthine artery
Basilar artery
Anterior
spinal artery
Fig. 6.4  Arteries at the base of the brain. The anterior part of the right temporal lobe has been removed to display the initial course of the middle cerebral artery
within the lateral fissure.
The vertebral arteries are derived from the subclavian arteries. They ascend
through the neck in the foramina transversaria of the upper six cervical ver-
tebrae and enter the cranial cavity through the foramen magnum, close to
the anterolateral aspect of the medulla (see Fig. 6.5). They converge medially
as they ascend the medulla and unite to form the midline basilar artery at
approximately the level of the junction between the medulla and the pons.
One or two meningeal branches arise from the vertebral artery near the
foramen magnum. These ramify between the bone and dura mater in the
posterior cranial fossa and supply bone, diploë and the falx cerebelli.
A small anterior spinal artery arises near the end of the vertebral artery and
descends anterior to the medulla oblongata to unite with its fellow from the
opposite side at the mid-medullary level. The single trunk then descends on
the ventral midline of the spinal cord and is reinforced sequentially by small
spinal rami from the vertebral, ascending cervical, posterior intercostal and
first lumbar arteries, which all enter the vertebral canal via intervertebral
foramina. Branches from the anterior spinal arteries and the beginning of their
common trunk are distributed to the medulla oblongata.
The largest branch of the vertebral artery is the posterior inferior cerebellar
artery. It arises near the lower end of the olive, which it curves back around,
and then ascends behind the roots of the glossopharyngeal and vagus nerves
to reach the inferior border of the pons. There it curves and descends along
the inferolateral border of the fourth ventricle before it turns laterally into
the cerebellar vallecula between the hemispheres and divides into medial and
lateral branches. The medial branch runs back between the cerebellar hemi-
sphere and inferior vermis and supplies both. The lateral branch supplies the
inferior cerebellar surface as far as its lateral border and anastomoses with
the anterior inferior and superior cerebellar arteries (from the basilar artery).
The trunk of the posterior inferior cerebellar artery supplies the medulla
oblongata dorsal to the olivary nucleus and lateral to the hypoglossal nucleus
and its emerging nerve roots. It also supplies the choroid plexus of the fourth
ventricle and sends a branch lateral to the cerebellar tonsil to supply the
dentate nucleus. The posterior inferior cerebellar artery is sometimes absent.
A posterior spinal artery usually arises from the posterior inferior cerebellar
artery, but it may come directly from the vertebral artery near the medulla
oblongata. It passes posteriorly and descends as two branches that lie anterior
and posterior to the dorsal roots of the spinal nerves. These are reinforced
by spinal twigs from the vertebral, ascending cervical, posterior intercostal
and first lumbar arteries, all of which reach the vertebral canal by the inter-
vertebral foramina, thereby sustaining the posterior spinal arteries to the
lower spinal levels.
Chapter 6 / Vascular Supply of the Brain and Spinal Cord
Anterior cerebral
arteries
Chapter 6
Anterior
communicating artery
Left internal
carotid artery
Choroidal artery
Infundibulum
Posterior
communicating artery
Oculomotor nerve
Abducens nerve
Facial and
vestibulocochlear
nerves
Anterior inferior
cerebellar artery
Left vertebral artery
Posterior inferior
cerebellar artery
Minute medullary arteries arise from the vertebral artery and its branches
and are distributed widely to the medulla oblongata.
Basilar Artery
This large median vessel is formed by the union of the vertebral arteries at
the mid-medullary level and extends to the upper border of the pons (see
Figs 6.5, 6.6). It lies in the pontine cistern and follows a shallow median groove
on the ventral pontine surface. The basilar artery terminates by dividing into
two posterior cerebral arteries at a variable level, but most frequently in the
interpeduncular cistern, behind the dorsum sellae.
Numerous small pontine branches arise from the front and sides of the
basilar artery along its course and supply the pons. The long and slender laby-
rinthine (internal auditory) artery has a variable origin. It usually arises from
the anterior inferior cerebellar artery, but it may originate from the lower part
of the basilar artery, the superior cerebellar artery or, occasionally, the pos-
terior inferior cerebellar artery. The labyrinthine artery accompanies the facial
and vestibulocochlear nerves into the internal acoustic meatus and is distrib-
uted to the internal ear.
The anterior inferior cerebellar artery (see Fig. 6.6) is given off from the
lower part of the basilar artery and runs posterolaterally, usually ventral to
the abducens, facial and vestibulocochlear nerves. It commonly exhibits a
loop into the internal acoustic meatus below the nerves, and when this
occurs, the labyrinthine artery may arise from the loop. The anterior inferior
cerebellar artery supplies the inferior cerebellar surface anterolaterally and
anastomoses with the posterior inferior cerebellar branch of the vertebral
artery. A few branches supply the inferolateral parts of the pons and occasion-
ally also supply the upper medulla oblongata.
The superior cerebellar artery (see Fig. 6.6) arises near the distal portion of
the basilar artery, immediately before the formation of the posterior cerebral
arteries. It passes laterally below the oculomotor nerve, which separates it
from the posterior cerebral artery, and curves around the cerebral peduncle
below the trochlear nerve to gain the superior cerebellar surface. There it
divides into branches that ramify in the pia mater and supply this aspect of
the cerebellum and also anastomose with branches of the inferior cerebellar
arteries. The superior cerebellar artery supplies the pons, pineal body, superior
medullary velum and tela choroidea of the third ventricle.
Posterior Cerebral Artery
The posterior cerebral artery (see Figs 6.5, 6.6) is a terminal branch of the
basilar artery.
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Section I / General

Anterior cerebral
artery Middle cerebral
artery

Optic nerve
Oculomotor
nerve

Cut end of internal

carotid artery
Posterior cerebral
artery

Posterior communicating Superior cerebellar

artery artery

Basilar
artery

Pontine arteries

Trigeminal
nerve

Anterior
inferior
cerebellar
artery

Posterior inferior
cerebellar artery

Vertebral
artery

Hypoglossal
nerve roots

Anterior
spinal
artery

Fig. 6.5  Arteries on the base of the brain injected with resin. (By permission from Crossman, A.R., Neary, D. 2000. Neuroanatomy, 2nd ed. Edinburgh, Churchill
Livingstone.)

The surgical nomenclature identifies three segments: P1, from the basilar
bifurcation to the junction with the posterior communicating artery; P2, from
the junction with the posterior communicating artery to the portion in the
perimesencephalic cistern; and P3, the portion running in the calcarine fissure.
The posterior cerebral artery is larger than the superior cerebellar artery,
from which it is separated near its origin by the oculomotor nerve and, lateral
to the midbrain, by the trochlear nerve. It passes laterally, parallel with the
superior cerebellar artery, and receives the posterior communicating artery.
It then winds around the cerebral peduncle and reaches the tentorial cerebral
surface, where it supplies the temporal and occipital lobes. Like the anterior
and middle cerebral arteries, the posterior cerebral artery has cortical and
central branches.
The cortical branches of the posterior cerebral artery are named by distri-
bution. Temporal branches, usually two, are distributed to the uncus and the
parahippocampal, medial and lateral occipitotemporal gyri. Occipital branches
supply the cuneus, lingual gyrus and posterolateral surface of the occipital
lobe. Parieto-occipital branches supply the cuneus and precuneus. The pos-
terior cerebral artery supplies the visual areas of the cerebral cortex and other
structures in the visual pathway.
The central branches supply subcortical structures. Several small postero-
medial central branches arise from the beginning of the posterior cerebral
artery (see Fig. 6.6) and, together with similar branches from the posterior
communicating artery, pierce the posterior perforated substance and supply
the anterior thalamus, subthalamus, lateral wall of the third ventricle and
globus pallidus. One or more posterior choroidal branches pass over the
lateral geniculate body and supply it before entering the posterior part of the
inferior horn of the lateral ventricle via the lower part of the choroid fissure.
Branches also curl around the posterior end of the thalamus and pass through
the transverse fissure, go to the choroid plexus of the third ventricle or tra-
verse the upper choroid fissure. Collectively, these supply the choroid plex-
uses of the third and lateral ventricles and the fornix. Small posterolateral
central branches arise from the posterior cerebral artery beyond the cerebral
peduncle and supply the peduncle and the posterior thalamus, superior and
inferior colliculi, pineal gland and medial geniculate body.
Circulus Arteriosus
The circulus arteriosus (circle of Willis) is a large arterial anastomosis that
unites the internal carotid and vertebrobasilar systems (see Figs 6.5, 6.6). It lies

96
 Chapter 6 / Vascular Supply of the Brain and Spinal Cord

Chapter 6
Anterior cerebral artery

Anterior communicating artery

Medial striate artery

Anteromedial group Internal carotid artery

Middle cerebral artery

Posterior communicating artery

Lateral striate group
Anterior choroidal artery

Posteromedial group

Oculomotor nerve Posterolateral group

Posterior cerebral artery

Superior cerebellar artery

Trochlear nerve

Pontine rami

Basilar artery

Fig. 6.6  Circulus arteriosus at the base of the brain showing the distribution of central (perforating or ganglionic) branches. The anteromedial, posteromedial,
posterolateral and anterolateral (lateral striate) vessels are shown. The medial striate and anterior choroidal arteries are also shown.

A B Central Temporo-
artery occipital artery
Postcentral
Precentral artery
Calcarine Parieto-occipital Pericallosal Callosomarginal artery
artery artery artery artery Parietal
Anterior cerebral
artery artery
Frontopolar
artery
Angular
Prefrontal artery
artery

Middle cerebral
Orbital artery
artery
Anterior temporal
artery
Superior Anterior
cerebral artery Superior
cerebellar artery Middle temporal cerebellar artery
artery
Anterior inferior Posterior
cerebellar artery Basilar Anterior inferior
cerebral artery cerebellar artery
artery
Posterior inferior
cerebellar artery Basilar artery Vertebral Posterior inferior
artery cerebellar artery
Fig. 6.7  Major arteries of the brain. A, Medial aspect. B, Lateral aspect.

in the subarachnoid space within the deep interpeduncular cistern and sur-
rounds the optic chiasma, the infundibulum and other structures of the inter-
peduncular fossa. Anteriorly, the anterior cerebral arteries, which are derived
from the internal carotid arteries, are joined by the small anterior communi-
cating artery. Posteriorly, the two posterior cerebral arteries, which are
formed by the division of the basilar artery, are joined to the ipsilateral inter-
nal carotid artery by a posterior communicating artery. In the majority of
cases, the posterior communicating arteries are very small; however, a limited
flow is possible between the anterior and posterior circulations. This is
important because the primary purpose of the vascular circle is to provide
anastomotic channels if one vessel is occluded. The normal-sized posterior
communicating artery usually cannot fulfill this role.
There are considerable individual variations in the pattern and calibre of
vessels that make up the circulus arteriosus. Although a complete circular

97
Section I / General

A B
Precuneus Paracentral lobule Cingulate gyrus Medial frontal gyrus
Superior frontal gyrus Precentral gyrus Postcentral gyrus
Superior parietal lobule
Middle frontal gyrus
Inferior parietal lobule

Isthmus

Fornix

Uncus

Arcus parieto-
occipitalis

Inferior frontal gyrus Middle temporal gyrus

Superior temporal gyrus Inferior temporal gyrus Cuneus Lingual gyrus Corpus callosum Parahippocampal gyrus

Fig. 6.8  A, Lateral surface of the left cerebral hemisphere, showing the areas supplied by the cerebral arteries. B, Medial surface of the left cerebral hemisphere,
showing the areas supplied by the cerebral arteries. In these figures, the area supplied by the anterior cerebral artery is coloured blue, that by the middle cerebral artery
is pink and that by the posterior cerebral artery is yellow.

Basilar artery Posterior cerebral artery Right posterior cerebral artery Superior cerebellar artery

Vertebral artery Posterior inferior cerebellar artery

Anterior inferior cerebellar artery Basilar artery Left vertebral artery
Fig. 6.9  Vertebral arteriogram. This image is a lateral projection obtained by
Fig. 6.10  Vertebral arteriogram. This image is a Towne’s projection obtained by
intra-arterial digital subtraction angiography. (Courtesy of Professor P. D.
intra-arterial digital subtraction angiography. (Courtesy of Professor P. D.
Griffiths, Academic Unit of Radiology, University of Sheffield.)
Griffiths, Academic Unit of Radiology, University of Sheffield.)

channel almost always exists, one vessel is usually sufficiently narrowed to
reduce its role as a collateral route. Cerebral and communicating arteries may
be absent, variably hypoplastic, double or even triple. The circle is rarely
functionally complete.
The haemodynamics of the circle is influenced by variations in the calibre
of communicating arteries and in the segments of the anterior and posterior
cerebral arteries that lie between their origins and their junctions with the
corresponding communicating arteries. The greatest individual variation in
calibre occurs in the posterior communicating artery. Commonly, the diam-
eter of the precommunicating part of the posterior cerebral artery is larger
than that of the posterior communicating artery, in which case the blood
supply to the occipital lobes is mainly from the vertebrobasilar system.
Sometimes, however, the diameter of the precommunicating part of the
posterior cerebral artery is smaller than that of the posterior communicating
artery, in which case the blood supply to the occipital lobes is mainly from
the internal carotids via the posterior communicating arteries. Agenesis or
hypoplasia of the initial segment of the anterior cerebral artery is more fre-
quent than anomalies in the anterior communicating artery and contributes
to defective circulation in about one third of individuals.
Central or Perforating Arteries
Numerous small central (perforating or ganglionic) arteries arise from the
circulus arteriosus or from vessels near it (see Fig. 6.6). Many of these enter
the brain through the anterior and posterior perforated substances (see Fig.
15.9). Central branches supply nearby structures on or near the base of the
brain, along with the interior of the cerebral hemisphere, including the internal
capsule, basal ganglia and thalamus. They form four principal groups. The
anteromedial group arises from the anterior cerebral and anterior communi-
cating arteries and passes through the medial part of the anterior perforated
substance. These arteries supply the optic chiasma; lamina terminalis; anterior,

98