Part 1

BY : Dr . Sameeha Khan
(MDRD)
 Understanding vascular anatomy is fundamental
to neuroimaging.
 About 18% of the total blood volume in the body circulates in
the brain, which accounts for about 2% of the body weight.
 The blood transports oxygen, nutrients, and other substances
necessary for proper functioning of the brain tissues and carries
away metabolites.
 Loss of consciousness occurs in less than 15 seconds after
blood flow to the brain has stopped, and irreparable damage to
the brain tissue occurs within 5 minutes.
 Cerebrovascular disease or stroke, occurs as a result of
vascular compromise or haemorrhage and is one of the most
frequent sources of neurologic disability.
 Part 1 –
 Aortic arch and great vessels
 Carotid arteries
 Circle of Willis
 Part 2 –
 Cerebral arteries
 Posterior fossa arteries – vertebrobasilar
system
1. Conventional intra-arterial angiography –
DSA system - techniques of image
acquisition
 Standard radiographic projections
 carotid angio-
▪ Lateral projection – centered on pituitary fossa
▪ AP view – with petrous ridge projected over the roof of
orbit
▪ I/L anterior oblique – for aneurysms in SAH
 Vertebral angio –
▪ lateral , half-axial ( Towne’s) and AP – petrous ridge
superimposed on lower border of orbit
2. Computed tomography angiography
3. Magnetic resonance angiography
I. Time of flight – inflow of unsaturated spin
II. Phase contrast – accumulation of phase shifts proportional to flow
velocity
III. Contrast enhanced MRA
 Intracerebral vessels -3D TOF MRA is technique of choice
 Circle of willis – single slab 3D TOF
 Larger part of intracranial circulation – 3-4 multiple overlapping
slabs ( MOTSA )
 Phase contrast sensitive for slow flow – used for cerebral veins
4. Doppler ultrasound
Starts from aortic arch :

Aortic arch

Left
Innonimate Left
common
artery subclavian
carotid
3 . Innonimate artery
10. Left subclavian
artery
15. Left common
carotid artery
 A.k.a Brachiocephalic trunk .
 1st vessel arising from the aortic arch .

Innonimate
artery

Right Right
subclavian common
artery carotid artery
4. Right subclavian
artery
5. Right common
carotid artery
 Right subclavian artery

Right
Internal Thyrocervical Costocervical
vertebral
mammary artery trunk trunk
artery
 6. Right vertebral artery
9. Internal mammary
artery
16. Thyrocervical trunk

16
 Common arch anomaly
 0.5-1% of all cases
 Here it is the last
brachiocephalic vessel arising
from aortic arch -4th branch
 Often asymptomatic – 10 % of
people can have dysphagia
lusoria.
 Right common carotid arises
directly from arch – first branch
Barium studies – fixed narrowing
of esophagus at the level of arch
without mucosal deformity –
bayonet deformity
 1st Branch of right subclavian artery
 Right vertebral artery dominant -25%
 Anomalous origin – uncommon
 Arises from proximal IA
 Only cervical part as it arises caudally
 RCCA – directly from aortic arch ( when
right SCA is aberrant )

RCCA
RSCA
 2nd major branch from aortic arch
 Thoracic and cervical part –in thoracic it travels upwards throu
superior mediastinum to the level of left sternoclavicular joint and
continues as cervical
15.Left common
carotid

CCA bifurcates into ICA and

ECA at midcervical level C3-
C6 level.
LCCA- common
origin with IA
 LCCA – hypoplastic
or absent – here the
ECA and ICA arise
directly from aortic
arch
 Non bifurcating
carotid artery –
origin to all the ECA
branches
  Last branch from aortic arch
 Major branches -

Left subclavian artery

Left vertebral Internal Thyrocervical Costocervical

artery mammary trunk trunk
 First branch of left subclavian artery
 Dominant in 50-60%
 In 25% right and left VA are equal in size

11.Left vertebral artery

14.Left internal
mammary
 Left vertebral artery –directly from aortic arch
-5% ( nondominant )
 RVA
RCCA
LVA

RSCA LCCA

LSCA
Innominate
artery
 Course - Runs within a
fascial plane – the carotid
sheath –also contains IJV
and vagus nerve, vein
lateral to artery , nerve
between the two
 Runs obliquely upwards
from the level of
sternoclavicular joint to the
level of thyroid cartilage
 Bifurcates at the level of C3-
C5 into external and
internal carotid artery
 At bifurcation ICA usually
lies posterior and lateral to
the ECA
 Smaller of the 2 carotids.
 Origin anterior and medial to ICA.
 Supplies the extracranial structures.
 Branches –( Sister Lucy’s Powdered Face
Attracts SO Many Medicos )

Internal carotid artery

External carotid artery

Common carotid artery

 External carotid artery

Anterior Posterior Medial Terminal

Superior Ascending
Occipital Maxillary
thyroidal pharyngeal

Posterior Superficial
Lingual
auricular temporal

Facial
ECA – branches
 Occipital artery
Posterior auricular
artery
Ascending
pharyngeal artery

Facial artery
Lingual artery
Superior thyroid artery

Early arterial phase of CCA angiogram

 Superficial temporal
artery
Maxillary artery Posterior auricular
artery
Transverse facial
Occipital artery

Facial artery
Lingual artery

Late arterial phase of CCA angiogram

 Internal maxillary artery-
 Runs forward deep to the
mandible.
 Branches – inferior
alveolar, middle meningeal,
deep temporal , accessory
meningeal , sphenopalatine
, infraorbital , descending
palatine, muscular
branches.
 Middle meningeal artery –
runs superiorly crosses STA
on lateral projection thro
foramen spinosum.
 Supplies – dura and inner
table of skull.
 On angiogram should be
differentiated from middle
meningeal artery –
characteristic hairpin turn Middle meningeal artery
of STA over zygomatic hairpin turn of STA
process
 Supplies –part of scalp STA
and ear.
 Branch – transverse facial
artery
 Variant – TFA may arise
from ECA directly
Maxillary artery Superficial
temporal artery
Occipital artery

Facial artery
Lingual artery
Vertebral artery

Thyrocervical trunk

Oblique view – MRA

 Superficial
temporal artery
Middle meningeal Hairpin turn of
artery STA
Maxillary artery

Facial artery
Lingual artery
Vertebral artery

Straight AP view – MRA

Orbital mucosal
blush High nasopharynx
mucosal blush
Nasal conchae
septal blush

Palatal Oropharynx mucosal

mucosal blush blush

Late arterial phase – prominent vascular blushes in the

mucosa of sinuses , nose ,orbit , oropharynnx -
not to be confused with vascular malformations
 Maxillary artery ICA

• Middle meningeal • Ethmoidal br of

artery opthalmic artery
• Foramen rotundum • Inferlolateral trunk
artery of ICA
• Accessory meningeal • Inferolateral trunk
• Vidian artery • Intratemporal ICA
• Ant / mid deep • Opthalmic artery
temporal
• Occipital • Vertebral
• Ascending • Vertebral C3 level
pharyngeal artery
• Ascending • ICA (petrous and
pharyngeal artery cavernous )
• Facial artery • ICA (opthalmic
• Posterior auricular artery)
artery • ICA (stylomastoid
artery)
 • Laminar flow in lumen of
proximal ICA
• Velocity of flow increases
towards the aorta ( 9 cm /
sec for each cm of distance
Intima – white endoluminal line from the carotid
Media – darker line underneath bifurcation)
Adventitia –thick peripheral white line
 • Origin -Lateral to
ECA.
• Can be divided into
number of segments
between the bulb
and its bifurcation
into MCA and ACA.
ECA
Internal carotid-
carotid bulb

Left CCA
Right CCA

3-D CTA
 Communicating
Opthalmic
Intracranial /
supraclinoid
Cavernous

Intraosseous
/ petrous
Lacerum

Cervical
 Supraclinoid
Cavernous
ICA
Petrous

Cervical

Carotid bulb

Lateral DSA Oblique DSA

 Distal 2-4 cm of CCA  Thinner media and thicker
 Bulbous dilatation of ICA adventitia containing many
origin receptor endings of
 Complex flow – glossopharyngeal nerve
 flow distal to bulb is laminar
 Flow reversal within posterior
bulb
 No narrowing
ICA
 No dilatation
 No branches ECA
ICA
 No tapering
Course – crosses
behind and
medial to ECA
 10%- ICA
originates
medial to ECA ICA
 Anomalous ECA ECA
branches arises
from cervical
ICA
 Persistent
embryonic vesels
may anastomose
with
vertebrobasilar
system
 •2 subsegments joined at genu
•Short vertical segment – anterior to IJV
•Genu – petrous ICA turns anteromedially in front of cochlea
•Longer horizontal segment

ICA –intraosseous
1. enters carotid canal
in petrous temporal
bone.
2. Surrounded by
sympathetic plexus
3. exit at petrous apex

Horizontal
Genu
Vertical
Axial NECT inferior to superior ( bone window )
 Petrous segment of ICA

Intrapetrous • Branches supply middle ear

• Inconstant
Vidian artery • Throu Foramen lacerum and vidian
(artery of Pterygoid canal
canal ) • Anastomose with branches of ECA
(Recurrent br of greater palatine)

Corticotympanic • Important branch –tympanic cavity

artery • Supplies middle and inner ear
Vidian canal Foramen lacerum
 Aberrant course
•Posterolateral course thro temporal bone
•ICA parallel jugular bulb
•Inferior aspect of cochlear promontory
Normal course of ICA
•Reduced diameter
•Anteromedial course thro temporal bone
•Visible pulsatile mass in hypotympanum
•ICA anterior to IJV
•Bony plate separating ICA from tympanic
•In front of cochlea
cavity absent
• 2 segments
•Vertical segment of carotid canal absent
 Aberrant ICA

ICA courses adjacent to jugular bulb ICA traverses the hypotympanum

d/d glomus tympanicum

paraganglionoma
biopsy – disastrous

Axial multidetector
CT images

Bony plate along tympanic portion of ICA absent

Rare- 0.48%
Intrapetrous embryonic vascular
channel stapedio-hyoid artery
Origin – petrous ICA/abICA
Course – passes throu the
footplate of stapes. Enclosed
within a bony canal near cochlear
promontary
Termination – as middle
meningeal artery
CT- absentI/Lforamenspinosum
d/d – glomus tumor
Recognised before surgery
Small segment that extends from petrous apex above foramen lacerum curving
upwards towards and lies extradurally until it reaches petrolingual ligament after
this it becomes the cavernous segment
Covered by trigeminal ganglion
No branches
Carotid angiogram
Starts from petrous apex
Terminates at its entrance into
intracranial subarchnoid space
adjacent to anterior clinoid process.
Covered by trigeminal ganglion
posteriorly.

C4 segments
1. Ascending (posterior vertical )
2. Posterior genu
3. Horizontal
4. Anterior genu
5. Anterior vertical

Branches
Meningohypophyseal artery
1
Inferolateral trunk
Small capsular branches
Carotid
angiogram
 Posterior genu as it
Axial CT courses anteromedially
into the cavernous sinus

ICA courses along the Posterior genu

bony grooves of carotid
sulcus along the
basisphenoid bone

Carotid sulcus

• Throu cavernous sinus proper turns superiorly

• Form grooves under anterior clinoid process
• Anterior genu of ICA .
• Curve upwards towards dural ring
• Enter subarchnoid space
Anterior genu
C4 within cavernous sinus
 Menigohypophyseal artery
•Posterior trunk
•Arises at junction of c4 and
c5
•Supplies –
•pituitary gland
•tentorium (artery of
Bernasconi and Cassinari )
•cavernous sinus
• clival dura
• cn3 n 4
•High quality D/FSA
•Enlarges to supply dural
vascular malformation /
neoplasm
Inferolateral trunk
• Lateral mainstream artery
• Arises – inferolaterally
from c4 segment
• Supplies –
• CN 3,4,6
• gasserian ganglion CN5
• cavernous sinus dura
• Anastomose with br of
internal maxillary artery .
Collaterals b/w ECA N
ICA
• DSA – lateral view
• Enlarged – vascular
neoplasm / malformation
/ collaterals to ECA
•Between proximal , distal dural rings of
cavernous sinus
•Ends as ICA enters subarachnoid space
near anterior clinoid process
•No important branches
•Unless OA arises within CS
Extends from distal
dural ring at superior
clinoid to just below
posterior
communicating artery
(PCoA) origin
Branches –
•Opthalmic artery
•Superior hypophyseal
artery

Anterior clinoid process C6

CECT
Origin –
• Intradural
•Antero-superior ICA
• Medial to anterior clinoid process

Course –
Anterior throu optic canal

Below optic nerve

Crosses superomedially over the nerve

Supply -globe
Gives off ocular , lacrimal , muscular
branches
•Anastomose with ECA
 Lateral DSA

Lateral view MRA

Mid arterial phase DSA

Arises from posteromedial aspect of
supraclinoid ICA
Course – across the ventral surface of
optic chaisma
Terminates- pituitary stalk and gland
Supplies – anterior pituitary ,
Infundibulum , optic nerve and
chaisma
Anastomose - with hypophyseal
branch from the contralateral ICA
forms plexus – superior hypophyseal
plexus
DSA – usually not visualized if not
enlarged
Unruptured
superior
hypophyseal
aneurysm
Normally SHA
not easily seen
•Extends from below PCoA to
terminal ICA bifurcation.
•Passes between optic and
occulumotor nerve.

AChA

PCoA
3D CTA

Lateral DSA

C7 segment branches

Posterior communicating
Anterior choroidal artery
artery
•Arises – posterior aspect
of intradural ICA just
below anterior choroidal
Lateral late
artery arterial DSA
•Course – posterolaterally
above the occulumotor
nerve to join posterior
cerebral artery
•Branches – anterior
thalamoperforating
arteries
•Supplies – optic chiasma,
pituitary stalk , thalamus ,
MRA
hypothalamus.
1. Hypoplasia – 1/3 rd cases
2. Persistence of embryonic PCoA hypoplasia
configuaration ( fetal origin of
posterior cerebral artery ) 20 –
25%
3. Junctional dilatation at PCoA
origin ( infundibuli ) 6 %
4. PCoA duplication/ fenestraion
– rare
PCoA fenestration
• PCoM is larger than P1 segment of PCA • Non fetal PCA , PCoM lies superomedial
and supplies the bulk of PCA . PCA to CN3
therefore is a part of anterior circulation • Fetal PCA, PCoM lies superior lateral
to CN 3

•Hypoplastic /
absent P1 segment
•PCoA is same
diameter as I/L
PCA
•Infundibular dilatation of
PCoA at origin from ICA- 5-
15%
•Should be 2 mm or less
•Funnel shaped , conical
•PCoA arises from apex
 AChA-origin few mms above PCoA
Cisternal segment

Cisternal Course :
Intraventricular segment

Within suprasellar cistern under optic tract

Posteromedially around temporal lobe uncus

Intraventricular course:
AChA angles sharply laterally

Enters choroidal fissure of temporal bone

Abrupt kink – plexal point

 Supplies
Choroidal plexus of lateral ventricle (
temporal horn and atrium )
Optic tract and cerebral peduncle
Uncal and parahippocampal gyri of
temporal lobe .
Thalamus and posterior limb of
internal capsule.
Anastamoses – with AChA segments
and LPChA and MPChA
Variants – uncommon AP mid arterial DSA
Aplasia rare
Hypoplasia – 3 %
Hyperplasia – 2.3 %

Choriodal
blush

MRA lateral view AP Late arterial DSA

 ACA

MCA
3D
ICACTA

Mid arterial phase DSA 3D CTA

Terminal ICA

Anterior cerebral artery Middle cerebral artery

 2ICAs

Horizontal segment
A1 of both ACAs

Anterior
communicating artery

2 Posterior
communicating
arteries
Horizontal segment
P1 of both PCA s

Basilar artery
Interconnected arterial
polygon
Location – surrounds
ventral surface of
diencephalon,
adjacent to optic nerve
and tracts, inferolateral
to hypothalamus

Anterior Posterior
circulation circulation
Basilar bifurcation
2 B/L ICAs from merged VAs

2PCAs from
2ACAs
BAs

Unpaired ACoA
anteriorly B/L PCoAs
 1. A1
2. P1
3. PCoA
4. ACoA

3DVRT CTA MRA

CT MRA
 Non
Invasive
invasive MRA- time of
Cerebral flight sequence
angiography- with multiple
single injection overlapping thin
slab technique

Contrast
enhanced CT – Transcranial
maximum Doppler
intensity ultrasound
projection
 ACAs • Medial lenticulostriate arteries
• Recurrent artery of Heubner
• Perforating branches – hypothalamus , optic
chiasma , cingulate gyrus , corpus callosum ,
ACoA fornix
• Large vessel – median artery of corpus callosum
arises from ACoA

PCoA • Anterior thalamoperforating arteries

Basilar artery, • Posterior thalamoperforating arteries

PCAs • Thalamogeniculate arteries

1.Optic
2.Infundibulu 3.Hypothala 4.Base of
Supplies- chiasma
m mus brain
and tracts
 Complete COW –only 20
– 25%
 Posterior circle
anomalies – 50%
anatomy specimens
Common variants
•Hypoplasia of 1 or both
PCoA – 34%
•Fetal origin of PCA from
ICA
•Hypoplasia or absent A1
ACA segment.
•Absent , duplicate or
multichannel ACoA – 10-15%
•Rare – congenital absence of 1 or
both ICAs
•Common – if 1 ICA absent
intrasellar intercommunicating
arteries
•ICA agenesis – intracranial
Absent ICA
aneurysm common
•ACA- ACoA complex
•Infraoptic origin of ACA
•Single (azygous) ACA
(holoprosencephalies )
•PCoA- PCA- BA complex
•Persistent carotid basilar
anastomosis
 ICAs develop from 3rd aortic arches ,
dorsal aortae
 Embryonic ICAs divide into cranial,caudal
 Cranial divisions –
▪ primitive olfactory , anterior / middle cerebral , anterior choroidal
arteries
▪ Anterior communicating artery – forms from coalescence of a midline
plexiform network ,it connects developing ACAs
 Caudal divisions –
▪ becomes posterior communicating arteries
▪ Supply stems of posterior cerebral arteries.
 Paired dorsal longitudinal neural arteries fuse – basilar artery
 Developing vertebrobasilar circulation usually incorporates PCAs
 Caudal ICA divisions regress forming PCoAs.
 PCoA

PTA

Otic
Hypoglossal

Proatlantal
intersegmental

 Represent persistent embryonic

circulatory patterns
 Channels between embryonic aorta
(caudal carotid artery) and paired
longitudinal neural arteries (form
basilar and vertebral arteries ) fail to
regress.
1. Primitive persistent trigeminal artery
2. Primitive hypoglossal artery
3. Persistent otic artery
4. Proatlantal intersegmental artery
•Most common carotid vertebro basilar anastomoses - 0.1- 0.6%
•In utero – embryonic trigeminal artery supplies basilar artery before the PCoA and
vertebral artery develops
•As these vessels enlarge – PTA normally disappears
course – arise when ICA exists carotid canal and
enters cavernous sinus

Runs posterolaterally along trigeminal nerve 41%

Crosses over / throu dorsum sella before

joining basilar artery

Connects ICA to vertebrobasilar system trident shape on lateral DSA

Saltzmann type •PCoA is absent
•Supply entire vertebrobasilar circulation distal to
Ι anastomosis

Saltzmann type • Fetal PCA and I/L P1 segment absent

• Fill superior cerebral arteries (SCA) with posterior
ΙΙ cerebral arteries (PCA ) fills via patent PCoA

•Increased incidence of intracranial aneurysms / malformations

•Increased importance in transpenoidal surgery

Hypoplastic basilar
 2nd most common- 0.027-
0.26%
Courses thro hypoglossal canal
 .

Parallel to CN 12

Connects cervical ICA with

basilar artery

 Intracranial aneurysms
 If present – single artery
that supplies brain stem
and cerebellum
Red – PHA Blue – sigmoid sinus Pink – coil mass with basilar
tip aneurysm
 Origin – petrous ICA
 Course – medially thro internal
auditory meatus and joins caudal
basilar artery
 VA – hypoplastic / absent – POA is
the sole arterial supply to basilar
artery

Basilar artery
POA
•Proatlantal infact is occipital artery •C2 connection is proatlantal type 2
•C1 segment connection is proatlantal • vertebral artery proximal to proatlantal
type 1 is hypoplastic
 ICA

Proatlantal
intersergmental

PIA – suboccipital anastamosis between ECA / cervical ICA and vertebral artery
– typically courses between the arch of C1 and occiput