NEUROSURGERY

Day 2: Vascular Anatomy

JAIME LOIS F. OPINION III, MD

Question: How many

arteries composes the
circle of Willis?
Answer: 9

VASCULAR = TERRITORIES
ANTERIOR CIRCULATION Angiograms usually indicated Petroclival Menigiomas or
AVM (Arteriovenous Malformation)
INTERNAL CAROTID ARTERY o C5 (Clinoid)- is the portion where your ICA becomes Intradural
• Begins at the bifurcation of o C6 (Ophthalmic)-
the Common Carotid o C7 (communicating)
Artery usually o Good to Know
accompanied by a localized ▪ “Carotid Siphon”
dilatation called the • IT is not a segment, but a region incorporating the
Carotid Sinus. cavernous, ophthalmic, and communicating segments.
• SEGMENTS:
o C1 (Cervical)- begins CLINICAL CORRELATE WITH ICA: RIGHT OR LEFT?
at the neck of the • Occlusion can occur
carotid artery without causing
bifurcation where symptoms or signs or can
CCA divides into the cause massive cerebral
ICA and ECA. Usually ischemia depending on
travels with the IJV the degree of collateral
and Vagal Nerve. anastomoses
o C2 (Petrous)- composed of three segments: • Contralateral Hemiparesis
▪ Vertical Segment- and hemianesthesia
▪ Posterior Loop- • There may be complete loss of sight on the same side but permanent
▪ Horizontal Segment- loss is rare.
o C3 (Lacerum)- forms the lateral
loop. Ascends to the canalicular
portion of the juxtasellar segment
o C4 (cavernous) = Area of
significance
▪ MHT (Meningohypophyseal
Trunk) a prominent MHT on

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ANTERIOR CEREBRAL 2 The muscle can move the joint it crosses through a full range
ARTERY of motion only if the part is properly positioned so that the
• Two Anterior force of gravity is eliminated
Cerebral 1 Muscle contraction is seen or identified with palpation, but it
Arteries join is insufficient to produce joint motion even with elimination of
together to gravity
form the 0 No muscle contraction is seen or identified with palpation;
ACOMM paralysis
(Anterior
Communicating MIDDLE CEREBRAL ARTERY
Artery) • M1 (Sphenoid) also known as horizontal segment. Origin to your
• Mainly supplies bifurcation.
the medial side of the cortex, as far back to the parieto-occipital sulcus. • M2- (Insular)- a.k.a
Supplies the leg area of the pre-central gyrus. Also supplies the Sylvian Segment,
lentiform and caudate nuclei. start from the
bifurcatio to the
The branches of the anterior cerebral artery per segments emergence from
Precommunicating Anteromedial central arteries Sylvian Fissure
part (A1) Anterior communicating artery • M3- (Opercular)
Infracallosal Orbitofrontal branches distal branches
segment (A2) Frontopolar artery • M4- (terminal branches)
Long striate/central artery (of Heubner) • Supplies the entire lateral surface of the hemisphere, except the
Perforating branches (to hypothalamus, septum narrow strip, and occipital pole. This artery supplies all the motor area
pellucidum, anterior commissure, fornix, striatum, except the leg area.
corpus callosum)
Precallosal part Pericallosal artery CLINICAL CORRELATE:
(A3) Callosomarginal artery • Contralateral
Medial frontal branches hemiparesis and
Cingular branch hemisensory loss
Supracallosal part Paracentral branches involving mainly the face
(A4) Precuneate branches and arm (precentral and
Postcallosal part Parietal branches postcentral gyri)
(A5) Parieto-occipital branches • Aphasia if Left
Inferior callosal branches hemisphere is affected
• Contralateral homonymous hemianopia (damage to the optic radiation)
• Anosogonia if the right hemisphere isaffected
Notes: Always remember how Trigeminal Nerve involves 3 segments

POSTERIOR CIRCULATION

CLINICAL CORRELATE
• Anterior Cerebral Artery Occlusion present as:
o Contralateral
Hemiparesis and
hemi sensory loss
involving mainly the
leg and foot VERTEBRAL ARTERY
o Left side ACA • First and largest
syndromes usually branch of the
present as apathy, personality changes subclavian artery,
Notes: Importance of NeuroPhysical Examination: ascend through
Muscle Strength (1, 2, 3, 4, 5) the neck by
passing through
Table 3. Grading of muscle strength the foramina in
Grade Ability to move the transverse
5 The muscle can move the joint it crosses through a full range process of the
of motion, against gravity, and against full resistance applied upper six cervical
by the examiner vertebrae. Enters
4 The muscle can move the joint it crosses through a full range the skull through
of motion against moderate resistance the foramen
3 The muscle can move the joint it crosses through a full range magnum. Joins the
of motion against gravity but without any resistance

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opposite side to become the basilar artery. • What vascular territory is affected? What syndrome?
• Segments:
o V1 (prevertebral/ preforaminal)- from subclavian artery, usually CASE NO 1:
pierces the 6th cervical vertebra • Essential findings:
o V2 (foraminal)- transverse foramen of c6- c2 o How do you test your concentration?
o V3 (extradural, extraspinal)- C2 to the dura o Mass at the parietal lobe
o V4 (intradural / intracranial)- dura to the confluence where it o Dysgraphia
becomes the basilar artery o Right to Left Disorientation
o Vascular territory??
BASILAR ARTERY o Syndrome: ??
• Formed by the
union of two CASE NO 2:
vertebral arteries. • Essential findings:
• Branches: o Thalamic stroke 5months ago
1. Pontine o Extensive pain
Arteries o Vascular territory-
2. Labyrinthine o Syndrome?
Artery-
internal ear CEREBRAL VENOUS
3. Anterior Inferior Cerebellar Artery- ANATOMY
4. Superior Cerebellar Artery • The right and left IJV
5. Posterior Cerebellar Artery are the major source
of outflow of blood
CLINICAL CORRELATE from the intracranial
(VERTEBROBASILAR component. Right >
ARTERY OCCLUSION) Left.
• Ipsilateral pain and • Torculi hereophili
temperature (confluence of
sensory loss of the sinuses)
face and 1. Occipital Sinus
contralateral pain 2. Superior Sagittal
and temperature Sinus
sensory loss of the 3. Straight Sinus
body.
• Hemianopia or
cortical blindness TRAUMA CASE
• Ipsilateral loss of gag reflex, dysphagia, and hoarseness as the result of • EJ, 26 y.o/M/ Filipino/ RC / was rushed to the ER. Witness saw the
the lesion of the nuclei. patient unconscious, with hit motorcycle 3 feet away from him and was
intoxicated. Initial management
CLINICAL CASE 1: of Emergency Responders initial
• Patient CC, 37 years old, findings showed:
right-handed. Was • GCS – 6 (E2V2M2), BP- 160/90;
rushed to the ER due to HR- 47; RR- irregular at average
sudden onset on tonic- of 20’s, O2 sat- 98%. Upon
clonic seizure, lasting for transport to the Emergency
a minute, happened only Room patient had 2 episode of
once for the past 24 hrs. seizures and vomiting. Initial
No other recurrence. Ct findings of EROD revealed that
showed a hyperdense the patient was intoxicated. GCS
lesion at the left parietal 6, with the ff vital signs- BP-
lobe. 160/75; HR- 51; RR- still irregular
• Upon Hx and PE significant findings showed: with the average of 20’s, o2 sats- 91%. Patient was started on double
o Patient had difficulty writing. Upon testing for concentration line. Intubated, CT scan requested which revealed the ff. and
patient had difficulty answering. Patient has also difficulty consequently referred to NROD.
identifying hemispheres. And has finger agnosia.
• What Vascular territory is affected? What clinical syndrome? CASE DISCUSSION
• Objectives
CLINICAL CASE 2: • Differentials
• A 48-year-old man, right-handed, • Case Discussion
who recently travelled from China • Principles and biomechanics of TBI
came in to the ER with sudden • Management
complaints of severe pain upon
touching his arms. Due to language
difficulties the only thing the
patient presented was a picture of
his scan dated 5 months ago.
History and physical examination
could not be totally performed due
to language difficulty. But of
significant finding is a that even the breeze from the AC triggers pain.

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