BJA Education, 21(10): 390e395 (2021)
doi: 10.1016/j.bjae.2021.05.004
Matrix codes: 1A01,
2F01, 3F00
Cerebral circulation 1: anatomy
A. Tan* and D. Roberts
St George’s University Hospitals NHS Foundation Trust, London, UK
*Corresponding author: audreytan@nhs.net
Keywords: anaesthesia; cerebrovascular circulation; neuroanatomy
Learning objectives
By reading this article, you should be able to:
 Describe the anatomy of cerebral circulation.
 Discuss the significance and importance of the
circle of Willis.
 Identify the conditions that affect the cerebral
arterial circulation and where it occurs
commonly.
 Explain why the cerebral venous circulation is
unique and how it is protective.
The brain is the most energy-hungry organ in the body.
Although the brain constitutes only 2% of the total body mass,
it consumes 20% of the body’s glucose-derived energy, oxygen
requirements and cardiac output.1 This article describes the
relationship between embryological development and cere-
bral anatomy, and the consequent neurological manifesta-
tions of diseases of the cerebral arterial supply and venous
drainage.
The unique features of the cerebral circulation are relevant
to all anaesthetists because we need to understand the risk of
perioperative stroke, and have strategies to manage patients
with a history of stroke or other abnormalities of the cerebral
circulation.
Audrey Tan FRCA is a consultant anaesthetist at St George’s Uni-
versity Hospitals NHS Foundation Trust and a senior lecturer at St
George’s, University of London. Her main interests are anaesthesia
for neurosurgery.
Daniel Roberts BSc (Hons) FRCA is a consultant anaesthetist at St
George’s University Hospitals NHS Foundation Trust and a senior
lecturer at St George’s, University of London. His main interests are
anaesthesia for trauma and neurosurgery.
Accepted: 9 May 2021
Crown Copyright © 2021 Published by Elsevier Ltd on behalf of British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: permissions@elsevier.com
Advance Access Publication Date: 14 July 2021
Key points
 The brain uses 20% of the body’s oxygen re-
quirements, cardiac output and glucose usage.
 Neuronal death occurs after 5 min of circulatory
arrest.
 Seventy percent of ischaemic strokes occur in the
anterior circulation; 90% of these occur in the
middle cerebral artery.
 Cerebral aneurysms are commonly found at bi-
furcations; 85% are in the anterior circulation.
 The cavernous sinus is the only place in the body
where an artery passes through a venous
structure.
Development
The development of the cerebral circulation occurs in two main
stages: vasculogenesis and angiogenesis. This development
occurs even before the heart starts beating. Vasculogenesis is
the de novo creation of blood vessels where previously none
existed. Angiogenesis is driven by hypoxia within the fetus and
is the production of new capillaries from existing blood vessels.
The circulatory system develops from the six pairs of
branchial arch arteries. The third pair of branchial arch ar-
teries and the distal segment of the paired dorsal aortae
become the internal carotid arteries (ICAs). The anterior di-
vision of the ICA goes on to form the primitive olfactory artery,
which becomes the middle (MCA) and anterior cerebral ar-
teries (ACA), whilst a posterior division eventually becomes
the posterior cerebral artery (PCA). Initially, the posterior cir-
culation relies on anastomoses from the anterior circulation
to the basilar artery before the development of the vertebral
arteries and the loss of the anastomoses.2
Arterial circulation
The blood supply to the brain is through the two ICAs and the
vertebrobasilar system, which provide 70% and 30% of the
390
 Cerebral circulation 1: anatomy

flow, respectively. The vertebral arteries originate from the

subclavian arteries and join to form the basilar artery. This
basilar artery then divides again to form the PCAs that anas-
tomose with the ICAs to form a system at the base of the brain
called the circle of Willis. The ICAs also continue on to form
the MCAs and join anteriorly to form two ACAs (Fig. 1). The
anterior cerebral circulation, made up of the ACAs and MCAs,
also includes the anterior choroidal artery, which can be sig-
nificant in disease. It usually arises from proximal to the
bifurcation of the ACAs and MCAs, although there are a
number of variations.
The ACAs supply most of the medial part of the cerebral
hemispheres; the MCAs supply the lateral sides of the hemi-
spheres, and the PCAs supply the occipital and inferior parts
of the temporal lobes.

Anterior cerebral arteries

The ACAs supply all of the medial surfaces of the frontal and
parietal lobe, the majority of the corpus callosum and the
frontobasal cerebral cortex. These areas include the frontal,
prefrontal, primary motor, primary sensory and supplemental
motor cortices (which contain Broca’s speech area). The main
motor and sensory functions relate to the lower limbs and
speech motor production.
The ACA is split into five segments: A1e5. These segments
denote the distance of the vessel from the origin of the ACA,
and supply distinct anatomical areas (Fig 2; Table 1).1
Fig 2 Sagittal view of non-contrast CT scan of the brain with a diagram of
the course of anterior cerebral artery superimposed on it. A, anterior ce-
rebral artery; A1, pre-communicating segment of the anterior cerebral ar-
tery; A2, post-communicating infracallosal segment of the anterior
cerebral artery; A3, precallosal segment of the anterior cerebral artery; A4,
supracallosal segment of the anterior cerebral artery; A5, postcallosal
segment of the anterior cerebral artery; B, orbitofrontal artery; C, fronto-
polar artery; D, callosomarginal artery; E, pericallosal artery; F, posterior
internal frontal artery; G, superior parietal artery; H, inferior parietal artery.

Middle cerebral arteries

The MCA is the largest of the intracerebral vessels. It supplies
a large area of the lateral surface of the brain, including the
cerebral cortex of the lateral frontal, parietal and temporal
lobes; part of the basal ganglia; and the internal capsule. The
basal ganglia are involved in motor control, learning and ex-
ecutive function along with emotions. The motor and sensory
areas supplied are mainly those of the face and upper limbs.
The MCA is split into segments M1e4. It arises from the ICA
and continues into the lateral sulcus where it divides further
and supplies the lateral cerebral cortex (Fig. 3; Table 1).1

Posterior cerebral arteries

The PCAs are the terminal branches of the basilar artery. They
supply the occipital lobe, which includes the visual areas and
the lower portion of the temporal lobe. It also supplies the
thalamus, which relays sensory and motor signals, deep
structures of the brain and part of the internal capsule, which
contains the descending parts of the lateral and anterior
corticospinal tracts.
The PCA is split into four segments P1e4. It arises from the
basilar artery and projects towards the occiput and over the
tentorium cerebelli to the occipital lobe (Fig. 4; Table 1).1

Conditions affecting the cerebral arterial

Fig 1 Contrast-enhanced magnetic resonance angiography (MRA) showing
cerebral arterial circulation. A1, A2, segments of anterior cerebral artery;
AICA, anterior inferior cerebellar artery; basilar, basilar artery; LICA, left
internal carotid artery; M1, M2, M3, M4, segments of middle cerebral artery;
P1, segment of posterior cerebral artery; RICA, right internal carotid artery;
RVA, right vertebral artery.
circulation
Vessel occlusion
Stroke is the fourth biggest cause of mortality in the UK.
Eighty-five percent of all strokes are ischaemic, and there are
around 100,000 strokes in the UK every year. Almost two
thirds of stroke survivors leave hospital with a disability,
with high costs to society.3

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Cerebral circulation 1: anatomy

Table 1 Segment, anatomy, cerebral area supplied and deficit if the cerebral artery is occluded

Artery Segment Anatomy Areas supplied Deficit

Anterior A1 (pre- Originating from the terminal bifurcation Caudate nucleus and anterior limb of - Contralateral
cerebral communicating) of the internal carotid artery, extending internal capsule, anterior hypothalamus, lower limb
artery ~14 mm in length and terminating at the septum pellucidum, anterior weakness
anterior communicating artery commissure, fornix and anterior - Contralateral
striatum face and arm
A2 (post- From the anterior communicating artery Anterior caudate nucleus, internal weakness
communicating, to the lamina terminalis and along the capsule and inferior and inferomedial - Isolated
sensory deficits
infracallosal) rostrum of the corpus callosum, surfaces of the frontal lobe
- Gait apraxia
terminating either at the genu of the
- Disinhibition
corpus callosum or at the origin of the
- Urinary
callosomarginal artery
incontinence
A3 (precallosal) From the corpus callosum or the Corpus callosum, superior frontal gyrus,
- Dysarthria
callosomarginal artery, terminating precuneus and medial aspect of the - Aphasia
directly posterior above the corpus hemisphere
callosum
A4 (supra- Above the body of the corpus callosum Corpus callosum
callosal) anterior to the plane of the coronal suture
A5 (postcallosal) Above the body of the corpus callosum Corpus callosum
posterior to the plane of the coronal
suture
Middle M1 (horizontal) Sphenoidal segment and runs within the Head and body of caudate nucleus, parts - Contralateral
cerebral Sylvian fissure parallel to the sphenoid of the internal capsule, putamen, lateral hemiplegia
artery ridge before becoming M2 segment pallidum and anterior temporal lobe - Hemi-
M2 (insular) From the limen insulae to the circular Parts of the parietal lobes anaesthesia
sulcus of the insular - Dysphagia
M3 (opercular) Run to the superficial border of the Frontal, parietal and temporal opercula - Dysarthria
Sylvian fissure before becoming the - Aphasia
cortical M4 segment - Hemianopia
- Neglect
M4 (cortical) Extends over the cortical surface of the Hemispheric surface of frontal and
cerebral hemisphere parietal lobes
Posterior P1 (pre- From the termination of the basilar artery Paramedian parts of the upper midbrain - Contralateral
cerebral communicating) to the posterior communicating artery and thalamus homonymous
artery within the interpeduncular cistern hemianopia
P2 (post- Around the midbrain through the crural Ventrolateral thalamus, geniculate body, - Hemi-sensory
communicating) and ambient cisterns posterior thalamus and hippocampus loss
P3 Quadrigeminal cistern to the entrance of Inferotemporal areas - Hemi-body
(quadrigeminal) the occipital lobe pain
P4 (cortical) Cortical surface of the occipital lobe Occipital cortex - Confusion
- Paraesthesia
- Dizziness
- Memory loss
- Aphasia
- Involuntary
movements

Anterior d From the internal carotid artery, runs Hippocampus, amygdala, posterior limb - Contralateral
choroidal along the optic tract to the choroidal internal capsule, midbrain, thalamus hemiplegia
artery fissure and geniculate nucleus - Hemi-
anaesthesia
- Hemianopia

Ischaemic strokes are caused by blockages to the blood
supply to parts of the brain. The effect and disability depend
on where the blockage occurs (Table 1).
The majority of ischaemic strokes (70%) occur in the anterior
circulation, that is, from the ICA, ACA or MCA. Pure ACA infarcts
are uncommon (2%), as there is good collateral blood supply.
The most common sites of ICA occlusion are the proximal 2 cm
and the carotid siphon. These sites can be silent, owing to the
fact that there is extensive collateral supply. Middle cerebral
artery occlusion is the most common of the anterior circulation
strokes accounting for 90% of infarcts and generally occurs in
M1 or M2 (Fig. 5). Thirty-three percent of these strokes are in the
deep MCA territory and 50% superficial.4
The large vessel occlusions of the proximal anterior and
posterior circulations have historically caused long-term
morbidity and mortality, as they are commonly refractory to
thrombolysis. These occlusions account for 24e46% of
ischaemic strokes, although it is hoped that with the advent of
mechanical thrombectomy, this will improve.5 The cerebral
arterial circulation is unique in that the circle of Willis allows
collateral blood flow to occur if a main artery is completely
occluded on one side. It is important to maintain the mean
arterial pressure in patients with an acute ischaemic stroke in
the hope that the collateral circulation will perfuse the
ischaemic areas to some extent before mechanical throm-
bectomy can be performed.

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 Cerebral circulation 1: anatomy

Moyamoya disease is a rare progressive congenital condi-

tion, in which the ICAs are narrowed, limiting the flow to the
brain. The brain compensates for the decreased blood supply
by developing tiny collateral vessels to the oxygen-deprived
areas. This appearance on imaging earns it the name, which
is Japanese for ‘puff of smoke’. Moyamoya disease is more
common in the East Asian population and is associated with
some diseases, such as Down syndrome, neurofibromatosis
type 1 and sickle cell disease. The incidence is one in 1,000,000
in Western populations with two peaks of presentation: one in
childhood (from 5 to 15 yrs) and another in adulthood (in their
40s).9 The initial presentation can be with a transient ischae-
mic attack or ischaemic or haemorrhagic stroke. The most
common symptoms are headaches, weakness or numbness in
limbs, paralysis and dysphasia. The gold standard for diag-
nosis is an angiogram. Treatment can be medical or surgical.
Medical treatment includes aspirin, which may reduce the
risk of strokes. Surgical treatments aim to restore blood flow
to the deprived areas of the brain by direct or indirect bypass
procedures. Direct bypass procedures, such as extracranial to
intracranial bypass, are preferred in older children and adults.
Fig 3 Coronal view of noncontrast CT scan of the brain with a diagram of Indirect bypass procedures, such as pial synangiosis, ence-
the course of middle cerebral artery superimposed on it. ACA, anterior
phaloduroarteriosynangiosis and dural inversion, are used in
communicating artery; ICA, internal carotid artery; M1, horizontal segment
children aged <10 yrs.
of the middle cerebral artery; M2, insular segment of the middle cerebral
artery; M3, opercular segment of the middle cerebral artery; M4, cortical
segments of the middle cerebral artery.
Venous circulation
The cerebral venous circulation (Fig. 6) has a wide variability
between people and even between the two hemispheres
compared with the arterial system. They differ from other
Cerebral aneurysm veins in the body, as they do not follow the pathway of the
associated cerebral arteries and do not have valves. This
Cerebral aneurysm (CA) is an abnormal bulging weakness in a
makes the venous circulation bidirectional, which is essential
cerebral artery wall that becomes thin and has the potential to
rupture. The estimated worldwide prevalence of CA is 3.2%.6
The rate of rupture is about 10 per 100,000. Most CAs are
saccular (berry), but there are a small percentage of fusiform
and mycotic aneurysms. Cerebral aneurysms are commonly
found at bifurcations in major cerebral arteries, where there is
most haemodynamic stress in a vessel. Eighty-five percent of
berry aneurysms are located in the anterior circulation. The
three most common areas are the anterior communicating
artery (30%), followed by the posterior communicating artery
(25%) and the MCA (20%).7
Fusiform aneurysms tend to occur in the posterior circu-
lation. Ten percent of all CAs are on the basilar artery,
particularly on the basilar tip, and 5% are on the vertebral
artery.7 Cerebral aneurysms are found incidentally, but
symptoms can range from headaches to unconsciousness and
death. Rupture of the CAs can cause intracranial and sub-
arachnoid haemorrhage. Treatment can be with surgical
clipping of aneurysm or endovascular coiling.

Arteriovenous malformation and collateral vessels

Arteriovenous malformations (AVMs) are arteriovenous
shunts. The lack of an intertwining capillary bed results in
pulsatile high flow and medium-to high-pressure channels
more liable to rupture. Arteriovenous malformations are
thought to be hereditary with a prevalence of 0.14% and a
lifelong risk of bleeding of 2e4%.8 Patients usually present
with haemorrhage or seizures. Diagnosis is via cerebral
angiogram. Treatment is by surgical excision, stereotactic
radiosurgery and embolisation.
Fig 4 Sagittal view of noncontrast CT scan of the brain with a diagram of
the course of posterior cerebral artery superimposed on it. A, basilar artery;
B, internal carotid artery; C, posterior cerebral artery; D, medial posterior
choroidal artery; E, lateral posterior choroidal artery; F, splenial artery; G,
posterior temporal artery; H, posterior temporal artery; I, occipital artery;
P1, precommunicating segment of the posterior cerebral artery; P2, post-
communicating segment of the posterior cerebral artery; P3, quad-
rigeminal segment of the posterior cerebral artery; P4, cortical segment of
the posterior cerebral artery.

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Cerebral circulation 1: anatomy
Fig 5 Angiogram showing M1 occlusion located at A (left). Scan showing a decreased blood vessel density in the area shaded with red (right).
in intracranial pressure (ICP) regulation in relation to posture
and cerebral venous outflow. These qualities make the cere-
bral venous circulation unique and protect against several
clinical conditions of the brain.
Venous circulation of the cerebrum consists of deep and
superficial cerebral veins, which drain into the dural venous
sinuses located in between the periosteal and meningeal
layers of the dura mater, and eventually drain into the inter-
nal jugular vein (IJV).
Deep cerebral veins
The deep cerebral veins are closely associated with the thal-
amus originating at the foramen of Munro, and run posteriorly
within the roof of the third ventricle. The two veins anasto-
mose to form the great vein of Galen (GV). The basal vein of
Rosenthal drains the midbrain structures and into the GV,
which drains into the straight sinus.
Superficial cerebral veins
These veins comprise the superior cerebral veins and the
Sylvian vein. The superior cerebral veins extend on the lateral
Fig 6 Angiogram showing anterior communicating artery (ACOM) aneurysm: anteroposterior view (left) and lateral view (right). A, basilar artery; B, anterior ce-
rebral artery; C, ACOM aneurysm; D, middle cerebral artery.
394 BJA Education - Volume 21, Number 10, 2021
surface of the brain superiorly to drain into the superior
sagittal sinus, which is within the falx cerebri. The Sylvian
vein lies in the Sylvian fissure and drains into three different
sinuses. It drains in the superior sagittal sinus via the superior
anastomotic vein of Trolard, transverse sinus via the inferior
anastomotic vein of Labbe and anteriorly into the cavernous
sinus. The cavernous sinus is located in the middle cranial
fossa next to the sella turcica and pituitary gland, and is the
only place in the body that an artery passes inside a venous
structure. This sinus contains important structures, such as
the ICA, carotid plexus and cranial nerves (oculomotor,
trochlear, ophthalmic, maxillary and abducens nerves).
The falx cerebri contains the superior sagittal, inferior
sagittal and straight sinus. These anastomose at the conflu-
ence of sinuses located at the internal occipital protuberance.
This becomes the transverse sinus, which emerges as the
sigmoid sinus and drains into the IJV together with the
cavernous sinus carrying deoxygenated blood back to the
heart. The IJV is able to drain 100% of the cerebral venous
outflow, but there is a second venous system; the vertebral
venous plexus (VVP) can drain up to 30% of the venous outflow

from the brain. The majority of veins in the posterior fossa
drain into the inferior petrosal sinus. This sinus is a connec-
tion between IJV and VVP.
Clinical conditions affecting the cerebral
venous circulation
Cerebral venous sinus thrombosis (CVST) is uncommon, ac-
counting for 0.5e1% of strokes, as there are substantial com-
pensations in the cerebral venous systems. This is because
cerebral veins and sinuses have no valves and no tunica
muscularis layer. Symptoms of CVST vary according to the
location of thrombus, but are commonly headaches, blurred
vision, focal deficits, seizures and coma. The most common
area affected is the superior sagittal sinus and the lateral si-
nuses.10 They are often unrecognised initially. Anti-
coagulation is the first line of treatment.
Infections of the brain can occur as dural sinuses are in
communication with extracranial venous systems via many
emissary veins. The absence of valves allows retrograde flow
of blood from superficial structures into the brain and can be a
site of entry of infection.
The cerebral venous drainage may also be affected by
postural changes. Excessive neck flexion and neck rotation
may result in kinking and obstruction of the IJV, which may in
turn lead to an increase in ICP. The VVP can compensate for
such changes to some extent in normal life.11 This may not be
true during surgery and anaesthesia.
Conclusions
The cerebral circulation is complex, and if interrupted or
affected, it can produce a number of clinical syndromes
dependent on the area of the brain affected; these are then
modified, depending on the extent of collateral blood flow
present. The anatomy of the circle of Willis allows extensive
protection and continued flow in the presence of a large vessel
occlusion.
Anaesthetists and intensivists should have a working
knowledge of cerebral vascular anatomy to help diagnose
patients and guide anaesthesia and resuscitation. Mainte-
nance of cerebral perfusion pressures is especially important
in patients with ischaemic stroke undergoing mechanical
thrombectomy to maintain collateral flow and improve out-
comes. Patients should be positioned carefully to avoid kink-
ing the IJV and potentially increasing intracranial pressures.
Cerebral circulation 1: anatomy
MCQs
The associated MCQs (to support CME/CPD activity) are
accessible at www.bjaed.org/cme/home for subscribers to BJA
Education.
Declaration of interests
The authors declare that they have no conflicts of interest.
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