BLOOD SUPPLY OF BRAIN AND IT’S

APPLIED ASPECT

PRESENTED BY-
DR. AYUSHI TYAGI

MODERATED BY-
DR. MOHD. NADEEM
 ARTERIAL SUPPLY OF BRAIN
• The brain receives blood from two sources: the
internal carotid arteries, which arise at the point in
the neck where the common carotid arteries
bifurcate, and the vertebral arteries.
• The internal carotid arteries branch to form, the
anterior and middle cerebral arteries.
• The right and left vertebral arteries come together
at the level of the pons on the ventral surface of
the brainstem to form the midline basilar artery.
• The basilar artery joins the blood supply from the
internal carotids in an arterial ring at the base of
the brain (in the vicinity of the hypothalamus and
cerebral peduncles) called the Circle of Willis.

• The posterior cerebral arteries arise at this

confluence, along with two small bridging
arteries which are the anterior and posterior
communicating arteries.
CIRCLE OF WILLIS
 PHYSIOLOGICAL SIGNIFICANCE
• The arrangement of the brain's arteries into
the Circle of Willis creates collaterals in the
cerebral circulation.
• If one part of the circle becomes blocked or
stenosed or one of the arteries supplying the
circle is affected, then blood flow from the
other blood vessels can often preserve the
cerebral perfusion well enough to avoid the
symptoms of ischemia.
ANTERIOR AND POSTERIOR CIRCULATION

• The major branches that arise from the internal

carotid artery—the anterior and middle cerebral
arteries—form the anterior circulation that supplies
the forebrain.
• Each gives rise to branches that supply the cortex
and branches that penetrate the basal surface of the
brain, supplying deep structures such as the basal
ganglia, thalamus, and internal capsule.
• Particularly prominent are the lenticulostriate
arteries that branch from the middle cerebral artery.
• These arteries supply the basal ganglia and thalamus.
Anterior Circulation

Posterior Circulation
• The posterior circulation of the brain supplies the
posterior cortex, the midbrain, and the brainstem.
• Comprises arterial branches arising from the
posterior cerebral, basilar, and vertebral arteries.
• Midline arteries supply medial structures, lateral
arteries supply the lateral brainstem, and dorsal-
lateral arteries supply dorso-lateral brainstem
structures and the cerebellum.
CORTICAL TERRITORIES
 ANTERIOR CEREBRAL ARTERY

• The ACA is divided into two segments:

• the precommunal (A1) -which connects the internal
carotid artery to the anterior communicating artery
• the postcommunal (A2) segment-distal to the
anterior communicating artery.
• The A1 segment gives rise to several deep
penetrating branches that supply the anterior limb of
the internal capsule, the anterior perforate
substance, amygdala, anterior hypothalamus, and the
inferior part of the head of the caudate nucleus
Anterior Cerebral Artery
 MIDDLE CEREBRAL ARTERY

The cortical branches of the MCA supply the

lateral surface of the hemisphere except for
(1) the frontal pole and a strip along the
superomedial border of the frontal and parietal
lobes supplied by the anterior cerebral artery
(ACA)
(2) the lower temporal and occipital pole
convolutions supplied by the posterior cerebral
artery (PCA)
• The proximal MCA (M1 segment) gives rise to
penetrating branches (termed lenticulostriate
arteries) that supply the putamen, outer globus
pallidus, posterior limb of the internal capsule,
adjacent corona radiata, and most of the
caudate nucleus.
• In the sylvian fissure, the MCA in most patients
divides into superior and inferior divisions (M2
branches). Branches of the inferior division
supply the inferior parietal and temporal
cortex, and those from the superior division
supply the frontal and superior parietal cortex.
Middle Cerebral Artery
 POSTERIOR CEREBRAL ARTERY

• P1 segment – proximal segment

• P2 segment - distal to the junction of the PCA
with the posterior communicating artery.
Posterior Cerebral Artery
 VERTEBRAL AND POSTERIOR INFERIOR
CEREBELLAR ARTERIES
• The vertebral artery, which arises from the
innominate artery on the right and the subclavian
artery on the left, consists of four segments.
• V1- extends from its origin to its entrance into the
sixth or fifth transverse vertebral foramen.
• V2- traverses the vertebral foramina from C6 to C2.
• V3- passes through the transverse foramen and
circles around the arch of the atlas to pierce the
dura at the foramen magnum.
• V4- courses upward to join the other vertebral
artery to form the basilar artery. Only the
fourth segment gives rise to branches that
supply the brainstem and cerebellum.
• The posterior inferior cerebellar artery (PICA)
in its proximal segment supplies the lateral
medulla and, in its distal branches, the inferior
surface of the cerebellum.
 BLOOD SUPPLY TO CEREBELLUM
• Superior cerebellar
artery (SCA) from
basilar artery
• Anterior inferior
cerebellar artery (AICA)
from basilar artery
• Posterior inferior
cerebellar artery (PICA)
from vertebral artery
 BLOOD SUPPLY TO SPINAL CORD
• The spinal cord is supplied by three arteries that run along
its length starting in the brain, and many arteries that
approach it through the sides of the spinal column.
• The three longitudinal arteries are called the anterior spinal
artery, and the right and left posterior spinal arteries.
• These travel in the subarachnoid space and send branches
into the spinal cord.
• They form anastomoses via the anterior and posterior
segmental medullary arteries, which enter the spinal cord at
various points along its length.
• It supplies blood upto cervical segments.
• Arterial blood supply below the cervical region comes
from the radially arranged posterior and anterior
radicular arteries, which run into spinal cord alongside
the dorsal and ventral nerve roots.

• These intercostal and lumbar radicular arteries arise

from the aorta, provide major anastomoses and
supplement the blood flow to the spinal cord.

• Impaired blood flow through these critical radicular

arteries, especially during surgical procedures that
involve abrupt disruption of blood flow through the
aorta (for example during aortic aneursym repair), can
result in spinal cord infarction and paraplegia.
BLOOD SUPPLY OF BRAINSTEM
STRUCTURE SUPPLY

MIDBRAIN -POSTERIOR CEREBRAL ARTERY

PONS -BASILAR ARTERY

-SUPERIOR CEREBELLAR ARTERY

MEDULLA -VERTEBRAL ARTERY

-POSTERIOR INFERIOR
CEREBELLAR ARTERY
BLOOD SUPPLY OF INTERNAL CAPSULE
 VENOUS DRAINAGE OF THE BRAIN

•External cerebral veins:

1- Superior cerebral veins - drain superiolateral surface of
cerebral hemisphere, terminate into superior sagittal veins.
2- Superficial middle cerebral vein - drains area around lateral
sulcus and terminate into cavernous sinus.

•Internal cerebral vein

1- Great cerebral veins : It is formed by union of two internal
cerebral veins. It terminates in the straight sinus, drains the deep
structures of the forebrain.
2- Basal veins : It is formed by union of deep middle cerebral vein
and anterior cerebral vein and terminates by joining great
cerebral vein.
Dural venous sinuses:

•The Dural venous sinuses are connected to extra

cranial veins via emissary (representative) veins.
APPLIED ASPECTS
 STROKE
• Stroke is defined as an abrupt onset of a
neurologic deficit that is attributable to focal
vascular cause.
• Transient Ischemic Attack- neurological signs
and symptoms resolve within 24 hours
without evidence of brain infarction on brain
imaging.
 Types of Stroke
Ischemic
Hemorrhagic-
 Ischemic Stroke
85% of strokes
Arterial occlusion of an intracranial vessel leads to
hypoperfusion of the brain region it supplies
Two etiological types
Thrombotic
Embolic
 STROKE SYNDROMES
Stroke syndromes are divided into:
(1) large-vessel stroke within the anterior
circulation
(2) large-vessel stroke within the posterior
circulation
 STROKE IN ANTERIOR CIRCULATION

• MIDDLE CEREBRAL ARTERY-

• Most common cause of occlusion is embolus
(artery-to-artery, cardiac, etc)
• Complete MCA occlusion at its origin leads to
contralateral hemiplegia, hemianesthesia,
homonymous hemianopia and gaze preference
to ipsilateral side.
• Global aphasia is seen when dominant
hemisphere is involved.
 Partial occlusion / branch occlusion
If superior division involved-
• Brachial syndrome- weakness of hand and arm
• Frontal opercular syndrome-Broca’s aphasia with facial
weakness with or without arm weakness
• Proximal part of the superior division involved- clinical features
of motor weakness, sensory disturbances and broca’s aphasia
If inferior division of M2 involved-
• If dominant hemisphere- Wernicke’s aphasia without
weakness with contralateral homonymous superior
quadrantanopia
• If non dominant hemisphere- Hemispatial neglect , spatial
agonosia without weakness
• ANTERIOR CEREBRAL ARTERY –
• Two segments A1 and A2
• Occlusion of the proximal ACA is usually well tolerated
because of collateral flow through the anterior
communicating artery and collaterals through the
MCA and PCA.
• Occlusion of a single A2 segment results in the
contralateral symptoms –paralysis and sensory loss
over opposite foot and leg, urinary incontinence, gait
apraxia.
• Both segments involvement will cause abulia (delay in
verbal and motor response) , bilateral pyramidal signs
with paraparesis or quadriparesis and urinary
incontinence.
• ANTERIOR CHOROIDAL ARTERY
• Arises from internal carotid artery
• Supplies posterior limb of internal capsule and white
matter posterolateral to it
• Complete syndrome rare due to collaterals from
MCA, PCA, and ICA.
• Syndrome comprises-
contralateral hemiplegia
contralateral hemianaesthesia
homonymous hemianopia
 STROKE IN POSTERIOR CIRCULATION
• POSTERIOR CEREBRAL ARTERY
• 2 clinical syndromes– P1 and P2
• P1 syndrome : midbrain, subthalamic, and
thalamic signs, which are due to disease of the
proximal P1 segment of the PCA or its penetrating
branches

• P2 syndrome: cortical temporal and occipital lobe

signs, due to occlusion of the P2 segment distal to
the junction of the PCA with the posterior
communicating artery.
P1 SYNDROMES
P2 SYNDROMES

• Occulsion of the PCA causes infarction of the medial

temporal and occipital lobes
• Contralateral homonymous hemianopia with macula
sparing is the usual manifestation
• Acute disturbance in memory (hippocampus)
• peduncular hallucinosis - visual hallucinations of
brightly colored scenes and objects
• Infarction in the distal PCAs produces cortical blindness
(blindness with preserved pupillary light reflex)
• Anton's syndrome – unaware of blindness and in denial
• VERTEBRAL ARTERY AND POSTERIOR INFERIOR
CEREBELLAR ARTERY
• Atherothrombotic lesions have predilection for V1
and V4 segment.
• Embolic occlusion or thrombosis of V4 produces
ischaemia of lateral medulla called lateral
medullary syndrome.
• It consists of vertigo , numbness of ipsilateral face
and contralateral limb.
• Hemiparesis is not typical feature of vertebral
artery occlusion , but quadriparesis may result
from occlusion of anterior spinal artery.
 Medial medullary syndrome (occlusion of
vertebral artery or of branch of vertebral or
lower basilar artery)
• On side of lesion
Paralysis with atrophy of one-half of the
tongue: Ipsilateral 12th nerve
• On side opposite to lesion
Paralysis of arm and leg, sparing face;
impaired tactile and proprioceptive sense over
one-half of the body: Contralateral pyramidal
tract and medial lemniscus
 Lateral medullary syndrome (occlusion of any of
—vertebral, posterior inferior cerebellar,
superior, middle, or inferior lateral medullary
arteries)
On side of lesion
• Pain, numbness, impaired sensation over one-
half the face: Descending tract and nucleus fifth
nerve
Ataxia of limbs, falling to side of lesion
• Nystagmus, diplopia, vertigo, vomiting:
Vestibular nucleus
• Horner’s syndrome: Descending sympathetic
tract
• Dysphagia, hoarseness, paralysis of palate, paralysis of
vocal cord, diminished gag reflex: Ninth and tenth
nerves
• Loss of taste: Nucleus of tractus solitarius
• Numbness of ipsilateral arm, trunk, or leg: Cuneate and
gracile nuclei
• Weakness of lower face: Genuflected upper motor
neuron fibers to ipsilateral facial nucleus

• On side opposite to lesion

Impaired pain and thermal sensation over half of the
body, sometimes face: Spinothalamic tract
CEREBELLAR STROKE SYNDROMES
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