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NORMAL NEUROVASCULAR
ANATOMY
Michael Meuse, M.D.
Vascular and Interventional Radiology
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References
Dr. David Kallmes
Introduction to Cerebral Angiography. Osborn
Clinical Brain Imaging. Hayman and Hinck
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Neurovasculature
2 Main Systems
- Carotid
- Vertebrobasilar
Cerebral perfusion
depends on multiple
sites of anastomosis
between the two
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Aortic Arch
Start from the source
Arch lies in the Superior Mediastinum and courses right to left, anterior to Trachea
3 trunks from the arch
1. Innominate A.(1)
2. Left Common Carotid(7)
3. Left Subclavian Artery(8)
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Arch Branches
Branches:
1: Innominate Artery
(Brachiocephalic trunk)
This splits into the:
2. R Subclavian Artery
3. R Common Carotid
Artery
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Arch Branches
The R Subclavian gives
rise to R Vertebral
Artery(4)
R Common Carotid (5)
splits into R ECA and R
ICA in most cases at
C3/4 (34%) or C4/5
(45%).
Can split anywhere
between C1 and T2
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Arch Branches
Branch 2 is the L
Common Carotid
Artery.(7)
Also splits at approx.
C3/4 (34%), C4/5
(45%)
Branch 3 is the L
Subclavian Artery(8)
which gives rise to L
Vertebral Artery(9)
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External Carotid
Proximal ECA(3) is
Ant/Med to ICA(4). As
it ascends it courses
Post/Lat
Supplies facial
structures
Splits into terminal
branches within Parotid
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External Carotid Artery
SALFOPS
S superior thyroid
A ascending pharyngeal
L lingual
F facial
O occipital
P posterior auricular
S superficial temporal
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ECA Branches
Branches:
1. Superior Thyroid(1):
supplies larynx and
upper thyroid
2. Asc. Pharyngeal(2):
supplies meninges,
middle ear, lower
cranial N’s
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ECA Branches
3. Lingual(3): supplies
pharynx and hyoid M’s
along w. submand. gland
and tongue.
4. Facial(4): Frequently
common trunk w. Lingual.
Supplies facial
musculature.
5. Occipital(5): Supplies
muscles and skin of neck,
scalp and post. meninges
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ECA Branches
6. Post. Auricular(6):
Supplies Parotid, scalp,
pinnae, tymp. cavity
7. Sup. Temporal(7):
smaller terminal branch
of ECA. essentially
cutaneous supply. Ant.
scalp, parotid, TMJ, ear
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Maxillary Artery
Larger terminal branch
of ECA.
Arises behind the neck
of the Mandible
3 Main Portions
1.Mandibular
2. Pterygoid
3. Pterygopalatine
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Mandibular portion
courses along the inf.
lateral pterygoid M.
Branches:
1. Deep Auricular(1)
2. Anterior
Tympanic(2)
3. Middle Meningeal(3)
4. Accessory Menin.(9)
5. Inferior Alveolar(4)
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Pterygoid Portion
Supplies muscles of
mastication.
Branches:
1. Buccal Artery(8)
2. Masseteric Artery(7)
3. Middle Temporal(5)
4. Deep Temporal(6)
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Pterygopalatine portion
Branches in PP fossa
Each branch of the maxillary leaves thru a bony canal or foramen.
Branches:
Posterior-
1. A. of Foramen Rotundum(3)
2. A. of Pterygoid Canal (Vidian a.)(4)
3. Pharyngeal Artery(5)
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Pterygopalatine portion
Anterior-
1. Post/Sup Alveolar A(4)- oral mucosa, teeth
2. Infraorbital Artery(2)-orbit and maxilla
3. Greater Palatine Artery(1)- hard palate
4. Sphenopalatine Artery(3)- nasal turbinates and septum
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Cervical ICA
Arises C3/4
Runs cephalad deep to
the SCM in a
neurovasc. bundle with
IJ and CNX
ICA initially is pos/lat to
ECA. Courses
medially as it ascends.
Lies medial to IJ
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Cervical ICA
Ends at the Carotid
canal of the petrous
temporal bone just
anterior to Jugular
Foramen
No cervical branches in
most people
Carotid sinus is
bulbous dilatation in
area of ICA origin
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Petrous ICA
2 segments:
1. Vertical
2. Horizontal
Initially ascends anterior to the jugular fossa just behind the Eustachian tube
Horizontal section begins as ICA turns Ant/med in front of tymp cavity and cochlea
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Petrous ICA
Petrous Branches occur in approx. 30% of patients
1. Vidian Artery(3): Most common branch. Usually arises from Maxillary A.
2. Caroticotympanic A(1).: tiny branch not usually visualized
3. Periosteal Branches
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Cavernous ICA
2 segments:
1. Presellar
2. Juxtasellar
Carotid Siphon refers to “S” shaped course of the cavernous ICA as it courses over the sphenoid bone.
Carotid is the most medial structure in Cavernous sinus
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Cavernous ICA
3 branches within
cavernous sinus:
1.Meningohypophyseal
Trunk: largest branch
gives rise to Tentorial
A.(Bernasconi &
Cassanari), Dorsal
Meningeal A., and Inf.
Hypophyseal A.
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Cavernous ICA
2. Inferolateral Trunk(4):
supplies dura of the
cav. sinus and CN’s in
cav. Sinus. Branches
into A. of Foramen
Rotundum(5).
3. McConnell’s capsular
A’s(6): only found in
30% of autopsies.
Supply the bony sella.
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Intracranial ICA
ICA pierces the dura on
the medial aspect of
the Anterior Clinoid
process
Courses superiorly
between optic and
oculomotor nerves
2 terminal branches are
the ACA and MCA.
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ICA Branches
Branches of the Intracranial
ICA include:
1. Superior Hypophyseal(3):
forms plexus around
base of hypophysis.
2. Ophthalmic A.(8):
occasionally arises from
ECA or Middle Mening.
Courses thru optic canal
along inf. Optic Nerve
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ICA Branches
Ophthalmic( con’t:
supplies globe and
orbital contents via
Ocular(1), Orbital(2),
and Extraorbital
branches.
3. Post. Communicating
4. Ant. Choroidal
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Circle of Willis
Arterial polygon surrounding the ventral surface of the diencephalon.
The “Classic” Circle of Willis is only seen in 20% of people.
Anterior portion consists of ICA’s, ACA’s(A1)(2), and the Ant. Communicating Art.(1)
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Circle of Willis
The posterior portion of
the circle is made up of
PCA’s(P1)(5) and
Posterior
Communicating
Art’s(4).
Most variants occur
because of hypoplasia
of one or more
components.
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Anterior Choroidal Art.
Extensive vascular supply
including Choroid of
temporal horns, Optic
tract, Thalamus and Int.
Capsule.
Usually arises as a single
trunk from the ICA
2 Segments:
1. Cisternal (Proximal)
2. Plexal (Distal)
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Anterior Choroidal Art.
Arises from medial ICA
curves posteromedially
around the uncus(1).
Abruptly kinks as it
enters the Choroidal
fissure(2)
Plexal portion(3)
undulates through the
Temporal horn.
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Anterior Cerebral Art.
Smaller of the two
terminal branches of
the ICA.
Courses medial and
anterior.
Consists of :
(A1) Horizontal/Precomm.
Portion(1)
(A2) Distal/Postcomm.
Portion
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ACA-A1
Extends from ACA origin to contralateral ACA via Acomm
A1 branches include the Medial Lenticulostriate A’s(2) which supply the anterior perforated substance, subfrontal area, optic chiasm, septum pellucidum, hypothalamus.
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ACA-A1
One of the MLS branches
is the Recurrent artery
of Heubner(4). In most
cases originates from
prox. A2.
Heubner supplies the
anterior Internal
Capsule and Basal
Ganglia
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Ant. Communicating Art.
Short artery that joins the
Ant. Cerebral A’s
Completes the Anterior
Circle of Willis
Common site of congenital
berry aneurysm
Multiple small branches
from the Acomm not seen
on angio. Including
supply to limbic areas.
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ACA-A2
Extends from Ant. Comm. to
distal ACA bifurcation
A2(1) branching is quite
variable. Branches
include:
1. Orbitofrontal Art.(2): first
cortical branch from A2.
Supplies the gyrus rectus
and inferomedial Frontal
lobes.
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ACA-A2
Near the genu of the corpus callosum the ACA(2) divides into two terminal branches.
1. Callosomarginal A.(5): smaller terminal ACA branch. Posterior course in the Cingulate sulcus to supply the medial hemispheres via small Frontal A’s
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ACA-A2
2. Pericallosal A.(6):
Considered the
continuation of the
ACA. Its major branch
is the Sup. Internal
Parietal(Precuneal) A.
which supplies the
superior Parietal lobe.
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Middle Cerebral Artery
The MCA is the larger of the
two terminal branches of
the ICA.
The proximal MCA (M1)
(1)extends lateral and
horizontally in the lateral
cerebral fissure to reach
the sylvian fissure
M1 gives rise to 6-20 lateral
Lenticulostriate A’s(2)
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MCA-M1
These Lat. LS(2) vessels
supply portions of the
Basal Ganglia, Internal
Capsule and Caudate.
The Genu of the MCA(3)
is the point at which it
curves up into the
Sylvian fissure
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Sylvian MCA
The MCA divides into
major cortical branches
1.5cm from its origin.
Branches first course
superiorly over the
insula(4)
They then turn inf/lat(5) to
pass under and around
the opercula to reach
the cerebral surface
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Cortical MCA branches
Origin and course of MCA branches is highly variable.
1. Ant. Temporal A.(1): arises from main MCA trunk near LS vessels.
Anterior Branches:
2. Orbitofrontal A.(2): Part of the ascending frontal complex. Supplies inf/lat frontal lobes.
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Cortical MCA branches
3. Operculofrontal A’s.(3);
includes all branches
anterior to Central
Sulcus A’s. Supply
middle and inf. Frontal
gyri including Broca’s
and premotor areas.
4. Central Sulcus A.(4):
supplies motor and
sensory strips.
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Cortical MCA branches
The posterior division of the MCA has 3 major branches.
5. Post Parietal A.(5): exits Sylvian fissure and courses post/sup to supply Parietal behind sensory strip.
6. Angular A.(6): terminal continuation and normally the largest cortical branch of MCA
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MCA Cortical branches
Angular A. courses
post/sup to supply
lateral parietal and
occipital lobes along
with sup. temp. gyrus.
7. Post. Temp. A.:
descends over the
lateral temporal lobe.
Supplies nearly the
entire Temporal lobe
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Posterior Cerebral Artery
Important in supply of visual function
PCA originates from terminal Basilar Artery ventral to the midbrain
3 segments:
1 Precommunicating(P1) (3)
2. Ambient(P2)(5)
3. P3
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PCA-P1
Lies within the
interpeduncular cistern.
Extends from PCA origin
to junction with Post.
Communicating A.
As it courses Post/Lat
around midbrain it
gives rise to multiple
perforating branches.
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P1 branches
1. Thalamoperforating A’s: Course sup. thru peduncle and supply Thalamus, Hypothal., CN 3, CN 4, and Post. Int. Capsule .
Pcomm-Ant. TPA’s(1)
P1-Post TPA’s(2)
2. Meningeal branches-Artery of Davidoff & Schecter
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PCA-P2
Extends from the Pcomm to the Post. Midbrain. Courses post. in the ambient cistern parallel to optic tract & Basal V.
Branches include:
Brain stem:
1. Thalamogeniculate A’s: 1-7 branches that supply Thal., Post Int. Capsule, and optic tract
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P2 branches
Vent. & Choroid br’s.:
1. Medial Post. Choroidal A.(3): courses around brainstem Sup/Med to supply 3rd & Lat. Vent. Choroid, Thal.&, Pineal.
2. Lateral Post Choroidal A’s(4): 1-9 branches. Supply choroid of temp horns & atria.
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PCA Cortical branches
Cortical branches:
1. Inferior Temporal A’s: only
cortical br. from P2.
Supplies Inf. Temp. lobes
and Hippocampus
P3 segment-cortical br’s
2. Parieto-occipital A.(7):
first of 2 terminal PCA
branches. Supplies
Cuneus, Precuneous, &
Sup Occipital gyrus.
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P3 Cortical Branches
3. Calcarine A.(8): other
terminal PCA branch.
Supplies visual cortex,
inf. cuneus, & lingual
gyrus.
4. Splenial A’s(5): small
rami off of PCA. Supply
the splenium of the
corpus callosum.
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Post. fossa arteries
Vertebral Art’s(1,2): Left is
usually the dominant
artery.
Vert. Is the first branch
from the Subclavian
Enters transverse
foramen of C6
Ascends thru C spine &
enters skull at Foramen
Magnum
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Vertebral Art.
Ant. To Medulla Vert’s unite
to form Basilar Art.(10)
Extracranial branches:
segmental branches to
vertebrae & supplemental
spinal circulation
Intracranial branches:
1. Post. Meningeal A.(2):
originates just below F.
Magnum. Course
Sup/Med to supply Falx
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Vertebral Arteries
Branches:
2. Post. Spinal A.: arises
from distal Vert. Or
PICA. Descends along
dorsal medulla and
cord as part of a
vascular network to
cord.
3. Ant. Spinal A.(3): Runs
caudad in Ant/median
sulcus of cord & also
supplies cord.
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Vertebral Arteries
4. PICA(5-9): largest and
most variable branch. 2
segments.
A. Ant. Medullary
segment
B. Lat. Medullary
segment
Supply the Choroid of the
4th Vent., cerebellar
hemispheres, vermis, &
tonsils
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Basilar Artery
Formed by union of 2
Vertebral A’s. adjacent
to lower Pons.
Extends along ventral
pons terminating in the
interpeduncular cistern
by forming PCA’s.
Branches: Pontine A’s.,
Int. Auditory A’s.,
AICA(5), Sup.
Cerebellar A’s(6),
PCA’s
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Basilar Artery branches
1. AICA(sm. arrow): arises
from proximal Basilar
Art.
Branches supply the
Middle Cerebellar Ped.,
Choroid, Flocculus.
In 85% of cases the
Internal Auditory A’s
arise from AICA.
Accompanies Acoustic
N. thru Internal Auditory
Meatus
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Basilar Artery branches
2. Superior Cerebellar
A’s(3-5): Encircles
brainstem. Each SCA
has 2 branches.
Lateral SCA: supplies
sup/lat cerebelli, sup.
Peduncle, dentate
nucleus, middle
peduncle
Medial SCA: supplies
sup. Cerebellum &
vermis