CNS Blood Supply

Welke, Ph.D.
 Objectives
*Understand the internal carotid arterial system to the
brain, the major branches and what structures they supply
*Understand the vertebral-basilar arterial system to the
brain, its major branches and what structures they supply
*Connect somatotopy to blood supply occlusions, if applicable
*Understand the circle of Willis and how it connects the
internal carotid and vertebral-basilar systems
*Know the blood supply syndromes: medial medullary, lateral
medullary, superior alternating
*Have a general understanding of vascular disruption and
watershed zones (but this will be covered mainly in N&P II)
*Understand the venous drainage of the brain and the major
sinuses involved in this drainage
*Understand the structure of the blood brain barrier and
why it is important
 Vertebral Arteries
Anterior Spinal Artery

Posterior Spinal Arteries

Posterior Segmental
Medullary Arteries
Anterior Posterior
Intercostal
Arteries

Lumbar Arteries

Sacral Arteries
 Spinal Cord Vasculature
Posterior Spinal Artery
Loss of
proprioceptive,
pressure and vibration
sense

Anterior Spinal Artery

(occlusion at level of
spinal cord!)
-Bilateral loss of pain
and temperature
-Bilateral paralysis
-No changes in touch,
proprioception,
pressure, or vibration
sense
 Internal Basilar
Carotid

2 Systems that
supply the Brain:
Anterior
Spinal Vertebra
Artery
1-Internal Carotid Arterial
System

2-Vertebral / Basilar
Arterial System
Common
Aorta Carotid
Artery
Internal Carotid System

Branches:
1-Ophthalmic artery
2-Anterior choroidal artery
3-Posterior communicating
artery
4-Middle cerebral artery
5-Anterior cerebral artery
 Branches of Internal
Carotid Artery

1-Opthalmic Artery
-travels along the
optic nerve to supply
the eyeball and
other orbital
structures

Opthalmic Artery

Internal Carotid Artery

 Branches of Internal Carotid Artery

Anterior Choroidal
Artery

2-Anterior Choroidal Artery

-supplies the optic tract,
some choroid plexus, part of
the cerebral peduncle, and
portions of the internal
capsule, thalamus &
hippocampus
Branches of Internal Carotid Artery
3-Posterior Communicating Artery
-joins posterior cerebral artery

Posterior
Communicating
Artery
Branches of Internal Carotid Artery

MCA MCA

4-Middle Cerebral Artery (MCA)

-into lateral sulcussupplies the insula & most of the
lateral surface of the cerebral hemisphere
-Lenticulostriate branches come off of the MCA and
supply deep structures like the basal ganglia and
internal capsule.
 Middle Cerebral Artery

Supplies most of the precentral (motor) and

postcentral (somatosensory) gyri
Occlusion of an middle cerebral artery causes
restricted contralateral motor and
somatosensory deficits
If the left hemisphere is involved, language
deficits may be apparent

Branches of Internal Carotid Artery
ACA

5-Anterior Cerebral
Artery
-courses along the
longitudinal fissure to
supply the medial aspect
of the frontal & parietal
lobes
 Anterior Cerebral Artery
Callosomarginal
Artery

Pericallosal
artery

ACA

Supplies some of precentral (motor) and

postcentral (somatosensory) gyri
Occlusion of an anterior cerebral artery causes
contralateral motor and somatosensory deficits
restricted to the lower limb

 Why is deficit
restricted to the
lower limb? Look at
course of the artery
& think about the
homunculus!
 Internal Basilar
Carotid

2 Systems that
supply the Brain:
Anterior
Spinal Vertebra
Artery
1-Internal Carotid Arterial
System

2-Vertebral / Basilar
Arterial System
Common
Aorta Carotid
Artery
Vertebral-Basilar System

Vertebral Artery

1-Anterior
Spinal Artery

2-PICA (Posterior
Inferior Cerebellar
Artery)

3-Posterior
Spinal Artery
 Medial Medullary Syndrome
-occlusion of branches of the anterior spinal artery (at the
level of medulla!) on one side or medullary branches of
vertebral artery
-affects:
-Corticospinal Tract
-Medial Lemniscus
-Hypoglossal Nucleus (CN XII)

Rememberanterior spinal artery occlusion at the level
of the spinal cord is different than the medulla!
Posterior Spinal Artery
Loss of
proprioceptive,
pressure and vibration
sense

Anterior Spinal Artery

(occlusion at level of
spinal cord!)
-Bilateral loss of pain
and temperature
-Bilateral paralysis
-No changes in touch,
proprioception,
pressure, or vibration
sense
 Vertebral Branches

PICA (Posterior Inferior Cerebellar Artery)
-supplies much of the inferior surface of the
cerebellar hemispheres
-supplies the lateral medulla
-also supplies choroid plexus of 4th ventricle
 Lateral Medullary Syndrome (Wallenberg s Syndrome)
-occlusion of PICA/Vertebral artery

-Affects:
-Inferior cerebellar peduncle
-Spinothalamic tract
-Sympathetic fibers
-Nucleus Ambiguus
-Nucleus Solitarius
 Vertebral-Basilar System

Branches of Basilar:
1-anterior inferior cerebellar artery (AICA)
2-superior cerebellar artery Most
important!

3-posterior cerebral arteries

4-paramedian pontine arteries
5-long circumferential branches
6-short circumferential branches
 Basilar Artery

1-AICA (Anterior Inferior

Cerebellar Artery)
-supplies anterior portions of
the inferior surface of the
cerebellum (flocculus) & parts
of the pons
-Labyrinthe artery supplies
the inner ear - usually comes off
of the AICA and is important
clinically because obstruction
can cause vertigo & possible
deafness

AICA (Anterior
Inferior Cerebellar
Artery)
1-AICA (Anterior Inferior Cerebellar Artery)

occlusion affects:
-Middle cerebellar peduncle
-Vestibular nuclei
-Spinal V nucleus & tract
-Spinothalamic tract
-Descending sympathetic fibers
 Superior
Cerebellar
Artery

2-Superior Cerebellar
Arteries
-supplies the superior
surface of the cerebellum
& most of the caudal
midbrain and rostral pons

Basilar Artery
 2-Superior Cerebellar Artery

occlusion affects:
-superior cerebellar peduncle & cerebellum
Posterior Cerebral
Artery

3-Posterior Cerebral Arteries

-supplies the medial & inferior
surfaces of the occipital &
temporal lobes
-sends branches to rostral
midbrain & caudal diencephalon
-gives rise to posterior choroidal
arteries which supply the
choroid plexus of the 3rd and
lateral ventricles
Superior Alternating (Weber s) Syndrome
-unilateral damage to the ventral region of the midbrain caused
by occlusion of the posterior cerebral/basilar arteries
-results in superior alternating hemiplegia (ipsilateral
oculomotor nerve palsy & contralateral hemiplegia)
Benedikt s Syndrome
-damage to the ventral & tegmental regions of the midbrain
caused by occlusion of the posterior cerebral/basilar arteries
-results in oculomotor palsy, contralateral hemiplegia &
contralateral ataxia, tremor & involuntary movements.
 Basilar Artery

Long Circumferential Branches:

-supply most of the tegmentum of the rostral & caudal
pons
Paramedian Branches:
Occlusion affects:
-supply the medial portion of lower & upper
pons -gaze centers, spinothalamic tract

occlusion affects: Short Circumferential Branches:

-corticospinal tract, facial nucleus,
abducens nucleus & pontine gaze center
supply an area in ventrolateral pons
occlusion affects:
-descending sympathetic fibers, pontocerebellar
fibers, spinothalamic tract
 Vertebral-Basilar System

Posterior
Cerebral
-Paramedian
Pontine
-Long & Short
Superior
Circumferential
Cerebellar

AICA
PICA
Anterior
Spinal
The Connector = Circle of Willis

Anterior cerebral, internal carotid & posterior

cerebral arteries of both sides are connected
creating a structure called the Circle of Willis
There is normally no flow around this circle,
but it provides critical anastomotic means of
flow in case any of the vessels become occluded
 Blue indicates those
arteries that are included Anterior Communicating Artery
in the Circle of Willis!
Internal Carotid
Anterior
Artery
Cerebral Artery

Middle Cerebral
Artery

Posterior
Communicating
Artery

Posterior
Cerebral Artery

Basilar Artery

Vertebral Artery
Cerebral
Arterial
Supply
Cerebral
Arterial
Supply
Coronal &
Axial
Sections
Brainstem &
Cerebellar
Arterial
Supply
Venous Drainage of Brain

Superior
Sagittal Sinus

Inferior
Sagittal Sinus
Great Vein of
Galen

Straight Sinus

Confluence of
Sinuses
 III Inferior
IV
Petrosal Sinus
VI V1
V2

Sphenoparietal
Sinus

Cavernous
Sinus Sigmoid
Sinus
Superior
Petrosal
Sinus
Great Vein of
Galen

Transverse
Sinus Straight
Sinus
 Angiography

2 seconds 5 seconds 7 seconds

-Injection of dyes to visualize vasculature

- (R)Internal carotid -> capillary beds -> veins/sinuses
 Disturbances in Vascular Supply

1-Stroke
-abrupt vascular insufficiency or bleeding
into or adjacent to the brain
-ischemic or hemorrhagic
-usually caused by a thrombus (clot
formed within a vessel) or embolism (clot
or plaque carried in the bloodstream)
2-Transient Ischemic Attack
-temporarycaused by minute particles
that occlude arteries and then are
degraded
3-Aneurysms
-swellings of arterial wallsusually at
bifurcations
-can compress brain structures as it
swells or it can rupture and can cause
severe problems.

 Watershed Zones
-regions of brain that receive dual blood supply
branches of two major arteries

One Vessel Occlusion:

-ischemia occurs in the region supplied by that vessel and there is usually sparing of
regions near adjacent vessels
Two Adjacent Vessels Occluded:
-regions between the 2 vessels are most likely to exhibit ischemia & infarction
ACA-MCA = proximal arm & leg weakness (regions of homunculus often include the trunk
& proximal limbs)
MCA-PCA = problems with visual processing
 Blood Brain Barrier

History:
Water soluble dyes that were injected into the peripheral
circulation did not stain the brain or the CSF but colored the
choroid plexus and the peripheral tissue
Injected the same dye into the subarachnoid space: colored the
brain and CSF but not the peripheral tissue

What is the BBB?

-A membrane that controls the passage of substances from the
blood into the CNS
-The BBB is composed of endothelial cells and tight junctions of
the capillaries of the CNS.
-Supporting cells of the brain, particularly astrocytes, are
thought to be important in producing signals or biochemicals
that induce tight junction formation in the endothelial cells.
A representative cross / longitudinal-section of a cerebral capillary of
the BBB. Shown are the astrocytic end feet (AE), basal lamina (BL),
and endothelial cell (EC).

http://users.ahsc.arizona.edu/davis/bbb.htm

Why is the BBB important?
The blood-brain barrier functions in preventing or slowing the
passage of various chemical compounds, radioactive ions,
and disease-causing organisms from the blood and into the
central nervous system
-BBB is a benefit and a hindrance - keeps many compounds out,
which can be good, but is a barrier when creating
pharmaceuticals

Disruptions in the BBB:

-Failure to maintain the integrity of the BBB can lead to effects
on the CNS
1 - Complete breakdown of barrier function
-Brain tumors
2 - Subtle barrier impairment without end organ damage
-Disease states
-MS, Alzheimer s, HIV, stroke, diabetes,
eating/weight disorders
Mechanisms of Transport Across the BBB

1. Paracellular Diffusion 6. Facilitated diffusion

2. Transcellular Diffusion 7. Active transport
3. Cation Channels 8. Active antiport transport
4. Ion Symports 9. Endocytosis
5. Ion Antiports
End!