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Cerebral Blood Circulation

Cerebral Blood Circulation

Cerebral Circulation

Lecture (16) ▪ Important ▪ Doctors Notes Please check our Editing File ▪ Notes/Extra explanation

ه هذا العمل مب ين بشكل أسا يس عىل عمل دفعة 436 مع المراجعة { َوَم نْ يَ َت َو َ ّكْ عَ َلْ ا َّْلل فَهُ َوْ َحْ سْ ُ ُُْ} والتدقيق وإضافة المالحظات وال يغ ين عن المصدر األسا يس للمذاكرة ▪ Objectives

At the end of the lecture, students should be able to: ✓ List the cerebral . ✓ Describe the cerebral arterial supply regarding the origin, distribution and branches. ✓ Describe the arterial Circle of Willis . ✓ Describe the cerebral venous drainage and its termination. ✓ Describe arterial & venous vascular disorders and their clinical manifestations. Only on the boy’s slides Cerebral Circulation o It is the movement of blood through the network of blood vessels to supply the . o The movement of blood in the cerebral circulation is called cerebral blood flow. o The arteries carry oxygenated blood and other nutrients to the brain. o The carry deoxygenated blood back to the heart removing carbon dioxide and other metabolic products. o The two anterior cerebral circulations (left and right) are connected to each other by ONE anterior communicating . o The anterior circulation (carotid) is interconnected to the posterior circulation (basilar) via bilateral TWO posterior communicating arteries. o Posterior communicating arteries are part of Circle of Willis.

Extra Cerebral Arterial supply

The arterial supply of the is composed of/provided by 2 arterial systems:

1) Carotid System (Posterior cerebral circulation) Composed of: • and its branches: • Anterior cerebral artery* (smaller) • Middle cerebral artery* (bigger)

Supply anterior portion of brain

2) Vertebro-Basilar System (Posterior cerebral circulation) Extra The two vertebral arteries (from the subclavian artery) unite to form basilar artery*. It divides at the upper border of pons into two posterior cerebral arteries*

Supply posterior portion of brain Extra *We will talk about these in more detail later. Cerebral Arterial supply

Origin Internal carotid artery Basilar artery Anterior Cerebral Artery Middle Cerebral Artery Posterior Cerebral Artery Branch (ACA) (MCA) (PCA) 1. Orbital and medial Entire Superolateral surface*: 1. Anterior and inferior temporal surfaces of frontal and 1. Somatosensory Cortex lobes parietal lobes. 2. Motor Cortex 2. : 2. A narrow part on the 3. Language areas: • Located on the tip end of the superolateral surface. • Broca's Area: linked to speech medial surface of the production. parahippocampal gyrus. Supplies • Wernicke’s Area: It is involved in • Part of the olfactory cortex the understanding of written and that processes information spoken language from the sense of smell. 4. Auditory areas: 3. Inferior temporal gyri • Primary auditory area 4. Inferior and Medial Occipital • Heschl’s Gyrus: to process lobe (visual area) incoming auditory information

*Except for a narrow part by the ACA, MCA supplies all the motor area except the leg area. (Snell) except foot and genitals Medial Surface of Superolateral Cerebral Hemisphere Surface of Cerebral Hemisphere Only on the boy’s slides Basilar artery

Supplies: Mid brain and cerebellum Branches: • Anterior inferior cerebellar artery. • Pontine branches. • Superior cerebellar artery. o The vertebral arteries unite at the lower border of the pons to form the basilar artery. o Pontine: related to the pons. o Its formed by 2 vertebral artery

Extra IMPORTANT Circulus Arteriosus (Circle of wills*) Playlist o It joins the carotid and vertebrobasilar systems**. o It is located on the base of the brain to supply deep structures o It encircles (surrounds): 1. Optic chiasma. 2. Hypothalamus. 3. Midbrain. 4. Extra It is formed by: Two internal carotid arteries

Two anterior cerebral arteries

Two posterior cerebral arteries

Two posterior communicating arteries

*Named after Thomas Willis (1621–1675), an English physician. One anterior communicating artery ** the circle of Willis is Formed by the anastomosis between the two internal carotid arteries and the two vertebral arteries. (Snell) Circulus Arteriosus (Circle of wills) o Branches: Perforating arteries numerous small vessels that penetrate the surface of the brain through the anterior and posterior perforating substances. o They are divided into: Anterior Perforating Arteries Posterior Perforating Arteries • Anterior cerebral artery. • Posterior cerebral artery . Arise from: • Anterior communicating artery. • Posterior communicating artery. • Middle cerebral artery. • Anterior perforated substance • Posterior Perforated substance. Enter brain (an irregularly quadrilateral (having 4 sides) (perforated substance: a layer of grey through: area in front of the and behind matter, that is pierced to allow blood the olfactory trigone). vessels to pass) 1. Large part of basal ganglia. 1. Ventral portion of Midbrain. 2. Optic chiasma. 2. Parts of Subthalamus and Supplies 3. Internal capsule ( a white matter Hypothalamus. structure). 4. Hypothalamus . Arterial Disorders

Stroke Angioma • It happens when blood supply • localized, blood-filled balloon- • benign tumors derived from to the brain is interrupted or like bulge in the wall of cells of the vascular or reduced. a . lymphatic vessel walls • Sudden occlusion • Dilation of the wall (may take () or derived from • It can be: Ischemic or years) cells of the tissues surrounding hemorrhagic. these vessels. Effects of Occlusion of Cerebral Arteries IMPORTANT Effects of Occlusion of Cerebral Arteries (Manifestations) (Important may come as scenario) Anterior Cerebral Middle Cerebral Artery Posterior Cerebral Artery (ACA) (MCA) Artery Artery Artery (PCA) 1- Motor disturbance in 1- Contralateral weakness of: 1- Visual disturbances: contralateral distal leg face, arm & hands “more than legs” • Unilateral lesion: 2- Difficulty in • 2- Contralateral sensory loss of: contralateral prefrontal lobe face, arm, and hands more than homonymous functions: legs hemianopsia • Cognitive thinking • Visual field cut (damage to optic • Bilateral lesions: cortical • Judgement radiation) blindness, patients • Motor initiation 4- Aphasia (language disturbance): unaware they cannot Effect Anterior • Self monitoring • In Broca’s area: production see (Anton’s Syndrome) cerebral artery • In Wernicke’s area: comprehension 2- Memory impairment: if is affected

Optic radiation: axons from the neurons in the lateral geniculate nucleus to the primary visual cortex. Hemianopsia: decreased vision or blindness in half the visual field. Homonymous hemianopsia: the loss of half of the visual field on the same side in both eyes (see picture on right). Extra Cortical blindness: total or partial vision loss because of damage to the occipital cortex. Cerebral Venous Drainage o The veins are thin walled and are devoid of (don’t have) valves. o The are: I. Superficial cortical veins II. Deep veins • Found in the subarachnoid space • Drain the deep structures • Drain the cortical surface

These veins ultimately drain into:

Dural venous sinuses Cerebral Venous Drainage I. Superficial Cortical Veins Extra

They lie on the brain surface, in the subarachnoid space. They are divided into: Course Termination Notes • Drain lateral • Terminate mainly into • 6 to 12 veins Superior surface of brain the Superior Sagittal cerebral above the , and partly into lateral sulcus superficial middle veins Superior cerebral anastomotic vein Inferior • Run below the • Terminate partly into • Drain the lateral surface of lateral sulcus superficial middle the temporal lobe cerebral cerebral vein & partly veins into Transverse sinus. • Runs along the • Terminates into the • Connected posteriorly by Superficial lateral sulcus Superior & Inferior middle anastomotic veins to cerebral Superior Sagittal & veins respectively Transverse sinus Cerebral Venous Drainage II. Deep Veins

They drain the internal structures: • Basal ganglia • Internal capsule • Thalamus

They merge to The two veins unit in This short vessel joins the form: the midline to form: Inferior Sagittal sinus to form:

Deep cerebral 2 Internal Great cerebral veins cerebral veins vein Only on the boy’s slides Cerebral sinuses o The • Lies along the superior border of the falx cerebri and empties into the . o The Inferior Sagittal Sinus • Lies in the inferior border of the falx cerebri. • The great cerebral vein of Galen joins the inferior sagittal sinus to form the straight sinus. o The Transverse Sinuses • Originate on each side of the confluence of sinuses. • Each transverse sinus travels laterally, and curves downward to form the that empties into the internal on the same side. o The Confluence of Sinuses • At the confluence of sinuses, the superior sagittal, straight, transverse, and occipital . sinuses join. o The Cavernous Sinuses • Located on each side of the . • Ophthalmic and superficial middle cerebral veins drain into these sinuses. o The Sphenoparietal Sinuses • Located below the sphenoid bone and drain into the cavernous sinus. o The Sigmoid Sinuses • Receive blood from posterior dural venous sinus veins. Only on the boy’s slides Superior vena cava o Formed by the union of the right and left brachiocephalic veins. o Brachiocephalic veins are formed by the union o Of internal jugular and subclavian veins. o Drains venous blood Superior vena cava o from: o Head, , thoracic wall & upper limbs o It passes downward and enter the right atrium.

o The dural venous sinuses are grouped into:

Paired: (right & left) Single: Transverse Superior sagittal Sigmoid Inferior sagittal Cavernous Straight Petrosal (superior & inferior) Occipital o Blood flows from transverse & sigmoid sinuses into IJV . Venous Disorders

• refers to tissue death (necrosis) that is caused by a local lack of oxygen due to obstruction of the tissue's blood supply

• SSS (superior sagittal sinus) *: Sinus can complicate ear infection • Cavernous sinus thrombosis: As a thrombosis complication of infection in the dangerous area of the face** ** o Obstruction of venous drainage of the brain leads to Cerebral swelling (edema) and raised Intracranial Pressure.

*Superior sagittal sinus thrombosis (SSST) is the most common type of dural venous sinus thrombosis and is potentially devastating Extra Only on the boy’s slides These 2 videos summarize the lecture: (to view them download the ppt version)

Duration: 01:42 Duration: 01:18 Summary

Cerebral arterial supply

Carotid system Vertebro basilar system Circulus arteriosus (of willis)

Internal carotid artery Divides into two posterior Joins carotid and vertebrobasilar cerebral A systems Anterior cerebral A Middle cerebral A Branches : Supplies: Composed of : Supplies entire Supplies : 1.orbital 1.Anterior and • 2 anterior cerebral superolatral surface: & medial surfaces of inferior parts of A 1.Motor cortex APA PPA frontal and parietal temporal lobe • 2 internal carotid A 2.somatosensory cortex lobes 2.Inferior temporal • 2 posterior cerebral 3.Language areas (Broca 3.Narrow part on gyrus A & Wernicke) Supply : Supply : the superolateral 3.uncus • 2 posterior 4.primary auditory area + 1. Large part of 1. Ventral portion surface 4.Inferior and communicating A association (heschl) basal ganglia of midbrain medial parts of • 1 anterior 2. Parts of occipital lobe communicating A 2. Optic chiasma 3. Internal subthalamus and capsule hypothalamus 4. hypothalamus Summary

Cerebral venous drainage

Superficial cortical veins Deep cortical veins

Drain the internal Internal cerebral veins structures (basal Great cerebral vein ganglia , internal Superior cerebral veins Inferior Superficial middle capsule , thalamus) Straight sinus (6-12) cerebral V cerebral V

• Drain lateral • Terminates into • Drain the lateral surface of brain cavernous sinus surface of the above the lateral • Connected temporal lobe sulcus posteriorly by • • Terminate partly Terminate mainly superior & inferior into superficial into superior anastomotic vein middle cerebral sagittal sinus and to superior sagittal vein& partly into partly into & transverse transverse sinus superficial middle sinuses cerebral vein respectively MCQs (1) What does the basilar artery supply? (6) Which of the following is not a branch of the basilar artery A) Mid brain B) Cerebellum A) Anterior inferior cerebellar artery. C) A&B D) Motor cortex B) Pontine branches C) Superior cerebellar artery (2) Which of the following are paired Dural sinuses? D) Middle cerebral artery A) Inferior sagittal B) Straight C) Cavernous D) Occipital (7) What do the cerebral veins NOT drain? A) Basal ganglia B) Internal capsule (3) Which of the following is the one of the effects that occur C) Thalamus D) Hypothalamus when the posterior cerebral artery is occluded? A) Visual disturbances (8) Which of the following runs below the lateral sulcus: B) Language disturbances A) Superficial cerebral veins B) Inferior cerebral veins C) Motor disturbance in the contralateral distal leg C) Superficial cerebral artery D) Inferior cerebral artery D) Contralateral sensory loss of face (9) A patient Came to the hospital and his family noticed (4) Which of the following supplies the optic chiasma? difference in his personality and he cant make decisions, A) Anterior perforating arteries what is the most likely diagnosis? B) Posterior perforating arteries A) Middle cerebral artery occlusion B) Superior sagittal sinus C) Middle perforating arteries C) Thrombosis anterior cerebral artery D) Anterior cerebral artery D) Right temporal and right nasal Fibers

(5) What does the the circle of willis not encircle? (10) Blood filled bulge in the wall of a blood vessel? A) Optic chiasma B) Hypothalamus A) Stroke B) Aneurysm C) Midbrain D) Cerebellum C) Angioma D) Sinus thrombosis Answers

(1) C (6) D (2) C (7) D (3) A (8) B (4) A (9) C (5) D (10) B SAQ

(1) From which arteries do the anterior perforating arteries arise fro, • Anterior cerebral artery • Anterior communicating artery • Middle cerebral artery

(2) Which parts do the posterior perforating arteries supply? • Ventral portion of Midbrain • Parts of Subthalamus and Hypothalamus

(3) A 35 year old man came to the hospital complaining of impaired memory and cortical blindness. (A) Which cerebral artery is affected? Posterior cerebral artery (B) Which side is most likely affected? Bilateral lesion (affecting both sides) which will lead to Anton’s syndrome Good luck Special thank for team436

Team Leaders: Faisal Fahad Alsaif Rawan Mohammad Alharbi

Team Members: Abdulaziz Aldukhayel Abdulrahman Alduhayyim Rinad Alghoraiby Rawan Mishal ▪ References: 1.Girls’ & Boys’ Slides Twitter.com/Anatomy437 2.Greys Anatomy for Students [email protected] 3.TeachMeAnatomy.com

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