Neurovascular Anatomy (2): Posterior Circulation Anatomy

Natthapon Rattanathamsakul, MD. December 28th, 2017 Contents: Neurovascular Anatomy

➢ Arterial supply of the ▪ Anterior circulation ▪ Posterior circulation ➢ Arterial supply of the spinal cord ➢ Venous system of the brain Neurovascular Anatomy (2): Anatomy of the Posterior Circulation

➢ Vertebral ➢ Basilar artery ➢ Blood supply of diencephalon, and

• Arise from the 1st part of

• Course posteromedially to reach the transverse foramen of C6 vertebra

• Run along the foramina then lie on the posterior arch of atlas (C1)

• Through the dura, join with each other at pontomedullary junction

Flemming KD, Jones LK. Mayo Clinic neurology board review: Basic science and psychiatry for initial certification. 2015 Vertebral Artery

• Divided into 4 parts

• V1: Ostium to transverse foramen of C6 • V2: Travels cephalad from C6 to C1 • V3: Lies on the posterior arch of C1 (atlas) • V4: Pierces dura, merges together at pontomedullary junction

Netter FH. Atlas of human anatomy, 6th ed. 2014 Angiographic Correlation

Uflacker R. Atlas of vascular anatomy: an angiographic approach, 2007 Angiographic Correlation Uflacker R. Atlas of vascular anatomy: an angiographic approach, 2007 MRI Correlation

Uflacker R. Atlas of vascular anatomy: an angiographic approach, 2007 MRI Correlation

Uflacker R. Atlas of vascular anatomy: an angiographic approach, 2007 MRI Correlation

Uflacker R. Atlas of vascular anatomy: an angiographic approach, 2007 MRI Correlation

Uflacker R. Atlas of vascular anatomy: an angiographic approach, 2007 Vertebral Artery

Netter FH. Atlas of human anatomy, 6th ed. 2014 Vertebral Artery

Branches of vertebral artery • Muscular • Segmental medullary arteries • Forming anterior & posterior spinal arteries • Meningeal arteries

• Perforating branches to medulla • • Posterior inferior cerebellar artery (PICA)

Műller KI, et al. Tidsskr Nor Legeforen. 2013; 133: 1320-4 Variation of VA Hypoplastic left VA

• Asymmetry due to • Vertebral arterial hypoplasia • Absence of vertebral artery • Termination into the PICA • Dominance: Left 45%, right 30%, co- dominant 25%

• Variations • Complete/partial VA duplication VA fenestration • VA fenestration • Variable origin • Aortic arch origin of left VA (5%) • 2nd part of subclavian artery • • Variable orientation of ostium https://radiopaedia.org Abnormal course of left VA

Partial ECA origin of duplication of VA left VA

Aortic arch origin of left VA

https://radiopaedia.org http://www.anatomyatlases.org/ Vertebral Artery Dissection

http://www.alamy.com/stock-photo-rotational-injury-of-the-vertebral-artery-7710492.html Rotational Vertebral Artery Occlusion (Bow Hunter’s Syndrome)

Neutral position Turn head to left

Stroke 2013; 44: 1817-24 J Korean Neurosurg Soc 2013; 54: 243-5 http://www.fanpop.com/ Effects of Neck Position on Vertebral Artery

Am J Neuroradiol. 2014; 35: 323-6 Subclavian Steal Syndrome

• Presence of occlusion of proximal subclavian artery • Blood flowing down the ipsilateral VA to supply the arm

• Usually asymptomatic, or syncope/vertigo • Atherosclerosis • Caucasian, women > men

Intern J Surg Case Rep. 2015; 16: 177-80 Circulation. 2014; 129: 2320-3 Posterior Inferior Cerebellar Artery

• 5 segments: • Anterior medullary • Lateral medullary (forming caudal loop) • Tonsillomedullary • Telovelotonsillar ( point) • Cortical branches

Branches Small perforating medullary branches Tonsillohemispheric branch Inferior vermian branch

**Occasionally, branch off the AICA in the common stem

World Neurosurg. 2017; 106: 493-503 Angiographic Correlation

Uflacker R. Atlas of vascular anatomy: an angiographic approach, 2007 Posterior Inferior Cerebellar Artery

Supply • Posteroinferior cerebellar hemisphere (up to great horizontal fissure) • Inferior portion of vermis • Lower part of medulla (50%) • Inferior cerebellar peduncle http://missinglink.ucsf.edu/ https://accessmedicine.mhmedical.com Development of Nervous System

Medial brainstem syndrome • Affect motor Lateral brainstem syndrome • Affect sensation

http://www.ultratwistersgym.com/Resources/Nervous/Nervous.html Brainstem Syndromes

Cranial nerve Long tract signs Other brainstem involvement features Medial : CN 3,4 Corticospinal tract MLF : CN 6 Corticobulbar tract Medial lemniscus (for Medulla : CN 12 lower brainstem) Lateral Midbrain : none Lateral spinothal tract Cerebellar tract Pons : CN 5,7,8 Spinal tract of N.V Medial lemniscus (for Medulla : CN 9,10,11 Descending autonomic tr. upper brainstem) Hearing pathway

Medial : ‘4Ms’ Lateral : ‘4Ss’ plus Motor nuclei : 3,4,6,12 Spinothalamic tract contralat Motor pathway Sensory tract of N.V Ipsilat Medial lemniscus Fine, proprio Sympathetic tract Horner MLF INO Spinocerebellar tract Plus CN5,7,8,9,10,11, vestibular 8 9 7 6 5 4 1: Pyramidal tract 2: Inferior olivary nuc. Complex 3: Medial lemniscus 11 4: MLF 10 5: Inferior cerebellar peduncle (restiform body) 3 6: Hypoglossal nucleus (XII) 12 7: Inferior salivatory nuc. (IX) 8: Nucleus & tractus solitaries 13 9: Vestibular nuclei 2 10: Ambiguus nucleus 11: Nuc. of spinal tract of N.V Post-olivary : 12: Spinothalamic tract CN.IX, X, XI 13: Descending sympathetic tract

1 Pre-olivary : CN.XII PICA Syndrome (Wallenburg) Clinical features : ‘4S plus’ Spinal tract of N.V • Loss of pain/temperature sensation of ipsilateral Spinothalamic tract face & contralateral body (alternating hemianesthesia) Spinocerebellar • Ipsilateral cerebellar sign Sympathetic tract • Ipsilateral Horner syndrome Plus • CN.IX, X • Dysphonia, dysarthria, dysphagia, absence of gag reflex • CN.XI • Ipsilateral shoulder drooping, difficulty turning head contralaterally • Vestibular nucleus • Vertigo, N/V, head impulse test • Area postrema • Persistent vomiting/hiccup (rare)

http://www.radiologyassistant.nl Variations of PICA

A Normal B AICA & PICA in common stem C Anastomosis between AICA & PICA D VA terminates into PICA E Distal PICA give rise the tonsillar loop to supply contralateral tonsil F Interhemispheric anastomosis NeuroiImage. 2013; 83: 58-65 Anterior Spinal Artery (Dejerine syndrome)

Clinical features : ‘3M’ Motor • Contralateral pathway • Hemiplegia cruciata • Flaccid quadriplegia Motor nuclei • Ipsilateral tongue of CN.XII deviation/fasciculation Medial • Contralateral loss of fine lemniscus touch/proprioception Others • Upbeat

https://accessmedicine.mhmedical.com J Pak Med Assoc. 2013; 63(3): 387-9 Arm Leg Contralateral hemiplegia

Hemiplegia cruciata Paraplegia Quadriplegia Ipsilateral hemiplegia

SA Orthop J. 2012; 11(4): 43-47 http://yuandanisaputra.blogspot.com/2013/07/brain-varcularisation-and-ventricular_1983.html Hemimedullary (Babinski-Nageotte syndrome, medullary tegmental paralysis)

• Combined medial & lateral medullary infarction • Reported in the case of vertebral artery dissection/stenosis

Arch Neurol. 2005; 62(4): 676-7 Neurology. 2001; 56(11): 1604 Dorsal Medullary Syndrome

• Occlusion of medial branch of PICA • Involvement of vestibular nuclei & restiform body (ICP) • N/V, vertigo, to the affected side • Ipsilateral gaze-evoked nystagmus

https://en.wikipedia.org Neurol India. 2016; 64(1): 121-8 J Clin Mov Disord. 2015; 2: 14 Submedullary Syndrome (Opalski syndrome)

• Involvement of lateral medulla below the level of motor decussation • Ipsilateral weakness with contralateral hemianesthesia (like upper C lesion) • No !! • Presence of palatal/tongue palsy, Horner syndrome, gaze-evoked nystagmus https://en.wikipedia.org Neurol India. 2016; 64(Suppl S1): 113-4 J Clin Diag Research. 2014; 8(7): MD05-MD06 Neurovascular Anatomy (2): Anatomy of the Posterior Circulation

➢ Vertebral artery ➢ Basilar artery ➢ Blood supply of diencephalon, brainstem and cerebellum Basilar Artery • Run along the basilar groove on the ventral surface of pons

• Terminated at the CN.III pontomesencephalic junction PCA

SCA Branches of basilar artery • Paramedian: Pontine artery Pontine • Short circumferential branches

Basilar a. Basilar CN.VI • Long circumferential branches: Laby • Anterior inferior cerebellar AICA (AICA) • PICA • Superior cerebellar artery (SCA) • Terminal branches Vertebral a. • Posterior cerebral artery (PCA) Postr spinal a. Antr spinal a. Uflacker R. Atlas of vascular anatomy: an Angiographic Correlation angiographic approach, 2007

1: Vertebral artery 5: SCA 17: Anterior spinal a. 6: PCA 2: PICA 4: AICA 3: Basilar artery 8: Posterior temporal branch of PCA Variation of BA

• BA fenestration & other variable fusion • Persistent carotid-basilar artery anastomoses

BA fenestration Unfused upper Unfused lower basilar basilar

http://msk-anatomy.blogspot.com/2012/08/variation-in-fusion-patterns-of-basilar.html http://radiopaedia.org Penetrating Branches of BA

Pract Neurol 2016; 16: 484-7 https://www.memorangapp.com/flashcards/94861/Neuroscience+L3-4+Internal+Anatomy/ 5

10 4 9 1: Pyramidal tract 8 5a 2: Pontocerebellar fibers 6 3: Medial lemniscus 6a 11 4: MLF 12 5: Inferior cerebellar peduncle 5a: Middle cerebellar peduncle 3 7 13

Pontine Pontine (brachium pontis) 6: Abducens nucleus (VI) 6a: Paramedian pontine reticular formation (PPRF)

pontis 7: Facial motor nucleus (VII) 1 8: Superior salivatory nuc (VII)

Basis Basis 9: Nucleus & tractus solitarius Post-olivary : 10: Vestibular nuclei 2 CN.VII 11: Nuc. of spinal tract of N.V 12: Spinothalamic tract 13: Descending sympathetic tract Pre-olivary : CN.VI • Occlusion of perforating Dorsal Pontine Syndrome branches of 1.Internuclear ophthalmoplegia (INO) 2 • Involvement of MLF 1 • Unable to adduct the ipsilateral eye in conjugate eye movement to contralateral side

2.One-and-a half syndrome • Involvement of MLF & PPRF • If involves CN.VII – called ‘eight- and-a half syndrome’

Right INO One-and-a half syndrome • Occlusion of perforating Dorsal Pontine Syndrome branches of pontine arteries 1.Internuclear ophthalmoplegia (INO) 2 • Involvement of MLF 1 • Unable to adduct the ipsilateral eye in conjugate eye movement to contralateral side

3 2.One-and-a half syndrome • Involvement of MLF & PPRF • If involves CN.VII – called ‘eight- and-a half syndrome’

3.Foville syndrome • Involvement of PPRF, CN.VII, pyramidal tract • Contralateral hemiparesis • Ipsilateral LMN facial palsy • Unable to gaze ipsilaterally • Occlusion of perforating Ventral Pontine Syndrome branches of pontine arteries 4.Raymond syndrome • Involvement of pyramidal tract & CN.VI • Contralateral hemiparesis • Ipsilateral weakness of LR (alternating abducens hemiplegia)

5.Millard-Guber syndrome • Involvement of pyramidal tract, 5 CN.VI, VII • Same as Raymond syndrome + ipsilateral LMN facial weakness

4 6.Locked-in syndrome (bilat ventral pontine) • Involvement of bilateral corticospinal & corticobulbar tracts, CN.VI • Spares the reticular formation • Quadriplegia, aphonia, impairment of horizontal eye movement • But spares vertical eye movement & blinking Lateral Pontine Syndrome • Occlusion of perforating branches of long circumferential branches

7.Marie-Foix syndrome • Involvement of pyramidal tract, spinothalamic tract & cerebellar connections • Contralateral hemiparesis • Contralateral hypoesthesia • Ipsilateral 7 2 1

3 Syndromes

MLF PPRF nerve Abducens nerve Facial tract Corticospinal MCP tract Spinothalamic 1.INO ✓ 2.One-and-a half ✓ ✓ 5 2.Eight-and-a half ✓ ✓ ✓ 7 3.Foville ✓ ✓ ✓ 4.Raymond ✓ ✓ 4 5.Millard-Guber ✓ ✓ ✓ 7.Marie-Foix ✓ ✓ ✓ Anterior Inferior Cerebellar Artery • Branches • Internal acoustic (labyrinthine) a. • Medial branch • Lateral branch Supply • Inferolateral portion of pons • Middle cerebellar peduncle • Flocculus • Anteroinferior surface of the cerebellum

https://clinicalgate.com http://missinglink.ucsf.edu/ https://accessmedicine.mhmedical.com AICA Syndrome

Clinical features : ‘4S plus’ Spinal tract of N.V • Loss of pain/temperature sensation of ipsilateral Spinothalamic tract face & contralateral body (alternating hemianesthesia) Spinocerebellar (MCP) • Ipsilateral cerebellar sign Sympathetic tract • Ipsilateral Horner syndrome Plus • CN.VII • Ipsilateral LMN facial palsy, loss of corneal reflex • CN.VIII • Ipsilateral complete sensorineural hearing loss • Vestibular nucleus • Vertigo, N/V, nystagmus, head impulse test

http://radiopaedia.org Labyrinthine Artery • Usually originates from the AICA (85%), BA (15%) or VA (5%)

• Main arterial supply to vestibular apparatus & cochlea

• 2 branches • Anterior vestibular artery • Cochlear artery

Internal acoustic meatus anatomy

http://radiopaedia.org Superior Cerebellar Artery

Supply • Parts of midbrain • Superior & middle cerebellar peduncles • Whole superior surface of cerebellar hemispheres down to the great horizontal fissure • Superior vermis

Branches • Perforating branches • To pons, midbrain, inf colliculus • Lateral branch (largest one) • Hemispheric branches • Superior vermian artery Variations • Frequently duplication 28% • Triplication 2% (rarely absent) • Common stem with PCA https://www.pinterest.com http://www.neurosurgery-blog.com/archives/tag/trigeminal-neuralgia SCA Syndrome Clinical features : ‘4S plus’ …?? Spinal tract of N.V • Loss of pain/temperature sensation of ipsilateral Spinothalamic tract face & contralateral body (alternating hemianesthesia) Spinocerebellar (MCP) • Ipsilateral cerebellar sign Sympathetic tract • Ipsilateral Horner syndrome Plus • Lateral lemniscus • Contralateral sensorineural hearing loss • Unknown • Ipsilateral choreiform movement • Unknown • Ocular contrapulsion

http://www.neuroradiologycases.com/ https://radiologyassistant.nl 6 1: Pyramidal tract (cerebral 7a peduncle) 8 7 9 2: Substantia nigra 12,13 3: Upper level = 10 5 Lower level = Decussation of superior cerebellar peduncle 4 (brachium conjunctivum) 3 4: Dentatorubrothalamic tract 5: Medial lemniscus 2 6: Superior colliculus 11 7: Cerebral aqueduct 1 7a: Periaqueductal gray 8: Edinger-Westphal nucleus CN.III: 9: Oculomotor nuclear complex Exit at 10: MLF 11: Fascicles of CN.III interpeduncular fossa 12: Spinothalamic tract 13: Descending sympathetic tract Vascular supply of midbrain 6 • Paramedian vessels from PCA 7a • Circumferential arteries: 8 7 9 • Quadrigeminal artery (from PCA) 12,13 • Superior cerebellar artery 10 5 • Posterior choroidal artery • Anterior choroidal artery (in some) 4 3 2 11 1

CN.III: Exit at interpeduncular fossa

https://accessmedicine.mhmedical.com Parinaud’s syndrome Nothnagel’s syndrome Red nucleus, brachium conjunctivum • Upward gaze palsy • Large with light-near • Ipsilateral oculomotor palsy with dissociation dilated pupils • Convergence-retraction nystagmus • Prominent cerebellar signs (asynergia, ataxia, , )

Benedikt’s syndrome Red nucleus, brachium conjunctivum, CN.III • Ipsilateral oculomotor palsy with dilated pupils • Contralateral tremor, hemichorea, hemiathetosis (red nucleus)

Weber’s syndrome Pyramidal tract + fascicles of CN.III • Ipsilateral oculomotor palsy with dilated pupils • Contralateral hemiplegia **Claude’s : cerebellar element in Nothnagel’s and Benedikt’s syndromes Austin J Radiol. 2015; 2(1): 1009 Top of the Basilar Artery Doi: 10.5772/31083 • Usually embolic • Infarction of the midbrain, & portions of the temporal/occipital lobes Eye • Unilateral/bilateral paralysis of upward/downward gaze movements • Abnormal convergence, convergence-retraction nystagmus. Collier’s sign, skew deviation Pupillary abn. • Small & reactive , large or midposition & fixed Behavioral • Somnolence, sleep-wake cycle disturbance • Peduncular hallucinosis, memory difficulties, agitated delirium Visual defects • Hemianopia, , Balint’s syndrome Neurovascular Anatomy (2): Anatomy of the Posterior Circulation

➢ Vertebral artery ➢ Basilar artery ➢ Blood supply of diencephalon, brainstem and cerebellum Brazis PW, et al. Localization in clinical Blood Supply of the Thalamus neurology, 2011.

Anterior thalamoperforator

Posterior thalamoperforator

Blood supply of thalamus • Polar artery (from PComm) • Paramedian artery (from P1) • Thalamogeniculate artery • Posteromedial choroidal artery DM dorsomedial nucleus • Posterolateraal choroidal artery LG lateral geniculate body MG medial geniculate body Angiographic Correlation

3: Basilar artery 5: SCA 6: PCA 7: Posterior communicating a. 11: Anterior thalamoperforator 12: Posterior thalamoperforator 13: Posterior choroidal artery

Borden NM, Costantini JK. 3D Angiographic Atlas of Neurovascular Anatomy & Pathology, 2007. Brazis PW, et al. Localization in clinical Thalamic Vascular Syndromes neurology, 2011.

4 major vascular territories • Tuberothalamic (polar artery) • Paramedian • Inferolateral • Posterior choroidal Brazis PW, et al. Localization in clinical Thalamic Vascular Syndromes neurology, 2011.

1. Paramedian territory • Clinical triads: • Somnolent apathy • Recent memory loss • Abnormality of vertical gaze (involvement of riMLF at the midbrain) • Other clinical features • Transient LOC or akinetic mutism • Behavioral change (confusion, agitation, aggression, apathy, disorientation, mania, frontal like syndrome) • Occasional blepharospasm • Contralateral hemiataxia, asterixis or weakness • Delayed action tremor in contralateral limbs • Usually seen in the top of basilar artery occlusion riMLF = rostral interstitial nucleus of MLF Brazis PW, et al. Localization in clinical Thalamic Vascular Syndromes neurology, 2011.

2. Thalamogeniculate territory • Territory: VP, VL nucleus, subthalamic nucleus • Dejerine-Roussy syndrome: • Hemianesthesia (occasionally, proprioception is spared) • Transient slight hemiparesis • Hemiataxia/hemiataxia-hypesthesia syndrome • Lack of nonvolitional utilization of contralateral body (damaged ‘automatic’ pilot) • Dysequilibrium (‘thalamic astasia’) • Choreoathetoid movements • Athetoid posture (‘thalamic hand’) • Paroxysmal pain (‘thalamic pain) • Homonymous hemianopia (often due to simultaneous medial occipital infarction) Brazis PW, et al. Localization in clinical Thalamic Vascular Syndromes neurology, 2011.

3. Tuberothalamic territory (anterolateral) • Territory: thalamopolar artery • Clinical features: • Apathy, verbal preservation • Anterograde memory loss • Facial paresis for emotional movement • Occasionally, hemiparesis & VF defects (sensation spared) • Superimposition of temporally unrelated information • Dysphasia with left-sided lesions • Hemineglect & impaired visuospatial processing with right-sided lesion Brazis PW, et al. Localization in clinical Thalamic Vascular Syndromes neurology, 2011.

4. Posterior choroidal artery territory • Territory: LGB, pulvinar, posterior thalamus, small portion of hippocampus • Clinical features: • Homonymous quandrantanopia, superior or inferior or horizontal sectoranopia, tubular or shaped-like a wedge • Decreased optokinetic nystagmus when moving the drum to the side of lesion • Hemisensory loss with mild hemiparesis • Mild hemiparesis, accompanied by sensory loss • Transcortical Artery of Percheron PICA = “Wallenburg’s syndrome” PICA* PCA PSA ASA Post.med

MEDULLA MIDBRAIN SCA SCA AICA AICA PICA Pontine

PONS CEREBELLUM Arterial Territories Blood Supply of Cerebellum Neurovascular Anatomy (2): Posterior Circulation Anatomy

Natthapon Rattanathamsakul, MD. December 28th, 2017