J. Neurosurg. / Volume 32 / February, 1970

Anatomical Studies of the Collateral Blood Supply to the Brain and Upper Extremity

HENRYK PAKULA, M.D., AND JERZY SZAPIRO, M.D. Neurosurgical Department, Medical Academy, Lodz, Poland

HE last decade has brought a growing between the occipital artery and vertebral ar- interest in cerebrovascular insuffi- teries are constant. The presence of these T ciency associated with occlusion of the connections has also been proved in angio- vertebral arteries and vessels contributing graphical examinations.2z,~~ blood to these arteries. 12,15,~2,~7,42 As one as- Cooper 9 demonstrated the connection be- pect of the problem, we have been studying tween the superior and inferior thyroid arter- the collateral circulation to determine the ies; he also demonstrated the presence of details of its channels of circulation and their contrast medium in the vertebral artery dis- interrelationship. tal to the site of the carotid or vertebral liga- tion. Ljubomudrow3~ showed that possible Review of Past Studies channels of collateral circulation are the Consideration has been given in the liter- arterial branches (and their connections) of ature to such factors as lesions in the cervi- the inferior and superior thyroid, ascending cal vertebrae, head movements, and anatomi- and transversing cervical, superior intercos- cal variants; the incidence and character of tal, and posterior auricular arteries. angiographical changes have also been care- In 1956, Whisnant and coworkers ~ per- fully analyzed?,~,~,1~,~,1~,2~,~,~,~,4~'"6'~5'~6'~~ formed similar investigations on 12 dogs, li- Detailed descriptions have been given gating the carotid and vertebral arteries. As of the clinical forms of these cir- a rule the dogs survived the operations, and culatory disturbancesY ,~1,~5 Attention has some showed little sign of damage to the been called to the "subclavian steal syn- central nervous system. In nine other dogs, drome."s,~9,2a,~3,26,3~,39,4~,47,5s Further clinical the authors tried to limit the flow of blood to studies have been stimulated by the develop- the brain by ligating both vertebral arteries ment of surgery of the blood vessels leaving at the level of the transverse process of the the aortic arch? ~ De Bakey, sixth vertebra, both the common external and et al., ~2,13 reported endarterectomies per- internal arteries, and also the pharyngeal as- formed on the common and internal carotid, cending artery and the occipital arteries. vertebral, and subclavian arteries, and brach- Coma was observed in only three dogs, iocephalic trunk. while in others the symptoms were hardly The inconsistencies noted between the noticeable. Postmortem examinations clinical picture, angiographic changes, and showed no important damage in the cerebral the autopsy findings are interesting. It is ob- tissue in seven of the nine animals. Injection vious that the various clinical pictures en- of contrast medium into the arterial system countered may be conditioned by a related demonstrated the role of the internal tho- variety in the sites of the occlusive lesions. racic artery and of the costo-cervical trunk This, however, does not explain the variety as possible channels of collateral blood sup- of clinical syndromes that occur with the ply. identical sites of occlusion. The role of com- New data concerning the channels of col- pensatory factors should not be underesti- lateral circulation were revealed by an- mated, and attention to the problem of col- giographic examinations performed in pa- lateral circulation seems justified. tients with occlusive lesions of vessels In postmortem investigations, Schultze leaving the aortic arch and with traumatic and Sauerbrey ~* showed that the anastomoses lesions of arteries supplying the upper ex- tremity2,5,1s,2~ These exam- Received for publication April 11, 1969. inations emphasized the following anastomo- 171 172 Henryk Pakula and Jerzy Szapiro

Material and Methods Our postmortem studies were made on patients who died of various diseases. As in the previous experiments, occlusive ligatures were placed on certain arteries and their connections to demonstrate the collateral blood circulation after injection of preserved blood or artificial materials such as synthetic latex plus Micropaque to obtain radiological verification. A total of 40 such experiments were carried out, which we divided into three main groups illustrated by Figs. 1-3.

Numbers in Fig. 1 and subsequent figures indicate the following arteries: 1. Vertebral artery 2. External carotid artery 3. Occipital artery 4. Subclavian artery 5. Thyro-cervical trunk 6. Transverse cervical artery 7. Costo-cervical trunk 8. Clamp of the brachio-cephalic trunk 9. Anterior and posterior intercostal arteries Fro. 1 A. Diagram of the posterior 10. Anastomoses between anterior and aorto-cerebral circle. posterior intercostal arteries and the branches of the axillary artery 11. Axillary artery sic connections: between the ascending cer- 12. Brachial artery vical and deep cervical arteries, and the 13. Internal thoracic artery vertebral artery; between the external caro- 14. Superior thoracic artery tid and ascending cervical arteries; between 15. Acromio-thoracic artery the two vertebral arteries; between the two in- 16. Lateral thoracic artery ferior thyroid arteries; between the superior 17. Aorta and inferior thyroid arteries; and between the 18. Ophthalmic artery. two internal thoracic arteries. 7,14,15,~4,~6 In earlier studies we identified an area Sza- piro calls the "anterior aorto-cerebral cir- Results cle. ''4s-~~ This area is especially impor- Collateral Circulation Between the Verte- tant to the collateral circulation of the brain bral Artery and the External Carotid Artery. and retina. We are reporting here experi- One group of experiments concerned circu- ments concerned with the connections be- lation between the vertebral and external ca- tween the "posterior aorto-cerebral circle" rotid arteries. As shown in Fig. 1 B, latex and other vascular areas. 36,~1,~2 The term medium or preserved blood injected into the "posterior aorto-cerebral circle" covers the vertebral artery reached the external carotid arterial terrain bounded by the aortic arch, artery and its branches, although the verte- the right brachiocephalic trunk, the proximal bral artery had previously been ligated intra- portion of the subclavian arteries (Fig. 1), cranially. The medium also reached the sub- and the vertebral arteries joining to form the clavian artery through anastomoses between basilar artery. the vertebral artery and the branches of the