7

VASCULATURE

Arterial System 7.17 Angiographic Anatomy of the Vertebrobasilar

7.1 Meningeal Arteries: Relationship to Skull and System
Dura 7.18 Occlusive Sites of the Vertebrobasilar System
7.2 Arterial Supply to the Brain and Meninges 7.19 Vascular Supply to the Hypothalamus and the
7.3 Common Sites of Cerebrovascular Occlusive Pituitary Gland
Disease 7.20 Arterial Blood Supply to the Spinal Cord:
7.4 Internal Carotid and Ophthalmic Artery Course Longitudinal View
7.5 Arterial Distribution to the Brain: Basal View 7.21 Anterior and Posterior Spinal Arteries and Their
7.6 Arterial Distribution to the Brain: Cutaway Basal Distribution
View Showing the Circle of Willis 7.22 Arterial Supply to the Spinal Cord: Cross-Sectional
7.7 Arterial Distribution to the Brain: Frontal View with View
Hemispheres Retracted
7.8 Arterial Distribution to the Brain: Coronal Forebrain Venous System
Section 7.23 Meninges and Superficial Cerebral Veins
7.9 Types of Strokes 7.24 Veins: Superficial Cerebral, Meningeal, Diploic, and
7.10 Schematic of Arteries to the Brain Emissary
7.11 Circle of Willis: Schematic Illustration and Vessels 7.25 Venous Sinuses
in Situ 7.26 Deep Venous Drainage of the Brain
7.12 Arterial Distribution to the Brain: Lateral and Medial 7.27 Deep Venous Drainage of the Brain: Relationship
Views to the Ventricles
7.13 Territories of the Cerebral Arteries 7.28 Carotid Venograms: Venous Phase
7.14 Magnetic Resonance Angiography: Frontal and 7.29 Magnetic Resonance Venography: Coronal and
Lateral Views Sagittal Views
7.15 Angiographic Anatomy of the Internal Carotid 7.30 Venous Drainage of the Brain Stem and the
Circulation Cerebellum
7.16 Vertebrobasilar Arterial System 7.31 Venous Drainage of the Spinal Cord

93
94 Overview of the Nervous System

Arachnoid granulations
Parietal (posterior) and frontal (anterior) Opening of superior
branches of middle meningeal artery cerebral vein
Venous lacuna
Middle meningeal artery
Superior
sagittal sinus

Anterior meningeal artery (from Dura mater

anterior ethmoidal artery)

Mastoid branch
of occipital artery

Anterior and posterior meningeal

branches of vertebral artery
Mastoid branch
of occipital artery

Meningeal branches of ascending pharyngeal artery

Tentorial branch (cut) and dorsal meningeal
branch of meningohypophyseal trunk

Middle and accessory meningeal arteries

Meningeal branch of posterior ethmoidal artery
Anterior meningeal artery (from anterior ethmoidal artery)
Internal carotid artery and its meningohypophyseal trunk (in phantom)
Middle meningeal artery
Accessory meningeal artery
Superficial temporal artery
Maxillary artery
Posterior auricular artery
Occipital artery
External carotid artery

ARTERIAL SYSTEM
quence of skull fractures. Fractures can rip a meningeal artery
7.1 MENINGEAL ARTERIES: RELATIONSHIP TO (usually the middle meningeal artery) and allow arterial blood
SKULL AND DURA to accumulate above the dura. Such an epidural hematoma is
Meningeal arteries are found in the outer portion of the dura; a space-occupying mass and can produce increased intracra-
they supply it with blood. They also help to supply blood to nial pressure and risk for herniation of the brain, particularly
adjacent skull and have some anastomoses with cerebral arter- across the free edge of the tentorium cerebelli. Even very fine
ies. The skull has grooves, or sulci, for the meningeal vessels. fractures can have this dangerous consequence.
This relationship reflects an important functional conse-
 Vasculature 95

Left middle meningeal artery Right and Ieft middle cerebral arteries

Right and Ieft posterior Right and Ieft anterior cerebral arteries
cerebral arteries Anterior communicating artery
Right and Ieft superior Right ophthalmic artery
cerebellar arteries
Right posterior
Basilar artery communicating artery
Mastoid branch of Cavernous sinus
Ieft occipital artery
Left internal auditory
(labyrinthine) artery
Right deep temporal artery
Posterior meningeal branch
of Ieft ascending Right maxillary artery
pharyngeal artery Right middle meningeal artery
Right and Ieft anterior
inferior cerebellar arteries Right superficial temporal artery
Right and Ieft posterior
inferior cerebellar arteries Right external carotid artery
Posterior meningeal branches Right facial artery
of right and Ieft vertebral arteries
Right lingual artery
Anterior meningeal branch
of right vertebral artery Carotid body
Right posterior auricular artery Right superior laryngeal artery
Right occipital artery Right superior thyroid artery
Right internal carotid artery
Thyroid cartilage
Right ascending pharyngeal artery
Right common carotid artery
Right carotid sinus
Right vertebral artery Right inferior thyroid artery

Transverse process of C6 Right internal thoracic artery

Right deep cervical artery
Right thyrocervical trunk Brachiocephalic trunk

Right costocervical trunk

Right subclavian artery

7.2 ARTERIAL SUPPLY TO THE BRAIN

CLINICAL POINT
AND MENINGES The paired carotid arteries and vertebral arteries supply the brain and
The internal carotid artery (ICA) and the vertebral artery part of the spinal cord with blood. The carotids supply the anterior
ascend through the neck and enter the skull to supply the circulation, including most of the forebrain except for the occipital
brain with blood. The tortuous bends and sites of branching lobe and inferior surface of the temporal lobe. The bifurcation of the
(such as the bifurcation of the common carotid artery into the common carotid artery is a common site of plaque formation in
atherosclerosis, leading to gradual occlusion of blood flow to the
internal and external carotids) produce turbulence of blood forebrain on the ipsilateral side. Early warnings can be seen in the
flow and are sites where atherosclerosis can occur. The bifur- form of transient ischemic attacks, forerunners of a full-blown stroke.
cation of the common carotid is particularly vulnerable to The best treatment is prevention, with exercise, proper diet and weight
plaque formation and occlusion, threatening the major ante- control, careful regulation of lipid levels and other contributing
rior part of the brain with ischemia, which would result in a factors such as inflammatory mediators. In cases in which severe and
symptomatic occlusion has occurred as the result of atherosclerotic
stroke. The ICA passes through the cavernous sinus, a site plaque, carotid endarterectomy can be performed to remove the
where carotid-cavernous fistulae can occur, resulting in plaque and attempt to open up more robust flow to the anterior cir-
damage to the extraocular and trigeminal cranial nerves, culation. Carefully performed controlled studies have established cri-
which also pass through this sinus. Studies of blood flow teria that determine which patients can best benefit from this surgical
through these arteries are important diagnostic tools. Mag- procedure as opposed to more conservative medical treatment.
Current studies are investigating the use of carotid stents to enhance
netic resonance arteriography and Doppler flow studies have, blood flow to the brain.
for most purposes, replaced the older dye studies for perform-
ing cerebral angiography.
96 Overview of the Nervous System

Middle cerebral
artery origin
Basilar artery
Anterior cerebral
artery origin Fourth segment
of vertebral artery
Siphon portion
of internal
carotid artery

Carotid bifurcation

First segment of
vertebral artery

Proximal
subclavian
artery

7.3 COMMON SITES OF CEREBROVASCULAR which are carried upstream into end branches of the vascular
OCCLUSIVE DISEASE system.
Atherosclerosis is the most common cause of internal carotid In addition to genetic factors, predisposing risks for ath-
disease, accounting for many cerebral ischemic events, par- erosclerotic plaque formation include smoking, type II diabe-
ticularly in the elderly. Atherosclerotic plaques are formed by tes, hypertension, and hypercholesterolemia.
deposition of circulating lipids and the accumulation of Illustrated here are the most common sites for atheroscle-
fibrous tissue in the subintimal layer of large and medium rosis in the cerebral circulation, including the bifurcation of
arteries, exacerbated by the presence of inflammatory media- the common carotid artery and origin of the internal carotid
tors and shearing forces from hypertension. Plaque formation artery, carotid siphon, main stems of the middle and anterior
particularly occurs at arterial branch points, where turbulence cerebral arteries, proximal subclavian artery, first segment of
is maximal. the vertebral artery, fourth segment of the vertebral artery,
Disruption of the endothelial surface can result in throm- and basilar artery.
bus formation, platelet aggregation, and production of emboli,
 Vasculature 97

Cavernous sinus Ophthalmic artery

Vidian nerve
Internal carotid artery
Lateral View Carotid plexus
Maxillary nerve
Great superficial petrosal nerve

Nervus intermedius

Facial nerve

Internal carotid artery

Carotid nerve
Spheno-palatine
Superior cervical ganglion ganglion

7.4 INTERNAL CAROTID AND OPHTHALMIC vascular disease. Because of its position as the first branch of
ARTERY COURSE the ICA, emboli from atherosclerotic plaques that are found
The ophthalmic artery is the first major branch of the internal at sites such as the bifurcation of the common carotid artery
carotid artery (ICA). It supplies the eyeball, ocular muscles, may travel through the ophthalmic artery, resulting in a tran-
and adjacent structures with blood. This artery is commonly sient ischemic attack with the symptom of fleeting blindness
involved in the first phases of clinical recognition of cerebro- (amaurosis fugax) in the affected eye.
98 Overview of the Nervous System

Anterior communicating artery

Anterior cerebral artery

Circle of Willis
(dotted outline)
Recurrent artery (of Heubner)

Internal carotid artery

Medial and lateral lenticulostriate arteries

Middle cerebral artery

Lateral orbitofrontal artery

Ascending frontal (candelabra) branch

Anterior choroidal artery

Posterior communicating artery

Posterior cerebral artery

Superior cerebellar artery

Basilar artery and pontine branches

Internal auditory (labyrinthine) artery

Anterior inferior cerebellar artery

Vertebral artery

Anterior spinal artery

Posterior inferior cerebellar artery

Posterior spinal artery

7.5 ARTERIAL DISTRIBUTION TO THE BRAIN:

CLINICAL POINT
BASAL VIEW The vertebrobasilar system supplies blood to the posterior circulation
The anterior circulation (middle and anterior cerebral arter- of the brain, including most of the brain stem, part of the diencepha-
ies; MCAs, ACAs) and the posterior circulation (the vertebro- lon, and the occipital and inferior temporal lobes of the forebrain. The
basilar system and its end branch, the posterior cerebral artery; paired PCAs are the end arteries of the vertebrobasilar system. An
PCA) and their major branches are shown. The right temporal infarct in the PCAs (top of the basilar infarct) results in damage to
the ipsilateral occipital lobe, including both the upper and lower banks
pole is removed to show the course of the MCA through the of the calcarine fissure. Functionally, this infarct affecting one side
lateral fissure. The circle of Willis (the paired ACAs, MCAs, results in contralateral blindness, called contralateral homonymous
and PCAs and the anterior and two posterior communicating hemianopia. There may be macular sparing if the MCA has some
arteries) surrounds the basal hypothalamic area. The circle of anastomoses with the posterior cerebral circulation.
Willis appears to allow free flow of blood around the anterior
and posterior circulation of both sides, but usually it is not
sufficiently patent to allow bypass of an occluded zone. See
Video 7-1.
 Vasculature 99

Anterior communicating artery

Recurrent artery (of Heubner)

Anterior cerebral artery

Middle cerebral artery

Posterior communicating artery

Anterior choroidal artery

Optic tract

Cerebral peduncle

Lateral geniculate body

Posterior medial choroidal artery

Posterior lateral choroidal artery

Choroid plexus of lateral ventricle

Medial geniculate body

Pulvinar

Lateral ventricle

7.6 ARTERIAL DISTRIBUTION TO THE BRAIN:

CLINICAL POINT
CUTAWAY BASAL VIEW SHOWING THE Obstruction of the MCA near its origin is relatively unusual compared
CIRCLE OF WILLIS with obstruction or infarcts in selected branches, but it demonstrates
The circle of Willis and the course of the choroidal arteries are the full range of blood supply of this critical artery. Obstruction near
shown. The arteries supplying the brain are end arteries and the origin usually results from embolization, not from atherosclerotic
do not have sufficient anastomotic channels with other arter- or thrombotic lesions. It causes contralateral hemiplegia (resolving to
spastic), contralateral central facial palsy (lower face), contralateral
ies to sustain blood flow in the face of disruption. The occlu- hemianesthesia, contralateral homonymous hemianopia, and global
sion of an artery supplying a specific territory of the brain aphasia if the left hemisphere is involved. Additional problems with
results in functional damage that affects the performance of anosognosia (inability to recognize a physical disability), contralateral
structures deprived of adequate blood flow. See Video 7-2. neglect, and spatial disorientation may occur.
100 Overview of the Nervous System

Frontal View with Hemispheres Retracted, Tilted for a View of the Ventral Brain Stem

Corpus callosum Paracentral artery

Medial and lateral
lenticulostriate arteries Frontal branches

Lateral orbitofrontal artery Pericallosal artery

Ascending frontal Callosomarginal artery

(candelabra) branch
Frontopolar artery
Anterior and posterior
parietal branches
Anterior cerebral
arteries
Precentral
(prerolandic)
and central Medial orbito-
(rolandic) frontal artery
branches
Recurrent artery
(of Heubner)
Angular branch

Temporal branches Internal carotid

(posterior, middle, I artery
anterior)

Middle cerebral II Anterior choroidal

artery and branches, artery
deep in lateral
cerebral (sylvian) fissure IV Posterior cerebral
III
Anterior commu- V artery
nicating artery VII VI
VIII Basilar artery
Posterior commu-
nicating artery Internal auditory
IX (labyrinthine) artery
Superior cerebellar artery XII X
Vertebral artery
Anterior inferior cerebellar artery
Posterior inferior cerebellar artery
XI
Posterior spinal artery Anterior spinal artery

7.7 ARTERIAL DISTRIBUTION TO THE BRAIN: capsule and damage to corticobulbar fibers traveling in the
FRONTAL VIEW WITH HEMISPHERES genu of the internal capsule.
RETRACTED
With the hemispheres retracted, the course of the ACAs and
their distribution along the midline are visible. This artery
supplies blood to the medial zones of the sensory and motor CLINICAL POINT
The ACA branches from the internal carotid as it splits from the
cortex, which are associated with the contralateral lower middle cerebral artery. It supplies a medial strip of the forebrain with
extremity; an ACA stroke thus affects the contralateral lower blood. ACA occlusion is usually caused by embolization, although an
limb. With the lateral fissure opened up, the MCA is seen to anterior communicating artery aneurysm, vasospasm resulting from
course laterally and to give branches to the entire convexity of a subarachnoid hemorrhage, or subfalcial herniation can occlude this
the hemisphere. End-branch infarcts of the MCA affect the artery. If the ACA is occluded distal to the recurrent artery of Heubner,
it results in contralateral spastic paresis and sensory loss in the lower
contralateral upper extremity and, if on the left, also affect extremity. A more proximal lesion involving the recurrent artery of
language function. More proximal MCA infarcts affecting the Heubner may involve the upper body and limb as well. In addition,
MCA distribution to the internal capsule can cause full con- there may be internal sphincter weakness of the urinary bladder,
tralateral hemiplegia with drooping of the contralateral lower frontal release signs, and conjugate deviation of the eyes toward the
face; this results from damage to corticospinal and other cor- side of the lesion (damage to frontal eye fields with unopposed devia-
tion from the intact side).
ticomotor fibers traveling in the posterior limb of the internal
 Vasculature 101

Coronal Section through the Head of the Caudate Nucleus

Frontal horn of lateral ventricle Falx cerebri

Corpus striatum (head of the

caudate and putamen) Callosomarginal
arteries
and
Pericallosal arteries
Medial and lateral (branches of anterior
lenticulostriate arteries cerebral arteries)

Limen of insula

Insula
Body of corpus
callosum
Precentral (prerolandic),
central (rolandic)
Internal capsule
and parietal branches
(anterior limb)

Lateral cerebral
(sylvian) fissure
Septum pellucidum

Temporal branches Rostrum of

corpus callosum

Anterior
Temporal lobe cerebral arteries

Middle cerebral artery Recurrent artery

(of Heubner)

Internal carotid artery

Anterior
communicating
artery

Optic chiasm

7.8 ARTERIAL DISTRIBUTION TO THE BRAIN: times called the arteries of stroke, are thin branches of the
CORONAL FOREBRAIN SECTION MCA that penetrate into the basal ganglia and internal capsule
The MCA is the major continuation of the internal carotid regions of the forebrain. A stroke in this territory produces a
artery (ICA). The MCA travels through the lateral fissure, classic contralateral hemiplegia (spastic) with aphasia, often
supplying branches both to deep structures and to the convex- worse in the upper extremity.
ity of the cerebral cortex. The lenticulostriate arteries, some-
102 Overview of the Nervous System

Diagnosis of Stroke
Ischemic Stroke Hemorrhagic

Thrombosis

Infarct

Clot in carotid artery

extends directly to
middle cerebral artery
Subarachnoid hemorrhage
Embolism
(ruptured aneurysm)
Infarct

Clot fragment carried

from heart or more
proximal artery
Hypoxia

Infarcts

Intracerebral hemorrhage
(hypertensive)
Hypotension and poor
cerebral perfusion:
border zone infarcts,
no vascular occlusion

7.9 TYPES OF STROKES arachnoid hemorrhages (ruptured aneurysm) and intracere-

There are two types of strokes, ischemic and hemorrhagic. The bral hemorrhages (hypertensive strokes or bleeds associated
ischemic strokes include thrombotic strokes, embolic strokes, with anticoagulant medication).
and hypoxic strokes. The hemorrhagic strokes include sub-
 Vasculature 103

Anterior cerebral artery

1
Middle cerebral artery Anterior communicating artery

Posterior communicating artery Ophthalmic artery

Caroticotympanic branch of 2 Supraorbital artery

internal carotid artery 3 3
3 Supratrochlear artery
Posterior cerebral artery 1
Lacrimal artery
Superior cerebellar artery
Dorsal nasal artery
Anterior tympanic artery 3
Middle meningeal artery
Middle meningeal artery
1 Angular artery
Maxillary artery 1
4 Superficial temporal artery
Basilar artery
Posterior auricular artery
Anterior inferior cerebellar artery 5 5
4 Facial artery
Posterior inferior cerebellar artery
Occipital artery
External carotid artery 5 5
Lingual artery
Internal carotid artery
5 Ascending pharyngeal artery
Superior thyroid artery
Anterior spinal artery
Common carotid artery 5
Spinal segmental medullary branches
Vertebral artery 5
Vertebral artery
Ascending cervical artery
Common carotid artery
Inferior thyroid artery 5
Deep cervical artery
Thyrocervical trunk
Transverse cervical artery

Suprascapular artery

Supreme intercostal artery

Costocervical trunk

Subclavian artery
Subclavian artery
Internal thoracic artery
Brachiocephalic trunk

Anastomoses
1 Right–Left
Arch 2 Carotid–Vertebral
Aorta Descending 3 Internal carotid–External carotid
Ascending 4 Subclavian–Carotid
5 Subclavian–Vertebral

7.10 SCHEMATIC OF ARTERIES TO THE BRAIN matic. The relative separation of the anterior (MCA, ACA)
This schematic diagram shows the entire layout of the arterial and posterior (vertebrobasilar system, PCA) circulation is
blood supply to the brain, including anastomoses. The circle evident in this diagram. See Videos 7-3 and 7-4.
of Willis is present in the upper central portion of this sche-
104 Overview of the Nervous System

Vessels Dissected Out: Inferior View

Anterior cerebral artery (A2 segment) Medial striate artery (recurrent artery of Heubner)

Anterior communicating artery Anteromedial central (perforating) arteries

Anterior cerebral artery (A1 segment) Hypothalamic artery

Ophthalmic artery Anterolateral central (lenticulostriate) arteries

Internal carotid artery

Middle cerebral artery

Posterior communicating artery Superior hypophyseal artery

Posterior cerebral artery Inferior hypophyseal artery

(P2 segment)
(P1 segment) Anterior choroidal artery

Thalamotuberal (premammillary) artery

Superior cerebellar artery Posteromedial central (perforating) artery

Basilar artery Thalamoperforating artery

Pontine arteries Posteromedial central (paramedian) arteries

Anterior inferior cerebellar artery Labyrinthine (internal acoustic) artery

Vertebral artery

Vessels in Situ: Inferior View

Anterior cerebral artery Anterior communicating artery

Hypothalamic artery Optic chiasm

Internal carotid artery Cavernous sinus

Superior hypophyseal artery Infundibulum (pituitary stalk) and

long hypophyseal portal veins
Middle cerebral artery
Adenohypophysis
(anterior lobe of pituitary gland)
Inferior hypophyseal artery
Neurohypophysis (posterior lobe of pituitary gland)
Posterior communicating artery

Efferent hypophyseal veins Posteromedial central (perforating) arteries

Posterior cerebral artery Superior cerebellar artery

Basilar artery

7.11 CIRCLE OF WILLIS: SCHEMATIC

CLINICAL POINT
ILLUSTRATION AND VESSELS IN SITU Saccular, or berry, aneurysms account for more than 80% of all intra-
The circle of Willis surrounds the optic tracts, pituitary stalk, cranial aneurysms; they are outpouchings of cerebral arteries that
and basal hypothalamus. It includes the three sets of paired probably form over a relatively short period of time (days to weeks).
cerebral arteries plus the anterior communicating artery, The most likely site of these berry aneurysms is at the junctions of
interconnecting the ACAs, and the posterior communicating arteries in the circle of Willis. Rupture of the aneurysm results in
arterial bleeding into the cerebrospinal fluid (subarachnoid hemor-
arteries, interconnecting the MCAs and PCAs. The free flow rhage), which produces an acute, excruciating headache, nausea,
of arterial blood through the communicating arteries usually vomiting, signs of meningeal irritation, and sometimes loss of con-
is insufficient to perfuse the brain adequately in the face of sciousness. A sudden subarachnoid hemorrhage may be immediately
an occlusion to a major cerebral artery; the circle of Willis is fatal. Autopsy studies show that most cerebral aneurysms never
fully patent and functional for free flow through the commu- rupture. Untreated ruptured aneurysms have approximately a one
third likelihood of rebleeding within 2 months, sometimes with fatal
nicating arteries in only approximately 20% of individuals. results; other sequelae are cerebral infarction and vasospasm of the
The circle of Willis is the most common site of cerebral affected vessel. Treatment sometimes involves clipping the aneurysm
aneurysms. or occluding it with coils or balloons.
 Vasculature 105

Anterior parietal branch Posterior parietal branch

Central (rolandic) branch Angular branch
Precentral (prerolandic) branch Terminal cortical branches
of Ieft posterior cerebral artery
Ascending frontal (candelabra) branch

Terminal cortical branches

of anterior cerebral arteries
Lateral orbitofrontal artery
Posterior temporal branches
Left middle cerebral artery

Anterior temporal branches

Left anterior cerebral artery
Anterior communicating artery

Right anterior cerebral artery

Left internal carotid artery

A. Lateral view

Pericallosal artery Paracentral artery

Precuneal artery
Posterior
Internal frontal branches Middle
Anterior Right posterior cerebral artery

Posterior pericallosal artery

Callosomarginal artery
Parietooccipital branch
Frontopolar artery
Posterior temporal branch
Right anterior cerebral artery
Anterior temporal branch

Calcarine branch
Medial orbitofrontal artery

Anterior communicating artery

Recurrent artery (of Heubner)

Right internal carotid artery

Posterior communicating artery
B. Medial view

7.12 ARTERIAL DISTRIBUTION TO THE BRAIN:

CLINICAL POINT
LATERAL AND MEDIAL VIEWS The MCA is a continuation of the ICA, extending through the lateral
A, The MCA sends named branches along the surface of the fissure to supply branches to the convexity of the hemisphere, as well
hemispheric convexity into the frontal and parietal lobes and as penetrating branches. Cerebrovascular “strokes” appear in several
into the anterior and middle regions of the temporal lobes. forms. Approximately one third are atherosclerotic/sclerotic strokes
Occlusion disrupts sensory and motor functions in the con- (usually preceded by a transient ischemic attack); about one third are
embolic strokes; close to 20% are lacunar (small distal) infarcts; 10%
tralateral body, especially the upper extremity, or in the entire are cerebral hemorrhages; and a small percent are ruptured aneurysms
contralateral body if the blood supply to the internal capsule or arteriovenous malformations. Lacunar infarcts are small infarcts
is affected. B, The ACA distributes to the midline region of (between 3 to 4 µm and 2 cm in diameter) in small penetrating vessels
the frontal and parietal lobes. Occlusion disrupts sensory and supplying the putamen, caudate, internal capsule, thalamus, pons, and
motor functions in the contralateral lower extremity. The PCA cerebral white matter. They occur most commonly as atherosclerosis-
related infarcts, particularly in the presence of hypertension or diabe-
distributes to the occipital lobe and the inferior surface of the tes. Symptoms are determined by which region of the brain is involved;
temporal lobe. Occlusion disrupts mainly visual functions in they can include weakness, hemiplegia, contralateral loss of sensation,
the contralateral visual field. ataxia, and other symptoms.
106 Overview of the Nervous System

Anterior cerebral artery

Middle cerebral artery

Posterior cerebral artery

7.13 TERRITORIES OF THE plied by these major arteries and make particularly clear the
CEREBRAL ARTERIES watershed zones at the junctions of the major cerebral
The specific midline and lateral territories of distribution of arteries.
the ACA, MCA, and PCA illustrate the exclusive zones sup-
 Vasculature 107

Anterior cerebral artery

Internal carotid artery

Middle cerebral artery Posterior cerebral artery

Basilar artery

Vertebral artery

A. Axial view
Branches of middle cerebral artery Posterior cerebral artery
Middle cerebral arteries
Basilar artery
Internal carotid arteries
Vertebral arteries
B. Lateral view
Midline portion, anterior cerebral artery
Middle cerebral artery
Anterior cerebral artery

Internal carotid artery

Basilar artery
Vertebral artery

Common carotid artery

Subclavian artery

Brachiocephalic trunk

Aortic arch

C. Coronal full vessel view

7.14 MAGNETIC RESONANCE ANGIOGRAPHY: defined mainly by the two fundamental flow effects in mag-
FRONTAL AND LATERAL VIEWS netic resonance: time-of-flight phenomena based on magni-
A, Axial view. B, Lateral view. C, Coronal full vessel view. The tude effects and phase contrast phenomena, based on
technique of magnetic resonance angiography (MRA) exploits phase-shift effect. The MRAs in these images were made by
the properties of macroscopic blood flow to render images of using the technique that exploits signal enhancement due to
cerebral blood vessels. Depending on the technique, the blood the effects of time of flight. Positive flow contrast is generated
signal can be made to appear dark or bright; with conven- by inflow effects, whereas the background (stationary tissue)
tional spin-echo pulse sequences, the blood vessels appear is saturated by the rapid, repeated application of the radiofre-
dark, and with gradient-echo pulse sequences, the blood quency pulses; thus the blood signal is higher than that of
vessels appear bright. There are two types of MRA that are stationary tissue.
108 Overview of the Nervous System

Cerebral Angiography
Lateral projection

Multiple branches of
Pericallosal artery
middle cerebral artery

Callosomarginal artery
Parieto-occipital
and
Anterior cerebral artery Posterior temporal
branches of
Posterior
Frontopolar artery cerebral artery

Posterior communicating artery

Medial orbitofrontal artery

Ophthalmic artery Supraclinoid,

Cavernous,
Petrous, and
Cervical segments
of internal caroid artery

Frontal projection

Right anterior cerebral artery

Anterior choroidal artery

Left anterior cerebral artery

Medial and lateral

lenticulostriate arteries
Anterior communicating artery

Middle cerebral artery

Frontopolar artery

Ophthalmic artery

Supraclinoid,
Cavernous,
Petrous, and
Cervical
segments of
internal carotid artery

7.15 ANGIOGRAPHIC ANATOMY OF THE that is a frontal view of the ICA circulation after injection of
INTERNAL CAROTID CIRCULATION a radiopaque contrast agent into the common carotid artery.
The top plate is an angiogram that is a lateral view of the ICA The major branches of this arterial system are delineated.
circulation after injection of a radiopaque contrast agent into MRA is used commonly to investigate the status of the cere-
the ICA. The major branches of the ICA, particularly the ACA bral arteries, but angiography with contrast agents can provide
and MCA, are delineated. The bottom plate is an angiogram excellent anatomical details for teaching purposes.
 Vasculature 109

Arteries of Posterior Cranial Fossa

Lateral and medial Right choroid plexuses

geniculate bodies of lateral ventricles
Left
of left thalamus
Crura of fornix Posterior horn of right lateral ventricle
Septum pellucidum Right and
left pulvinars
Corpus callosum
Anterior cerebral arteries Splenium of
corpus callosum
Longitudinal
Right posterior
(interhemispheric) fissure
pericallosal artery
Heads of caudate nuclei Parieto-occipital and
Thalamogeniculate arteries Calcarine branches
of right posterior
Medial and lateral cerebral artery
lenticulostriate arteries
Left superior colliculus
Anterior choroidal artery
Superior vermian artery
Anterior cerebral artery
Posterior medial choroidal
Optic (II) nerve artery (to choroid plexus
and ophthalmic artery of 3rd ventricle)
Middle cerebral artery Posterior lateral choroidal artery
III IV
Thalamoperforating arteries Left posterior cerebral artery
V with anterior and posterior
Posterior communicating artery
temporal branches
Left internal carotid artery VIII
Superior cerebellar artery Lateral marginal branch of
VI VII superior cerebellar artery
Basilar artery IX
X Inferior vermian artery (in phantom)
Pontine branches
Choroidal point and choroidal artery
Left internal auditory (labyrinthine) artery XI to 4th ventricle
Anterior inferior cerebellar artery
Tonsillohemispheric branches
Posterior inferior cerebellar artery Outline of 4th ventricle (broken line)
Anterior meningeal branch of vertebral artery
Posterior meningeal branch of vertebral artery
Left vertebral artery Left posterior spinal artery
Anterior
spinal artery

7.16 VERTEBROBASILAR ARTERIAL SYSTEM tralateral body and the ipsilateral face. The end branch of the
The vertebral arteries unite at the midline to form the basilar basilar artery is the PCA, which distributes to the visual cortex
artery. Medial penetrating branches extend into medial zones and inferior temporal lobe. Occlusion results in contralateral
of the brain stem, supplying wedgelike territories. Infarcts in hemianopsia.
these branches can produce “alternating hemiplegias,” result-
ing in contralateral motor deficits (corticospinal system
damage above the decussation of the pyramids), and ipsilat- CLINICAL POINT
eral brain stem/cranial nerve signs and symptoms. The verte- The vertebrobasilar system gives rise to several types of arterial
bral and basilar arteries also give rise to larger short and long branches. Those located most medially are the paramedian branches.
circumferential branches, such as the posterior inferior cere- An infarct in such a branch commonly involves ipsilateral damage to
bellar artery (PICA), the anterior inferior cerebellar artery a cranial nerve and its function as well as contralateral hemiplegia
because of involvement of the corticospinal tract before it decussates
(AICA), and the superior cerebellar artery (SCA). Strokes in on its way to the spinal cord. These infarcts are known as alternating
these arterial territories generally produce a constellation of hemiplegias. The short and long circumferential arteries distribute
ipsilateral brain stem sensory, motor, and autonomic symp- into more lateral territories, and infarcts commonly result in a complex
toms and contralateral somatosensory symptoms. For mixture of sensory, motor, and autonomic symptoms, as seen in the
example, an infarct in the vertebral artery or the PICA can lateral medullary syndrome resulting from an infarct in the vertebral
artery or the PICA on one side.
result in loss of pain and temperature sensation on the con-
110 Overview of the Nervous System

Arteries of Posterior Cranial Fossa

Vertebral Angiograms: Arterial Phase
A. Lateral projection
Posterior lateral choroidal arteries Posterior pericallosal artery
Superior cerebellar arteries
Parieto-occipital
Posterior cerebral arteries
Posterior temporal Branches of posterior cerebral artery
Thalamoperforating arteries
Calcarine

Posterior communicating arteries Inferior vermian artery

Tonsillohemispheric branches
Basilar artery
Posterior inferior cerebellar artery
Anterior inferior cerebellar artery
Vertebral artery
B. Frontal projection
Posterior cerebral arteries
Superior cerebellar arteries

Anterior inferior
cerebellar arteries Inferior vermian branches
of
Basilar artery Right and left posterior
inferior cerebellar arteries
and
Left hemispheric branch
of left posterior inferior cerebellar artery

Vertebral artery

7.17 ANGIOGRAPHIC ANATOMY OF THE tion of a radiopaque contrast agent into the vertebral artery.
VERTEBROBASILAR SYSTEM The major arterial branches of this system are delineated.
These figures show angiograms of both lateral and frontal
views of the vertebrobasilar (posterior) circulation after injec-
 Vasculature 111

Posterior
cerebral Internal carotid artery
artery
Middle cerebral artery
SCA
Posterior communicating artery
Basilar
artery Thalamoperforating arteries
to medial thalamus
Pons Thalamoperforating arteries
AICA to lateral thalamus
Posterior cerebral artery
Vertebral
artery Superior cerebellar artery
Medulla Basilar artery and obstruction
PICA Anterior inferior cerebellar artery
Dura Vertebral artery
Anterior
spinal
artery
C
Intracranial obstruction of vertebral artery proximal to origin of
posterior inferior cerebellar artery (PICA) may be compensated
by preserved flow from contralateral vertebral artery. If PICA
origin is blocked, lateral medullary syndrome (shown above)
may result. Clot also may extend to block anterior spinal artery
branch, causing hemiplegia, or embolization to basilar
bifurcation may cause “top of basilar” syndrome.
A
Posterior Areas supplied by posterior
cerebral cerebral arteries (blue)
arteries and clinical manifestations
of infarction
SCA
Pons Medial thalamus and midbrain
Hypersomnolence
Paramedian Small, nonreactive pupils
and short Bilateral third cranial
circumferential nerve palsy
penetrating Behavioral alterations
branches Hallucinosis
Basilar artery
Lateral thalamus and posterior
(occluded)
limb of internal capsule
AICA
Hemisensory loss
Medulla
Hippocampus and medial
Vertebral arteries temporal lobes
PICA Memory loss
Anterior spinal artery
Splenium of corpus callosum
Collateral circulation via superior cerebellar (SCA), anterior Alexia without agraphia
inferior cerebellar (AICA), and posterior inferior cerebellar (PICA)
arteries may partially compensate for basilar occlusion. Basilar Calcarine area
artery has paramedian, short circumferential and long circum- Hemianopsia (or bilateral
ferential (AICA) and (SCA) penetrating branches. Occlusion of blindness if both posterior
any or several of these branches may cause pontine infarction. D cerebral arteries occluded)
Occlusion of AICA or PICA may also cause cerebellar infarction.
B

7.18 OCCLUSIVE SITES OF THE and long circumferential branches. C. Vertebrobasilar arterial
VERTEBROBASILAR SYSTEM system with posterior cerebral artery end branches, illustrat-
A. Arteries of the base of the brain stem, illustrating a vertebral ing a top of the basilar occlusion. D. The territories of brain
artery/PICA occlusion, and a top of the basilar syndrome. B. supplied by the posterior cerebral arteries and the possible
Arteries of the brain stem in lateral view, showing potential functional consequences of occlusion.
collateral circulation among paramedian branches and short
112 Overview of the Nervous System

Hypothalamic vessels

Primary plexus of
hypophyseal portal system

Long hypophyseal Anterior branch

portal veins Superior hypophyseal artery (from internal carotid
Posterior branch artery or posterior communicating artery)
Short hypophyseal
portal veins
Artery of trabecula
Capillary plexus of
infundibular process Trabecula

Posterior lobe
Efferent vein to cavernous sinus

Anterior lobe
Secondary plexus of hypophyseal portal system
Stalk
Anterior lobe

Posterior
lobe

Cavernous sinus
Efferent vein to
cavernous sinus Internal carotid artery
Lateral branch Efferent vein to Posterior communicating artery
and cavernous sinus Superior hypophyseal artery
Medial branch Portal veins
of Lateral hypophyseal veins
Inferior hypophyseal artery
(from the internal carotid artery) Inferior hypophyseal artery
Posterior lobe veins Inferior aspect

7.19 VASCULAR SUPPLY TO THE HYPOTHALAMUS

CLINICAL POINT
AND THE PITUITARY GLAND The primary hypophyseal portal system coalesces into long hypophy-
The superior hypophyseal arteries (from the ICA or the pos- seal portal veins that give rise to a secondary hypophyseal plexus. This
terior communicating artery) supply the hypothalamus and arrangement allows the secretion of releasing and inhibitory factors
infundibular stalk and anastomose with branches of the infe- from nerve endings, whose cell bodies are located in the hypothalamus
rior hypophyseal artery (from the ICA). A unique aspect of and other structures, into a private vascular portal system, to be deliv-
ered to the pituicytes in the anterior pituitary gland in extraordinarily
this arterial distribution is the hypophyseal portal system, high concentrations. The ultimate CNS control of the releasing and
whose primary plexus derives from small arterioles and capil- inhibitory factors profoundly influences neuroendocrine secretion
laries that then send branches into the anterior pituitary and its downstream effects both target endocrine organs and the
gland. This plexus allows neurons producing hypothalamic entire body. For example, corticotrophin releasing hormone or factor
releasing factors and inhibitory factors to secrete these factors induces the release of adrenocorticotropic hormone from the anterior
pituitary, which is released into the systemic circulation and activates
into the hypophyseal portal system, which delivers a very high the adrenal cortex to release cortisol and other steroid hormones. This
concentration directly into the secondary plexus in the ante- hypothalamo-pituitary-adrenal system helps to regulate glucose
rior pituitary. Thus, anterior pituitary cells are bathed in metabolism, insulin secretion, immune responses, adipose distribu-
releasing and inhibitory factors in very high concentrations. tion, and a host of other vital functions. The corticotrophin releasing
This private vascular communication channel allows the hormone neurons are under extensive regulatory control by neural
inputs, hormonal feedback, and inflammatory mediators; these
hypothalamus to exert fine control, both directly and through neurons help to orchestrate stress reactivity for the organism as a
feedback, over the secretion of anterior pituitary hormones. whole.
 Vasculature 113

Anterior View Posterior View

Posterior cerebral artery Posterior inferior cerebellar artery

Superior cerebellar artery
Basilar artery Posterior spinal arteries
Anterior inferior cerebellar artery
Vertebral artery
Posterior inferior cerebellar artery
Anterior spinal artery Posterior radicular arteries

Vertebral artery Cervical

vertebrae Deep cervical artery
Anterior radicular arteries
Ascending cervical artery Ascending cervical artery

Deep cervical artery

Subclavian artery Subclavian artery

Anterior radicular artery

Posterior radicular arteries

Posterior intercostal artery

Posterior intercostal arteries

Thoracic vertebrae

Artery of Adamkiewicz
(major anterior radicular artery)

Anterior radicular artery

Posterior radicular arteries

Lumbar artery
Lumbar arteries
Anastomotic loops to
posterior spinal arteries Lumbar vertebrae

Anastomotic loops to anterior spinal artery

Lateral sacral (or median sacral) artery

Lateral sacral (or median sacral) artery

Sacrum

7.20 ARTERIAL BLOOD SUPPLY TO THE SPINAL from the aorta, provide major anastomoses with the anterior
CORD: LONGITUDINAL VIEW and posterior spinal arteries and supplement the blood flow
The major arterial blood supply to the spinal cord derives to the spinal cord. The largest of these anterior radicular arter-
from the anterior spinal artery and the paired posterior spinal ies, often from the L2 region, is the artery of Adamkiewicz.
arteries, both branches of the vertebral artery. The actual Impaired blood flow through these critical radicular arteries,
blood flow through these arteries, derived from the posterior especially during surgical procedures that involve abrupt dis-
circulation, is inadequate to maintain the spinal cord caudally ruption of blood flow through the aorta, can result in spinal
beyond the cervical segments. Radicular arteries, deriving cord infarct.
114 Overview of the Nervous System

Arteries of Cervical Cord

Exposed from the Rear

Basilar artery
Posterior inferior cerebellar artery
Vertebral artery
Anterior spinal artery
Spinal ramus
Posterior spinal artery
Posterior radicular artery
Pre-laminar branch

Anterior spinal artery

Post-central branch
Anterior central artery
Spinal ramus
Neural branch
Anterior radicular artery
Posterior radicular artery
Internal spinal arteries
Posterior central artery
Pre-laminar branch
Posterior spinal artery

Arteries of Spinal Cord Diagrammatically Shown in Horizontal Section

7.21 ANTERIOR AND POSTERIOR SPINAL (resulting from upper motor neuron axonal damage), and
ARTERIES AND THEIR DISTRIBUTION contralateral loss of pain and temperature sensation below
The anterior and posterior spinal arteries travel in the sub- the affected level (resulting from damage to the anterolateral
arachnoid space and send branches into the spinal cord. The spinothalamic/spinoreticular system). The posterior spinal
anterior spinal artery sends alternating branches into the ante- artery branches supply the dorsal third of the spinal cord.
rior median fissure to supply the anterior two thirds of the Occlusion affects the ipsilateral perception of fine discrimina-
spinal cord. Occlusion of one of these branches can result in tive touch, vibratory sensation, and joint position sense below
ipsilateral flaccid paralysis in muscles supplied by the affected the level of the lesion (resulting from damage to fasciculi
segments, ipsilateral spastic paralysis below the affected level gracilis and cuneatus, the dorsal columns).
 Vasculature 115

Posterior spinal arteries

Anterior spinal artery

Anterior radicular artery

Posterior radicular arteries

Branch to vertebral body and dura mater

Spinal branch

Dorsal ramus of posterior intercostal artery

Posterior intercostal arteries

Paravertebral anastomosis

Prevertebral anastomosis

Aorta

Section through Thoracic Spine

Right posterior spinal artery

Peripheral branches from pial plexus

Central branches to right side of spinal cord Central branches to left side of spinal cord

Left posterior spinal artery

Anterior radicular artery
Zone supplied by penetrating
branches from pial plexus
Pial arterial plexus Zone supplied by central branches

Zone supplied by both central branches

Posterior radicular artery and branches from pial plexus

Anterior spinal artery Posterior radicular artery

Anterior radicular artery

Schema of Arterial Distribution
Pial arterial plexus

7.22 ARTERIAL SUPPLY TO THE SPINAL CORD:

anterior spinal artery, acute radiating leg pain is experienced. Depend-
CROSS-SECTIONAL VIEW ing on the level of insult, acute flaccid paraparesis or quadraparesis
The major contribution to the arterial blood supply of the occurs, resolving to spastic paraparesis or quadraparesis with hyper-
spinal cord below the cervical segments derives from the reflexia as the result of the upper motor neuron lesion resulting from
radicular arteries (top). This intercostal blood supply also dis- damage to the bilateral lateral funiculi. Only at the level of the infarct,
tributes to adjacent bony and muscular structures. The pen- where lower motor neurons are lost, does flaccid paralysis remain,
along with hyporeflexia. Bilateral plantar extensor responses are
etrating vessels supplying the spinal cord derive from central seen. Bilateral loss of pain and temperature sensation is seen because
branches of the anterior spinal artery and from a pial plexus of ischemia to the anterolateral territory of the spinothalamic/
of vessels that surround the exterior of the spinal cord. spinoreticular protopathic system. Descending fibers for control of the
bladder and bowel travel in the lateral funiculus and are damaged by
an anterior artery infarct. In a lesion of the anterior spinal artery above
CLINICAL POINT the T1 level, bilateral damage to descending central sympathetic fibers
Alternating branches arise from the anterior spinal artery into the regulating T1 intermediolateral cell column outflow produces bilat-
anterior two thirds of the spinal cord. Following an infarct in the eral Horner’s syndrome, with bilateral ptosis, myosis, and anhidrosis.
116 Overview of the Nervous System

Superior sagittal sinus

Calvaria Arachnoid granulation
Galea aponeurotica Emissary vein Tributary of superficial
Pericranium temporal vein

Skin

Diploic vein Cerebral hemisphere

Falx cerebri
Epidural space (potential) Pia mater
Dura mater Superior cerebral vein
Subdural space Cerebral artery

Arachnoid
Subarachnoid space

VENOUS SYSTEM
CLINICAL POINT
7.23 MENINGES AND SUPERFICIAL Arachnoid granulations act as one-way valves that convey cerebrospi-
CEREBRAL VEINS nal fluid into the dural sinus, channeling it back into the venous
circulation. The cerebral veins also extend across the subarachnoid
The superior sagittal sinus and other dural sinuses receive space and enter into the superior sagittal sinus. With severe head
venous blood from a variety of veins, including superficial trauma, these bridging veins can be torn, with resultant venous bleed-
cerebral veins draining blood from the cortical surface, men- ing into the subdural space; this bleed dissects the dura from the
ingeal veins draining blood from the meninges, diploic veins arachnoid and becomes a space-occupying mass. It also brings
draining blood from channels located between the inner and about cerebral edema and swelling. Acute subdural hematomas can
be life-threatening, especially in young individuals with head trauma.
outer tables of the calvaria, and emissary veins, which link the Chronic subdural hematomas often occur in the elderly with relatively
venous sinuses and diploic veins with veins on the surface minor trauma; the bridging veins tear because of some mild atrophy
of the skull. These channels do not have valves and permit of the underlying hemisphere, making the course of the bridging veins
free communication between these venous systems and the more extended and more vulnerable to tearing. Slow accumulation of
venous sinuses. This is a significant factor in the possible subdural blood eventually can result in increased intracranial pressure
with headache, lethargy, confusion, seizures, and focal neurological
spread of infections from foci outside the cranium to the abnormalities. Surgical drainage is often performed for large subdural
venous sinuses. Recent studies demonstrate a lymphatic drain- hematomas, whereas small hematomas usually regress naturally in the
age network for the meningeal system. elderly.
 Vasculature 117

Scalp, Skull, Meningeal, and Cerebral Blood Vessels

Superior sagittal sinus Arachnoid Cerebral vein penetrating subdural space to enter sinus (bridging veins)
Diploic vein granulation Dura mater (two layers)
Emissary vein Epidural space (potential)
Frontal and parietal tributaries Arachnoid
of superficial temporal vein
Subarachnoid space
Frontal and parietal branches
of superficial temporal artery Pia mater

Arachnoid granulation Middle meningeal

indenting skull (foveola) artery and vein

Venous lacuna Deep middle and

superficial temporal
Inferior sagittal sinus
arteries and veins
Thalamostriate and
internal cerebral veins
Deep and
superficial middle
cerebral veins

Diploic and Emissary Veins of Skull

Parietal emissary vein

Frontal diploic vein
Posterior temporal diploic vein

Occipital emissary vein

Occipital diploic vein

Anterior temporal diploic vein Mastoid emissary vein

7.24 VEINS: SUPERFICIAL CEREBRAL, sinuses. This is a point of vulnerability where potential infec-
MENINGEAL, DIPLOIC, AND EMISSARY tions and contamination from the more superficial venous
Venous blood drains from the skull, the meninges, and the drainage networks can be allowed into the central venous
cerebral cortex into the superior sagittal sinus and other dural sinus channels.
118 Overview of the Nervous System

Falx cerebri (cut) Optic (II) nerve

Intercavernous (circular) sinus and pituitary gland
Superior ophthalmic vein
Internal carotid artery
Basilar plexus Cavernous sinus
Sphenoparietal sinus
Superficial middle cerebral vein
Cavernous sinus Oculomotor (III) nerve
Trochlear (IV) nerve
Trigeminal (V) nerve
Tentorial artery Middle meningeal vein
Abducens (VI) nerve
Superior petrosal sinus
Petrosal vein
Superior and Facial (VII) nerve and nervus intermedius
inferior Vestibulocochlear (VIII) nerve
petrosal Glossopharyngeal (IX) nerve
sinuses Vagus (X) nerve
Jugular foramen
Sigmoid sinus
Tentorium cerebelli Accessory (XI) nerve
Hypoglossal (XII) nerve
Straight sinus Transverse sinus
Great cerebral vein (of Galen)
Falx cerebri (cut) Opening of an inferior cerebral vein
Confluence of sinuses

Superior sagittal sinus

Falx cerebri
Inferior sagittal sinus
Great cerebral vein (of Galen)
Sphenoparietal sinus
Intercavernous sinus
Superior petrosal sinus
Straight sinus
Inferior petrosal sinus
Sigmoid sinus
Jugular foramen
Transverse sinus
Confluence of sinuses
Occipital sinus

7.25 VENOUS SINUSES

CLINICAL POINT
The falx cerebri and tentorium cerebelli, protrusions of fused Venous sinus thrombosis commonly occurs with infection. Cavernous
inner and outer dural membranes, confine the anterior, sinus thrombosis can occur as the result of infection in the paranasal
middle, and posterior fossae of the skull. Outer (superior sag- sinuses or middle ear or following a furuncle in the region of the face.
ittal) and inner (inferior sagittal) venous channels, found in Anterior cavernous sinus thrombosis can result in severe pain and
split layers of the dura, drain blood from the superficial and headache, ipsilateral visual loss, exophthalmos (protrusion of the
eyeball), edema of the eyeball (chemosis), and palsies of the extraocu-
deep regions of the central nervous system, respectively, into lar nerves (III, IV, VI) and V1 (ophthalmic division) that traverse the
the jugular veins. The great cerebral vein of Galen and the sinus. This lesion can expand to cause hemiparesis and can involve
straight sinus merge with the transverse sinus into the conflu- the interconnected cavernous sinus of the other side, the superior
ence of sinuses to drain the deep, more posterior regions of petrosal sinuses, and other venous structures.
the central nervous system. Infection can be introduced into The petrosal sinuses can undergo a process of thrombosis caused
by the spread of infection in the middle ear. An inferior petrosal sinus
the cerebral circulation through these sinuses. Venous sinus thrombosis may cause damage to the VI (abducens) nerve; a superior
thrombosis can cause stasis (a backup of the venous pressure), petrosal sinus thrombosis can result in damage to the semilunar gan-
which results in inadequate perfusion of the regions where glion, producing facial pain. If the transverse sinus is thrombosed,
drainage should occur. The protrusions of dura, such as the cranial nerve deficits in nerves IX, X, and XI may occur.
tentorium cerebelli and falx cerebri, are tough, rigid mem-
branes through which portions of the brain can herniate when
intracranial pressure increases.
 Vasculature 119

Longitudinal fissure
Anterior cerebral veins
Rostrum of corpus callosum
Septum pellucidum
Anterior septal vein
Head of caudate nucleus
Anterior terminal (caudate) vein
Caudate veins
Interventricular foramen (of Monro)
Columns of fornix
Thalamostriate vein
Superior choroidal vein and
choroid plexus of lateral ventricle
Thalamus
Tela choroidea of 3rd ventricle
Direct lateral vein
Posterior terminal (caudate) vein
Internal cerebral veins
Basal vein (of Rosenthal)
Great cerebral vein (of Galen)
Inferior sagittal sinus
Straight sinus
Tentorium cerebelli
Transverse sinus
Confluence of sinuses
Superior sagittal sinus

A. Dissection from Above

Uncal vein

Anterior cerebral vein

Superficial middle cerebral vein

(draining to sphenoparietal sinus)

Deep middle cerebral vein

Inferior cerebral
Cerebral peduncle veins

Basal vein (of Rosenthal)

Lateral geniculate body

Medial geniculate body

Pulvinar

Splenium of corpus callosum

Great cerebral vein (of Galen)

Inferior
anastomotic
vein (of Labbé)
B. Dissection from Below

7.26 DEEP VENOUS DRAINAGE OF THE BRAIN brain stem removed illustrates the drainage of forebrain and
A, This superior view of the thalamus and basal ganglia reveals mesencephalic venous blood into the great cerebral vein of
the venous drainage of deeper forebrain regions into the pos- Galen, heading toward the straight sinus.
terior venous sinuses. B, This basal view of the brain with the
120 Overview of the Nervous System

Subependymal Veins Veins on lateral wall of ventricle

Veins on medial wall and floor of ventricle
Superior choroidal vein All other veins
Caudate veins Posterior septal vein
Lateral ventricle Direct lateral vein
Thalamostriate vein Posterior terminal (caudate) vein (posterior part of thalamostriate vein)
Anterior terminal (caudate) vein Internal cerebral vein
Anterior septal vein Medial atrial vein
Genu of corpus Lateral atrial vein
callosum Splenium of corpus callosum
Inferior sagittal sinus
Posterior pericallosal vein
Internal occipital vein
Great cerebral vein
(of Galen)
Post horn of
lateral ventricle

Interventricular Straight sinus

foramen (of Monro)
Superior thalamostriate veins
Anterior commissure
Interthalamic adhesion
3rd ventricle
Anterior cerebral vein
Optic chiasm
Deep middle cerebral vein
Inferior thalamostriate veins
Basal vein (of Rosenthal)
Inferior horn of lateral ventricle
Cerebellum
Posterior mesencephalic vein 4th ventricle
Hippocampal and inferior ventricular veins Median aperture (of Magendie)
Cerebral aqueduct Lateral aperture (of Luschka)

7.27 DEEP VENOUS DRAINAGE OF THE BRAIN:

CLINICAL POINT
RELATIONSHIP TO THE VENTRICLES Venous thrombosis can occur following an infectious process, espe-
Subependymal regions of the central nervous system drain cially in the nearby sinuses, middle ear, or adjacent facial areas. Non-
venous blood into the inferior sagittal sinus superiorly or into infectious causes of venous thrombosis include dehydration, cancer,
the great cerebral vein of Galen inferiorly, both of which drain polycythemia vera and other hyperviscosity syndromes, inflammatory
into the straight sinus. Occlusion of a vein in this region conditions, and other disorders. The symptoms vary according to the
affected focal territory and the spread of the underlying pathological
causes a blockage of drainage and a backup of perfusion, with process; they include severe headache, nausea and vomiting, weakness
resultant ischemia of the tissue in the regions of drainage. and sensory losses, sometimes aphasia, and sometimes coma.
 Vasculature 121

Subependymal and Superficial Veins Opacified

A. Lateral projection
Caudate vein Posterior terminal (caudate) vein

Anterior terminal (caudate) vein Superior anastomotic vein (of Trolard)

Superior sagittal sinus

Inferior sagittal sinus

Internal cerebral vein

Great cerebral vein (of Galen)

Straight sinus

Anterior septal vein Internal Transverse sinus

jugular
vein Inferior anastomotic vein (of Labbé)
Thalamostriate vein
Basal vein (of Rosenthal)
Superior choroidal vein

B. Frontal projection Thalamostriate vein Superior sagittal sinus

Superficial cortical veins

Straight sinus

Transverse sinus

Internal jugular vein Internal cerebral vein

Basal vein (of Rosenthal) Great cerebral vein (of Galen)

7.28 CAROTID VENOGRAMS: VENOUS PHASE the transverse sinus, the basal vein of Rosenthal, and the inter-
These lateral and anterior venous-phase angiograms illustrate nal jugular, through which the venous blood of the brain
the superior sagittal sinus, the inferior sagittal sinus, and the drains back to the heart. See Video 7-5.
great cerebral vein of Galen draining into the straight sinus,
122 Overview of the Nervous System

Superior sagittal sinus

Transverse sinus

Sigmoid sinus

Internal jugular vein

A. Coronal view

Cerebral veins

Superior sagittal sinus

Internal cerebral vein

Great vein of Galen

Basal vein of Rosenthal

Straight sinus

Confluence of sinus

Transverse sinus

B. Lateral view

7.29 MAGNETIC RESONANCE VENOGRAPHY: above the heart prior to placing imaging slices. In a typical
CORONAL AND SAGITTAL VIEWS magnetic resonance venography of the head, a saturation slab
Magnetic resonance venography uses the same principles of is placed at the level of the carotid bifurcation, and traveling
flow imaging used in MRA (see Fig. 7.14). The flow of venous saturation is placed inferiorly to the slice. Multiple two-
blood in the brain is relatively slow and steady compared to dimensional thin slices are placed nearly perpendicular to the
the flow of arterial blood. Gradient echo sequences are sensi- vessels. A, Coronal view. B, Sagittal view. These images illus-
tive to flow but are not sensitive to direction of flow. To dis- trate the major cerebral veins and sinuses of the brain. See
tinguish arterial flow from venous flow, a presaturation slab Video 7-6.
must be applied downstream below the heart or upstream
 Vasculature 123

Parts of cerebellum
L lingula TU tuber
CL central lobule P pyramid
Left superior and inferior colliculi C culmen U uvula
Left pulvinar D declive N nodule
Basal vein (of Rosenthal) Right thalamus F folium T tonsil
Posterior mesencephalic vein
Internal cerebral veins
Medial geniculate body
Splenium of corpus callosum
Lateral mesencephalic vein
Cut surface of Great cerebral vein (of Galen)
left thalamus Inferior sagittal sinus
Lateral geniculate Superior
body cerebellar
Optic tract vein
Inferior (inconstant)
thalamostriate
vein Superior
Anterior vermian
cerebral vein vein
Straight
Optic (II) sinus
nerve
Falx cerebri
Deep C
C Superior
middle
sagittal sinus
cerebral
vein CL D Tentorium
cerebelli (cut)
F Intraculminate
Anterior L
pontomesen- TU vein
cephalic Preculminate vein
vein N P Confluence
Trigeminal of sinuses
(V) nerve U
Petrosal vein Left transverse sinus
(draining to
Inferior vermian vein
superior
petrosal sinus) T Falx cerebelli
Transverse pontine vein (cut) and occipital sinus
Vestibulocochlear (VIII) nerve Inferior cerebellar
hemispheric vein
Facial (VII) nerve
Precentral vein
Anterior medullary vein
Left lateral brachial vein
Vein of lateral recess of 4th ventricle
Inferior retrotonsillar vein
Superior, middle, and
inferior cerebellar peduncles Superior retrotonsillar vein
4th ventricle Posterior spinal vein
Anterior spinal vein

7.30 VENOUS DRAINAGE OF THE BRAIN STEM medial portion of the superior and inferior cerebellar hemi-
AND THE CEREBELLUM spheres into the transverse sinus or the straight sinus.
The venous drainage of the cerebellum and the brain stem is
anatomically diverse. The veins of the posterior fossa drain
the cerebellum and brain stem. The superior group drains the
superior cerebellum and upper brain stem posteriorly into the CLINICAL POINT
great cerebral vein of Galen and the straight sinus or laterally The confluence of sinuses occurs at the junction of the posterior fossa
and the occipital lobe. The superior sagittal sinus drains into this
into the transverse and superior petrosal sinuses. The anterior, confluence of sinuses as the blood flows ultimately toward the jugular
or petrosal, group drains the anterior brain stem, the superior vein. The most common sinus thrombosis is that of the superior sagit-
and inferior surfaces of the cerebellar hemispheres, and the tal sinus. Thrombosis in the posterior portion of this sinus results in
lateral regions associated with the fourth ventricle into the headache, increased intracranial pressure with resultant papilledema
superior petrosal sinus. The posterior, or tentorial, group (after 24 hours), and often a diminished state of consciousness or
coma.
drains the inferior portion of the cerebellar vermis and the
124 Overview of the Nervous System

Veins of Spinal Cord and Vertebrae

Anterior external venous plexus

Posterior external venous plexus
Anterior internal venous plexus
Intervertebral vein
Basivertebral vein

Anterior internal
Anterior external venous plexus
venous plexus

Basivertebral vein

Anterior and posterior

radicular veins
Anterior spinal vein Basivertebral vein
Posterior internal
venous plexus
Anterior central vein Anterior internal
venous plexus Intervertebral vein

Posterior external
venous plexus

Intervertebral vein
Anterior radicular vein
Posterior radicular vein
Internal spinal veins
Pial venous plexus
Posterior central vein
Posterior spinal vein
Posterior internal venous plexus

7.31 VENOUS DRAINAGE OF THE SPINAL CORD

CLINICAL POINT
An external and internal plexus of veins extends along the A venous plexus is present in the epidural space surrounding the
entire length of the vertebral column, forming a series of spinal cord, along with epidural fat. This epidural space is wide
venous rings with extensive anastomoses around each verte- enough for the insertion of a catheter and infusion of local anesthesia.
bra. Blood from the spinal cord, the vertebrae, and the liga- The local anesthesia is absorbed into this plexus and diffuses into the
ments drains into these plexuses. Changes in intrathoracic adjacent spinal cord, producing profound analgesia at and below the
level of the infusion. This technique of epidural anesthesia often is
pressure and cerebrospinal fluid pressure can be conveyed used for analgesia in childbirth and also for a variety of surgeries in
through these venous plexuses, affecting the venous volume. which epidural anesthesia is preferable to general anesthesia.
Ultimately, these venous plexuses drain through the interver-
tebral veins into vertebral, posterior intercostals, subcostal,
and lumbar and lateral sacral veins.