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Cerebral Vascular Lecture

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This lecture was presented to the Osteopathic students at the Pacific Northwest University of Health Sciences in Yakima Washington.

This lecture was presented to the Osteopathic students at the Pacific Northwest University of Health Sciences in Yakima Washington.

Published in: Health & Medicine

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  • CLINICALLY RELEVENT FOR THE BRAIN INJURED PATIENT CPP-CEREBRAL PERFUSION PRESSURE, MAP-MEAN ARTERIAL PRESSURE=DIASTOLIC PRESSURE + 1/3(PULSE PRESSURE) NORMAL RANGE 80-90mmHg, ICP- INTRACRANIAL PRESSURE -ABOVE 20mmHg is pathologic (normal range varies from 3-20 mmHg)[MONRO-KELLIE HYPOTHESIS]-THE SUM OF THE INTRACRANIAL VOLUMES OF BLOOD, BRAIN, CSF, AND OTHER COMPONENTS (e.g. TUMOR, HEMATOMA) IS CONSTANT, AND AN ICREASE IN ANY ONE OF THESE MUST BE OFFSET BY AN EQUAL DECREASE IN ANOTHER OR ELSE PRESSURE WILL RISE
  • SOME TEXTS CONSIDER PCOM TO BE IN THIS CATEGORY SINCE A PCOM ANEURYSM IS CONSIDERED AN ANT. CIRCULATION ANEURYSMANT. AND POST. CIRCULATION DIVISION DESCRIPTIONS ARE USED IN THE CLINICAL SETTING TO HELP DESCRIBE THE REGION OF A CEREBRAL VASCULAR EVENT
  • CAVERNOUS SEGMENT AND IT’S ASSOCIATIONS WITH CN’S WITHIN THE CAVERNOUS SINUS HAS CLINICAL IMPORTANCE (e.g. CAVERNOUS SINUS THROMBOSIS SECODARY TO SINUS INFECTION) . THIS IS ADDRESSED LATER.
  • THIS SLIDE SUMMERIZES THE ENTIRE ANTERIOR CIRCULATING SYSTEM
  • VERT. ART. ENTRY INTO THE SPINE MAY VARY C-7 TO C3V-3 SEGMENT LOOPS CAUDAL AND MEDIALLY AROUND LATERAL MASS OF ATLAS ( VULNERABLE TO INJURY) SEE NEXT SLIDE FOR DIAGRAM
  • NOTE ARCHES AROUND POST-LAT MEDULLA THEN BRANCHES FEEDING MEDIAL INFERIOR CEREBELLUM
  • THIS IS THE FIRST MAJOR BRANCH OF THE BASILAR ARTERYPASSES THROUGH CEREBELLOPONTINE CISTERN
  • NOTE: THE BASILAR ARTERY RESIDES IN THE PREPONTINE CISTERN.NOTE: CN III EXITS PONS BETWEEN SCA AND PCANOTE: AICA’S RELATIONSHIP TO CN’S 7&8NOTE: SCA’S RELATIONSHIP TO CN 5 – TRIGEMINAL NEURALGIA IS FREQUENTLY CAUSED BY THIS ARTERY COMPRESSING THE TRIGEMINAL NERVE NEAR IT’S EXIT.
  • SEE DORSAL VIEW OF BRAIN IMAGEWHAT ARE SOME OF THE MAJOR DIFFERENCES BETWEEN ANTERIOR AND POSTERIOR CIRCULATION STROKES?
  • Note: cavernous sinus and close relationship with upper brain stem cn’s
  • Note: ANASTOMOTIC CONNECTIONS FORMING A COLLATERAL FLOW SYSTEMVENOUS OCCLUSSION CAN LEAD TO LARGE HEMORRHAGIC INFARCTS.THE RIGHT LATERAL SINUS IS USUALLY DOMINANT
  • NOTE THE DEEP CEREBRAL VEINS
  • Transcript

    • 1. DR. MICHAEL THOMAS CEREBRAL VASCULAR ANATOMY
    • 2. Chapter 8 Cerebral vascular system Causes of vascular compromise Internal carotid system Vertibrobasilar system Arteries and infarcts Circle of Willis Veins Spinal cord blood flow The blood-brain barrier Focus on these aspects: 1. Classification of bleeds 2. Principal branches and areas supplied by the internal carotid system 3. The vertebral and basilar arteries and the associated areas 4. Anastomoses between ICS and VBS 5. The circle of Willis 6. Superficial and deep venous drainage of the brain 7. The blood-brain barrier
    • 3. HEMODYNAMICS  BRAIN REQUIRES 20% OF TOTAL BODY O2  CEREBRAL BLOOD FLOW IS16% OF CARDIAC OUTPUT  CEREBRAL PERFUSION PRESSURE (CPP) – MUST BE GREATER THAN 50mmHg TO MAINTAIN CELLULAR INTEGRETY  IRREVESIBLE BRAIN DAMAGE OCCURS AFTER 4 MIN OF CIRCULATORY ARREST
    • 4. CPP=MAP-ICP NORMAL ICP <20 mmHg MAP-mean arterial pressure
    • 5. ANTERIOR CIRCULATION  ICA –INTERNAL CAROTID ARTERY  ACA –anterior cerebral artery  Acom – anterior communicating artery  MCA – middle cerebral artery
    • 6. POSTERIOR CIRCULATION  VERTEBROBASILAR SYSTEM  PICA – posterior inferior cerebellar artery  AICA – anterior inferior cerebellar artery  SCA – superior cerebellar artery  PCA – posterior cerebral artery PRIMARY SOURCE OF BLOOD FOR BRAIN STEM AND CEREBELLUM
    • 7. INTERNAL CAROTID ARTERY SEGMENTS  CERVICAL – common carotid bifurcation to skull base  PETROUS –encased by petrous portion of temperal bone  CAVERNOUS – contained within cavernous sinus (hypophyseal and meningeal branches)  CEREBRAL – cavernous carotid to terminus (opthalmic, posterior communicating, and anterior choroidal arteries)
    • 8. 4 Main Branches of the Internal Carotid Artery and Sub-branches Posterior communicating artery.Usually small artery that connects to Frontal branches the vertebral system Parietal branches Anterior choroidal artery.Small artery that supplies the optic track (anterior choroidal artery syndrome), and internal capsule Middle cerebral artery. The major branch. Supplies most of superolateral surface of the hemispheres M1 + lenticulostriate (sylvian cistern) internal superior and inferior M2 insular cortex M3 opercular (over the insula) M4 cortical Anterior cerebral artery. Other major branch. Supplies the medial surface of the frontal and parietal cortex and corpus callosum A1 cistern of the lamina terminalis A2 infracallosal A3 precallosal A4 supracallosal A5 postcallosal Temporal branches Anterior communicating artery. Short stout channel between the two anterior cerebral arteries near their origin Frontopolar arteries supply anteromedial frontal lobe. Pericallosal artery sweeps posterior just superiorly to the corpus callosum Callosomarginal artery usually in the cingulate sulcus
    • 9. ACA MCA Larger in 70% Ophthalamic Post communicating Anterior choroidal Pierces dura Hypophysial and meningial Carotid canal
    • 10. Coronal section middle cerebral artery Supply basal ganglia and internal capsule
    • 11. Dorsal surface branches
    • 12. Medial surface of hemispheres and inferior surface of temporal lobe border
    • 13. MCA M4 surface segments
    • 14. Regions served by ACA / MCA / PCA
    • 15. VERTEBRAL ARTERY  4 SEGMENTS V-1 TO V-4  V-1 ORIGIN SUBCLAVIAN TO C-6 TRANSVERSE FORAMEN  V-2 C-6 TRANSVERSE FORAMEN TO C-2  V-3 C2 TO ATLANTO-OCCIPITAL MEMBRANE  V-4 TRAVERSES DURA TO UNITE WITH OPPOSITE VERTEBRAL ARTERY
    • 16. The vertebrobasilar artery system. Supply spinal cord, brainstem, cerebellum, and posteroinferior cerebral hemisphere. 1. Spinal arteries branch from the vertebral. Anterior and posterior spinal artery Basilar 2. Posterior inferior cerebellar artery branches from each vertebral artery. Supplies lateral medulla and PI cerebellum 3. Basilar artery formed from union of two vertebral arteries 4. Basilar artery ends in bifurcation into paired posterior cerebral arteries
    • 17. PICA  LOCATION CISTERNA MAGNA  MAJOR BLOOD SUPPLY TO THE MEDULLA  POSTERIOR SPINAL ARTERY USUALLY BRANCHES FROM PICA  POSITIONED NEXT TO CRANIAL NERVES 9, 10, AND 11
    • 18. AICA  BLOOD SUPPLY TO VENTRAL-LATERAL CEREBELLUM, PONS, CHOROID PLEXUS  POSITIONED NEXT TO CRANIAL NERVES 7&8
    • 19. SUPERIOR CEREBELLAR ARTERY SUPPLIES MEDIAL, LATERAL, AND SUPERIOR CEREBELLAR CORTEX AND CEREBELLAR NUCLEI AND MIDBRAIN PASSES JUST CAUDAL TO CN III THROUGH AMBIANT CISTERN
    • 20. PCA  P-1 – FROM BASILAR BIFURCATION TO PCOM ( GIVES OFF SMALL BRAINSTEM FEEDERS)  P-2 – FROM PCOM TO INFERIOR TEMPERAL BRANCHES ( GIVES OFF SMALL THALAMOGENICLATE BRANCHES)  P-3 – PORTION THAT GIVES RISE TO TEMPERAL BRANCHES  P-4 – BRANCHES MEDIAL FORMING CALCARINE AND PARIETAL-OCCIPITAL ARTERIES
    • 21. DORSAL BRAINSTEM VIEW
    • 22. VENTRAL BRAINSTEM VIEW
    • 23. The circle of Willis. A series of arteries that provides anastomotic communication between the left and right arterial trees and between the internal carotid and vertebral systems 1. 2. 3. 4. 5. Anterior communicating artery Anterior cerebral artery Internal carotid artery Posterior communicating artery Posterior cerebral artery Ganglion arteries (not shown) branch from the circle of Willis and supply diencephalon and base of telencephalon Segments of the anterior and posterior cerebral arteries
    • 24. DEEP GANGLIONIC PERFORATING ARTERIES
    • 25. Spinal cord blood supply 3 MAIN ARTERIES -ANTERIOR SPINAL ARTERY - 2 POSTERIOR SPINAL ARTERIES - ADAMKIEWCZ- ORIGIN IS LEFT SPINOMEDULLARY ARTERY T-12 – L1 SUPPLIES LOWER THORACIC AND UPPER LUMBAR CORD
    • 26. Venous Circulation
    • 27. CEREBRALVENOUSCHARACTERISTICS  MULTIPLE ANASTOMOTIC CHANNELS  MULTIPLE VENOUS SINUSES CAVERNOUS,PETROSAL, SUPERIOR, INFERIOR, STRAIGHT, TRANSVERSE, SIGMOID  NONVALVULAR SYSTEM  4 UNPAIRED VEINS SUPERIOR SAGITAL SINUS, INFERIOR SAGITAL SINUS, VEIN OF GALEN, STRAIGHT SINUS
    • 28. DIVISIONS 1. BASAL VIENS (LATERAL SINUS, ROSENTHAL, PETROSAL SINUS, CAVERNOUS SINUS)
    • 29. 2. CEREBRAL – (SUPERIOR SAGITAL SINUS, ANASTOMOTIC VEINS - TROLARD,LABBE, SUPERIOR MIDDLE CEREBRAL VEIN
    • 30. 3. INTERNAL VEINS – DRAIN INTO THE VEIN OF GALEN
    • 31. Galen Vein of Straight sinus VEIN OF GALEN MALFORMATION
    • 32. Blood Brain Barrier
    • 33. BLOOD BRAIN BARRIER - PHYSIOLOGICBARRIERPREVENTS MOVEMENT OF HIGH MOLECULAR WEIGHT MOLECULES - ABSENT FENESTRATIONS - TIGHT JUNCTIONS
    • 34. REGIONS WITH NO BBB 1. AREA POSTREMA 2. PINEAL AND PREOPTIC RECESSES 3. TUBER CINEREUM 4. HYPOPHYSIS 5. CHOROID PLEXUS
    • 35. BBB DISRUPTION GLIOBLASTOMA MULTIFORME WITH VASOGENIC EDEMA BBB BREAKS DOWN UNDER DISEASE STATES
    • 36. CEREBRAL SPINAL FLUID PRODUCTION & ABSORPTION
    • 37. SUPERIOR SAGITAL SINUS OCCLUSION FROM MENINGIOMA
    • 38. Causes of vascular compromise: A. Aneurysm small (berry or saccular) large >2cm fusiform (elongated) 85% ICA system 15% VB system B. Embolism thrombus – blood transient ischemic attack septic emboli C. arteriovenus malformation teens and young adult share some features of neoplasm 1. dynamic 2. lead to hemorrhage
    • 39. SUBARACHNOID HEMORRHAGE  CLOSED HEAD INJURY MOST COMMON ETIOLOGY  ANEURYSM RUPTURE ALMOST ALLWAYS CAUSE SAH  TRAUMATIC SAH OCCURS COMMONLY AT CONVEXITIES  ANEURYSMAL SAH OCCURS COMMONLY IN BASILAR CISTRNS  RARELY ANEURYSMAL SAH WILL EXTEND INTO THE VENTRICLE  MAY CAUSE HYDROCEPHALUS
    • 40. SUBARACHNOID HEMORRHAGE POSTERIOR COMMUNICATING ARTERY ANEURYSM
    • 41. CEREBRAL ANEURYSMS  85% ANTERIOR CIRCULATION  OCCURS NEAR BRANCHING VESSELS  CAN CAUSE COMPRESSIVE CRAINIAL NEUROPAHTY(pcom aneurysm compressing cn III causing ptosis AND PUPIL DILATION  3 TYPES SACCULAR FUSIFORME MYCOTIC
    • 42. Common patterns of aneurysms: branches and tortuous turns ICA system VB system
    • 43. ANEURYSM TREATMENT  SURGICAL CLIP LIGATION  ENDOVASCULAR COILING  ANEURYSM BYPASS AND CLIP LIGATION  COMBINATION COILING AND CLIPPING
    • 44. Basilar Artery Apex Aneurysm Occipital AVM
    • 45. The cavernous sinus Aneurysm Fistula
    • 46. ARTERIAL VENOUS MALFORMATION  DIRECT CONNECTION BETWEEN ARTERY AND      VEIN CAPILLARY BED IS ABSENT NO INTERVIENING BRAIN TISSUE MEDIUM TO HIGH FLOW USUALLY PRESENTS WITH HEMORRAGE OR SEIZURE PREGNANCY MAY CAUSE AVM TO GROW
    • 47. AVM TREATMENT SURGICAL RESECTION  INDICATED IF ELEQUENT BRAIN IS NOT INVOLVED EMBOLIZATION  ENDOVASCULAR TECHNIQUES MAY HELP FACILITATE SURGERY. USUALLY REQUIORES MULTIPLE PROCEDURES RADIATION  STEREOTACTIC RADIATION MAY BE USED FOR COMBINATION THERAPY  ALL THREE TREATMENT OPTIONS MAY BE SMALL AVMs. USED FOR COMPLEX AVMs
    • 48. AVM
    • 49. ARTERIOVENOUS MALFORMATION
    • 50. SUBDURAL HEMORRHAGE