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Normal cerebral angiogram final
- 1. Presenter: Dr. Nikhilpanpalia Guide: Dr.K.R.Naik
- 2. Understanding vascularanatomy is fundamental to neuroimaging. About 18% of the total blood volume in the body circulates in the brain, which accounts for about 2% of the body weight. The blood transports oxygen, nutrients, and other substances necessary for proper functioning of the brain tissues and carries away metabolites. Loss of consciousness occurs in less than 15 seconds after blood flow to the brain has stopped, and irreparable damage to the brain tissue occurs within 5 minutes. Cerebrovascular disease or stroke, occurs as a result of vascular compromise or haemorrhage and is one of the most frequent sources of neurologic disability.
- 3. Part 1– Aortic arch and great vessels Carotid arteries Circle ofWillis Part 2 – Cerebral arteries Posterior fossa arteries – vertebrobasilar system
- 4. 1. Conventional intra-arterialangiography – DSA system - techniques of image acquisition Standard radiographic projections carotid angio- ▪ Lateral projection – centered on pituitary fossa ▪ AP view – with petrous ridge projected over the roof of orbit ▪ I/L anterior oblique – for aneurysms in SAH Vertebral angio – ▪ lateral , half-axial (Towne’s) and AP – petrous ridge superimposed on lower border of orbit 2. Computed tomography angiography 3. Magnetic resonance angiography 4. Doppler ultrasound
- 5. Starts from aorticarch : Aortic arch Innonimate or brachiocephalic artery Left common carotid Left subclavian Brachiocephalic or innonimate Rt common carotid Rt subclavian
- 6. 3 . Innonimateartery 10. Left subclavian artery 15. Left common carotid artery
- 7. 4. Right subclavian artery 5.Right common carotid artery
- 8. Right subclavian artery Right vertebral artery Internal mammaryartery Thyrocervical trunk Costocervical trunk
- 9. 6. Right vertebralartery 9. Internal mammary artery 16.Thyrocervical trunk 16
- 10. Common archanomaly 0.5-1% of all cases Here it is the last brachiocephalic vessel arising from aortic arch -4th branch Often asymptomatic – 10 % of people can have dysphagia lusoria. Right common carotid arises directly from arch – first branch
- 11. Barium studies –fixed narrowing of esophagus at the level of arch without mucosal deformity – bayonet deformity
- 12. 1st Branchof right subclavian artery Right vertebral artery dominant -25% Anomalous origin – uncommon
- 13. Arises fromproximal brachicephalic Only cervical part as it arises caudally
- 14. RCCA –directly from aortic arch ( when right SCA is aberrant ) RCCA RSCA
- 15. 2nd majorbranch from aortic arch Thoracic and cervical part –in thoracic it travels upwards throu superior mediastinum to the level of left sternoclavicular joint and continues as cervical 15.Left common carotid CCA bifurcates into ICA and ECA at midcervical level C3-C6 level.
- 16.
- 17. LCCA –hypoplastic or absent – here the ECA and ICA arise directly from aortic arch
- 18. Last branchfrom aortic arch Major branches - Left subclavian artery Left vertebral artery Internal mammary Thyrocervical trunk Costocervicalt runk
- 19. First branchof left subclavian artery Dominant in 50-60% In 25% right and leftVA are equal in size 11.Left vertebral artery 14.Left internal mammary
- 20. Left vertebralartery –directly from aortic arch -5% ( nondominant )
- 21.
- 22. Course -Runs within a fascial plane – the carotid sheath – also contains IJV and vagus nerve( vein lateral to artery , nerve between the two) (VNA) Runs obliquely upwards from the level of sternoclavicular joint to the level of thyroid cartilage Bifurcates at the level of C3- C5 into external and internal carotid artery At bifurcation ICA usually lies posterior and lateral to the ECA
- 23. Smaller ofthe 2 carotids. Origin anterior and medial to ICA. Supplies the extracranial structures. Branches –( Sister Lucy’s Powdered Face Attracts SO Many Medicos ) Internal carotid artery External carotid artery Common carotid artery
- 24. External carotid artery Anterior Superior thyroidal(sister) Lingual (lucy) Facial (face) Posterior Occipital Posterior auricular (powdered) Medial Ascending pharyngeal (attracts) Terminal Maxillary (many) Superficial temporal (so)
- 25.
- 26. Superior thyroid artery Lingualartery Facial artery Occipital artery Posterior auricular artery Ascending pharyngeal artery Early arterial phase of CCA angiogram
- 27. Late arterial phaseof CCA angiogram Posterior auricular artery Occipital artery Facial artery Lingual artery Superficial temporal artery Maxillary artery Transverse facial
- 28. Internal maxillaryartery- Runs forward deep to the mandible. Branches – inferior alveolar, middle meningeal, deep temporal , accessory meningeal , sphenopalatine , infraorbital , descending palatine, muscular branches. Middle meningeal artery – runs superiorly crosses STA on lateral projection thro foramen spinosum. Supplies – dura and inner table of skull.
- 29. On angiogramshould be differentiated from middle meningeal artery – characteristic hairpin turn of STA over zygomatic process Supplies –part of scalp and ear. Branch – transverse facial artery Variant –TFA may arise from ECA directly STA Middle meningeal artery hairpin turn of STA
- 30. Oblique view –MRA Vertebral artery Thyrocervical trunk Facial artery Lingual artery Superficial temporal artery Occipital artery Maxillary artery
- 31. Straight AP view– MRA Superficial temporal artery Hairpin turn of STA Maxillary artery Facial artery Lingual artery Vertebral artery Middle meningeal artery
- 32. Left CCA Right CCA Internalcarotid- carotid bulb ECA 3-D CTA • Origin -Lateral to ECA. • Can be divided into number of segments between the bulb and its bifurcation into MCA and ACA.
- 33.
- 34.
- 35. Distal 2-4cm of CCA Bulbous dilatation of ICA origin Thinner media and thicker adventitia containing many receptor endings of glossopharyngeal nerve
- 36. No narrowing No dilatation No branches No tapering Course – crosses behind and medial to ECA ICA ICA ECA
- 37. 10%- ICA originatesmedial to ECA Anomalous ECA branches arises from cervical ICA Persistent embryonic vesels may anastomose with vertebrobasilar system ICA ECA
- 38. Vertical •Short vertical segment– anterior to IJV •Genu – petrous ICA turns anteromedially in front of cochlea •Longer horizontal segment ICA –intraosseous 1. enters carotid canal in petrous temporal bone. 2. Surrounded by sympathetic plexus 3. exit at petrous apex Horizontal Genu
- 39. Petrous segment ofICA • Branches supply middle earIntrapetrous • Inconstant • Throu Foramen lacerum and vidian canal • Anastomose with branches of ECA (Recurrent br of greater palatine) Vidian artery (artery of Pterygoid canal ) • Important branch –tympanic cavity • Supplies middle and inner ear Corticotympanic artery
- 40. Axial NECT inferiorto superior ( bone window )
- 42. Aberrant course •Posterolateral coursethro temporal bone •Vertical segment of carotid canal absent Normal course of ICA •Anteromedial course thro temporal bone •3 segments
- 43. Rare- 0.48% Intrapetrous embryonicvascular channel. Origin – petrous ICA Course – passes throu the footplate of stapes. Termination – as middle meningeal artery CT- absentI/Lforamenspinosum d/d – glomus tumor Recognised before surgery
- 44. Small segment thatextends from petrous apex above foramen lacerum curving upwards and then becomes the cavernous segment Covered by trigeminal ganglion No branches
- 45.
- 46. C4 segments 1. Ascending(posterior vertical ) 2. Posterior genu 3. Horizontal 4. Anterior genu 5. Anterior vertical Branches Meningohypophyseal artery Inferolateral trunk Small capsular branches Starts from petrous apex Terminates at its entrance into intracranial subarchnoid space adjacent to anterior clinoid process. Covered by trigeminal ganglion posteriorly.
- 47.
- 48. Axial CT Posterior genuas it courses anteromedially into the cavernous sinus ICA courses along the bony grooves of carotid sulcus along the basisphenoid bone •Throu cavernous sinus proper turns superiorly • Form grooves under anterior clinoid process • Anterior genu of ICA . • Curve upwards towards dural ring • Enter subarchnoid space Posterior genu Carotid sulcus Anterior genu
- 50. Menigohypophyseal artery •Posterior trunk •Arisesat junction of c4 and c5 •Supplies – •pituitary gland •tentorium •cavernous sinus • clival dura • CN 3 , 4 •Enlarges to supply dural vascular malformation / neoplasm Inferolateral trunk • Lateral mainstream artery • Arises – inferolaterally from c4 segment • Supplies – • CN 3,4,6 • gasserian ganglion CN5 • cavernous sinus dura • Anastomose with br of internal maxillary artery . • Enlarged – vascular neoplasm / malformation / collaterals to ECA
- 51. •Starts distal lyto cavernous sinus •Ends as near anterior clinoid process •No important branches
- 52. Extends from superior clinoidto just below posterior communicating artery (PCoA) origin Branches – •Opthalmic artery •Superior hypophyseal artery CECT Anterior clinoid process C6
- 53. Origin – • Intradural •Antero-superiorICA • Medial to anterior clinoid process Course – Anterior throu optic canal Below optic nerve Crosses superomedially over the nerve Supply -globe Gives off ocular , lacrimal , muscular branches •Anastomose with ECA
- 54. Mid arterial phaseDSA Lateral view MRA Lateral DSA
- 55. Arises from posteromedialaspect of supraclinoid ICA Course – across the ventral surface of optic chaisma Terminates- pituitary stalk and gland Supplies – anterior pituitary , Infundibulum , optic nerve and chaisma Anastomose - with hypophyseal branch from the contralateral ICA forms plexus – superior hypophyseal plexus DSA – usually not visualized if not enlarged
- 56. •Extends from belowPCoA to terminal ICA bifurcation. •Passes between optic and occulumotor nerve. C7 segment branches Posterior communicating artery Anterior choroidal artery Lateral DSA AChA PCoA 3D CTA
- 57. •Arises – posterioraspect of intradural ICA just below anterior choroidal artery •Course – posterolaterally above the occulumotor nerve to join posterior cerebral artery •Branches – anterior thalamoperforating arteries •Supplies – optic chiasma, pituitary stalk , thalamus , hypothalamus. Lateral late arterial DSA MRA
- 58. 1. Hypoplasia –1/3 rd cases 2. PCoA duplication/ fenestraion – rare PCoA fenestration PCoA hypoplasia
- 59. • PCoM islarger than P1 segment of PCA and supplies the bulk of PCA . PCA therefore is a part of anterior circulation
- 60. •Infundibular dilatation ofPCoA at origin from ICA- 5-15% •Should be 2 mm or less •Funnel shaped , conical •PCoA arises from apex
- 61. Within suprasellar cisternunder optic tract Posteromedially around temporal lobe uncus Cisternal Course : Intraventricular course: AChA angles sharply laterally Enters choroidal fissure of temporal bone Abrupt kink – plexal point AChA-origin few mms above PCoA Cisternal segment Intraventricular segment
- 62. Supplies Choroidal plexus oflateral ventricle ( temporal horn and atrium ) Optic tract and cerebral peduncle Uncal and parahippocampal gyri of temporal lobe . Thalamus and posterior limb of internal capsule. Anastamoses – with AChA segments and LPChA and MPChA Variants – uncommon Aplasia rare Hypoplasia – 3 % Hyperplasia – 2.3 % AP mid arterial DSA AP Late arterial DSAMRA lateral view Choriodal blush
- 63. Terminal ICA Anterior cerebralartery Middle cerebral artery 3D CTA MCA ACA ICA 3D CTAMid arterial phase DSA
- 65. Maxillary artery • Middlemeningeal artery • Foramen rotundum artery • Accessory meningeal • Vidian artery • Ant / mid deep temporal ICA • Ethmoidal br of opthalmic artery • Inferlolateral trunk of ICA • Inferolateral trunk • Intratemporal ICA • Opthalmic artery
- 66. • Occipital • Ascendingpharyngeal artery • Ascending pharyngeal artery • Facial artery • Posterior auricular artery • Vertebral • Vertebral C3 level • ICA (petrous and cavernous ) • ICA (opthalmic artery) • ICA (stylomastoid artery)
- 67. 2ICAs Horizontal segment A1 ofboth ACAs 2 Posterior communicating arteries Anterior communicating artery Horizontal segment P1 of both PCA s Basilar artery
- 68. Interconnected arterial polygon Location –surrounds ventral surface of diencephalon, adjacent to optic nerve and tracts, inferolateral to hypothalamus Anterior circulation 2 B/L ICAs 2ACAs UnpairedACoA anteriorly Posterior circulation Basilar bifurcation from mergedVAs 2PCAs from BAs B/L PCoAs
- 69. 3DVRT CTA MRA CTMRA 1. A1 2. P1 3. PCoA 4. ACoA
- 70. • Medial lenticulostriatearteries • Recurrent artery of HeubnerACAs • Perforating branches – hypothalamus , optic chiasma , cingulate gyrus , corpus callosum , fornix • Large vessel – median artery of corpus callosum arises from ACoA ACoA • Anterior thalamoperforating arteriesPCoA • Posterior thalamoperforating arteries • Thalamogeniculate arteries Basilar artery, PCAs Supplies- 1.Optic chiasma and tracts 2.Infundibulum 3.Hypothalam us 4.Base of brain
- 71. Complete COW–only 20 – 25% Posterior circle anomalies – 50% anatomy specimens Common variants •Hypoplasia of 1 or both PCoA – 34% •Fetal origin of PCA from ICA
- 72. •Hypoplasia or absentA1 ACA segment. •Absent , duplicate or multichannelACoA – 10-15%
- 73. Represent persistentembryonic circulatory patterns Channels between caudal carotid artery and paired basilar and vertebral arteries fail to regress. 1. Primitive persistent trigeminal artery 2. Primitive hypoglossal artery 3. Persistent otic artery 4. Proatlantal intersegmental artery PCoA PTA Otic Hypoglossal Proatlantal intersegmental
- 74. •Most common carotidvertebro basilar anastomoses - 0.1- 0.6% •In utero – embryonic trigeminal artery supplies basilar artery before the PCoA and vertebral artery develops •As these vessels enlarge – PTA normally disappears course – arise when ICA exists carotid canal and enters cavernous sinus Runs posterolaterally along trigeminal nerve 41% Crosses over / throu dorsum sella before joining basilar artery Connects ICA to vertebrobasilar system trident shape on lateral DSA
- 75. 2nd mostcommon- 0.027- 0.26% . Intracranial aneurysms If present – single artery that supplies brain stem and cerebellum Courses thro hypoglossal canal Parallel to CN 12 Connects cervical ICA with basilar artery
- 76. Red – PHABlue – sigmoid sinus Pink – coil mass with basilar tip aneurysm
- 77. Origin –petrous ICA Course – medially thro internal auditory meatus and joins caudal basilar artery VA – hypoplastic / absent – POA is the sole arterial supply to basilar artery Basilar artery POA
- 78. Cerebral arteries Vertebral artery Basilar artery
- 79. Distal ICA Anterior cerebral artery Middlecerebral artery Basilar artery Posterior cerebral artery
- 80. A1 horizontal segment • FromACA origin to ACoA junction. • Inferior br – supply superior surface of optic nerve and chaisma. • Superior br – anterior hypothalamus , septum pellucidum , anterior commisure , fornix , anterior inferior portion of corpus straitum.
- 81. Arise fromA1 segment- perforatingbranches. • Pass cephalad thro anterior perforated substance. • Supply head of caudate nucleus and anterior limb of IC, putamen .
- 82. • Largest ofthe perforating branches. • May arise fromA1 or A2 segment. • A1 – 44% • Proximal A2 – 50% • ACoA – less common • Derives its name from the fact that it doubles back on its parent artery at an acute angle to join lenticulostriate vessel. • Lies parallel to A1 .
- 83. From ACoA junction Ascendin front of 3rd ventricle in cistern of lamina terminalis br –Orbitofrontal, frontopolar Curves around corpus callosum genu gives terminal branches A2 terminal branches- Pericollasal Collasomarginal
- 84. • Supply theanterior 2/3rds of medial hemispheric surface + small superior area over the convexities. • Callosomarginal a.– lies in cingulate gyrus supplies medial frontal lobe • Pericallosal a.– course along the posterior aspect of corpus callosum and supplies it and medial parietal lobe
- 85. Lateral DSA midarterial phase A1 A2 A3 orbitofrontal Callosomarginal Pericollasal Medial lenticulostriate Recurrent artery heubner Pericollasal A2 Orbitofrontal Frontopolar A3 Callosomarginal AP DSA mid arterial 3D MRA A2 Pericollasal Callosomarginal
- 86. ACA –ACoA complex – normal 1/3rd anatomy dissection Absent , duplicate or multichannelACoA – 10-15%
- 87. • Hypoplasia orabsent A1 ACA segment-distal segments fill preferentially from other side via ACoA.
- 88.
- 89. M1 horizontal Origin -Laterallyfrom ICA bifurcation Till its bi/trifurcation at sylvian fissure. Br – Lateral Lenticulostriate branch course superiorly Anterior temporal artery Supplies-Lentiform nucleus Part of IC , caudate nucleus M2 insular At its genu divides into branches Loop over insula pass laterally to exit from sylvian fissure M3 opercular Emerge from sylvian fissure Ramify over hemispheric surface Supplies –cerebral cortex and white matter
- 92. 1. Orbitofrontal artery(lateral frontobasal ) 2. Prefrontal arteries 3. Precentral (prerolandic ) 4. Central sulcus (rolandic) 5. Postcentral sulcus (anterior parietal) artery 6. Posterior parietal artery 7. Angular artery 8. Posterior temporal 9. Temporooccipital artery 10. Medial temporal
- 93. AP DSA midarterial phase AP DSA early arterial phase
- 94. Early arterial phase LateralDSA Mid arterial phase
- 95. Lateral •M1 horizontal •MCA bifurcation •M2insular •M3 opercular CT
- 96.
- 97. • Origin -M1 • Supplies – • Part of head and body of caudate • Globus pallidus • Putamen • Posterior limb of internal capsule
- 98. • Supplies • Inferolateral frontallobe • Insular cortex • Parietal lobe • Temporal lobe
- 99. Supplies – • Lateral cerebrum •Insula • Ant- lateral temporal lobe
- 100. Less frequent Fenestration and duplication Single trunk Accessory arteries All uncommon ≤5 %
- 102. • It iseither hypertrophied RA heubner or medial ACA perforator. • To be called accessory MCA it should have cortical branches.
- 103. PCA origin frombifurcation of basilar artery in interpeduncular cistern. Lies above occulomotar nerve. Circles midbrain above tentorium cerebelli.
- 104. P1 precommunicating / peduncular •Basilar bifurcation extends laterally • Junction with PCoA • Br – • Post thalamoperforating- thalamus , midbrain • Medial posterior choroidal artery – anteromedially along roof of 3rd ventricle –tectal plate , midbrain , thalamus posterior , pineal gland , tele choroidae of 3rd ventricle. P2 ambient / crural • PCA- PCoA junction posterior • Above trochlear nerve and tentorial incisura • Br – • Thalamogeniculate arteries- MGB , pulvinar , brachium superior colliculus , crus cerebri , LGB • Lateral post choroidal artery – over pulvinar of thalamus – posterior thalamus , lateral ventricular choroid plexus
- 106. P3 quadrigeminal Behind midbrainin quadrigeminal plate cistern Reciprocal relationship with MCA Inferior temporal artery • Undersurface of temporal bone • Anastamose -MCA Parietooccipital artery • Posterior 1/3rd interhemispheric surface • ACA Calcarine artery( P4 ) • Visual cortex • Occipital pole Posterior pericollasal artery (splenial) • Splenium of corpus callosum • ACA
- 107. AP DSA AP DSAmid arterial phase
- 108. Early arterial phase Lateral DSAMid arterial phase
- 109.
- 110. • Supply – •Medial +posterior temporal lobe • Medial parietal lobe • Occipital lobe
- 111. Fetal originof PCA from ICA instead of basilar – 15- 20 % Carotid basilar anastomosis – supply PCA via trigeminal artery or other persistent channels
- 112. V1 Courses –Cephaladto enter transverse foramina at C6 Ascend directly to C2 (V2) Turns laterally and superiorly thro C1 vertebral foramina Looping posteriorly along atlasV3 extraspinal EachVA passes superomedially thro foramen magnum In Posterior fossa anterior to medulla (intradural ) VAs unite to form basilar artery From subclavian arteries LeftVA dominant 50%
- 113. Vertebral artery Anterior spinalartery Joins ASA from oppositeVA along anteromedial sulcus of cervical cord. Medial medullary syndrome Posterior inferior cerebellar artery Arises from distalVA Lateral medullary syndrome
- 115. Lateral DSA AP DSA V1-extraosseous V2 –foraminal V3 – extraspinal V4 – intradural
- 116. • Front ofmedullaAnterior medullary segment • Along side of medulla caudally to level of CN 9-11Lateral medullary segment • Around inferior half of cerebellar tonsilTonsilomedullary segment • Cleft btw tela choridae and inferior medullary velum rostrally and superior pole of tonsil caudallyTelovelotonsillar segment Cortical / hemispheric segment
- 117. Lateral DSA early arterial LateralDSA late arterial
- 119. Anterior medullary segment Posteriormedullary segment Lateral medullary segment
- 120. •Choroid plexus of4th ventricle. •Posterolateral medulla. •Cerebellar tonsil. •Inferior vermis. •Posteroinferior cerebellar hemisphere. Supplies
- 121. Persistent vertebrobasilar anastamosis LeftVA– aortic arch origin – 5% HypolasticVA – 40 % HypoplasticVA
- 122. VA terminates inPICA – 1%
- 123. Orange arrow – duplicatedVA Red– originalVA from subclavian VA duplication- ocassionally
- 124.
- 125. Extradural origin ofPICA PICA fromVA below foramen magnum
- 126. Right and leftVAs unite – BA Course cephalad in front of pons Pontine cistern in the space delineated by lateral margin of clivus and dorsum sellae Terminates in interpeduncular cistern Divides into PCAs •Average length – 3 cm •Width 1.5- 4 mm •Diameter <4.5 mm
- 127. 1. AICA –Anterior Inferior CerebellarArtery 1st major branch. Posterior laterally in cerebellopontine angle cistern toward the internal auditory canal. Here typically anteroinferior to facial and vestibulocochlear nerve. Few mms from origin AICA crossed by abducens nerve. Supplies- ▪ Nerves ▪ Inferolateral pons ▪ Middle cerebellar peduncle ▪ Flocculus ▪ Anterolateral cerebelllar hemisphere
- 128. 2. SCA- SuperiorCerebellar Artery– Arises from BA apex. Posterolaterally around Pons and mesencephalon below tentorial incisura and CNS 3 n 4. Supplies – ▪ Superior surface of vermis n cerebellar hemisphere. ▪ Deep cerebellar white matter. ▪ Dentate nucleus. Perforating branches – short n long segment BA – terminates into PCA s
- 129.
- 131.
- 135. SCAs- can arise fromP1 segment
- 136. Osborne radiology Gionni Boris bradac –Cerebral angiography