cerebral circulation & CSF

Blood Supply to Brain

About 18% -20% of the total blood volume in the body
circulates in the brain(about 750ml), 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 hemorrhage and is one of the
most frequent sources of neurologic disability.
Nearly half of the admissions to many busy neurologic
services are because of strokes.
Cerebrovascular disease is the third most common
cause of death.
Blood Supply to Brain
The brain is unusual in that it is only able to withstand very short
periods of lack of blood supply (ischaemia). This is because
neurons produce energy (ATP) almost entirely by oxidative
metabolism of substrates including glucose and ketone bodies, with
very limited capacity for anaerobic metabolism. Without oxygen,
energy dependent processes cease leading to irreversible cellular
injury if blood flow is not re-established rapidly (3 to8 minutes under
most circumstances).
Therefore, adequate cerebral blood flow must be maintained to
ensure a constant delivery of oxygen and substrates and to remove
the waste products of metabolism
Cerebral blood flow (CBF) is dependent on a number of factors that
can broadly be divided into:
a. Those affecting cerebral perfusion pressure
b. Those affecting the radius of cerebral blood vessels
Blood Supply of Brain & Applied
aspects
internal carotid
circulation
Vertebrobasilar
circulation
Circle of Willis
Stroke
Venous drainage
CSF
 Internal carotid artery

Arises from common carotid artery

Enters skull through carotid canal of
petrous bone & proceeds through
cavernous sinus curving in an S shape
(carotid siphon)
Supplies rostral 2/3rds of brain including
main parts of basal nuclei & internal
capsule
cerebral circulation
 Internal carotid artery

gives off several collateral branches

before it divides into its two terminal
branches:
middle cerebral artery &
anterior cerebral artery
 ICA - collateral branches

inferior & superior hypophyseal arteries &

the ophthalmic artery come off the ica as
soon as the artery has entered the skull
posterior communicating & anterior
choroidal arteries are the other named
branches
Ophthalmic artery
Ophthalmic artery:
It passes into the orbit through
the optic foramen.
It supplies the structures of the
orbit, frontal and ethmoidal
sinuses, frontal part of the scalp
and dorsum of the nose.

Anterior choroidal artery:

It supplies the optic tract,
choroid plexus of the lateral
ventricle, hippocampus and
some of the deep structures of
the hemisphere, including the
internal capsule and globus
pallidus.
Ophthalmic artery

1. ethmoidal arteries
2. ciliary arteries
3. optic nerve & ophthalmic
artery
4. central retinal artery
5. retinal arteries
6. supratrochlear artery
7. supraorbital artery
8. dorsal nasal artery
9. anterior ciliary artery
Middle cerebral artery
largest terminal branch of the ica
runs between temporal & frontal lobes in
lateral fissure
many perforating branches (7-10 striate
arteries) emerge from the initial segment of
the mca and penetrate the anterior
perforating space to supply:
striatum, putamen, globus pallidus & internal
capsule
middle cerebral striate arteries
middle cerebral artery

MCA divides into several large arteries on

the surface of the insula
continues laterally to emerge on surface
of hemisphere
practically the whole lateral surface of the
brain including motor & sensory areas of
the cortex is supplied by branches of the
mca
cortical distribution of MCA
functional distribution of MCA
anterior cerebral artery

smaller than middle cerebral artery

this terminal branch of the ica runs
between the optic nerve and anterior
perforating space to the region of the
longitudinal fissure
connected with the corresponding artery
on the opposite side by the short anterior
communicating artery
anterior cerebral artery

perforating arteries to the hypothalamus

and to other important structures in the
basal parts of the brain arise from the
proximal part of the ACA
distal to the anterior communicating artery
the two ACAs ascend in the longitudinal
fissure (where they curve upwards &
backwards above the corpus callosum)
anterior cerebral artery

although the two arteries lie close together

during their course in the longitudinal
fissure they are separated by the falx
cerebri
terminal ramifications of the aca supply
most of the corpus callosum as well as the
medial surfaces of the frontal & parietal
lobes - including leg area in the
paracentral lobule
cortical distribution of ACA
functional distribution of ACA
vertebrobasilar system

two vertebral arteries (carrying about

1/3rd of cerebral blood) arise from first
part of the subclavian arteries
ascend through foramen transversarium
of cervical vertebrae then enter skull
through foramen magnum
vertebrobasilar system

major branches of vertebral artery

anterior spinal artery
posterior inferior cerebellar artery
bulbar branches
+/- anterior inferior cerebellar artery
both vertebral arteries unite at the
pontomedullary junction to form the basilar
artery
vertebrobasilar system
basilar artery continues in midline of pons
before it bifurcates into its two terminal
posterior cerebral arteries at
pontomesencephalic junction
gives off:
anterior inferior cerebellar artery
internal auditory artery
pontine arteries
superior cerebellar artery
cortical distribution of PCA
functional distribution of PCA
the circle of Willis

anterior & posterior communicating

arteries help form an arterial circle of
Willis on the ventral aspect of the brain
provides possibility of collateral circulation
in event of occlusion in one of the major
arteries proximal to the circle
the circle of Willis
regional blood supply
stroke - definition
sudden neurological deficit of vascular
aetiology lasting more than 24 hours
compared with TIA (transient ischaemic attack)
indicates a transient neurological deficit of
vascular origin lasting less than 24 hours
stroke - categorized as

cerebral infarction (80%)

signifying ischaemic brain damage due to
occlusion of a vessel
cerebral haemorrhage
primary pathology involves vascular rupture &
extravasation of blood into surrounding tissue
or compartments
 stroke
artery territory stroke syndrome
mca occluson contralateral hemiplegia,
hemianaesthesia,
homonymous hemianopia,
aphasia, inattention,
cortical sensory loss

aca occlusion hemiparesis

chiefly in the leg
 stroke
artery territory stroke syndrome
internal carotid mixture of aca & mca
artery occlusion syndromes (may be
asymptomatic)
pca occlusion homonymous hemianopia,
disconnection syndromes,
hemianaesthesia, amnesia,
midbrain & thalamic
syndromes
 stroke
artery territory stroke syndrome
vertebrobasilar quadriparesis, bulbar
thrombosis (basilar paralysis, impaired gaze,
occlusion) coma

ventral pontine quadriparesis, absent

infarction horizontal (but retained
vertical) gaze, normal
conscious state (locked in
syndrome)
 stroke
artery territory stroke syndrome
lateral medullary ipsilateral ataxia (icp),
syndrome Horners syndrome,
(vertebral, pica or dysphagia & dysarthria
aica) (CN 9 & 10), vertigo,
nausea & Nystagmus
(vest. nuclei), ipsilateral
facial anaesthesia (CN 5),
contralateral pain &
temperature loss
(spinothalamic tract)
 stroke
artery territory stroke syndrome
medial medullary ipsilateral paralysis of
syndrome tongue (CN 12),
contralateral
hemiparesis
(corticospinal tract),
contralateral
impairment of touch &
position sense (medial
lemniscus)
lateral medullary syndrome
Weber syndrome
venous drainage

superior sagittal sinus --> right transverse

sinus (confluence of sinuses) --> right
sigmoid sinus
inferior sagittal sinus --> straight sinus -->
left transverse sinus (confluence of
sinuses) --> left sigmoid sinus
the sigmoid sinuses --> (become) internal
jugular veins at jugular foramen
cavernous sinus

located lateral aspect sphenoid

receives blood from pituitary gland, orbit
through ophthalmic veins & middle
cerebral veins
cavernous sinus --> superior & inferior
petrosal sinuses
cavernous sinus

superior petrosal sinus --> junction

transverse & sigmoid sinuses
inferior petrosal sinus --> internal jugular
vein
emissary veins link CS with facial & scalp
veins
cerebrospinal fluid circulation

clear & colorless water-like fluid

formed by choroid plexus
mainly in lateral ventricles (& to lesser degree
in 3rd & 4th ventricles)
formation of CSF complex
includes both passive filtration & active
secretary mechanisms
CSF circulation

CSF produced in lateral ventricles

enters third ventricle through interventricular
foramen
flows through cerebral aqueduct
into fourth ventricle
from fourth ventricle it reaches the
subarachnoid space
CSF circulation

CSF enters subarachnoid space via three

openings:
median aperture (posterior medullary velum)
two lateral apertures (lateral recesses of fourth
ventricle)
CSF circulation

collections of microscopic arachnoid villi

form macroscopic elevations (arachnoid
granulations) that protrude into the lateral
expansions of the superior sagittal sinus
through openings in the dura
flow of CSF is fairly rapid
CSF circulation

total volume of CSF in the ventricular

system & subarachnoid space is only
about 125 ml
but it is estimated that about four times
that amount (~500 ml) is formed during a
24 hr period
a small amount of CSF seeps down
around the spinal cord
 A 65-year-old man has loss of pain and temperature sensation on the right
side of the face and on the left side of the body. Examination shows
partial paralysis of the soft palate, larynx, and pharynx, and ataxia, all
on the right. The most likely cause of these findings is thrombosis to which
of the following arteries?
Basilar
Right posterior inferior cerebellar
Left posterior inferior cerebellar
Right superior cerebellar
Left superior cerebellar
A 59-year-old male suffered a stroke and later presented with a spastic
paralysis. Which of the following structures was affected by the stroke that
accounts for the spasticity?
Ventral horn cells
Corpus callosum
Postcentral gyrus
Internal capsule
Substantia nigra
 A 81-year-old woman had a cerebrovascular accident month ago. Her past medical
history is remarkable. She initially presented with slurred speech and right
hemiparesis. The hemiparesis resolved, but her speech is still agrammatic and
nonfluent, and she has difficulty finding words and completing sentences. Her
comprehension is intact, and she appears frustrated when she attempts to speak.
The remainder of the neurologic examination is normal. Which of the following best
describes her deficit?
Apraxia
Ataxia
Brocas aphasia
Wernickes aphasia
A 77-year-old right-handed man with a history of atrial fibrillation and diabetes
mellitus is brought to the emergency department by his family. His son describes that
when his father awoke that morning, he was unable to use words or sentences that
made any sense. On examination, the patient has spontaneous, fluent speech, with
normal grammatical constructs and prosody. However, the majority of what he says
is meaningless. He is unable to follow commands, except to close his eyes. When
asked to identify objects, he uses inappropriate substitutions of words. He also fails
to repeat words and is unable to read. A lesion of which of the following areas would
most likely account for his language deficits?
Inferior frontal gyrus
Crus cerebri
Prefrontal cortex
Superior temporal gyrus
 A 3-month-old infant was admitted to the pediatric ward because of a large
head. The infant stayed quietly in bed most of the day. The circumference of
the head was 44 cm (normal value for this age is about 40 cm). The
fontanelles protruded, and the cranial sutures were separated. The skull
could be transilluminated with a flashlight. Magnetic resonance imaging
showed enlarged lateral, third, and fourth ventricles. The closure of the
vertebrae was defective in the lower back (spina bifida). Treatment was
surgical implantation of a catheter into the lateral ventricle with drainage into
the peritoneum.
Is this a communicating or Non-communicating type of hydrocephalus?
Communicating; because the CSF drainage is impaired within the
subarachnoid space or at the level of the arachnoid villi
Noncommunicating; the fluid communication between the ventricular
system and the subarachnoid space is impaired
None of above
 Indicate The Correct Letter Shown
in the MRI to the appropriate sign or
symptom given below.
Difficulty in swallowing the oral
secretions?
Patient is finding difficulty from
sitting to standing posture?
Alexia without Agraphia?
Contralateral Leg Weakness?
Patient is unable to clench his
teeth?