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Cerebral Vascular Lecture

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Information about Cerebral Vascular Lecture
Health & Medicine

Published on February 19, 2014

Author: MichaelThomas29

Source: slideshare.net

Description

This lecture was presented to the Osteopathic students at the Pacific Northwest University of Health Sciences in Yakima Washington.
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DR. MICHAEL THOMAS CEREBRAL VASCULAR ANATOMY

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

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

CPP=MAP-ICP NORMAL ICP <20 mmHg MAP-mean arterial pressure

ANTERIOR CIRCULATION  ICA –INTERNAL CAROTID ARTERY  ACA –anterior cerebral artery  Acom – anterior communicating artery  MCA – middle cerebral artery

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

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)

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

ACA MCA Larger in 70% Ophthalamic Post communicating Anterior choroidal Pierces dura Hypophysial and meningial Carotid canal

Coronal section middle cerebral artery Supply basal ganglia and internal capsule

Dorsal surface branches

Medial surface of hemispheres and inferior surface of temporal lobe border

MCA M4 surface segments

Regions served by ACA / MCA / PCA

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

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

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

AICA  BLOOD SUPPLY TO VENTRAL-LATERAL CEREBELLUM, PONS, CHOROID PLEXUS  POSITIONED NEXT TO CRANIAL NERVES 7&8

SUPERIOR CEREBELLAR ARTERY SUPPLIES MEDIAL, LATERAL, AND SUPERIOR CEREBELLAR CORTEX AND CEREBELLAR NUCLEI AND MIDBRAIN PASSES JUST CAUDAL TO CN III THROUGH AMBIANT CISTERN

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

DORSAL BRAINSTEM VIEW

VENTRAL BRAINSTEM VIEW

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

DEEP GANGLIONIC PERFORATING ARTERIES

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

Venous Circulation

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

DIVISIONS 1. BASAL VIENS (LATERAL SINUS, ROSENTHAL, PETROSAL SINUS, CAVERNOUS SINUS)

2. CEREBRAL – (SUPERIOR SAGITAL SINUS, ANASTOMOTIC VEINS - TROLARD,LABBE, SUPERIOR MIDDLE CEREBRAL VEIN

3. INTERNAL VEINS – DRAIN INTO THE VEIN OF GALEN

Galen Vein of Straight sinus VEIN OF GALEN MALFORMATION

Blood Brain Barrier

BLOOD BRAIN BARRIER - PHYSIOLOGICBARRIERPREVENTS MOVEMENT OF HIGH MOLECULAR WEIGHT MOLECULES - ABSENT FENESTRATIONS - TIGHT JUNCTIONS

REGIONS WITH NO BBB 1. AREA POSTREMA 2. PINEAL AND PREOPTIC RECESSES 3. TUBER CINEREUM 4. HYPOPHYSIS 5. CHOROID PLEXUS

BBB DISRUPTION GLIOBLASTOMA MULTIFORME WITH VASOGENIC EDEMA BBB BREAKS DOWN UNDER DISEASE STATES

CEREBRAL SPINAL FLUID PRODUCTION & ABSORPTION

SUPERIOR SAGITAL SINUS OCCLUSION FROM MENINGIOMA

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

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

SUBARACHNOID HEMORRHAGE POSTERIOR COMMUNICATING ARTERY ANEURYSM

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

Common patterns of aneurysms: branches and tortuous turns ICA system VB system

ANEURYSM TREATMENT  SURGICAL CLIP LIGATION  ENDOVASCULAR COILING  ANEURYSM BYPASS AND CLIP LIGATION  COMBINATION COILING AND CLIPPING

Basilar Artery Apex Aneurysm Occipital AVM

The cavernous sinus Aneurysm Fistula

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

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

AVM

ARTERIOVENOUS MALFORMATION

SUBDURAL HEMORRHAGE

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