BLOOD SUPPLY TO THE BRAIN

Presenter: Kondapaneni Anusha

INTRODUCTION
• The Blood Supply
• Blood transports oxygen and other nutrients necessary for the health of neurons, so a
constant flow of blood to the brain must be maintained.

• According to Love and Webb,1992, the brain uses approximately twenty percent of
the body's blood and needs twenty-five percent of the body's oxygen supply to
function optimally. Blood flow in a healthy person is 54 milliliters per 1000 grams of
brain weight per minute.

• Blood circulation to the brain depends upon elaborate network of arteries

and viens.
• Arteries carry blood away from heart to the brain.
• veins return the circulated blood back to the heart.
Circle of willis
• The Circle of Willis or the Circulus Arteriosus is the main arterial
anastomatic trunk of the brain.
• According to Bhatnagar and Andy, 1995, anastomosis occurs when blood vessels
bring blood to one spot from which it is then redistributed.

• The Circle of Willis is a point where the blood carried by the two internal carotids and
the basilar system comes together and then is redistributed by the anterior, middle,
and posterior cerebral arteries.

• The wedge shaped circle of willis is located at the ventral surface of the brain , and
connects with the carotid arterial system with the vestebrobasilar system

• It consists of the anterior and posterior communicating arteries and proximal

portions of the anterior, middle and posterior cerebral arteries.

• Posterior communicating arteries connect the internal carotid arteries with the
basilar artery.
Circle of willis
• The anterior cerebral arteries of the two hemispheres are joined together by the
anterior communicating artery. The middle cerebral arteries are linked to the
posterior cerebral arteries by the posterior communicating arteries. This
anastamosis or communication between arteries make collateral circulation
Love and Webb, 1995, define as "the flow of blood through an alternate route”

• This is a safety mechanism, allowing brain areas to continue receiving adequate

blood supply even when there is a blockage somewhere in an arterial system. The
blood streams of the internal carotid system and the basilar system meet in the
posterior communicating arteries.

• If there are no problems in either system, the pressure of the streams will be equal
and they will not mix. However, if there is a blockage in one of them blood will flow
from the intact artery to the damaged one, preventing a cerebral vascular accident.
Circle of willis
• Clinically it is important to equalize the vascular blood supply to both sides
of brain
• As long as the Circle of Willis can maintain blood pressure at fifty percent of
normal, no infarction or death of tissue will occur in an area where a
blockage exists. If collateral circulation is good, no permanent effects may
result from a blockage.( Webster, 1999)

Meyer and Denny-Brown (1957) showed that even occlusion of the middle
cerebral artery need not necessarily cause infarction of the brain if the circle
of Willis is intact and if the systemic blood-pressure is adequate.
• Incomplete Circle of Willis and Right Axillary Artery Perfusion
• Päivi Merkkola, MD a , Harri Tulla, MD, PhD a , * , Antti Ronkainen, MD,
PhD b , Ville Soppi, MD b , Anni Oksala, MD b , Timo Koivisto, MD, PhD b ,
Mikko Hippeläinen, MD, PhD a a Department of Thoracic and Cardiovascular
Surgery, Kuopio University Hospital, Kuopio, Finland
b Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland

• Accepted for publication February 9, 2006.

• BACKGROUND: The aim of our anatomic study was to assess whether the commonly
used method of perfusion through the right axillary artery is sufficient in providing
uniform distribution of blood to both hemispheres of the brain in patients
undergoing surgery of the aortic arch. We considered that critical arteries to examine
are anterior and left posterior communicating arteries of the circle of Willis because
the absence or insufficiency of either one would drastically endanger perfusion to the
left hemisphere of the brain. The existence and the diameters of these arteries were
studied.
• METHODS: The material was collected as a part of normal forensic medicine
autopsies. The anatomy of the cerebral arteries of 87 deceased individuals was
assessed by angiography and permanent silicone casts. A new classification was
created for this study. According to a recent observation in the literature we defined
the minimum threshold of arterial diameter that allows cross flow to be 0.5 mm. We
also repeated analyses using 1 mm as a threshold, which has also been recommended.
•
• RESULTS: In our material 22% of the anterior
communicating arteries and 46% of the left posterior
communicating arteries were missing. In this anatomic
population the perfusion to the left hemisphere might
have been insufficient in 14% of the patients at a
threshold of 0.5 mm and in 17% at a threshold of 1 mm.
• CONCLUSIONS: When the right axillary artery is used
for perfusion, the circulation to the contralateral
hemisphere seems to be good for most patients
undergoing operations of the aortic arch, but additional
means of brain protection are still needed.
Circle of willis

• C. J. DICKINSON ( 1979)
• Analysis of the data from a necropsy perfusion study of
the four main cerebral arteries in their cervical course suggests that stenosis
of these arteries, though an important cause of stroke, has very little
influence on the actual site of the lesion, which is probably determined
mainly by local arterial disease within the cranial cavity.
•
• The indirect evidence of this study suggests that the circle of Willis is a
highly efficient anastomosis in man, even when considerable arterial
disease is present.
Blood supply
• Brain receives its blood supply from 2 arterial systems.
▫ Carotid
▫ Vestibral basilar

• These arterial system join at the circle of Willis at the base of the
brain.

• Cortical and sub cortical penetrating arteries that originates from

the circle of Willis supply blood to the internal and external
structures of forehead.
• Carotid system: it begins with the common carotid artery
that ascends on each side of the neck.

• Posterior to the jaw, the common carotid artery divides into

external and internal carotids.

• The external carotid artery and its branches supply blood to the
facial muscles and forehead and oral, nasal and orbital cavities.

• The internal carotid artery which is a major source of blood to the

brain, enters the cranium through the carotid foramen in the
petrous bone and curves forward and medially to enter the
cavernous sinus.
• At that level, the internal carotid artery gives off the anterior
choroidal and opthalmic branches.

• The opthalmic artery supplies blood to the eyeball and ocular

muscles. It then connects with branches of external cerebral
arteries.

• This artery then emerges from cavernous sinus and joins the
circle of Willis.

• It then divides into 2 cortical arteries.

▫ Anterior cerebral
▫ Middle cerebral
Anterior cerebral artery

• After arising from the bifurcation of the internal cerebral artery at

the circle of Willis, the anterior cerebral artery travels rostrally in
the inter hemispheric fissure along the mid saggital surface of the
brain.

• It follows the genu of the corpus collosum and continues

posteriorly along the dorsal surface of the C.C.

• Its branches are the orbital, fronto polar, calassomarginal, and

pericalasso arteries, it supplies the orbital and medial cortical
surfaces of the frontal and parietal lobes.

• Many terminal branches of the A.C.A cross over to the lateral

cortical surface and develop anatomizing continuity with the
branches of the middle cerebral artery.
Anterior cerebral artery
• In the interruption of the blood circulation in the A.C.A usually
results in the paralysis of the legs and feet, because of the
decreased blood supply to the motor cortex in which the lower
extremities are represented.

• The vascular impairments of this artery may also lead to many

pre frontal lobes symptoms, which include cognitive impairments
such as impaired thinking, reasoning, abstracting, self monitoring
and planning.

• Additional impairments include decreased spontaneity, motor

inaction, impaired judgment and limited concentration.
Anterior cerebral artery
• Tominaga - Paraparesis is a rare but characteristic manifestation of
ruptured anterior communicating artery or anterior cerebral artery
(ACA) aneurysms, but the pathogenesis remains unclear

• Dickinsonand Thomson, 1959, 1960- Stenosis of one main cerebral

artery such as the internal carotid is generally thought to predispose
to ischaemic damage of the cerebral hemisphere of the same side
Medial cerebral artery

• M.C.A, the largest of cortical arteries, is the direct continuation of

internal cerebral artery.

• After leaving the circle of Willis, it runs laterally and emerges

through the sylvian fissure on the lateral brain surface.

• On the lateral surface it devides into temporal (ant & post),

frontal (rolandic & pre rolandic) and parietal (ant, post &angular
artery branches).

• M.C.A branches supply blood to the entire lateral surface of the

brain, the site of speech, language and large part of sensory
motor areas.
• The important areas as follow:

• Somato sensory cortex in the post central gyrus

• Motor cortex in the pre central gyrus

• broca’s area in premotor region

• Frontal cortex
• Primary auditory cortex in the transverse heschel’s gyrus
on the superior surface of the first temporal gyrus.

• Wernicke’s area in the superior posterior temporal lobe.

• Angular and supra marginal gyri In the inferior parietal
lobe.
• While passing through the lateral sulcus M.C.A gives off lateral and medial
lenticulostriate branches that supply the basal ganglia and the
diencephalon.

• Medial lenticulostriate artery supplies blood to the globus pallidus, the

posterior internal capsule, medial ventral area of thalamus.

• The lateral lenticulostriate artery supplies the entire pulvinar and caudate
nucleus except for its anterior portion which is served by the anterior
cerebral artery.
• Impaired vascular circulation of the M.C.A results in contra lateral
hemiplegia.

• Impaired sensory system that include discriminative and diffuse touch,

position sense, pain and temperature.

• Other symptoms are aphasia, constructional apraxia, temporo spatial

defects, homonymous hemi anopia, reading and writing deficits.

• Lenticulostriate artery damages results in involuntary motor movements

and sensory motor symptoms.
Posterior cerebral artery
• The basilar artery bifurcates to form 2 posterior cerebral arteries.

• Each of these arteries receive a potential anasotomotic flow from

the posterior communicative artery, and which curves lateral
caudally along the inferior brain structure, where it supplies blood
to the
• anterior and inferior temporal lobe,
• the uncus, the inferior temporal gyri and
• the inferior and medial occipital lobe including calcarian region,
the primary visual cortex.

• The end branches of the artery also cross over to the lateral
surface and anasotomise with the terminal branches of the M.C.A.
Posterior cerebral artery
• Occlusion of the P.C.A results - homonymous hemianopia.
• The occlusion of the basilar artery which supplies blood to the
both P.C.A, can result in

▫ total blindness and

▫ numerous pontine and cerebellar symptoms.

Central (penetrating) arteries
• The central arteries are the branches that arise either from
the proximal portion of the cortical arteries or from the
circle of Willis and penetrate the inferior surface of the
brain.

• These supply blood to the sub cortical structures that

include
▫ Thalamus
▫ Hypo thalamus
▫ Caudate nucleus
▫ Globus pallidus
▫ Putamen
▫ Basil ganglia
▫ Internal capsule
▫ Choroid plexus
▫ And other structures.
Central (penetrating) arteries
• One important aspect of the C.A is the overlapping of blood
supply as the branches distribute to the sub cortical areas.
• The overlapping blood supply facilitates development of
anasotomic channels in response to occlusive vascular
problems.
• Important C.A are

• Anterio medial
• Anterio choroidal
• Posterio choroidal
• Posterio medial
• Medial striate
• Posterio lateral
• The anterio medial artery arise from the anterior communicating and
anterior cerebral arteries and penetrates the anterior perforated areas to
supply the hypo thalamus, preoptic and supra chiasmic regions of the brain.

• Impairement of these arterial twigs results in anasotomic nervous system

and associated hypothalamic disorders.
Medial striate arteries
• These arise from the anterior cerebral arteries and supply blood
to the parts of the caudate nucleus, putamen and anterior limb of
the internal capsule.

• The lenticulostriate branches of the M.C.A supplies the remaining

parts of the caudate nucleus and putamen.

• Circulatory disturbances in these arteries result in motor

movement disorders.
Anterior choroidal arterial
• It travel caudally along the optic tract and around peduncle and
supplies blood to the
• choroid plexus, hippocampus, portion of the globus pallidus,
posterior internal capsule,
• putamen,
• tail of the caudate nucleus and
• lateral geniculate body.

• Signs of its occlusion consist of

• contra lateral hemiplegia,
• hemi anesthesia, and
• involuntary movements because the posterior internal capsule
and globus pallidus are affected.( McKissock et al. (1960)
Posterior choroidal artery

• It originates from the posterior cerbral and supplies

blood to the choroid plexus of the IIIrd ventricle, tectum
and peneal gland.
Posteromedial arteries
• These supply blood to the parts of the thalamus, red nucleus,
substantia nigra, medial portion of the cerebral peducle,
subthalamic nucleus, mid brain reticular formation and superior
cerebral peducle with blood.

• Damage to the red nucles leads to contra lateral ataxia.

• Damage to substantia nigra leads to involuntary movements.

• Damage to the sub thalamic nucleus leads to hemi ballism.

• Most importantly, a pathology of the mid brain, reticular formation

results in a coma.
posterio lateral arteries

• These penetrates the inferior surface of the brain to supply blood

to the caudal and parts of lateral thalamus and posterior pulvinar.

• An occlusion of this artery results in somato sensory disturbances

in the opposite half of the body.
Ventricular supply to sub cortical
structures
structures artery

Thalamus Posterior medial, posterio lateral, choroidal arteries.

Hypo Anterio medial and posterio medial arteries

thalamus
Caudate Anterio lateral, medialstriate and lenticulostriate
nucleus arteries.
Putamen Lenticulostriate, medial striate and anterior choroidal
arteries.
Globus Anterior choroidal artery
pallidus
Sub thalamus Posterio medial arteries

Red nucleus Posterio medial artery

and substantia
nigra
Arteries of brainstem, spinal cord
and cerebellum
structures arteries

Mid brain Posterior cerebral artery

pons Basilar artery, anterior inferior

cerbellar artery
medulla Posterior spinal artery, anterior spinal
artery, basilar artery.
cerebellum Posterior inferior, anterior inferior,
superior cerbellar artery
Spinal cord Posterior spinal artery (posterior 3rd of
the cord), anterior spinal artery
(anterior 2/3rd of cord)
Vascular supply to the brain
surface and lobes
Brain area artery

Frontal

•Lateral surface Medial cerebral artery

•Medial surface Anterior cerebral artery

•Inferior surface Both middle and anterior cerebral surface

Vascular supply to the brain surface and
lobes
Brain area artery

Parietal
lobe
Lateral Medial cerebral artery
surface
Medial Anterior cerebral artery
surface
Vascular supply to the brain surface and
lobes
Brain area artery
Temporal lobe
Lateral surface Middle cerebral artery

Medial surface Jointly by middle cerebral, posterior

cerebral, posterior communicating and
anterior choroidal arteries.
Inferior surface Posterior cerebral artery
Occipital lobe (lateral and medial Posterior cerebral artery
surface)
Collateral circulation
• It refers to the alternative supply to a given structure after it has
lost its primary arterial blood supply.

• It is important in the natural recovery process of damaged brain

structures.

• The variability in arterial anatomy and the degree of vascular

pathology are two factors that contribute to the development of
collateral circulation.

• In general better CC develop if an artery is blocked near the main

arterial trunk or major branches.

• Obstruction of the terminal arteries or capillaries after they have

penetrated deep into the brain reduces the capabilities of
developing CC.
Collateral circulation
• The arterial system from one hemisphere can never adequately
perfuse the other hemisphere.

• A slow increase in arterial insufficiency facilitates maximum

development of compensatory circulation.

• A sudden arterial occlusion usually does not lead to the

development of an alternate circulation.
• There are 4 common points of CC within one hemisphere or
across both.

• A – anterior communicating artery connects both anterior

cerebral arteries or internal carotid systems.

• B – the vertebral basilar system feeds through posterior

communicating artery if the internal carotid artery blood flow
is insufficient. Similarly, the posterior communicating arteries
may feed into posterior cerebral arteries if the vertebral
basilar arterial system is occluded.

• C – although not frequent a thromboembolic involvement of

the internal carotid artery can trigger a retrograde blood flow
from the external carotid artery through the opthalmic artery
branches in the eye.

• D – the terminal branches of all cortical arteries may

anasotomise in the warershed zone in the lateral brain surface
in case of reduced blood volume through any one of the
arteries.
Vertebral Artery
• Both of the vertebral arteries ascend through the spinal column and
enter the brain through the magnum foramen. Once in the brain, they
continue to ascend, traveling beside the brain stem. At the lower border of
the pons the two vertebral arteries join together to form the basilar artery
or vertebro-basilar artery.
• The vertebral arteries and the basilar are straight arteries and therefore not
as subject to blockages due to the build up of cholesterol as are the internal
carotids.
• The posterior inferior cerebellar not only supply the cerebellum but take
blood to the lateral medulla. Anterior and posterior spinal arteries the
ventral and dorsal medulla, respectively (FitzGerald 1996). The three
arteries are branches of the vertebral.
• The side of the pons and the cerebellum receive blood from the anterior
inferior cerebellar artery and the superior cerebellar artery. These arteries
are branches of the basilar. The anterior inferior cerebellar artery also has a
branch, the labyrinthine artery, that supplies the inner ear. The basilar also
gives off about twelve pontine arteries that supply the medial pons
(FitzGerald, 1996).
Vertebral Artery
• At the superior border of the pons, the basilar artery divides to form the two
posterior cerebral arteries.
• Before the basilar artery divides, several other arteries arise from it. These
include the anterior, inferior, and posterior cerebellar arteries as
well as pontine branches. So, the cerebellum and pons are supplied by
branches of the basilar.
• The posterior cerebral arteries supply the part of the brain found in the
posterior fossa of the skull, including the medial area of the occipital lobes
and the inferior aspects of the temporal lobes. They also supply the
midbrain and deliver blood to the thalamus and some other subcortical
structures. Blockages in this artery can affect the sense of smell, and cause
cranial nerve damage, as well as visual problems, including visual agnosia,
hemianopsia and alexia.
• The choroidal arteries, which arise both from the divisions of the
internal carotid arteries and from the basilar system, supply blood to the
choriod plexuses and also to the hippocampus. Blockages in these arteries
can affect the production of cerebrospinal fluid and can also cause memory
problems
vertebral arteries
• The investigation of Hutchinson and Yates (1957) supported an
important role for the vertebral arteries in causing hind-brain
stroke.

• Hypertension is extremely common in vertebral basilar arterial

"

disease (Meyer et al., 1960).

Reference

• Bhatnagar : neuro science in communication

disorder.
• Gerand J. Tortora et al: principles of anatomy
and physiology (6th ed.). Harper and row,
publisher.
• Willard R. zemlin: speech and hearing science
anatomy and physiology (4th ed). Library of
congress cataloging in publishing data.