In this chapter, we will be covering the vascular anatomy of the brain, brainstem, and spinal cord. Additionally, we will be covering typical stroke presentations. After reviewing this chapter, one will (1) better understand the anterior and posterior cerebral vascular systems, (2) be able to identify stroke syndromes based on the neurological deficit, and (3) be able to identify vascular territories on imaging.

If you want to learn more about the pathophysiology and management of stroke check out our Vascular Neurology chapter.

Author: Brian Hanrahan MD

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Figure 1: The Cerebral Vascular System
Diagram of the Cerebral Vascular System with the circle of willis
The Cerebral Vascular System

Introduction

  • The cerebral vascular system can be subdivided into anterior and posterior circulatory systems.
    • Two internal carotid arteries (ICAs) provide the anterior circulation.
    • The vertebral arteries/basilar artery provides the posterior circulation.
  • Cerebral angiogram (DSA) provides the best imaging quality to identify any vascular pathology.
    • CT angiograms and MRA imaging can also be used to evaluate vascular anatomy but is less sensitive than a cerebral angiogram.

Anterior Circulation

  • The left common carotid artery branches off the aortic arch while the right common carotid artery branches off the brachiocephalic artery.
    • The common carotid artery divides into external and internal carotid arteries at the level of the fourth cervical vertebra.
      • The external carotid supplies structures in the neck, face, and meninges.
      • The internal carotid supplies the anterior portion of the brain, eye, optic nerve, anterior pituitary, and meninges.
  • The internal carotid artery has seven segments (according to the Bouthillier Classification):
Add terminal branches
    • Cervical (C1)
    • Petrous (C2)
    • Lacerum (C3)
    • Cavernous (C4)
    • Clinoidal (C5)
    • Ophthalmic (C6)
    • Communicating (C7)
    • Cervical (C1)
    • Petrous (C2)
      • Caroticotympanic artery
      • Vidian artery
    • Lacerum (C3)
    • Cavernous (C4)
      • Meningohypophyseal trunk
      • Inferolateral trunk
      • Capsular arteries of McConnell (variable)
    • Clinoidal (C5)
    • Ophthalmic (C6)
      • Ophthalmic artery
      • Superior hypophyseal artery
    • Communicating (C7)
      • Posterior communicating artery (PCOM)
      • Anterior choroidal artery
      • Anterior cerebral artery (ACA)
      • Middle cerebral artery (MCA)

(Note: Gibo and Fisher Classifications number these slightly different)

Diagram of the anatomy of the Internal Carotid Artery Segments on MRA imaging
Internal Carotid Artery (ICA) Segments on MRA imaging
 

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