Ch10 cerebral hemispheres and vascular supply
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CH10. Cerebral hemispheres and vascular supply. By: Laurence Poliquin-Lasnier R2 Neurology. Outline. Review of the main functional cortical areas Anterior circulation Posterior circulation Circle of Willis Anatomy and vascular territories of: a) ACA b ) MCA c ) PCA

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Ch10 cerebral hemispheres and vascular supply

CH10. Cerebral hemispheres and vascular supply

By: Laurence Poliquin-Lasnier

R2 Neurology


Outline

Outline

  • Review of the main functional cortical areas

  • Anterior circulation

  • Posterior circulation

  • Circle of Willis

  • Anatomy and vascular territories of:

    a) ACA

    b) MCA

    c) PCA

  • Clinical syndromes of the 3 main cerebral arteries

  • Venous drainage of the cerebral hemispheres

  • Clinical scenarios


Main functional areas of the brain

Main functional areas of the brain


Anterior and posterior circulation

Anterior and posterior circulation


4 segments of internal carotid artery

4 segments of internal carotid artery

  • Cervical segment

  • Petrous segment

  • Cavernous segment

  • Intracranial/supraclinoid segment


The anterior circulation branches of the supraclinoid intracranial carotid artery

The anterior circulation: branches of the supraclinoid/intracranial carotid artery

  • Mnemonic “OPAAM”

  • O = Ophtalmic artery

  • P = Posterior communicating artery

  • A = Anterior choroidal artery

  • A = Anterior cerebral artery

  • M = Middle cerebral artery


The anterior circulation branches of the intracranial carotid artery

The anterior circulation: branches of the intracranial carotid artery


The posterior circulation

The posterior circulation


Circle of willis

Circle of Willis


3 main arteries

3 main arteries

  • Anterior cerebral artery (ACA)

  • Middle cerebral artery (MCA)

  • Posterior cerebral artery (PCA)

  • ACA and MCA arise from the internal carotid artery

  • PCA arise from the basilar artery


Circle of willis1

Circle of willis


Vascular territories of the 3 main cerebral arteries

Vascular territories of the 3 main cerebral arteries

  • Vascular territories of the superficial cerebral structures

  • Vascular territories of the deep cerebral structures


Superficial branches of aca

Superficial branches of ACA


Distribution of vascular supply

Distribution of vascular supply


Superficial branches of the mca

Superficial branches of the MCA


Distribution of vascular supply1

Distribution of vascular supply


Superficial branches of pca

Superficial branches of PCA


Distribution of vascular supply2

Distribution of vascular supply


Vascular territories of deep cerebral structures

Vascular territories of deep cerebral structures

  • Lenticulostriate arteries

  • Anterior choroidal artery

  • Recurrent artery of Heubner

  • Thalamoperforator arteries


Vascular territories of deep cerebral structures1

Vascular territories of deep cerebral structures


Lenticulostriate arteries

Lenticulostriate arteries


Superficial and deep vascular supply of the brain

Superficial and deep vascular supply of the brain


Superficial and deep vascular supply of the brain1

Superficial and deep vascular supply of the brain


Clinical syndromes of the 3 main cerebral arteries

Clinical syndromes of the 3 main cerebral arteries

  • MCA

  • ACA

  • PCA


Where is the lesion

Where is the lesion?

  • R face/arm UMN weakness, broca aphasia,+/- R face/arm cortical-type sensory loss


Distribution of vascular supply3

Distribution of vascular supply


Where is the lesion1

Where is the lesion?

  • R pure motor hemiparesis (UMN)

  • R hemiplegia, R hemianesthesia, R homonymous hemianopsia, global aphasia, L gaze preference


Superficial and deep vascular supply of the brain2

Superficial and deep vascular supply of the brain


Where is the lesion2

Where is the lesion?

  • R leg weakness (UMN), R leg cortical-type sensory loss, grasp, dishinibition

  • R homonymous hemianopia, alexia without agraphia


Clinical pearl alexia without agraphia

Clinical pearl: Alexia without agraphia

  • Lesion in dominant (usually L) occipital cortex extending to the posterior corpus callosum

  • Prevents processing of information in R visual field, including written material

  • Information about L visual field is transmitted to R occipital lobe, but cannot cross to the left to the language areas by the corpus callosum lesion


Lacunar syndromes

Lacunar syndromes

  • Lacune: small vessel infarct

  • Ressemble small lake or cavity when examined on pathologic section

    6 major lacunar syndromes:

  • Pure motor hemiparesis

  • Pure sensory stroke

  • Ataxic hemiparesis

  • Sensorimotor stroke

  • Dysarthria-clumsy hand syndrome

  • Basal ganglia lacune


1 pure motor hemiparesis

1- Pure motor hemiparesis

  • Unilateral face, arm, leg (UMN) weakness with dysarthria

  • Location:

    • Posterior limb internal capsule (common)

      • Lenticulostriate, anterior choroidal, thalamoperforator

    • Ventral pons (common)

      • Ventral penetrating branches of basilar artery

    • Corona radiata

      • Small MCA branches

    • Cerebral peduncle

      • Small MCA branches


2 pure sensory stroke

2- Pure sensory stroke

  • Sensory loss to all primary modalities in the contralateral face and body

  • Location:

    • Ventral posterior lateral nucleus (VPL) of thalamus

      • Thalamoperforator branches of PCA


3 ataxia hemiparesis

3- Ataxia hemiparesis

  • Pure motor hemiparesis with ataxia on same side as weakness

  • Location: Same as pure motor hemiparesis

  • Vascular supply: Same as pure motor hemiparesis


4 sensorimotor thalamocapsular

4- Sensorimotor (thalamocapsular)

  • Contralateral face/arm/leg sensory loss and weakness +/- dysarthria

  • Location:

    • Posterior limb internal capsule and either thalamic VPL or thalamic somatosensory radiations

      • Thalamoperforator arteries or lenticulostriate arteries


5 dysarthria clumsy hand

5- Dysarthria-clumsy hand

  • Facial weakness, dysarthria, dysphagia, and slight weakness and clumsiness of one hand

  • Location:

    • Pons

      • Pontine arteries

    • Genu of internal capsule


6 basal ganglia lacune

6- Basal ganglia lacune

  • Hemiballismus or asymptomatic

  • Locations:

    • Caudate, putamen, globuspallidus, or subthalamic nucleus

      • Lenticulostriate, anterior choroidal, thalamoperforator, or heubner’s arteries


Overview of venous drainage

Overview of venous drainage

  • Superficial veins drain into the superior sagittal sinus and cavernous sinus

  • Deep veins drain into great vein of Galen

  • Majority of veins ultimately drain to the internal jugular veins

  • Superior sagittal sinus –> transverse sinuses ->sigmoid sinus -> jugular foramen to become the internal jugular vein

  • Cavernous sinus (int carotid artery, CN III-IV-V-VI) ->superior petrosal sinus -> transverse sinus

  • Cavernous sinus -> inferior petrosal sinus ->internal jugular vein


Deep venous drainage

Deep venous drainage

  • Internal cerebral veins, basal veins of Rosenthal, and other veins ->great cerebral vein of Galen -> joined by inferior sagittal sinus –> to form straight sinus

  • Confluence of sinus (torcularHerophili) = superior sagittal sinus + straight sinus + occipital sinus

  • Confluence of sinus drained by transverse sinus


Overview of venous drainage1

Overview of venous drainage


Deep venous drainage1

Deep venous drainage


Clinical scenario 1

Clinical scenario #1

  • ID: 67yo woman

  • PMHx: HTN, PVD, smoker

  • HPI: after breakfast, she tried to stand up and suddenly felt she could not support her weight -> fell -> 911

  • Physical:

  • Alert & oriented

  • Unaware at times of L sided weakness

  • Language fluent

  • CN normal except minimally decreased L nasolabial fold + mild dysarthria


Clinical scenario 11

Clinical scenario #1

  • Motor: 5/5 except 1-2/5 in L leg prox and distal and 4/5 prox L arm

  • L leg hyperreflexia, L Babinski

  • Sensory: inconsistent decreased response to pinprick on L

  • Tactile extinction on L

  • One month later, partially recovered power, but feels that her L arm is out of control, grasp onto things without her being aware and would have to use her R arm to release the grasp

  • When distracted, can use both arms normally


Where is the lesion3

Where is the lesion?

  • R primary motor cortex foot area

  • Supplementary area given Alien hand syndrome

  • Adjacent to R frontal and R parietal lobes

  • R anterior cerebral artery occlusion


Clinical scenario 2

Clinical scenario #2

  • ID: 52F

  • RFC: difficulty raising L arm

  • PMHx: HTN, smoker

  • HPI: noticed last night inability to raise L arm to grasp cup of coffee. This mvt caused her L arm to flop up in the air and knock the coffee on the floor

  • Physical:

  • R carotid bruit


Clinical scenario 21

Clinical scenario #2

  • Decreased L arm power proximally (4-/5 deltoid, tricep 4/5, bicep 4+/5, 5/5 distally)

  • Decreased L leg power proximally (iliopsoas 4/5) and rest 5/5

  • L hyperreflexia arm and leg, L babinski

  • Sensory N

  • N FTN

  • Falls to the left on tandem gait


Where is the lesion4

Where is the lesion?

  • Unilateral proximal arm and leg weakness

  • Man in the barrel

  • Contralateral motor cortex proximal arm and leg area, and trunk

  • ACA-MCA watershed area 2ary decreased right carotid perfusion


Watershed areas

Watershed areas


Conclusion

Conclusion

  • 3 main cerebral arteries

    • ACA, MCA, PCA

  • Anterior circulation composed of internal carotid artery that leads to ACA and MCA within the circle of willis

  • Posterior circulation arises from vertebrobasilar system and leads to PCA within the circle of willis


Conclusion1

Conclusion

  • ACA supplies medial frontal and medial parietal lobes (sensorimotor cortex for lower extremities)

  • PCA supplies the medial and inferior occipital and temporal lobes (primary visual cortex)

  • MCA supplies entire lateral surface of the brain (face and arm sensorimotor regions + association cortex)


Conclusion2

Conclusion

  • MCA deep territory supplies internal capsule and most of basal ganglia

  • ACA deep territory supplies anterior basal ganglia and internal capsule

  • PCA deep territory supplies thalamus, midbrain, midbrain, posterior internal capsule


Conclusion3

Conclusion

  • Venous drainage occurs via superficial and deep cerebral veins

  • Superficial veins drain into superior sagittal sinus and cavernous sinus

  • Deep veins drain into great vein of Galen

  • Ultimately all venous drainage reaches internal jugular vein mostly via transverse and sigmoid sinus


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