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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




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




Circle of willis
Circle of Willis carotid artery


3 main arteries
3 main arteries carotid artery

  • 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 carotid arterywillis


Vascular territories of the 3 main cerebral arteries
Vascular territories of the 3 main cerebral arteries carotid artery

  • Vascular territories of the superficial cerebral structures

  • Vascular territories of the deep cerebral structures








Vascular territories of deep cerebral structures
Vascular territories of deep cerebral structures carotid artery

  • Lenticulostriate arteries

  • Anterior choroidal artery

  • Recurrent artery of Heubner

  • Thalamoperforator arteries



Lenticulostriate arteries
Lenticulostriate carotid artery arteries





Where is the lesion
Where is the lesion? carotid artery

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



Where is the lesion1
Where is the lesion? carotid artery

  • R pure motor hemiparesis (UMN)

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



Where is the lesion2
Where is the lesion? carotid artery

  • 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 carotid arteryagraphia

  • 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 carotid artery 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 carotid arteryhemiparesis

  • 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 carotid artery

  • 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 carotid arteryhemiparesis

  • 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- carotid arterySensorimotor (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- carotid arteryDysarthria-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 carotid arterylacune

  • 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 carotid artery

  • 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 carotid artery

  • 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



Deep venous drainage1
Deep venous drainage carotid artery


Clinical scenario 1
Clinical scenario #1 carotid artery

  • 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 carotid artery

  • 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? carotid artery

  • 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 carotid artery

  • 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 carotid artery

  • 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? carotid artery

  • 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 carotid artery


Conclusion
Conclusion carotid artery

  • 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 carotid artery

  • 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 carotid artery

  • 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 carotid artery

  • 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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