Henkle 1_Blood Supply

Question 1

Segments of Internal Carotid•Cervical (extracranial) – ___•Petrous – __•Cavernous – __•Supraclinoid– __

Answer 1

Segments:•Cervical (extracranial) – C1•Petrous – C2•Cavernous – C3•Supraclinoid– C4

Question 2

Segments/Relationships of Vertebral Artery:•Prevertebral (V_)•Cervical (V_)•Suboccipital (V_)•Posterior cranial fossa (V_) – supplies brainstem and cerebellum•The left and right vertebral arteries merge to form the ___ artery completing formation of the posterior circulation to the brain

Answer 2

Segments/Relationships•Prevertebral (V1)•Cervical (V2)•Suboccipital (V3)•Posterior cranial fossa (V4) – supplies brainstem and cerebellum•The left and right vertebral arteries merge to form the basilar artery completing formation of the posterior circulation to the brain

Question 3

Two types of strokes are:_____ strokesare frominadequate blood supply to a region of the brain, often caused bythrombosis, embolism, or hypoxia.Thethrombotictype of ischemic stroke occurs when a ___forms directly at the site of infarction, often over an____plaque. The most common location is the___ ___artery.Theembolictype of ischemic stroke occurs when an ____ from elsewhere in the body obstructs a cerebral vessel. This type of ischemic stroke can affect multiple cerebral vascular territories. This type is associated withcardiogenic causesanddeep vein thrombosis (DVT) in the presence of a patent foramen ovale.Thehypoxictype of ischemic stroke is due tohypoperfusion or hypoxemia.This type tends to affect ____ areas and is common during cardiovascular surgical procedures.Watershed areas/zonesare areas of the brain between major ____ arteries, for example between anterior/middle cerebral arteries or middle/posterior cerebral arteries.Watershed infarctscan occur in these brain areas due to hypoxic ischemic stroke and often present with disturbances in visual processing with upper leg/arm weakness.___ strokesoccur due torupture of cerebral blood vessel leading to intracerebral bleeding

Answer 3

Two types of strokes are:Ischemic strokesare frominadequate blood supply to a region of the brain, often caused bythrombosis, embolism, or hypoxia.Thethrombotictype of ischemic stroke occurs when a clotforms directly at the site of infarction, often over anatheroscleroticplaque. The most common location is the middle cerebralartery.Theembolictype of ischemic stroke occurs when an clot from elsewhere in the body obstructs a cerebral vessel. This type of ischemic stroke can affect multiple cerebral vascular territories. This type is associated withcardiogenic causesanddeep vein thrombosis (DVT) in the presence of a patent foramen ovale.Thehypoxictype of ischemic stroke is due tohypoperfusion or hypoxemia.This type tends to affect watershed areas and is common during cardiovascular surgical procedures.Watershed areas/zonesare areas of the brain between major cerebral arteries, for example between anterior/middle cerebral arteries or middle/posterior cerebral arteries.Watershed infarctscan occur in these brain areas due to hypoxic ischemic stroke and often present with disturbances in visual processing with upper leg/arm weakness.Hemorrhagicstrokesoccur due torupture of cerebral blood vessel leading to intracerebral bleeding

Question 4

Two sources of blood supply:___ ____ system – gives major branches to lateral and medial surfaces of cerebral cortex and perforating arteries to deep cerebral nuclei___ ____ system - supplies the brainstem, cerebellum, occipital cortex,inferior part of temporal lobe, and spinal cord

Answer 4

Two sources of blood supply:Internal carotid system – gives major branches to lateral and medial surfaces of cerebral cortex and perforating arteries to deep cerebral nucleiVertebrobasilar system - supplies the brainstem, cerebellum, occipital cortex,inferior part of temporal lobe, and spinal cord

Question 5

The brain receives its blood supply from the___ arteriesand the___ systemwhich provide input to the Circle of Willis.

Answer 5

The brain receives its blood supply from thecarotidarteriesand thevertebrobasilar systemwhich provide input to the Circle of Willis.

Question 6

The branches of the internal carotid artery is:A VIP’S COMMA

Answer 6

A:anterior choroidal artery(C7)V:Vidian artery(C2)I:inferolateral trunk(C4)P:posterior communicating artery(C7)S:superior hypophyseal artery(C6)C:caroticotympanic artery(C2)O:ophthalmic artery(C6)M:meningohypophyseal trunk(C4)M:middle cerebral artery(C7)A:anterior cerebral artery(C7)

Question 7

Superficial branches of the ____Medial cortical branches supply:•Primary motor and somatosensory cortex–Lower limb, foot representation•Anterior corpus callosum

Answer 7

Superficial branches of the ACAMedial cortical branches•Primary motor and somatosensory cortex–Lower limb, foot representation•Anterior corpus callosum

Question 8

____ artery:Lateral cortical branches•Superior branches–Primary motor areas–Face, hand, upper limb representationMCA –Broca’s area–Prefrontal cortex•Inferior branches–Primary somatosensory cortex–Parietal integrative areas–Wernicke’s area–Meyer’s loop of optic radiations

Answer 8

Lateral cortical branches•Superior branches–Primary motor areas–Face, hand, upper limb representation–Broca’s area–Prefrontal cortex•Inferior branches–Primary somatosensory cortex–Parietal integrative areas–Wernicke’s area–Meyer’s loop of optic radiations**Deep branches to subcortical regions to be described below

Question 9

____ divides in the Sylvian fissure into superior and inferior divisions and stroke may be localized to one or both divisions. More superior branches radiate onto the lateral surface of frontal and anterior part of parietal cortex including ___ area.Inferior branches supply posterior parietal, and primary and secondary auditory cortices including ____ area, Myers loop (superior quadrantanopia).___ division infarcts may result in paralysis of face and upper limb as well as motor speech deficits (Broca’s aphasia)____ division infarcts may result in Wernicke’s or more global aphasia, hemineglect, some somatosensory loss from face and upper limb, and visual field deficits

Answer 9

MCA divides in the Sylvian fissure into superior and inferior divisions and stroke may be localized to one or both divisions. More superior branches radiate onto the lateral surface of frontal and anterior part of parietal cortex including Broca’s area.Inferior branches supply posterior parietal, and primary and secondary auditory cortices including Wernicke’sarea, Myers loop (superior quadrantanopia).Superiordivision infarcts may result in paralysis of face and upper limb as well as motor speech deficits (Broca’s aphasia)Inferiordivision infarcts may result in Wernicke’s or more global aphasia, hemineglect, some somatosensory loss from face and upper limb, and visual field deficits

Question 10

___ artery:Posterior cortical branches–Occipital cortex•Visual areas–Inferior temporal lobe–Orbital surface of frontal lobe–Parietal association areas–Posterior corpus callosum

Answer 10

PCA•Posterior cortical branches–Occipital cortex•Visual areas–Inferior temporal lobe–Orbital surface of frontal lobe–Parietal association areas–Posterior corpus callosumragment–>

Question 11

____ arteries are penetrating branches of the MCA that supply the internal capsule and structures of the basal ganglia.

Answer 11

Lenticulostriatearteries are penetrating branches of the MCA that supply the internal capsule and structures of the basal ganglia.

Question 12

___ arteries are often common in lacunar strokes.

Answer 12

Lenticulostriate arteries

Question 13

Deep Cerebral Arteries:___ ___ from the MCA___ ___ from the ACA___ ___ ___ from the ICA____ from the PCA

Answer 13

Deep Cerebral Arteries:Lenticulostriate branches rom the MCAStriate branchesfrom the ACAAnterior choroidal arteries from the ICAThalamoperforatorsfrom the PCA

Question 14

The terminal segment of ICA and initial segments ACA, MCA, and PCA give rise to deep cerebral branches that perforate the ___ ___ , ___ ____ and thalamus and related fiber tracts. These are common sites of small, lacunar infarcts and are distinct from more superficial strokes in the cortical fields of these vessels. Four named groups are:1. MCA (lenticulostriate branches)2. ACA(____)3. ICA (____)4. PCA (____)

Answer 14

The terminal segment of ICA and initial segments ACA, MCA, and PCA give rise to deep cerebral branches that perforate the basal ganglia, internal capsule, and thalamus and related fiber tracts. These are common sites of small, lacunar infarcts and are distinct from more superficial strokes in the cortical fields of these vessels. Four named groups are:MCA (lenticulostriate branches)ACA (striate branches)ICA (Anterior choroidal branches)PCA (Thalamoperforators)

Question 15

____ – ____ branches supply putamen and globus pallidus, and upper part of the internal capsule.___ – branches of ___ ____ ___ supply mostly posterior limb of internal capsule___ - ___ ___ ___such as recurrent branch of Hubner supply parts of caudate, lower region of anterior limb of internal capsule___ - ___ ____ ____ supply thalamus and posterior limb internal capsule

Answer 15

•MCA – lenticulostriate branches supply putamen and globus pallidus, and upper part of the internal capsule.•ICA – branches of anterior choroidal artery supply mostly posterior limb of internal capsule•ACA – medial striate arteries such as recurrent branch of Hubner supply parts of caudate, lower region of anterior limb of internal capsule• PCA – thalamo perforating branches supply thalamus and posterior limb internal capsule->

Question 16

•____ arteries are deep branches of the M1 segment of ____. Globus pallidus and putamen are mainly supplied by these vessels along with upper part of the anterior and posterior limbs and genu of internal capsule (overlaps ACA in anterior limb and anterior choroidal artery in posterior limb) . Lenticulostriate lacunar infarcts are most common.•Other deep, striate branches (like the recurrent artery of Heubner) are branches of the A1 segment of ___. The head of the basal ganglia and anterior limb of internal capsule are supplied mainly by these vessels._____ arteries are branches of P1 (PCA). The thalamus as well as the posterior limb of internal capsule are mainly supplied by these vessels.•Before giving off the posterior communicating branch and after the ophthalmic, the internal carotid artery gives rise to the __ ___ artery. Thisartery along with other choroidal arteries supplies choroidal plexus. In addition it also supplies the ___ limb of the internal capsule.

Answer 16

•Lenticulostriate arteries are deep branches of the M1 segment of MCA. Globus pallidus and putamen are mainly supplied by these vessels along with upper part of the anterior and posterior limbs and genu of internal capsule (overlaps ACA in anterior limb and anterior choroidal artery in posterior limb) . Lenticulostriate lacunar infarcts are most common.•Other deep, striate branches (like the recurrent artery of Heubner) are branches of the A1 segment of ACA. The head of the basal ganglia and anterior limb of internal capsule are supplied mainly by these vessels.•Thalamoperforating arteries are branches of P1. The thalamus as well as the posterior limb of internal capsule are mainly supplied by these vessels.•Before giving off the posterior communicating branch and after the ophthalmic, the internal carotid artery gives rise to the anterior choroidal artery. The anterior choroidal artery along with other choroidal arteries supplies choroidal plexus. In addition it also supplies the posterior limb of the internal capsule.

Question 17

A ‘classic’ teaching lesion is PICA infarct in the dorsolateral medulla (and, of course, posterior inferior cerebellum) – This is called ____syndrome

Answer 17

Another ‘classic’ teaching lesion is PICA infarct in the dorsolateral medulla (and, of course, posterior inferior cerebellum) – Wallenberg’s syndrome•Ataxia – cerebellar or inferior cerebellar peduncle damage•Loss of pain and temperature on ipsilateral side of the face- spinal trigeminal tract and nucleus (there may be some contralateral loss given possible inclusion of cross trigeminothalamic fibers)•To varying degrees loss of pain and temperature on contralateral side of the body – depending on extent of anterolateral spinothalamic tract involved•Vertigo – vestibular nucleus•Swallowing – CN X or nucleus ambiguus•Hoarseness – CN X or nucleus ambiguus•Changes in taste – nucleus solitarius and CN IX•Autonomic signs – mostly due to medullary sympathetic centers, but also vagus and vagal nuclei

Question 18

___ ___ syndrome – infarcts of paramedian branchesoContralateral hemiparalysis and paralysis of contralateral face – corticospinal and corticobulbar fibersoIpsilateral weakness of the face – damage to the internal genu of the facial nerveoContralateral loss of vibration sense (touch) and conscious proprioception – medial lemniscusoInability to abduct ipsilateral eye beyond the midpoint – abducens nerve and nucleus

Answer 18

·Medial pontine syndrome – infarcts of paramedian branchesoContralateral hemiparalysis and paralysis of contralateral face – corticospinal and corticobulbar fibersoIpsilateral weakness of the face – damage to the internal genu of the facial nerveoContralateral loss of vibration sense (touch) and conscious proprioception – medial lemniscusoInability to abduct ipsilateral eye beyond the midpoint – abducens nerve and nucleus

Question 19

____ syndrome is a ‘classic’ teaching lesion for caudal, lateral pontine strokesoIpsilateral ataxia – damage to cerebellum and middle cerebellar peduncleoVertigo – damage to vestibular nucleioIpsilateral loss or decrease of pain and temperature sensation on the face – damage to spinal trigeminal tractoContralateral loss or decrease of pain and temperature sensation on body and face – damage to anterolateral systemoIpsilateral hearing loss – this may result from damage to cochlear nuclei or involvment of the labyrinthine artery that branches from AICA and supplies the cochlea

Answer 19

·AICA syndrome is a ‘classic’ teaching lesion for caudal, lateral pontine strokesoIpsilateral ataxia – damage to cerebellum and middle cerebellar peduncleoVertigo – damage to vestibular nucleioIpsilateral loss or decrease of pain and temperature sensation on the face – damage to spinal trigeminal tractoContralateral loss or decrease of pain and temperature sensation on body and face – damage to anterolateral systemoIpsilateral hearing loss – this may result from damage to cochlear nuclei or involvment of the labyrinthine artery that branches from AICA and supplies the cochlea

Question 20

·Lateral pontine syndromes can differ from this depending involvement of other short and long circumferential lesions. For instance __ ___ artery strokes involve the trigeminal motor and chief sensory nucleus whereas AICA syndrome does not.

Answer 20

·Lateral pontine syndromes can differ from this depending involvement of other short and long circumferential lesions. For instance superior cerebellar artery strokes involve the trigeminal motor and chief sensory nucleus whereas AICA syndrome does not.

Question 21

___ ___syndrome – infarcts of paramedian branchesoContralateral hemiparalysis and paralysis of contralateral face – corticospinal and corticobulbar fibersoIpsilateral weakness of the face – damage to the internal genu of the facial nerveoContralateral loss of vibration sense (touch) and conscious proprioception – medial lemniscusoInability to abduct ipsilateral eye beyond the midpoint – abducens nerve and nucleus

Answer 21

·Medial pontine syndrome – infarcts of paramedian branchesoContralateral hemiparalysis and paralysis of contralateral face – corticospinal and corticobulbar fibersoIpsilateral weakness of the face – damage to the internal genu of the facial nerveoContralateral loss of vibration sense (touch) and conscious proprioception – medial lemniscusoInability to abduct ipsilateral eye beyond the midpoint – abducens nerve and nucleus

Question 22

Arterial Supply of Midbrain:____ branches supplies:–CN III–Parts of cerebral peduncle and SN–Red nucleus–Superior cerebellar peduncle_____l branches of basilar or ____ ____ arterysupplies:•Medial lemniscus•Anterolateral system•Parts of cerebral peduncle and SN__ ___ artery supplies the:–Tectum

Answer 22

Arterial Supply of Midbrain:•Paramedian branches–CN III–Parts of cerebral peduncle and SN–Red nucleus–Superior cerebellar peduncle•Circumferential branches of basilar or PCA•Medial lemniscus•Anterolateral system•Parts of cerebral peduncle and SN•e.g., superior cerebellar artery–Tectum->

Question 23

____ syndromes: basal lesions involving paramedian branches to the midbrain arise from the P1 segment of the posterior cerebral artery. Infarcts involve the cerebral peduncle and CN III along with parts of the substantia nigra and red nucleus. Neurological deficits includea) contralateral hemiparalysisb) oculomotor palsy (the eye is in down and out position) and mydriatic (dilated) pupil.•Other basal midbrain lesions may include loss or decreased somatosensation (medial lemniscus and anterolateral system) and tremor or other involuntary movements (___ ___ is the region important for movement).•As mentioned above, berry aneurysm is common at distal branch points of the basilar artery. Infarct or ischemia may result at base of the midbrain and/or damage to the oculomotor nerve.Berry aneurysm: A smallaneurysmthat looks like aberryand classically occurs at the point at which acerebralartery departs from the circular artery (the circle of Willis) at the base of thebrain.

Question 24

What kind of syndrome?

Answer 24

Weber’s SyndromeParamedian branches are occluded.•Weber’s syndrome (another classic teaching lesion): basal lesions involving paramedian branches to the midbrain arise from the P1 segment of the posterior cerebral artery. Infarcts involve the cerebral peduncle and CN III along with parts of the substantia nigra and red nucleus. Neurological deficits include a) contralateral hemiparalysis and b) oculomotor palsy (the eye is in down and out position) and mydriatic (dilated) pupil.•Other basal midbrain lesions may include loss or decreased somatosensation (medial lemniscus and anterolateral system) and tremor or other involuntary movements (substantia nigra).

Question 25

Theanterior choroidal arteryis a branch of the internal carotid. It contributes blood supply to the lateral ___ body, __ __, and posterior limb of the ___ ___.

Answer 25

Theanterior choroidal arteryis a branch of the internal carotid. It contributes blood supply to the lateral geniculate body, globus pallidus, and posterior limb of the internal capsule.