Vascular

Question 1

A 48-year-old woman presents for a diagnostic angiogram and is found to have bilateral
hypoplastic vertebral arteries. An angiogram (Figure 1) and a CT scan (Figure 2) are shown.
Through which of the following arteries is the posterior circulation being supplied?
Answers:
A. Vertebral artery
B. Persistent hypoglossal artery
C. Anterior choroidal artery
D. Posterior communicating artery
E. Persistent trigemeninal artery

Answer 1

Persistent hypoglossal artery

Discussion:
The angiogram demonstrates a persistent hypoglossal artery arising from the cervical segment of
the right internal carotid artery. An enlarged hypoglossal canal is seen on CT imaging. In early
embryonic development, there are 4 types of fetal carotid-vertebrobasilar anastomoses, which
include the primitive trigeminal, hypoglossal, otic, and proatlantal intersegmental arteries. As the
embryo develops, the posterior communicating arteries develop, and the anastomotic arteries
begin to regress at approximately the 30–40th days of fetal development. When this regression
fails, the embryonic arteries persist. The persistent hypoglossal artery is the second most common
carotid-vertebrobasilar anastomosis, arising from the cervical ICA and entering the posterior fossa
via the hypoglossal canal, before finally anastamosing with the terminal segment of the vertebral
artery.
References:
Chapter 3. Osbourn AG. Diagnostic Cerebral Angiography. 2nd Ed. Lippincott, Williams, and
Wilkins, 1999; Ozawa et al. Bilateral persistent hypoglossal arteries: a case report and literature
review. PMID: 31016350

Question 2

A patient undergoes a left pterional craniotomy for aneurysm clipping. The aneurysm clip occludes
the small vessel indicated by the arrow in the image shown. Which of the following areas will
appear infarcted on CT scan?
Answers:
A. Left hypothalamus
B. Right thalamus
C. Left cingulate gyrus
D. Left caudate
E. Left optic nerve

Answer 2

Left caudate

Discussion:
The arrow points to the recurrent artery of Heubner, which can be injured during anterior
communicating artery aneurysm surgery. This vessel usually arises from the A2 segment of the
ACA, immediately after the Anterior Communicating Artery. The caudate head, anterior portion of
the lentiform nucleus, and anterior limb of the internal capsule are supplied by the recurrent artery
of Heubner.
References:
Ghika JA, Bogousslavsky J, Regli F. Deep perforators from the carotid system. Template of the
vascular territories. Arch Neurol. 1990:47(10):1097-1100.; Loukas M, Louis RG Jr, Childs RS.
Anatomical examination of the recurrent artery of Heubner. Clin Anat. 2006 Jan; 19(1):25-31

Question 3

In 95% of the population, the vertebral artery enters the foramen transversarium at which of the
following cervical levels?
Answers:
A. C7
B. T1
C. C5
D. C4
E. C6

Answer 3

C6

Discussion:
The vertebral Artery usually enters the foramen transversarium of C6, to form the V2 segment. The
V2 segment ends as the artery leaves the foramen transversarium of C2.
References:
Osborn AG. Diagnostic Neuroradiology: A text/Atlas. 1st ed. Philadelphia: Mosby-Elsevier 1994;
Satti SR, Cerniglia CA, Koenigsberg RA. Cervical vertebral artery variations: an anatomic study.
AJNR Am J Neuroradiol. 2007;28 (5): 976-80.

Question 4

A 45-year-old man with a presumed left-sided glomus jugulare tumor (paraganglioma) undergoes
preoperative angiography and embolization before surgical resection. The lateral projection left
common carotid angiogram (Figure A) and dedicated (selective) external carotid artery angiogram
(Figure B) are shown. Which of the following arteries is indicated by the arrow in both images?
Answers:
A. Posterior auricular artery
B. Lingual artery
C. Persistent primitive trigeminal artery
D. Superficial temporal artery
E. Ascending pharyngeal artery

Answer 4

Ascending pharyngeal artery

Discussion:
The ascending pharyngeal artery can be seen arising from the proximal external carotid artery
close to the source of the occipital artery and coursing superiorly.
References:
Osborn AG, Slazman KL, Jhaveri MD, et al, eds. Diagnostic Imaging: Brain 3e. 3rd ed. Elsevier,
2015; Cortés-Franco S, Muñoz AL, Franco TC, Ruiz T. Anomalous ascending pharyngeal artery
arising from the internal carotid artery: report of three cases. (2013) Annals of vascular surgery. 27
(2): 240.e1-4

Question 5

A 60-year-old man is evaluated for acute onset of hemiplegia, hemisensory loss, and ipsilateral
gaze preference with no visual field deficit. Which of the following is the most likely location of this
patient’s occlusion?
Answers:
A. anterior choroidal artery
B. PICA
C. middle cerebral artery
D. AICA
E. cavernous internal carotid artery

Answer 5

middle cerebral artery

Discussion:
MCA stroke can result in contralateral hemiplegia and hemisensory loss as well as ipsilateral gaze
preference. In this case, primary motor and sensory areas are involved. Anterior choroidal stroke
results in homonymous hemianopsia.
References:
Ropper A, Samuels M, Klein J, eds. Adams and Victor’s Principles of Neurology. McGraw-Hill
Education; Afifi A, Bergman R, eds. Functional Anatomy: Text and Atlas. 2nd ed. New York, NY:
McGraw-Hill Education; 2005:362

Question 6

The lenticulostriate arteries enter which of the following structures immediately after originating
from the middle cerebral artery?
Answers:
A. Globus pallidus interna
B. Caudate nucleus
C. Sylvian fissure
D. Anterior perforated substance
E. Internal capsule

Answer 6

Anterior perforated substance

Discussion:
The lenticulostriate arteries enter the anterior perforated substance immediately after originating
from the middle cerebral artery. The basilar tip perforators enter the posterior perforated
substance.
References:
Rosner et al. Microsurgical anatomy of the anterior perforating arteries. Journal of Neurosurgery,
61(3), 468–485. doi:10.3171/jns.1984.61.3.0468; Lawton MT: Middle Cerebral Artery Aneurysms.
In: Conerly K (ed). Seven Aneurysms: Tenets and Techniques for Clipping. New York: Thieme.
2011

Question 7

Which of the following sets represents the proximal to distal order of vessels as they arise from the
aortic arch?
Answers:
A. Brachiocephalic trunk, left common carotid artery, left subclavian artery
B. Brachiocephalic trunk, right mammillary artery, left common carotid artery left subclavian
artery
C. Right subclavian artery, right common carotid artery, brachiocephalic trunk
D. Brachiocephalic trunk, right vertebral artery, left common carotid artery, left vertebral artery
E. Brachiocephalic trunk, right vertebral artery, left common carotid artery, left subclavian
artery

Answer 7

Brachiocephalic trunk, left common carotid artery, left subclavian artery

Discussion:
The aortic arch can exhibit normal variations in branching pattern. The most common variant,
comprising 80.9% of arches, is the classic pattern, consisting of the brachiocephalic trunk, left
common carotid artery, left subclavian artery. This pattern is followed by the bovine variant, where
the left common carotid arises from the brachiocephalic trunk (13.6%), and the left vertebral artery
variant, where the left vertebral artery arises directly from the aorta rather than from the left
subclavian artery (2.8%).
References:
Popieluszko et al., J Vasc Surg 2018 PMID 28865978. Osborn AG. Diagnostic Neuroradiology: A
text/Atlas. 1st ed. Philadelphia: Mosby-Elsevier; 1994.

Question 8

A 28-year-old woman with aqueductal stenosis is undergoing endoscopic third ventriculostomy.
Which of the following veins is indicated by the arrow in the intraoperative image shown?
Answers:
A. Septal Vein
B. Thalamostriate vein
C. Caudate vein
D. Venous Angle
E. Terminal Vein

Answer 8

Septal Vein

Discussion:
The image shows a view through the foramen of monro from the right lateral ventricle. The
columns of the fornix form the anterior and superior margins of the foramen. The anterior septal
vein passes posteriorly along the septum and crosses the column of the fornix.
References:
Anderson RCE, Walker ML. Neuro-endoscopy. In: Albright AL, Adelson PD and Pollack IF, eds.
Principles and Practice of Pediatric Neurosurgery. New York: Thieme; 2007: 133; Osborn AG.
Diagnostic Neuroradiology: A text/Atlas. 1st ed. Philadelphia: Mosby-Elsevier 1994

Question 9

Which of the following is the main function of occludin and claudin?
Answers:
A. Axonal transport
B. Epithelial tight junction maintenance
C. Regulation of clotting cascade
D. Inflammatory mediation
E. Glycolysis

Answer 9

Epithelial tight junction maintenance

Discussion:
Occludin and claudin are tight junction proteins that maintain blood brain barrier integrity.
References:
Neurology in Clinical Practice, Volume 2. 5th ed. 2008: 1695; Tsukita and Furuse,Overcoming
barriers in the study of tight junction functions: from occludin to claudin, https://doi.org/10.1046
/j.1365-2443.1998.00212.x

Question 10

Which of the following is the primary source of the venous blood carried from the inferior petrosal
sinus to the internal jugular vein?
Answers:
A. Cavernous sinus
B. Internal cerebral vein
C. Emissary veins
D. Basal vein of Rosenthal
E. Vein of Trolard

Answer 10

Cavernous sinus

Discussion:
The origin of the inferior petrosal sinus is the cavernous sinus. The cavernous sinus drains to the
superior and inferior petrosal sinuses. The superior and inferior petrosal sinuses do not receive
drainage from the deep venous system. In the non-pathologic setting, emissary veins play a
relatively minor role in the circulatory system of the brain.
References:
Nolte J. The Human Brain: An Introduction to Its Functional Anatomy. St. Louis: Mosby; 1999;
Osborn AG. Diagnostic Neuroradiology: A text/Atlas. 1st ed. Philadelphia: Mosby-Elsevier; 1994

Question 11

From proximal to distal, which of the following is the most common order of the internal carotid
artery branches?
Answers:
A. posterior communicating, ophthalmic, anterior choroidal, anterior cerebral, middle cerebral
B. posterior communicating, anterior choroidal, ophthalmic, anterior cerebral, middle cerebral
C. ophthalmic, posterior communicating, anterior choroidal, anterior cerebral, middle cerebral
D. ophthalmic, anterior choroidal, posterior communicating, anterior cerebral, middle cerebral
E. anterior choroidal, ophthalmic, posterior communicating, anterior cerebral, middle cerebral

Answer 11

ophthalmic, posterior communicating, anterior choroidal, anterior cerebral, middle cerebral

Discussion:
The ophthalmic artery is the first branch of the ICA distal to the cavernous sinus. The posterior
communicating artery typically arises proximal to anterior choroidal artery.
References:
Carpenter MB, ed. Core text of neuroanatomy. 4th ed. Baltimore, MD: Lippincott, Williams &
Wilkins, 1991; Osborn AG. Diagnostic Neuroradiology: A text/Atlas. 1st ed. Philadelphia: MosbyElsevier 1994

Question 12

The inferior hypophyseal artery arises from which of the following?
Answers:
A. Superior hypophyseal artery
B. Thyrocervical trunk
C. Clinoidal internal carotid
D. Meningohypophyseal trunk
E. Posterior cerebral artery

Answer 12

Meningohypophyseal trunk

Discussion:
The inferior hypophyseal artery arises from the meningohypophyseal trunk and supplies the
posterior pituitary. The meningohypophyseal trunk arises from the posterior genu of the cavernous
internal carotid.
References:
Yasargil. Microneurosurgery. Vol 1; Osborn AG. Diagnostic Neuroradiology: A text/Atlas. 1st ed.
Philadelphia: Mosby-Elsevier; 1994

Question 13

Which of the following arises from the internal carotid artery below the level of the petrolingual
ligament and supplies blood to a large glomus jugulare tumor?
Answers:
A. Labyrinthine artery
B. Otic artery
C. Caroticotympanic artery
D. Anterior choroidal artery
E. Vidian artery

Answer 13

Caroticotympanic artery

Discussion:
The petrous portion of the internal carotid artery has been described to branch out into the
caroticotympanic branch, the pterygoid canal (Vidian) and the periosteal
branch. A glomus jugulare tumor may extend anteriorly to involve the carotid canal and
caroticotympanic artery territory.
References:
Osborn AG, ed. Diagnostic Cerebral Angiography. 2nd ed. Lippincott, Williams & Wilkins, 1999:71;
Andreo et al. https://doi.org/10.1159/000016745; Hesselink AJNR 2:289-297, July/ August 1981

Question 14

The internal auditory artery most often arises from which of the following arteries?
Answers:
A. Superior cerebellar artery
B. Posterior choroidal artery
C. Posterior Inferior Cerebellar Artery
D. Anterior Inferior Cerebellar Artery
E. Middle Meningeal Artery

Answer 14

Anterior Inferior Cerebellar Artery

Discussion:
The internal auditory artery, or Labyrinthine artery, originates from the AICA, although some
studies have reported that as many as 17% arise from the Basilar Artery.
References:
Kazawa N, Togashi K, Ito J. The anatomical classification of AICA/PICA branching and
configurations in the cerebellopontine angle area on 3D-drive thin slice T2WI MRI. Clin Imaging.
2013 Sep-Oct;37(5):865-870. Epub 2013 Jun 14.; Rhoton A. Cranial Anatomy and Surgical
Approaches. Neurosurgery. 2003; 53(3): 545

Question 15

Which artery of the following branches of the external carotid artery provides the blood supply to
the lower cranial nerves?
Answers:
A. Superior thyroid artery
B. Ascending pharyngeal artery
C. Internal maxillary artery
D. Occipital artery
E. Lingual artery

Answer 15

Ascending pharyngeal artery

Discussion:
Cranial nerves IX, X, XI, XII are supplied by distal branches of the neuromeningeal trunk arising
from the ascending pharyngeal artery.
References:
Ozanne A, Pereira V, Krings T, et al. Arterial vascularization of the cranial nerves. Neuroimaging
Clin N Am. 2008 May;18(2):431-439, xii.Krisht A, Barnett DW, Barrow DL, et al. The blood supply
of the intracavernous cranial nerves: an anatomic study. Neurosurgery. 1994 Feb;34(2):275-279

Question 16

The persistent hypoglossal artery is a connection between the basilar artery and which of the
following arteries?
Answers:
A. Petrous internal carotid artery
B. External carotid artery
C. Cervical internal carotid artery
D. Anterior cerebral artery
E. Cavernous internal carotid artery

Answer 16

Cervical internal carotid artery

Discussion:
The persistent hypoglossal artery arises at the level of C1 to C3 as a robust branch from the
cervical internal carotid artery (ICA). The persistent trigeminal artery arises from the cavernous
ICA, while the persistent otic artery arises from the petrous ICA.
References:
Brismar. “Persistent Hypoglossal Artery, Diagnostic Criteria: Report of a Case.” Acta Radiologica
Diagnosis, 1976. PMID: 1274653; Fujita N, Shimada N, Takimoto H et-al. MR appearance of the
persistent hypoglossal artery. AJNR Am J Neuroradiol. 1995;16 (4): 990-2. AJNR Am J
Neuroradiol (abstract) - Pubmed citation

Question 17

A 45-year-old woman is evaluated because of a debilitating pulsatile tinnitus and worsening
headaches. In the lateral right common carotid angiogram shown, the arrows indicate branches of
which of the following feeding arteries to this high-risk dural arteriovenous fistula?
Answers:
A. Meningohypophyseal trunk
B. Anterior choroidal artery
C. Occipital artery
D. Middle meningeal artery
E. Superior Hypophyseal Artery

Answer 17

Occipital artery

Discussion:
Transcranial branches of the occipital artery are seen supplying this transverse-sigmoid sinus dural
arteriovenous fistula
References:
Osborn AG, ed. Diagnostic Cerebral Angiography. 2nd ed. Philadelphia, PA: Lippincott, Williams &
Wilkins, 1999; Susan Standring. Gray’s Anatomy. ISBN: 9780702052309

Question 18

Occlusion of which of the arteries shown in the frontotemporal operative exposure would result in
an infarct localized to the anterior limb of the internal capsule?
Answers:
A. Anterior choroidal artery
B. Posterior communicating artery
C. M1 branch of the middle cerebral artery
D. Recurrent artery of Heubner
E. Distal anterior cerebral artery

Answer 18

Recurrent artery of Heubner

Discussion:
The recurrent artery of Heubner (also known as the medial distal striate artery) arises just distal
(and less commonly proximal) to the anterior communicating artery. It supplies the head of the
caudate, anterior limb of the internal capsule, anterior putamen and globus pallidus, the septal
nuclei, and the inferior frontal lobe. It is termed recurrent due to its course from its origin
backwards towards the ipsilateral proximal A1. The artery is often at risk of injury during surgical
treatment of an anterior communicating artery aneurysm and may develop subsequent
vasospasm. Compromise of blood flow in the recurrent artery of Heubner classically results in
contralateral arm and face weakness, and occasionally dysarthria. Bilateral injury results in
akinetic mutism. Involvement of the distal anterior cerebral artery would result in infarctions in
paramedian cortices. Vascular compromise of the anterior choroidal artery primarily affects the
posterior limb of the internal capsule. Compromise of the M1 branch would result in hemispheric
infarction throughout the middle cerebral artery territory. Finally, compromise of the posterior
communicating artery may or may not result in infarction, depending on collateral flow through the
posterior circulation.
References:
Falougy et al., Biomed Res Int 2013 PMID 23936853. Loukas M, Louis RG, Jr., Childs RS.
Anatomical examination of the recurrent artery of Heubner. Clin Anat. Jan 2006;19(1):25-31

Question 19

Which of the following is the most proximal segment of the posterior inferior cerebellar artery
(PICA) that may be sacrificed with little risk of neurological compromise?
Answers:
A. Telovelotonsillar
B. Lateral Medullary
C. Cortical branches
D. Anterior Medullary
E. Tonsillomedullary

Answer 19

Telovelotonsillar

Discussion:
The PICA can be be divided into five segments. The proximal most segments (anterior and lateral
medullary) segments contribute branches to the brainstem. The tonsillomedullary segment is a
transitional zone which may produce some perforating vessels. The distal most segments
(telovelotonsillar and cortical) do not supply blood to the brainstem. The first three segments of the
PICA are usually preserved, while the last 2 can be sacrificed without major neurological deficits.
References:
Lewis et al. Distal posterior inferior cerebellar artery aneurysms: clinical features and
management. Journal of Neurosurgery. 2002; Lister JR, Rhoton AL Jr, Matsushima T, et al.
Neurosurgery. 1982 Feb;10(2):170-199

Question 20

The blood-brain barrier effectively prevents the passage of which of the following into the brain?
Answers:
A. Oxygen
B. Glucose
C. Carbon dioxide
D. Amino acid
E. Gadolinium

Answer 20

Gadolinium

Discussion:
Small lipophilic substances such as oxygen and carbon dioxide diffuse freely across plasma
membranes of the blood-brain barrier along their concentration gradient. Nutrients including
glucose and amino acids enter the brain via transporters. Gadolinium only enters the brain at sites
of blood-brain barrier disruption.
References:
Ballabh et al. The blood-brain barrier: an overview: structure, regulation, and clinical implications.
PMID: 15207256; Citow J, Macdonald R, Puffer R et al., Comprehensive Neurosurgery Board
Review, ed. 3rd Edition. Thieme; 2019. doi:10.1055/b-005-148973

Question 21

The anterior choroidal artery supplies blood to which of the following structures?
Answers:
A. Arcuate nucleus
B. Optic tract
C. Pineal gland
D. Gyrus rectus
E. Medial longitudinal fasciculus

Answer 21

Optic tract

Discussion:
The anterior choroidal artery most often arises from the internal carotid artery distal to the posterior
communicating artery. It supplies the posterior limb of the internal capsule, the optic tract, the
lateral geniculate nucleus, the medial temporal lobe, and the globus pallidus pars interna (GPi).
Ischemia of its territory classically results in contralateral hemisensory loss, hemiparesis, and
hemianopia.
References:
Hupperts, R. M. M., et al. “Infarcts in the anterior choroidal artery territory Anatomical distribution,
clinical syndromes, presumed pathogenesis and early outcome.” Brain 117.4 (1994): 825-834;
Yasargil, Microneurosurgery Volume 1

Question 22

A microvascular decompression is performed through a suboccipital craniotomy on a 65-year-old
man with right V3 trigeminal neuralgia. Which of the following venous structures is seen in the
middle of the operative field during the approach to the trigeminal nerve in the image shown?
Answers:
A. Superior Petrosal Vein
B. Superior Petrosal Sinus
C. Superior Vermian Vein
D. Internal Cerebral Vein
E. Vein of Rosenthal

Answer 22

Superior Petrosal Vein

Discussion:
The superior petrosal vein or “Dandy’s vein” is seen. Initially described by Walter E. Dandy in its
anatomical relation to the trigeminal nerve and cerebellum, the superior petrosal vein is known as
an important venous drainage system in the posterior cranial fossa and is an important landmark in
the retrosigmoid approach to the trigeminal nerve. The vein empties into the superior petrosal
sinus.
References:
Watanabe T, Igarashi T, Fukushima T, et al. Anatomical variation of superior petrosal vein and its
management during surgery for cerebellopontine angle meningiomas. Acta Neurochir (Wien). 2013
Oct;155(10):1871-8; Blue et al. World Neurosurg. 2020 Jun;138:e420-e425. doi:
10.1016/j.wneu.2020.02.142

Question 23

A 37-year-old man undergoes surgery for a right posterior communicating artery aneurysm.
Postoperatively, he is fully awake and alert and is following commands, but there is a dense
hemiparesis involving the left face, arm, and leg, as well as a left visual field cut. Which of the
following blood vessels was most likely compromised during the surgery?
Answers:
A. Posterior Medial Choroidal
B. Recurrent Artery of Heubner
C. Anterior choroidal artery
D. Lenticulostriate arteries
E. Posterior Lateral Choroidal

Answer 23

Anterior choroidal artery

Discussion:
The Anterior Choroidal Artery supplies the posterior limb of the internal capsule, the optic
tract/radiations and globus pallidus internus. Damage to this artery results in contralateral
hemiplegia, contralateral hemianesthesia and homonimous hemianopsia.
References:
Spetzler RF, Kalani MYS, Nakaji P, eds. Neurovascular Surgery. Thieme:25, 512; Hupperts, R. M.
M., et al. “Infarcts in the anterior choroidal artery territory Anatomical distribution, clinical
syndromes, presumed pathogenesis and early outcome.” Brain 117.4 (1994): 825-834

Question 24

Which of the following arteries is indicated by the arrows in the cadaveric dissection photograph
shown?
Answers:
A. Posterior cerebral artery
B. Posterior communicating artery
C. Basilar artery
D. Superior cerebellar artery
E. Anterior inferior cerebellar artery

Answer 24

Superior cerebellar artery

Discussion:
The superior cerebellar artery can be seen arising from the distal basilar artery just before the
posterior cerebral artery. The occulomotor nerve travels between the superior cerebellar and
posterior cerebral arteries.
References:
Rhoton AL, Apuzzo MLJ, eds. Cranial Anatomy and Surgical Approaches. 1st ed. Lippincott
Williams & Wilkins, 2003; Osborn AG, Slazman KL, Jhaveri MD, et al, eds. Diagnostic Imaging:
Brain 3e. 3rd ed. Elsevier, 2015

Question 25

The pituitary gland is supplied by branches of which of the following arteries?
Answers:
A. Anterior cerebral artery
B. Recurrent artery of Huebner
C. Anterior communicating artery
D. Middle cerebral artery
E. Internal carotid artery

Answer 25

Internal carotid artery

Discussion:
The pituitary gland is supplied largely by branches of the internal carotid artery (ICA), including the
superior hypophyseal artery, the prechiasmal artery (branching off the ophthalmic artery), and
branches of the cavernous ICA (the inferior hypophyseal artery, the capsular artery, and the
inferolateral trunk). There is also supply from the infundibular artery branching off the posterior
communicating artery.
References:
Gibo et al. “Arteries to the pituitary.” Nihon Rinsho, 1993. PMID: 8254920; Yasargil.
Microneurosurgery. Vol 1

Question 26

A patient undergoes clipping of an anterior communicating artery aneurysm. The patient awakens
slowly from anesthesia and has a mild contralateral hemiparesis. Which of the following vessels
indicated by the arrow in the photograph shown is the most likely cause of such an injury?
Answers:
A. middle cerebral artery
B. ophthalmic artery
C. anterior choroidal artery
D. recurrent artery of heubner
E. lenticulostriate artery

Answer 26

recurrent artery of heubner

Discussion:
The recurrent artery of heubner exits A2 and traverses posteriorly. This artery can be inadvertently
injured during clipping of anterior communicating artery aneurysms causing contralateral
weakness.
References:
Gomes F, Dujovny M, Umansky F, et al. Microsurgical anatomy of the recurrent artery of Heubner.
J Neurosurg. 1984 Jan;60(1):130-9; Loukas M, Louis RG, Jr., Childs RS. Anatomical examination
of the recurrent artery of Heubner. Clin Anat. Jan 2006;19(1):25-31

Question 27

Perforators off of which of the following arteries provide the blood supply to the subthalamic
nucleus?
Answers:
A. Calcarine artery
B. Posterior choroidal artery
C. Posterior cerebral artery
D. Superior cerebellar artery
E. Anterior choroidal artery

Answer 27

Posterior cerebral artery

Discussion:
The posterior choroidal arteries arise from the P2 segment of the posterior cerebral artery and are
made up of a number of branches. One to 2 medially placed branches arise from the distal P1 or
proximal P2 segment of the posterior cerebral artery. These supply the subthalamic nucleus and
midbrain, the medial half of the medial geniculate nucleus, the posterior parts of the intralaminar
nuclei of the thalamus, and the pulvinar nuclei.
References:
Schmahmann JD. Vascular syndromes of the thalamus. Stroke. 2003 Sep;34(9):2264-78. Epub
2003 Aug 21; Haines DE. Neuroanatomy. Lippincott Williams & Wilkins. (2008) ISBN:0781763282

Question 28

A 50-year-old woman has mild left hemiparesis on awakening after undergoing clipping of an
unruptured intracranial aneurysm. Postoperative CT scan of the head shows an infarct involving
the head of the right caudate nucleus, the anterior limb of the right internal capsule, and the
anterior right putamen. Which of the following arteries was most likely occluded?
Answers:
A. Frontopolar branch
B. Anterior communicating artery
C. Lateral lenticulostriate artery
D. Anterior choroidal artery
E. Recurrent artery of Heubner

Answer 28

Recurrent artery of Heubner

Discussion:
The caudate head, anterior portion of the lentiform nucleus, and anterior limb of the internal
capsule are supplied by the recurrent artery of Heubner, which can be injured during anterior
communicating artery aneurysm surgery. This vessel usually arises from the A2 segment of the
ACA, immediately after the Anterior Communicating Artery.
References:
Loukas M, Louis RG Jr, Childs RS. Anatomical examination of the recurrent artery of Heubner. Clin
Anat. 2006 Jan; 19(1):25-31; Falougy et al., Biomed Res Int 2013 PMID 23936853

Question 29

The recurrent artery of Heubner most frequently arises from the
Answers:
A. A1 segment of the anterior cerebral artery
B. Ophthalmic segment of the internal cerebral artery
C. Communicating segment of the anterior cerebral artery
D. Communicating segment of the internal cerebral artery
E. A2 segment of the anterior cerebral artery

Answer 29

A2 segment of the anterior cerebral artery

Discussion:
The recurrent artery of Heubner most commonly arises from the post-communicating segment of
the anterior cerebral artery (A2) in 47.81% of cases, from the communicating segment in 43.4% of
cases, and from the pre-communicating segment in only 3.55% of cases.
References:
Falougy et al., Biomed Res Int 2013 PMID 23936853. Loukas M, Louis RG, Jr., Childs RS.
Anatomical examination of the recurrent artery of Heubner. Clin Anat. Jan 2006;19(1):25-31

Question 30

From which of the following arteries does the tentorial artery originate?
Answers:
A. Meningohypophyseal trunk
B. Petrous internal carotid
C. Maxillary artery
D. Middle meningeal artery
E. Middle cerebral artery

Answer 30

Meningohypophyseal trunk

Discussion:
The tentorial artery arises from the meningohypophyseal trunk and supplies the mass of the
tentorium and its petrous attachment. The meningohypophyseal trunk arises from the posterior
genu of the cavernous internal carotid.
References:
Yasargil. Microneurosurgery. Vol 1; Osborn AG. Diagnostic Neuroradiology: A text/Atlas. 1st ed.
Philadelphia: Mosby-Elsevier; 1994

Question 31

The artery that appears to be the primary contributor to the tumor “blush” illustrated on the lateral
carotid angiogram shown also typically supplies blood to which of the following brain structures?
Answers:
A. cerebellar vermis
B. internal capsule
C. medial lemniscus
D. midbrain
E. lateral lemniscus

Answer 31

internal capsule

Discussion:
The anterior choroidal artery is depicted this lateral carotid angiogram. It supplies the posterior
limb of the internal capsule, the optic tract/radiations and globus pallidus internus. Damage to this
artery results in contralateral hemiplegia, contralateral hemianesthesia and homonimous
hemianopsia.
References:
Radiographia.org. Accessed August 20, 2016.Krayenbu¨hl H, Yas¸argil MG, eds. Cerebral
angiography. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins, 1968; Hupperts, R. M. M., et
al. “Infarcts in the anterior choroidal artery territory Anatomical distribution, clinical syndromes,
presumed pathogenesis and early outcome.” Brain 117.4 (1994): 825-834

Question 32

A 56-year-old man undergoes surgical clipping of a left posterior communicating artery aneurysm.
The patient awakens with a contralateral hemiparesis and contralateral visual field loss.
Compromise of which of the following vessels is implicated in this patient’s new deficit?
Answers:
A. Artery of Huebner
B. posterior communicating artery
C. Lenticulostriate artery
D. Anterior choroidal artery
E. Tentorial artery

Answer 32

Anterior choroidal artery

Discussion:
The Anterior Choroidal Artery supplies the posterior limb of the internal capsule, the optic
tract/radiations and globus pallidus internus. Damage to this artery results in contralateral
hemiplegia, contralateral hemianesthesia and homonimous hemianopsia.
References:
Afifi A, Bergman R, eds. Functional Anatomy: Text and Atlas. 2nd ed. New York, NY: McGraw-Hill
Education; 2005:362; Hupperts, R. M. M., et al. “Infarcts in the anterior choroidal artery territory
Anatomical distribution, clinical syndromes, presumed pathogenesis and early outcome.” Brain
117.4 (1994): 825-834

Question 33

Which of the following structures is supplied predominantly by extradural branches of the internal
carotid artery?
Answers:
A. Maxillary branch (CN V2)
B. Tentorium cerebelli
C. Hypothalamus
D. Abducens nerve
E. Oculomotor nerve

Answer 33

Tentorium cerebelli

Discussion:
The tentorium cerebelli is supplied by the Artery of Bernasconi and Cassinari, the Italian Artery.
Tentorial meningioms and arterovenous malformations are typically supplied by this branch.
References:
Harris FS, Rhoton AL Jr. Microsurgical anatomy of the cavernous sinus: A microsurgical study. J
Neurosurg. 1976;45:169-80; Osborn AG. Diagnostic Neuroradiology: A text/Atlas. 1st ed.
Philadelphia: Mosby-Elsevier 1994

Question 34

The persistent trigeminal artery connects the basilar artery with which of the following arteries?
Answers:
A. Petrous Internal Carotid Artery
B. Posterior communicating artery
C. Cavernous Internal Carotid Artery
D. Cervical Internal Carotid Artery
E. External Carotid Artery

Answer 34

Cavernous Internal Carotid Artery

Discussion:
The persistent trigeminal artery arises from the cavernous segment of the internal carotid artery
and courses to the basilar artery. It is present in 0.1 to 0.5 percent of individuals and is the most
common persistent fetal intracranial artery in adults.
References:
Carpenter MB, ed. Core text of neuroanatomy. 4th ed. Baltimore, MD: Lippincott, Williams &
Wilkins, 1991; Osborn AG. Diagnostic Neuroradiology: A text/Atlas. 1st ed. Philadelphia: MosbyElsevier 1994

Question 35

The anterior choroidal artery most likely supplies which of the following structures?
Answers:
A. Gyrus rectus
B. Lateral geniculate nucleus
C. Habenula
D. Anterior insula
E. Anterior limb of the internal capsule

Answer 35

Lateral geniculate nucleus

Discussion:
The anterior choroidal artery most often arises from the internal carotid artery distal to the posterior
communicating artery. It supplies the posterior limb of the internal capsule, the optic tract, the
lateral geniculate nucleus, the medial temporal lobe, and the globus pallidus pars interna (GPi).
Ischemia of its territory classically results in contralateral hemisensory loss, hemiparesis, and
hemianopia.
References:
Ois et al., J Neurological Sciences 2009 PMID 19324377; Hupperts, R. M. M., et al. “Infarcts in the
anterior choroidal artery territory Anatomical distribution, clinical syndromes, presumed
pathogenesis and early outcome.” Brain 117.4 (1994): 825-834

Question 36

The arrow on the sagittal MR image shown is pointing to which of the following structures?
Answers:
A. Vein of galen
B. Internal cerebral vein
C. Vein of Trolard
D. Inferior sagittal sinus
E. Thalamostriate vein

Answer 36

Internal cerebral vein

Discussion:
The arrow points to the internal cerebral vein. The internal cerebral veins are paired and run in the
roof of the third ventricle between the two leaves of the velum interpositum. The basal veins of
rosenthal join with the internal cerebral veins to create the Vein of Galen. The thalamostriate vein
commences in the groove between the corpus striatum and thalamus and unites with a number of
veins behind the crus of the fornix with the choroid vein to form the internal cerebral vein. The vein
of Trolard is formed by a number of parietal veins to drain into the superior sagittal sinus.
References:
Osborn AG, ed. Diagnostic Cerebral Angiography. 2nd ed. Philadelphia, PA: Lippincott, Williams &
Wilkins, 1999; Krayenbühl H, Yaşargil MG, Huber P et-al. Cerebral angiography. Thieme
Publishing Group. (1982) ISBN:3136125029

Question 37

A patient undergoes a right pterional craniotomy for clipping of an aneurysm. A postoperative CT
scan of the head is shown. This finding is most likely related to injury of which the following
structures?
Answers:
A. Anterior cerebral artery
B. Posterior communicating artery
C. Anterior choroidal artery
D. Recurrent artery of Heubner
E. Superior Hypophyseal Artery

Answer 37

Recurrent artery of Heubner

Discussion:
CT scan demonstrates infarction of the caudate head, anterior portion of the lentiform nucleus, and
anterior limb of the internal capsule. These structures are supplied by the recurrent artery of
Heubner which can be injured during anterior communicating artery aneurysm surgery. This vessel
usually arises from the A2 segment of the ACA, immediately after the Anterior Communicating
Artery.
References:
Calis M, Oz Z, Isikay I, et al. An extremely rare complication following frontoorbital advancement:
infarction of the recurrent artery of Heubner. Childs Nerv Syst. 2017 Jan;33(1):197-199. Loukas M,
Louis RG, Jr., Childs RS. Anatomical examination of the recurrent artery of Heubner. Clin Anat.
Jan 2006;19(1):25-31

Question 38

A 59-year-old man is evaluated for right-sided hemisensory loss. Physical examination shows no
additional abnormalities. Which of the following vessels is most likely occluded?
Answers:
A. Left middle cerebral artery
B. Right posterior cerebral artery
C. Left lateral posterior choroidal artery
D. Right superior cerebellar artery
E. Left anterior cerebral artery

Answer 38

Left lateral posterior choroidal artery

Discussion:
Sensory loss is most likely due to an infarct of the ventral posterior nucleus of the thalamus which
is supplied by the lateral posterior choroidal artery.
References:
Galloway JR, Greitz T. The medial and lateral choroid arteries. An anatomic and roentgenographic
study. Acta radiol. 1960 May;53:353-366; Neau, J.-P., & Bogousslavsky, J. (1996). The syndrome
of posterior choroidal artery territory infarction. Annals of Neurology, 39(6), 779–788.
doi:10.1002/ana.410390614

Question 39

Which of the following arteries supplies the descending spinal nucleus of the trigeminal nerve?
Answers:
A. Posterior inferior cerebellar artery
B. Posterior communicating artery
C. Superior cerebellar artery
D. Vertebral artery
E. Anterior inferior cerebellar artery

Answer 39

Posterior inferior cerebellar artery

Discussion:
Posterior inferior cerebellar artery (PICA) occlusion causes lateral medullary syndrome, also
known as Wallenberg syndrome. One aspect of this syndrome is ipsilateral loss of facial sensation
secondary to involvement of the spinal nucleus of the trigeminal nerve. Other findings in this
syndrome include contralateral loss of pain and temperature sense in the body, decreased gag and
taste, dysphagia and hoarseness, Horner’s syndrome, and cerebellar ataxia from involvement of
cranial nerves IX and X, the lateral spinothalamic tract, the descending sympathetic fibers, and the
inferior cerebellar peduncle.
References:
Citow J, Macdonald R, Puffer R et al., Comprehensive Neurosurgery Board Review, ed. 3rd
Edition. Thieme; 2019. doi:10.1055/b-005-148973; Carpenter MB. Core Text of Neuroanatomy. 4th
ed. Baltimore: Williams and Wilkins; 1991: 453

Question 40

Which of the following arteries arises from the cavernous segment of the internal carotid artery?
Answers:
A. Anterior choroidal artery
B. Otic artery
C. Caroticotympanic artery
D. Superior hypophyseal artery
E. Tentorial artery

Answer 40

Tentorial artery

Discussion:
The cavernous ICA normally emits 3 major arteries. The meningohypophyseal trunk, which arises
from the posterior genu of the cavernous ICA, subsequently divides into the tentorial artery, the
inferior hypophyseal artery, and the dorsal meningeal artery. The second artery consists of the
inferolateral trunk, which supplies the cranial nerves that traverse the cavernous sinus. Finally, the
cavernous ICA frequently emits capsular arteries of McConnell, which contribute to the vascular
supply of the pituitary gland. Importantly, the cavernous ICA can also emit the anomalous
trigeminal artery, which represents a persistent carotico-basilar anastomosis.
References:
Tran-Dinh, Neurosurgery 1987 PMID 3561725; Osborn AG. Diagnostic Neuroradiology: A
text/Atlas. 1st ed. Philadelphia: Mosby-Elsevier; 1994.

Question 41

Which of the following veins is formed by fusion of the septal and thalamostriate veins?
Answers:
A. Vein of Galen
B. Basal vein of Rosenthal
C. Anterior caudate vein
D. Superior choroidal vein
E. Internal cerebral vein

Answer 41

Internal cerebral vein

Discussion:
The fusion of the septal and thalamostriate veins gives rise to the internal cerebral vein. The
bilateral internal cerebral veins and bilateral basal veins of Rosenthal join to form the vein of
Galen. The vein of Galen drains to the straight sinus at its junction with the inferior sagittal sinus.
The anterior caudate vein drains into the thalamostriate vein. The septal vein can be sacrificed at
surgery if needed, the others cannot.
References:
Kendall & Schwartz. Principles of Neural Science. 4th ed; Ono et al., Neurosurgery 1984 PMID
6504279; Osborn AG. Diagnostic Neuroradiology: A text/Atlas. 1st ed. Philadelphia: MosbyElsevier; 1994.

Question 42

During a retrosigmoid approach for a small vestibular schwannoma resection, which of the
following arteries is at greatest risk for injury?
Answers:
A. Posterior Inferior Cerebellar Artery
B. Anterior Inferior Cerebellar Artery
C. P1 segment of the Posterior Cerebral Artery
D. Superior Cerebellar Artery
E. posterior communicating artery

Answer 42

Anterior Inferior Cerebellar Artery

Discussion:
The AICA, as well as the Labyrinthine artery (most commonly a branch of the AICA) are at risk
during a retrosigmoid approach for schwannoma resection. The labyrinthine artery courses into the
internal auditory meatus and damage to this artery can lead to hearing loss.
References:
Rhoton A. Cranial Anatomy and Surgical Approaches. Neurosurgery. 2003; 53(3): 545; Koos WT,
Spetzler RF, Lang J. Color Atlas of Micro-neurosurgery: Microanatomy Approaches and
Techniques. 2nd ed. Vol 1. Thieme; 1993: 514

Question 43

A 25-year-old man is evaluated because of a one-month history of headache and unsteady gait.
An MR image and a CT scan are shown. This patient’s abnormality is most likely in which of the
following vascular distributions?
Answers:
A. internal carotid artery
B. posterior communicating artery
C. posterior cerebral artery
D. anterior cerebral artery
E. posterior inferior cerebellar artery

Answer 43

posterior cerebral artery

Discussion:
A choroid plexus papilloma is seen in the left lateral ventricle. The choroid of the lateral ventricles
is supplied by the posterior choroidal artery arising from the posterior cerebral artery. The medial
posterior choroidal artery supplies the choroid plexus of the third ventricle. The lateral posterior
choroidal artery supplies the choroid plexus of the lateral ventricles.
References:
Osborn AG. Diagnostic Neuroradiology: A text/Atlas. 1st ed. Philadelphia: Mosby-Elsevier 1994;
James R. Galloway & Torgny Greitz (1960) The medial and lateral choroid arteries, Acta
Radiologica, 53:5, 353-366, DOI: 10.3109/00016926009171684

Question 44

Which of the following structures is indicated by the arrows in the dissection shown?
Answers:
A. Transverse sinus
B. Superior petrosal sinus
C. Straight sinus
D. Inferior petrosal sinus
E. Cavernous sinus

Answer 44

Inferior petrosal sinus

Discussion:
The inferior petrosal sinus can be seen in its course from the cavernous sinus to drain into the
internal jugular vein via the jugular foramen.
References:
Rhoton AL, Apuzzo MLJ, eds. Cranial Anatomy and Surgical Approaches. 1st ed. Lippincott
Williams & Wilkins, 2003; Osborn AG, Slazman KL, Jhaveri MD, et al, eds. Diagnostic Imaging:
Brain 3e. 3rd ed. Elsevier, 2015

Question 45

Which of the following structures is indicated by the arrow in the photograph shown?
Answers:
A. ophthalmic artery
B. anterior choroidal artery
C. Anterior inferior cerebral artery
D. Posterior Communicating Artery
E. superior cerebellar artery

Answer 45

anterior choroidal artery

Discussion:
The anterior choroidal artery exits the ICA just distal to the origin of the posterior communicating
artery.
References:
Cooper IS. Ligation of the anterior choroidal artery for involuntary movements of parkinsonism.
Psychiatr Q. 1953 Apr;27(2):317-9; Hupperts, R. M. M., et al. “Infarcts in the anterior choroidal
artery territory Anatomical distribution, clinical syndromes, presumed pathogenesis and early
outcome.” Brain 117.4 (1994): 825-834

Question 46

Which of the following structures of the brain is supplied by the recurrent Heubner’s artery?
Answers:
A. Internal capsule
B. Uncus
C. External capsule
D. Thalamus
E. Hypothalamus

Answer 46

Internal capsule

Discussion:
The internal capsule, parts of the putamen and caudate and the septal nuclei are supplied by the
recurrent artery of Heubner. This vessel usually arises from the A2 segment of the ACA,
immediately after the Anterior Communicating Artery.
References:
Falougy et al., Biomed Res Int 2013 PMID 23936853. Loukas M, Louis RG, Jr., Childs RS.
Anatomical examination of the recurrent artery of Heubner. Clin Anat. Jan 2006;19(1):25-31

Question 47

In the angiogram shown, which of the following vascular structures appears to be abnormally
dilated?
Answers:
A. Middle meningeal artery
B. Ascending pharyngeal artery
C. Superior hypophyseal artery
D. Caroticotypmpanic branch
E. Meningohypophyseal trunk

Answer 47

Meningohypophyseal trunk

Discussion:
The meningohypophyseal trunk arises from the distal genu of the cavernous carotid artery and
supplies portions of the pituitary gland, tentorium, and clivus. It has important ICA–ECA
anastomoses through the ascending pharyngeal and middle meningeal arteries. The three major
branches of the MHT are the artery of Bernasconi and Cassinari, inferior hypophseal artery and
clival dural branches. The MHT may be enlarged in pathological conditions, for example, tentorial
meningiomas and dural arteriovenous fistulas.
References:
Lasjaunias P, Berenstein A, Ter Brugge KG, eds. Surgical Neuro-Angiography, Volume 1. 2nd ed.
Springer, 2001; Barrow, D. L., Spector, R. H., Braun, I. F., Landman, J. A., Tindall, S. C., & Tindall,
G. T. (1985). Classification and treatment of spontaneous carotid-cavernous sinus fistulas. Journal
of Neurosurgery, 62(2), 248–256. doi:10.3171/jns.1985.62.2.0248

Question 48

Which of the following is the most common primitive/persistent fetal intracranial artery in adults?
Answers:
A. Persistent hypoglossal artery
B. Persistent otic artery
C. Persistent trigeminal artery
D. Primitive prepontine artery
E. Proatlantal intersegmental artery

Answer 48

Persistent trigeminal artery

Discussion:
The persistent fetal cranial arteries that may be seen in the adult include - in order from most to
least common - the persistent trigeminal artery, the persistent hypoglossal artery, the proatlantal
intersegmental artery, and the persistent otic artery. The persistent trigeminal artery is seen in
between 0.1% and 0.5% of individuals.
References:
Tubbs RS, Verma K, Riech S, et al. Persistent fetal intracranial arteries: a comprehensive review of
anatomical and clinical significance. J Neurosurg. 2011 Apr;114(4):1127-34; Osborn AG, Slazman
KL, Jhaveri MD, et al, eds. Diagnostic Imaging: Brain 3e. 3rd ed. Elsevier, 2015

Question 49

Which of the following arterial branches usually supply low-flow carotid cavernous fistulas?
Answers:
A. Posterior communicating artery
B. Recurrent artery of Heubner
C. Ophthalmic artery
D. Internal maxillary artery
E. Anterior choroidal artery

Answer 49

Internal maxillary artery

Discussion:
The internal maxillary artery usually supplies low-flow carotid cavernous fistulas. Indirect, low-flow
carotid cavernous fistulas (CCFs) are categorized into type B, C, and D. Type B CCFs arise from
meningeal branches of the internal carotid artery (ICA), Type C CCFs arise from meningeal
branches of the external carotid artery (ECA), and Type D CCFs arise from meningeal branches of
the ICA and ECA. Of the choices listed, the internal maxillary artery is the only meningeal branch
of the ICA or ECA.
References:
Ellis & Goldstein. “Carotid-cavernous fistulas.” Neurosurg Focus, 2012. PMID: 22537135; Barrow,
D. L., Spector, R. H., Braun, I. F., Landman, J. A., Tindall, S. C., & Tindall, G. T. (1985).
Classification and treatment of spontaneous carotid-cavernous sinus fistulas. Journal of
Neurosurgery, 62(2), 248–256. doi:10.3171/jns.1985.62.2.0248

Question 50

A 65-year-old woman is evaluated after undergoing intracranial anterior cerebral artery bypass and
trapping of a fusiform anterior communicating artery aneurysm. Postoperatively, MR imaging of the
brain reveals diffusion restriction in bilateral anterior internal capsules. This patient is most likely to
have which of the following neurological deficits?
Answers:
A. Hemihypestensia
B. Hemianopsia
C. Hemineglect
D. Paraplegia
E. Akinetic mutism

Answer 50

Akinetic mutism

Discussion:
Akinetic mutism is a disorder of consciousness characterized by unresponsiveness but with the
superficial appearance of alertness. The patient’s eyes are open and he may seem to look at the
examiner but he neither speaks nor moves, nor is the examiner able to communicate with the
patient. Bilateral lesions of the head of the caudate nucleus associated with destruction of medial
putamen, septum, medial frontal cortex, and cingulate cortex can result in akinetic mutism. This
could arise from compromise of the bilateral recurrent arteries of Huebner.
References:
Uzun I, Gurdal E, Cakmak YO, Ozdogmus O, Cavdar S. A reminder of the anatomy of the
recurrent artery of heubner. Cent Eur Neurosurg. 2009 Feb;70(1):36-8. Toyoda K. Anterior cerebral
artery and Heubner’s artery territory infarction. Front Neurol Neurosci. 2012;30:120-2. Freemon
1971. http://dx.doi.org/10.1136/jnnp.34.6.693