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Neurosurgery > Vascular topics > Flashcards

Vascular topics Flashcards

1
Q

Most common location of atherosclerosis involving aortic arch and its branches

A

Common carotid bifurcation and proximal ICA

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2
Q

Non-atheromatous causes of stenosis of ICA

A
  1. Cervical
    - Increased ICP
    - Fibromuscular dysplasia
    - Arteritis
    - Blunt trauma
    - Arterial thrombosis
    - Invasive neoplasms of neck
  2. Juxtasellar or supraclinoid
    - Tumors (meningioma, craniopharyngioma, other skull base)
    - Inflammatory disease of sphenoid sinus or basilar meninges
    - Arteritis
    - FMD
    - Radiation therapy
    - Vascular spasm from SAH
    - Trauma
    - Increased ICP
    - Menkes kinky hair syndrome with systemic vascular involvement
    - Neurocutaneous disorders such as NF
    - Moyamoya disease (psudoangiomatous network bears resemblance to puff of smoke)
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3
Q

Cerebral circulatory arrest

A

“Brain death”

  • Documented angiographically either by selective common carotid and vertebral studies or by using the aortocervical technique (aortic arch injection with simultaneous filming over the head)
  • Non-filling of cerebral vessels with prolonged stasis of contrast in carotid artery is present
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4
Q

DDx of “sting of beads” appearance on angiography

A
  • Fibromuscular dysplasia (usually affects cervical ICA around C1-C2; shows multiple arterial dilatations separated by irregularly spaced concentric stenosis)
  • Arterial hypoplasia
  • Arteritis
  • Diminished vessel caliber secondary to decreased distal blood flow
  • Vascular spasm from catheterization itself
  • Rarely atherosclerosis and dissecting or traumatic aneurysm mimic this appearance
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5
Q

Post-traumatic injuries in ICA

A
  • Thrombosis
  • Stenosis or occlusion
  • Intimal tears
  • Dissection
  • AV fistula
  • False aneurysm
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6
Q

Mass lesions commonly displacing the cervical ICA

A
  • Paraganglioma
  • Neurofibroma
  • Enlarged cervical lymph nodes
  • Thyroid masses
  • Infiltrating malignant neoplasms
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7
Q

ICA segments and branches

A
  1. Cervical segment
  2. Petrous segment
    - Caroticotympanic (superior aspect of genu)
    - Small periosteal branches
    - Vidian (in 30%; arises from inferior aspect of petrous ICA and goes through foramen lacerum to anastamose with ascending pharyngeal and accessory meningeal)
  3. Cavernous segment (presellar segment and juxtasellar segment); double curvature which resembles letter “S” is called carotid siphon)
    - Meningohypophyseal trunk
    - Artery of the inferior cavernous sinus (lateral main stem artery)
    - Capsular arteries (of McConnell)
  4. Intracranial segment
    - Superior hypophyseal
    - Ophthalmic
    - Posterior communicating
    - Anterior choroidals
    - Small branches to hypothalamus, optic nerve, and optic chiasm
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8
Q

Meningohypophyseal trunk

A
  • Largest and most proximal branch off intracavernous portion of ICA
  • Found in ~100% of people
  • Arises near apex of initial curve of the juxtasellar segment of ICA and is adjacent to the cavernous sinus roof
  • Usually gives off three branches: tentorial artery (AKA artery of Bernasconi and Casinari), dorsal meningeal artery, and the inferior hypophyseal artery
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9
Q

Tentorial artery

A
  • AKA artery of Bernasconi and Casinari
  • Most constant branch of meningohypophyseal trunk (which is first branch of cavernous ICA)
  • Passes posterolaterally along free margin of the tentorium to the incisural apex where it anastomoses with its counterpart from the opposite side and with meningeal branches of the ophthalmic artery
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10
Q

Dorsal meningeal artery (clival branch)

A
  • Second major branch off meningohypophyseal trunk (which is first branch of cavernous ICA)
  • Present in 90% of people
  • Runs posteriorly and medially through the cavernous sinus, passing over the dorsum sellae and rostral clivus to anastomose with the opposite dorsal meningeal artery
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11
Q

Inferior hypophyseal artery

A
  • Third and least frequently identified branch of the meningohypophyseal trunk (which is the first branch of the cavernous ICA)
  • Courses anteromedially to the pituitary sulcus, branches then encircle the hypophysis primarily supplying the posterior lobe and the dura of the sella turcica and cavernous sinus; also anastomoses with its mate from the contralateral ICA
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12
Q

Lateral main stem artery (AKA artery of the inferior cavernous sinus or inferolateral trunk)

A
  • Second branch off cavernous ICA; seen in 80-85% of people
  • Corresponds to proximal remnant of the embryonic dorsal ophthalmic artery
  • Originates from the inferolateral aspect of the juxtasellar ICA, then curves over CN VI and gives rise to branches that supply the dura of the cavernous sinus and the CNs within the cavernous sinus
  • Its most important branch is the artery of the foramen rotundum (which passes through foramen rotundum and anastomoses with its counterpart from the ipsilateral ECA)
  • NOTE: numerous anastomoses are present between rami of lateral main stem artery and branches of ophthalmic, maxillary, accessory meningeal, and middle meningeal which may assist in supplying variety of vascular lesions at the skull base and provide source of collateral blood flow in ICA occlusion
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13
Q

McConnell’s capsular arteries

A
  • Most distal branches of cavernous ICA
  • Least constant, found in < 30% of people
  • Inferior capsular artery courses inferomedially to supply floor of sella turcica and anastomoses with its counterpart from opposite side as well as with branches of inferior hypophyseal artery
  • Anterior capsular artery courses medially around roof of sella
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14
Q

Intracranial segment of ICA (origin and course)

A
  • Cavernous segment of ICA passes anteriorly in cavernous sinus and pierces dura on medial aspect of anterior clinoid process then courses superiorly and slightly laterally between the optic and oculomotor nerves
  • Just below the anterior perforated substance, it divides into terminal branches (ACA and MCA)
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15
Q

Superior hypophyseal artery

A
  • Together with its mate from the opposite side forms arterial collar or plexus around the base of the hypophyseal stalk
  • Branches from this plexus also serve the optic chiasm and anterior lobe of hypophysis
  • Usually not identified on normal angiography
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16
Q

Ophthalmic artery

A
  • Arises from antero or superomedial surface of infraclinoid ICA as it emerges from cavernous sinus
  • Origin is actually intradural in 89% of people
  • Occasionally, it arises from middle meningeal, other branches of ECA, or proximal cavernous ICA
  • Courses anteriorly in optic canal along underside of optic nerve then runs forward on medial orbital wall below the trochlea
  • Supplies globe and orbital contents
  • Forms extensive anastomoses with branches of ECA which may become important source of intracranial blood flow in ICA occlusive disease
  • Three major groups of branches: ocular (central retinal and ciliary branches), orbital (lacrimal and muscular arteries), and extraorbital (supraorbital, anterior and posterior ethmoidal, dorsal nasal, palpebral, medial frontal, and supratrochlear)
  • Occasionally the middle meningeal artery may arise from the ophthalmic artery or vice versa
17
Q

Ethmoidal arteries

A
  • Pass superiorly through their respective foramina to supply the dura of the cribriform plate and planum sphenoidale
  • Also have small branches that anastomose with ethmoidal branches of the sphenopalatine artery to supply the nasal fossa
  • Anterior falx artery arises from anterior ethmoidal branch of ophthalmic artery and supplies part of the falx cerebri
18
Q

Intracavernous aneurysm

A
  • Usually asymptomatic
  • Rupture can cause carotid-cavernous sinus fistula with resulting pulsating exophthalmos, conjunctival injection, and orbital bruit
19
Q

Primary orbital tumors which may derive blood supply from branches of ophthalmic artery

A
  • Hemangioma (most common, benign, usually seen in kids)
  • Meningioma
  • Sarcoma
  • Neurofibromata
  • Lacrimal gland neoplasms
  • Optic nerve gliomas

*Non-neoplastic mass-lesions in orbit include fibrous dysplasia and mucocele

20
Q

Structures served by numerous small branches off circle of Willis

A

Several important structures at base of brain:

  • Optic nerves
  • Optic chiasm
  • Optic tracts
  • Infundibulum
  • Internal capsule
  • Portions of the basal ganglia
21
Q

Percent of people with classic circle of Willis (no hypoplastic or absent connections)

A

18-20%

  • Hypoplasia of one or both PCommAs in 22%
  • Hypoplasia/absence of A1 present in 25%
  • Fetal origin of PCA (direct origin of PCA from ICA) with hypoplasia of P1 present in 15%
  • Multichanneled/duplicated ACommA present in 9%
22
Q

Recurrent artery of Heubner

A

Small vessel that originates from A1 portion of ACA
Doubles back on its parent vessel accompanying both the ACA and MCA for a variable distance before entering the brain, it then passes posteriorly and laterally following the lenticulostriate arteries to supply part of the basal ganglia, internal capsule, and hypothalamus

23
Q

Anterior thalamoperforating arteries

A

Arise from PCommAs and pass superiorly to supply the:

  • tuber cinereum
  • ventral and paraventricular thalamic nuclei
  • mammillary bodies
  • posterior hypothalamus and subthalamic nucleus
  • Posterior chiasm
  • Part of cerebral peduncles
  • Posterior limb of internal capsule

These thalamoperforating arteries surround the 3rd ventricle and are best demonstrated by magnification vertebral artery angiography when PCommAs are refluxed

24
Q

Aneurysm % by location

A 
MCA bifurcation: 20%
ACommA: 30%
ICA at origin of PCommA: 20-30%
Basilar tip: 15%
MISC locations (peripheral arteries, origin of anterior choroidal): 5%
25
Q

Percent of intracranial aneurysms that are multiple

A

15-20%

26
Q

Angiographic evidence to sugggest location of aneurysm rupture

A
  • Extravasation of contrast medium from ruptured aneursm is rare
  • Adjacent mass effect caused by associated intracerebral hematoma
  • Spasm of adjacent vessels
  • Size (largest aneurysm most likely to have ruptured)
  • Irrgularity, lobulation, or apical “tit”
27
Q

Most commonly involved areas for atherosclerotic disease in arteries of base of brain

A
  1. Upper basilar
  2. ICA bifurcation
  3. Proximal M1 segment
  4. P1 segment
28
Q

Angiographic findings of atherosclerosis

A
  • Arterial calcification
  • Ectasia
  • Tortuousity
  • Irregularities of intima
  • Actual ulcerations
  • Stenosis
29
Q

Occlusion of ACA proximal to recurrent artery of Heubner

A

Results in: severe contralateral spastic hemiplegia due to involvement of anterior part of internal capsule and paracentral lobule
Other possible results: memory loss, retardation, confusion, disorientation, emotional lability, and dementia
If on dominant side, may result in temporary expressive aphasia
-Apraxia may be present, but masked by paresis
-Often sensory impairment of LE

30
Q

Branches off basilar artery in order

A
  1. AICA
  2. Pontine arteries
  3. Internal auditory (labyrinthine) arteries
  4. Superior cerebellar
  5. Posterior cerebral
31
Q

PICA segments and branches

A

Largest and most variable branch of VA
Arises 1-2 cm below BA origin
1.Anterior medullary segment: 1st segment courses laterally around medulla
2. Lateral medullary segment: 2nd segment which forms distinct caudal loop along side of medulla
3. Cranial loop which courses over cerebellar tonsil sends small branches to choroid plexus of 4th ventricle (choroidal branches) and to tonsil itself
4. Curves downward after crossing cerebellar tonsil and gives off medial branches to inferior vermis (vermian branches of PICA) and lateral branches to cerebellar hemispheres (hemispheric branches of PICA)

32
Q

Where does AICA course through after arising from proximal BA?

A
  • Cerebellopontine angle cistern

- Lies ventral and medial to facial and acoustic nerves

33
Q

What does AICA supply?

A
  • Anterior segments of the inferior semilunar lobules
  • Flocculus
  • Part of quadrangular lobule
  • Choroid plexus in lateral recess of 4th ventricle
  • Part of middle cerebellar peduncle
34
Q

Where is origin of the superior cerebellar artery?

A

-Near pontomesencephalic junction (where pons and midbrain meet)

35
Q

Where do superior cerebellar arteries course through?

A
  • Perimesencephalic cisterns above the trigeminal nerve
  • In proximal portion, they are separated from the PCAs by CN III
  • In distal portion, they are separated from the PCAs by the tentorium cerebelli
36
Q

Branches of superior cerebellar arteries

A

Two main branches

  1. Lateral branch: supplies superolateral aspects of cerebellar hemispheres, superior cerebellar peduncle, dentate nucleus, and part of the middle cerebellar peduncle
  2. Medial branch: supplies superior surface of cerebellar hemisphere, and rami to the superior vermis

Also: the superior vermian branches of both SCAs anastomose with each other in the quadrigeminal cistern, then course posteriorly over vermis close to midline

37
Q

Extracranial branches of VA

A

-Segmental muscular and radiculomedullary branches

Neurosurgery (9 decks)

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