Blood Supply of the Central Nervous System

- metabolically, the central nervous system is one of the most active systems of the body
- require 17% of the cardiac output and 20% of the oxygen utilized by the body
- normal blood flow: 50 ml/100 g of brain tissue per minute
- a brain of average weight has a normal blood flow of about 750 ml/ minute and a mean oxygen of about
3.3ml/100g of brain tissue per minute
- not a homogenous organ and metabolic activity in various regions reflect the functional activity of distinct
brain regions
- Positron Emission Tomography (PET) – provides images of brain functions in living individuals
A. Makes us of deoxyglucose to visualize the metabolic activity of various cortical regions and
subcortical nuclei
- Stroke of cerebrovascular accident – refers to the neurologic symptoms and signs, usually focal and acute, that
result from diseases involving blood vessels
A. May be:
 Occlusive – due to closure of a blood vessel
 Hemorrhagic – due to bleeding from a blood vessel
- Ischemia – refers to the insufficiency of blood supply
A. Brief temporary ischemia – neurologic symptoms and signs may disappear rapidly, without leaving
traces of tissue damage
B. Severe and prolonged ischemia – deprives brain tissue not only of oxygen but also of glucose
 Prevents removal of toxic metabolites such as lactic acid
 Usually leads to the death of neuron cells in the ischemic zone, a condition referred to as
infarction
C. Neural tissue deprived of an adequate blood supply constitutes the most common cause of central
nervous system lesions
- Vascular Lesions – most commonly result from arteriosclerosis of cerebral and cervical vessels, which reduce
blood flow and can lead to thrombosis
- Hemorrhage – may result from vascular lesions
A. Most common cause of spontaneous hemorrhage into the brain and subarachnoid space is rupture
of cerebral aneurysm (abnormal sacculations)

BLOOD SUPPLY OF THE SPINAL CORD

- supplied by branches of the vertebral arteries that descend and multiple radicular arteries derived from
segmental vessels

I. Vertebral Arteries
- ascend along the anterolateral surfaces of the medulla
- gives rise to two paired descending vessels:
A. Posterior Spinal Arteries
 paired
 Descend on the posterior surface of the spinal cord medial to the dorsal roots
 Receive variable contributions from the posterior radicular arteries and form two longitudinal
plexiform channels near the dorsal entry zone
 Arteries and their small branches supply the posterior third of the spinal cord
B. Anterior Spinal Arteries
 paired
 unite to form a single descending midline vessels that supplies the midline rami to the lower
medulla and sulcal branches that enter the anterior fissure of the spinal cord
 continuity is dependent upon anastomotic branches that it receives from the anterior
radicular arteries
 anterior radicular arteries join the anterior spinal artery by branching gently upward or
sharply downward
 two anterior radicular arteries reach the same level of the spinal cord = diamond-shaped
arterial configuration results
 branches of the vertebral arteries provide the principal blood supply of virtually the entire
cervical spinal cord
  thoracic regions: anterior spinal artery narrows to such extent that it may not form a
functional anastomosis if the radicular arteries are occluded above or below

II. Radicular Arteries

- Derived from segmental vessels (ascending cervical, deep cervical, intercostal, lumbar, and sacral arteries
- pass through the intervertebral foramina and divide into anterior and posterior radicular arteries
- provide the principal blood supply of thoracic, lumbar, sacral and coccygeal spinal segments
- are most frequently on the left side in the thoracic and lumbar regions of the spinal cord
- enters the subarachnoid space where the epineurium blends with the dura mater
- a single radicular artery may become wither an anterior or posterior radicular artery, or divide to form both
- blood supply of the spinal cord may be jeopardized in certain transitional regions where its arterial supply is
derived from more than one source
A. Anterior Radicular Arteries
 Cervical spinal cord receives up to 6 anterior radicular arteries
 Thoracic cord receives 2-4
 Lumbar cord receives 1 or 2
 Artery of Adamkiewicz (artery of the lumbar enlargement) – anterior radicular artery in the
lumbar region which is appreciably larger than all others
o Originates at the level of the vertebral segment T9 to T12
o Travels with the lower thoracic or upper lumbar spinal root most frequently on the
left side
 The occlusion of one radicular artery may seriously compromise its circulation
 Upper thoracic (T1-T4) and L1 spinal segments are among the most vulnerable regions of the
spinal cord
B. Posterior Radicular Artery
 Divide on the posterolateral surface of the spinal cord and join the paired posterior spinal
arteries
 More often on the left side, left predominance is not as evidence
C. Anterior Spinal Artery
 Gives rice to a number of sulcal branches that enter the anterior median fissure pass to the
right or left
 Supply the anterior horn, the lateral (intermediate) horn, the central gray matter, and the
basal part of the posterior horn
 Supply the anterior and lateral funiculi
 Peripheral portions of the lateral funiculi receive branches from the arterial vasocorona
D. Posterior Spinal Arteries
 Supply the posterior horn and the posterior funiculus

III. Spinal Veins

- Distribution is similar to that of the spinal arteries
- Anterior longitudinal venous trunks consist of anteromedian and anterolateral veins
 Each sulcal vein drains regions on both sides of the spinal cord
 Anterolateral regions of the spinal cord drain into the anterolateral veins and in the venous
vasocoronal
 Anteromedian and anterolateral spinal veins are drained by 6 to 11 anterior radicular veins
that empty in to the epidural venous plexus
 Vena Radicularis Magna – large radicular vein in the lumbar region
- Posterior longitudinal venous trunks consists of a posteromedian vein and paired posterolateral veins
 Drain the posterior funiculus, the posterior horns (including their basal regions), and the white
matter in the lateral funiculi adjacent to the posterior horn
 Drained by 5 to 10 posterior radicular veins that enter the epidural venous plexus
- Longitudinal vein are connected with each other by coronal veins (venous corona) that encircle the spinal
cord
- Inter vertebral venous plexus (epidural venous plexus) – located between the dura mater and the vertebral
periosteum consisting of two or more anterior and posterior longitudinal venous channels that are
interconnected at many levels from the clivus to the sacral region
  Spinal venous network has no valves  blood flowing in these channels may pass directly
into the systemic venous system
 Jugular vein obstruction  blood leaves the skull via this plexus
 Continuity of this plexus with the prostatic plexus is believed to be a route whereby neoplasm
may metastasize

BLOOD SUPPLY OF THE BRAIN

- Supplied by two pairs of arterial trunk, the internal carotid arteries and the vertebral arteries
- Common carotid artery bifurcated at the upper level of the thyroid cartilage forming the internal and external
carotid arteries
I. Internal Carotid Artery
- Can be divided into 4 segments:
A. Intracavernous Segment
 Lies close to the medial wall of the cavernous sinus, courses nearly horizontal and bears
Carotid important relationships with Cranial nerves III, IV, VI and portions (divisions I and II) of nerve V
Siphon  Pass into the tympanic cavity and the cavernous and inferior petrosal sinuses, as well as the
trigeminal ganglion and the meninges of the middle cranial fossa
B. Cerebral Segment
 Begins as the artery emerges from the cavernous sinus and passes medial to the anterior
clinoid process
 Gives rise to all major branches of the internal carotid artery
C. Cervical Segment
 Extends from the bifurcation of the common carotid to the carotid canal in the petrous bone
and has no branches
D. Intrapetrosal Segment
 Surrounded by dense bone
- Branches of the internal carotid artery are:
A. Ophthalmic Artery
 Enters the orbit through the optic foramen, ventral and lateral to the optic nerve
B. Posterior Communicating Artery
 Arises from the dorsal aspect of the carotid siphon and passes posteriorly and medially to join
the posterior cerebral artery
C. Anterior Choroidal Artery
 arises from the internal carotid artery distal to the posterior communicating artery
 passes backward across the optic tract and then laterally to enter the choroidal fissure in the
temporal lobe
- Lateral to the optic chiasm, the internal carotid artery divides into two terminal branches
A. Anterior Cerebral Artery – smaller
B. Middle Cerebral Artery – larger and regarded as the direct continuation of the internal carotid artery
 Rostral parts of the brain are supplied by these two arteries: rostral half of the thalamus, the
basal ganglia, the corpus callosum, most of the internal capsule, the medial and lateral
surfaces of the frontal and parietal lobes, and the lateral surface of the temporal lobe

II. Vertebral Artery

- Arises as the first part of the subclavian artery
- Traverse the foramen of the 6th cervical vertebra, and ascend through the transverse foramina of all higher
cervical vertebrae
- Pierces the atlanto-occipital membrane and the dura mater to enter the posterior cranial fossa through the
foramen magnum
- Thin radicular branches of the vertebral artery pass through the intervertebral foramina to supply the meninges
and portions of the cervical spinal cord
- Gives rise to: posterior spinal artery, anterior spinal artery, posterior inferior cerebellar artery, and posterior
meningeal artery
- Two vertebral arteries course along the anterolateral surface of the medulla and unite at the caudal border of
the pons to form the Basilar Artery
 Passes rostrally in the basilar sulcus and bifurcates at the upper border of the pons, forming
the posterior cerebral arteries
  Branches include:
o anterior inferior cerebellar arteries
o labyrinthine arteries
 do not supply the brainstem but pass laterally through the internal
auditory meati to the inner ear
o numerous paramedian and circumferential pontine rami
o superior cerebellar arteries
o posterior cerebellar artery
 represent the terminal branches of the basilar artery
 furnishes branches that supply parts of the midbrain, thalamus and large
regions of the temporal and occipital lobes

III. Cerebral Arterial Circle

- Cerebral Arterial Circle ( of Willis) – an arterial wreath encircling the optic chiasm , the tuber cinereum, and the
interpeduncular region formed by anastomosing branches of the internal carotid artery and the most rostral
branches of the basilar artery
- Formed by anterior and posterior communicating arteries and proximal portions of the anterior middle, and
posterior cerebral arteries
- Anterior cerebral arteries run medially and rostrally toward the interhemispheric fissure  optic chiasm: joined
by a connecting vessel, the anterior communicating artery
- Posterior communicating artery arise from the internal carotid arteries  run caudomedially  anastomose with
proximal portions of the posterior cerebral arteries
- Posterior Cerebral Arteries – formed by the bifurcation of the basilar artery at the rostral border of the pons
 Gives rise to numerous small branches that enter the interpeduncular fossa and
hypothalamus
 Main vessels pass laterally, rostral to the root fibers of the oculomotor nerve and encircle part
of the midbrain before passing above the tentorium cerebella
- Equalize blood flow to various parts of the brain, but normally there is little exchange of blood between the
right and left halves of the arterial circle because of the equality of blood pressure
- Circle of Willis is a common site for saccular cerebral aneurysm
 Commonest sites of occurrence of saccular cerebral of aneurysms are at the origin of the
anterior communicating
 other sites include the bifurcation of the middle cerebral artery, the cavernous carotid artery,
the internal carotid bifurcation, and various loci on the vertebrobasilar arteries
 rupture of these aneurysms lead to subarachnoid hemorrhage
- two branches arise from the arterial circle and the principal cerebral arteries and forms two distinct systems:
A. Central (Ganglionic) Arteries
 Arise from the circle of Willis and the proximal portions of the three cerebral arteries
 Dip perpendicularly into the brains substance
 Supply the diencephalon, basal ganglia, and internal capsule
 Occlusion of one of these arteries produces a softening in the area deprived of an
adequate blood supply
 Anterior and posterior choroidal arteries may be included in this group
B. Cortical (Circumferential) Branches
 Enter the pia mater, where they form a superficial plexus of more or less freely anastomosing
vessels
 From these plexuses arise the smaller terminal arteries that enter the brain substance at right
angles and run for variable distances
 Occlusion of one of these vessels is compensated to a variable extent by the blood supply
from neighboring branches, although such collateral circulation is often not sufficient to
prevent brain damage
- Watershed zones- brain damage in these areas that may occur with hypertension
 Resulting condition is termed borderzone infarction
IV. Cortical Branches
- Derived from the anterior, middle, and posterior cerebral arteries
A. Anterior Cerebral Artery
 ORIGIN: originates at the bifurcation of the internal carotid artery lateral to the optic chiasm
and nerve
 COURSE: passes rostromedially. dorsal to the optic nerve  approaches the corresponding
artery of the side which it connects via the anterior communicating artery  enters the
interhemispheric fissure  passes upward on the medial surface of the hemisphere  curves
around the genu of the corpus callosum  continues posteriorly on the superior surface of
the corpus callosum
 BRANCH:
o Medial Striate Artery (Recurrent Artery of Heubner)
 ORIGIN: may arise proximal or distal to the anterior communicating artery
 78% (majority): originates distal to the anterior communicating
artery
 14%: arises proximal to the anterior communicating artery
 8%: arises at the level of the anterior communicating artery
 COURSE: courses caudally and laterally  doubles back on its parent
vessel undergoes significant branching  enters the anterior perforated
substance as multiple vessels
 TERMINATION: Sylvian fissure lateral to the anterior perforated substance or
in the inferior frontal lobe
 SUPPLIES: anteromedial part of the head of the caudate nucleus,
adjacent parts of the septal nuclei
 anastomose with the lenticulostriate arteries and surface branches of the
anterior and middle cerebral arteries
 Frequently gives rise to several branches supplying the inferior surface of
the frontal lobe
o Orbital Branches
 ORIGIN: arise from the ascending portion of this vessel central to the genu
of the corpus callosum
 SUPPLIES: orbital and medial surfaces of the frontal lobe
o Frontopolar Branch
 Given off as the anterior cerebral artery
 COURSE: curves around the genu of the corpus callosum  extend
laterally on reaching the convexity of the hemisphere
 SUPPLY: medial parts of the frontal lobe
o Callosomarginal Artery
 ORIGIN: arise distal to the frontopolar artery
 COURSE: passes caudally in the callosomarginal sulcus, dorsal to the
cingulated gyrus
 SUPPLIES: paracentral lobule and pars of the cingulated gyrus
o Pericallosal Artery
 Regarded as the terminal branch of the anterior cerebral artery
 COURSE: caudally along the dorsal surface of the corpus callosum
 SUPPLIES: medial surface of the parietal lobe, including the precuneus
 Anomalies : occur in about 25% of brains and include unpaired arteries and instances where
branches are given off to the contralateral hemisphere
 OCCLUSIONS:
o Trunk of one anterior cerebral artery
 Contralateral muscle weakness and sensory losses, greatest in the distal
lower limbs
 Main sensory modalities affected: Discriminative sensation such as
stereogenesis and two-point discrimination and proprioception
 Pain, temperature and light touch sensation are relatively spared
 o Very proximal occlusion of the anterior cerebral artery
 May compromise blood supply to the internal capsule, with additional
weakening of the contralateral arm and face
o Obstruction of BOTH anterior cerebral arteries
 Bilateral paralysis, especially in the lower limbs, and impaired sensation
that mimics a spinal cord lesion
 Bilateral medial prefrontal damage may result in motor and psychomotor
abnormalities, including bradykinesia, rigidity, abulia and a variety of
other emotional or intellectual impairments
B. Middle Cerebral Artery
 COURSE: passes laterally over the anterior perforated substance  enters the lateral cerebral
fossa between the temporal lobe and the insula  divides into a number of large branches
 courses upwards and backward  uppermost portions of the insula  loop abruptly
downward toward the lateral sulcus
 Insular Region: 5-8 branches lie within the Sylvian Triangle
o Sylvian point (apex): established angiographically by the most posterior branch of
the middle cerebral artery to emerge from the lateral sulcus
o Inferior margin of the Sylvian triangle: formed by the lower branches of the middle
cerebral artery
o Superior Margin: formed by the looping branches of this artery that are reversing
their course
 Branches emerge from the lateral sulcus and are distributed “fanlike” fashion over the lateral
convexity of the hemisphere
o Lenticulostriate arteries: first branches to arise from the middle cerebral artery 
enters the anterior perforated substance
o Anterior Temporal Artery: frequently anastomoses with temporal branches of the
posterior cerebral artery
o Orbitofrontal artery: may anastomose with the frontopolar branch of the anterior
cerebral artery
o Pre-Rolandic Branches, a Rolandic Branch, an anterior parietal (or post-Rolandic)
branch and a posterior parietal branch: ascending branches of the middle
cerebral artery that are given off more distally
o Posterior temporal branch: extends backwards to supply lateral portions of the
occipital lobe
o Angular Branches: supplying the angular gyrus constitute the terminal part of the
middle cerebral artery
 SUPPLIES:
o Lateral parts of the orbital gyri, the inferior and middle frontal gyri, most of the
precentral and postcentral gyri, the superior and inferior parietal lobules, and the
superior and middle temporal gyri including the temporal pole
o Largest cortical areas supply the temporo-occipital and angular areas
o Extensive and functionally important region supplied by the middle cerebral artery
includes the motor and premotor areas, the somesthetic and auditory projection
areas and large regions of the association cortex
 OCCLUSION (near the origin of its cortical branches)
o Contralateral hemiplegia, most marked in the upper extremity and face
o Contralateral loss of position discriminative tactile sense
o Severe aphasia, when the dominant hemisphere is involved
C. Posterior Cerebral Artery
 Formed by the bifurcation of the basilar artery
 COURSE: passes laterally around the crus cerebri  receives anastomoses from the posterior
communicating arteries  continues along the lateral aspect of the midbrain  passes
dorsally to the tentorium  takes course on the medial and inferior surfaces of temporal and
occipital lobes
 SUPPLIES: parts of the inferior temporal gyrus, variable portions of the occipital lobe, and
parts of the superior parietal lobule
 Divides into 2 main branches:
 o Posterior temporal (temporo-occipital) artery
 Gives off an anterior temporal branch: supplies the inferior surface of the
temporal lobe anteriorly
 Frequently anastomoses with branches of the anterior temporal artery
 Posterior branches: supply the occipitotemporal and lingual gyri
o Internal Occipital artery
 Divides into: parieto-occipital artery and calcarine artery
 Supply different regions on the medial aspect of the occipital lobe and
portions of the splenium of the corpus callosum
 Cortical Branches
o Supply the medial and inferior surface of the occipital lobe and the inferior surface
of the temporal lobe, except for the temporal pole
 Calcarine Branches – of major importance because it supplies the primary visual cortex
 Occlusion of the posterior cerebral artery produces a contralateral homonymous
hemianopsia¸ frequently with sparing of macular division
 Cerebral aneurysm are mostly congenital origin and appear to arise frequently vessels on
the inferior surface of the brain
 It is more difficult to ascertain the presence of vascular occlusions in the distal branches of
the anterior, middle and posterior cerebral arteries because of direct end-to-end
anastomoses between branches of these vessels on the surface of the brain
 Certain highly vascular brain tumors may produce what is called a tumor stain in the
cerebral angiogram
 Injection of the internal carotid artery usually permits visualization of the main branches of
the anterior and middle cerebral arteries on the side of the injection

V. Central Branches
A. Central or Ganglionic Arteries
 ORIGIN: arise from proximal portions of the major cerebral and communicating arteries
 SUPPLIES: diencephalon, basal ganglia and internal capsule
 Arranged in four groups
o Anteromedial arteries
 ORIGIN: arise from the anterior cerebral and anterior communicating
arteries
 some come directly from the terminal portion of the internal
carotid
 COURSE: enter the most medial part of the anterior perforated substance
 distributed to the anterior hypothalamus, including the preoptic area,
and supraoptic regions
o Posteromedial Arteries
 Enter the tuber cinerium, mammillary bodies, and interpeduncular fossa
 Derived from the most proximal portion of the posterior cerebral and from
the whole extent of the posterior communicating arteries
 SUPPLIES: hypophysis, infundibulum and tuberal regions of the
hypothalamus
 Caudal group supplies the mammillary region of the
hypothalamus, the subthalamic region, and sends small
branches to the medial nuclei of the thalamus
 Thalamo-perforating arteries – penetrate more deeply and are distributed
to the anterior and medial portions of the thalamus
o Posterolateral Arteries
 ORIGIN: arise from the posterior cerebral arteries, lateral to its anastomosis
with the posterior communicating artery
 SUPPLIES: caudal half of the thalamus
 Referred to as the thalamogeniculate arteries
  Occlusion of these arteries results in the thalamic syndrome of Dejerine
and Roussy
 Includes variable degrees of motor loss, sensory loss, pain and
hyperpathia in the contralateral face, body or extremities
o Anterolateral Arteries
 Commonly referred as the striate arteries
 ORIGIN: arise primarily from proximal portions of the middle cerebral artery
and, to a lesser extent, from the anterior cerebral artery
 Medial striate artery (Heubner)
 Derived from the anterior cerebral artery and enters the anterior
perforated substance
 SUPPLIES: portions of the basal ganglia and internal capsule,
rostrovental part of the head of the caudate nucleus and
adjacent portions of the putamen and internal capsule
 Lateral Striate arteries
 Derived from the middle cerebral artery
 SUPPLIES: remaining portions of the striatum except for extreme
caudal parts of the putamen and the tail of the caudate
nucleus
 Also nourishes the lateral part of the globus pallidus, the
anterior limb of the internal capsule and dorsal portions
of the posterior limb of the internal capsule
B. Choroidal Arteries
 Anterior and posterior choroidal arteries may be regarded as distinctive central branches
o Anterior choroidal artery
 Characterized by its long subarachnoid course and its relatively small
caliber
 ORIGIN: arises from the internal carotid artery distal to the origin of the
posterior communicating artery
 May arise from the middle cerebral artery
 COURSE: pass caudally across the optic tract  laterally toward the
rostromedial surface of the temporal lobe enters the inferior horn of the
lateral ventricle through the choroid point of the choroidal fissure
 SUPPLIES: choroid plexus, hippocampal formation, portions of both
segments of the globus pallidus, ventrolateral parts of the posterior limb of
the internal capsule, and the entire retrolenticular portion of the internal
capsule
 Small branches supply parts of the amygdaloid nuclear
complex, ventral parts of the tail of the caudate nucleus,
extreme posterior parts of the putamen and ventrolateral parts
of the thalamus
 Highly susceptible to thrombosis because of its long subarachnoid course
 Surgical occlusion of the proximal portion of the anterior choroidal artery
o Posterior Choroidal artery
 ORIGIN: arise from the posterior cerebral artery
 Consist of one medial posterior and at least two lateral choroidal artery
 Medial posterior choroidal artery
 Arise from the proximal parts of the posterior cerebral
artery
 Curves around the midbrain to reach the region of the
pineal body
 Gives off branches to the tectum, the choroid plexus of
the third ventricle, and the superior and medial
 Lateral Posterior choroidal Arteries
 Arise from the posterior cerebral artery
 Encircle the brainstem  enter the choroidal fissure
 Supply the choroid plexus of the lateral ventricle
 PART
Striatum
- Rostromedial parts of the head of the
caudate nucleus
- Tail of the caudate nucleus and
caudal parts of the putamen
- Lateral segment of globus pallidus
- Lateral part of the medial pallidal
segment
- Most medial parts of the pallidal
segment
Internal Capsule
- Rostromedial parts of the anterior limb
of the internal capsule
- Genu
- Ventral parts of the posterior limb and
its entire retrolenticular part
Thalamus
- Medial and anterior regions of the
thalamus
- Pulvinar and the lateral nuclei of the
thalamus
- Choroid plexus of the third ventricle
and superior and medial portions of
the thalamus
- Regions of the rostral thalamus to the
territory of the thalamoperforating
arteries
Hypothalamus
- Anterior hypothalamus and preoptic
region
- Caudal parts and the subthalamic
region
Medulla and Pons
SUPPLYING ARTERY OCCLUSION
Mainly, Lateral striate arteries (derived
from the middle striate artery
Medial striate artery (Heubner)
Anterior choroidal artery
Branches of both the lateral striate
and anterior choroidal arteries
Branches from the anterior choroidal
artery
Branches of the posterior
communicating artery
Primarily by the lateral striate branches
of the middle cerebral artery
Medial striate artery
Direct branches from the internal
carotid artery
Branches of the anterior choroidal
artery
Mainly by branches of the posterior
cerebral artery
Thalamoperforating branches –
referred to as the posteromedial
arteries that course dorsally and
medially
Thalamogeniculate branches
- Referred to as the
posterolateral arteries
- Arise from the posterior
cerebral artery as it winds
around the crus cerebri and
the choroidal arteries
Medial posterior choroidal arteries
Inferior thalamic arteries
- Arise from the posterior
communicating artery and
the bifurcation of the basilar
artery
- Course rostrally and dorsally
and enter the inferior portions
of the thalamus
Anteromedian ganglionic arteries
Posteromedian group derived from
the posterior cerebral and posterior
communicating arteries
Supplied by the anterior and posterior
spinal arteries, the posterior inferior
cerebellar arteries, branches of the
vertebral and basilar arteries and the

- Gracile and cuneate fascicule and
their nuclei, and the caudal and
dorsal portions of the inferior
cerebellar peduncle
- Parts of the nucleus of the solitary
fasciculus and vagal nuclei and
portions of the spinal trigeminal
nucleus
- Penetrate the taenia to supply the
postrema
- Paramedian region of the medulla,
includes: pyramids, medial lemniscus,
medial longitudinal fasciculus, most
of the hypoglossal nucleus except its
most cephalic portion, caudal parts
of the solitary nucleus and dorsal
motor nucleus of the vagus nerve and
the medial accessory olive
- Region between the inferior olivary
nuclear complex and the inferior
cerebellar peduncle
- Pyramids at the lower border of the
pons, the most cephalic part of the
hypoglossal nucleus and large parts
of the inferior olivary nucleus
including the dorsal accessory olive
- Olivocerebellar fibers traversing the
reticular formation, portions of the
dorsal motor nucleus of the vagus,
and the solitary nucleus and
fasciculus
- Short: spinal trigeminal and
spinocerebellar tracts
- Long: deeper regions
- Lateral medullary supplied by direct
bulbar branches of the vertebral
artery
- Retro-olivary region contains:
spinothalamic tract, spinal trigeminal
nucleus and tract, the emerging fibers
from nucleus ambiguous, the dorsal
motor nucleus of the vagus nerve, as
well as the ventral part of the inferior
cerebellar peduncle
inferior and superior cerebellar arteries
make a small contribution
Small or missing – its territory is
Posterior spinal artery supplied by the posterior inferior
cerebellar artery
Inferior alternating hemiplegia
Anterior Spinal Artery - Ipsilateral paralysis of the
- Distribution in the upper tongue and a
medulla is reduced gradually contralateral hemiplegia
an is replaced by branches - Involves portions of the
of the vertebral and basilar medial lemniscus which
arteries result in contralateral
sensory deficits
bulbar branches of the vertebral artery
- Arise as a series of rami that
enter the brainstem in
relation to rootlets of IX, X, XI
- Inferior rami – arise directly
from the vertebral artery 
enter the medulla between
the rootlets of the accessory
nerve
- Larger and more important
group of rami that enter the
lateral surface of the medulla
in relation to the
glossopharyngeal and vagus
nerve
- 2 types of arteries enter the
medulla: short and long
arteries
Lateral medullary syndrome
(Wallenberg’s syndrome)
- produced by sudden occlusions
of the posterior inferior cerebellar
artery or bulbar branches of the
vertebral artery
- associated with lesions in the
Posterior inferior cerebellar artery dorsolateral part of the medulla
- characterized by:
A. loss of pain and thermal
sense in the face
(ipsilaterally) and over the
body (contralaterally)
B. Ipsilateral paralysis of the
pharynx and larynx

- medial pontine area that include the
pontine nuclei and the
corticopontine, corticospinal, and
corticobulbar tracts
- ventromedial part of the pontine
tegmentum, including a portion of the
medial lemniscus
- adjacent anterolateral part of the
pons, and variable parts of overlying
tegmentum
- ascend to supply the cerebral
peduncle
- Most of the tegmentum in the caudal
portions of the pons
- Supply similar area in the more rostral
levels of the pons
- Important structures within this area
include: nuclei of the oculomotor to
vestibulocochlear cranial nerves,
spinal trigeminal nucleus and tract,
MLF, medial lemniscus, spinothalamic
and spinocerebellar tracts, superior
cerebellar peduncle, reticular
formation
Midbrain
- raphe region, oculomotor complex,
MLF, red nucleus, medial parts of the
substantia nigra and crus cerebri
Basilar artery grouped as:
paramedian, short circumferential and
long circumferential
- Paramedian arteries – leave
the dorsal surface of the
parent vessel
- Short Circumferential arteries
- Anterior Inferior Cerebellar
Arteries
- Long Circumferential Arteries
– course laterally over the
anterior surface of the pons
and anastomose with smaller
branched of the anterior
inferior cerebellar and
superior cerebellar arteries
- Superior Cerebellar Arteries
Posterior cerebellar artery, posterior
communicating artery, anterior
choroidal artery
GROUPED INTO:
- Paramedian Arteries – derived from
the posterior communicating artery
and from proximal portions of the
posterior cerebral artery
C. Ipsilateral Horner’s syndrome
- Disturbances of equilibrium usually
are transient
Precipitous loss of muscle tone,
dilated or pinpoint pupils that do not
react to light and bilateral Babinski
responses
- Lock-in syndrome – paralysis
prevents communication with
gesture or voice; pt. may have full
comprehension but can only
communicate using vertical eye
movements or blinking
one side: produce lesions in the
basilar part of the pons that result in
a contralateral hemiparesis and
damage to the root fibers of the
ipsilateral abducens nerve
- Ex. Middle Alternating
Hemiplegia
ipsilateral cerebellar and autonomic
disturbances and impairment of
contralateral sensation
Cranial nerve disturbances, paresis
of conjugate eye movements,
contralateral hemianesthesia,
ipsilateral cerebellar disturbances
and frequent nystagmus
Superior alternating hemiplegia
- ipsilateral oculomotor
disturbances and a
contralateral hemiplegia
(Weber’s Syndrome)
- results from lesions involving
portions of the crus cerebri
and fibers of CN III
lesion in the paramedian tegmental
zone
- destroys portions of the red
nucleus, the superior cerebellar
peduncle, and intra-axial rootlets of
the oculomotor nerve (Benedikt’s
syndrome)

- central and lateral parts of the crus
cerebri, the substantia nigra, and lateral
portions of the midbrain tegmentum
Superior and inferior colliculi
Tectum
Cerebellum
- dorsolateral region of the medulla
- inferior vermis, especially the uvula
and nodulus, cerebellar tonsil and the
inferolateral surface of the cerebellar
hemisphere
- portion of the choroid plexus of the 4th
ventricle
- pyramids, tuber flocculus and portions
of the inferior surface of the cerebellar
hemisphere, portions of the dentate
nucleus and the surrounding white
matter
Flocculus and portions of the tonsil and
biventer lobule
Colliculi (midbrain tectum) and the
superior medullary velum
Superior (tentorial) and petrosal
surfaces of the cerebellum and in some
instances, the region of the horizontal
fissure (marginal branches)
Middle and superior cerebellar
peduncles, the deep cerebellar nuclei,
the superior medullary velum, and the
corpus medullary velum
Arteries of the Dura Mater
Most of the dura and practically its
entire calvarial portion
Dura of the middle fossa and the
trigeminal ganglion
Short Circumferential arteries – arising
from the interpeduncular plexus and
proximal portions of the posterior
cerebral and superior cerebellar
arteries
Long circumferential arteries – arise
primarily from the posterior cerebral
artery
Quadrigeminal or collicular artery –
encircles the brainstem
Posterior choroidal artery and the
superior cerebellar artery
Superior cerebellar, anterior inferior
cerebellar, posterior inferior cerebellar
Posterior inferior cerebellar – derived
from the vertebral artery
 course rostrally along the
surface of the medulla
 curves upward onto the
inferior surface of the cerebellum
 medial branches of the artery
Anterior inferior cerebellar artery –
most caudal large vessel arising from
the basilar artery  crosses the
cerebellopontine angle  laterally
above the flocculus  inferior surface
of the cerebellum
Nausea, vomiting, deafness, facial
Inconstant middle inferior cerebellar
paralysis and cerebellar
artery
disturbances
Superior cerebellar artery – arise from
the rostral part of the basilar artery
GIVES OFF:
 precerebellar branches
 cortical branches (divided into
vermian, hemispheric and marginal
arteries)
 hemispheric arteries (give rise
to numerous branches that extend
deeply into the cerebellum)
Middle meningeal artery – branch of
maxillary artery, which enter the
cranial cavity through the foramen
spinosum and then divides into an
anterior and posterior branch
Accessory meningeal artery – may
arise from the maxillary artery or the
middle meningeal artery  enters the

Dura of the middle fossa
Dura of the anterior and posterior fossa
Dura of the posterior fossa
middle fossa through the foramen
ovale
Meningeal branches from the
intracavernous portions of the internal
carotid artery
Anterior and posterior meningeal rami
or arteries
One or more meningeal branches
from the occipital artery entering
through the jugular and hypoglossal
foramina; meningeal branches of the
vertebral artery reaching the posterior
fossa through the foramen magnum;
several branches of the ascending
pharyngeal artery entering through
the foramen lacerum and hypoglossal
canal

VENOUS SYSTEM:
I. Brainstem Venous Drainage
- paramedian veins which run near the midline to the ventral surface of the brainstem are inclined caudally in
the upper pons
- veins draining ventral portions of the pons usually empty into the paired longitudinal venous plexuses several
millimeters lateral to the basilar artery
- in the lower medulla: posterior veins are larger than anterior veins and penetrate deeper regions
- large veins draining the choroid plexus, of the 4th ventricle, most of the pons, and the upper medulla empty into
the sigmoid sinus or the superior or inferior petrosal sinus
- veins draining caudal parts of the medulla empty into the anterior and posterior spinal veins
- numerous veins of the mesencephalic arise from capillaries and, in general, run near the arteries but not
directly with them
 forms an extensive peripheral plexus in the pia and are collected by the basal veins,  drain
into either cerebral vein (Galen) or the internal cerebral veins
II. Cerebellar Veins
- superior and inferior median vein drain respective portion of the vermis, paravermal regions and the deep
cerebellar nuclei
 superior vein terminates in the great cerebral vein (Galen)
 inferior vein empties into the rectus and transverse sinus
- superior and inferior lateral veins drain respective portions of the cerebellar hemispheres and empty into the
superior petrosal sinuses
III. Cerebral Veins
- consist of superficial and deep groups
- large surface areas can be drained through the great cerebral vein (Galen)
- territories supplied by deep cerebral veins may be drained , when necessity arises, by surface vessels
- when occlusion or increase in pressure occurs suddenly, there will be a marked hyperemia and often extensive
hemorrhages as in birth injuries and, occasionally incases of thrombosis in adults
 COLLECTS BLOOD
VEINS JOINS WITH DRAINS/EMPTY INTO OTHER DESCRIPTION
FROM
SUPERFICIAL CEREBRAL VEINS
Convex and medial Blood flow in these veins, as
Superior cerebral Superior sagittal
surfaces of the they enter the sinus, is
veins sinus
cerebral hemisphere opposite to that in the sinus
Basal sinus
- rostral region:
Basal hemispheric cavernous and
surface and ventral sphenoparietal
Inferior cerebral veins
parts of the lateral sinuses
surface - caudal:
petrosal and
transverse sinus
-courses along the lateral
sulcus and receives smaller
veins on the lateral surface
of the hemisphere
- receives anastomotic
branch, the most constant
and prominent of which are
Superficial middle
the superior anastomotic
cerebral vein
(Trolard) and the inferior
anastomotic (Labbe) 
connect the superficial
middle cerebral vein
respectively with the
superior sagittal and
transverse sinuses
Small inferior cerebral
veins arising from
Basal sinuses
extensive pial
plexuses
Tentorial surface of Transvers and
the hemisphere petrosal sinuses
Veins from the
anterior temporal
Cavernous and
lobe and from the
sphenoparietal sinus
interpeduncular
regions
Join the superior
Veins from the orbital
and inferior
region
sagittal sinus
DEEP CEREBRAL VEINS
Rostral part of
- paired
the
- located near the midline
quadrigeminal
Internal cerebral in the tela choroidea of
cistern: paired
veins the roof of the 3rd
veins join to
- receives: ventricle (velum
form the great
interpositum
cerebral vein
(Galen)
A. thalamostriate veins
 runs forward in the terminal sulcus at the junction of the thalamus and caudate nucleus
 RECEIVES:
- Anterior Ventricular surface of
terminal vein the head of the
caudate nucleus
Enter the white matter
Join the adjacent to the lateral angle
- Transverse thalamostriate of the lateral ventricle; their
caudate nucleus vein throughout smaller tributaries in this
its course region form the longitudinal
caudate veins
Drains the dense
-superior striate Formed by the transvers and
capillary plexus of the
veins longitudinal caudate veins
lentiform nucleus
Converge upon the anterior
- inferior striate Capillary plexus (from
perforated substance and
veins below)
enter the deep middle vein
Portions of the
choroid plexus and
B. choroidal vein
adjacent
hippocampal regions
Join the internal
cerebral vein in
Septum pellucidum
the region of
C. Septal Vein and rostral portions of
the
the corpus callosum
interventricular
foramen
Enter the
internal cerebral
D. epithalamic Dorsal part of the vein or the
Vein diencephalon great vertebral
vein near their
junction
Enter the
internal cerebral
E. lateral
vein as it joins
ventricular vein
the great
cerebral vein
Basal vein (Rosenthal) Great cerebral Near the medial part of the
-RECEIVES: vein temporal lobe
Orbital surface of the
frontal lobe, anterior
A. Anterior portions of the corpus
cerebral vein callosum and rostral
portion of the Unite with the
cingulate gyrus basal vein
B. Deep Middle Insular and adjacent
cerebral vein opercular cortex
C. Inferior striate Ventral portions of
vein the basal ganglia
Great Cerebral Vein (Galen)
- RECEIVES
A. paired basal internal cerebral veins
B. paired internal cerebral veins Pass caudally beneath the
C. paired Basal Veins Rectus sinus splenium of the corpus
D. paired occipital veins (drain inferior callosum
and medial surfaces of the occipital lobe and
adjacent parietal regions)
E. posterior callosal vein (drain the
splenium of the corpus callosum and adjacent
medial surface of the brain

 cerebral veins are more important than the superficial veins which exhibit extremely variable
configurations
 deep veins are concerned primarily with the drainage of the ventricular surface, the choroid plexuses,
the deep medullary substance, caudate nucleus and the dorsal portions of the lentiform nucleus and
the thalamus