Neuroanatomy, Cerebral Blood Supply

Konan LM, Mesfin FB.

Introduction
The brain vasculature provides the nutrients necessary for the well functioning of the central nervous system. Anatomical and angiographic
studies considerably details the topography of the arterial architecture and the related relationships. We review the arterial blood supply to the
brain. Awareness of its normal anatomy and its common variations and anomalies are critical for diagnostic and treatment of stroke and
associated vascular disorders.

Structure and Function

Four principal arteries supply the brain, namely one internal carotid artery (ICA) and one vertebral artery on each side. Classically the internal
carotid arteries on both sides are referred to as the anterior circulation while the posterior circulation is composed by the vertebra-basilar arterial
system [1]. At the central cranial base, the anterior and posterior circulation connect with each other to form an anastomotic ring called
“circle/polygon of Willis.” The sides of the polygon of Willis are made of the anterior cerebral arteries (ACA), the posterior cerebral arteries
(PCA), anterior communicant branch (Acom A) which bridge both ACA and the posterior communicant arteries (Pcom A) which links ICA and
PCA on each hemi-brain [2].

Each ICA divides into three terminal branches: the ACA, the middle cerebral artery (MCA) and the anterior choroidal (artery ACh. A). The
PCAs are the terminal branches of the vertebrobasilar artery. Anatomists describe different segments of ACA, MCA, and PCA based on the
bifurcating pattern [3]. Hence, ACA is subdivided in:

A1: Horizontal or pre- communicating begins at the carotid bifurcation and ends at the level of ACom A.
A2: vertical or post communicating segment or pre callosal begins at Acom A and ends at the junction rostrum-genu of the corpus
callosum.
A3: pre callosal
A4: supra callosal
A5: postero-callosal

A3 together with A4 and A5 are referred as peri-callosal artery.

MCA is subdivided in:

M1: sphenoidal
M2: insular
M3: opercular
M4: cortical

PCA is subdivided in:

P1: pre-communicating
P2: post communicating
P3: quadrigeminal
P4: calcarine

ACA, MCA, and PCA harbor important perforating branches which supply vital structures such as the pituitary gland and its infundibular stalk,
the optic chiasm, hypothalamus and thalamus, midbrain and basal ganglia. We will dedicate another section for the perforating branches.

Embryology
The internal carotid arteries (ICAs) develop from the third aortic arches, the dorsal aortae, and a plexiform primordial vascular network near the
developing fore- and mid-brain [3]. The third aortic arches appear on day 28 as the first and second arch progressively involute. The proximal
segment of ICA arises from the third aortic arch while the distal one emanates from the cranial prolongation of the dorsal aortae.

The primitive ICAs divide into cranial (forerunner of the future anterior cerebral artery) and caudal divisions (precursor of the Pcom A). The
cranial divisions initially end as the primitive olfactory arteries and ultimately give rise to the definitive anterior cerebral arteries (ACAs), and to
the anterior choroidal and middle cerebral arteries. The anterior communicating artery (ACom A) is formed from a plexiform vascular network
that coalesces in the midline and connects the two developing anterior cerebral arteries.

The caudal ICA divisions anastomose with the dorsal longitudinal neural arteries. Normally, the caudal divisions regress to form the posterior
communicating arteries (PCom As) while the paired dorsal longitudinal neural arteries fuse in the midline to become the basilar artery. The
vertebral arteries arise from the coalesce of the cervical intersegmental arteries and later anastomose with the basilar artery. As the definitive
vertebral-basilar circulation matures, it annexes the posterior cerebral arteries and their proximal connections to the anterior circulation partially
involute.

Blood Supply and Lymphatics

The arterial vasculature supplies distinct brain territories[4]. Hence, we will discuss this chapter based on each main cerebral artery, its
perforating branches and the related supplied territory.

Anterior cerebral artery, Acom A and its branches

Recurrent artery (of Heubner) is the largest artery arising from A1 or proximal A2 [5]. It passes above and laterally to the
optic chiasm and penetrates the anterior perforated substance. The recurrent artery supplies the head of the caudate nucleus,
anterior third of the putamen, anterior part of the globus pallidus externus, antero-inferior portion of the anterior limb of the
internal capsule, and the uncinate fasciculus, and, rarely, the anterior hypothalamus.
Basal perforating arteries (Medial lenticulo-striate arteries) arising from ACA and Acom A supply the anterior perforated
substance, the dorsal surface of the optic nerve and optic chiasm, the optic tract, the suprachiasmatic portion of the
hypothalamus, the rostrum of the corpus callosum, the lower surface of the frontal lobe and the medial part of the sylvian
fissure [6].

Peri-callosal artery is the distal part of the artery surrounding the corpus callosum. It gives rise to its largest branch: the calloso-marginal artery.
The calloso-marginal artery is recognizable as it courses in or near the cingulate sulcus. Both calloso-marginal and distal peri-callosal artery give
five main cortical branches. They are orbitofrontal, fronto-polar, internal frontal, paracentral and parietal arteries. The cortical branches supply
the basal surface of the frontal lobe, the superior frontal gyrus and the anterior two-thirds of the medial hemisphere (including the pre-central,
central and post-central gyri). Some distal ACA may supply part of the contralateral hemisphere.

Anterior choroidal artery

The anterior choroidal artery (AChA) is a small but relatively constant vessel that arises from the posteromedial aspect of the supra-clinoid ICA
a short distance above the PCoA origin. The AChA may exist either as a single trunk or a plexus of small vessels. AChA territory is variable and
may include the optic tract, the posterior limb of the internal capsule, cerebral peduncle, choroid plexus and medial temporal lobe[7].

Middle cerebral artery

The proximal segment (M1) courses laterally to the optic chiasm to reach the medial entrance of the sylvian fissure. During its journey, it
describes two parts: pre and post bifurcation. This main trunk mainly bifurcates but, in some instances, may trifurcate. M1 harbors perforating
branches, named lateral lenticulo-striate arteries, which supply most of the caudate nucleus, internal capsule, basal ganglia. Its cortical branches
supply the anterior pole of the temporal lobe. The insular segment (M2) consists to six to eight main arteries that lie over the insula and end on
top of the circular sulcus. The distal segments M3 and M4 lie from the surface of the lateral cerebral fissure to most of the lateral surface of the
brain. Its cortical branches are orbitofrontal, pre-frontal, pre and post central sulcus, parietal, angular, temporal and temporo-occipital arteries.
M3 and M4 territory cover almost the entire lateral surface of the brain. Although anastomoses are developed between the ACA, MCA and PCA
arterial territories, watershed areas exist on the cortical surface leading to vulnerable brain areas during hypotensive events.

Posterior cerebral artery

From the basilar bifurcation to the junction with Pcom A, the proximal segment (P1) of PCA gives numbers of important perforating branches
that supply the brainstem, thalamus, oculomotor and trochlear nuclei. P2 courses between the junction and the posterior aspect of the midbrain
where it gives thalamo-perforating, thalamo-geniculate, peduncular perforating, posterior choroidal and posterior temporal arteries. The distal
part of PCA (P3 and P4) extends from the quadrigeminal plate to the calcarine fissure where they supply the occipital lobe, part of the parietal
and temporal lobe and the posterior third of the medial brain hemisphere.

Vertebrobasilar system

The intradural portion of the vertebral artery (VA) courses antero-medially through the foramen magnum, runs supero-medially toward the
midline where the two VAs unite to form the basilar artery (BA) [8]. During its journey to BA, VA gives the Postero Inferior Cerebellar Artery
(PICA), the anterior spinal artery which supplies the upper spinal cord, lateral medulla, tonsils, the vermis and the inferior cerebellar hemisphere
[9].

From the confluence of the VAs, the Basilar courses superiorly in front of the medulla, pons and bifurcate at the junction pons/mesencephalon
where it gives the posterior cerebral arteries. Along its course, BA gives the anterior inferior cerebellar arteries (AICA), pontine perforating
branches and the superior cerebellar arteries (SCA). BA supplies the brainstem, midbrain, part of thalamus, posterior internal capsule, the mid-
and upper cerebellum and vermis.

Physiologic Variants
Variations in the origin, course, and position of arteries are common, whereas variations in size are rare. Developmental anomalies during
angiogenesis lead to reported cases of hypoplasia, atresia, agenesis, absence, duplication and fenestration.

Surgical Considerations
Vascular anomalies such as arteriovenous malformations or aneurysms necessitate a surgical treatment. Perfect knowledge of the brain
vasculature is mandatory in pre-operative assessment of vascular diseases. In this pre-operative assessment, an armamentarium of studies of can
be used such as angioscanner, digital substraction angiogram (DSA), magnetic resonance angiography (MRA). Of those, the angiogram
represents the exam of choice [10].

Questions
To access free multiple choice questions on this topic, click here.

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Publication Details

Author Information

Landry M. Konan1; Fassil B. Mesfin2.

1 University of Missouri
2 MU School of Medicine

Publication History
Last Update: October 9, 2018.

Copyright
Copyright © 2018, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use,
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NLM Citation
Konan LM, Mesfin FB. Neuroanatomy, Cerebral Blood Supply. [Updated 2018 Oct 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.