Am J Electroneurodiagnostic Technol

48:249-257, 2008
© ASBT, Missouri

Transcranial Doppler Series Part I:

Understanding Neurovascular Anatomy

Heather A. Nicoletto, BS, RVT and

Marilyn H. Burknnan, BS, RDCS, RVT

Neurodiagnostic Laboratory
Duke University Hospital
Durham, North Carolina

ABSTRACT. Transcranial Doppler (TCD) is an ultrasound study

that cvahiütcs ihr hlooil ßnw in íhc brain and is considered hy many to
he the most difficult vascular study topciform. The circle of Willis ix the
group of vessels that are insonated with TCD. Knowledge of the arteries
that comprise the circle of Willis, the origins of these ves.wls. and their
vessel segments can make the test easier to perform. The technologist
performing the TCD must also he aware that the circle of Willis is not
complete in approximately 50% of all cases. Knowledge of the various
anomalies will help a technologist understand why tiiey may not he able
to insonate a vessel.

KEY WORDS. Circle of Willis, extracranial arteries, intracranial

arteries, transcranial Doppler.

INTRODUCTION
The carotid and vertebral arteries are the four main vessels that supply blood
How to the brain and they join in the skull to form the circle of Willis which lies
at the base of the brain. If any one of these vessels is compromised. blot>d carrying
oxygen to the brain is decreased which can result in a str(>ke. Transcranial Dopplet
(TCD) is an ultrasound study used to evaluate the blood flow in these vessels. The
key to perfomiing a TCD is to understand tbe vasculai anatomy of the carotid
arteries, vertebral ailcrics, and the ciiclc ot Willis, as well as their vessel segtnents
and the possible anomalies that can occur.

Received tor publication: August JÍ. 2(K)S. Accepted for publicalion September 31.

249
250 NEUROVASCULAR ANATOMY

ANATOMY
Extracranial Arteries
Extracranial is a term to describe the blood vessels that lie outside of the skull; the
blood vessels in the neck. These vessels are the main blood supply to the arm. face.
and brain.
As the aorta exits the heart, it courses upward toward the neck where it divides
into three branches: the brachiocephalie artery (also known as the innominate
artery), left common carotid arter>', and left subclavian artery.
The brachiocephalic artery is the lirst branch off the aorta. It courses superiorly
under the right clavicle and divides into the right subclavian artery and right
common carotid artery (CCA).
The left CCA is the second branch off the aorta. The bilateral CCAs ascend
through the lateral neck and divide into the internal carotid artery (ICA) and extemal
carotid artery (ECA) at approximately the level of the third or fourth cervical
vertebrae.
The left subclavian artery is the third branch off the aorta. Branching from the
subclavian arteries are the right and left vertebral arteries (VA).
The subclavian arteries course laterally between the clavicle and the first rib and
supply blood to the arms. The vertebral arteries ascend through the foramina in the
transverse processes of the cervical vertebrae and enter the skull through the foramen
magnum. Their branches supply the cervical spinal cord, some deep structures of the
neck, the medulla, and the inferior .surface of the cerebellum. The extemal carotid
arteries run superiorly and send off multiple branches that supply blood to the face.
larynx, tongue, and .scalp. The intemal carotid arteries run superiorly and enter the
skull through the carotid canals of the temporal bones and supply blood to the orbits
and brain (Eigure 1 ).

Intracranial Arteries
Intracranial is a term to describe the blood vessels that lie within the skull; i.e.. the
vessels that supply blood to the eyes and the brain. These vessels are the ophthalmic
arteries and a group of vessels that form the circle of Willis.
The ophthalmic artery is the tirst branch off of the supraclinoid ICA after it enters
the skull. It supplies blood to the eyes, orbits, forehead, and nose. The intracranial
ICA is also referred to as the carotid siphon or cavemou.s carotid artery and it is
subdivided into three named areas. The parasellar ICA is the portion that courses
toward the eye. The supraclinoid ICA is the portion that travels away from the eye
and back toward the brain. The genu portion of the ICA is when the ICA curves
between the parasellar and supraclinoid ICA (Eigure 2).
 NEUROVASCULAR ANATOMY 251

Liteinal Cai'otid Ai-tery Intpnial Carotid Artery

External Carotid Aiteiy External Caiotid Aiteiy

Common Carotid Aiterv Conunon Caiotid Artery

Subcla\ian Ai-ter>-

Bracltiocephalic Aitery
\
Subclaviaii Aiteiy

FIG. 1. Anatomy of the extracranial cerebrovascular circulation

The terminal internal carotitl artery (TTCA) is the porti(>n of the intiacranial ICA
just distal to the .supraclinoid ICA and betöre the ICA bifurcates into the middle
cerebral artery atid anterior ceœbral artery (Figure 2).
After the ophthalmic ailery branches off. the ICA dividey into the anterior cerebral
ailery (ACA) and the middle cerebral artery (MCA). The anterior ceiebial arteries
course anteroiaterally and supply the anterior, superior, and medial portions of the
frontal lobes and the medial surface of the cerebral hemispheres (Saver and
Feldmann 1993). The middle cerebral arteries run in the lateral tissures of the
252 NEUROVASCULAR ANATOMY

MCA Supraclînoîd ICA

Terminal ICA
Ophthalmic
Carotid Siphon Artery
Ge nu

Parasellar ICA

FIG. 2. Anatomy of the intracrania! internal carotid artery (ICA) demonstrating the named
portions of the carotid siphon, MCA - middle cerebral artery, ACA - anterior cerebral artery

cerebral hemispheres and supply the lateral parts of tbe temporal and parietal lobes
{Figure 3).
Once tbe vertebral arteries enter tbe skull through the foramen magnum they join
to tbnn the basilar artery (BA). Tlie basilar ai1ei-y ascends along the anterior aspect
of the brainstem giving off branches to tbe cerebellum, pons, and middle ear. At the
pons-midbrain border the basilar artery divides into a pair of posterior cerebral
arteries (PCA). They supply blood to the occipital k)bes and tbe inferior pails of the
temporal lobes ofthe cerebral hemispheres (Figure 3).

The Circle of Willis

Tbe branches of tbe internal carotid arteries and vertebral arteries are joined at
the base of tbe brain by an arterial circle known as the circle of Willis, The cirele of
Willis is comprised of tbe middle cerebral and anterior cerebral arteries (anterior
 NEUROVASCULAR ANATOMY 253

Antrrior Communiratíng ATtrry

Anterior Cerfbrat^rtery

Middle Cerebrat Artery

.
Ptisterior Cmimiuiiicjling Ait

Tntmut Carotid Aitrrv

Vertebral Artrrifs
FIG. 3. Anatomy of the circle of Willis

circulation) and the posterior cerebral arteries (posterior circulation) (Figure 3). The
circle is completed by arteries that connect the left and right hemispheres and the
posterior and anterior circulations.
The anterior communicating artery (AcoA). which lies between the right and left
anterior cerebral arteries, connects the left and right anterior circulation. Hu- Icli
and right posterior communicating arteries (PcoA) lie between the internal tamiKi
arteries and the posterior cerebral arteries and connect the posteiior ciri.ulation to the
anterior circulation bilaterally (Figure 3). Under normal circumstances the
communicating arteries have little to no function until collateral flow is needed as
a result of significant narrowing or occlusion of tlic internal carotid or vertebral
arteries.

Vessel Se}inu'nl.s/Branches
Some of the arteries of the circle of Willis will be a-ferred to as segments oi
branches and it is important to understand these segments so tliat an exact location
of disease can be interpreted. Think of it like a tree. The "segments" arc the trunk
with "branches" coming off it.
The middle cerebral artery is made up of the MI segment and M2 and M'}
branches. The Ml segtnent is the main part of the middle cerebral artery. The Ml
254 NEUROVASCULAR ANATOMY

M3 Branch«?

FIG. 4, The segments and branches of the main arteries that form the circle of Willis

,segment bifurcates into two branches tbat are called tbe M2 branches and each of
these divides into otber branches called tbe M3 branches. Usually, only the Ml
segment and M2 branches can be seen witb TCD.
The anterior cerebral artery has tbe Al and A2 segments. Tbe AI segment is the
portion of the artery tbat lies before tbe anterior communicating artery (AcoA) and is
tbe only segment that can be seen on TCD. The A2 segment is the long segment tbat
lies after the AcoA.
The posterior cerebral artery bas the PI and P2 segments. Tbe PI segment lies
before tbe posterior communicating artery (PcoA) and the P2 segment lies after the
PcoA. Both of these segments can be seen witb TCD (Figure 4).

ANOMALIES
Tbe circle of Willis is considered complete wben all vessels are present and are
normal size. A complete circle of Willis is seen in only about 50% of cases
(Grossman and Yousem 2003). There are at least nine congenital variations that can
occur within the circle of Willis (Dietbrich 1992).

Aplastie or Hypopiustic Vessels

Tbe most common anomalies involve the absence of a vessel (aplasia) or small
vessels (bypoplasia). Hypoplasia or aplasia of one or both PcoAs is tbe most common
anomaly and is seen in 25 to 33% of eases. Hypoplasia or aplasia ofthe Al segment
 NEUROVASCULAR ANATOMY 255

Aplastic AcoA

FIG. 5. The circle of Willis showing an aplastic (absent) anterior cummunicating arlery
(AcoA) and a hypoplastic (small) posterior communicating cerebral artery (PcoA).

of an ACA is seen in approximately 10 to 20% of cases (Grossman and Youseni

20()?<). In a few cases there may be a hypoplastic or aplastic AcoA (Figure 5).

Fetal Origin
Another common variation is an anomalous origin of one or both postctior
cerebral arteries called a fetal origin. This is when the posterior cerebial artery
originates from the internal carotid artery instead of the basilar artery (Figure 6).
This type of anomaly is seen in approximately 15 to 259ii of cases ((ïrossman and
Yousem 2003).

CONCLUSION
Transcranial Doppler is an ultrasound study that is used to evaluate blood flow
in the basal cerebral arteries. To perform a proper TCD it is impotlant to uruicrstantl
the anatotiiy of the circle of Willis, ils origin vessels, and all of its segments anil
branches. It is also important to know that not everyone's anatomy will be identical
and there are many anotnalies that can iK'Cur in the circle of Willis that will iiffcct the
TCD tindings. TCD may not always detect tîow in a bypoplastic vessel and ¡low in
256 NEUROVASCULAR ANATOMY

FIG. 6. Tbecircleof Willis with a fetal origin of the posterior cerebral artery {PCA). There is
no PI segment of the posterior cerebral artery and the P2 segment originates from the
internai carotid artery.

an aplastic vesset will not be identified. TCD can be a difficult study to perform.
however, knowledge of the anatomy that needs to be insonated will make
pertorming the study much easier.
In subsequent articles that will be published in future editions of AfET, we will
cover how to perform a TCD. interpretation of TCD findings, and specific TCD
cases.

ACKNOWLEDGEMENTS
We would like to thank the Duke Llnivcrsity Hospital Neurodiagnostic Lab staff
for their support, and especially Rebecca Rendahl, R. EEG T.. RPSGT, BS and
Mike Blake, BS for their a.ssistance with this paper.

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Elaine N. Marieb's Human Anatomy and Phy.siology. 3rd edition. Redwood City: The Benjamin/
Cutntnings Publishing Company. Inc: 1995. p. 674-75.
 NEUROVASCULAR ANATOMY 257

Fujinka KA. Donvillc CM. Analomy aiitl frecliíind exumitialion techniques. In: Newell DW. Aa.slid
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