NEUROANATOMY Lecture # 07 (BLOOD SUPPLY OF CNS)
NEUROANATOMY Lecture # 07 (BLOOD SUPPLY OF CNS)
NEUROANATOMY Lecture # 07 (BLOOD SUPPLY OF CNS)
Arterial Supply
• The central nervous system,
like any system of the body,
requires constant oxygenation
and nourishment. The brain
has a particularly high oxygen
demand – at rest it represents
one fifth of the body’s total
oxygen consumption. It is also
very sensitive to oxygen
deprivation, with ischemic cell
death resulting within minutes.
• There are two paired arteries which are responsible for the blood
supply to the brain; the vertebral arteries, and the internal
carotid arteries. These arteries arise in the neck, and ascend to
the cranium.
• Other parts of the CNS, such as the pons and spinal cord, are
supplied by smaller branches from the vertebral arteries.
• The vertebral arteries enter the cranial cavity via the foramen
magnum. Within the cranial vault, some branches are given off:
• Anterior spinal artery – formed from branches of the vertebral arteries, travelling in
the anterior median fissure. Gives rise to the sulcal arteries, which enter the spinal
cord.
• Two posterior spinal arteries – originate from the vertebral artery or the
posteroinferior cerebellar artery, anastomosing with one another in the pia mater.
• However, below the cervical level supply from these longitudinal arteries is
insufficient. There is support via anastomosis with the segmental medullary and
radicular arteries.
• The anterior and posterior segmental medullary arteries are derived from spinal
branches of a number of arteries, before entering the vertebral canal through the
intervertebral foramina.
• The great anterior segmental artery of Adamkiewicz reinforces circulation to the
inferior 2/3 of the spinal cord, and is found on the left in the majority of individuals.
• The radicular arteries supply (and follow the path of) the anterior and posterior
nerve roots. Some radicular arteries may also contribute to supplying the spinal
cord.
Clinical Notes
Stroke
• The brain is particularly sensitive to oxygen starvation. A stroke is an
acute development of a neurological deficit, due to a disturbance in the
blood supply of the brain.
• There are four main causes of a cerebrovascular accident:
Superficial System
• The superficial system of veins is largely responsible for draining the cerebral cortex:
• Superior cerebral veins: Drain the superior surface, carrying blood to the superior
sagittal sinus.
• Superficial middle cerebral vein: Drains the lateral surface of each hemisphere,
carrying blood to the cavernous or sphenopalatine sinuses.
• Inferior cerebral veins: Drain the inferior aspect of each cerebral hemisphere,
depositing blood into cavernous and transverse sinuses.
• Superior anastamotic vein (Trolard): Connects the superficial middle cerebral vein to
the superior sagittal sinus.
• Inferior anastamotic vein (Labbé): Connects the superficial middle cerebral vein to
the transverse sinus.
Deep System
• Subependymal veins – There are numerous subependymal
veins, which will not be described here in detail. These
receive blood from the medullary veins and carry it to the
dural venous sinuses. The great cerebral vein (vein of
Galen) is worthy of a mention; it is formed by the union of
two of the deep veins, and drains into the straight sinus.
• Medullary veins: Originate 1-2cm below the cortical grey
matter, and drain into subependymal veins. These drain
the deep areas of the brain.
Other Structures in the Central Nervous System
Cerebellum
• There are two main veins responsible for the venous drainage of the cerebellum
– the superior and inferior cerebellar veins. They empty into the superior
petrosal, transverse and straight dural venous sinuses.
Brainstem
• Venous drainage of the brainstem is carried out by numerous vessels – many of
which are beyond the scope of this article. Examples of veins that drain the
brainstem include the transverse pontine vein, anteromedian medullary vein,
and the anterior and posterior spinal veins.
Spinal Cord
• The spinal cord is supplied by three anterior and three posterior spinal veins.
These veins are valveless, and form an anastamotic network along the surface
of the spinal cord. They also receive venous blood from the radicular veins.
• The spinal veins drain into the internal and external vertebral plexuses, which in
turn empty into the systemic segmental veins. The internal vertebral plexus also
empties into the dural venous sinuses superiorly.
Cavernous Sinus
• The cavernous sinus is a paired dural venous sinus located within
the cranial cavity. It is divided by septa into small ‘caves’ – from
which it gets its name.
• Each cavernous sinus has a close anatomical relationship with
several key structures in the head, and is arguably the most
clinically important venous sinus.
Anatomical Location and Borders
• The cavernous sinuses are located within the middle cranial fossa, on
either side of the sella turcica of the sphenoid bone (which contains
the pituitary gland). They are enclosed by the endosteal and meningeal
layers of the dura mater.
• The cavernous sinus is the only site in the body where an artery (internal
carotid) passes completely through a venous structure. This is thought to
allow for heat exchange between the warm arterial blood and cooler venous
circulation.
• A useful mnemonic to remember the contents and their relation to one
another is: O TOM CAT, where OTOM (oculomotor nerve, trochlear
nerve, ophthalmic branch, maxillary branch) refers to the lateral wall
contents from superior to inferior, and CAT (internal carotid artery,
abducens nerve, trochlear nerve) refers to the horizontal contents,
from medial to lateral.
Dural Venous Sinus System
• Each cavernous sinus receives venous drainage from:
• Ophthalmic veins (superior and inferior) – these enter the cavernous sinus via the
superior orbital fissure.
• Central vein of the retina – drains into the superior ophthalmic vein, or directly
into the cavernous sinus.
• Sphenoparietal sinus – empties into the anterior aspect of the cavernous sinus.
• Superficial middle cerebral vein – contributes to the venous drainage of the
cerebrum
• Pterygoid plexus – located within the infratemporal fossa.
• It is important to note that the superior ophthalmic vein forms an anastomosis
with the facial vein. Therefore, the ophthalmic veins represent a potential route
by which infection can spread from an extracranial to an intracranial site.
• The cavernous sinuses empty into the superior and inferior petrosal sinuses, and
ultimately, into the internal jugular vein. The left and right cavernous sinuses are
connected in the midline by the anterior and posterior intercavernous sinuses.
They travel through the sella turcica of the sphenoid bone.
Clinical Notes
Cavernous Sinus Thrombosis
• Cavernous sinus thrombosis (CST) refers to the formation of a clot within
the cavernous sinus.
• This most common cause of CST is infection; which typically spreads from
an extracranial location such as the orbit, paranasal sinuses, or the ‘danger
zone’ of the face. Infection is able to spread in this manner due to the
anastomosis between the facial vein and superior ophthalmic veins.
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