Blood supply of the neck and head

Meninges
Ventricular system
 Learning objectives
• To know the major sources which supply the head and
neck: origin, course, branches
• To know the vassels which supply each lobe of the
cerebral hemisphere: origin, course, branches
• To know the venous drainage of the head and neck
• To know the sinuses of dura mater
• To know the location of the arachnoid cisterns
• To know the location and the limits of the cerebral
ventricles
 Vascular supply of the neck

• Common carotid arteries and their branches, the

external and internal carotid arteries supply all
structures of the head and neck
• Associated with this arterial system are the internal
jugular veins and their tributaries which receive blood
from all sructures of the head and neck
 Carotid system

The common carotid arteries are the beginning of the

carotid system.
Origin:
- the right common carotid artery originates from the
brachiocephalic trunk
- the left common carotid artery begins in the thorax as
a direct branch of the aortic arch
Course: both right and left common carotid arteries
ascend through the neck, just lateral to the trachea and
esophagus
 Carotid system
• Near the superior edge of the
thyroid cartilage each common
carotid artery divides into its two
terminal branches: external and
internal carotid arteries
• At the bifurcation the common
and the internal arteries are
dilated.This dilatation is called the
carotid sinus
• This containes receptors that
monitor changes in blood pressure
and are innervated by a branch of
the glossopharingeal nerve
 External carotid artery branches
It begins giving off branches
immediately after the bifurcation
of the common carotid artery
Branches:
- superior tyroid artery
- ascending pharingeal
artery
- lingual artery
- facial artery
- occipital artery
- posterior auricular artery
- superficial temporal artery
- maxillary artery
 External carotid artery: branches
Superior tyroid artery divides into anterior and posterior glandular branches
Lingual artery divides into: hyoid , sublingual , dorsal lingual artery and its terminal
branch- ranine artery
Facial artery (external maxillary artery) divides into :
Branches given off below the jaw(cervical)
- ascending palatine artery
- tonsillar artery
- submaxillary artery
- submental artery
- muscular arteries for stylohyoid (cervical), masseter, buccinator, medial pterigoid
(face)
Branches of the face :
- inferior labial branches
- superior labial branches
- lateral nasal branch
- angular artery is the terminal branch of facial artery that ascends to the inner
angle of the orbit
 Branches of the external carotid artery
Occipital artery gives off:
- sternomastoid ,
- auricular,
- meningeal and muscular branches which supply the digastric, stylo-hyoid muscles
The posterior auricular artery divides into:
- mastoid,
- auricular and
- stylomastoid branches
The ascending pharingeal artery divides into:
- pharyngeal,
- tympanic,
- meningeal,
- prevertebral arteries
The superficial temporal artery divides into:
- anterior and posterior branches,
- transverse facial artery,
- middle temporal artery,
- anterior auricular artery
 Maxillary artery

Maxillary artery gives off several branches which contribute to the arterial supply of the
face:
-Tympanic artery
-Middle and small meningeal arteries
-Deep auricular arteries
-Deep temporal arteries
-Muscular branches for masseter,buccal,pterygoid and mylohyoid muscles
-Infra-orbital artery
-Mental artery
- Anterior and posterior – superior alveolar arteries
- inferior alveolar artery
-sphenopalatine artery
 Venous drainage of the neck

The external jugular and anterior jugular veins are the primary venous channels for
superficial drainage of the neck.
External jugular vein
- Origin . It forms near the angle of the mandible from the retromandibular and
posterior auricular veins
- Course. It descends through the neck in the superficial fascia. After crossing the
sternocleidomastoid muscle enters the posterior triangle and continues its vertical
descent.
Anterior jugular vein
- Origin. They begin as small veins and come together at or just superior to the hyoid
bone.
- Course. Near the medial attachement of the sternocleidomastoid muscle each of
these veins pierces the investing layer of cervical fascia to enter the subclavian
vein. Often, they communicate with each other through a jugular venous arch.
 Vascular supply of the head

• It is estimated that about 15 percent of cardiac output

reaches the brain; about 20 percent of oxygen utilization
of the body is consumed by the adult brain

• Consciousness is lost if the blood supply is interrupted for

about 5 s, and irreparable damage to the brain tissue
occurs within 5 minutes.

• Cerebrovascular disease occurs as a result of vascular

compromise ( hemorrhage) or as a blokage of the vasel
(stroke) and is one of the most frequent sources of
neurologic disability.
 Internal jugular vein

Origin. It begins as a dilated

continuation of the sigmoid sinus,
initial part named the superior
bulb of jugular vein, which unites
with the inferior petrosal sinus.
Course. It exits the skull through
the jugular foramen associated
with the glossopharyngeal, vagus,
accesory nerves. It enters the
vasculonervous bundle of neck,
placed laterally to the common
carotid artery. It joins with the
subclavicular vein.
The brain receives its blood supply from four
arterial trunks:

-two internal carotid arteries and

– two vertebral arteries.

• On the right side, the brachiocephalic

trunk gives rise to the right subclavian and
right common carotid arteries. The right
subclavian artery gives rise to the right
vertebral artery, and the right common
carotid artery bifurcates into the right
internal and external carotid arteries.

• On the left side, the vertebral artery arises

from the left subclavian artery, and the
internal carotid artery arises from the left
common carotid artery.
 Internal carotid artery
Origin: from common carotid artery
(in both, right and left sides)
Course: the internal carotid arteries
enter the base of the skull through the
carotid canals. The internal carotid
artery lies in the cavernous sinus and
pierces the dura to begin its
subarachnoid course.
Branches of the internal carotid
artery:
- collateral branches:
intrapetrous, intrasinusal and
ophtalmic arteries
- terminal branches : anterior
cerebral, middle (Sylvian)
cerebral, posterior
communicating and choroidal
arteries
 Ophtalmic artery
The ophthalmic artery is
the first intracranial branch
(collateral) of the internal
carotid as it courses
through the cavernous
sinus.
• Enters the orbit through
optic canal joined by
optic nerve
• Inside the orbit is
placed laterally to the
medial rectus muscle
and below the superior
oblique muscle
 Ophtalmic artery
In the orbit ophtalmic artery gives off numerous branches. Some
of them are terminal branches:
- frontal (supratrochlear artery)
- dorsal nasal artery
Collateral branches are:
- central retinal artery
- long and short posterior ciliary arteries
- muscular arteries
- posterior and anterior ethmoidal arteries
- lacrimal artery
- supra-orbital artery
- medial palpebral artery
 Anterior choroidal artery

• The anterior choroidal artery

arises from the internal
carotid artery after it emerges
from the cavernous sinus.
• It passes ventral to the optic
tract and supplies the optic
tract, cerebral peduncles,
lateral geniculate body,
posterior part of the posterior
limb of the internal capsule,
tail of the caudate nucleus,
uncus, amygdala, anterior
hippocampus, choroid plexus
of the temporal horn, and
sometimes the globus pallidus
 Anterior cerebral artery
The anterior cerebral artery
originates from the internal
carotid artery lateral to the
optic chiasm and courses
dorsal to the optic nerve to
reach the interhemispheric
fissure.
Here it curves around the
genu of the corpus callosum
and continues as the
pericallosal artery dorsal to the
corpus callosum.
As the two anterior cerebral
arteries approach the
interhemispheric fissure, they
are joined by the anterior
communicating artery.
 Anterior cerebral artery
The following are among its major branches.
Medial Striate Artery. It supplies the
anterior limb and genu of the internal
capsule and parts of the head of the caudate,
rostral putamen, and globus pallidus. It also
provides blood supply to the posterior
portions of the gyrus rectus and orbitofrontal
cortex.
Orbitofrontal Artery. This branch supplies
the orbital giri at the base of the frontal lobe
and part of the septal area.
Fronto-polar Artery. This artery supplies
most of the pole of the frontal lobe.
Callosomarginal Artery. This is the major
branch of the anterior cerebral artery. It
passes backward and upward and gives off
internal frontal branches before terminating
in the paracentral branch around the
paracentral lobule.
Pericallosal Artery. This is the terminal
branch of the anterior cerebral artery, which
supplies the precuneus gyrus of the parietal
lobe
 Middle cerebral artery
The middle cerebral artery-Sylvian
artery is a continuation or the main
branch of the internal carotid artery
(terminal branch). It is divided into
four segments (surgical
nomenclature):
– the M1 (sphenoidal) segment
courses posterior and parallel
to the sphenoid ridge;
– the M2 (insular) segment lies
on the insula (island of Reil);
– the M3 (opercular) segment
courses over the frontal,
parietal, and temporal
opercula;
– and the M4 (cortical)
segment spreads over the
cortical surface.
It courses within the lateral (Sylvian)
fissure and divides into a number of
branches that supply most of the
lateral surface of the hemisphere.
 Middle cerebral artery
Cortical Branches include the frontal branch, the temporal branch and the parietal
branch.
Central (Perforating) Branches include the lenticulostriate arteries, which supply the
major parts of the caudate, putamen, globus pallidus, internal capsule, and thalamus.
The middle cerebral artery thus supplies the following important neural structures:
- primary and association motor and somatosensory cortices,
- Broca's area of speech,
- prefrontal cortex,
- primary and association auditory cortices (including Wernicke's area), and
- the major association cortex (supramarginal and angular gyri).
Occlusion of the middle cerebral artery results in contralateral paralysis (more
marked in the upper extremity and face), contralateral loss of kinesthesia and
discriminative touch, changes in mentation and personality, and aphasia when the left
(dominant) hemisphere is involved
 Posterior communicating artery
It connects the internal carotid
artery with the posterior
cerebral artery.
Branches of the posterior
communicating artery supply:
- the genu and anterior part
of the posterior limb of the
internal capsule,
- the anterior part of the
thalamus
- parts of the hypothalamus
and subthalamus
 The vertebral artery
• Origin: the vertebral artery arises
from the subclavian artery.
• Course: It ascends within the
foramina of the transverse
processes of the upper six cervical
vertebrae (intraosseous segment),
curves backward around the lateral
mass of the atlas (atlantoaxial
segment), and enters the cranium
through the foramen magnum
(intracranial segment). Within the
cranium, the vertebral arteries lie
on the inferior surface of the
medulla oblongata and join to each
other at the caudal end of the pons
to form the basilar artery.
• Branches:the vertebral artery
gives rise to the posterior spinal,
anterior spinal, and posterior
inferior cerebellar branches.
 The vertebral artery
Posterior spinal artery
• The two posterior spinal arteries supply the posterior aspect of the medulla below
the obex, as well as the posterior column and posterior horns of the spinal cord. One
or both posterior spinal arteries may arise from the posterior inferior cerebellar
arteries.
Anterior spinal artery
• The anterior spinal artery starts as two vessels that join to form a single artery that
descends on the ventral aspect of the medulla and into the anterior median fissure of
the spinal cord. It supplies the medullary pyramids and the paramedian medullary
structures, as well as the anterior two-thirds of the spinal cord.
Posterior inferior cerebellar artery (PICA)
• These arteries follow an S-shaped course over the olive and inferior cerebellar
peduncle to supply the inferior surface of the cerebellum, dorsolateral surface of the
medulla oblongata, choroid plexus of the fourth ventricle, and part of the deep
cerebellar nuclei. Occlusion of this artery gives rise to a characteristic group of
signs and symptoms comprising the lateral medullary syndrome (Wallenberg
syndrome).
• The posterior inferior cerebellar artery may have common origin with the
anterior inferior cerebellar artery from the basilar artery.
 Basilar artery
Formed by the union of the two vertebral arteries at the caudal end of the pons, the basilar
artery runs in the pontine groove on the ventral aspect of the pons and terminates at the rostral
end by dividing into the two posterior cerebral arteries.
Branches include :
• Paramedian penetrating arteries. These branches penetrating the brain stem.
• Short circumferential arteries. These branches supply the anterolateral and
posterolateral parts of the pons.
• Long circumferential arteries
Auditory (Labyrinthine) Artery. This artery accompanies the facial (CN VII) and
vestibulocochlear (CN VIII) cranial nerves and supplies the inner ear and root fibers of the
facial nerve. Occlusion of this artery gives rise to deafness.
Anterior Inferior Cerebellar Artery (AICA). This artery supplies the inferior surface of the
cerebellum, the brachium pontis, and the restiform body, as well as the tegmentum of the
lower pons and upper medulla.
Superior Cerebellar Artery. It supplies the superior surface of the cerebellum, part of the
dentate nucleus, the brachium pontis and conjunctivum, the tegmentum of the upper pons, and
the inferior colliculus.
 Branches of the basilar artery

Posterior cerebral arteries. They supply:

- the medial surfaces of the occipital lobe, including the primary and
association visual cortices,
- temporal lobe,
- caudal part of the parietal lobe and the splenium of the corpus callosum.
The main trunk of the posterior cerebral artery bifurcates into medial and
lateral branches:
- The lateral branch gives rise to anterior and posterior temporal
branches, which supply the lateral surface of the temporal lobe except for
its most rostral part, which is supplied by the middle cerebral artery.
- The medial branch gives rise to parieto-occipital and occipital
(including calcarine) branches, which supply the medial surface of the
occipital lobe, part of the posterior parietal lobe, and the splenium of the
corpus callosum
 CIRCLE OF WILLIS
• The proximal portions of the anterior,
middle, and posterior cerebral arteries
connected by the anterior and posterior
communicating arteries form a circle, the
circle of Willis around the infundibulum of
the pituitary and the optic chiasm. The
circle constitutes an important anastomotic
channel between the internal carotid and
the vertebral basilar systems.
• When either the internal carotid arteries
(anterior circulation) or the vertebral
basilar system (posterior circulation)
becomes occluded, collateral circulation in
the circle of Willis will provide blood to
the area deprived of blood supply. The
circle of Willis is complete in only 20
percent of individuals. In the majority of
individuals, variation in size and/or origin
of vessels is the rule
 Cerebral venous drainage
Cerebral venous drainage occurs through two
systems: the superficial and the deep.
Superficial venous system is divided into three
groups:
• Superior cerebral group: These veins drain
the dorsolateral and dorsomedial surfaces of
the hemisphere and enter the superior
sagittal sinus
• Middle cerebral group: These veins run
along the Sylvian fissure, drain the
inferolateral surface of the hemisphere, and
open into the cavernous sinus
• Inferior cerebral group: These veins drain
the inferior surface of the hemisphere and
open into the cavernous and transverse
sinuses.
The medial surface of the hemisphere is drained
by a number of veins that open into the superior
and inferior sagittal sinuses, as well as into the
basal vein and the great cerebral vein of Galen.
 Deep venous system
• The deep venous system consists of a number of veins
that drain into two main tributaries:
– the internal cerebral vein
– and the basal vein.
• The two join beneath the splenium of the corpus
callosum to form the great cerebral vein of Galen,
which opens into the straight sinus.
Internal cerebral vein. This vein receives two tributaries:
– Terminal Vein (Thalamostriate). Draining the
caudate nucleus and possibly the thalamus, this
vein passes forward in a groove between the
caudate nucleus and thalamus in the body of the
lateral ventricle and empties into the internal
cerebral vein at the interventricular foramen of
Monro.
– Septal Vein. This vein drains the septum
pellucidum, the anterior end of the corpus
callosum, and the head of the caudate nucleus
and passes backward from the anterior column of
the fornix to open at the interventricular foramen
into the internal cerebral vein.
 Deep venous system

Basal vein (of ROSENTHAL)

• This vein begins under the anterior perforated substance near
the medial part of the anterior temporal lobe and runs
backward to empty into the great cerebral vein. It drains blood
from the base of the brain
Great cerebral vein (of GALEN)
• This vein receives the internal cerebral vein and the basal vein
of Rosenthal and a number of other smaller veins (occipital,
posterior callosal) and extends for a short distance under the
splenium of the corpus callosum to empty into the straight
sinus (rectus sinus).
 Cerebral dural venous sinuses

The superior sagittal sinus (1)and the

inferior sagittal sinus (2) lie in the
superior and inferior margins of the falx
cerebri, respectively. The superficial
cerebral veins drain into the superior and
inferior sagittal sinuses. The superior
sagittal sinus, in addition, drains
cerebrospinal fluid from the subarachnoid
space via arachnoid granulations,
evaginations of the arachnoid matter
(arachnoid villi), into the superior sagittal
sinus.
• Caudally, the inferior sagittal sinus is
joined by the great cerebral vein of
Galen to form the straight sinus (3)
(rectus sinus) located at the junction
of the falx cerebri and tentorium
cerebelli.
 Cerebral dural venous sinuses

• The straight sinus drains into the confluence of sinuses.

• The two transverse sinuses (4)arise from the confluence of sinuses
(torcular Herophili) and pass laterally and forward in a groove in the
occipital bone.
• At the occipitopetrosal junction, they curve downward and backward as
the sigmoid sinus (5), which drains into the internal jugular vein.
• The occipital sinus (6) connects the confluence of sinuses (torcular
Herophili) to the marginal sinus (7) at the foramen magnum.
• The superior petrosal sinus (8) lies in the dura at the anterior border of
the tentorium cerebelli. It connects the petrosal vein and transverse sinus to
the cavernous sinus.
• The inferior petrosal (8)sinus joins the cavernous sinus to the jugular bulb
and extends between the clivus and the petrous bone.
 Cerebral dural venous sinuses
The cavernous sinus (10) lies on each
side of the sphenoid sinus, the sella
turcica, and the pituitary gland. The sinus
contains the internal carotid artery and the
abducens cranial nerve. The lateral wall
contains the oculomotor and trochlear
cranial nerves and the ophthalmic and
maxillary divisions of the trigeminal
cranial nerve.
• The two cavernous sinuses
intercommunicate via the basilar
venous plexuses and via venous
channels anterior and posterior to the
pituitary gland.
• Anteriorly, the ophthalmic vein
drains into the cavernous sinus.
Posteriorly, the cavernous sinus drains
into the superior and inferior petrosal
sinuses. Laterally, it joins the
pterygoid plexus at the foramen ovale
 Cranial meninges
Dura mater
Arachnoid mater: epithelial
layer and arachnoid
trabeculae
Pia mater: sticks to brain
surface
Pia and arachnoid
leptomeninges
Dural folds hold the brain in
position
 Ventricles of the brain
Lateral ventricles (first and second) are
paired cavities, one in each cerebral hemisphere
Third ventricle is inside the diencephalon
Fourth ventricle is located between pons and
cerebellum, continuous with central canal of
spinal cord.
Ventricular cavities are lined by ependymal
epithelium. In some specific sites, the
ependymal lining is invaginated by a vascular
pial fold known as the choroid plexus.
Such choroid plexus sites are encountered in the:
- body, atrium, inferior horn of the lateral
ventricle,
- foramen of Monro,
- roof of the third ventricle, and
- posterior part of the roof of the fourth
ventricle
 Subarachnoid cisterns
The subarachnoid cisterns are dilatations in the subarachnoid
spaces located principally at the base of the brain.
• The cisterna magna (cisterna cerebellomedullaris), largest
of the subarachnoid cisterns, is located between the
medulla oblongata, the cerebellum, and the occipital bone.
CSF from the fourth ventricle reaches the cisterna magna
via the foramina of Magendie and Luschka.
• The medullary cistern lies ventral and lateral to the
medulla oblongata.
• The cisterna pontis is located between the basis pontis and
the clivus.
• The cisterna interpeduncularis extends between the
cerebral peduncles.
• The suprasellar cistern is located dorsal to the sella
turcica and communicates with the cisterna
interpeduncularis.
• The superior (quadrigeminal) cistern is located dorsal to
the midbrain.
• The interpeduncular and superior (quadrigeminal) cisterns
are connected along the lateral surface of the midbrain by
the ambient cistern (cisterna ambiens).
• The clinically relevant spinal subarachnoid cistern is the
lumbar cistern, site of lumbar puncture.
 Cerebrospinal fluid

Functions of the cerebrospinal fluid are:

- It provides mechanical protection
- It maintains a stable extracellular environment for the brain
- It removes some waste products nutrition
- It conveys messages? (hormones/ releasing factors/ neurotransmitters)
Most of the CSF is secreted by the choroid plexuses in the lateral, third and fourth
ventricles. However, there is also a small contribution from the ependymal lining of the
ventricles and from the extracellular fluid from the brain parenchyma
The total CSF volume is c.150 ml, of which 125 ml is intracranial.
CSF Circulation
• lateral ventricles--> foramen of Monro--> third ventricle --> aqueduct of Sylvius -->
fourth ventricle --> foramina of Magendie and Luschka --> subarachnoid space over
brain and spinal cord --> reabsorption into venous sinus blood via arachnoid
granulations
 Arachnoid villi
• They are microscopic one-
way valves (modified pia and
arachnoid) that penetrate the
meningeal dural layer that
line the sinuses; hence,
arachnoid villi reside within
the sinuses (especially the
superior sagittal sinus).
Clumps of arachnoid villi =
arachnoid granulations.
• Arachnoid villi are one-way
valves that open when the
hydrostatic pressure of CSF
in the subarachnoid space is
about 1.5 mm Hg greater
than venous hydrostatic
pressure in the dural sinuses
(i.e., passive process)