Microsurgical Anatomy of the Cerebral Arteries Gregory J. Zipfel, M.D. Department of Neurosurgery Washington University Sources • Rhoton, Microsurgical Anatomy • Yasargil, Operative Microsurgery Circle of Willis The Circle of Willis ICA ACA MCA AComA PComA Basilar PCA SCA = = = = = = = = internal carotid artery anterior cerebral artery middle cerebral artery anterior comm. artery posterior comm. artery basilar artery posterior cerebral artery superior cerebellar artery 1 Circle of Willis Circle of Willis: Variations Frontal Lobe ACA (A2) AComA AComA ACA (A1) ICA Olfactary Tract Optic Chiasm Optic Nerve ACA (A1) Circle of Willis ICA Circle of Willis: Variations Optic Nerve Pituitary Gland Optic Nerve Pituitary Gland ICA ICA PComA PComA Basilar Basilar PCA PCA Midbrain Midbrain Oculomotor Nerve Oculomotor Nerve 2 Circle of Willis: Most common aneurysm location The Internal Carotid Artery ICA Branches OphA = SupHypA = PComA = AChorA = Ophthalmic Artery Sup. Hypophyseal Artery Post. Comm. Artery Ant. Choroidal Artery ICA Segments 3 ICA Segments ICA Segments Supraclinoid Segment PetSeg CavSeg ClinSeg OphSeg ComSeg ChorSeg = = = = = = Petrous Segment Cavernous Segment Clinoidal Segment Ophthalmic Segment Communicating Segment Choroidal Segment SupraClinSeg = Supraclinoid segment Cavernous Segment Petrous Segment Cavernous ICA Segment Cavernous Sinus Anterior Clinoid Process Foramen Ovale Cavernous Sinus Foramen Spinosum CN III ACP CN IV CN VI Foramen Lacerum Carotid Canal Cavernous Segment CN V 4 Cavernous ICA Segment Clinoidal ICA Segment CN III CN III ACP ACP CN IV CN IV CN VI Clinoidal Segment CN VI CN III CN V CN IV CN V CN VI CN III CN IV Cavernous Segment CN V CN V Clinoidal ICA Segment CN III Clinoidal Segment CN IV Clinoidal ICA Aneurysms Ophthalmic Artery CN V CN III CN IV CN V 5 Supraclinoid ICA Segment Ophthalmic Segment Aneurysm Supraclinoid Segment PComA AChorA MCA ACA 1. Ophthalmic Segment 2. Communicating Segment 3. Choroidal Segment ACA MCA Ophthalmic Segment Aneurysm Post. Comm. & Ant. Choroidal Artery Aneurysms 6 Posterior Carotid Wall Aneurysm The Middle Cerebral Artery MCA Segments MCA Segments M3 M4 M2 M1 7 MCA Perforators MCA Aneurysms MCA Aneurysm The Anterior Cerebral Artery 8 ACA Segments A4 ACA Branches Pericallosal Artery A5 A3 D D A2 Callosomarginal Artery A1 ACA: Segments & Branches ACOM Artery ACOM A2 Pericallosal A. Callosomarginal A. A3 Callosomarginal A. M1 A2 A1 M1 A1 Optic Chiasm ICA Optic Nerve Optic Nerve ICA A2 9 ACOM Artery ACOM Artery Aneurysm Distal ACA Aneurysm Vertebral & Basilar Artery 10 V-B Arterial System V-B Arterial System PCA CN III CN IV PComA PCA SCA AICA PICA Basilar Vertebral = = = = = = = posterior comm. Artery posterior cerebral artery superior cerebellar artery ant. inf. cerebellar artery post. inf. cerebellar artery basilar artery vertebral artery SCA CN V Basilar CN VI AICA CN VII/VIII CN IX/X/XI PICA CN XII Vertebral Basilar Apex V-B Artery Aneurysms PComA P.C.A. P.C.A. P.C.A. B.A. S.C.A. S.C.A. S.C.A. B.A. B.A. CN III A.I.C.A. P1 A.I.C.A. PComA P1 P.I.C.A. A.I.C.A. P2 CN III SCA P.I.C.A. SCA P.I.C.A. V.A. V.A. V.A. Basilar 11 PCA Segments Basilar Apex Perforators ICA PComA Midbrain P1 P2A P2P CN III P1 P1 P3 P.Co. A. M1 Clivus PCA Branches Parietal-occipital artery Calcarine Artery P4 Cerebellar Arteries Upper complex • SCA • Midbrain • CN III, IV, V Middle complex • AICA • Pons • CN VI, VII, VIII SCA AICA PICA Lower complex • PICA • Medulla • CN IX, X, XI, XII 12 Superior Cerebellar Artery Anterior Inferior Cerebellar Artery CN III Basilar CN V CN VI Midbrain CN IV CN VII CN VIII Pons AICA Midbrain CN III CN IV CN V Vertebrals PICA Posterior Inferior Cerebellar Artery Posterior Inferior Cerebellar Artery 1. Anterior medullary segment 2. Lateral medullary segment 3. Tonsillomedullary segment 4. Telovelotonsillar segment 5. Cortical segment CN IX-XI CN XII Medulla 13 Basilar Apex Aneurysms V-B System Aneurysms SCA Aneurysms AICA Aneurysms PCA SCA Basilar AICA PICA Vertebral 14 PICA Aneurysms Basilar Apex Aneurysms Basilar Apex Aneurysm Basilar Apex Aneurysm 15 Basilar Apex Aneurysm Post-op Angio Indirect Aneurysm Treatment Unclippable MCA Aneurysm 4 year post-coil (2012) Aneurysm trapping + Bypass Immediate post-coil (2008) 16 Aneurysm trapping + Bypass 17
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