Clinical Anatomy Circle Of Willis & Cavernous Sinus

This presentation will guide you through the basic anatomy of the Cirlce of Willis and Cavernous Sinus

1. Circle of Willis
and
Cavernous Sinus
Clinical Anatomy
Dr. Ankit M. Punjabi
Dept of Ophthalmology,
KIMS Hospital,
Bangalore
Karnataka, INDIA
[email protected]

2. CIRCLE
OF
WILLIS

14. TERRITORIES OF MAJOR ARTERIES OF BRAIN

15. TERRITORIES OF MAJOR ARTERIES OF BRAIN

16. TERRITORIES OF MAJOR ARTERIES OF BRAIN

19. Representation
to show
major arterial supply
in the Circle of Willis

22. TERRITORIES OF MAJOR ARTERIES OF BRAIN

23. Branches and distribution of MIDDLE CEREBRAL ARTERY

24. Branches and distribution of ANTERIOR CEREBRAL ARTERY and
some branches of POSTERIOR CEREBRAL ARTERY

25. Branches and
distribution
of POSTERIOR
CEREBRAL
ARTERY

26. Deep brain structure supply

28. •Cerebral Infarction
•Transient Ischemic Attacks
•Vascular Malformations (Aneurysm, etc)
•Intracranial Hemorrhage
•Tumors of adjacent structures
•Inflammatory Diseases of Arteries

30. Common Sites for Plaque Formation
•Internal Carotid
–Ipsilateral blindness
–Contralateral hemiparesis
–Contralateral hemianesthesia
–Hemianopia
–Aphasia, hemineglect
•Middle Cerebral
–Main trunk : Hemiplegia, hemianesthesia,
hemianopia, Aphasia
–Upper division : Hemiparesis &
sensory loss ( arm/face > leg)
–Lower division : Wernicke Aphasia
–Penetrating Artery : pure motor hemiparesis

31. Common Sites for Plaque Formation
•Anterior Cerebral
–Hemiparesis & sensory loss (leg>arm)
–Impaired responsiveness
•Posterior Cerebral
–Cortical (U/L) : isolated hemianopia
(or quadrantic defect),
color anomia
–Cortical (B/L) : cerebral blindness
(+/- macular sparing)
–Thalamic : Pure sensory stroke
–Subthalamic : Hemiballism
–B/L inf temporal lobe : Amnesia
–Midbrain : Oculomotor &
other Cr. N. palsy

32. 30-35%
30-35%
20%
5%
5%

33. Site of Aneurysm
Impaired Visual Sensory
Structures (Frequency)
Impaired Ocular Motor
Structures (Frequency)
Cavernous carotid artery Ipsilateral optic nerve,
anterior chiasm (rare)
Ipsilateral cranial nerves III,
IV, VI, V
1
, and
oculosympathetic complex
(common and early)
Carotid-ophthalmic artery Ipsilateral optic nerve,
lateral chiasm (common)
Exceptional
Supraclinoid carotid artery Ipsilateral optic nerve,
lateral chiasm, optic tract
(common)
Exceptional
Posterior communicating
artery
Ipsilateral optic nerve,
lateral chiasm, optic tract (rare)
Ipsilateral cranial nerve III
Anterior communicating
artery
Contralateral > ipsilateral optic
nerves, chiasm (common)
Exceptional
Posterior circulation
Basilar artery
Chiasm (rare); occipital cortex
(uncommon emboli)
Unilateral or bilateral cranial
nerve III, midbrain, pons
(common)
Posterior inferior cerebellar-
vertebral artery
None Unilateral cranial nerve VI

35. Watershed Infarctions Resulting from
Occlusion of the Internal Carotid Artery
Anterior
Contralateral hemiparesis predominating in the leg and sparing the face
Contralateral decrease in superficial and deep sensation in the same distribution
Mutism/aphasia if dominant hemisphere
Posterior
Contralateral homonymous hemianopia, incomplete, with macular sparing
Contralateral brachiofacial cortical hypoesthesia
Contralateral motor weakness rare and mild
Fluent aphasia if dominant hemisphere
Contralateral hemispatial neglect and anosognosia if nondominant hemisphere
Supranuclear horizontal gaze paresis with reduced or no spontaneous eye movements
toward the side of the lesion
Subcortical
Contralateral brachiofacial hemiparesis
Contralateral hemisensory deficit
Expressive speech disturbances if dominant hemisphere

36. Hemispheric Infarctions Resulting from
Occlusion of the Anterior Cerebral Artery
Proximal to its junction with the anterior
communicating artery
Asymptomatic if good anterior communicating artery
Optic chiasmal syndrome
Entire territory infarcted Severe contralateral hemiplegia, Cortical anesthesia over the leg
Apraxia affecting the left arm (damage to corpus callosum)
Behavioral changes (see below)
Distal to the anterior communicating
artery
Contralateral hemiplegia predominating on the leg
Apraxia of left arm
Contralateral forced grasping and groping if motor deficit mild
Alien hand sign
Intermanual conflict
Transcortical aphasia if left lesion
Abulia, Incontinence, Dementia
Distal occlusion (caudate nucleus) Slight transient hemiparesis
Dysarthria
Behavioral and cognitive disturbances (abulia, agitation, contralateral
neglect, difficulties with language)

37. Hemispheric Infarctions Resulting from
Occlusion of the Middle Cerebral Artery

38. Thalamic Arterial Supply and Principal
Clinical Features of Focal Infarction

40. •Macular area is
watershed area

42. CAVERNOUS SINUS

43. CAVERNOUS SINUS

48. Structures in lateral
wall
•Oculomotor nerve
•Trochlear nerve
•Ophthalmic nerve
•Lacrimal
•Frontal
•Nasociliary
•Maxillary nerve
•Trigeminal ganglion
Structures in centre of
sinus
•Internal carotid artery
•Men.Hypo. A
•Capsular A
•A. to Cav sinus
•Sympathetic plexuses
•Abducent nerve

51. VENOUS
VASCULATURE
OF BASE OF SKULL
5.Sup. Oph. Vein
6.Ant. Int. Cav. Sinus
7.Inf. Oph. Vein
8.Pterygoid Plexus
9.Mid. Menng. Vein
10.Sup. Petr. Sinus
11.Inf. Petr. Sinus
12.Basilar plexus
13.Transverse Sinus
14.Post. Int. Cav. Sinus
15.Cavernous Sinus
16.Sphenoparietal Sinus

52. •Fig. 1A. —Anatomic diagrams of cavernous sinus. Drawings of
coronal (A) and lateral (B) views show structure of cavernous sinus.
1 = carotid artery, 2 = oculomotor nerve, 3 = trochlear nerve, 4 =
ophthalmic nerve, 5 = maxillary nerve, 6 = abducens nerve, 7 =
pituitary gland, 8 = sympathetic nerve, 9 = mandibular nerve.

53. •Fig. 1B. —Anatomic diagrams of cavernous sinus. Drawings
of coronal (A) and lateral (B) views show structure of
cavernous sinus. 1 = carotid artery, 2 = oculomotor nerve, 3
= trochlear nerve, 4 = ophthalmic nerve, 5 = maxillary
nerve, 6 = abducens nerve, 7 = pituitary gland, 8 =
sympathetic nerve, 9 = mandibular nerve.

54. CAVERNOUS SINUS SYNDROMES
•Multiple cranial neuropathies:
–Unilateral & isolated 3
rd
,4
th
,5
th
, 6
th
nerve palsy
–Conbimation patterns of ophthalmoplegia
–Painful ophthalmoplegia
–Proptosis
–Ocular & cranial bruits
–Conjunctival congestion, arterialization of conjunctival veins
–Ocular hypertension
–Optic disc edema/pallor
–Retinal hemorrhage
–Anaesthesia in ophthalmic division of trigeminal
–Horner’s syndrome

55. CAVERNOUS SINUS SYNDROMES

57. Carotico-Cavernous Fistula

58. Cavernous Hemangioma

59. Intra-Cavernous Carotid Aneurysm

60. Thank You