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1.2 Intracranial stenoses and occlusive processes
Basic anatomy of the intracranial arterial system: Reinhard Putz
Conservative treatment: Sophia Göricke, Marc Schlamann, Isabel Wanke
Doppler/duplex ultrasonography: Tom Schilling
Endovascular treatment: Sophia Göricke, Marc Schlamann, Isabel Wanke
Surgical treatment: Peter Horn
1.2.1 Basic anatomy of the intracranial arterial system
The interior of the cranium is supplied by two large paired arteries, in addition to several smaller afferents from the external carotid artery. The internal carotid artery, which flows without branches as far as the base of the skull, passes into the cranium through the carotid canal. Dorsally, the vertebral artery, after following a tortuous course in the vertebral artery groove, enters the vertebral canal through the atlanto-occipital membrane just under the foramen magnum. Four segments of the internal carotid artery are distinguished along its course: a cervical part (this is described in more detail in section A 1.1), a petrous part, a cavernous part, and a cerebral part (Fig. 1.2-1).
The petrous part has a diameter of around 5 mm, is approximately 3–4 cm long; accompanied by a venous plexus and an autonomic nerve plexus, it courses in the double-curved carotid canal without giving off any branches.
The cavernous part starts as the artery enters the cavernous sinus; this part of the artery also has a double S-curve, although it is highly variable. A few very small arterial branches are given off by the internal carotid artery in the sinus and pass to the trigeminal nerve ganglion, the pituitary gland, and the dura mater. Embedded in the spongy sinus, the artery is partly also enclosed by endothelium externally. Laterally, it is obliquely crossed by the abducent nerve.
Fig. 1.2–1 The parts of the internal carotid artery.
Fig. 1.2–2 The intracranial arterial supply.
The cerebral part starts as it passes through the diaphragma sellae (Fig. 1.2-2). From this point on, the wall structure of the internal carotid artery and of all its intracranial parts changes. The elastic fibroreticulate structures in particular are less developed. The first branch after the artery emerges from the cavernous sinus is the ophthalmic artery, which—covered by the optic nerve—passes obliquely forward to the base of the optic canal. It then gives off a few very small branches to the upper part of the pituitary gland and the anterior choroid artery, as well as giving off the anterior cerebral artery, and after a very short course the artery then passes into the middle cerebral artery.
The middle cerebral artery bends in its sphenoid part (the M1 segment) almost at a right angle into the lateral cistern. Lenticulostriate branches from the M1 segment pass