뇌혈관 해부학

중요한 뇌혈관질환에는 어떤것이 있을까?

 

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- STROKE(뇌졸중, aka 중풍) / Cerebral infarction

 

- Subarachnoid hemorrhage(SAH, 지주막하출혈)

    > Trauma

    > Aneurysm 

    > AVM

 

- Intracranial hemorrhage(ICH)

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- moyamoya disease

- CNS vasculitis 

- Dissection

 

리스트에 있는 혈관질환들의 이름들을 보면 상당히 무시무시한 이름들이 많은 것을 알 수 있다. 

이런 혈관질환들을 평가, 진단하려면 어떻게 해야할까? CT angiography, MR angiography, digital subtraction angiography와 같은 혈관조영술 영상으로 뇌혈관의 이상을 평가할수 있겠다. 혈관조영술은 조영제를 사용해 혈관을 평가한다. 

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CT angiography나 MR angiography의 indication은 다음과 같은것들이 알려져 있다. 

 

- Acute SAH

- Cerebral aneurysm or AVM without acute SAH

- TIA/stroke 

- brain tumor: blood supply 평가

- vasculitis

- cerebral artery stenosis 평가 

- cerebral venous thrombosis 

- 각종 vascular anomalies(moyamoya)

 

혈관조영술로 혈관을 평가하기 위해선 뇌혈관에 대해 알고 있어야한다. 

뇌혈관 영상해부학에 대해 알아보자

 

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Vascular anatomy

- Anterior circulation

• Internal carotid artery 
• Anterior cerebral artery
• Middle cerebral artery
• Circle of Willis

- Posterior circulation

• Vertebral artery
• Branches of vertebro-basilar system
• Basilar perforators to brainstem
• Posterior cerebral artery
• Thalamoperforators

- Circle of willis: ACA, Acom, PCA, Pcom, ICA 

 -> 교수님들이 맨날 물어보는 왕족보, 국룰 , 시험에도 많이 나올것이다. 

-> 85%의 saccular aneurysm이 circle of willis에서 발생한다고 흔히 알려져 있다. Anterior communicating artery(35%), internal carotied artery(30%), Middle cerebral artery, basilar artery bifurcation이 aneurysm의 호발 부위다. 

(Keedy A. An overview of intracranial aneurysms. Mcgill J Med. 2006;9(2):141-146.)

 

Vascular territory 

• Anterior cerebral artery(ACA): medial part of frontal and parietal lobe, anterior portion of corpus callosum, basal ganglia, internal capsule
• Middle cerebral artery(MCA): lateral surface of hemisphere, except for the medial part of the frontal and the parietal lobe(ACA cover)/ inferior part of temporal lobe(PCA),
• Posterior cerebral artery(PCA):
  • Posterior thalamoperforating arteries: midbrain/thalamus
  • Cortical branch: infereromedial part of the temporal lobe, occipital pole, visual cortex, splenium of the corpus callosum
• Superior cerebellar artery(SCA): superior and tentorial surface of the cerebellum
• Anterior inferior cerebellar artery(AICA): lateral side of the cerebellum
• Posterior inferior cerebellar artery(PICA): inferior occipital surface of the cerebellum
• Verebral / basilar artery: medulla oblongata and the pons

 

ref: CT and MRI of the whole body 

Vascular territory를 이해하는 것은 stroke/TIA를 평가하는데 중요하다. 

KMLE와 학교시험에도 자주 나오는 부분이다. 임상증상을 통해 어떤 뇌 부위가 손상받았는지 맞추는 문제가 주로 나온다. 

 

- ACA infarction:

• contralateral sensory and motor symptom in the lower extremity, sparing hands and face 
• incontinence (bilateral lesion)
• Left sided lesion: (typically) akinetic mutism / transcortical motor aphasia
• right sided infarction: (typically) confusion / motor hemineglect 

ACA infarction의 경우 하체에 더 심한 운동장애가 나타나는 것이 특징이다. 

 

- MCA infarction: stroke가 가장 많이 호발하는 혈관이다. 

• (typically) hemiparesis, facial plegia, contralateral sensory loss
• Neurological deficitis affecting the face and upper extremity more than the lower extremity 
• dominant hemisphere involvement: aphasia(receptive, expressive, or both)
• nondominant hemisphere: inattention, neglect, extinction on double-simultaneous stimulation, dysarthria without aphasia, constructional apraxia
• homonymous hemianopsia and gaze preference toward the side of the infarct 

MCA infarctinon 은 상체에 더 심한 운동장애, 실어증, gerstmann syndrome, 편측 무시, 반맹이 국룰 처럼 알려지고 있다. 

 

- PCA infarction

• ataxia, nystagmus, vertigo
• unilateral limb weakness, dizziness, gait ataxia, headache, dysarthria
• visual field loss,  blurry vision: contralateral homonymous hemianopsia

 

 

- Veretebral artery

• Medulla 침범 증상: ipsilateral horner's syndrome, cranial nerve V symptom, unilateral limb ataxia... 

- Cerebellar infarction

• dizziness(with or without vertigo), nausea, vomiting, gait instability, headache, limb ataxia
• dysmetria
• nystagmus
• intractable hiccups
• cerebellar edema -> obstructing hydrocephalus or symptomatic mass effect(응급) 

- Lacunar infarction

• pure motor on sensory deficits caused by infarction of small penetrating arteries 

Venous anatomy

- superficial venous system

• Superior cerebral vein ->  Superior sagittal sinus
• Superficial middle cerebral vein
  • Sup. anastomosing vein of Trolard -> superior sagittal sinus
  • Inf. anastomosing vein of Labbe  -> transverse sinus
• Inferior cerebral vein

- deep venous system

• internal cerebral vein -> vein of galen
• Deep middle cerebral vein -> basal vein of rosenthal -> vein of glaen 

- dural sinus 

 

cortical venous drainage와 deep venous drainage로 나뉘고 합쳐져서 dural sinus로 배출됨 

 

S. Mahal, Looking deep into cerebral venous system: Is that a pathology or just a normal variant?, DOI:10.26044/ecr2020/C-07764