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_address]

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

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

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

42. CAVERNOUS SINUS

43. CAVERNOUS SINUS

55. CAVERNOUS SINUS SYNDROMES

57. Carotico-Cavernous Fistula

58. Cavernous Hemangioma

59. Intra-Cavernous Carotid Aneurysm