1. Brain Arterial pathology and its relationship to neurological disease
Jose Gutierrez, MD, MPH
Assistant Professor of Neurology
Columbia University Medical Center
New York, NY.

2. Objectives:
To understand the principle of offer and demand and how it relates to brain arterial pathology
To identify the basic terminology of brain arterial phenotypes
To identify possible pathways by which brain arterial pathology may influence neurological disease.

3. Coupling between supply and demand is a basic principle of life.
Key concept:
Coupling between supply and demand is a basic principle of life.

4. What comes first? Demand or supply?
Say’s law
Demand: Keynes’s law

5. Evolution at play -Large heart
-Arteries below the heart have small lumina and thick muscularis.
-Carotid arteries have valves to avoid blood backflow
-Usual MAP around 200 at the base of the skull.
Goetz et al. Circ Res. 1960

6. Big cats
Carnivores
Strong bite = strong facial muscles

7. Tiger
Diogo et al. Anat Rec, (2012).

8. Tiger neck arteries Creighton Medical School, Omaha, Nebraska.
The explorers journal, winter 2006/2007.

9. Key concept
Arterial anatomy matches the need of each system with histological changes as a result of physiological adaptations

10. What comes first? Demand or supply?
Say’s law
Demand: Keynes’s law

11. Brain supply across species
-Medulla and
paleostriatum
- Neostriatum
-Superior colliculus and cerebellum
-Cerebral cortex
-Caudal portion of the carotid system
-No independent posterior circulation
-Carotid caudal and cephalic
-Primitive communication between VA and BA
-Dominant basilar
-Interconnected anterior and posterior systems
-Ant vs. post dominance varies
Kier, L. In: Radiology of the skull and brain, (1971)

12. Brain supply across species
Brain anatomy:
-Frontal lobe
--Most of the posterior flow is infratentotial while the bulk of the carotid flow supply the frontal lobe
-ICA to BA diameter ratio – 2:1
Kier, L. In: Radiology of the skull and brain, (1971)
Gutierrez et al. J Neuroimaging. (2013)

13. Circle of Willis and embryogenesis
-The COW vessels are symmetrical in diameter until the 4th month, when asymmetric arterial flow occur that matches the differential growth of the brain parenchyma supplied.
-The diameter of a given brain artery is directly proportion to the capillary density in the tissue it perfuses
(Lazorthes et al. 1971)
(Streeter et al )

14. Embryogenesis of the brain arterial supply
(3 mm embryo stage: ~ 3 weeks)
Menshawy et al. Journal of Stroke, 2015

15. Posterior circulation
The rapid growth of the occipital lobes determines the configuration of the posterior part of the circle of Willis
The best “energy saving” solution turns out to be the enlargement of P1 and subsequent thinning of PCA
Menshawy et al. Journal of Stroke, 2015

16. VASCULOGENESIS
ANGIOGENESIS
REMODELING
Risau, W. Nature. (1997)

17. Brain Arterial Remodeling Study (BARS)
MHBB, N=208
146 HIV +, 62 HIV –
Miami brain bank, N=18
5 HIV +, 13 HIV–
NY Psychiatric Institute/ MTC
N=104 HIV -
NYPH brain bank
N=32 HIV -
N=362 brains
2,791 large arteries
1,918 penetrating arteries

18. Brain Arterial Remodeling Study (BARS)

19. Brain Arterial Remodeling Study (BARS)