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MAYO CLINIC Neurology Board Review

Kelly D, Flemming

EDITOR - IN - CHIEF

MAYO CLINIC NEUROLOGY BOARD REVIEW

Second Edition

Mayo Clinic Atlas of Regional Anesthesia and Ultrasound-Guided Nerve Blockade

Edited by James R. Hebl, MD, and Robert L. Lennon, DO

Mayo Clinic Preventive Medicine and Public Health Board Review

Edited by Prathibha Varkey, MBBS, MPH, MHPE

Mayo Clinic Infectious Diseases Board Review

Edited by Zelalem Temesgen, MD

Just Enough Physiology

By James R. Munis, MD, PhD

Mayo Clinic Cardiology: Concise Textbook, Fourth Edition

Edited by Joseph G. Murphy, MD, and Margaret A. Lloyd, MD

Mayo Clinic Electrophysiology Manual

Edited by Samuel J. Asirvatham, MD

Mayo Clinic Gastrointestinal Imaging Review, Second Edition

By C. Daniel Johnson, MD

Arrhythmias in Women: Diagnosis and Management

Edited by Yong-Mei Cha, MD, Margaret A. Lloyd, MD, and Ulrika M. Birgersdotter-Green, MD

Mayo Clinic Body MRI Case Review

By Christine U. Lee, MD, PhD, and James F. Glockner, MD, PhD

Mayo Clinic Gastroenterology and Hepatology Board Review, Fifth Edition

Edited by Stephen C. Hauser, MD

Mayo Clinic Guide to Cardiac Magnetic Resonance Imaging, Second Edition

Edited by Kiaran P. McGee, PhD, Eric E. Williamson, MD, and Matthew W. Martinez, MD

Mayo Clinic Neurology Board Review, First Edition [2 Volumes]

Edited by Kelly D. Flemming, MD, and Lyell K. Jones Jr, MD

Mayo Clinic Critical Care Case Review

Edited by Rahul Kashyap, MBBS, J. Christopher Farmer, MD, and John C. O’Horo, MD

Mayo Clinic Medical Neurosciences, Sixth Edition

Edited by Eduardo E. Benarroch, MD, Jeremy K. Cutsforth-Gregory, MD, and Kelly D. Flemming, MD

Mayo Clinic Principles of Shoulder Surgery

By Joaquin Sanchez-Sotelo, MD

Mayo Clinic Essential Neurology, Second Edition

By Andrea C. Adams, MD

Mayo Clinic Antimicrobial Handbook: Quick Guide, Third Edition

Edited by John W. Wilson, MD, and Lynn L. Estes, PharmD

Mayo Clinic Critical and Neurocritical Care Board Review

Edited by Eelco F. M. Wijdicks, MD, PhD, James Y. Findlay, MB, ChB, William D. Freeman, MD, and Ayan Sen, MD

Mayo Clinic Internal Medicine Board Review, Twelfth Edition

Edited by Christopher M. Wittich, MD, PharmD, Thomas J. Beckman, MD, Sara L. Bonnes, MD, Nerissa M. Collins, MD, Nina M. Schwenk, MD, Christopher R. Stephenson, MD, and Jason H. Szostek, MD

Mayo Clinic Strategies for Reducing Burnout and Promoting Engagement

By Stephen J. Swensen, MD, and Tait D. Shanafelt, MD

Mayo Clinic General Surgery

By Jad M. Abdelsattar, MBBS, Moustafa M. El Khatib, MB, BCh, T. K. Pandian, MD, Samuel J. Allen, and David R. Farley, MD

MAYO CLINIC NEUROLOGY BOARD REVIEW

SECOND EDITION Kelly D. Flemming, MD

Consultant, Department of Neurology

Mayo Clinic, Rochester, Minnesota; Professor of Neurology

Mayo Clinic College of Medicine and Science

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Library of Congress Cataloging-in-Publication Data

Names: Flemming, Kelly D., editor. | Mayo Clinic, issuing body.

Title: Mayo Clinic neurology board review / [edited by] Kelly D. Flemming. Other titles: Neurology board review | Mayo Clinic scientific press (Series) Description: Second edition. | New York, NY : Oxford University Press, [2022] | Series: Mayo Clinic scientific press | Includes bibliographical references and index.

Identifiers: LCCN 2021008357 (print) | LCCN 2021008358 (ebook) | ISBN 9780197512166 (paperback) | ISBN 9780197512180 (epub) |

ISBN 9780197512197

Subjects: MESH: Nervous System Physiological Phenomena | Nervous System Diseases | Study Guide

Classification: LCC RC343.5 (print) | LCC RC343.5 (ebook) | NLM WL 18.2| DDC 616.80076—dc23

LC record available at https://lccn.loc.gov/2021008357

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DOI: 10.1093/med/9780197512166.001.0001

Mayo Foundation does not endorse any particular products or services, and the reference to any products or services in this book is for informational purposes only and should not be taken as an endorsement by the authors or Mayo Foundation. The incidental appearance of brand names on any equipment or the mention of brand names in the narration in the accompanying videos has been avoided when at all possible; any occurrences were left to preserve the educational integrity of the videos and should not be taken as endorsement by the authors or Mayo Foundation. Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication. This book should not be relied on apart from the advice of a qualified health care provider.

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Preface

Neurology is an exciting and rapidly expanding area of medicine. This new edition of Mayo Clinic Neurology Board Review is designed to assist both physicians-intraining who are preparing for the initial American Board of Psychiatry and Neurology (ABPN) certification examination and neurologists who are preparing for recertification. Trainees and other physicians in related specialties such as psychiatry, neurosurgery, or physiatry may also find this book useful in preparation for their own certification examinations. While erring on the side of thoroughness, Mayo Clinic Neurology Board Review, Second Edition, is not intended to replace an in-depth textbook or serve as a guide to the most current therapies. Instead, this book provides a core of essential knowledge of both basic and clinical aspects of neurology. The emphasis is on clinical knowledge related to diagnostic and therapeutic approaches to patient management. In addition, this text has an expansive array of illustrations, pathology, and radiologic images.

There are different needs for those who are taking the initial board examination and for those who are recertifying. Chapters 1 through 47 cover basic sciences and psychiatry, and Chapters 48 through 134 cover clinical neurology. It is intended that people taking the board examination for the first time would benefit from reviewing all chapters, whereas those recertifying may wish to mainly focus on Chapters 48 through 134. Throughout the book, high-yield facts and questions have been included for your review.

We all become consumers of medicine; thus, it is our obligation to teach. This includes teaching facts but also experience and compassion. I want to thank all the dedicated, hardworking contributors to this text who

share the same enthusiasm for teaching. The faculty responsible for this text included Mayo Clinic physicians in the Department of Neurology, the Department of Neurologic Surgery, the Department of Radiology, the Department of Ophthalmology (Neuro-ophthalmology Team), the Department of Physical Medicine and Rehabilitation, the Division of Sleep Medicine, the Division of Infectious Diseases, and the Department of Psychiatry and Psychology at Mayo Clinic in Arizona, Mayo Clinic in Florida, and Mayo Clinic in Rochester, Minnesota. Some chapters were written by trainees, but all chapters were reviewed by staff clinicians. I am deeply grateful to these incredibly talented experts who have provided such high-quality content. I thank Lyell K. Jones Jr, MD, for his help with initiating and organizing the second edition and for his ongoing commitments to education. I also thank Nima Mowzoon, MD, for creating some of the illustrations and for spending countless hours gathering many of the figures that appear in this work.

I want to thank the staffs of Mayo Clinic Scientific Publications, the Mayo Clinic Division of Media Support Services, Mayo Clinic Scientific Press, and Oxford University Press.

Cover images, clockwise from upper left: Figure 58.1, Retinal subhyaloid and peripapillary hemorrhage in the hyperacute stage of Terson syndrome; Figure 36.2A, Computed tomographic perfusion in a patient with acute stroke; Figure 7.6B, Magnetic resonance image showing syringomyelia at the level of the cervical spinal cord; Figure 119.2A, Gross specimen showing cortical tubers associated with tuberous sclerosis complex.

Kelly D.

Flemming, MD

Table of Contents

Contributors xiii

Section I: Neuroscience and Neuroanatomy

1 • Cerebrovascular Anatomy and Pathophysiology 3

Kelly D. Flemming, MD

2 • Meninges and Ventricles 17

Ruple S. Laughlin, MD

3 • Afferent System Overview 21

Stephen W. English Jr, MD, and Eduardo E. Benarroch, MD

4 • Peripheral and Central Pain Pathways and Pathophysiology 29

Jery D. Inbarasu, MD, and Eduardo E. Benarroch, MD

5 • Special Somatic Sensory Afferent Systems Overview 34

Scott D. Eggers, MD, and Eduardo E. Benarroch, MD

6 • Anatomy of Peripheral Nerves, Neuromuscular Junctions, and Skeletal Muscles 41

Jennifer A. Tracy, MD

7 • Anatomy of the Spinal Cord 60

Jennifer A. Tracy, MD

8 • Brainstem and Cranial Nerves: Overview and Medulla 68

Kelly D. Flemming, MD

9 • Brainstem and Cranial Nerves: Pons 82

Kelly D. Flemming, MD, and Paul W. Brazis, MD

10

• Brainstem and Cranial Nerves: Midbrain 92

Kelly D. Flemming, MD, and Paul W. Brazis, MD

11

• Brainstem and Cranial Nerves: Longitudinal Pathways of the Brainstem 99

Kelly D. Flemming, MD

12 • Supranuclear Ocular Motor Systems 105

Scott D. Eggers, MD

13 • Cranial Nerves I and II 115

Kelly D. Flemming, MD, and Eduardo E. Benarroch, MD

14 • Thalamus 120

Kelly D. Flemming, MD, and Eduardo E. Benarroch, MD

15 • Principles of Neuroendocrinology and Hypothalamic Function 127

Elizabeth A. Coon, MD, and Eduardo E. Benarroch, MD

16 • Limbic System 133

Vijay K. Ramanan, MD, PhD, and Eduardo E. Benarroch, MD

17 • Basal Ganglia 141

Farwa Ali, MD, and Eduardo E. Benarroch, MD

18 • Cerebellum 147

Anhar Hassan, MB, BCh

19 • Autonomic Nervous System 158

Jeremy K. Cutsforth-Gregory, MD

20

• Cortex: Gross Anatomy 169

Kelly D. Flemming, MD

21 • Cortex: Topography and Organization 175

Richard J. Caselli, MD, and David T. Jones, MD

22 • Cortex: Circuitry, Networks, and Function 179

David T. Jones, MD

23 • Focal Cognitive Syndromes 186

Richard J. Caselli, MD

24 • Cellular Signaling 196

Nathan P. Staff, MD, PhD, and Nicolas N. Madigan, MB, BCh, PhD

25 • Cellular Processes 204

Nathan P. Staff, MD, PhD, and Nicolas N. Madigan, MB, BCh, PhD

26 • Cellular Injury and Death 209

Nicolas N. Madigan, MB, BCh, PhD, and Nathan P. Staff, MD, PhD

27 • Neuropharmacology 215

Amy Z. Crepeau, MD

28

• Sleep Pathophysiology 225

Gabriel Anders, DO, and Melissa C. Lipford, MD

29 • Patterns of Inheritance in Neurogenetic Disease 233

Ralitza H. Gavrilova, MD

30 • Chromosomal Syndromes 238

Ralitza H. Gavrilova, MD

31 • Electroencephalography: Basic Concepts 246

David B. Burkholder, MD, and Jeffrey W. Britton, MD

32 • Electroencephalography: Evaluation of Neurologic Disorders 255

David B. Burkholder, MD, and Jeffrey W. Britton, MD

33

• Nerve Conduction Studies and Needle

Electromyography 264

Brian A. Crum, MD

34 • Cerebrospinal Fluid 274

Ruple S. Laughlin, MD

35 • Evoked Potentials 277

E. Matt Hoffman, DO, PhD

36 • Neuroimaging 283

Dong Kun Kim, MD, and David F. Black, MD

Questions and Answers 292 Suggested Reading 307

Section II: Psychiatry

37 • Principles of Psychiatry and Psychology 311

Angelina J. Polsinelli, PhD, and Mary M. Machulda, PhD, LP

38 • Psychological Development Through the Life Cycle 316

Maria I. Lapid, MD, and Mark W. Olsen, MD

39 • Mood Disorders 322

Simon Kung, MD

40 • Anxiety Disorders 326

Ahmed T. Makhlouf, MB, BCh

41 • Psychotic Disorders 333

Keith G. Rasmussen, MD

42 • Personality and Illness 338

Brian A. Palmer, MD

43 • Miscellaneous Psychiatric Disorders 343

Kari A. Martin, MD

44 • Psychiatric Disorders Associated With Infancy, Childhood, and Adolescence 348

Jyoti Bhagia, MD

45 • Substance Use Disorders 353 Bhanuprakash Kolla, MD, and Sara E. Hocker, MD

46 • Pharmacologic Treatment of Psychiatric Disorders 359

Keith A. Miller, MD, and Robert J. Morgan III, MD, PhD

47 • Nonpharmacologic Treatment of Psychiatric Disorders 371

Jarrod M. Leffler, PhD, LP

Questions and Answers 375 Suggested Reading 379

Section III: Cerebrovascular Disorders

48 • Ischemic Stroke: Common Causes and Diagnosis 383

Kelly D. Flemming, MD

49 • Ischemic Stroke: Uncommon and Special Situations 399

Catherine E. Arnold Fiebelkorn, MD, and James P. Klaas, MD

50 • Acute Ischemic Stroke Evaluation and Treatment 410

Eugene L. Scharf, MD

51 • Secondary Prevention of Ischemic Stroke 417

Lindsy N. Williams, MD

52 • Intraparenchymal Cerebral Hemorrhage 422

Maria I. Aguilar, MD

53 • Unruptured Intracranial Aneurysms and Vascular Malformations 429

Robert D. Brown Jr, MD, MPH

54 • Neurorehabilitation 440

Billie A. Schultz, MD

Questions and Answers 445 Suggested Reading 449

Section IV: Neurologic Intensive Care Disorders

55 • Impaired Consciousness and Coma 453

Maximiliano A. Hawkes, MD, and Eelco F. M. Wijdicks, MD, PhD

56 • Principles and Management of Increased Intracranial Pressure 466

Shivram Kumar, MBBS, and Eelco F. M. Wijdicks, MD, PhD

57 • Status Epilepticus 473

Maximiliano A. Hawkes, MD, and Sara E. Hocker, MD

58 • Nontraumatic Subarachnoid Hemorrhage 479

Tia Chakraborty, MD, and Jennifer E. Fugate, DO

59 • Anoxic-Ischemic Encephalopathy 485

Tia Chakraborty, MD, and Jennifer E. Fugate, DO

60 • Traumatic Brain Injury 489

Lucas P. Carlstrom, MD, PhD, and Eelco F. M. Wijdicks, MD, PhD

61 • Acute Spinal Cord Compression, Spinal Cord Trauma, and Peripheral Neural Injury 501

Christopher R. Marcellino, MD, and Eelco F. M. Wijdicks, MD, PhD

62 • Neuromuscular Disease in the Neuroscience Intensive Care Unit 511

Maximiliano A. Hawkes, MD, and Eelco F. M. Wijdicks, MD, PhD

63 • Acute Hyperthermia Syndromes 519

Maximiliano A. Hawkes, MD, and Eelco F. M. Wijdicks, MD, PhD

Questions and Answers 523

Suggested Reading 527

Section V: Demyelinating Diseases

64 • Pathologic Factors and Spectrum of Central Nervous System Inflammatory Demyelinating Diseases 531

Claudia F. Lucchinetti, MD, and Yong Guo, MD, PhD

65 • Diagnosis of Multiple Sclerosis 540 W. Oliver Tobin, MB, BCh, BAO, PhD

66 • Treatment of Multiple Sclerosis 548 Orhun H. Kantarci, MD

67 • Non–Multiple Sclerosis Central Nervous System Inflammatory Disease 555

Nicholas L. Zalewski, MD, and Sean J. Pittock, MD

Questions and Answers 565 Suggested Reading 567

Section VI: Movement Disorders

68 • Classification and Approach to Movement Disorders 571

Paul E. Youssef, DO, Kenneth J. Mack, MD, PhD, and Kelly D. Flemming, MD

69 • Hypokinetic Movement Disorders: Parkinson Disease 576

Sarah M. Tisel, MD, and Bryan T. Klassen, MD

70 • Atypical Parkinsonian Syndromes 583

Shannon Y. Chiu, MD, and Jeremy K. Cutsforth-Gregory, MD

71 • Hyperkinetic Movement Disorders: Tremor and Myoclonus 593

Farwa Ali, MBBS, and Jeremy K. Cutsforth-Gregory, MD

72 • Hyperkinetic Movement Disorders: Chorea, Tic, and Dystonia 602

Elizabeth A. Coon, MD

73 • Cerebellar Disorders and Ataxias: Acquired Disorders 610

Anhar Hassan, MB, BCh

74 • Cerebellar Disorders and Ataxias: Inherited Disorders 618

Anhar Hassan, MB, BCh

75 • Childhood Movement Disorders 632

Paul E. Youssef, DO, and Kenneth J. Mack, MD, PhD

Questions and Answers 648

Suggested Reading 652

Section VII: Behavioral Neurology

76 • Syndromes of Cognitive Dysfunction 655 Shivram Kumar, MBBS, and Kelly D. Flemming, MD

77 • Mild Cognitive Impairment and Alzheimer Disease 662

Philip W. Tipton, MD, and Nilüfer Ertekin-Taner, MD, PhD

78 • Frontotemporal Dementias 672

Ryan Townley, MD, and Hugo Botha, MB, ChB

79 • Parkinsonism and Related Dementias 680 Rodolfo Savica, MD, PhD, Pierpaolo Turcano, MD, and Bradley F. Boeve, MD

80 • Nondegenerative Dementias and Encephalopathies 689

Eoin P. Flanagan, MB, BCh

Questions and Answers 699

Suggested Reading 702

Section VIII: Seizure and Epilepsy

81 • Classification of Epilepsy 705

Jamal F. Khattak, MD, and David B. Burkholder, MD

82 • Epidemiology and Pathophysiology of Epilepsy 719

David B. Burkholder, MD

83 • Evaluation of Seizures and Seizurelike Events 722

Angela M. Parsons, DO, and Joseph F. Drazkowski, MD

84 • Treatment of Epilepsy 731

Matthew T. Hoerth, MD

Questions and Answers 738

Suggested Reading 740

Section IX: Neuromuscular and Spine Disorders

85 • Myelopathies 743

Shivram Kumar, MBBS, and Kelly D. Flemming, MD

86 • Motor Neuron Diseases 752

Eric J. Sorenson, MD

87 • Peripheral Nerve Disorders 760

Sarah E. Berini, MD, and Nathan P. Staff, MD, PhD

88 • Neuromuscular Junction Disorders 772

Brent P. Goodman, MD

89 • Acquired Muscle Disorders 779

Teerin Liewluck, MD, and Margherita Milone, MD, PhD

90 • Inherited Muscle Disorders 785

Teerin Liewluck, MD, and Margherita Milone, MD, PhD

91 • Autonomic Disorders 798

Wolfgang Singer, MD

Questions and Answers 805

Suggested Reading 809

Section X: Clinical Disorders of the Cranial Nerves and Brainstem

92 • Neuro-ophthalmology: Visual Fields 813

Jacqueline A. Leavitt, MD

93 • Neuro-ophthalmology: Disorders of Visual Perception, Pupils, and Eyelids 821

Shivram Kumar, MBBS, and Kelly D. Flemming, MD

94 • Neuro-ophthalmology: Extraocular Muscles and Cranial Nerves III, IV, and VI 834

Paul W. Brazis, MD, and Kelly D. Flemming, MD

95

• Clinical Neurotology 841

Scott D. Eggers, MD

96 • Disorders of the Cranial Nerves and Brainstem 851

Kelly D. Flemming, MD

Questions and Answers 862

Suggested Reading 867

Section XI: Headache and Pain

97

• Introduction and Approach to Headache 871

Rashmi B. Halker Singh, MD, and Juliana H. VanderPluym, MD

98 • Primary Headache Disorders: Migraine, TensionType, and Chronic Daily Headaches 874

Mark A. Whealy, MD, and F. Michael Cutrer, MD

99 • Primary Headache Disorders: Trigeminal Autonomic Cephalalgias, Headaches With Specific Triggers, and Other Primary Headache Disorders 884

Juliana H. VanderPluym, MD, and Rashmi B. Halker Singh, MD

100 • Secondary Headache Disorders 892

Amaal J. Starling, MD, and David W. Dodick, MD

101 • Neuropathic Pain Syndromes 901

James C. Watson, MD

Questions and Answers 906

Suggested Reading 909

Section XII: Neuro- oncology

102 • Introduction to Neoplastic Disease 913

Alyx B. Porter, MD

103 • Glial Tumors 916

Akanksha Sharma, MD, and Derek R. Johnson, MD

104 • Nonglial Central Nervous System Tumors 931

Akanksha Sharma, MD, and Alyx B. Porter, MD

105 • Spinal Cord Tumors 949

I. Darin Carabenciov, MD, and Joon H. Uhm, MD

106 • Peripheral Nerve Sheath Tumors 956

Shivram Kumar, MBBS, and Michael W. Ruff, MD

108

• Neurologic Complications of Radiation Therapy and Chemotherapy 967

Gretchen E. Schlosser Covell, MD, Akanksha Sharma, MD, and Alyx B. Porter, MD

109 • Paraneoplastic and Other Autoimmune Neurologic Disorders 974

A. Sebastian Lopez Chiriboga, MD, and Andrew McKeon, MB, BCh, MD

Questions and Answers 982

Suggested Reading 986

Section XIII: Neurologic Infectious Disease

110

• Syndromic Approach to Neuroinfectious Diseases 989

Shivram Kumar, MBBS, and Kelly D. Flemming, MD

111

• DNA and RNA Viral Infections of the Nervous System 996

Michel Toledano, MD, and Allen J. Aksamit Jr, MD

112

• Retroviral Infections of the Nervous System 1009

Michel Toledano, MD, and Allen J. Aksamit Jr, MD

113

• Bacterial Infections of the Nervous System 1016

Michel Toledano, MD

114

• Fungal Infections of the Central Nervous System 1028

John W. Wilson, MD

115 • Parasitic Infections of the Central Nervous System 1037

Micah D. Yost, DO, and Michel Toledano, MD

116

• Prion Disorders: Creutzfeldt-Jakob Disease and Related Disorders 1044

Jeremy K. Cutsforth-Gregory, MD

Questions and Answers 1050

Suggested Reading 1054

Section XIV: Pediatric Neurology

117 • Malformation of the Brain, Skull, and Spine 1057

Lily C. Wong-Kisiel, MD

118

• Neurodevelopmental Disabilities 1071

107

• Metastatic Disease 962

Akanksha Sharma, MD, and Alyx B. Porter, MD

Katherine C. Nickels, MD

119 • Neurocutaneous Disorders 1077

Gesina F. Keating, MD

120 • Neurometabolic Disorders Associated With Disturbances of Small Molecule Metabolism 1092

Deborah L. Renaud, MD

121 • Lysosomal Storage Disorders 1106

Radhika Dhamija, MBBS, Erin Conboy, MD, and Lily C. Wong-Kisiel, MD

122 • Inherited Leukoencephalopathies 1114

Deborah L. Renaud, MD

123 • Mitochondrial Disease 1126

Radhika Dhamija, MBBS, Erin Conboy, MD, and Ralitza H. Gavrilova, MD

Questions and Answers 1134

Suggested Reading 1138

Section XV: Neurologic Disorders

Due to General Medical Illness

124 • Electrolyte Disturbances and Acid-Base Imbalance 1141

Sara E. Hocker, MD, and Ali Daneshmand, MD

125 • Neurologic Complications of Nutritional Disorders 1147

Brent P. Goodman, MD

126 • Neurologic Manifestations of Endocrine Diseases 1154

Shivram Kumar, MBBS, and Kelly D. Flemming, MD

127 • Neurologic Associations With Cardiac, Pulmonary, Renal, Hepatobiliary, and Hematologic Disease 1160

Shivram Kumar, MBBS, and Kelly D. Flemming, MD

128 • Toxins and Environmental Neurologic Injury 1170

Sara E. Hocker, MD, and Ali Daneshmand, MD

129 • Neurology and Pregnancy 1177

Lauren M. Jackson, MD, and Deena M. Nasr, DO

Questions and Answers 1185

Suggested Reading 1188

Section XVI: Sleep Disorders

130 • Polysomnography and Other Sleep Testing 1191

Pablo R. Castillo, MD

131 • Neuropharmacology of Sleep 1195

Pablo R. Castillo, MD

132 • Clinical Sleep-Related Breathing Disorders 1199

Vichaya Arunthari, MD, and Brynn K. Dredla, MD

133 • Hypersomnias and Sleep-Related Movement Disorders 1203

Vichaya Arunthari, MD, and Brynn K. Dredla, MD

134 • Circadian Disorders, Insomnia, and Parasomnias 1208

Brynn K. Dredla, MD, and Vichaya Arunthari, MD

Questions and Answers 1217

Suggested Reading 1220

Index 1221

Contributors

Maria I. Aguilar, MD

Consultant, Department of Neurology, Mayo Clinic Hospital, Phoenix, Arizona Present address: Centura Health, Colorado Springs, Colorado

Allen J. Aksamit Jr, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Farwa Ali, MBBS

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Gabriel Anders, DO

Fellow in Sleep Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: Truman Medical Center, Kansas City, Missouri

Catherine E. Arnold Fiebelkorn, MD

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Vichaya Arunthari, MD

Consultant, Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida; Assistant Professor of Medicine, Mayo Clinic College of Medicine and Science

Eduardo E. Benarroch, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Sarah E. Berini, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Jyoti Bhagia, MD

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Psychiatry, Mayo Clinic College of Medicine and Science

David F. Black, MD

Consultant, Department of Radiology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology and of Radiology, Mayo Clinic College of Medicine and Science

Bradley F. Boeve, MD

Chair, Division of Behavioral Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Hugo Botha, MB, ChB

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Paul W. Brazis, MD

Emeritus Professor of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, Florida

Jeffrey W. Britton, MD

Chair, Division of Epilepsy, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Robert D. Brown Jr, MD, MPH

Chair, Division of Stroke and Cerebrovascular Diseases, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

David B. Burkholder, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

I. Darin Carabenciov, MD

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota

Lucas P. Carlstrom, MD, PhD

Resident in Neurologic Surgery, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota

Richard J. Caselli, MD

Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Professor of Neurology, Mayo Clinic College of Medicine and Science

Pablo R. Castillo, MD

Consultant, Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida; Assistant Professor of Medicine and Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Tia Chakraborty, MD

Resident in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: Spectrum Health, Grand Rapids, Michigan

Shannon Y. Chiu, MD

Fellow in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: University of Florida Health, Gainesville, Florida

Erin Conboy, MD

Fellow in Clinical and Biochemical Genetics, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: Indiana University School of Medicine, Indianapolis, Indiana

Elizabeth A. Coon, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Amy Z. Crepeau, MD

Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Brian A. Crum, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

F. Michael Cutrer, MD

Chair, Division of Headache, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Jeremy K. Cutsforth-Gregory, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Ali Daneshmand, MD

Fellow in Neurocritical Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: Boston University Medical Campus, Boston, Massachusetts

Radhika Dhamija, MBBS

Consultant, Departments of Clinical Genomics and Neurology, Mayo Clinic, Scottsdale, Arizona; Associate Professor of Medical Genetics and Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

David W. Dodick, MD

Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Professor of Neurology, Mayo Clinic College of Medicine and Science

Joseph F. Drazkowski, MD

Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Professor of Neurology, Mayo Clinic College of Medicine and Science

Brynn K. Dredla, MD

Consultant, Division of Pulmonary, Allergy, and Sleep Medicine and Department of Neurology, Mayo Clinic, Jacksonville, Florida; Instructor in Neurology, Mayo Clinic College of Medicine and Science

Scott D. Eggers, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Stephen W. English Jr, MD

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Jacksonville, Florida

Nilüfer Ertekin-Taner, MD, PhD

Consultant, Department of Neurology, Mayo Clinic, Jacksonville, Florida; Professor of Neurology and of Neuroscience, Mayo Clinic College of Medicine and Science

Eoin P. Flanagan, MB, BCh

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Kelly D. Flemming, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Jennifer E. Fugate, DO

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Ralitza H. Gavrilova, MD

Consultant, Departments of Clinical Genomics and Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Medical Genomics and of Neurology, Mayo Clinic College of Medicine and Science

Brent P. Goodman, MD

Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Yong Guo, MD, PhD

Research Associate, Multiple Sclerosis Laboratory, Mayo Clinic, Rochester, Minnesota

Rashmi B. Halker Singh, MD

Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Anhar Hassan, MB, BCh

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Maximiliano A. Hawkes, MD

Fellow in Critical Care Neurology, Mayo Clinic School of Graduate Medical Education; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: University of Nebraska Medical Center, Omaha, Nebraska

Sara E. Hocker, MD

Chair, Division of Critical Care and Hospital Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Matthew T. Hoerth, MD

Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

E. Matt Hoffman, DO, PhD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Jery D. Inbarasu, MD

Fellow in Neurology, Mayo Clinic School of Graduate Medical Education and Instructor in Neurology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: Momenta Pain Care, Omaha, Nebraska

Lauren M. Jackson, MD

Resident in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota

Derek R. Johnson, MD

Senior Associate Consultant, Department of Radiology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology and of Radiology, Mayo Clinic College of Medicine and Science

David T. Jones, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology and of Radiology, Mayo Clinic College of Medicine and Science

Orhun H. Kantarci, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Gesina F. Keating, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Instructor in Neurology, Mayo Clinic College of Medicine and Science

Jamal F. Khattak, MD

Fellow in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: Henry Ford Health System, Detroit, Michigan

Dong Kun Kim, MD

Senior Associate Consultant, Department of Radiology, Mayo Clinic, Rochester, Minnesota

James P. Klaas, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Bryan T. Klassen, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Bhanuprakash Kolla, MD

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Psychiatry, Mayo Clinic College of Medicine and Science

Shivram Kumar, MBBS

Research Trainee, Department of Neurology, Mayo Clinic, Rochester, Minnesota Present address: East Tennessee State University, Johnson City, Tennessee

Simon Kung, MD

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Psychiatry, Mayo Clinic College of Medicine and Science

Maria I. Lapid, MD

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Professor of Psychiatry, Mayo Clinic College of Medicine and Science

Ruple S. Laughlin, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Jacqueline A. Leavitt, MD

Emeritus Member, Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota; Emeritus Professor of Ophthalmology, Mayo Clinic College of Medicine and Science

Jarrod M. Leffler, PhD, LP

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Psychology, Mayo Clinic College of Medicine and Science

Teerin Liewluck, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Melissa C. Lipford, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

A. Sebastian Lopez Chiriboga, MD

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Jacksonville, Florida; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Claudia F. Lucchinetti, MD

Chair, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Mary M. Machulda, PhD, LP

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Professor of Psychology, Mayo Clinic College of Medicine and Science

Kenneth J. Mack, MD, PhD

Chair, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology and of Pediatrics, Mayo Clinic College of Medicine and Science

Nicolas N. Madigan, MB, BCh, PhD

Associate Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Ahmed T. Makhlouf, MB, BCh

Resident in Psychiatry, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: Private practice, Boston, Massachusetts

Christopher R. Marcellino, MD

Resident in Critical Care Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota

Kari A. Martin, MD

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Scottsdale, Arizona; Assistant Professor of Psychiatry, Mayo Clinic College of Medicine and Science

Andrew McKeon, MB, BCh, MD

Consultant, Division of Clinical Biochemistry and Immunology and Department of Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Laboratory Medicine and Pathology and of Neurology, Mayo Clinic College of Medicine and Science

Keith A. Miller, MD

Fellow in Psychiatry, Mayo Clinic School of Graduate Medical Education and Instructor in Psychiatry, Mayo Clinic College of Medicine and Science, Rochester, Minnesota

Margherita Milone, MD, PhD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Robert J. Morgan III, MD, PhD

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Psychiatry, Mayo Clinic College of Medicine and Science

Deena M. Nasr, DO

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Katherine C. Nickels, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Mark W. Olsen, MD

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Psychiatry, Mayo Clinic College of Medicine and Science

Brian A. Palmer, MD

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Professor of Psychiatry, Mayo Clinic College of Medicine and Science Present address: Allina Health, Fridley, Minnesota

Angela M. Parsons, DO

Resident in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona Present address: OhioHealth Physician Group, Columbus, Ohio

Sean J. Pittock, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Angelina J. Polsinelli, PhD

Research Collaborator in Psychology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota

Alyx B. Porter, MD

Consultant, Department of Neurology, Mayo Clinic Hospital, Phoenix, Arizona; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Vijay K. Ramanan, MD, PhD

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Keith G. Rasmussen, MD

Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Professor of Psychiatry, Mayo Clinic College of Medicine and Science

Deborah L. Renaud, MD

Consultant, Departments of Neurology and Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology and of Pediatrics, Mayo Clinic College of Medicine and Science

Michael W. Ruff, MD

Senior Associate Consultant, Department of Neurology and Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Rodolfo Savica, MD, PhD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Eugene L. Scharf, MD

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Gretchen E. Schlosser Covell, MD

Fellow in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona Present address: Southern California Permanente Medical Group, San Diego, California

Billie A. Schultz, MD

Consultant, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine and Science

Akanksha Sharma, MD

Research Collaborator in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona Present address: University of Washington Palliative Medicine Fellowship Program, Seattle, Washington

Wolfgang Singer, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Eric J. Sorenson, MD

Chair, Division of Neuromuscular Medicine, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Nathan P. Staff, MD, PhD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Amaal J. Starling, MD

Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Philip W. Tipton, MD

Fellow in Movement Disorders, Mayo Clinic School of Graduate Medical Education and Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota

Sarah M. Tisel, MD

Resident in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address : Intermountain Healthcare SW, Saint George, Utah

W. Oliver Tobin, MB, BCh, BAO, PhD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology, Mayo Clinic College of Medicine and Science

Michel Toledano, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Ryan Townley, MD

Fellow in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Present address: University of Kansas Medical Center, Kansas City, Kansas

Jennifer A. Tracy, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Pierpaolo Turcano, MD

Resident in Neurology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida

Joon H. Uhm, MD

Chair, Division of Neuro-oncology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Juliana H. VanderPluym, MD

Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

James C. Watson, MD

Consultant, Departments of Neurology and Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota; Professor of Neurology and of Anesthesiology, Mayo Clinic College of Medicine and Science

Mark A. Whealy, MD

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Eelco F. M. Wijdicks, MD, PhD

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Professor of Neurology, Mayo Clinic College of Medicine and Science

Lindsy N. Williams, MD

Consultant, Department of Neurology, Mayo Clinic, Jacksonville, Florida; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

John W. Wilson, MD

Consultant, Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota; Professor of Medicine, Mayo Clinic College of Medicine and Science

Lily C. Wong-Kisiel, MD

Consultant, Departments of Neurology and Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; Associate Professor of Neurology and of Pediatrics, Mayo Clinic College of Medicine and Science

Micah D. Yost, DO

Senior Associate Consultant, Mayo Clinic Health System — Southwest Minnesota region, Mankato, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Paul E. Youssef, DO

Consultant, Department of Neurology, Mayo Clinic, Rochester, Minnesota; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Nicholas L. Zalewski, MD

Senior Associate Consultant, Department of Neurology, Mayo Clinic, Scottsdale, Arizona; Assistant Professor of Neurology, Mayo Clinic College of Medicine and Science

Neuroscience and Neuroanatomy I Section

Cerebrovascular Anatomy and Pathophysiologya

KELLY D. FLEMMING, MD

Introduction

The cerebrospinal vasculature originates at the aortic arch. The right brachiocephalic artery divides into the right common carotid artery and the right subclavian artery. The left common carotid and left subclavian arteries arise directly from the aortic arch. The 2 common carotid arteries bifurcate into the internal and external carotid arteries. The anterior circulation of the brain includes the distal branches from the internal carotid artery, including the anterior cerebral artery (ACA) and the middle cerebral artery (MCA). The vertebral arteries arise from the subclavians and join at the pontomedullary junction, forming the basilar artery. The vertebrobasilar system and distal branches are commonly known as the posterior circulation of the brain.

The deep and superficial veins of the brain ultimately drain into the venous sinuses and then into the jugular veins.

Reduced blood flow may result in symptoms and, potentially, irreversible damage. The core of ischemic damage is surrounded by tissue in the ischemic penumbra, an area with low cerebral blood flow that can be preserved if blood flow is restored in a timely manner or if collateral circulation is adequate.

Cerebral and Spinal Vasculature

Cerebral Arteries and Arterial Territories

From the aortic arch arise 3 major blood vessels (from right to left): brachiocephalic (innominate), left common carotid,

and left subclavian arteries (Figure 1.1). The brachiocephalic artery branches into the right subclavian and right common carotid arteries. The vertebral arteries branch from their respective subclavian arteries.

The common carotid arteries bifurcate into the internal and external carotid arteries at approximately the level of cervical vertebra 3 or 4. The external carotid artery supplies the face, scalp, jaw, and base of the brain. The middle meningeal artery enters the skull at the foramen spinosum. The extracranial internal carotid artery has no branches.

The internal carotid artery is divided into several segments (Table 1.1). The ophthalmic segment is intradural in more than 80% of people, whereas the petrous and cavernous segments are extradural (ie, below the dural ring). Although the intracranial carotid artery has several minor branches, the 3 main branches are (in order of occurrence): the ophthalmic, posterior communicating, and anterior choroidal arteries (Figure 1.2 and Table 1.2).

The internal carotid artery terminates, bifurcating into the ACA and the MCA. The ACA is composed of perforating and cortical arteries (Figure 1.3). Perforating or penetrating arteries (including the recurrent artery of Heubner and the medial lenticulostriate arteries) supply deep structures: the head of the caudate, the corpus callosum, and part of the fornix. Cortical branches of the ACA, named in accordance with where they terminate, supply the medial and parasagittal aspect of the hemispheres. The 2 ACAs are connected through the anterior communicating artery.

Figure 1.4 displays an example of a stroke in the distribution of the recurrent artery of Heubner.

a Portions previously published in Flemming KD, Brown RD Jr, Petty GW, Huston J III, Kallmes DF, Piepgras DG. Evaluation and management of transient ischemic attack and minor cerebral infarction. Mayo Clin Proc. 2004 Aug;79(8):1071-86; used with permission of Mayo Foundation for Medical Education and Research.

Abbreviations: ACA, anterior cerebral artery; MCA, middle cerebral artery; PCA, posterior cerebral artery

Right internal carotid

Right vertebral

Right common carotid

Right subclavian

Brachiocephalic (innominate) © MAYO 2014

Left internal carotid

Left vertebral

Left common carotid

Left subclavian

Aortic arch

Figure 1.1 Major Arteries Supplying the Supratentorial and Posterior Fossa Levels.

(From Benarroch EE, Cutsforth-Gregory JK, Flemming KD. Mayo Clinic medical neurosciences: organized by neurologic systems and levels. 6th ed. New York [NY]: Oxford University Press; c2018. Chapter 13, Vascular system; p. 435-71. [Mayo Clinic Scientific Press series]; used with permission of Mayo Foundation for Medical Education and Research.)

Table 1.1 • Segments of the Internal Carotid Artery

Segment Description

Cervical Has no branches

Petrous Enters the carotid canal of the temporal bone

Vidian and caroticotympanic arteries arise from this segment

Cavernous Traverses the cavernous sinus (along with cranial nerves III, IV, VI, V1, and V2)

Branches include the meningohypophyseal trunk, inferolateral trunk, and capsular arteries

Clinoid A small segment without branches

Ophthalmic Gives rise to the ophthalmic artery (supplies the retina) and superior hypophyseal artery

Communicating Two branches include the posterior communicating artery and the anterior choroidal artery

Table 1.2 • Main Branches of the Internal Carotid Artery System

Artery Structures Supplied by Artery

Ophthalmic

Anterior choroidal Eye (retina)

Optic tract, posterior limb of internal capsule, cerebral peduncle, choroid plexus, medial temporal lobe, globus pallidus, and lateral geniculate body

Posterior communicating

Anastomosis with the posterior cerebral artery

Anterior thalamoperforating arteries from the posterior communicating artery extend to anterior portions of the thalamus

Modified from Flemming KD. Cerebrovascular disease. In: Mowzoon N, Flemming KD, editors. Neurology board review: an illustrated study guide. Rochester (MN): Mayo Clinic Scientific Press and Florence (KY): Informa Healthcare USA; c2007. p. 435-84; used with permission of Mayo Foundation for Medical Education and Research.

Figure 1.2 Lateral Angiogram Showing the Major Branches of the Internal Carotid Artery. The labeled branches are the ophthalmic artery (A), the posterior communicating artery (B), the anterior choroidal artery (C), the middle cerebral artery (D), and the anterior cerebral artery (E).

The MCA also has perforating and cortical branches (Figure 1.5). Perforating branches such as the lateral lenticulostriates arise from the M1 segment (carotid terminus to the MCA bifurcation) and supply the basal ganglia and internal capsule. The cortical branches supply the lateral aspect of the cerebral hemisphere and anterior temporal lobe, the anterior division supplies the frontal lobe, and the posterior division supplies the parietal and temporal lobes.

Several anastomoses supply the collateral circulation of the brain. The circle of Willis (Figure 1.6) is an anastomotic ring connecting the anterior (carotid) and posterior (vertebrobasilar) systems. Only 30% to 35% of people have a full circle of Willis. Often the missing component is an ACA A1 segment (from the carotid terminus to the anterior communicating artery segment), the posterior communicating artery, or a posterior cerebral artery (PCA) P1 segment (from the basilar terminus to the posterior communicating segment). Collateral circulation can occur through leptomeningeal collaterals and external carotid or vertebral arteries to an intracranial artery. One of the common external carotid collaterals is an anastomosis with the ophthalmic artery.

The vertebral arteries arise from their respective subclavian arteries. The cervical segments of the vertebral arteries ascend through the transverse foramina of the

Recurrent artery of Heubner

Figure 1.3 Anterior Cerebral Artery (ACA). A, Medial aspect of the cerebral hemisphere with cortical branches of the ACA. B, Coronal section of the cerebral hemispheres with cortical and penetrating branches of the ACA. A1 and A2 indicate ACA segments; ACom, anterior communicating artery.

(From Flemming KD. Cerebrovascular disease. In: Mowzoon N, Flemming KD, editors. Neurology board review: an illustrated study guide. Rochester [MN]: Mayo Clinic Scientific Press and Florence [KY]: Informa Healthcare USA; c2007. p. 435-84; used with permission of Mayo Foundation for Medical Education and Research.)

vertebral bodies from C6 to the axis, with minor meningeal branches arising from this segment. The vertebral arteries enter the foramen magnum and pierce the dura. The intracranial (intradural) segments extend from the medulla to the pontomedullary junction (Figure 1.7), where the 2 vertebral arteries join, forming the basilar artery. Commonly, 1 vertebral artery is dominant or larger in diameter along its entire length. Also common is an intracranial vertebral artery that ends with the posterior inferior cerebellar artery and does not contribute to the basilar artery. The branches of the intracranial vertebral