PROFESSOR DIAMOND: Let's
continue with our arteries
and go then to the
vertebral arteries.
So why vertebral?
If we have our heart
with our ascending--
lets do it in red
while we've got it.
Ascending aorta coming
out into the subclavian
here after the arch
our brachiocephalic,
and then our subclavian.
The first branch coming
off here is what?
Pardon?
Common carotid, right.
So that's common carotid.
So you go one beyond the common
carotid on the subclavian
and you'll come
to the vertebral.
So our second one
is our vertebral.
It has an unusual pathway as it
goes up the neck to the brain.
It will go through--
let's put in-- this
will be our skull
and our destination is
this big foramen here.
What do we call it?
Foramen magnum, good.
Foramen magnum.
And then we have the cervical
vertebrae 1, 2, 3, 4, 5, 6, 7,
do I put an 8th one?
No, all right, and their
transverse processes.
Remember the transverse
processes on the vertebra.
Little ones up here, these
are transverse processes.
So here we have these
vertebral arteries coming off
and they will go through foramen
in the transverse processes
as they go up to
the foramen magnum.
Now who can tell me why we
have that kind of adaptation?
These would be
vertebral arteries.
These were all our
cervical vertebra.
Rather an interesting
arrangement.
Just twist your head like
this, like you do all day long,
why do you think those vessels
are within those processes?
It must be advantageous.
I'll leave that to your
imagination and some time
you'll tell me.
All right let's continue on
then with the subclavian.
The subclavian then
will come around
and as it comes
to the axilla it's
going to change its name
to the axillary artery.
As it goes down to the arm what
are you going to call it there?
The brachial artery.
And how many have had
their blood pressure taken?
Got some hands.
So this is where you
take your blood pressure,
on the brachial artery.
And just about a
centimeter below the elbow
the brachial artery branches
into the radial and ulnar
arteries.
So this will be about one
centimeter below elbow.
And we'll have them, which
is going to be on the outside
and which on the medial side?
Which is on the lateral side?
Radial artery, ulnar.
And then the hand will have the
palmar arch and the digitals.
Palmar arch and digitals
in the fingers and thumb.
So that gives-- roughly
where do we take our pulse?
We take it distal where?
Yes.
So x equals area to take
pulse distal radial.
You take it with your
thumb or with your fingers?
With your fingers of course.
So let's now follow
the descending aorta.
Let's start at the top of a
page because I want to go clear
down to the leg if possible.
So we have our arch.
And then we have the
descending aorta.
And we know where the
diaphragm is now as long
as our heart is there because
we know the pericardium will
attach to the diaphragm.
So you can start putting
things together now
as we get more systems.
So this will give us
the thoracic aorta here.
And inferior to
the diaphragm we'll
have the abdominal aorta, all
part of the descending aorta.
And within the thoracic we
have the esophageal artery
coming off.
We have the intercostals,
and we have the bronchials.
So this will be
esophageal letting
you know the esophagus is
passing through this area.
We had it in the
mediastinum, and then we
have the intercostals
to get all the muscles
between the costal
cartilages and ribs.
And then we have the bronchial
arteries going where?
Pardon?
Lung sure.
So now we come down to
the abdominal aorta.
And at the abdominal aorta we
have many vessels coming off,
some are paired, and
some are not paired.
See if we have room for
them over there-- well
we'll put them here.
We have-- these
are the abdominal.
We'll have first the unpaired,
which will be the celiac--
celiac and the celiac will be
supplying blood to your liver,
very rich in blood
to your stomach,
to your spleen, also rich
in blood, to pancreas,
as examples.
So many of your
abdominal organs.
So the celiac will be the
first to come off here.
Then the second coming
off, it's unpaired,
will be the superior
mesentery, superior mesentery.
So it will supply the
small intestine and part
of the large intestine.
Large intestine
we call the colon.
And so we'll have a colon
form sort of picture frame
around your abdominal wall.
You have an ascending,
transverse, descending colon.
So if we put in our colon
like this, this is ascending,
then it goes across
the abdominal cavity,
then it goes down,
then it comes over,
so it can get to the rectum.
So the part that the
superior mesentery
will be the up to half
of the transverse colon.
This will be supplied
by superior mesentery.
And we'll put our superior
mesentery in here.
And our next one is
the inferior mesentery.
To use-- inferior
mesentery and it
will supply the rest of the
intestine and the rectum.
Rest of large
intestine and rectum.
So this, if you're going to be
an abdominal surgeon like we
had speaking to
us the other day,
if they have to take out part
of a colon because of cancer
whether they take out part
of the transverse or--
we had an automobile
accident reported
and they'd crushed
the whole transverse,
so they had the seat belt
going across there right.
So they had to sew the
ascending to the descending.
They have to know
the blood supply
when they're cutting these out.
So number three, we're going to
put it down a little further,
leave space here.
So these are your unpaired
arteries off the abdominal.
Now we have the paired arteries.
The first paired will be the
renal arteries to the kidney.
So let's make it four will
be the renal arteries.
As the name applies,
renal is kidney
so we know where they're going.
And the vascular
surgeon will be alluding
to these when he comes.
So be sure that you keep
these orators in place.
He'll be talking about the
renals, how they use them
for landmark.
So here's my renal
coming off here.
And my next one will be
the gonadal arteries.
Gonadal arteries, we
have the ovarian arteries
going to the ovaries.
And the testicular arteries
going to the testis.
And-- so whether
it's male or female
we just call it gonadal here.
It will be coming--
they'll be coming off
as paired arteries.
Make this a little longer.
Five for gonadal.
So you can see, if this
is going to the testis,
the gonadal is going to be
long, the testicular artery,
to go all the way to
the testis versus just
to the pelvic cavity if
it's the ovarian artery.
So that gives us the branches
off of our abdominal aorta.
You'll see some
pictures in 131a where
they'll have an aneurysm
of the abdominal aorta
usually occurs below the renals
and normally a one inch aorta
will be swollen to five inches.
And they can see it when you
lie down, it pulses out here.
Phenomenal what this artery
can take and then be mended.
So at L4 the abdominal aorta
divides into a common iliac,
into the two common iliacs.
This is a common iliac.
So you can feel where
L4 is roughly there's
going to be right about there.
So you transfer
that around to see
where you're
getting the division
of your abdominal aorta.
And the common iliac will
go into an internal iliac
and an external iliac.
This is internal
iliac and it will
be going to the pelvic organs.
And the external iliac--
external iliac will go into--
become the femoral artery.
Becomes femoral artery.
What landmark do you think it
becomes, the femoral artery?
What do you have coming
from here, to here,
at this region of the groin?
The inguinal ligament.
So we've learned that
the femoral artery
is on the inferior part
of the inguinal ligament.
So from here on, this is
going to be femoral artery.
Now the femoral artery
will go down the thigh
and at the posterior
aspect of the knee--
it's going down
by posterior knee
it will be called a popliteal.
Popliteal artery, do you
know what popliteal means?
Not going to help you any.
It means ham.
Well, if they're calling
these hamstrings,
they call the artery
down there popliteal.
I didn't name them.
I'm just telling you why
you get such funny names.
Then we go on down,
that's posterior knee,
and then we're going to
divide into an anterior
tibial and a posterior tibial.
Anterior tibial, posterior
tibial, on the other side,
and so forth.
And you'll get your
types of arches.
They're similar but not
identical and on down
to your toes.
But I think why--
I want to be sure that you
know the anterior tibial.
How many have ever
had surgery where
you're out for quite some time?
One or two.
If they want to be sure that
the feet are getting blood
supply after a long, prolonged
hours, and hours of surgery,
they take the pulse on
the distal anterior tibial
to be certain circulation
is adequate after surgery.
You remember them doing that?
No.
All right.
So that gives you a bird's
eye view of your arteries.
Obviously there are
many, many, many, more
than we have time to
give in this class.
So let's turn to veins then.
And veins are not quite as
regularly arranged as arteries
nor are their coats as regular.
Veins have three coats to.
And we can say how they
differ from arteries.
We're not going to
go into all of them.
One, they are thinner.
They have a larger lumen.
And what's another
characteristic
of veins that you
don't find in arteries?
They have valves.
I mean you've got this blood
coming up from your legs
so in the extremities
the veins have valves.
Have you ever tried
to see your valves?
Put your hands down, see if
they really have to be down
it's kind of hard when
you're sitting on the floor.
But if you're sitting there
and then see if they swell.
In my body, I've got
huge veins in my hand
so I can push out the blood and
then let it come back in again.
It's stopped by the--
by the valve.
You don't have such
large veins I'm sure,
but they're good for something.
The students often
come to office hours
and they want to see it close.
See those veins because you can
see the valve is way up here.
I've pushed out the blood,
there's no blood in that valve.
I don't know what
you can see but then
it all comes back again right.
But it lets you know, in the
extremities, you have valves.
So blood in veins
is pushed along
by contraction of
our skeletal muscles
that's why we get up
and walk after sitting
in a plane for a long time.
The legs begin to swell.
So the skeletal
muscles of the leg--
they help propel blood in veins.
That's why you exercise.
You want to keep
strong healthy muscles
and strong healthy veins.
So where does all of
the blood from the lower
extremities and lower trunk
collect to get into the heart?
Inferior vena cava, sure.
Where does all the
blood from the head
and the upper extremities
collect to get into the heart?
Superior vena cava,
simple little thing
that you want to
review every now
and then to keep these in mind.
They-- she's asking about the
valves in the extremities.
They look like semilunar valves.
I've only seen them
with two flaps.
The ones I'll show
you today for--
in the slides, will just have
two flaps, one on each side.
All right, no it's
a good question.
No you don't want
all the baggage
that you have in the
heart for a valve.
You want a simple one that's
going to go against the wall
when the blood goes up and
when it tries to come back it
flaps back out.
So what we want to look at
now are the arrangements
for getting blood
out of the brain.
So in the brain
venous blood is going
to go into veins,
nothing unusual.
But then it's going to go into
venous sinuses, something new.
Venous sinuses.
And from venous sinuses it's
going to leave the brain
and go into the internal
jugular vein outside the skull.
So what we want to discuss
now is to introduce you
to these important structures.
What are venous sinuses?
There are channels for venous
blood in folds of dura,
dura mater folds I put, for lack
of a better term, dura mater.
What is dura mater?
What does it mean?
What's dura?
Hard, what's mater?
Mother, hard mother.
We can tell little
stories about that
because we have the pia mater.
And what's the pia mater?
Gentle mother.
I was talking with
little kids once
and they said where's
the mad mother?
You know where they were
coming from that day.
So dura mater is sort
of like a bathing cap.
I mean, we've all
seen bathing caps
that hug the scalp
when you go swimming.
If you just take off
the scalp and the hair
and put one of
those on the brain,
you've got this cap of
thick connective tissue.
But it has many variations too.
So it's a thick ct
covering over brain.
So how do we put venous
sinuses into this?
Let's take what we call a
coronal section of the head.
Coronal section is cutting
straight across this way.
So this will be a coronal
section of the head.
And we'll put a brain in
it, in its simplest form.
So we'll have our dura mater--
there are other membranes,
I'm not going to put those in.
I'm just going to give
you the dura mater.
So one layer of
the dura mater is
adherent to the
inside of the skull.
This equals brain.
This equals dura mater.
And there are actually two
layers of dura mater here.
But when we get to the
midline they separate.
These two are closely adherent.
And here is where we have
formed a venous sinus.
It's between the
layers of dura coming
across the top of your head.
Part of this dura will come down
between the hemispheres here.
Later we'll put in
the other membranes,
we are just doing the dura.
And this sinus that
we've developed here,
with venous blood
flowing between the dura,
is the superior
longitudinal sinus.
So let's take now a midsagittal
cut, right down the center
of the head.
And we'll have our
superior sagittal
of superior longitudinal
sinus running up here
in it's fold of dura.
And then we had the dura
that was coming down here.
So we have to put
this coming down here.
It's coming down lets see
how we want it, like this.
So all of this is dura
between the hemispheres.
What's it look like?
Looks like a sickle that
they use to cut the hay,
have your handle
here, sharp edge.
It's called a falx,
which is sickle, falx--
sorry, F-A-L-X, cerebri.
And that's just the
dura mater here.
This is a falx cerebri here.
In this view, crosswise, and
this is it in this manner.
What do we see in
the free edge here?
We see the inferior
longitudinal sinus.
Blood flow is going in this
direction, through these.
This as my inferior
longitudinal sinus.
All blood in the brain will
be running into these sinuses
eventually.
When you study it
carefully you see
what veins are leading into
these inferior longitudinal
sinus.
So we're flowing back.
And we're not going
to give all of these,
but we'll put in here
the straight sinus, which
will be connecting my
superior with my inferior.
This is the straight sinus.
Ever heard of these before?
Ever thought this is going
on inside your skulls?
Now we have what's called
the tent of the cerebellum.
Separating the
cerebral hemispheres
is a layer of dura
separating the cerebellum.
So we're going to put in this
tentorium cerebelli here.
You have to imagine that the
cerebellum is underneath.
But just to give it it's
appropriate name here,
this is called the tentorium.
It's dura between
cerebrum and cerebellum.
Ten- torium.
A very useful landmark,
cerebellum, very simple.
And when these two
sinuses here run together,
our straight and our superior--
I'm doing this simply,
it's actually more complex
but I'm doing it simply.
Along the edge of
the skull where
the tentorium comes we have
what's called a trance--
a transverse sinus.
It's going to come out
as a transverse sinus.
Transverse sinus all getting
blood from the brain.
You saw the picture
of all the blood that
was getting into the brain.
And now it's going to
come up here and make
an S shape, sigmoid sinus.
Sigmoid sinus.
And this, finally, will go out
through the jugular foramen.
Jugular foramen, jugular
means neck, jugular foramen.
And become the
internal jugular vein
that's going to go down to
your superior vena cava.
Internal jugular vein.
So you could see
how all this blood--
you can picture it
in your own head.
As it's coming around, sideways
and then down and coming out.
And see when you
get a concussion
and you get a subdural hematoma.
Know two of my friends have just
died from subdural hematomas
because they're
elderly and they fell.
So keep your bodies healthy
so when you fall you can--
I see you sitting
up straight now.
Anyhow very serious
things can happen.
But you'll learn all that
in your clinical neurology.
But this gives you how
the blood leaves the brain
and goes back into circulation.
There's one other
sinus that I think
you should know because
it's an important one.
I'm just going to put it in--
in here like this because
it's right on each side
of the pituitary.
So I'm going to put an x there
because I can't draw much
in there.
This is called the
cavernous sinus.
Cavernous sinus, they
are folds of dura
on each side of
the sella turcica.
After Cavernous sinus.
So they'll be folds of dura
lateral to sella turcica.
So you know where we are now.
Terribly important area, but for
now, we'll just put it there.
So at least you've heard of it,
where the cavernous sinus is.
So it gives you an idea of the
complexity of the blood supply
leaving the brain, going
into these venous sinuses.
So now let's just
take a little bit
by looking at veins
at extremities
where we've shown you already
that they have valves.
I'm only going to
take a few veins here.
So veins of extremities.
So let's just take upper--
the median cubital vein.
Who knows the
median cubital vein?
Where is your
median cubital vein?
It's right here in the
anterior aspect of your elbow.
It's the one that you use if
you're going to give blood.
They withdraw blood
from the median cubicle.
This is anterior
elbow, withdraw blood,
and you get the infusion
of blood there right.
If you ever had to have
either blood or saline
or anything injected
into your body,
they'll put it in the median.
And so infuse blood here.
All right just a few veins
in the lower extremity.
Lower extremity, let's
just take two examples.
Let's take a deep
femoral, so you can
imagine where it's going to be.
You've seen the femoral
artery in the thigh.
This is going to be the
deep vein in the thigh.
And it can be subject to a
condition called phlebitis.
How many have ever
heard of phlebitis?
Nobody, phlebitis is
inflammation of the vein.
So you can picture a
veins wall because you
know it has the three
coats, just like the artery,
but they're not as well formed.
We'll show a
picture in a moment.
And, in phlebitis, with the
inflammation of the vein,
clots are formed.
For the leg gets painful.
When do they frequently
see phlebitis?
After surgery.
And then you're immobile
for weeks or so, don't move.
Phlebitis can occur.
They can go in and tie
off the deep femoral vein
and you have to set up all
new, what we call collateral
circulation, terribly painful.
If we have a deep vein,
we have superficial vein.
The superficial vein
of the lower extremity.
Super ficial vein
lower extremity--
anybody know the name of it?
It's the-- thank you.
Longus vein, in your body.
The saphenous vein, saphenous.
Never heard of it?
It's the longest vein in body.
It's coming from
the medial aspect
of the arch of your foot.
Can't read that
very well, sorry.
Medial arch of foot.
Where is it going to empty
into the femoral vein?
Where is your femoral
vein on the surface?
Oh, femoral triangle right.
I've said femoral triangle 20
times if I've said it once.
All right, so it's going
to enter femoral vein
at femoral triangle.
Remember femoral triangle,
navel, N-A-V-E-L.
What did our V stand for?
Vein right.
Review, review,
review because this,
when you go into the
field, it's essential.
So what did they use the
saphenous vein for today?
Anybody know anybody
who's had bypass surgery?
Yeah, lots of us.
Professor Wake here
had bypass surgery.
Went down, cut out a piece
of his saphenous vein.
Use that to replace
his carotid artery--
his coronary artery.
Something to think about.
Saphenous vein used
for bypass surgery.
Oh are we finished?
No, I-- I'll do this because
I want you to appreciate this.
Because somebody in
bioengineering right now
is trying to use stem cells
to grow endothelial cells
and smooth muscle cells to
make artificial arteries
because you're putting a
vein where an artery-- let's
look at a vein.
Slides please.
See if you would
like a vein being
supplemented for your arteries.
Here we are with the arteries
we've just discussed.
We have our internal--
our common carotid and our
external internal carotid.
They won't show the
subclavian coming off here.
I mean the vertebrals but
we'll just take this one.
This is a subclavian
coming down to the axillary
around the armpit, the axilla.
The brachial, that's what
branching into radial, ulnar,
palmar arch, and digitals.
And then we had the arteries
from the descending aorta.
They don't show the branches
of the thoracic here
but they have a celiac
and they show the--
this would be the superior
mesentery, the renals,
the gonadals, the inferior
mesentery coming down
to the common iliac,
the internal iliacs,
the external iliacs
will become femorals,
popliteal down to posterior
tibial, anterior tibial,
down to arches and digitals.
Next one, next one please.
Now these are just cross
sections with a scanning EM
to see blood vessels.
Beautiful, clear blood vessels.
Next one, next one please.
This is outside of a scanning
EM and this is a Perry site.
It's thought that Perry
sites pick up things that
are leaking from blood vessels.
The next slide will
be a unique one
that you won't find anywhere.
In the next slide.
This is a blood vessel in
a Alzheimer individual.
These are the multiplication of
parasites which tell us about
leaky blood vessels
in Alzheimer's.
This was my husband's work at
UCLA and he showed this decades
ago and he told me yesterday
this has become fashionable now
that leaky blood vessels may
play a big role in Alzheimer's.
But you can see these parasites.
In the next one.
And then this is our
descending aorta.
It'll be giving off
the intercostals.
It won't show everything.
Now we see the
diaphragm coming down
to the abdominal aorta with
our celiac and our mesenteries,
our renals coming off here.
In the next one.
Now this is an artery.
You've seen this.
What kind of artery,
elastic or muscular?
Muscular, good for you.
Your internal elastic
membrane, your muscle,
and your connective tissue.
Next one.
What's that?
Large lumen, thin
wall, it's a vein.
Would you like a vein
substituting for an artery?
You would if your coronary
is blocked, today's world.
But hopefully that
someday they'll
have replaced arteries rather
than using the saphenous vein.
In the next one.
And this is a vein.
It's a larger one.
This is smooth muscle,
connective tissue.
Next one
Now this is a vein with valves.
You asked about valves.
These are endothelial
flaps of connective tissue.
And they're sort of like pockets
on a coat, if I had worn a coat
today, you know you
have your pocket when
you're want to go down.
My hands are too dirty to
put them in my pockets.
But the flap goes out
when the blood goes
by the pocket goes sideways.
You can see how that would work.
So we have two flaps
here, in a vein.
Next one
And this just shows the veins.
They look pretty
rich but you could
see how they're coming up for.
You have the popliteal vein.
Here's your long saphenous
coming up from down here,
all the way up to
your femoral here.
You have your external iliac
vein, internal as we said.
Pretty much they
follow the arteries.
But here you'll have
your inferior vena cava.
Here you have your
superior vena cava.
And the next one
shows, next one please.
Here's the saphenous vein.
See how big it is.
When you get varicose veins it
frequently swells tremendously,
but they feel they
could get rid of this
because there are so many
other veins to take blood
from the foot.
So they'll take a piece
of vein but you never
take a piece of an artery.
In the next one.
And here it is
coming all the way up
into our femoral triangle,
here, at the superior aspect
of the thigh.
And the next one.
And these then are the
traverses for the venous blood
in the skull.
We'd have the superior
longitudinal sinus,
the inferior longitudinal
sinus, the straight sinus,
the transverse sinus.
See they've taken out the
tentorium cerebelli here.
It's on the ridge,
and then it'll
curve around in
the sigmoid sinus
and go out through
the jugular foramen.
Just one more I think, next one.
This shows the transverse
sinus, as I showed you,
with a coronal section.
They call it either
superior sagittal,
or superior
longitudinal but we'll
learn more when we talk about
cerebral spinal fluid coming
back into this sinus.
All right.
