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THORACIC WALL
MEDIASTINUM
CARDIVASCULAR SYSTEM
12. 10.2012
Kaan Yücel
M.D., Ph.D.
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Dr.Kaan Yücel
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Thoracic wall, mediastinum & CVS
THORACIC WALL
The thorax is the part of the body between the neck and abdomen. Posterior surface is formed by the 12
thoracic vertebræ and the posterior parts of the ribs. Anterior surface is formed by the sternum and costal cartilages.
Lateral surfaces are formed by the ribs, separated from each other by the intercostal spaces, eleven in number,
which are occupied by the intercostal muscles and membranes. The true thoracic wall includes the thoracic cage and
the muscles that extend between the ribs as well as the skin, subcutaneous tissue, muscles, and fascia covering its
anterolateral aspect. The same structures covering its posterior aspect are considered to belong to the back. The
mammary glands of the breasts lie within the subcutaneous tissue of the thoracic wall.
The thoracic skeleton forms the osteocartilaginous thoracic cage, which protects the thoracic viscera and some
abdominal organs. The thoracic skeleton includes 12 pairs of ribs and associated costal cartilages, 12 thoracic
vertebrae and the intervertebral (IV) discs interposed between them, and the sternum.
One of the principal functions of the thoracic wall and the diaphragm is to alter the volume of the thorax and
thereby move air in and out of the lungs.
During breathing, the dimensions of the thorax change in the vertical, lateral, and anteroposterior directions.
Elevation and depression of the diaphragm significantly alter the vertical dimensions of the thorax. Depression
results when the muscle fibers of the diaphragm contract. Elevation occurs when the diaphragm relaxes.
The breasts are the most prominent superficial structures in the anterior thoracic wall, especially in women.
The breasts (L. mammae) consist of glandular and supporting fibrous tissue embedded within a fatty matrix,
together with blood vessels, lymphatics, and nerves.
MEDIASTINUM
The mediastinum (Mod. L. middle septum, L, mediastinus, midway), occupied by the mass of tissue between
the two pulmonary cavities, is the central compartment of the thoracic cavity. Mediastinum extends from superior
thoracic aperture superiorly to the diaphragm inferiorly and from sternum and costal cartilages anteriorly to to the
bodies of the thoracic vertebrae posteriorly. The mediastinum is divided into superior and inferior parts for purposes
of description.
Superior mediastinum: Superior to sternal angle, Inferior mediastinum: Inferior to sternal angle. Inferior
mediastinum has three parts:
Anterior mediastinum: Between the anterior surface of pericardium and posterior surface of the sternum
Middle mediastinum: Pericardium, heart and beginings of the great vessels emerging from the heart lie here
Posterior mediastinum: Lies posterior to the pericardium and diaphragm
CARDIOVASCULAR SYSTEM
The heart has two sides. The right side of the heart (right heart) receives poorly oxygenated (venous) blood
from the body through the superior vena cava (SVC) and inferior vena cava (IVC) and pumps it through the
pulmonary trunk and arteries to the lungs for oxygenation. The left side of the heart (left heart) receives welloxygenated (arterial) blood from the lungs through the pulmonary veins and pumps it into the aorta for distribution
to the body. The four chambers of the heart are: right and left atria and right and left ventricles. The atria are
receiving chambers that pump blood into the ventricles (discharging chambers). The synchronous pumping actions
of the heart's two atrioventricular (AV) pumps (right and left chambers) constitute the cardiac cycle.
The coronary arteries, the first branches of the aorta, supply the myocardium and epicardium. The right and
left coronary arteries arise from the corresponding aortic sinuses. The heart is drained mainly by veins that empty
into the coronary sinus and partly by small veins that empty into the right atrium. The sinuatrial (SA) node is the
pacemaker of the heart. The SA node initiates and regulates the impulses for the contractions of the heart. The
atrioventricular (AV) node distributes the signal to the ventricles through the AV bundle.
The pericardium is a fibroserous membrane that covers the heart and the beginning of its great vessels. The
pericardium is a closed sac composed of two layers. The tough external layer, the fibrous pericardium, is continuous
with the central tendon of the diaphragm. The internal surface of the fibrous pericardium is lined with a glistening
serous membrane, the parietal layer of serous pericardium.
The right and left brachiocephalic veins are formed by the union of the internal jugular and subclavian veins.
They unite to form the SVC and shunt blood from the head, neck, and upper limbs to the right atrium.
The ascending aorta begins at the aortic orifice. Its only branches are the coronary arteries. The arch of the
aorta (aortic arch), the curved continuation of the ascending aorta. The usual branches of the arch are the
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brachiocephalic trunk, left common carotid
artery, and left subclavian artery. The brachiocephalic trunk, the first 2
and largest branch of the arch of the aorta divides into the right common carotid and right subclavian arteries.
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1. THORACIC WALL
The thorax is the part of the body between the neck and abdomen. Posterior surface is formed by the 12
thoracic vertebræ and the posterior parts of the ribs. Anterior surface is formed by the sternum and costal
cartilages. Lateral surfaces are formed by the ribs, separated from each other by the intercostal spaces, eleven in
number, which are occupied by the intercostal muscles and membranes.
The floor of the thoracic cavity is deeply invaginated inferiorly (i.e., is pushed upward) by viscera of the
abdominal cavity.
Regions
•
Thoracic wall
•
Thoracic cavity
The thorax includes the primary organs of the respiratory and cardiovascular systems. The majority of the
thoracic cavity is occupied by the lungs, which provide for the exchange of oxygen and carbon dioxide between
the air and blood. Most of the remainder of the thoracic cavity is occupied by the heart and structures involved
in conducting the air and blood to and from the lungs. Additionally, nutrients (food) traverse the thoracic cavity
via the esophagus, passing from the site of entry in the head to the site of digestion and absorption in the
abdomen.
THORACIC WALL
The true thoracic wall includes the thoracic cage and the muscles that extend between the ribs as well as the
skin, subcutaneous tissue, muscles, and fascia covering its anterolateral aspect. The same structures covering its
posterior aspect are considered to belong to the back. The mammary glands of the breasts lie within the
subcutaneous tissue of the thoracic wall.
The domed shape of the thoracic cage provides its components enabling to:
•
Protect vital thoracic and abdominal organs (most air or fluid filled) from external forces.
•
Resist the negative (sub-atmospheric) internal pressures generated by the elastic recoil of the lungs and
inspiratory movements.
•
Provide attachment for and support the weight of the upper limbs.
•
Provide the anchoring attachment (origin) of many of the muscles that move and maintain the position of
the upper limbs relative to the trunk, as well as provide the attachments for muscles of the abdomen, neck, back,
and respiration.
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The thorax is one of the most dynamic regions of the body. With each breath, the muscles of the thoracic wall—
working in concert with the diaphragm and muscles of the abdominal wall—vary the volume of the thoracic
cavity, first by expanding the capacity of the cavity, thereby causing the lungs to expand and draw air in and
then, due to lung elasticity and muscle relaxation, decreasing the volume of the cavity and causing them to expel
air.
SKELETON OF THORACIC WALL
The thoracic skeleton forms the osteocartilaginous thoracic cage, which protects the thoracic viscera and
some abdominal organs. The thoracic skeleton includes 12 pairs of ribs and associated costal cartilages, 12
thoracic vertebrae and the intervertebral (IV) discs interposed between them, and the sternum. The ribs and
costal cartilages form the largest part of the thoracic cage; both are identified numerically, from the most
superior (1st rib or costal cartilage) to the most inferior (12th).
Figure 1. Thoracic cage (skeleton)
http://www.tutorvista.com/content/biology/biology-iv/locomotion-animals/thoracic-cage.php
THORACIC APERTURES
While the thoracic cage provides a complete wall peripherally, it is open superiorly and inferiorly. The
superior opening is a passageway that allows communication with the neck and upper limbs. The larger inferior
opening provides the ring-like origin of the diaphragm, which completely occludes the opening.
Structures that pass between the thoracic cavity and the neck through the superior thoracic aperture:
Trachea
Esophagus
Nerves, and vessels that supply and drain the head, neck, and upper limbs.
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Figure 2. Superior and inferior thoracic apertures
http://quizlet.com/4653983/2-thorax-i-flash-cards/
JOINTS OF THORACIC WALL
Although the joints between the bones of the thorax have limited movement ability, the whole outcome of these
movements permit expansion of the cavity during inspiration. During inspiration, the thoracic cavity can expand
in antero-posterior, vertical and transverse dimensions.
1. Costa transverse joints
2. Sterno costal joint
3. Costachondralis joint
4. Intercondral Joints
5. Sternal Joints
MUSCLES OF THORACIC WALL
Some muscles attached to and/or covering the thoracic cage are primarily involved in serving other
regions. Several (axioappendicular) muscles extend from the thoracic cage (axial skeleton) to bones of the upper
limb (appendicular skeleton). Muscles, such as sternocleidomasteoid muscle, abdominal muscles, pectoral
muscles, function as accesory muscles of respiraton and work in forced respiration; when the person needs to
breathe in and out more than usual; 100 meter sprinters, patients with respiratory problems.
Muscles of the thoracic wall
–
Serratus posterior muscles
–
Levator costarum muscles
–
Intercostal muscles (External, internal and innermost)
–
Subcostal muscle
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Transverse thoracic muscle
These muscles either elevate or depress the ribs helping to increse the volume of the thoracic cavity.
The diaphragm is a shared wall (actually floor/ceiling) separating the thorax and abdomen. Although it has
functions related to both components of breathing, expiration is considered as a passive process.
Figure 3. Muscles of the thoracic wall
http://by411.blogspot.com/2011/03/breathing.html
When we need more air while breathing (running fast or problems in the lung), we used the accessory
respiratory muscles such as pectoralis major muscle, sternocleidomastoid muscle, trapeziu muscles. Abdominal
muscles are accessory muscles for expiration. These muscles extend the space so that more air can enter.
VASCULATURE OF THORACIC WALL
In general, the pattern of vascular distribution in the thoracic wall reflects the structure of the thoracic cage—
that is, it runs in the intercostal spaces, parallel to the ribs.
NERVES OF THORACIC WALL
The 12 pairs of thoracic spinal nerves supply the thoracic wall. As soon as they leave the intervertebral
(IV) foramina in which they are formed, the mixed thoracic spinal nerves divide into anterior and posterior
(primary) rami or branches. The anterior rami of nerves T1-T11 form the intercostal nerves that run along the
extent of the intercostal spaces. The intercostal nerves pass to and then continue to course in or just inferior to
the costal grooves, running inferior to the intercostal arteries (which, in turn, run inferior to the intercostal
veins). The neurovascular bundles (and especially the vessels) are thus sheltered by the inferior margins of the
overlying rib.
MOVEMENTS OF THE THORACIC WALL
One of the principal functions of the thoracic wall and the diaphragm is to alter the volume of the thorax
and thereby move air in and out of the lungs.
During breathing, the dimensions of the thorax change in the vertical, lateral, and anteroposterior
directions. Elevation and depression of the diaphragm significantly alter the vertical dimensions of the thorax.
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Depression results when the muscle fibers of the diaphragm contract. Elevation occurs when the diaphragm
relaxes.
Figure 4. Movements of the thoracic wall
http://www.studydroid.com/index.php?page=studyPack&packId=9240
DERMATOMES
Through its posterior ramus and the lateral and anterior cutaneous branches of its anterior ramus, most thoracic
spinal nerves (T2-T12) supply a strip-like dermatome of the trunk extending from the posterior median line to
the anterior median line. The skin area supplied by a segment of the spinal cord.
Figure 5. Dermatomes
http://sandysscience.wordpress.com/2010/01/04/dermatomes-2/dermatomes-4/
T2- Sternal angle
T4- Nipple
T6- Xiphoid process
T8- Costal arch
T10-Umbliculus
T12-Midpoint between umbilicus
and symphysis pubis
BREASTS
The breasts are the most prominent superficial structures in the anterior thoracic wall, especially in women. The
breasts (L. mammae) consist of glandular and supporting fibrous tissue embedded within a fatty matrix, together
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with blood vessels, lymphatics, and nerves. Both men and women have breasts; normally they are well
developed only in women. The mammary glands are in the subcutaneous tissue overlying the pectoralis major
and minor muscles. At the greatest prominence of the breast is the nipple, surrounded by a circular pigmented
area of skin, the areola (L. small area).
The mammary glands within the breasts are accessory to reproduction in women. They are rudimentary and
functionless in men, consisting of only a few small ducts or epithelial cords. Usually, the fat present in the male
breast is not different from that of subcutaneous tissue elsewhere, and the glandular system does not normally
develop.
Female Breasts
The amount of fat surrounding the glandular tissue determines the size of non-lactating breasts. The
roughly circular body of the female breast rests on a bed that extends transversely from the lateral border of the
sternum.
The lymphatic drainage of the breast is important because of its role in the metastasis of cancer cells.
Most lymph, especially from the lateral breast quadrants, drains to the axillary lymph nodes. Most of the
remaining lymph, particularly from the medial breast quadrants, drains to the parasternal lymph nodes or to the
opposite breast, whereas lymph from the inferior quadrants may pass deeply to abdominal lymph nodes.
Figure 6. Internal structure of the breast
http://anthingblissful.blogspot.com/2006/04/anatomy-of-human-breast.html
Figures 7. Lymphatic drainage of the breast
http://ourhumananatomy.blogspot.com/2008/08/19-breast-lymphatic-drainage.html
http://www.breastdiseases.com/anat.htm
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2. MEDIASTINUM (Interpleaural space)
The thoracic cavity is divided into three major spaces: the central compartment or mediastinum that
houses the thoracic viscera except for the lungs and, on each side, the right and left pulmonary cavities housing
the lungs.
The mediastinum (Mod. L. middle septum, L, mediastinus, midway), occupied by the mass of tissue between the
two pulmonary cavities, is the central compartment of the thoracic cavity. It is covered on each side by
mediastinal pleura and contains all the thoracic viscera and structures except the lungs. Mediastinum extends
from superior thoracic aperture superiorly to the diaphragm inferiorly and from sternum and costal cartilages
anteriorly to to the bodies of the thoracic vertebrae posteriorly.
The looseness of the connective tissue and the elasticity of the lungs and parietal pleura on each side of the
mediastinum enable it to accommodate movement as well as volume and pressure changes in the thoracic
cavity, for example, those resulting from movements of the diaphragm, thoracic wall, and tracheobronchial tree
during respiration, contraction (beating) of the heart and pulsations of the great arteries, and passage of
ingested substances through the esophagus.
The mediastinum is divided into superior and inferior parts for purposes of description.
•
Superior mediastinum (some important structures here; trachea, esophagus, thymus, vagus nerve,
phrenic nerve and great vessels such as arch of aorta, brachiocephalic vein).
–
Superior to sternal angle
Inferior mediastinum: Inferior to sternal angle
•
Anterior mediastinum (the major structure here is part of the thymus)
–
Between the anterior surface of pericardium and posterior surface of the sternum
•
Middle mediastinum
–
Pericardium, heart and beginings of the great vessels emerging from the heart lie here
•
Posterior mediastinum (some important structures here; thoracic aorta, esophagus)
–
Lies posterior to the pericardium and diaphragm
Some structures, such as the esophagus, pass vertically through the mediastinum and therefore lie in more than
one mediastinal compartment. The thoracic duct which drains ¾ of the lymph in the body is in the superior
mediastinum as well as in the posterior mediastinunm.
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Figure 8. Mediastinum and its parts
http://medicinexplained.blogspot.com/2011/06/mediastinum.html
3. CARDIOVASCULAR SYSTEM
The vascular system is divided for descriptive purposes into (a) the blood vascular system, which
comprises the heart and blood vessels for the circulation of the blood; and (b) the lymph vascular system,
consisting of lymph glands and lymphatic vessels, through which a colorless fluid, the lymph, circulates. The two
systems communicate with each other and are intimately associated developmentally. The heart is the central
organ of the blood vascular system, and consists of a hollow muscle; by its contraction the blood is pumped to all
parts of the body through a complicated series of tubes, termed arteries. The arteries undergo enormous
ramification in their course throughout the body, and end in minute vessels, called arterioles, which in their turn
open into a close-meshed network of microscopic vessels, termed capillaries. After the blood has passed through
the capillaries it is collected into a series of larger vessels, called veins, by which it is returned to the heart. The
passage of the blood through the heart and blood-vessels constitutes what is termed the circulation of the blood.
HEART
The heart, slightly larger than a clenched fist, is a double, self-adjusting suction and pressure pump, the
parts of which work in unison to propel blood to all parts of the body.
The right side of the heart (right heart) receives poorly oxygenated (venous) blood from the body through the
superior vena cava (SVC) and inferior vena cava (IVC) and pumps it through the pulmonary trunk and arteries to
the lungs for oxygenation. The left side of the heart (left heart) receives well-oxygenated (arterial) blood from
the lungs through the pulmonary veins and pumps it into the aorta for distribution to the body.
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The heart has four chambers: right and left atria and right and left ventricles. The atria are receiving
chambers that pump blood into the ventricles (the discharging chambers). The synchronous pumping actions of
the heart's two atrioventricular (AV) pumps (right and left chambers) constitute the cardiac cycle. The cycle
begins with a period of ventricular elongation and filling (diastole) and ends with a period of ventricular
shortening and emptying (systole).
The wall of each heart chamber consists of three layers, from superficial to deep:
•
Endocardium, a thin internal layer
•
Myocardium, a thick, helical middle layer composed of cardiac muscle.
•
Epicardium, a thin external layer
Externally, the atria are demarcated from the ventricles by the coronary sulcus (atrioventricular groove),
and the right and left ventricles are demarcated from each other by anterior and posterior interventricular (IV)
sulci (grooves). The heart appears trapezoidal from an anterior or posterior view, but in three dimensions it is
shaped like a tipped-over pyramid with its apex (directed anteriorly and to the left), a base (opposite the apex,
facing mostly posteriorly), and four sides.
The four surfaces of the heart are the:
•
Anterior (sternocostal) surface
•
Diaphragmatic (inferior) surface
•
Right pulmonary surface
•
Left pulmonary surface
Right atrium
The right atrium forms the right border of the heart and receives venous blood from the SVC, IVC, and
coronary sinus. A distinct feature of the right atrium is fossa ovalis (the closed foramen ovale which was open
prior to the birth).
Right ventricle
The right ventricle forms the largest part of the anterior surface of the heart, a small part of the
diaphragmatic surface, and almost the entire inferior border of the heart. The right ventricle receives blood from
the right atrium through the right AV (tricuspid) orifice. The interventricular septum lies between the two
ventricles, bulging into the right ventricle.
Left Atrium
The left atrium forms most of the base of the heart. The valveless pairs of right and left pulmonary veins enter
the atrium.
Left Ventricle
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The left ventricle forms the apex of the heart, nearly all its left (pulmonary) surface and border, and most of the
diaphragmatic surface. Because arterial pressure is much higher in the systemic than in the pulmonary
circulation, the left ventricle performs more work than the right ventricle.
The interior of the left ventricle has:
• A smooth-walled, non-muscular, superoanterior outflow part, the aortic vestibule, leading to the aortic orifice
and aortic valve.
• A double-leaflet mitral valve that guards the left AV orifice.
Figure 9. Heart chambers
http://www.starsandseas.com/SAS%20Physiology/Cardiovascular/Cardiovascular.htm
Both atria and ventricles have muscular elevations in order to increase the strength of the pumping
function.
Vasculature of the Heart
The blood vessels of the heart comprise the coronary arteries and cardiac veins, which carry blood to and
from most of the myocardium.
Arterial Supply of the Heart
The coronary arteries, the first branches of the aorta, supply the myocardium and epicardium. The right
and left coronary arteries arise from the corresponding aortic sinuses. Anastomoses between the branches of the
coronary arteries exist, which enables the development of the collateral circulation. The coronary arteries supply
both the atria and the ventricles. The right coronary artery (RCA) arises from the right side of the ascending
aorta. The left coronary artery (LCA) arises from the left side of the ascending aorta.
Venous Drainage of the Heart
The heart is drained mainly by veins that empty into the coronary sinus and partly by small veins that empty into
the right atrium.
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Figure 10. Arterial supply of the heart; coronary arteries
http://medical-dictionary.thefreedictionary.com/coronary+artery+disease
STIMULATING, CONDUCTING, AND REGULATING SYSTEMS OF HEART
The conducting system consists of nodal tissue that initiates the heartbeat and coordinates contractions of the
four heart chambers, and highly specialized conducting fibers for conducting them rapidly to the different areas
of the heart. The impulses are then propagated by the cardiac striated muscle cells so that the chamber walls
contract simultaneously. Impulse generation and conduction can be summarized as follows:
• The SA node (pacemaker of the heart; in the right atrium) initiates an impulse that is rapidly conducted to
cardiac muscle fibers in the atria, causing them to contract.
• The impulse spreads by myogenic conduction, which rapidly transmits the impulse from the SA node to the AV
node (in the right atrium).
• The signal is distributed from the AV node through the AV bundle and its branches (the right and left bundles),
which pass on each side of the IVS to supply subendocardial branches to the papillary muscles and the walls of
the ventricles.
Innervation of the Heart
Innervation of the heart is through the autonomic nerves (both sympathetic and parasympathetics) from the
cardiac plexus.
Figure 11. SA and AV nodes
http://www.mountnittany.org/articles/healthsheets/7488
PERICARDIUM
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The pericardium is a fibroserous membrane that covers the heart and the beginning of its great vessels. The
pericardium is a closed sac composed of two layers.
The pericardium is a closed sac composed of two layers:
1)
Fibrous pericardium (external)
continuous with the central tendon of the diaphragm
2) Serous pericardium (internal)
Parietal layer
Visceral layer (epicardium)
The pericardial cavity is the potential space between opposing layers of the parietal and visceral layers of serous
pericardium. It normally contains a thin film of fluid that enables the heart to move and beat in a frictionless
environment.
Figure 12. Pericardium
http://www.physioweb.org/circulation/heart_structure.html
THE GREAT VESSELS
The right and left brachiocephalic veins are formed by the union of the internal jugular and subclavian veins. The
brachiocephalic veins unite to form the superior vena cava (SVC). The superior vena cava (SVC) returns blood
from all structures superior to the diaphragm, except the lungs and heart. It ends by entering the right atrium of
the heart. The inferior vena cava (IVC)
The ascending aorta begins at the aortic orifice. Its only branches are the coronary arteries, arising from the
aortic sinuses. The arch of the aorta (aortic arch) is the curved continuation of the ascending aorta. The usual
branches of the arch are the brachiocephalic trunk, left common carotid artery, and left subclavian artery.The
ligamentum arteriosum, the remnant of the fetal ductus arteriosus, passes from the root of the left pulmonary
artery to the inferior surface of the arch of the aorta.
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Figure 13. The great vessels (arteries)
http://genericlook.com/anatomy/Aortic-Arch
What happens to descending aorta (thoracic aorta) which is the continuation of the arch of aorta is that after
passing through the diaphragm, it becomes the abdominal aorta which finally terminates as common iliac
arteries which will then bifurcate into the external and internal iliac arteries. The external iliac arteries, after
passing below the inguinal ligament, will become femoral arteries. The femoral arteries will supply the lower
limbs. On both sides, these arteries will continue as popliteal arteries which then will branch into anterior and
posterior tibial arteries.
The subclavian artery will continue as axillary artery, and later brachial artey on both arms. The brachial artery
will divide into ulnar and radial arteries.
The common carotid artery will divide into external carotid artery and internal carotid artery (Şah damarı). The
external carotid artery basically supplies blood to the face and neck, and the internal one to the brain. The other
artery of the brain is the vertebral artery which is a thick branch of the subclavian artery.
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Figure 14. Arteries in the body
http://mlkshk.com/r/CU70
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