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THORACIC WALL MEDIASTINUM CARDIVASCULAR SYSTEM 12. 10.2012 Kaan Yücel M.D., Ph.D. http://yeditepepharmanatomy.wordpress.com Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com 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 http://www.youtube.com/yeditepeanatomy 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. Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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. http://twitter.com/yeditepeanatomy 3 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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. http://www.youtube.com/yeditepeanatomy 4 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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 http://twitter.com/yeditepeanatomy 5 Dr.Kaan Yücel – yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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. http://www.youtube.com/yeditepeanatomy 6 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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 http://twitter.com/yeditepeanatomy 7 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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 http://www.youtube.com/yeditepeanatomy 8 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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. http://twitter.com/yeditepeanatomy 9 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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. http://www.youtube.com/yeditepeanatomy 10 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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 http://twitter.com/yeditepeanatomy 11 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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. http://www.youtube.com/yeditepeanatomy 12 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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 http://twitter.com/yeditepeanatomy 13 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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. http://www.youtube.com/yeditepeanatomy 14 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS 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. http://twitter.com/yeditepeanatomy 15 Dr.Kaan Yücel yeditepepharmanatomy.wordpress.com Thoracic wall, mediastinum & CVS Figure 14. Arteries in the body http://mlkshk.com/r/CU70 http://www.youtube.com/yeditepeanatomy 16