Recurrent Artery of
Heubner
N Venkateshwarlu MBBS (Kurnool), MD (Medicine) (AIIMS/Lady Hardinge)
Professor and HOD
Department of Internal Medicine
SVS Medical College Mahabubnagar Telangana
Recurrent
Artery of
Heubner
N Venkateshwarlu MBBS (Kurnool), MD (Medicine)
(AIIMS/Lady Hardinge)
Professor and HOD
Department of Internal Medicine
SVS Medical College Mahabubnagar Telangana
Let’s start remembering and recollecting from
our great INDIAN VEDAS
•“आ नो भ॒ द्राः क्रत॑वो यन्तु वव॒ श्वत:”
• “Let noble thoughts come to all from all directions”
– Rigveda
Introduction
• First described by the German pediatrician Johann Otto
Leonhard Heubner (1872), H.F. Aitken (an artist at the
Massachusetts General Hospital) later labelled it as
‘Heubner’s artery’ (1909).
• Joseph Shellshear, an anatomist at St. Bartholomew’s
Hospital in London, later termed the more appropriate and
the current term ‘recurrent artery of Heubner’ for the same,
pertaining to its characteristic course along the A1 portion of
the anterior cerebral artery (ACA) subsequent to its origin
(1920).[1]
Structure
• The recurrent artery of Heubner (RAH) is typically the largest of the
perforating medial lenticulostriate arteries arising from ACA.
• The recurrent artery of Heubner can arise from A1, from A2, or at the
junction of the ACA-ACoA (anterior communicating artery) of the
ACA.
• Later the artery characteristically turns posteriorly and runs in close
relation to the gyrus rectus to reach the anterior perforating
substance.
• The recurrent artery of Heubner showed a mean diameter of 0.8 +/0.04, with a mean length of 23.4 +/- 1.1 mm in one study.
RECURRENT ARTERY OF HEUBNER
• Also called Medial Striate artery
• Supplies orbital cortex, passes through the anterior
perforated space to join the deep branches of MCA
The recurrent artery of Heubner has vascular
supply mainly to
1.
2.
3.
4.
5.
The head of the caudate nucleus
The medial portion of globus pallidus
Anterior crus of the internal capsule
Anterior hypothalamus
Nucleus accumbens, a connection between caudate and the
putamen
6. Parts of the uncinate fasciculus connecting the limbic system with
the frontal lobe
7. Diagonal band of Broca connecting the septal area to the amygdala
and
8. The basal nucleus of Meynert located in the substantia innominata
Variations
• The most common origin of the recurrent artery of Heubner was from
the A2, followed by the ACA-ACoA junction (43.4%) in one study.
• However, in other studies, the recurrent artery of Heubner most
commonly originated from the junction of the A1 (origin of the ACA
to the junction of the anterior communicating artery) and A2
(junction of the ACoA to the anterior border of the corpus callosum)
segment of the ACA in 76.2% followed by A2 segment in 16.3% of
cases.
• It was either absent or duplicated in around 6% of the cases in the
series.
• It was triple in number in 0.14 % of cases in one study.
Variations
• The pattern of recurrent course of the recurrent artery
of Heubner in its relation with A1 while moving
towards the anterior perforated substance divide into:
1. Type I or the superior course (63%)
2. Type II or anterior course (34%)
3. Type III or posterior course (3%)
Variations
• The intracerebral course of the recurrent artery of
Heubner is uni-vectorial, thereby heading towards the
head of the caudate nucleus.
• The recurrent artery of Heubner, during the extra- and
intracerebral course, may join with the middle group
of the lenticulostriate arteries or directly with the
middle cerebral artery to form a rete.
Clinical Significance
1. Large artery disease due to greater than 50% stenosis of
large vessels such as the carotid artery
2. Small vessel disease secondary to hypertension, diabetes,
and hypercholesterolemia
3. Cardiac emboli following atrial fibrillation, cardiac
hypokinesis, mural thrombus, and dilated
cardiomyopathies
4. Trauma predisposing to the dissection of the vessel as well
as the microthrombi formation
Clinical Significance
5. Vasospasm following a ruptured aneurysm
6. Inadvertent clipping during microsurgical clipping of
anterior communicating artery aneurysm
7. Dissecting aneurysm of the recurrent artery of
Heubner (e.g., in a patient with osteogenesis imperfecta)
8. Vascular malformations like cavernoma
HEUBNER’S ARTERY
• A stroke in the anterior cerebral artery distribution as a
“crural monoplegia – or hemiplegia with crural
predominance,”
• “Rare cases of occlusion of Heubner's artery” there may be
“a severe degree of contralateral hemiplegia affecting
particularly…the face, tongue and shoulder.”
• Other symptoms described were ideomotor apraxia, the
“phenomena of forced grasping and groping,” and rare
“aphasic speech defects.”
Clinical significance
1. Hemiparesis with fascio-brachiocrural predominance
2. Dysarthria due to the involvement of the cortico-lingual
and the cortico-striato-cerebellar pathways
3. Choreoathetosis
4. Behavioral changes like abulia or hyperactivity due to
interruptions between the associative cortex with the deep
cortical regions
5. Aphasia in left-sided involvement
6. Left visual neglect in right-sided involvement
Diagnosis
• The diagnosis of the involvement of the recurrent artery of
Heubner is diagnosable with the aid of plain computerized
tomography of head revealing hypodensity in the caudate region
in cases of infarction and hyperdensity in cases with hemorrhage.
• The ultra-early diagnosis of the infarction in the caudate region
due to the involvement of the recurrent artery of Heubner can be
facilitated with magnetic resonance imaging (MRI) of the brain
with special sequences such as diffusion-weighted images (DWI)
and apparent diffusion coefficient (ADC).
Diagnosis
• The endovascular approach has a dual advantage in that it
can diagnose the vasospasm in the selected vessels as well
have the benefits of simultaneous therapeutic benefits
through the application of stents and vasodilators.
Differential diagnosis of the involvement of the
head of the caudate nucleus
1. Recurrent artery of Heubner supplying the inferior part of
the head of the caudate nucleus and the anterior limb of
the internal capsule
2. Anterior lenticulostriate arteries originating from the A1
segment of ACA and supplying the anterior area of the
head of the caudate nucleus and
3. Lateral lenticulostriate arteries originating from the MCA
and supplying a significant portion of the head of the
caudate nucleus, anterior internal capsule, and putamen.
Summary
• Anterior cerebral circulation is mainly by anterior cerebral
artery and middle cerebral artery
• Anterior cerebral artery block causes mainly lower limb
paresis or palsy
• Recurrent artery of Hubner occlusion leads to upper limb
paresis