Monro Kellie Doctrine/ Principle

Monro-Kellie hypothesis is a pressure-volume relationship that aims to keep a dynamic
equilibrium among the essential non-compressible components inside the rigid compartment of
the skull 1-3.
The average intracranial volume in the adult is around 1700 mL, composed of brain tissue
(~1400 mL), CSF (~150 mL), and blood (~150 mL) 3,4. The volume of these three components
remains nearly constant in a state of dynamic equilibrium (Figures 1 and 2). Thus, a decrease in
one component should be compensated by the increase in other and vice-a-versa (Figures 3, 4
and 5).
It is important to note that most of the blood in the cranial cavity is contained in the low-
pressure venous system, so venous compression serves as a means of displacing blood volume 2.
There are many classic brain imaging findings that this theoretical hypothesis can explain:
venous distention in intracranial hypotension

sulcal effacement in brain oedema or expansive lesion
brain shift with intracranial hypertension
hydrocephalus in idiopathic intracranial hypertension
Figure 1: The equilibrium among csf, blood and brain tissue.

Figure 2. The equilibrium among CSF, blood and Brain tissue.
Figure 3: A tumour increasing brain tissue volume.

Figure 4. A increase in CSF volume.
Figure 5: An increase in the blood volume.

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The Circle of Willis

The Circle of Willis or the Circulus Arteriosus is an arterial polygon where the blood carried by
the two internal carotid arteries and
the basilar system comes together and then is redistributed by the anterior, middle, and
posteriorcerebral arteries. The posterior cerebral artery is connected to the internal carotid artery
by the posterior communicating artery.
The anterior communicating artery joins the anterior cerebral arteries of the two hemispheres
together. The middle cerebral arteries are connected to the posterior cerebral arteries by the
posterior communicating arteries. This anastomosis between arteries is responsible for
developing collateral circulation. It provides a safety mechanism. If one of the major vessels
becomes occluded within the
Circle or proximal to it, the circle will still provides the brain with continued supply of blood.
Thus the circle of Willis is of great use in preventing neurological damage. As long as this circle
is successful at maintaining blood pressure at fifty
Percent of normal, no infarction or death of brain tissue will occur in the blocked area and no
permanent effects are produced.Smaller arteries arise from the circle of Willis and from the
major cerebral arteries. They form four groups which include the anteromedial, the anterolateral,
the posteromedial and the posterolateral.
Internal Carotid System
The internal carotid artery divides into two main branches called the middle cerebral artery and
the anterior cerebral artery. The middle cerebral artery supplies blood to the frontoparietal
somatosensory cortex.
The anterior cerebral artery supplies blood to the frontal lobes and medial aspects of the parietal
and occipital lobes. Before this divide, the internal carotid artery gives rise to the anterior
communicating artery and the posterior communicating artery.
Vertebral Artery
The two vertebral arteries run along the medulla and fuse at the pontomedullary junction to form
the midline basilar artery, also called the vertebro-basilar artery.
Before forming the basilar artery, each vertebral artery gives rise to the posterior spinal artery,
the anterior spinal artery, the posterior inferior cerebellar artery (PICA) and branches to the
medulla.
Basilar Artery
At the ponto-midbrain junction, the basilar artery divides into the two posterior cerebral arteries.
Before this divide, it gives rise to numerous paramedian, short and long circumferential
penetrators and two other branches known as the anterior inferior cerebellar artery and the
superior cerebellar artery.
Venous Drainage Arteries provide the brain blood supply. The veins take the blood away,after the
brain has taken nutrition from it.The prime course of venous drainage of the brain is through
cerebral veins that empty into the dural venous sinuses and ultimately into the internal jugular
vein.
Cerebral veins are divided into two groups, superficial and deep. The superficial veins usually lie
on the surface of the cerebral hemispheres and empty themselves into the superior sagittal sinus.
The deep veins drain internal structures and ultimately drain into the straight sinus.
Cerebral veins are thin-walled and valveless. They
are also interconnected by several functional anastomoses both within a group and between the
superficial and deep groups. The numerous connections between cerebral veins and dural sinuses
and venous systems of the meninges, skull, scalp and nasal sinuses assist the spread of thrombus
or infection between these vessels.
The middle cerebral artery territory is the most commonly affected territory in a cerebral
infarction, due to the size of the territory and the direct flow from internal carotid artery into
the middle cerebral artery, providing the easiest path for thromboembolism.
Score [3] Stroke severity
0 No stroke symptoms
1-4 Minor stroke
5-15 Moderate stroke
16-20 Moderate to severe stroke
21-42 Severe stroke

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Monro-Kellie hypothesis is a pressure-volume relationship that aims to keep a dynamic

venous distention in intracranial hypotension

Figure 1: The equilibrium among csf, blood and brain tissue.

Figure 3: A tumour increasing brain tissue volume.

Figure 5: An increase in the blood volume.

The Circle of Willis

Score [3] Stroke severity

1-4 Minor stroke

5-15 Moderate stroke

16-20 Moderate to severe stroke

21-42 Severe stroke

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