颞下-经岩前硬膜外入路定位内听道的方法

目的 探讨颞下-经岩前硬膜外入路操作中定位内听道的方法.方法 国人成人尸头湿标本10例(20侧),经福尔马林固定,红、蓝硅胶灌注动、静脉系统.颞下-经岩前硬膜外入路开颅.掀起中颅窝底硬膜,暴露并磨除岩尖骨质,保留内听道(IAC).观察并测量颞骨颧突起点后缘(TOZP)、岩浅大神经(GSPN)、弓状隆起(AE)、棘孔(FS)与内耳门前缘、后缘的解剖关系.结果 颞骨颧突起点后缘、棘孔及内耳门前缘所成角度为97.6°±11.4°(81.3°～114.7°),颞骨颧突起点后缘、棘孔后缘与内耳门后缘所成角为82.6°±10.8°(67.0°～105.0°).颞骨颧突起点后缘、棘孔后缘与内耳门前缘所成角约为90°.GSPN与AE所成角度为122.7°±7.6°(108.1°～137.5°),GSPN与内听道内侧壁所成角度为46.6°±4.9°(35.0°～55.2°).结论 利用颞骨颧突起点后缘、棘孔后缘为定位标志,可用于经硬膜外处理岩斜区病变时内听道的定位与保护.定位标志直观,是一种定位内听道的新方法.     

经颞下和乙状窦前入路显露岩尖部的虚拟现实解剖学研究

目的在虚拟现实解剖模型中量化比较经颞下入路与经乙状窦前入路显露岩尖部的显微解剖学特征。方法利用15例(30侧)尸头CT和MRI影像构建岩尖部虚拟现实三维解剖模型。在颅盖上分别选取颞骨颧突根部上缘和乳突尖部为经颞下和乙状窦前入路的开颅标记点,颅底上选择岩尖部为显露标记点,以开颅和显露标记点连线为轴线作圆柱模拟经颞下和乙状窦前入路手术路径,观察和测量两种手术路径中解剖结构显露情况,采用配对t检验进行比较分析。结果经颞下入路手术路径经过颅中窝底和颞叶到达岩尖部,磨开岩骨后显露内耳道、面神经和迷路,向前显露三叉神经、岩上窦和海绵窦。经乙状窦前入路经乳突磨除岩骨,经面神经垂直段向深部依次显露颈静脉球、后组脑神经、听骨链、迷路和颈内动脉,路径到达内耳道时显露小脑前下动脉和面听神经复合体,到达岩尖部时包含小脑上动脉、岩上窦、岩下窦、海绵窦、三叉神经和部分颞叶。经乙状窦前入路手术路径中骨性结构、面听神经复合体、迷路和静脉体积均大于经颞下入路(P=0.000),颞叶、三叉神经和听骨链体积均小于经颞下入路(P=0.000)。经乙状窦前入路中包含后组脑神经体积为(32.38±2.86)mm~3、包含颅底动脉体积为(262.74±16.93)mm~3,经颞下入路不包含上述结构。结论经乙状窦前入路对岩骨周围和岩骨内结构的显露范围多于经颞下入路,对重要结构保护较好;经颞下入路经过颞叶到达岩尖部,适用于治疗累及岩骨并将颞叶向上推挤的颅中窝病变。     

颞下入路术中颞骨岩部安全磨除范围分析

目的 探讨颞下入路术中岩斜区安全磨除范围。方法 选择25具（50侧）正常成人颅骨标本,观察并测量颞骨岩部重要解剖结构,包括岩浅大神经孔（A）、岩骨嵴（B）、三叉神经压迹外侧缘最高点（C）、颈内动脉岩骨水平段（D）、BC中点（G）、CD中点（H）、岩尖（I）、内听道顶部、AC中点（J）;然后,应用影像学资料加以验证,同时,应用成人尸头模拟颞下入路手术,在安全范围（矩形CGHJ）内磨除三叉神经压迹及其后外侧部分并观察显露的解剖结构。结果 HJ连线可作为内听道内侧缘在岩骨前壁的投影,此方法能有效定位内听道。在矩形CGHJ范围内磨除部分岩骨后,可观察到上斜坡、中斜破和内听道下方。结论 HJ连线可作为内听道内侧缘的岩骨前壁的投影;矩形GHJI可作为颞下硬膜外入路术中岩骨磨除的安全区域,而且有足够的暴露范围。     

岩斜区脑膜瘤的手术入路

正岩斜区脑膜瘤指起源于以岩-斜裂为中心的中上斜坡和三叉神经内侧岩骨的脑膜瘤[1],不包括起源于下斜坡和内听道外侧的脑膜瘤。岩斜区位置深在,局部解剖复杂,与脑干及重要血管神经结构毗邻,因此,岩斜区脑膜瘤手术入路的选择尤为重要。根据手术入路与岩骨的关系,岩斜区脑膜瘤的手术入路可分为前方入路(包括额颞-眶-颧入路等)、侧方入路(包括颞下经岩骨前入路/Kawase入路,各种经岩骨入路等)、后方入路(包括枕下乙状窦后入路)     

神经导航辅助下前颞下经硬膜外前岩骨锁孔入路的显微解剖学研究

背景蝶岩斜区手术入路的选择和设计成为神经外科界关注和探索的难题之一.此部位手术多采用颞下入路、扩大中颅窝入路、Kawase入路、额颞眶颧入路等,但这些入路颅外组织损伤较多,存在大范围的无效暴露及不必要的结构破坏.为此,本实验应用微创锁孔入路的新理念,在颞下入路基础上,模拟前颞下经硬膜外前岩骨锁孔入路,并将神经导航技术运用到该入路中,进行显微解剖学研究,探讨其可行性,为临床应用提供依据.方法①导航资料的建立尸头切口周围6-8枚钛钉标记,行螺旋CT连续、无间隙扫描,影像资料输入Stoker神经导航系统.在导航系统Contour功能栏内,分别标出前岩骨、耳蜗、内听道的轮廓,指导术中岩骨的磨除范围.②模拟前颞下经硬膜外前岩骨锁孔入路尸头向对侧旋转约90°,取耳屏前约1 cm、颧弓上缘上行长约4 cm的直切口,在颧弓根部用磨钻磨开一小骨孔,以铣刀取下直径2.0～2.5 cm的小骨瓣.自中颅窝底抬起颞部硬脑膜,切断脑膜冲动脉.在下颌神经表面切开硬膜,进入海绵窦外侧壁浅、深两层之间,用显微剥离子向圆孔、眶上裂分离硬膜融合区,暴露海绵窦外侧壁,通过海绵窦三角显露内部结构.用神经导航定位耳蜗、内听道,依次磨除Kawase菱形区及三叉神经节下方的岩尖部,暴露上、中斜坡及桥小脑角等结构,观察并比较暴露结构的不同.③神经导航记录确定海绵窦三角、Kawase菱形区、最大限度磨除前岩骨后形成的菱形区的各点坐标,应用空间任意两点的距离函数由Excel算出长度,应用三角形面积公式算出面积.结果 1.海绵窦外侧壁由浅、深两层构成,深浅两层之间存在潜在的间隙,其内没有神经、血管穿过,动眼神经、滑车神经、三叉神经走行于该间隙之下.剥离该间隙,可以暴露海绵窦外侧壁全貌.暴露的相关海绵窦三角为①滑车神经上三角可暴露海绵窦后上腔、内侧腔,颈内动脉水平部上面、后曲部及其脑膜垂体干分支②Parkinson三角可暴露海绵窦前下腔、后上腔、内侧腔,颈内动脉后升部、水平部、后曲部及其脑膜垂体干分支,海绵窦下动脉,外展神经;③Mullan三角(前内侧三角)可暴露颈内动脉水平部、前曲部,海绵窦下动脉,外展神经④前外侧三角可显露卵圆孔与圆孔间的蝶骨表面.2.Meckel腔位于海绵窦后部韵外下方,小脑幕附着缘和岩上窦下方,是颅后窝向颅中窝突入的硬膜陷窝,形成一个中颅窝和后颅窝之间沟通的自然通路.Meckel腔包裹三叉神经根、节及三个分支至各自的出颅孔.3.计算出Kawase菱形区的面积为(248.2±12.4)mm2,最大限度磨除前岩骨后形成的菱形区面积为(318.4±36.2)mm2.两者比较有显著性差异(t=27.53,P《0.05).4. 通过三叉神经上间隙暴露上斜坡、基底动脉中部通过三叉神经下间隙暴露内听道下方的部分中斜坡、脑桥下部、脑桥延髓沟、延髓上部、椎基底动脉交接部、椎动脉近端、小脑前下动脉脑桥前段和脑桥外侧段.磨除三叉神经压迹下方的骨质,可进一步暴露展神经、Dorello管孔、小脑前下动脉的起始点.结论前颞下经硬膜外前岩骨锁孔入路具有可行性.通过一个直径2.0～2.5 cm的小骨窗,可以充分显露海绵窦、Meckel腔及三叉神经分支等结构,对原发或侵及上述部位的肿瘤可以直视下完全暴露.如病变扩展至后颅窝,通过最大限度磨除前部岩骨,暴露上、中斜坡,进行切除.但因岩斜区和海绵窦区解剖复杂,该锁孔入路在解决微创问题的同时,仍然存在传统入路相似的不足.     

岩斜区病变的手术入路

岩斜区病变的手术入路数目众多,且变化极大.处理岩斜区硬脑膜下病变常用的手术方法有枕下外侧入路、岩前入路、远外侧入路和联合岩骨入路,切除以硬脑膜外生长为主的肿瘤可以采用口咽入路或耳前-颞下入路.本文详细阐述了上述各种入路的应用指征、操作要点和可能出现的手术并发症,并对每个入路的优点和不利因素进行了具体分析.     

经后颞下入路暴露岩斜区及小脑桥脑角的神经内镜解剖学研究

目的研究经后颞下入路-经天幕暴露岩斜区及小脑桥脑角的神经内镜下血管神经解剖结构,探索岩斜区及小脑桥脑角可利用的间隙。方法成年新鲜尸头9例(18侧),交替使用0°、30°角神经内镜经后颞下入路-经小脑幕探查岩斜区及小脑桥脑角,并用摄像系统对相关的解剖结构及解剖标志纪录。结果小脑桥脑角在神经内镜下分为结构清晰的上、中、下三个间隙,三个间隙均有充分的操作空间,分别经三个间隙推进神经内镜后岩斜区得以暴露。结论神经内镜下经后颞下入路-经天幕能充分的暴露岩斜区、小脑桥脑角及周边解剖结构。     

颞下锁孔入路的显微解剖学研究

目的进行颞下锁孔入路解剖学结构研究,为临床颞下锁孔入路手术入路提供解剖依据。方法在显微镜下对6例经甲醛固定的国人成人尸头模拟颞下锁孔入路手术进行解剖,测量重要神经血管及其相关结构之间的距离以及观察显露范围和相关解剖关系。结果颧弓至小脑幕缘、脑干和前床突的最短距离分别为41.1±5.1mm、45.6±3.3mm和61.1±7.4mm。颞骨岩部扩大磨除前后显露的Day菱形区面积有显著差异(P0.05)。颞下锁孔入路可清楚的显露海绵窦外侧壁上的各神经血管及三角,鞍侧区可清晰的显露颈内动脉、后交通动脉及其穿支、脉络膜前动脉和垂体柄,磨除颞骨岩尖部可显著增加岩斜区脑干显露。结论颞下锁孔入路对于海绵窦外侧壁,岩斜区及鞍侧区显露效果好,入路简单直接,组织损伤小。     

岩斜区应用解剖及手术入路研究进展

岩斜区由蝶骨、颞骨和枕骨组成,部位特殊,毗邻重要结构,相关解剖包括岩骨、脑干、第Ⅲ～Ⅻ脑神经、幕下重要血管等。岩斜区手术难度大,手术入路众多,目前,主要采用岩前入路和经岩骨乙状窦前入路。为进一步提高手术疗效,岩斜区解剖和手术入路有待进一步研究。     

颞下经硬膜外锁孔入路显微解剖学研究

目的　应用锁孔入路的新理念进行显微解剖学研究，为临床应用颞下经硬膜外锁孔入路提供依据。方法　模拟颞下经硬膜外锁孔入路，对10具经10％甲醛固定的成人尸头标本在显微镜下进行观察并测量显露的解剖结构。结果　颞下经硬膜外锁孔入路可以充分暴露海绵窦外侧壁及其内部结构。结论　颞下经硬膜外锁孔入路可用于累及海绵窦肿瘤的手术治疗。     

扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤

目的 探讨扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤的治疗效果.方法 我科2007 - 2010年应用扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤21例.术前CT及MRI评估位于中、后颅窝肿瘤大小及岩骨侵蚀程度,分为三种类型:Mp型12例,MP型7例及mP型2例.结果 肿瘤全切19例,次全切2例,无手术死亡,术后出现新的暂时性脑神经麻痹4例,1例脑脊液漏,经腰大池引流脑脊液治愈.随访18例,时间6个月-3年(平均22.4个月),2例次全切除肿瘤复发,均位于后颅窝,经乙状窦后入路再次手术治愈.结论 扩大中颅底硬膜外入路经岩骨窗切除哑铃型三叉神经鞘瘤是一种有效的治疗方法,尤其对于肿瘤明显侵蚀破坏岩骨者.然而,如果后颅窝肿瘤部分过大时,该入路显露不足,难以全切肿瘤.     

Heterotopic brain cyst from middle cranial fossa to submandibular region

The case of a newborn boy with a congenital cystic neck mass causing respiratory distress is reported. This lesion extended from the submandibular region through a bone defect to the middle cranial fossa but remained totally extradural. There was no underlying brain abnormality. The cyst was composed mainly of mature neuroglial tissue, with some ependymal and choroid plexus elements, and was diagnosed as heterotopic brain. After 8 years' follow-up, the child still has no deficits.     

扩大颅中窝硬膜外入路手术治疗颅中窝底肿瘤

目的 探讨扩大颅中窝硬膜外入路手术切除颅中底肿瘤的效果.方法 回顾性分析2019年1～11月采用扩大颅中窝硬膜外入路显微手术切除的7例颅中底肿瘤的临床资料.结果 术后病理检查显示脑膜瘤4例,神经鞘瘤1例,胆脂瘤1例,脊索瘤1例.术后3d复查颅脑MRI增强检查显示,肿瘤全切除6例,次全切除1例.术后无干眼、眼球运动障碍、...     

Diagnosis and outcomes of middle cranial fossa repair for patients with superior semicircular canal dehiscence syndrome

The aim of this study was to retrospectively review the clinical presentation, diagnostic features, in particular cervical vestibular evoked myogenic potentials (cVEMPs), and the outcomes of surgical repair for superior semicircular canal dehiscence syndrome (SSCDS). SSCDS is a well-described syndrome of auditory and vestibular symptoms due to a bony dehiscence of the superior semicircular canal in the middle cranial fossa. A series of six procedures on five patients with SSCDS who underwent surgical repair via a middle fossa craniotomy were retrospectively reviewed. Preoperative and postoperative audiometric and vestibular symptoms as well as investigation findings were reviewed. Auditory and vestibular symptoms improved and hearing was preserved in all patients. The low frequency pseudo-conductive loss was corrected in four out of five patients, and the lowered preoperative cVEMP thresholds normalised following successful middle cranial fossa repair. In this series, middle fossa repair of SSCD was safe and effective with excellent sensorineural hearing preservation.     

Extradural hematoma complicating middle fossa arachnoid cyst

Two cases of post-traumatic extradural hematoma complicating an arachnoid cyst of the middle cranial fossa in children are described. While subdural and intracystic hemorrhages are well-known complications from this malformation, the association with extradural hematoma has never been previously reported in the literature. The pathogenetic mechanisms are discussed and the particular vulnerability of intracranial arachnoid cysts is stressed.     

Facial nerve neurinoma presenting as middle cranial fossa and cerebellopontine angle mass: a case report

Facial nerve neurinomas are rare. The tumours arising from the geniculate ganglion may grow anteriorly and superiorly and present as a mass in the middle cranial fossa. Only a few cases of facial nerve neurinomas presenting as middle cranial fossa mass have so far been reported. These tumours present with either long standing or intermittent facial palsy along with cerebellopontine angle syndrome.     

Assessment of endoscopic treatment for middle cranial fossa arachnoid cysts

Background

Endoscopic cystocisternotomy is one of three surgical methods used to treat middle cranial fossa arachnoid cysts. There is debate about which method is the best.

Objective

The aim of this study is to evaluate the effectiveness and safety of endoscopic cystocisternotomy for treatment of arachnoid cysts of the middle cranial fossa.

Methods

Thirty-two patients with arachnoid cysts of the middle cranial fossa who had undergone endoscopic cystocisternal fenestration between 2004 and 2009 were studied retrospectively. Data were obtained on clinical and neuroradiological presentation, indications to treat, surgical technique, complications, and the results of clinical and neuroradiological follow-up.

Results

Among the 27 patients with symptoms before surgery, 8 had disappearance of symptoms and 17 had improvement of symptoms. The cyst was reduced in size or it completely disappeared in 24 (75%) patients. The incidence rate of complications was 18.8%.

Conclusions

Endoscopic cystocisternal fenestration is an effective treatment for symptomatic arachnoid cysts of the middle cranial fossa and should be the initial surgical procedure.     

Arachnoid cysts of the middle cranial fossa presented as subdural hematomas

The aim of the study was to present the authors' own experience and discuss the treatment method of arachnoid cysts of the middle cranial fossa disclosed as subdural hematoma. Three cases of male patients operated on because of chronic subdural hematoma are presented. Control CT studies after evacuation of hematomas revealed arachnoid cysts of the middle cranial fossa and all patients were qualified for delayed cystocisternostomy by open craniotomy. Indirect signs of presence of arachnoid cysts in the form of bony abnormalities and expanded the middle cranial fossa in the first CT were seen in all patients. Cysts were asymptomatic until the injury in all cases. The volumes of cysts in MRI scans were: 17.8 ml, 52.9 ml and 92.4 ml, respectively. All cysts were type II according to Galassi classification. After control MRI described above made to evaluate cyst appearance, delayed cystocisternostomy to basal cisterns was undertaken in two cases with full success. No complications were observed. The third patient refused surgery. During surgery the thick and non-transparent medial cyst wall and arachnoidea of tentorial notch cisterns were observed impeding the exact identification of neurovascular structures. In our opinion arachnoid cysts of the middle cranial fossa revealed as subdural hematoma should be operated on in two stages: in the first step subdural hematoma should be evacuated and in the second step cystocisternostomy should be performed. With regard to observed morphological changes of arachnoidea and cyst walls we think that open cystocisternostomy is treatment of choice in these cases.     

中颅窝区脑外肿瘤的MRI表现

目的 探讨中颅窝区脑外肿瘤的MRI特点,提高其诊断准确率. 方法 经手术病理证实的31例中颅窝区脑外肿瘤(包括三叉神经鞘瘤13例,脑膜瘤6例,蛛网膜囊肿3例,皮样囊肿3例,骨母细胞瘤2例,脊索瘤2例,表皮样囊肿2例)均行MR平扫及增强扫描检查,并对其影像资料进行回顾性分析. 结果 不同的中颅窝区脑外肿瘤各具不同MR特征;(1)三叉神经鞘瘤MR/T1WI像多呈等或低混杂信号,T2WI像呈高或低混杂信号,本组13例三叉神经鞘瘤增强后有9例可见"包壳征";(2)脑膜瘤多表现为等或稍低T1、等或低或高T2信号,增强后呈中度较均匀强化;(3)骨母细胞瘤可见"骨包壳",脊索瘤骑跨中、后颅窝生长,其一侧与斜坡紧密相连;(4)蛛网膜囊肿与表皮样囊肿均呈长T1、长T2囊状信号,增强后无强化或囊壁轻微强化;蛛网膜囊肿多呈膨胀生长,而表皮样囊肿多有"见缝就钻"的特点;(5)皮样囊肿均呈短T1、长T2囊状信号,脂肪抑制序列扫描呈低信号,可出现"爆米花"样改变. 结论 中颅窝区脑外肿瘤均有比较特征性的MRI表现,密切结合临床可进一步提高其术前诊断的正确率.     

Surgical treatment of middle cranial fossa arachnoid cyst in children with atypical symptoms--report of three cases

We report three cases of symptomatic arachnoid cyst in the middle cranial fossa who presented with atypical symptoms including speech delay, vomiting and personality changes. They were improved by a cyst-peritoneal shunt operation. In many patients with a small or middle sized arachnoid cyst in the middle cranial fossa, their symptom tends to be so trivial that surgery is not the choice of treatment. The present cases suggest that peculiar symptoms caused by a limbic system lesion may be improved by treating the arachnoid cyst in the middle cranial fossa.