小脑动脉的临床解剖探讨

目的：为神经外科临床提供解剖学资料。方法：手术显微镜下观察５０例成人脑标本小脑动脉的起始、行径、主要分支、穿动脉及大致分布，检查各小脑动脉与出入脑干的颅神经的接触关系。结果：５０例人脑有小脑下后动脉（ＰＩＣＡ）９４支，小脑下前动脉（ＡＩＣＡ）９７支和小脑上动脉（ＳＣＡ）１１２支。２侧ＰＩＣＡ和１２侧ＳＣＡ接触三叉神经根，２侧ＡＩＣＡ接触面神经根，动脉与神经根接触多形成压迹。结论：小脑动脉的局部解剖有助于神经外科医生在颅后窝手术时，对这些动脉尤其是行程可能有变异的动脉及穿支要特别谨慎，避免损伤，并保护与小脑动脉关系密切的脑神经根；对某些脑干血管综合征患者及某些三叉神经痛、面肌痉挛患者采取相应的治疗。     

孤立双侧桥臂梗死1例报道

桥臂亦称小脑中脚（middle cerebellar peduncle,MCP）,主要由小脑前下动脉（anterior inferior cerebellar artery,AICA）支配,小脑上动脉（superior cerebell arartery,SCA）也部分参与,而MCA主要供血范围为脑桥外侧、小脑中脚以及小脑前下侧。桥臂主要恒定由AICA的侧支供血。但因此处血供侧支丰富,很少发生梗塞。孤立的桥臂梗死少见,占急性脑梗死的0．12％,而孤立的双侧脑梗死更是鲜有报道。     

显微血管减压术治疗三叉神经痛

采用显微血管减压术治疗原发性三叉神经痛３３例，术中发现小脑上动脉压迫２２例，小脑下前动脉压迫５例，小脑后下动脉压迫１例，静脉压迫５例；三叉神经根受动脉压迫扭曲或有明显压迹者２４例，神经与动脉接触但无扭曲、压迹４例。２８例动脉压迫者术后疼痛均消失，但２例三叉神经根仅与动脉接触而无明显压迹和扭曲者术后疼痛复发；５例静脉压迫者仅３例疼痛消失，２例疼痛减轻。提出神经根受压的部位在本病的发病中不是决定因素，关键是神经根受压的程度。静脉压迫和动脉仅与三叉神经根接触而无压迹、扭曲者显微血管减压术的疗效远不如三叉神经根明显受压者显著，应同时行感觉根切断术，以提高三叉神经痛的治疗效果。     

经乙状窦后入路小脑前下动脉显微解剖学研究

目的 研究小脑前下动脉(AICA)的显微解剖学特点及临床应用价值。方法 取6具尸头,经乙状窦后入路,用手术显微镜、神经内镜观察AICA的行程、分支、分布及其与周围结构的关系。结果 共观察到15支AICA,无AICA缺如,AICA发出四组重要的分支:桥延支、内听动脉、回返穿通支和弓状下动脉。AICA紧贴面听神经腹侧行走,并发出分支营养神经。结论 AICA与脑干、面听神经关系密切。听神经瘤手术中应妥善保护其主干及分支,以提高面听神经功能保留率。     

136例三叉神经痛微血管减压术临床报道

目的探讨三叉神经痛微血管减压术的疗效与责任血管的解剖特点。方法通过对136例三叉神经痛患者行微血管减压手术治疗，术中观察和判定责任血管的来源、压迫三叉神经根部的位置，探讨责任血管的解剖特点及疗效。结果责任血管以小脑上动脉的外侧支的分支压迫三叉神经的上表面最常见，共80侧（58．8％）；小脑前下动脉的分支压迫三叉神经的下表面较少，共20侧（14．7％）；两支血管分别压迫三叉神经的上、下表面的有18侧（13．2％）；单纯静脉压迫三叉神经根部的有12侧（8．8％）；附近无任何血管压迫但术中发现三叉神经覆盖的蛛网膜明显增厚者6侧（4．4％）。136例病人中，术后疼痛消失134例，治愈率为98．5％，无效2例。术后随访112例，平均4．3年．102例疼痛完全消失，4例部分缓解，6例复发或无效。结论邻近血管的压迫是三叉神经痛的主要病因，微血管减压术是治疗三叉神经痛最有效的方法，其疗效取决于熟练的显微解剖知识和显微操作技巧。仔细寻找所有的责任血管并隔离确实，保护好邻近区域的神经和血管，是增加疗效、减少术后并发症的关键。     

岩上静脉的应用解剖及其在显微血管减压术中的意义

目的 研究岩上静脉的解剖特点，为临床施行显微血管减压术提供应用解剖学资料。方法取15例（30侧）成人尸头标本．经静脉乳胶灌注处理后，在手术显微镜下观察和测量岩上静脉的位置、形态、分支及变异等情况，以及与三叉神经、面神经、位听神经等的毗邻关系。对60例三叉神经痛或面肌痉挛病人施行显微血管减压术，术中观察岩上静脉及其属支的各项情况。结果①岩上静脉位于蛛网膜下腔间隙内，呈游离悬空状．多由2-3支属支静脉汇成．最终注入岩上窦的内、中2／3段。其属支静脉起自小脑半球的前缘部分和脑桥腹侧面，岩上静脉主干之间或两侧的岩上静脉之间存在交通连接。②根据尸头单侧岩上静脉的数量．可以将其分为单干型（9侧，30．0％）、双干型（17侧，56．7％）和三干型（4侧，13．3％）；根据55支岩上静脉注入岩上窦的位置与内听道的关系．可将其分为内侧组（17支，30．9％）、中间组（24支，43．6％）和外侧组（14支。25．5％）。临床所见与解剖结果基本一致。③岩上静脉的主干或属支与三叉神经密切相关，可与三叉神经直接接触，形成压迫。没有见到岩上静脉或其属支与面神经、位听神经相接触形成压迫的情况。结论岩上静脉是颅后窝最大的和最常遇到的静脉，其主干和属支在走行过程中与三叉神经、面神经和位听神经相毗邻．并且可以对三叉神经形成压迫。在显微血管减压术中，对作为责任血管和阻挡手术人路的岩上静脉或其属支静脉．可以完全切断。     

后颅凹蛛网膜的显微外科解剖学研究

目的 根据头颅解剖研究结果，为后颅凹病变的显微外科手术提供解剖学依据。方法 采用显微外科技术解剖和观察后颅凹蛛网膜解剖结构。结果 后颅凹蛛网膜包括Liliequist膜，基底动脉分叉蛛网膜，后穿蛛网膜，动眼神经外侧蛛网膜，中脑-脑桥内侧蛛网膜，中脑-脑桥外侧蛛网膜，基底蛛网膜，脑桥腹侧蛛网膜，脑桥-延髓内侧蛛网膜，脑桥-延髓外侧蛛网膜，小脑-脑桥蛛网膜，小脑-延髓腹侧蛛网膜，小脑上蛛网膜，小脑前中央蛛网膜，小脑-延髓背侧蛛网膜，小脑后下动脉蛛网膜和小脑蚓部背侧蛛网膜，这些结构均与脑干，颅神经及血管关系密切。结论 （1）后颅凹蛛网膜可分为颅底蛛网膜，凸面蛛网膜和小梁蛛网膜。（2）颅神经蛛网膜鞘为手术中分离，保护颅神经提供了可靠的解剖界面；（3）对蛛网膜及其小梁必须采取锐性分离。     

中脑背外侧区相关解剖及手术入路研究

中脑背外侧区是指中脑、脑桥上部背外侧及对应的小脑幕切迹区域，位置深在，结构复杂，包括中脑、脑桥背外侧、小脑幕面、环池、小脑中脑裂、滑车神经、三叉神经，大脑后动脉、小脑上动脉等重要组织结构[1]。该区域常见疾病包括胶质瘤、海绵状血管瘤、血管母细胞瘤、动脉瘤等，其手术难度大、风险高、并发症多。近年来，随着解剖学、显微神经外科学、影像学及神经电生理检测技术等发展，该区域的手术效果明显提高。本文就国内外对中脑背外侧区相关解剖及手术入路的研究进行综述。     

三叉神经根入脑干区MRI形态学研究

目的研究原发性三叉神经痛(TN)患者三叉神经根入脑干区(REZ)的形态结构及其临床应用价值。方法 36例TN患者和20例非TN患者作为健康对照纳入研究。所有受试对象采用3.0TMRI扫描,采用可变翻转角的三维快速自旋回波序列(3D-SPACE)分别扫描两侧REZ区的形态学结构。采取图像分析软件测量分析三叉神经脑池段长度、三叉神经脑桥角、桥小脑角池面积和三叉神经脑池段面积。结果患侧三叉神经脑池段长度的均值、三叉神经脑桥角的均值、桥小脑角池面积的均值以及三叉神经脑池段面积的均值均小于健侧。对照组的三叉神经脑池段长度、三叉神经脑桥角、桥小脑角池面积及三叉神经脑池段面积的均值均大于疾病组。结论三叉神经脑池段较短,三叉神经脑桥角锐利,易发生神经血管冲突,临床上易导致TN;三叉神经脑池段面积缩小提示三叉神经根的萎缩性改变。MRI形态学信息有利于疾病的诊断及手术决策的选择。     

小脑前下动脉瘤五例报告

目的探讨小脑前下动脉（AICA）动脉瘤的临床特征、治疗方式的选择及操作技巧。方法回顾性分析5例AICA动脉瘤的临床资料。结果AICA远端囊性动脉瘤3例，其中2例位于内听道口，1例化于小脑绒球腹侧、面听神经背侧，并伴有同侧小脑半球小型隐匿性血管畸形，术中借助神经内镜发现动脉瘤，3例均行手术夹闭，并于术后住院期间行脑血管造影复查，夹闭满意；AICA近端囊性动脉瘤2例，均采用血管内介入治疗。患者预后优4例，良1例。结论AICA远端动脉瘤宜首选手术夹闭，术是辅助神经内镜有助于提高显微手术效果；AICA近端动脉瘤宜首选血管内介入治疗。     

Ultrastructure and immunohistochemistry of the trigeminal peripheral myelinated axons in patients with neuralgia

Objective

Detailed ultrastructural and immunohistochemical examination of the trigeminal axons surrounded by the peripheral type of the myelin could add new information about the extent of the trigeminal nerve lesion in neuralgia.

Patients, materials and methods

The examination comprised, firstly, the 10 trigeminal nerve roots (TNRs) in which the neurovascular contact was found in 20% of the cases, and the 2 additional control TNRs. Secondly, the biopsy specimens were taken from 6 patients with trigeminal neuralgia and 2 patients with trigeminal neuropathy following a partial TNR rhizotomy. The specimens were examined under the electron microscope (EM) and/or using the immunohistochemical (IHC) methods.

Results

In addition to the central zone of demyelination, the EM examination of the TNR also revealed alterations of the peripheral myelin, i.e. deformation, thickening, demyelination and remyelination, as well as changes of the peripheral axons, that is, atrophy or hypertrophy, neurofilaments increase, loss of the myelin and sprouting occasionally. Some Schwann cells were also damaged. The IHC examination usually showed a moderate immune reaction against neuron-specific enolase (NSE) and protein gene product 9.5 (PGP9.5), but sporadically weaker reaction against the S-100 protein, synaptophysin (SY), neurofilament protein (NFP) and glial fibrillary acidic protein (GFAP). The substance P (SP) and calcitonin gene-related peptide (CGRP) immunoreactivity was weak at some sites, but strong at some other places.

Conclusions

The pathological changes affect not only the central nerve fibers of the TNR, but also some of the peripheral axons, their myelin sheath and Schwann cells. These are signs of the retrograde ultrastructural and biochemical alterations, which could participate in the pathophysiological mechanism underlying the trigeminal neuralgia.     

Parvalbumin, calretinin and carbonic anhydrase in the trigeminal and spinal primary neurons of the rat

The cell-body size of parvalbumin-immunoreactive (-ir) primary neurons was measured in the trigeminal (TG) and lumber dorsal root ganglia (DRG). In the DRG, parvalbumin-ir was mostly detected in large cells (94% in the range of 600–2800 μm²). Parvalbumin-ir TG cells were smaller than similar DRG cells and yet parvalbumin-ir TG cells of < 400 μm² (2.86%) were rare. Trichrome stains for parvalbumin, calretinin (CR) and carbonic anhydrase (CA), and for parvalbumin, calcitonin gene-related peptide (CGRP) and CA were performed to estimate possible overlap of these substances. Virtually all parvalbumin-ir DRG cells contained CA activity while a small subpopulation (28.5%) of CR-ir DRG cells lacked CA activity. All the CR-ir DRG cells that exhibited CA were also ir for parvalbumin. 31.1% of parvalbumin-ir DRG cells exhibited CR-ir while 71.5% of CR-ir DRG cells showed parvalbumin-ir. All the CR-ir DRG cells of < 400 μm² lacked CA activity and parvalbumin-ir while all those of > 800 μm² exhibited both activities. 30% of CR-ir DRG cells in the size range of 400–800 μm² co-expressed CA. DRG cel co-expressing parvalbumin and CGRP were rare (1%). As was the case for the DRG, most of parvalbumin-ir TG cells exhibited CA activity (89.24%) and lacked CGRP-ir (96.6%). CR-ir TG cells were also subdivided into two groups; one with and the other without co-expression of CA. Unlike in the DRG, however, co-expression of parvalbumin and CR could never be detected in the TG.     

Resolution of trigeminal neuralgia following pontine haemorrhage

Trigeminal neuralgia is characterized by paroxysms of pain in the sensory distribution of the trigeminal nerve usually caused by vascular compression of the trigeminal nerve at the root entry zone. We describe a 57-year-old woman who experienced complete resolution of trigeminal neuralgia following hypertensive pontine haemorrhage.     

DZY-C型三叉神经立体定向仪在治疗三叉神经痛中的临床研究

目的 为了治疗三叉神经痛,使穿刺卵圆孔更加快捷与准确,获得好的解痛疗效,减少术中疼痛,术后并发症和复发率,研制成一种新的三叉神经立体定向仪(DZY-C型)供临床应用。方法 首先将病人头部固定在定向仪上,用普通X-线机摄取颅底片及侧位片,测算卵圆孔的位置,在定向仪的引导下穿刺针经卵圆孔进入三叉神经半月节及三叉神经节池。然后选择不同治疗方法,如射频热凝法、甘油注射或酒精注射法治疗原发性三叉神经痛。结果 实验研究及临床应用证明,该定向仪精度高,穿刺卵圆孔靶点的误差小于0.3mm。一次性穿刺的成功率高达100％。结论 三叉神经立体定向仪(DZY-C型)的结构设计合理,精密度高,达到临床应用的要求。手术操作简易,调节灵活,组织损伤少,使用安全。     

S100 protein-immunoreactive primary sensory neurons in the trigeminal and dorsal root ganglia of the rat

The cell body size (cross-sectional area) of S100-immunoreactive (-ir) primary neurons was measured in the trigeminal (TG) and lumbar dorsal root ganglia (DRG). About a half of neurons exhibited S100-immunoreactivity (-ir) in the DRG (44.0%) and TG (59.0%). DRG neurons with cell bodies >1200 μm² mostly exhibited S100-ir (96.5%), whereas S100-ir DRG neurons <600 μm² were rare (8.0%). 36.6% of DRG neurons in the cell size range 600–1200 μm² showed the ir. TG neurons >800 μm² mostly exhibited S100-ir (93.1%), whereas those <400 μm² were devoid of it (positive cells 10.5%). 58.3% of TG cells in the range 400–800 μm² contained S100-ir. Double-immunofluorescence method revealed the co-expression of S100 and other calcium-binding proteins. Parvalbumin-ir neurons mostly exhibited S100-ir in the DRG (97.4%) and TG (97.0%). The co-expression of S100 and calbindin D-28k was very rare in the DRG, because the DRG contained few calbindin D-28k-ir neurons. Unlike in the DRG, numerous neurons co-expressed S100- and calbindin D-28k-ir in the TG. Most calbindin D-28k-ir TG neurons were also immunoreactive for S100 (90.7%). Sub-populations of calretinin (CR)-ir neurons co-expressed S100-ir in both the DRG (68%) and TG (50.0%). Virtually all CR-ir neurons >1400 μm² co-expressed S100-ir in the DRG (100%) and TG (95.9%). CR-ir neurons <800 μm² were rarely exhibited S100-ir (DRG 18.0%, TG 21.9%). 71.3 and 60.5% of CR-ir neurons in the range 800–1400 μm² co-expressed S100-ir in the DRG and TG, respectively. The present study indicates that S100 is closely correlated to the primary neuronal cell size in the DRG and TG.     

简易三叉神经定向仪(DC-Ⅲ型)的临床应用

目的：为了治疗三叉神经痛，获得好的解痛疗效，减少术中疼痛、术后并发症和复发率。我们研制成ＤＣ－Ⅲ型简易三叉神经定向仪供临床应用。方法：自１９９２年６月至１９９６年１２月，采用立体定向引导下经皮半月神经节后根甘油注射治疗三叉神经痛２００例。从颅底Ｘ线摄片上测算卵圆孔的立体坐标数值，将定向仪固定在双侧颧弓上。在立体定向导引下，可顺利地把针经卵圆孔穿入三叉神经池，缓慢注射９９．５％甘油（０．２～０．４ｍｌ）。结果：术后一个月内的近期解痛率９８％；随访１７０例，期限６～３６个月，平均２５个月，远期解痛率９１．７％，无严重并发症及死亡。结论：此手术的主要优点是：解痛效果佳，无严重感觉缺失及眼角膜的并发症。手术技术简易，可获较好的疗效     

Neurophysiological assessment of trigeminal nerve reflexes in disorders of central and peripheral nervous system.

The trigeminal nerve and nuclei (the trigeminal complex) are unique in the human body with regard to their anatomical and physiological characteristics. They are also special regarding the lesions in which they are involved, both at the peripheral level because of the susceptibility of some terminal branches, and at the nuclei because of their large size and the large amount of connections with other centers. Conventional magnetic resonance imaging studies are often not sufficiently informative to demonstrate very tiny lesions that could be responsible for an important damage in the brainstem. Therefore, clinical neurophysiology and specifically, the techniques used in the study of the trigeminal functions, remain as convenient diagnostic and research tools to document clinically evident lesions or uncover subclinical abnormalities. This review is focussed on the clinical applicability of the study of trigeminal reflexes, including methods employed in the documentation of focal lesions of peripheral branches, trigeminal involvement of peripheral neuropathies, specific lesions of the trigeminal ganglia, central nervous dysfunctions causing abnormalities in the excitability of trigeminal neurons, and the possible use of trigeminal nerve reflexes in the study of facial pain syndromes and headache.     

应用卵圆孔定位仪治疗三叉神经痛

目的总结卵圆孔定位仪在选择性经皮温控射频热凝治疗三叉神经痛的应用方法和技巧。方法对三叉神经第Ⅱ、Ⅲ支疼痛者或第Ⅰ、Ⅱ、Ⅲ支同时疼痛者应用Hartel前入路半月神经节射频热凝治疗,其中260例患者应用三叉神经卵圆孔定位仪辅助定位,对39例患者术中应用X线或三维CT进行卵圆孔靶点验证。结果所有病例穿刺成功。术后即刻疗效:优良206例,良好42例,无疗效12例,总有效率95.4%,无严重并发症发生。结论卵圆孔定位仪可用于射频热凝治疗三叉神经痛的辅助定位,可以提高穿刺的成功率和安全性。     

半月节立体定向毁损治疗三叉神经痛(附124例报告)

目的 探讨CRW立体定向导航系统以及三维CT在三叉神经半月节射频热凝术中的应用价值.方法 广东省第二人民医院自2007年7月至2009年12月共收治124例原发性三叉神经痛患者,均采用CRW立体定向系统辅助下经皮穿刺卵圆孔,再在三维CT辅助下进针到达半月节切迹,方波刺激及预毁损确认穿刺到位后,采取逐渐加温的方式进行毁损.结果 124例患者均穿刺成功,无穿刺副损伤所致并发症.一次穿刺成功89例(71.8%),二次穿刺成功33例(26.6%),2例(1.6%)因颅底骨质结构有变异,经多次穿刺成功.术后即刻总体有效率为98.4%.术后出现患侧面部麻木感即浅感觉减退87例(70.2%),1例患者出现角膜炎(0.8%),未出现复视、咀嚼无力、张口困难等并发症.所有患者随访3月～2年,复发7例(5.6%).结论 采用立体定向导航系统及三维CT重建可以大大提高穿刺卵圆孔的准确性,减少并发症:个体化穿刺策略的制定可以进一步确保疗效,提高治愈率.     

半月节立体定向毁损治疗三叉神经痛(附124例报告)

目的 探讨CRW立体定向导航系统以及三维CT在三叉神经半月节射频热凝术中的应用价值.方法 广东省第二人民医院自2007年7月至2009年12月共收治124例原发性三叉神经痛患者,均采用CRW立体定向系统辅助下经皮穿刺卵圆孔,再在三维CT辅助下进针到达半月节切迹,方波刺激及预毁损确认穿刺到位后,采取逐渐加温的方式进行毁损.结果 124例患者均穿刺成功,无穿刺副损伤所致并发症.一次穿刺成功89例(71.8%),二次穿刺成功33例(26.6%),2例(1.6%)因颅底骨质结构有变异,经多次穿刺成功.术后即刻总体有效率为98.4%.术后出现患侧面部麻木感即浅感觉减退87例(70.2%),1例患者出现角膜炎(0.8%),未出现复视、咀嚼无力、张口困难等并发症.所有患者随访3月～2年,复发7例(5.6%).结论 采用立体定向导航系统及三维CT重建可以大大提高穿刺卵圆孔的准确性,减少并发症:个体化穿刺策略的制定可以进一步确保疗效,提高治愈率.