The proatlas: a comprehensive review with clinical implications

Background  

The proatlas is derived from the fourth occipital sclerotome in human embryos. It usually fuses with the three upper occipital sclerotomes to form the occipital bone. However, this does not always occur. Manifestations of a partial proatlas structure may persist due to failure of fusion.     

岩下窦的显微解剖

目的观察岩下窦（IPS）的显微解剖学特征,防止术中及术后的出血等并发症。方法通过10例（20侧）经过彩色乳胶灌注的成人尸头标本进行测量。并对结果进行统计学处理。结果IPS行于颅底内面的岩下窦沟内,即由斜坡和颞骨岩部组成的岩斜裂内,形状不规则。IPS60％的右侧大于左侧。IPS经颈静脉孔的岩部进入颈静脉孔,4侧经Ⅸ前方（占20％）,14侧经Ⅸ与Ⅹ之间穿行（占70％）．2侧位于Ⅹ与Ⅺ之间（占10％）,16侧汇入颈静脉球,占80％;4侧汇入颈内静脉,占20％,未见同时汇入二者的。并且IPS接收多条属支。结论明确了IPS的解剖特点,为术中处理好IPS,顺利开展岩斜区及颈静脉孔区手术创造良好条件。     

Abducens nerve palsy due to inferior petrosal sinus thrombosis

Isolated unilateral abducens nerve palsy is usually due to ischemia, trauma or neoplasm. Dorello’s canal is the space between the petrous apex and superolateral portion of the clivus, bound superiorly by Gruber’s ligament. The abducens nerve travels with inferior petrosal sinus (IPS) though the Dorello’s canal before entering the cavernous sinus. A 31-year-old man presented with neck pain, and binocular horizontal diplopia, worse looking towards left and at distance. He had a history of intravenous drug abuse but no history of hypertension or diabetes. On examination, he had complete left 6th nerve palsy with normal fundi, pupils, and other cranial nerves. Methicillin-resistant Staphylococcus aureus bacteremia was detected with naïve tricuspid valve endocarditis and multiple septic emboli to lungs with infarcts. His cerebrospinal fluid was normal. MRI of the brain was normal. MRV of head and neck showed thrombosis of the left internal jugular vein, left sigmoid sinus and left inferior petrosal sinus with normal cavernous sinus and no evidence of mastoiditis. He was treated with broad spectrum antibiotics. He was not anticoagulated for fear of pulmonary hemorrhage from pulmonary infarcts. Although cerebral venous sinus thrombosis commonly presents with elevated intracranial pressure, isolated ipsilateral 6th nerve palsy from its compression in Dorello’s canal due to thrombosis of the ipsilateral inferior petrosal sinus is extremely rare. To our knowledge, only two patients have been reported with isolated abducens palsy due to IPS thrombosis; one caused by septic emboli and the other developed it during IPS cortisol level sampling.     

The inferior petrosal sinus: assessment by transcranial Doppler ultrasound using the suboccipital approach.

Recently, intracranial veins and sinuses have been successfully insonated using the transtemporal and transoccipital approaches by transcranial Doppler ultrasound. The purpose of this study was to prove the capacity of the Doppler method to evaluate the inferior petrosal sinus via the suboccipital approach. Venous transcranial ultrasound was performed with a range-gated 2-MHz transducer in 80 healthy volunteers and patients without central nervous system disorders ranging in age from 15-84 years (mean +/- standard deviation [SD], 37.6 +/- 15.2 years). A venous signal with a flow directed toward the probe was considered to originate from the inferior petrosal sinus because of its proximity to the basilar artery. The inferior petrosal sinus was insonated in 96.3% of the cases at least on one side. It was found bilaterally in 48 (60%), on the right side in 74 (92.5%), and on the left side in 51 (63.8%) subjects, respectively. Mean blood flow velocity ranged from 8-53 cm/s (mean +/- SD, 19.6 +/- 8.7 cm/s). A significant age dependency of venous velocities was found. Weak but significant side-to-side differences were observed, reflecting the known right-sided predominance of venous outflow in humans. Using the suboccipital approach, the inferior petrosal sinus can be insonated in a high percentage of subjects without major difficulties and is defined by its vicinity to the basilar artery.     

经岩下窦静脉入路治疗颈动脉海绵窦瘘

目的探讨经岩下窦静脉入路治疗颈动脉海绵窦瘘(CCF)的疗效。方法经股静脉-岩下窦入路到达病变侧海绵窦，用各种弹簧圈如GDC、EDC、Matrix、FreeCoil和丝线等多种材料填塞海绵窦，同时闭塞瘘口。结果经股静脉-岩下窦入路对18例、21侧海绵窦进行了栓塞治疗。16例治疗后造影显示海绵窦和瘘口完全闭塞，无静脉引流；2例虽将海绵窦瘘口密实填塞，但仍有低流量翼丛引流，术后临床症状减轻，压颈1周后症状消失。栓塞术后病人主要表现为头痛和呕吐。2例术前伴有动眼神经麻痹病人，栓塞治疗后其他症状消失，但动眼神经功能未恢复。1例栓塞术后出现一过性外展神经麻痹，后自行恢复。有7例为外伤性，经动脉途径球囊栓塞后复发，或经弹簧圈治疗未成功。有11例为自发性，除3例岩下窦引流不明显，经硬导丝努力打通该通路，余者岩下窦均引流明显，导丝较易通过。随访3个月至24个月，6例病人术后3个月回医院行全脑血管造影检查，未发现复发；余者因术后无症状未回医院复查。结论经岩下窦静脉入路治疗CCF安全有效，对于外伤性CCF，为经动脉入路失败后治疗该病的主要治疗方法，而对于自发性CCF，应作为首选治疗。     

经岩下窦入路Onyx联合弹簧圈栓塞治疗海绵窦区硬脑膜动静脉瘘

目的探讨经岩下窦入路Onyx联合可脱性弹簧圈栓塞治疗海绵窦区硬脑膜动静脉瘘的安全性和有效性。方法回顾性分析2010年7月~2013年6月经岩下窦入路Onyx结合弹簧圈栓塞治疗的18例海绵窦区硬脑膜动静脉瘘患者的临床资料,评价疗效及手术并发症。结果栓塞后即刻血管造影显示瘘口完全闭塞15例,次全闭塞3例。4例术中出现心动过缓,3例术后出现眶部疼痛。随访3~12个月,所有患者术前症状消失,无复发。结论经岩下窦入路Onyx联合弹簧圈栓塞海绵窦区硬脑膜动静脉瘘疗效确切,安全可靠。     

岩下窦入路Onyx胶联合弹簧圈栓塞治疗双侧海绵窦区硬脑膜动静脉瘘

目的 探讨岩下窦入路Onyx胶联合弹簧圈栓塞治疗双侧海绵窦区硬脑膜动静脉瘘（CSDAVF）的安全性和有效性。方法 回顾性分析2013年9月至2018年9月经岩下窦入路Onyx胶联合弹簧圈栓塞治疗的7例双侧CSDAVF的临床资料。结果 7例14侧CSDAVF中,完全栓塞13侧,次全栓塞1侧。术后动眼神经麻痹加重1例,外展神经麻痹加重1例。术后随访6个月,14侧瘘口均未显影,1例动眼神经麻痹基本恢复,1例外展神经麻痹部分恢复。结论 经岩下窦入路Onyx胶联合弹簧圈栓塞治疗双侧CSDAVF疗效确切,并发症较单侧更常见;有效使用弹簧圈及Onyx胶对手术成功及减少并发症至关重要。     

Influence of inferior petrosal sinus drainage symmetry on detection of adenomas in Cushing's syndrome

BackgroundAsymmetric inferior petrosal sinuses (IPS) are not infrequently encountered during bilateral IPS sampling. There is little data on whether IPS symmetry influences success in predicting the adenoma side in patients with ACTH-dependent Cushing's syndrome (CS).ObjectiveTo assess the influence of IPS drainage patterns on detection of an adenoma in CS.MethodsRetrospective single-center cohort analysis reviewing records of patients with CS and negative MRI findings who subsequently underwent BIPSS.ResultsBIPSS was performed in 38 patients with a mean age of 45 ± 15 years. The overall technical success rate was 97% for bilateral cannulation. Asymmetric IPS were observed in 11 (39%) patients with Cushing's disease (CD). A side-to-side ACTH ratio was not significantly different between patients with symmetric outflow and those with asymmetric outflow at baseline (8.6 ± 2.7 versus 16.4 ± 6.0; P = 0.45), but ratios were significantly different after ovine corticotropin-releasing hormone (oCRH) stimulation (6.0 ± 2.5 versus 35.7 ± 22.5; P = 0.03). BIPSS correctly predicted the side of the adenoma in 25 (96%) patients with CD. Prediction was better when the venous outflow was symmetric (100%) rather than asymmetric (93%), although the difference was not significant (P = 0.42). Remission from CS was achieved in 32 patients (87%), independent of the symmetry of IPS.ConclusionsBearing in mind the sample size of this audit, asymmetric IPS at least do not seem to diminish the accuracy of diagnosis of ACTH-dependent CS, nor do they influence the clinical outcome.     

经未显影的岩下窦途径栓塞海绵窦区硬脑膜动静脉瘘

目的探讨经未显影的岩下窦途径栓塞海绵窦区硬脑膜动静脉瘘(CSDAF)的治疗方法。方法回顾性分析7例CSDAF病人的临床资料,均经未显影的岩下窦插管,以微弹簧圈栓塞海绵窦和瘘口。结果5例插管成功并达到完全致密栓塞;2例导管虽插入海绵窦,但海绵窦分隔致导管位置与瘘口不相通,而改行面静脉-眼静脉途径插管行栓塞治疗。7例病人均治愈,随访5～20个月,均无复发。结论经岩下窦途径栓塞是CSDAF最常用的治疗方法,即使岩下窦未显影,也有相当部分病人可插管和治疗成功。     

A neurological complication of inferior petrosal sinus sampling during investigation for Cushing's disease: a case report.

A 45 year old woman with hirsutism was found to have classic biochemical features of ACTH dependent Cushing''s disease, with partial cortisol suppression in response to dexamethasone. As no pituitary adenoma could be visualised by CT or MRI, she proceeded to bilateral simultaneous inferior petrosal sinus sampling before possible surgery. During the course of this procedure she had a stroke affecting the brainstem at the level of the pontocerebellar junction. This complication of petrosal sinus sampling has been previously described but is not widely recognised; the procedure should only be undertaken when results of less invasive tests are equivocal.     

岩下窦静脉取血在疑难ACTH依赖性库欣综合征诊断中的应用

目的 探讨岩下窦静脉取血(IPSS)在疑难库欣综合征诊断中的价值.方法 对20例疑难库欣综合征行岩下窦和外周静脉取血,测定血ACTH浓度比,评价其对库欣病诊断的敏感性和特异性.结果 18例患者的岩下窦与外周静脉血ACTH的比值＞2,其中13例行经蝶窦垂体术后病理为垂体ACTH腺瘤;1例行鞍区γ-刀治疗、4例行生长抑素治疗后病情缓解.2例岩下窦与外周静脉血ACTH的比值＜2,其中1例为右肺类癌,另1例为垂体ACTH腺瘤.本组IPSS诊断库欣病的敏感性和特异性分别为93%和100%.结论 IPSS操作安全,并发症少,可作为疑难库欣综合征的重要鉴别方法.     

岩下窦的DSA图像分析对血管内治疗颈动脉海绵窦瘘的指导价值

目的分析颈动脉海绵窦瘘(CCF)患者岩下窦(IPS)的DSA图像,探讨其对血管内治疗CCF的指导价值。方法选择福建医科大学福总临床医学院(第九〇〇医院)神经外科自2013年1月至2019年12月采用血管内治疗的76例CCF患者,回顾性分析患者的手术过程及全脑DSA图像。依据Barrow分型将患者分为直接CCF组(52例)、间接CCF组(24例)。比较2组患者患侧IPS的显影情况,比较IPS全程显影患者中直接CCF、间接CCF患者IPS汇入颈内静脉(IJV)的位置,分析经IPS行血管内治疗CCF的疗效。结果间接CCF组患者中IPS显影不良者所占比例(45.8%,11/24)明显高于直接CCF组(17.3%,9/52),差异有统计学意义(P<0.05)。IPS全程显影的56例CCF患者中,除1例患者IPS直接汇入椎静脉丛(VVP)而与IJV无连接外,直接CCF组、间接CCF组患者中IPS颅内汇入者所占比例差异无统计学意义(P>0.05)。24例间接CCF患者均首选经IPS栓塞,其中13例IPS全程显影者超选时均比较顺利(开通率为100%),微导管到位耗时较短(平均32 min);11例IPS显影不良的患者术中使用泥鳅导丝引导以及微导丝成袢技术成功开通5例(开通率为45%),微导管到位耗时较长(平均69 min)。结论间接CCF有较高的IPS闭塞率,造影侧位及3D成像可见IPS与颈内动脉岩骨段呈近似平行关系,掌握IPS的走行及其末端汇入IJV的位置关系,对于经静脉途径将微导管通过显影不良的IPS进入海绵窦进行介入栓塞具有非常重要的指导价值。     

Superior petrosal sinus dural arteriovenous malformation with varix indenting brain stem--report of a case and review of the literature

A rare case of the dural AVM mainly around the left petrosal sinus was reported. A 64 years old man was admitted just after the sudden onset of severe headache and nausea. The CT scan revealed subarachnoid hemorrhage in the left ambient cisterns. A small hematoma was also found in the left cerebellar peduncle. External carotid angiogram showed a dural AVM which nidus was located adjacent to the left superior petrosal sinus. Its feeding arteries were as follows; the middle meningeal artery, the artery of foramen rotundum, the accessory meningeal artery, the dural branch of occipital artery and the ascending pharyngeal artery. The voluminous petrosal vein and the dilated cortical veins were identified as drainers and, the portion of the latter appeared as "varix" embedded in the pons, which was clearly delineated by MRI. In the venous phase, stenotic straight sinus and residual Falcine sinus were illustrated. Superselective embolization of the feeding arteries was employed followed by the direct clippings of draining vein. Postoperative course was uneventful. The present case should be classified into the tentorial dural AVM. Only 26 cases of this rarely encountered entity was reported in the literature. Based on both the present and the previously reported cases, the clinical features, treatment and pathogenesis of this disease were briefly discussed.     

Status epilepticus: a review, with emphasis on refractory cases

Status epilepticus is among the most dramatic of clinical presentations encountered by emergency room physicians, neurologists, neurosurgeons and intensivists. While progress in its management has been aided significantly with an increasing number of effective treatment options, improved diagnostic methods and more effective monitoring, poor outcomes and diagnostic failures are still frequently encountered. Refractory cases still carry significant morbidity and mortality rates, including poor cognitive outcomes. This review discusses basic pathophysiology and management of status epilepticus, neuroimaging findings, the role of continuous electroencephalogram monitoring and nonconvulsive status epilepticusas well as recent developments in treatment options for refractory cases.     

Sneddon syndrome: a comprehensive clinical review of 53 patients

Journal of Neurology - The presence of livedo reticularis in patients with ischaemic stroke is associated with Sneddon syndrome (SS). Our objective was to present the clinical features of SS...     

The antidepressant effect of beta-adrenoreceptor subsensitivity: a brief review and clinical implications

This paper reviews briefly the very common finding in chronic antidepressant use, of subsensitivity of the beta-adrenoreceptor-linked cyclic AMP system. This subsensitivity is observed with a number of different antidepressant treatments, including pharmacological, electrical and sleep deprivation. The subsensitivity requires intact noradrenergic and serotonergic systems, functionally linking the two neurotransmitters most often implicated in depression. Thyroid hormones and estrogens also cause subsensitivity, while the opposite effect is seen with Reserpine and Propranolol. A modified conditioning/sensitization model is proposed, implicating psychosocial stressors with a biological inability to down-regulate beta-adrenoreceptors.