鞍区的显微解剖学研究

目的 为临床神经外科提供鞍区显微解剖和解剖参数。方法 用汉族成人尸头湿标本、漂白干颅骨各30例,在显微镜下进行显微解剖观察并测量。结果 鞍区重要的解剖学结构有:①骨性标志有鞍结节、前后床突、视神经管、鞍底、蝶窦内视神经管隆起和颈内动脉隆起;②相关硬膜结构有鞍膈、海绵窦和海绵间窦;③相关蛛网膜结构有颈动脉池、视交叉池;④重要的神经血管结构有垂体和垂体柄、视神经和视交叉以及Willis环及其分支。结论 该显微解剖学研究提供了鞍区的重要解剖结构和解剖参数,对鞍区的临床手术具有重要价值。     

垂体血供的显微解剖及在鞍区显微手术中的临床应用研究

目的 鞍区显微手术的开展,迫切需要垂体血供的显微解剖资料。方法 借助手术显微镜对40例成人头颅的颈内动脉(ICA)海绵窦段和床突上段的分支及分布进行了显微解剖研究。结果 每侧从ICA床突上段眼段下内侧壁发出(1.31±0.77)支、直径(0.38±0.11)mm的垂体上动脉;从ICA海绵窦段后弯部发出1支、直径为(0.66±0.19)mm、主干长(7.99±3.94)mm的垂体下动脉;垂体被膜动脉出现率为15％。结论 垂体上动脉和垂体下动脉是供应垂体的主要动脉,在鞍区显微手术中保护好各分支是预防或减少术后并发症,获得良好疗效的关键。     

动眼神经三角的显微解剖结构及临床应用

目的探讨动眼神经三角的显微解剖结构并讨论其临床意义,为术中动眼神经的保护提供解剖学参考。方法经血管灌注后观测10例(20侧)尸头的动眼神经三角及其毗邻结构。复习岩斜区三叉神经鞘瘤、脑膜瘤各5例,蝶骨嵴内侧脑膜瘤5例,后交通动脉瘤25例的手术录像并总结术中保护动眼神经的手术策略。结果动眼神经三角由前岩床突韧带、后岩床突韧带、床突间韧带三边构成。动眼神经由动眼神经三角中央处穿入海绵窦,动眼神经人海绵窦处距颈内动脉床突上段发起处后方约2～7 mm,平均5 mm。其外上方与脉络膜前动脉相邻,内上方与后交通动脉相邻。滑车神经从动眼神经后外侧进人海绵窦,在海绵窦外侧壁后方的动眼神经下方行走。40例手术患者中,后交通动脉瘤患者术前即有动眼神经损伤5例,其中2例动眼神经功能于术后3个月内恢复,另3例未恢复;余35例中术后有动眼神经损伤症状2例,但无动眼神经解剖性损伤,术后3个月内动眼神经功能损伤均恢复。结论动眼神经三角解剖结构毗邻结构复杂,前岩床突韧带、后岩床突韧带、后床突及颈内动脉床突上段发起处是手术中较好的解剖标志。存鞍区、鞍旁及岩尖等部位手术时应特别注意辨认和保护动眼神经。     

扩大经蝶入路显微镜与内镜的解剖学研究

研究背景目前普遍认为,传统经蝶入路对侵袭性垂体腺瘤的治疗效果较差,如何切除向蝶鞍外生长的肿瘤即成为神经外科的难题之一。本文通过研究扩大经蝶手术入路的解剖学特点,以为侵袭性垂体腺瘤的外科手术治疗提供理论依据。方法于成人尸头标本模拟内镜下扩大经蝶入路手术范围,并对相关解剖结构进行测量。结果 (1)蝶窦开口距鼻前棘52.62~63.16 mm,平均(59.68±4.28)mm;距后鼻孔上缘10.47~15.61 mm,平均(12.88±1.46)mm。(2)视神经和颈内动脉隆起率分别为11/20和17/20。(3)海绵窦内侧壁由一层硬脑膜组成,前、后、下海绵间窦和基底窦出现率分别为17/20、12/20、11/20和20/20。(4)双侧颈内动脉内缘在隐匿段间距为12.42~21.76 mm,平均(15.30±1.25)mm;在下水平段中点间距为10.42~18.43 mm,平均(14.03±1.19)mm;在前垂直段间距为16.75~24.88mm,平均(18.87±1.44)mm;在鞍结节内缘间距为9.97~16.18 mm,平均(12.73±0.94)mm。(5)颈内动脉海绵窦段与海绵窦内侧壁蝶鞍部之间有7侧直接接触(7/20);颈内动脉海绵窦段与海绵窦内侧壁蝶骨部之间均可见静脉丛伸入(20/20)。(6)共有9侧颈内动脉沿垂体下1/3走行(9/20)、7侧沿垂体下2/3走行(7/20)、3侧沿整个垂体走行(3/20)、1侧沿鞍底水平以下走行(1/20)。(7)有4侧(4/20)垂体出现侧突。结论扩大经蝶入路显露海绵窦内结构清晰,适用于处理由鞍内向海绵窦侵袭的垂体腺瘤。     

扩大经鼻蝶入路的海绵窦显微解剖学研究

目的 研究扩大经鼻蝶入路下的海绵窦显微解剖特点,制定大小范围合适的骨窗暴露海绵窦,为临床手术提供形态学基础.方法 在7具动脉灌注乳胶的成人尸头上模拟扩大经鼻蝶入路手术,在显微镜下观察颈内动脉海绵窦段及其分支、脑神经的解剖关系并测量相关解剖参数.结果 鞍结节、鞍底、斜坡、颈内动脉和视神经骨性隆起是确定手术区域的重要标志.颈内动脉与上颌神经入圆孔处的平均距离为6.8 mm.扩大的骨窗平均宽度值为37.6 mm(范围28.7 mm～44.0 mm).结论 骨窗越过颈内动脉骨性隆起扩大至圆孔的内侧缘的扩大经鼻蝶入路可有效的暴露一侧海绵窦全景,是处理由鞍内向海绵窦内侵袭病变的良好手术方式.     

神经内镜下经鼻扩大入路至中颅底的解剖学研究

目的明确神经内镜下经鼻扩大入路至中颅底的各种重要解剖标志,探讨该入路临床应用的影响因素和手术特点。方法分别运用直径4 mm,长度18 cm的0°、30°和45°硬质内镜(Karl Storz),在动脉灌注后的成人尸头上模拟手术过程,神经导航的引导下经双侧鼻腔扩大入路对中颅底进行内镜解剖。测量各个解剖标志之间的距离。结果蝶窦后壁可分为鞍区、鞍上区、海绵窦区和斜坡区。在蝶窦后壁可见鞍底、后组筛房、蝶骨平台、鞍结节、斜坡、斜坡隐窝、海绵窦、颈内动脉隆起、视神经管隆起、颈内动脉-视神经隐窝。在蝶窦腔的外侧壁可见眶尖隆起、上颌神经隆起、下颌神经隆起和翼管神经,并分别形成视神经颈内动脉和动眼神经三角、V_1~V_2三角、V_2~V_3三角。两侧颈内动脉-视神经隐窝内侧距离为(11.3±1.2)mm,两侧垂体前部距离为(12.2±2.1)mm,两侧垂体中部距离为(21.5±2.5)mm,两侧垂体后部距离为(17.6±3.4)mm,垂体前后径为(9.1±2.9)mm。硬膜内的鞍上区又可分为视交叉上部、视交叉下部、鞍背后部和脑室部。在剪开海绵窦和垂体之间的硬膜后,海绵窦段的颈内动脉可分为三叉神经段、后曲段、下水平段、前曲段和上水平段。结论神经内镜经鼻扩大入路至中颅底可清晰显示鞍区、鞍上区和海绵窦区的解剖结构,为该区域的病变提供一条有价值微侵袭的手术方法。颈内动脉-视神经隐窝是该区域手术的关键性标志。     

鞍区硬膜结构相关的临床解剖研究

目的 研究鞍区硬膜结构的显微解剖及其手术意义。方法 观测尸颅鞍区硬膜结构的显微解剖特征。结果 床突间皱襞将海绵窦顶分为两个三角，少数鞍隔向内下倾斜成盆状，动眼神经硬膜孔大致位于后床突水平。隔孔区的垂体腺由二层组织覆盖，上层是蛛网膜，下是更薄的膜样结构，少数蛛网膜层以脂肪垫形式填塞于鞍隔与垂体腺之间，仅见一例垂体池。结论 隔孔大者垂体容易下陷，蛛网膜坠入鞍隔下方与隔孔较大有关，垂体池是形成空蝶鞍的潜在因素。国人鞍隔屏障性能差，经蝶手术后容易脑脊液漏。     

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。     

经额底前纵裂入路显微手术治疗鞍区病变的解剖研究

目的 对经额底前纵裂入路视野下的鞍区重要结构及其解剖学参数作客观分析,为其显微手术临床应用提供数据支撑。方法 以9具成人尸头标本为研究对象,模拟经额底前纵裂入路显微手术过程,在手术显微镜下观察该入路条件下鞍区关键解剖结构、显露范围及手术操作范围;并深入解剖,观察重要血管、神经及其毗邻结构。结果 鸡冠至前床突、视神经管颅内口、视交叉前缘及垂体柄的距离分别为40.4±3.2、35.6±3.5、39.8±3.6、42.1±3.9 mm;眉间至各部分的距离分别为69.9±4.2、63.4±4.3、68.1±4.8、72.6±5.3 mm。经额底前纵裂入路可良好暴露下嗅三角、视神经、视交叉等重要结构;终板面积为（50.9±2.9） mm2,终板到额叶前段距离为（57.6±2.8） mm。结论 经额底前纵裂入路不仅适用于鞍区局部病变的手术,还可用于其上方、前上方及向三脑室生长的病变,本研究对鞍区重要结构及解剖学参数的客观观察可为临床医生设计手术入路、改进手术操作技巧提供指导。     

垂体窝的显微解剖

本文在手术显微镜下观察和测量20例成人尸体垂体窝的标本。鞍隔厚度平均为0.2mm。垂体腺平均长度10.8mm,宽度14.5mm,高度5.1mm。两侧海绵窦间距平均为12.6mm。其中18例存在前海绵间窦,9例存在下海绵间窦。垂体硬膜囊的动脉呈放射状,走向鞍底中心;静脉不与动脉伴行。19例鞍底骨质厚度不足1mm。本文对经蝶窦入路和解剖变异进行了联系和讨论。     

Surgical anatomy of the dural walls of the cavernous sinus

The external structure of each cavernous sinus (CS) is made of four dural walls. The aim of this study was to describe the anatomy of the dural walls of the CS. We studied 42 adult cadaveric heads, fixed with formalin and injected with coloured silicon. The main findings were: (i) the lateral wall of the CS has two layers – the external, which is thick and pearly grey, and the internal, which is semi-transparent and containing the cranial nerves (CNs); (ii) the medial wall of the CS has two areas – sellar and sphenoidal, both made up of one dural layer only; and (iii) the superior wall of the CS is formed by three triangles – oculomotor, clinoid and carotid – CN III may be found in a cisternal space of the oculomotor triangle; and (iv) the posterior wall of the CS is made up of two dural layers – meningeal dura and periostic dura – and this wall is close to the vertical segment of CN VI.     

前床突及床突间隙的显微解剖学研究

目的 对前床突及床突间隙进行显微外科解剖学研究，为手术入路提供解剖学基础。方法 利用10例经福尔马林固定的国人成人尸头共20侧，15例头颅干标本共30侧，对前床突及床突间隙相关解剖标志进行了详细地显微解剖、观察、拍摄、测量和统计。结果 床突间隙是磨除前床突后人为形成的锥形腔隙，其容积与前床突及周围组织结构的构成、范围和边缘的大小有关，并影响经该处的显微手术操作。通过它可显露颈内动脉海绵窦段的前升部、前曲部和眼动脉的起点。术中磨除前床突及视柱，应注意其周围重要组织结构的构成。颈内动脉出海绵窦处的远、近环均存在颈内动脉穴。远环硬膜囊内是蛛网膜，而近环内是海绵窦静脉丛。结论 通过床突间隙拓展海绵窦-眶尖区手术入路，为利用颅底间隙进行入路提供了依据．     

与中枢性尿崩症相关的穿动脉显微外科解剖

目的 探讨下丘脑、垂体柄和神经垂体的穿动脉的显微解剖，为减少术后中枢性尿崩症提供解剖学依据。方法 借助手术显微镜观察20例成人尸头标本的第三脑室前部、垂体柄和神经垂体的穿动脉的显微解剖关系。结果 室旁核和视上核的血供来自于前交通动脉的穿支，该区域自外下部的血供主要来自后交通动脉的穿支；垂体柄的血供来自于垂体上动脉；神经垂体的血供来自垂体下动脉。结论 与中枢性尿崩症相关的穿动脉可分为3组：（1）前组：主要来自前交通动脉附近发出的穿动脉；（2）外侧组：来自颈内动脉床突上段和后交通动脉发出的穿动脉；（3）下组：发自颈内动脉海绵窦段的垂体下动脉。了解这些血管的分布，可减少在鞍区肿瘤手术时对这些血管的损伤，避免中枢性尿崩症的发生。     

Anatomy and embryology of the lateral sellar compartment (cavernous sinus) medial wall

Abstract

In order to study the microanatomy of the lateral sellar compartment (cavernous sinus) medial wall, serial histological sections of human fetuses and adults, as well as dissections under operative microscope, were performed. The results were compared to high resolution Magnetic Resonance Images in human, to microdissections and to serial histological sections in adult nonhuman primates (Papio Cynocephalus anubis). We were able to show that. the sellar compartment and both lateral sellar osteodural compartments are not separated from each other by a dural wall, but by a more or less dense, interrupted, fibrous tissue which derived from the mesenchyme surrounding the hypophysis, carotid artery, cranial nerves and venous channels. In the human fetus, the previous mentioned structures are located in a unique interperiosteodural space. Histoarchitecture of the superior and lateral wall dura-mater was different from the underlying mesenchyme derived connective tissue and was easily distinguished through histological examination. These findings correspond to MRI data. We conclude that there is no medial dural wall limiting the lateral sellar compartment (cavernous sinus), both parasellar and the hypophyseal compartment should be considered as a unique extradural space. The only dense connective tissue surrounding the pituitary gland is its own glandular capsule and the periosteum. [Neural Res 1998; 20: 585–592]     

Comparative microanatomy of the lateral wall of the ‘cavernous sinus’ in humans and the olive baboon

Abstract

Despite many studies of the ‘cavernous sinus’ lateral wall, the anatomy of this area remains controversial. We performed a comparative microanatomical and histoarchitectural study in 14 humans and in 10 nonhuman primates (Papio cynocephalus anubis). Venous channels and cranial nerves were embedded in the ‘interperiosteodural space’. The dura propria of the lateral wall could be removed without entering the venous compartment. The oculomotor and trochlear nerves were accompanIed by an arachnoidal and dural sheath. The oculomotor nerVe sheath stopped under the anterior clinoid process in baboons. The trigeminal ganglion was covered posteriorly with an arachnoid membrane and adhered firmly to the dura propria on lateral aOnd anterior sections. The three branches of the trigeminal nerve had no arachnoid covering, except for arachnoid granulations in humans. In baboons, the oculomotor and trochlear nerves were thicker than in humans, while the ophthalmic nerve was thinner. The abducens nerve belonged to the lateral wall of the sinus in baboons and had no arachnoidal sheath except in the first millimeters of Dorello’s canal. After leaving their arachnoidal and dural sheath, the intracavernous cranial nerves acquired a typical peripheral sheath. The venous channels in both species’ were true dural sinuses. Willis cords and adipose tissue were identified. [Neural Res 1997; 19: 571-576]     

海绵窦显微外科相关三角解剖学研究

目的为海绵窦显微外科手术提供解剖学参数。方法在６～２０倍手术显微镜放大下,对２０例成人头颅进行了海绵窦１２个三角解剖学测量。结果测量了上壁４个三角,外侧壁６个三角,后壁２个三角,通过这些三角所显示海绵窦内结构及腔隙的范围。结论应用这些三角解剖学测量可指导与海绵窦相关的手术,安全切开海绵窦上壁、侧壁、后壁,不损伤重要神经和血管     

Meningo-orbital band detachment: A key step for the extradural exposure of the cavernous sinus and anterior clinoid process

The meningo-orbital band (MOB) is the most superficial dural band that tethers the fronto-temporal dura to the periorbita. It is usually encountered when performing a pterional or fronto-temporo-sphenoidal approach, and it disrupts surgical access to deeper regions.Our objective was to perform a detailed anatomy study and a stepwise method to successfully detach the MOB using cadaveric specimens. We used six formalin‐fixed, silicone‐injected cadaveric heads. On each side, we performed a pterional approach plus mini‐peeling of the anterior third of the middle fossa and/or extradural anterior clinoidectomy. We also applied this technique in three clinical cases to prove its safety and efficacy. The detachment of the MOB consists in four steps, 1) detachment of the temporal and frontal dura, 2) cutting of the MOB, 3) exposure and drilling of the anterior clinoid process, and 4) pealing of the lateral wall of the cavernous sinus. Using clinical cases, we explain how to adapt the technique depending on the localization of the lesion. The detachment of the MOB is the key to safely expose the cavernous sinus and the anterior clinoid process. The authors proposed a step-by-step method for the safe and effective detachment of the MOB. It is recommended, particularly to less experienced neurosurgeons that are starting with skull base surgery, and also to experts that want to expand their knowledge.     

累及眶尖的海绵窦肿瘤的手术探讨

目的讨论累及眶尖的海绵窦肿瘤手术方法及相关解剖。方法22例全部采用额颞弧形切口，翼点人路。当肿瘤位于视神经外侧或海绵窦外侧壁时，选择颞部偏大的切口。取下骨瓣，磨除蝶骨嵴，剪开硬膜，分开外侧裂。依据肿瘤的位置用微钻磨除前床突和视神经管上壁。选择肿瘤突出部位切开海绵窦外侧壁或眶筋膜，分块切除肿瘤。结果22例肿瘤中，17例全切，3例近全切，1例大部分切除，1例活检。结论详细了解海绵窦和眶尖肿瘤的外科解剖是达到其外科切除的良好结果所必需。     

内镜下经鼻蝶入路治疗鞍区病变的解剖学研究

目的研究内镜下蝶窦和鞍区的解剖结构。方法对8例成人头颅标本在内镜下模拟经鼻蝶手术入路,解剖观察蝶窦后壁和鞍区。结果将蝶窦后壁“井”字线划分为九个区,中间从上到下分别为视交叉区、鞍区和斜坡区,两侧从上到下分别为视神经管区、鞍旁海绵窦区和斜坡旁海绵窦区。鞍型蝶窦后壁中常见的解剖标志有斜坡凹陷、视神经管隆突、颈内动脉隆突和视神经颈内动脉隐窝;其中视神经颈内动脉隐窝是恒定的骨性解剖标志,毗邻视神经、海绵窦、海绵窦内颈内动脉、眶尖;两侧视神经颈内动脉隐窝的连线是鞍结节的投影。鞍旁海绵窦区是骨缺损好发的位置。结论对蝶窦后壁的九分区法适用于骨质层、硬膜层和颅内层,使复杂的鞍区及附近结构相对简化,易于识别和定位;视神经颈内动脉隐窝是重要的解剖标志。