岩斜区脑膜瘤的显微外科治疗(附18例报告)

目的提高岩斜区脑膜瘤的手术效果。方法回顾性分析我院自１９９５年１月至１９９７年１１月连续收治的１８例岩斜区脑膜瘤。１３例肿瘤大于４．５ｃｍ。采用了经颞下小脑幕、颞下－乙状窦前、颞下－迷路、枕下－极外侧入路。结果肿瘤全切除１１例（６１％）,其中２例术后发生Ｗｅｂｅｒ’ｓ综合征,１例死于肺炎。结论影响手术预后的最主要因素是小脑前下动脉（ＡＩＣＡ）、小脑上动脉（ＳＣＡ）和小脑后下动脉（ＰＩＣＡ）及其供应脑干的穿通支被肿瘤包裹和脑干受累,血管因素可能更为重要。     

小脑下后动脉切断的实验研究

目的研究切断一侧小脑下后动脉（ＰＩＣＡ）的可行性及在增加延髓后区术野显露方面的作用。方法将ＰＩＣＡ分为４段（ＰＩＣＡ１－ＰＩＣＡ４），自ＰＩＣＡ１－ＰＩＣＡ３逐段切断实验。结果ＰＩＣＡ１、ＰＩ－ＣＡ２切断后果严重，ＰＩＣＡ３切断不仅安全可行，且能充分显露自同侧内耳门－导水管下端－对侧四室壁－枕大孔这一区域，无需切开小脑蚓部。结论ＰＩＣＡ１、ＰＩＣＡ２切断后果严重，ＰＩＣＡ３切断安全可行且具有较大的临床意义，为临床开辟了新的手术入路。     

岩斜区脑膜瘤的显微外科治疗

目的 提高岩斜区脑膜瘤的手术效果。方法 回顾性分析我院自１９９５年１月至１９９７年１１月连续收治的１８例岩斜区脑膜瘤。１３例肿瘤大于４．５ｃｍ。采用了经颞下－小脑幕、颞下－乙状窦前、颞下－迷路、枕下－＝极外侧入路。结果 肿瘤全切除１１例（６１％）,其中２例术后悔ｅｂｅｒ‘ｓ综合征,１例死于肺炎。结论 影响手术预后的最主要因素是小脑前下动脉ＡＩＣＡ）、小脑上动脉（ＳＣＡ）和小脑后下动脉（ＰＩＣＡ）及     

三叉神经根血液供应的显微解剖学研究

目的探讨三叉神经根动脉的解剖学特点，为临床桥小脑角区手术提供解剖学资料。方法手术显微镜下解剖、观察三叉神经根动脉的来源及其配布方式。结果0）43．5％三叉神经根动脉源于脑桥支，另外还可来源于小脑下前动脉（AICA）、三叉小脑动脉、小脑上动脉（SCA）等；②这些滋养动脉间可发生吻合，构成头侧环和尾侧环；③50％的滋养动脉自神经根下面穿入，30．7％从其上面穿入。结论①脑桥支和AICA是三叉神经根动脉的主要来源；②三叉神经根动脉的分支间的吻合在近入根区处较多，而在根干部较少；③三叉神经根动脉的穿支多自神经根的上面或下面穿入。     

巨大脑动脉瘤的手术探讨

目的　对应用不同手术方法治疗的１６ 例巨大脑动脉瘤（≥２５ｍｍ） 作回顾性分析。方法　近１０ 年来收治１６ 例巨大脑动脉瘤, 颈动脉系１２ 例： 外伤性右侧颈内动脉（ＩＣＡ） 瘤２ 例, 左侧颈总动脉（ＣＣＡ） 夹层动脉瘤１ 例, 右侧大脑中动脉（ＭＣＡ） 瘤２ 例, 前交通动脉（ＡｃｏＡ） 瘤１ 例,右（左） 颈内动脉（ＩＣＡ） 瘤６ 例; 椎基动脉系４ 例： 右侧小脑上动脉（ＳＣＡ） 瘤１ 例; 右侧椎基动脉连接处动脉（ＶＢＪＡ） 瘤１ 例, 右侧大脑后动脉（ＰＣＡ） 梭状动脉瘤２ 例。根据临床表现和神经放射学（ＣＴＤＳＡＭＲＩ） 评估。结果　１４ 例治愈,２ 例死亡。１４ 例生存者随访７ 月至５ 年, 按Ｓｕｎｄｔ 标准,结果满意９ 例, 良好４ 例, 差１ 例。结论　巨大脑动脉瘤的治疗, 特别是有占位效应者, 以闭锁瘤颈,切除膨大的瘤囊为宜     

椎基底动脉供血不足ENG,BAEP,TCD的对照研究

目的：探讨眼震电图（ＥＧＮ）脑干听觉诱发电位（ＢＡＥＰ）及脑超声波（ＴＣＤ）三项检查联合用于椎基底动脉供血不足（ＶＢＩ）的诊断价值。方法：５２例临床诊断为ＶＢＩ的病人均在发病一周内行ＥＮＧ、ＢＡＥＰ及ＴＣＤ检查。结果：ＥＮＧ异常率为８８％ＢＡＥＰ异常率为５３％，ＴＣＤ异常率为７６％，结论：三项检查联合应用，可以反应小脑及脑干的功能，为评估小脑及脑干的供血情况提供有益的信息。     

犬与鼠脑血管痉挛病变的比较研究

探讨犬与鼠之间脑血管痉挛病变的不同特点。采用２次枕大孔注血致蛛网膜下腔出血（ＳＡＨ）后迟发性脑血管痉挛（ＤＣＶＳ）犬的模型，及３次视神经孔注血致ＳＡＨ鼠的模型，对２种模型做了病理观察及形态定量的比较研究。结果显示，ＤＣＶＳ犬基底动脉的管腔明显缩小（Ｐ＜０．０１），管壁明显增厚（Ｐ＜０．０５）。ＳＡＨ鼠中动脉的管腔无狭窄（Ｐ＞０．０５），管壁无增厚（Ｐ＞０．０５）。病理观察发现ＤＣＶＳ犬比ＳＡＨ鼠的脑动脉病变明显严重。提示ＤＣＶＳ犬的模型恒定、可靠、发生率高。ＳＡＨ鼠的模型不易产生ＤＣＶＳ，故较适用于ＳＡＨ急性期的实验研究。     

面神经血管束显微外科解剖与临床研究

目的探讨面神经自脑干发出处至颞骨内侧段及其毗邻结构的显微解剖,为枕下乙状窦后入路面神经微血管减压术（MVD）及桥脑小脑角（CPA）区手术提供显微解剖相关资料。方法对用福尔马林固定的成人尸头标本10例20侧（男性6例,女性4例）,模拟枕下乙状窦后锁孔入路手术方法,显微技术解剖CPA区域面神经及其毗邻神经血管等结构,进行观察和测量;对128例面神经MVD手术资料进行观察、整理和分析。研究面神经血管束的组成与变异,并将解剖标本与手术所见进行对比分析。结果尸头解剖：面神经根与毗邻血管压迫或接触9侧（9／20）,其中：小脑前下动脉（AICA）5侧,小脑后下动脉（PICA）2侧,椎动脉（VA）1侧,多支血管1侧;手术资料：半侧面肌痉挛（HFS）的责任血管绝大多数位于桥脑延髓沟,其中AICA79例（61．72％）;PICA21例（16．4l％）;椎-基底动脉6例（4．69％）;多支血管22例（17．18％）。结论面神经血管束,特别是其桥脑延髓沟段的显微外科解剖和术中充分暴露是面神经MVD手术成功的关键。     

实验性迟发性脑血管痉挛时痉挛动脉的自由基代谢

为探讨蛛网膜下腔出血（ＳＡＨ）后迟发性脑血管痉挛（ＤＣＶＳ）时痉挛动脉的自由基代谢变化。通过了对ＤＣＶＳ时痉挛动脉的自由基含量、自由基清除酶超氧化物岐化酶（Ｃｕ－ＺｎＳＯＤ）与过氧化氢酶（Ｃａｔ）活性以及自由基代谢产物脂质过氧化物（ＬＰＯ）含量的测定。结果显示：（１）痉挛动脉的自由基含量比对照组明显升高（Ｐ＜０．０１）；（２）Ｃｕ－ＺｎＳＯＤ活性明显降低（Ｐ＜０．０５），Ｃａｔ活性明显升高（Ｐ＜０．０１）；（３）ＬＰＯ含量明显升高（Ｐ＜０．０１）。本实验结果证实ＳＡＨ后ＤＣＶＳ时痉挛动脉存在自由基的代谢紊乱，自由基介导的病理作用可能在ＤＣＶＳ发病机理中起重要作用。     

MRI和BAEP在多系统萎缩不同类型中的诊断价值

目的：探讨多系统萎缩（ＭＳＡ）的临床特点,以及磁共振成像（ＭＲＩ）和脑干听觉诱发电位（ＢＡＥＰ）对不同类型ＭＳＡ的诊断价值。方法：对５０例ＭＳＡ的临床资料、ＭＲＩ和ＢＡＥＰ进行回顾性分析。结累：５０例ＭＳＡ中,散发型橄榄桥脑小脑萎缩（ＳＯＰＣＡ）２５例,占５０．０％,临床上以小脑型共济失调为主要表现,ＢＡＥＰ最敏感,ＭＲＩ次之;纹状体黑质变性（ＳＮＤ）１５例,占３０％,以肌张力增高为主,ＭＲＩ最敏感,ＢＡＥＰ次之。Ｓｈｙ—ｄｒａｇｅｒ综合征（ＳＤＳ）１０例,占２０％,以直立性低血压和头晕为主,ＢＡＥＰ最敏感。而且将ＳＮＤ与原发性帕金森综合征（ＩＰＤ）的ＢＡＥＰ相比,前者的敏感性明显升高,差别有显著性。结抡：ＭＳＡ分型不同临床表现各有侧重,ＭＲＩ及 ＢＡＥＰ在 ＭＳＡ诊断和鉴别诊断中有极重要价值。     

听神经瘤显微手术中瘤周血管的保护与处理

目的探讨听神经瘤手术中瘤周血管保护的意义和方法。方法回顾性分析64例听神经瘤患者的临床与手术资料,全部病例均采用枕下乙状窦后入路,显微镜下切除肿瘤。结果听神经瘤64例,其中肿瘤全切52例(81.25%),次全切12例(18.75%)。术中小脑上动脉、小脑后下动脉及其主要的分支完整保留58例(90.62%)。面神经未能解剖保留11例(17.19%);术后早期面瘫21例(32.81%),6个月至6年的随访期中14例无改善;术后死亡3例(4.69%)。结论手术中注意保护肿瘤周围正常的供血动脉,对于减少相关的并发症,改善预后十分重要。熟悉解剖和细致的显微操作是提高听神经瘤手术效果的关键。     

Anatomy of the cerebellar arteries

Origin, course and distribution of the cerebellar arteries and of their branches are described. Anatomical drawings of the territory of these arteries are presented. They are based on a neuropathological study of 64 cases of cerebellar infarctions, the detailed study of which is reported elsewhere. The superior cerebellar artery (SCA) supplies a small brain stem territory, located on the dorsal tegmentum and the tectum of the upper part of the pons. The superior part of the cerebellum supplied by this artery includes the following lobules: lobulus anterior, lobulus simplex, lobulus semilunaris superior, and, in the vermis, lobulus centralis, culmen and clivus. The dentate nucleus belongs to this territory. The anterior inferior cerebellar artery (AICA) irrigates a ponto-cerebellar territory. It usually supplies the lateral territory of the lower part of the pons, the middle cerebellar peduncle, the flocculus and the neighbouring lobules of cerebellum. When the posterior inferior cerebellar artery (PICA) is hypoplastic, AICA takes over the territory usually supplied by the lateral branch of the PICA. The PICA always gives rami to the group of arteries supplying the dorsal medullary territory, but rarely participates to the supply of the lateral medullary territory. It supplies the lobulus semilunaris inferior, the lobulus gracilis, the lobulus biventer, the tonsilla cerebelli, and, in the vermis, the clivus, the tuber, the pyramis, the uvula and the nodulus. PICA never supplies the dentate nucleus. The flocculo-nodular lobe is usually supplied by 2 arteries: the flocculus is supplied by the AICA and the nodulus is supplied by the PICA.     

Multiple large and small cerebellar infarcts

To assess the clinical, topographical, and aetiological features of multiple cerebellar infarcts,18 patients (16.5% of patients with cerebellar infarction) were collected from a prospective acute stroke registry, using a standard investigation protocol including MRI and magnetic resonance angiography. Infarcts in the posterior inferior cerebellar artery (PICA)+superior cerebellar artery (SCA) territory were most common (9/18; 50%), followed by PICA+anterior inferior cerebellar artery (AICA)+SCA territory infarcts (6/18; 33%). One patient had bilateral AICA infarcts. No infarct involved the PICA+AICA combined territory. Other infarcts in the posterior circulation were present in half of the patients and the clinical presentation largely depended on them. Large artery disease was the main aetiology. Our findings emphasised the common occurrence of very small multiple cerebellar infarcts (<2 cm diameter).These very small multiple cerebellar infarcts may occur with (13 patients/18; 72%) or without (3/18; 22%) territorial cerebellar infarcts. Unlike previous series, they could not all be considered junctional infarcts (between two main cerebellar artery territories: 51/91), but also small territorial infarcts (40/91). It is suggested that these very small territorial infarcts may be endzone infarcts, due to the involvement of small distal arterial branches. It is possible that some very small territorial infarcts may be due to a microembolic process, but this hypothesis needs pathological confirmation.     

Intra-operative measurement of cortical arterial flow volumes in posterior circulation using Doppler sonography

Little has been reported on the flow volume of cortical arteries in the posterior circulation. During craniotomy in 28 patients, we measured the flow velocity of the arteries using microvascular Doppler sonography and recorded their arterial radii and the insonation angle. The flow velocities and radii were 25.7 cm sec-1 and 0.11 cm for the posterior cerebral artery (PCA), 19.5 cm sec-1 and 0.07 cm for the superior cerebellar artery (SCA), 19.6 cm sec-1 and 0.04 cm for the anterior inferior cerebellar artery (AICA), 14.9 cm sec-1 and 0.05 cm for the posterior inferior cerebellar artery (PICA), 28.3 cm sec-1 and 0.18 cm for the basilar artery, and 18.5 cm sec-1 and 0.16 cm for the vertebral artery, respectively. Since the flow velocities of these arteries were confined in a narrow range compared to the cross-sectional areas, the latter was considered to be the primary determinant for flow volume in these arteries. Based on certain assumptions, we estimated the flow volume of the PCA, SCA, AICA and ICA to be 60, 20, 10 and 10 ml min-1, respectively, which could be regarded as the current reference values for the arterial flow volumes.     

Neuroendoscopy in microvascular decompression for trigeminal neuralgia and hemifacial spasm: technical note

Miocrovascular decompression is an effective treatment for trigeminal neuralgia (TN) and hemifacial spasm (HFS). A complete cure cannot be obtained, and additional adjuncts for extended use of endoscopy are needed. The use of an endoscope combined with the operating microscope can enhance the surgeon's ability to view deep structures during operation. We study the application of combined microsurgical and endoscopic techniques in 21 cases of HFS and 12 cases of TN. With these techniques the surgeon can explore the ventral aspect of the brainstem and cranial nerves without further retraction, can see the groove caused by compression of the offending artery, and can confirm the proper position of the prosthesis after attachment to the dura by fibrin glue. In HFS the most common offending vessels in 75% of cases were the posterior inferior cerebellar artery (PICA) and anterior inferior cerebellar artery (AICA) and in 25% of cases the vertebral artery (VA). In trigeminal neuralgia the offending vessel in 60% of cases was the superior cerebellar artery (SCA), and in 40% of cases the AICA. The overall success rate was 97% with minimal morbidity 3% (facial palsy) and no mortality. The aim of this work is to study advantages and disadvantages of using endoscopy during microvascular decompression for TN and HFS.     

The clinical and topographic spectrum of cerebellar infarcts: A clinical—magnetic resonance imaging correlation study

We studied 34 consecutive patients with non–mass-producing cerebellar infarcts using a standard protocol of investigations including magnetic resonance imaging (MRI). We analyzed the topography of infarcts to determine the involved arterial territories and we correlated the findings with neurological dysfunction and potential causes of stroke. Sixteen patients had an infarct in the territory of the posterior inferior cerebellar artery (PICA); 2, in the territory of the anterior inferior cerebellar artery (AICA); 13, in the territory of the superior cerebellar artery (SCA); and 8 had junctional infarcts between the territories of the medial and lateral branches of the PICA or PICA/SCA territories. PICA or medial PICA territory infarcts were manifested by acute vertigo and truncal ataxia, while the patients with lateral PICA territory infarcts presented with unsteadiness, limb ataxia and dysmetria without dysarthria. Patients with infarcts in the AICA territory were characterized by limb and trunk ataxia associated with signs of lateropontine involvement. Patients with SCA territory infarcts presented with dysarthria, unsteadiness and/or vertigo, limb ataxia, and dysmetria. Cardiac embolism was the main cause of large infarcts in the territories of the PICA (8/16) or SCA (4/7). Multiple small infarcts were associated with vertebrobasilar atherosclerosis (8/12). These clinical–MRI correlations allow better definition of the topographic and etiological spectrum of cerebellar infarction, which was previously based on pathological studies in subjects with severe infarction.     

Neuroendoscopy in microvascular decompression for trigeminal neuralgia and hemifacial spasm: Technical note

Abstract

Miocrovascular decompression is an effective treatment for trigeminal neuralgia (TN) and hemifacial spasm (HFS). A complete cure cannot be obtained, and additional adjuncts for extended use of endoscopy are needed. The use of an endoscope combined with the operating microscope can enhance the surgeon’s ability to view deep structures during operation. We study the application of combined microsurgical and endoscopic techniques in 21 cases of HFS and 12 cases of TN. With these techniques the surgeon can explore the ventral aspect of the brainstem and cranial nerves without further retraction, can see the groove caused by compression of the offending artery, and can confirm the proper position of the prosthesis after attachment to the dura by fibrin glue. In HFS the most common offending vessels in 75% of cases were the posterior inferior cerebellar artery (PICA) and anterior inferior cerebellar artery (AICA) and in 25% of cases the vertebral artery (VA). In trigeminal neuralgia the offending vessel in 60% of cases was the superior cerebellar artery (SCA), and in 40% of cases the AICA. The overall success rate was 97% with minimal morbidity 3% (facial palsy) and no mortality. The aim of this work is to study advantages and disadvantages of using endoscopy during microvascular decompression for TN and HFS. [Neural Res 2000; 22: 522-526]     

Intra-operative measurement of cortical arterial flow volumes in posterior circulation using Doppler sonography

Abstract

Little has been reported on the flow volume of cortical arteries in the posterior circulation. During craniotomy in 28 patients, we measured the flow velocity of the arteries using microvascular Doppler sonography and recorded their arterial radii and the insonation angle. The flow velocities and radii were 25.7 cm sec^–1 and 0.11 cm for the posterior cerebral artery (PCA), 19.5 cm sec^–1 and 0.07 cm for the superior cerebellar artery (SCA), 19.6 cm sec^–1 and 0.04 cm for the anterior inferior cerebellar artery (AICA), 14.9 cm sec^–1 and 0.05 cm for the posterior inferior cerebellar artery (PICA), 28.3 cm sec^–1 and 0.18 cm for the basilar artery, and 18.5 cm sec^–1 and 0.16 cm for the vertebral artery, respectively. Since the flow velocities of these arteries were confined in a narrow range compared to the cross-sectional areas, the latter was considered to be the primary determinant for flow volume in these arteries. Based on certain assumptions, we estimated the flow volume of the PCA, SCA, AICA and ICA to be 60, 20, 10 and 10 ml min^–1, respectively, which could be regarded as the current reference values for the arterial flow volumes. [Neurol Res 2000; 22: 194-196]     

微血管减压术治疗125例面肌痉挛临床分析

目的探讨微血管减压术（MVD）治疗面肌痉挛（HFS）的疗效及并发症。方法125例HFS患者行乙状窦后入路面神经根MVD,手术时经绒球小叶显露面神经脑干段,仔细找寻责任血管后,将其推移离开面神经,在血管与脑干之间放置Teflon棉固定。结果术中发现责任血管为小脑前下动脉63例,小脑后下动脉34例,椎基动脉6例,椎基动脉及其分支血管（小脑前下动脉或小脑后下动脉）共同压迫22例。术后随访4年,全部病例抽搐完全消失,有效率为100％。1例术后出现面瘫（0．8％）,经针灸、理疗、药物治疗后仍有轻微的面瘫（House-Brackmann评分II级）;3例出现迟发性面瘫（2．4％）,经针灸、理疗、药物治疗后均完全恢复;1例出现咽部不适（0．8％）。无脑脊液漏及死亡病例。结论MVD是HFS最有效的治疗方法。术中不遗漏责任血管,在血管与脑干间恰当的放置Teflon棉,使责任血管远离面神经是提高手术疗效的关键。