颈动脉海绵窦瘘治疗的进展(综述)

颈动脉海绵窦瘘的治疗问题迄今尚未彻底解决,常因颈内动脉和颈外动脉存在着很多交通支而使很大一部分病例术后复发甚至加重。近年来很多作者对海绵窦段颈动脉解剖作了更多研究,加上脑血管造影技术的改进,对本病的病理结构关系的认识较前明确,疗效较前有所提高。解剖学颈内动脉虹吸部发出很多小分支,可     

向鞍上、鞍旁扩展的经蝶窦手术入路相关结构的显微解剖研究

目的为扩大经蝶窦手术提供蝶窦外侧壁和海绵窦内侧面观、蝶骨平台骨窗腹面观以及蝶窦后方斜坡周围的显微解剖参数。方法20具干颅骨漂白标本(40侧)用于观察入路相关的骨性解剖结构;15具成人头颅灌注标本(30侧)模拟扩大经蝶窦入路,研究垂体周边解剖结构的位置关系,测量相应的距离或手术相关角度。同时,利用血管铸型技术,对鞍周静脉窦及动脉分支进行形态学观察。结果后组筛窦形成蝶旁、蝶上筛房,对扩大经蝶窦入路术中视野显露有直接影响。视神经管颅口内侧缘间距为(15.7±3.2)mm,鞍结节处颈内动脉间距为(13.9±3.8)mm,鞍结节后缘与筛板后缘之间的距离平均为(23.3±3.2)mm,视神经管与矢状面夹角为36.3°±1.6°。提示扩大经蝶窦手术入路相关的骨窗为“”型。结论扩大经蝶窦入路向鞍旁、鞍前、蝶骨平台扩展适合沿中线生长的的中、小型病灶。向鞍旁海绵窦扩展时,垂体与海绵窦段颈内动脉关系密切,增加施行扩大经蝶手术的风险。术中最易损伤的是颈内动脉和外展神经。     

高流量血管搭桥治疗海绵窦段动脉瘤的手术配合

对6例颈内动脉海绵窦段动脉瘤患者施行颈外动脉-大隐静脉移植、大脑中动脉架桥及动脉瘤孤立术。手术经过顺利,预后良好5例,死亡1例。提出颈内动脉海绵窦段动脉瘤的治疗是显微神经外科的难题,术前加强心理护理、充分准备物品,术中严密观察病情变化、熟练掌握手术配合是手术成功的关键。     

血管内治疗外伤性颈内动脉眼动脉段假性动脉瘤1例

颅内假性动脉瘤在动脉瘤中相当少见．是由于外伤、感染等原因引起血管壁全层损伤，导致血管破口处形成动脉瘤。因其不具有完整的动脉瘤壁结构，手术风险很高。外伤性假性动脉瘤多由颅底骨折碎片损伤颈内动脉引起，好发于颈内动脉海绵窦段．常伴有颈内动脉海绵窦瘘。但颈内动脉眼动脉段少见。本文对1例颈内动脉眼动脉段假性动脉瘤采用栓塞载瘤动脉方法治疗，效果满意。结合文献复习，报告如下。     

颞下锁孔入路的显微解剖学特点与临床应用研究

目的:研究颞下锁孔入路的显微解剖学,为临床颞下锁孔手术入路提供解剖依据与支持.方法:对6例国人成人尸头模拟颞下锁孔入路手术进行显微解剖,对各重要结构及间隙之间的距离进行测量,观察显露范围和解剖关系.结果:颧弓至小脑幕缘、脑干和前床突的最短距离分别为(42.3±4.7)mm、(42.8±2.5)mm和(59.8±6.1)mm.颞骨岩部扩大磨除前后的显露面积有显著差异(P＜0.05).颞下锁孔入路可以清楚的显露海绵窦外侧壁结构、鞍侧区、颈内动脉、后交通动脉、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结构显露.结论:颞下锁孔入路对于海绵窦外侧壁,岩斜区及鞍侧区手术具有良好显露效果,入路直接,损伤小.     

神经内镜下经海绵窦内侧壁途径切除海绵窦区转移瘤1例

目的探讨神经内镜下经海绵窦内侧壁途径切除海绵窦区转移瘤的手术方式。方法术中多普勒定位颈内动脉海绵窦段的行走,磨除蝶窦后壁骨质,暴露垂体及海绵窦内侧壁结构,准确定位海绵间窦,经海绵窦内侧壁途径切除海绵窦区肿瘤,术后多重颅底重建。结果术后常规病理转移性肝细胞性肝,免疫组化ck-p(+)、cd34(管+)、AFP(+)、cg-A(-)、ki-67(5%)、HMB45(-)、syn(-)、p53(+)。术后MR加增强提示海绵窦区转移瘤全切,术后随访3个月无脑膜脑膨出和脑脊液漏。结论神经内镜下结合术中超声多普勒经海绵窦内侧壁途径是处理海绵窦区病变的良好手术方式。     

外伤性鼻衄的血管内介入栓塞治疗

目的：探讨外伤性鼻衄的血管内介入栓塞治疗的策略和疗效。方法对10例行血管内介入栓塞治疗的外伤性鼻衄患者的临床资料进行了回顾性分析。结果全部病例均行脑血管造影检查,3例为颈内动脉海绵窦段破裂,其中两例脑血管造影为颈内动脉海绵窦段假性动脉瘤,采用弹簧圈栓塞破口、假性动脉瘤及闭塞同侧载瘤动脉,3例一次性栓塞破口、假性动脉瘤及载瘤动脉;7例为颈外动脉颌内动脉分支破裂,4例采用明胶海绵颗粒栓塞颌内动脉,即刻造影见颌内动脉远端不显影,3例采用弹簧圈栓塞颌内动脉,其中2例即刻造影弹簧圈远端破口不显影,1例颌内动脉破口大部分消失,同侧面动脉通过远端分支动脉向破口少量供血,2周后脑血管造影随访提示破口完全消失。6例随访3个月至2年,平均1.5年,无再出血及神经功能障碍。结论血管内介入治疗外伤性鼻衄是一种安全、微创和有效的治疗方法,外伤性鼻衄应尽早进行介入栓塞治疗。     

大型听神经瘤的手术治疗和显微手术技巧

目的探讨大型听神经瘤与毗邻神经、血管的关系，并对全切肿瘤的显微外科技巧进行讨论。方法回顾性分析经显微外科手术治疗的大型听神经瘤63例，对听神经瘤的供血来源、与颅神经及重要血管结构的解剖关系、肿瘤全切除的手术技巧进行分析。结果63例听神经瘤均有小脑前下动脉分支参与供血；术中发现面神经绝大多数位于肿瘤的前方（占84．1％），其中面神经位于听神经瘤前上方13例，正前方31例，前下方9例。术中面神经解剖保留51例（81％），肿瘤全切53例（84．1％）。结论掌握听神经的显微解剖特征和手术技巧对全切除听神经瘤和颅神经功能保护具有重要的意义。     

颞下窝咽旁间隙的显微外科解剖研究

目的 研究颞下窝、咽旁间隙的显微外科解剖，探讨该区域的解剖境界及临床意义。方法 选择经10％福尔马林固定成人头颈标本10具，显微镜下模拟耳前颞底，颞下窝入路的手术操作，逐层显露颞下窝和咽旁间隙，研究该区域肌肉、神经血管和骨性结构的相互及定位标志。结果 颞下窝内的主要结构有翼内肌、翼外肌、上颌动脉、翼静脉丛、下颌神经及其分支等。茎突隔膜将咽旁间隙分为茎突前区和茎突后区，颈内动脉、颈内静脉及Ⅸ、Ⅹ、Ⅺ、Ⅻ脑神经等重点结构位于茎突后区内。茎突隔膜由二腹肌后腹、茎突肌群、茎突舌骨韧带和茎突下颌韧带、茎突咽筋膜和由二腹肌延至胸锁乳突肌的筋膜构成。结论 颞下窝为下颌骨和翼内侧板之间的区域，咽旁间隙系颞下窝后方、鼻咽外侧及颈椎腹侧的区域；茎突隔膜包绕颈内动脉，为颞下窝咽旁间隙区域的重要解剖标志。     

海绵窦外侧壁肿瘤的诊断和显微手术治疗

目的：报道海绵窦外侧壁肿瘤的临床诊断和显微手术治疗效果。方法：回顾分析4年来收治的7例海绵窦外侧壁肿瘤的临床资料，7例临床均表现为海绵窦综合征，MRI检查显示一侧海绵窦外侧壁边界清楚的占位病变，颈内动脉海绵窦段向内侧移位，颈内动脉无狭窄或肿瘤包绕，全部采用显微手术治疗。结果：手术全切除6例，次全切除1例，无死亡病例，术后出现脑脊液漏1例，动眼神经麻痹1例。结论：海绵窦外侧壁肿瘤的诊断主要靠临床表现及MRI检查，采用合理的手术入路，施行显微手术治疗能取得较好疗效。     

Surgical approaches to the cavernous sinus--repair of a C-C fistula at the C5 portion of the internal carotid artery

It has been generally accepted that the direct approach to the cavernous sinus under the normal temperature is very difficult and dangerous. Bleeding from the cavernous sinus is thought to be very difficult to control. However, when the patient is kept in semi-sitting position during the operation, the venous pressure of the cavernous sinus can be decreased nearly to 0 and the cavernous sinus can be opened without any serious bleeding. Either insertion of Biobond soaked Oxycel or alternative insertion of fibrinogen soaked Gelfoam and thrombin soaked Gelfoam into the opened cavernous sinus is made to control bleeding. In the case of C-C fistula, if the cavernous portion of the carotid artery is trapped by application of temporary clips to the cervical portion of the external and internal carotid artery and the C2 portion of the internal carotid artery, one could perform the operation without any uncontrollable serious bleeding in the same manner. In such cases, in order to prevent ischemia of the brain during interruption of the internal carotid flow, EC-IC bypass is indicated and performed about two weeks prior to the direct attack of the cavernous sinus. The operation consists of subfronto-pterional transsylvian approach, removal of the anterior clinoid process, removal of the superior, lateral and inferior walls of the optic foramen as far anteriorly as possible, opening of the anterior inferior cavity and the medial cavity through the medial triangle in order to isolate the C3 and C4 portions of the internal carotid artery, and then exposure of the C5 portion of the internal carotid artery via the Parkinson's triangle.     

海绵窦上壁的显微外科解剖学研究

目的 研究海绵窦上壁的显微解剖,为海绵窦直接显微手术的开展提供形态学依据。方法 在手术显微镜下观察和测量了４４侧成人海绵窦上壁结构。 结果 海绵窦上壁呈纵长的四边形。外侧界为前床岩韧带和前床突外缘;内侧界为鞍隔的硬膜缘;前界为前床突基底部和镰状硬膜皱褶;后界为后床岩韧带。上壁的硬膜由浅、两层组成,分别与外侧壁的浅、深层相延续。颈内动脉穿出海绵窦上壁时,浅、深两层硬膜分别形成远侧硬膜环和近侧硬膜环。     

Topographic microsurgical anatomy of the paraclinoid carotid artery

In this publication, the authors describe the microanatomic topography of the entire paraclinoid area with respect to the paraclinoid segment of the internal carotid artery and its surrounding anatomical structures. Special attention was given to the borders of the paraclinoid area, cavernous sinus, arterial vessels, and cranial nerves passing through the region. The paraclinoid region was defined as a pyramid-formed space formed by the dural covering of the anterior clinoid process. The superior border is formed by the continuity of the anterior petroclinoid fold, anteriorly on the superior surface of the anterior clinoid process and medially in the direction of the diaphragma sellae. This dural sheet encircles the internal carotid artery and forms the so-called distal dural ring of the internal carotid artery. The medial border of the paraclinoid region is formed by the body of the sphenoid bone and the adjacent periosteal sheet. The inferior border is formed by a fibrous plate between the middle and anterior clinoid processes. This so-called proximal dural ring separates the venous compartments of the cavernous area from the paraclinoid area. The lateral border is formed by the lateral surface of the anterior clinoid process with its dural covering. The arterial supply of this region is provided by branches of the intracavernous carotid segment and the ophthalmic artery. The important nerves in close vicinity to the paraclinoidal area are the optic and the oculomotor nerves. Understanding and knowledge of the topographic anatomy of the paraclinoid area is essential for microsurgical exposure of this region. Electronic Publication     

Microvascular anatomy of the uncus and the parahippocampal gyrus.

The microanatomical examination of the uncal and the parahippocampal arteries was performed in 17 brain hemispheres injected with India ink and gelatin. The mentioned arteries may originate from the anterior choroidal artery, the internal carotid artery, the middle cerebral artery, and the posterior cerebral artery. The uncal or the unco-parahippocampal branches of the anterior choroidal artery were divided into rostral and caudal; the former were present in 70.6%, and the latter were present in 94.1%. The uncal or the unco-parahippocampal branches of the internal carotid artery, which originated 1.4 to 4.2 mm from its bifurcation site, existed in 58.8%. The same branches of the middle cerebral artery, which most often arose from the temporopolar artery, were present in 64.7%. Finally, these branches of the posterior cerebral artery, which usually arose from the anterior hippocampal artery, were observed in 47.1%. Large parahippocampal branches of the anterior choroidal artery were noted in 52.9%. The internal carotid artery and middle cerebral artery gave rise to these branches in 23.5 and 64.7%, respectively. The posterior cerebral artery always gave off 2 to 10 parahippocampal vessels. The largest of them originated within the rostral hippocampo-parahippocampal arterial complex. The authors discuss the microanatomical characteristics and possible clinical significance of the uncal and the parahippocampal arteries.     

Microsurgical anatomy of the distal anterior cerebral artery

The microsurgical anatomy of the distal anterior cerebral artery (ACA) has been defined in 50 cerebral hemispheres. The distal ACA, the portion beginning at the anterior communicating artery (ACoA), was divided into four segments (A2 through A5) according to Fischer. The distal ACA gave origin to central and cerebral branches. The central branches passed to the optic chiasm, suprachiasmatic area, and anterior forebrain below the corpus callosum. The cerebral branches were divided into cortical, subcortical, and callosal branches. The most frequent site of origin of the cortical branches was as follows: orbitofrontal and frontopolar arteries, A2; the anterior and middle internal frontal and callosomarginal arteries, A3; the paracentral artery, A4; and the superior and inferior parietal arteries, A5. The posterior internal frontal artery arose with approximately equal frequency from A3 and A4 and callosomarginal artery. All the cortical branches arose more frequently from the pericallosal than the callosomarginal artery. Of the major cortical branches, the internal frontal and paracentral arteries arose most frequently from the callosomarginal artery. The distal ACA of one hemisphere sent branches to the contralateral hemisphere in 64% of brains. The anterior portions of the hemisphere between the 5-cm and 15-cm points on the circumferential line showed the most promise of revealing a recipient artery of sufficient size for an extracranial-intracranial artery anastomosis. The distal ACA was the principal artery supplying the corpus callosum. The recurrent artery, which arose from the A2 segment in 78% of hemispheres, sent branches into the subcortical area around the anterior limb of the internal capsule.     

Strategies for embolization of the internal carotid artery for cavernous sinus tumors

Skull base tumors, in addition to blood supply from the external carotid artery, frequently receive a portion of their blood supply from the cavernous portion of the internal carotid artery, especially when the cavernous sinus is invaded by tumor. Preoperative embolization routinely includes obliteration of the supply to the tumor from the external carotid system. However, a variety of strategies are available that enable preoperative embolization of supply from the internal carotid artery as well. These include direct catheterization of cavernous branches of the internal carotid artery, temporary occlusion of the internal carotid artery during external carotid embolization, embolization of the internal carotid artery supply during temporary or permanent occlusion of the internal carotid artery, and internal carotid artery sacrifice. The angiographic anatomy in any particular case dictates these options.     

Strategies for Embolization of the Internal Carotid Artery for Cavernous Sinus Tumors

Skull base tumors, in addition to blood supply from the external carotid artery, frequently receive a portion of their blood supply from the cavernous portion of the internal carotid artery, especially when the cavernous sinus is invaded by tumor. Preoperative embolization routinely includes obliteration of the supply to the tumor from the external carotid system. However, a variety of strategies are available that enable preoperative embolization of supply from the internal carotid artery as well. These include direct catheterization of cavernous branches of the internal carotid artery, temporary occlusion of the internal carotid artery during external carotid embolization, embolization of the internal carotid artery supply during temporary or permanent occlusion of the internal carotid artery, and internal carotid artery sacrifice. The angiographic anatomy in any particular case dictates these options.     

The paraclinoid carotid artery: anatomical aspects of a microneurosurgical approach

The paraclinoid area is investigated anatomically for possible microneurosurgical approaches to the C3 segment of the internal carotid artery and to structures in the vicinity of the anterior siphon knee. Removal of the anterior clinoid process reveals a tight connective tissue ring that fixes the internal carotid artery to the surrounding osseous structures at the point of its transdural passage. Transection of this fibrous ring opens a microsurgical pathway to the carotid C3 segment. The artery is surrounded by a loose connective tissue layer that allows blunt preparation along the C3 segment, without compromising the cranial nerves and without damaging venous compartments of the cavernous sinus. This approach provides neurosurgical access to paraclinoidal aneurysms, to partly intracavernous aneurysms, and to carotid-ophthalmic aneurysms, allowing control of the proximal aneurysm neck and of the parent artery itself. In cases of tumors involving the medial sphenoid ridge, the apex of the orbit, or the cavernous sinus, the pericarotid connective tissue can serve as a guide layer for access along the internal carotid artery.     

Proposed classification of segments of the internal carotid artery: anatomical study with angiographical interpretation

The nomenclature and borders of the segments of the internal carotid artery (ICA) remain confusing. A classification of segments of the ICA is proposed based on constant anatomical structures, such as the carotid foramen and canal, the petrous bone, the petrolingual ligament (PLL), and the proximal and distal dural rings. The bilateral ICAs were dissected in 15 cadaveric head specimens using different neurosurgical approaches. The bilateral lacerum foramina were studied in five dry skulls. The bilateral segments of the ICA were also examined on carotid angiograms of 10 normal patients and another with the ophthalmic artery originating from the intracavernous portion of the ICA. The present classification divides the ICA into five segments in the direction of the blood flow. The cervical segment is extradural and extracranial, the petrous segment is extradural and intraosseous, the cavernous segment is interdural and intracavernous, the clinoidal segment is interdural and paracavernous, and the cisternal segment is intradural and intracisternal. The ICA did not pass through the lacerum foramen in any specimen. In all specimens, 1/8 to 5/8 of the lacerum foramen was under the deep dural layer of the cavernous sinus. The term 'lacerum segment' as used previously and called the 'trigeminal segment' by us cannot be justified. The PLL is the posterolateral border of the cavernous sinus and the lacerum and trigeminal segments should be included in the cavernous and petrous segments. The ophthalmic artery may originate from the clinoidal ICA, from the cavernous ICA, or from the middle meningeal artery. Instead of using the term 'ophthalmic segment,' the term 'cisternal segment' should be used for the anatomically distinct ICA in the subarachnoid space. This classification should be minimally affected by anatomical variations.