经颅入路视神经管减压开放术的应用解剖

目的　探讨视神经管及有关结构在经颅视神经管减压开放术中的意义。方法　利用显微解剖和大体解剖学技术对 30个成人尸头和 5 0个颅骨的视神经管及有关结构进行观察。结果　视神经管颅口镰状襞在视神经上形成压迹者占15 .0 % ;与视神经相贴者占 6 6 .7% ;与视神经间有间隙者 18.3% .视神经管上壁前部厚后部薄 ,其长度为 (10 .0± 0 3)mm。视神经管颅口大于眶口。两侧视神经之间的夹角为 6 3.2°± 5 .8°。视神经管颅口与颈内动脉和眼动脉起始部关系密切。管内段眼动脉行于视神经腹侧 ,并有分支入视神经。结论　经颅视神经管减压术应切开镰状襞 ,利用视神经与颅正中矢状面的角度可确定视神经管上壁的位置。手术过程中应注意保护颈内动脉和眼动脉。     

螺旋CT仿真内镜技术在内镜下经鼻视神经减压术中的应用

目的 评价螺旋CT仿真内镜技术在内镜下经鼻视神经减压术中视神经管定位的应用价值.方法 回顾性病例研究.收集2009年10月至2011年3月在温州医学院附属眼视光医院行内镜下经鼻视神经减压术的患者45例,男38例,女7例,平均年龄(32.8±15.1)岁.所有患者术前行螺旋CT扫描并通过CT仿真内镜技术重建蝶窦或筛窦外侧壁及定位视神经管,并与术中实际结果进行对比.结果 除4例视神经管粉碎性骨折患者外,其他患者经CT仿真内镜均能很好显示蝶窦或筛窦外侧壁以及定位视神经管,并与术中结果基本一致.CT仿真内镜显示具有定位意义的蝶窦内骨嵴8例(19.51％),视神经-颈内动脉隐窝患者35例(85.37％),与术中结果一致.结论 螺旋CT仿真内镜能立体的、直观的显示蝶窦或筛窦外侧壁以及视神经管定位,可以为术者提供立体、直观的影像学资料.     

视神经管周围结构解剖的实验研究

目的 了解视神经管周围结构的解剖并为临床视神经管减压术及鼻窦手术提供解剖学依据.方法 实验研究.(1)成人干性颅骨标本50个,观察和测量筛窦和蝶窦的形态和大小;(2)甲醛溶液固定的成年湿性头颅标本15个,观察和测量蝶窦中部外侧壁与颈内动脉的距离、眼动脉起始处与颈内动脉的夹角,测量视神经颅内段的长度、视神经于视交叉前方之间的夹角、视神经颅内段颅口处两侧视神经内侧缘之间的距离,测量眼动脉在视神经管内的长度和直径;(3)选取6例经甲醛溶液防腐固定的完整成年无明显病变的成年湿性头颅标本,应用CT对筛、蝶窦进行轴位和冠状位扫描,观察视神经管与筛、蝶窦的关系;然后将CT扫描后的湿性头颅标本利用工业用钢锯行筛、蝶窦的断面(6例)、水平断面(3例)、冠状断面(3例)解剖,层厚均为6 mm.将筛窦、蝶窦、视神经管的CT扫描图像和相对应的解剖断面标本进行对比、观察.采用SPSS 13.0统计学软件进行数据处理.男性与女性湿性颅骨标本的测量值比较,采用两组独立样本的t检验.结果 全筛窦前后径(39.02±4.89)mm,前部横径(12.26±2.12)mm,前筛窦上下径(11.89±2.56)mm;蝶窦前后径(24.08±4.87)mm,蝶窦中部外侧壁与颈内动脉的距离(1.23±0.56)mm;眼动脉起始处与颈内动脉的夹角54.33°±7.89°;视神经颅内段的长度(9.91±2.89)mm,两侧视神经于视交叉前方之间的夹角59.89°±4.79°,视神经颅口处两侧视神经内侧缘之间的距离(14.26±3.23)mm;眼动脉在管内段的长度(5.38±1.87)mm,眼动脉外径(2.18±0.37)mm.男性与女性间的视神经颅内段长度(t=0.25)、两侧视神经于视交叉前方之间的夹角(t=0.71)、视神经颅口处两侧视神经内侧缘之间的距离(t=0.57)、蝶窦中部外侧壁与颈内动脉的距离(t=0.29)、眼动脉起始处与颈内动脉的夹角(t=0.99)、眼动脉在视神经管内段的长度(t=0.50)、眼动脉外径(t=0.52)测量值比较,差异均无统计学意义(P>0.05).结论 (1)切开视神经管内侧壁时,在蝶窦内切开的深度不宜超过13 mm,否则有可能损伤颈内动脉并引起大出血;(2)在进行视神经管减压术时,穿破前部筛窦的左右深度不宜超过15 mm,上下不宜超过12 mm,否则易穿破到对侧筛窦或向上穿破颅底进入颅内;(3)应特别注意保护眼动脉,防止眼部缺血和失明.     

视神经管和管内结构的断面观测

目的研究人视神经管和管内组织结构，为视神经减压术提供解剖参考数据，并为探索视神经间接损伤的病理机理提供形态学依据。方法18例视神经管和管内段视神经标本作连续组织切片后显微镜下观察，并取眶端、中部和颅端三处的切片，用计算机IMAGEPRO图像分析系统测量视神经管骨壁的厚度，视神经管、硬膜管、视神经及蛛网膜下腔的横截面积。计算视神经管前、中、后三部的蛛网膜下腔与骨管横截面积比(subarachnoid space to canal transverse area ratio SSTA/CTA)和蛛网膜下腔与硬膜管横截面积(subarachnoid space to dural sheath transverse area, SSTA/DSTA)。结果内壁中部是视神经管最薄的部位（0.48±0.35）mm。视神经管的中部最为狭窄，横截面积为（17.54±2.12）mm²。从颅端到眶端，蛛网膜下强的横截面积逐渐减小，SSTA/CTA和SSTA/DSTA也逐渐减小。结论因为代偿扩张的空间很有限，从视神经管颅端到眶端，可提供代偿扩张空间的能力逐渐减小，而且中部又是视神经管最狭窄的部位，所以视神经管内少量的出血或视神经轻度的水肿就会引起视神经受压，视神经减压术打开中部和眶端是手术成功的关键。(中华眼底病杂志,1999,15:24-26)     

应用计算机辅助三维重建技术重建和测量视神经管和管内结构

目的　重建人视神经管和管内结构,为视神经减压术提供解剖参考数据,为进一步探索视神经间接损伤的病理机制提供形态学依据。方法　应用计算机辅助三维重建技术重建６ 例成人视神经管及管内结构,并用计算机图像分析系统测量视神经管的厚度,视神经管、管内段视神经、硬膜鞘、蛛网膜下腔的横截面积和蛛网膜下腔的容积。在重建的三维模型上,对管内各结构间的空间关系进行系统观察。结果　视神经管内壁中部厚度为（０－４５ ±０－３５）ｍｍ ,是视神经管壁最薄的部位。管中部横截面积为（１８－２１ ±２－５０）ｍｍ２ ,是视神经管最狭窄的部位。蛛网膜下腔在颅口、中部及眶口处的横截面积分别为（４－４５±１－１２）ｍｍ２、（２－６８±１－３２）ｍｍ２ 、（１－２３±０－８３）ｍｍ２ ,依次呈逐渐减小趋势,其容积为（２１－１６±４－３１）ｍｍ３,可能为损伤后视神经水肿、硬膜出血的代偿空间。结论　视神经管内代偿扩张的空间有限,所以视神经轻度水肿和视神经鞘内少量出血就可能使视神经受压。当视神经间接损伤后,视神经管最狭窄的中部对视神经的束缚作用可能最强,而从视神经管的颅口到眶口段,代偿扩张空间逐渐减小。因此,切实开放视神经管和硬膜鞘的中段和前段是视神经减压术成功     

视神经管的显微解剖学

作者对83个尸体标本进行了研究,认为人的视神经管是一种复杂的解剖结构,可有多种正常的变异。对其邻近组织及与该区手术暴露有关的界标和尺度作了记录,并对视神经管颅外减压的眶筛途径也进行了研究,以观察颅外进路是否可以将视神经充分减压。资料和方法:对尸体的83个视神经管的正常解剖及其变异在3—40倍放大镜下进行研究。暴露视神经管可通过眶筛径路到达。取标准的内眥切口,沿骨膜下剥离,暴露出泪囊、筛骨前后神经血管束和眶内侧壁。通过一个开口进入筛窦和蝶窦;即可暴露视神经管(图1)。此刻用一个金钢小钻和微型刮齿从内侧通过眶筛径路进行视神经管的完全减压术(图1)。     

鼻内镜下视神经管减压术治疗外伤性视神经病变

目的探讨鼻内镜下视神经管减压术对外伤性视神经病变的疗效及预后相关因素。方法分析10例(10眼)鼻内镜下视神经管减压术治疗外伤性视神经病变的临床特征及治疗效果。10例术前CT资料显示眶部无明显骨折者4例,眶前部骨折5例,眶后部骨折仅1例;术前无光感者7例,有部分视力者3例。结果术后随访6个月,7例无光感者术后视力无改善者5例,3例有部分视力者术后视力有不同程度提高;4例眶部无明显骨折者2例视力有不同程度改善,5例眶前部骨折者3例不同程度改善,而1例眶后部骨折者术后视力无改善。无手术并发症。结论外伤性视神经病变预后因素可能包括眶部有无骨折、视力受损程度、接受治疗的措施及时间等;鼻内镜下视神经管减压术是目前治疗外伤性视神经病变的一种微创、有效的手段之一。     

不同入路视神经管减压开放术疗效分析

目的：对比分析不同入路视寞刘经管减压术的疗效。方法：比较1989年10月至2000年10月北京同仁医院收治178例进行不同入路视神经管减压术的患者的手术效果。结果：鼻外开筛视神经管减压开放术总有效率为64.5%，眶缘筛前-筛后入路视神经管减压开放术总有效率为63.0%。经颅视神经管减压开放术总有效率为78.0%。结论：经颅视神经管减压开放术，术野开阔，解剖清晰，可直接充分有效地开放视神经管骨壁，本术式疗效高，安全，有条件的地方应积极推广应用。     

60例眶颅沟通肿瘤的诊断分析

目的探讨眶颅沟通肿瘤的临床特征、种类及诊断方法。方法选择60例手术后经病理或随访结果证实的眶颅沟通肿瘤患者,所有患者均行CT扫描,54例行MR I扫描,其中增强扫描42例。20例摄视神经管X光像。结果最常见的阳性体征是眼球突出(58/60)、眶压升高(39/60)和视力下降(36/60),最常见的症状是头痛(22/60)。较多见的眶颅沟通肿瘤是脑膜瘤(20/60)、骨纤维异常增殖症(5/60)和转移癌(5/60)。眶颅沟通肿瘤的CT、MR I扫描及视神经孔X光像有一定影像学特征。眶颅沟通途径包括:视神经管、眶上裂和眶颅交界骨壁。结论掌握眶颅沟通肿瘤的临床特征、病种分类,综合运用CT、MR I和X光等检查方法可提高诊断和鉴别诊断水平。     

影像导航在鼻内镜下眼眶手术的临床研究

目的:探讨影像导航技术在鼻内镜眼眶微创手术中应用。方法:回顾性分析7例患者,其中视神经损伤3例;眶内球后异物3例;球后肿瘤1例(血管瘤)。所有病例均采用BrainLab影像导航系统及鼻内镜实施手术。结果:影像导航术前准备时问(包括配准、头架定位、常规器械注册等)10～20(平均15)min。手术区域影像标志与实体解剖标志间的误差≤1.3mm。影像导航可准确定位视神经等解剖标志,无手术并发症发生。结论:影像导航系统可以帮助术者在术中定位眼眶内重要的解剖结构,并可使手术视野扩展到内镜之外,使术者在术野中进行手术操作的同时,能顾及到术野周围的重要结构。特别是在复杂的手术中,可提高手术的精确性和安全性。     

A congruous superior quadrantanopsia following a junctional scotoma induced by asperogillosis

A 69-year old man presented to us with decreased vision in his right eye and a relative afferent pupillary defect. Under the presumption that he was suffering from retrobulbar optic neuritis or ischemic optic neuropathy, visual field tests were performed, revealing the presence of a junctional scotoma. Imaging studies revealed tumorous lesions extending from the sphenoid sinus at the right superior orbital fissure, with erosion of the right medial orbital wall and optic canal. Right optic nerve decompression was performed via an endoscopic sphenoidectomy, and histopathologic examination confirmed the presence of aspergillosis. The patient did not receive any postoperative antifungal treatment; however, his vision improved to 20 / 40, and his visual field developed a left congruous superior quadrantanopsia 18 months postoperatively. A junctional scotoma can be caused by aspergillosis, demonstrating the importance of examining the asymptomatic eye when a patient is experiencing a loss of vision in one eye. Furthermore, damage to the distal optic nerve adjacent to the proximal optic chiasm can induce unusual congruous superior quadrantanopsia.     

Optic Neuropathy with Delayed Onset After Trauma: Case Report and Review of the Literature

The authors report a case of a 16-year-old healthy male who experienced loss of vision in the right eye immediately after getting punched by a fist. His visual acuity improved to 20/20 within hours, and the optic nerve head appeared normal. Computed tomography (CT) scan of the orbits showed fractures of the right inferior orbital wall and lamina papyracea. The morning after the injury, he awoke with right eye vision decline to count fingers. There was pallid optic nerve swelling. Magnetic resonance imaging (MRI) scan of the orbits showed right medial rectus enlargement and no optic canal abnormalities. The patient was treated with intravenous (IV) methylprednisolone with improvement in visual acuity. Literature of delayed traumatic optic neuropathy (TON) and anterior TON is reviewed.     

The revised anatomy of the canals connecting the orbit with the cranial cavity

Orbits are connected with the middle cranial fossa via the optic canal, the superior orbital fissure, the M-type orbitomeningeal foramen, the metoptic canal, an accessory anterior opening of the foramen rotundum, and Warwick’s canal. They are also in communication with the anterior cranial fossa via the ethmoidal canals and the A-type orbitomeningeal foramen. The anatomy of these conduits has been recently enriched with several details that are summarized and reviewed in this article.     

Computed tomography of the orbit

Computerized tomography (CT) has revolutionized the analysis of patients with orbital tumors. A new CT scanner devised by the author resolves structures less than 1 mm with an image section as thin as 2 mm. This improved resolution shows all the extraocular muscles, including the obliques; enlargement of the optic nerve to the orbital end of the optic canal; and the sclera, crystalline lens, aqueous, and vitreous. Experience with 700 orbital studies shows that CT scanning now identifies pathologic changes in the orbital soft tissues with the same diagnostic accuracy as bone pathology.     

Biometric study of the optic canal during cranial development

To study optic canal dimensions and symmetry during cranial development, 146 silicon rubber left- and right-side models of the optic canal were cast from 51 dry skulls and 22 individual bones. The sample was divided in three age groups: fetuses (including newborns), children and adults with ages ranging from seven months of fetal life to 68-year-old. A digital caliper was used to measure the optic canal orbital and cranial diameters as well as model length. Results for the right and the left sides were, respectively, in millimeters: a) Maximum diameter of the orbital opening: fetuses, 4.68/4.47--children, 5.51/5.41--adults, 5.43/5.34; b) Minimum diameter of the orbital opening: fetuses, 2.89/2.84--children, 3.54/3.61--adults, 3.78/3.73; c) Diameter of the cranial opening: fetuses, 3.79/3.76--children, 4.67/4.72--adults, 5.24/5.43; d) Length of the optic canal: fetuses, 3.27/3.05--children, 3.93/3.71--adults 4.94/5.21. The diameter of the cranial opening of the optic canal increases significantly (p < 0.001) during the fetal period and throughout child and adulthood. The greater and smaller orbital apertures increase during the fetal period and during childhood, keeping the same size in adulthood. Optic canal length increases at some point between childhood and adulthood. Concerning symmetry, the only significant difference found was greater right than left optic canal diameter on the orbital side.     

视神经外伤经颅视神经管减压术的效果分析

目的分析经颅显微视神经减压术治疗视神经外伤的效果。方法回顾性分析27例经颅显微视神经减压术的手术的时机,效果及影响疗效的相关因素。结果无光感患者13,手术有效率23．1％,视力为光感者11例,有效率63．6％;眼前手动者3例,均有效。总有效率48．1％。无手术并发症。有效患者均为2周内手术病例。结论单纯视神经受压,尚有光感以上视力的患者,早期、充分视神经减压术疗效确切。