椎-基底动脉结合部相关手术入路的显微解剖研究

目的研究显露椎-基底动脉结合部的相关手术入路的显微解剖,评价显露效率及范围及优缺点。方法显微解剖10例(20侧)成人头颅标本,通过乙状窦前入路、枕下乙状窦后入路、远外侧入路及经口入路4种方法显露椎-基底动脉结合部,测量各自显露的距离和范围。显露范围行主观评分。结果乙状窦前入路到椎-基底动脉汇合点距离为(55.23±3.80)cm,枕下乙状窦后入路到椎-基底动脉汇合点距离为(58.93±2.49)cm,远外侧入路到椎-基底动脉汇合点距离为(50.03±3.50)cm,经口入路到椎-基底动脉汇合点距离为(18.78±2.09)cm。经口入路显露距离最短,远外侧入路次之,乙状窦前入路再次,枕下乙状窦后入路显露距离最长。显露范围经口入路最小,其他三者差异无统计学意义。结论远外侧入路显露椎-基底动脉结合部距离较短,范围较大,效率相对较高。     

乙状窦后手术入路的显微解剖和虚拟解剖

目的 探索运用显微解剖和虚拟解剖的方法 研究乙状窦后手术入路,为该入路提供多种方式的形态学基础. 方法 10具(20侧)头颅固定标本,在显微镜下模拟乙状窦后入路手术,观察桥脑小脑三角内结构,并以岩上窦乙状窦汇合处、内耳门为基点进行相关测量;磨除内听道后壁,暴露其内结构;5例患者薄层CT和MRI影像数据,利用Dextroscope系统进行计算机三维重建,虚拟解剖乙状窦后入路手术过程. 结果 岩上窦乙状窦汇合处距三叉神经、面听神经复合体、舌咽神经、舌下神经穿硬膜处的距离分别是(38.50±2.64)mm、(27.80±2.25)mm、(32.70±2.11)mm、(44.30±2.05)mm;内耳门距三叉神经、展神经、小脑幕、舌咽神经穿硬膜处的距离分别是(5.68±1.55)mm、(13.80±1.81)mm、(5.00±0.66)mm、(6.34±1.24)mm.以面听神经复合体和舌咽神经为标志将桥脑小脑三角分为前、中、后3个间隙;在内听道后壁磨除后,该区结构层次充分显示.Dextroscope系统成功模拟乙状窦后手术入路,可显示星点、横窦乙状窦膝、颈静脉孔、内耳门、岩尖、基底动脉系统等结构及其空间关系. 结论 将桥脑小脑三角分为前、中、后3个间隙,有助于了解其内神经血管等结构的层次特点;以岩上窦乙状窦汇合处、内耳门为基点进行测量,可量化结构间的关系,有助于判断各间隙深浅、空间大小;识别内听道内的解剖标志,有利于手术时保护其内结构;通过Dextroscope系统能个体化显示局部结构,方便术前方案的设计.两种方法 各有优缺点,两者互补能提高对乙状窦后入路手术时桥脑小脑三角内结构的认识.     

锁孔入路治疗基底动脉瘤的应用解剖

目的 :研究眶上、颞下锁孔入路到达基底动脉顶端的入路解剖 ,探讨其治疗基底动脉分叉部动脉瘤的可行性。方法 :在 2 1例福尔马林固定尸体头颅标本上测量入路相关数据 ,在 9例新鲜尸体头颅标本上模拟行内窥镜辅助经眶上锁孔入路、经颞下锁孔入路基底动脉分叉部动脉瘤夹闭的手术操作 ,观察显露范围及操作范围 ,入路中各解剖结构对手术区显露及操作的影响。结果 :眶上孔、角突及颧弓上缘颞颧缝处与同侧及对侧后床突尖的距离分别为 (61.5± 1.7)mm、(92 .1± 3 .6)mm、(3 3 .5± 3 .1)mm、(73 .6±1.1)mm、(95 .6± 1.7)mm、(5 2 .3± 2 .2 )mm ;眶上孔、角突及颧弓上缘颞颧缝处与同侧及对侧后床突尖分别连线与中线的夹角分别为 (3 6.6± 1.2 )°、(8.5± 2 .3 )°、(82 .6± 3 .0 )°、(4 5 .1± 3 .0 )°、(3 0 .5± 3 .4)°、(83 .5± 4.0 )°。眶上、颞下锁孔入路均能通过多种神经血管间隙达到靶区 ,显露良好 ,照明充分 ,操作空间充分。结论 :采用内窥镜辅助的锁孔入路能满意的治疗基底动脉分叉部动脉瘤。     

经翼点入路鞍区手术间隙显微解剖研究

目的 对鞍区的显徽解剖研究，进一步掌握和熟悉鞍区内重要结构及其毗邻关系，为临床提供参考．方法 15例(30侧)福尔马林固定的成人头颅标本，模拟翼点入路双侧开颅，对鞍区手术常用的3个手术间隙及其内部结构进行解剖和测量．结果 描述和测量了各间隙内血管和神经的毗邻、走行及直径、长度．间隙I为视交叉间隙，垂体柄的形状呈上粗下细的近似圆锥形，与活体差异较大，翼点入路中通过间隙Ⅱ更能清楚地看见垂体柄；间隙Ⅱ为视神经、颈内动脉(ICA)和大脑前动脉(ACA)问隙，ICA床突上段分为眼段、交通段和脉络膜段；间隙Ⅲ为ICA、小脑幕游离缘间隙．AchA是视束的主要供血动脉之一．结论 在鞍区显微手术中，间隙I、Ⅱ是最常用的间隙，间隙Ⅲ、Ⅳ主要配合间隙I、Ⅱ完成手术．间隙Ⅲ内进行手术操作时，动眼神经的识别和保护比较重要．垂体上动脉分支对视神经血供有非常重要的作用，熟悉这3个间隙的显徽解剖是鞍区手术成功的关键．     

翼点入路不同视角下鞍区常用手术间隙的显微解剖

目的经翼点入路不同视角下对鞍区手术间隙Ⅰ、Ⅱ进行显微解剖学研究,掌握和熟悉手术间隙的界线、大小及不同视角下其内重要结构的可见度及临床意义。方法15例成人湿性头颅标本模拟翼点入路双侧开颅,经手术显微镜沿颅底方向在不同手术视角(0°、30°、45°、60°)下对鞍区手术间隙Ⅰ、Ⅱ进行观测,所得数据用SPSS10.0软件进行统计学分析。结果在不同视角下,描述和测量了间隙Ⅰ、Ⅱ内血管和神经的毗邻、走行、直径和长度。两个间隙沿颅底视角从0°至60°,内侧边、外侧边均逐渐延长,底边逐渐缩短,且在30°视角下面积最大。结论间隙Ⅰ、Ⅱ是鞍区手术中最常用的间隙,在30°视角下,其手术操作空间最大;后交通动脉、颈内动脉末端及基底动脉分叉部在30°视角下显露最充分,最利于手术的进行。     

颞底-经小脑幕手术入路的应用解剖学

目的 :对后颞部进行解剖学研究 ,为颞底 -经小脑幕手术入路提供解剖学基础。方法 :采用干性颅骨标本 2 0例及福尔马林固定的头颅标本 15例 ,进行解剖研究和模拟颞底 -经小脑幕入路。结果 :横窦从窦汇处开始向前逐渐升高 ,在顶乳突缝前角处 ,呈弧形向外移行于乙状窦 ,上缘与颧弓延长线的距离为 (11.2± 2 .2 )mm (8.2～ 14 .5mm )。顶乳突缝前角、星点与STP距离分别是 (2 .1± 2 .6)mm (0～ 9.3mm) ;(2 0 .4± 4.0 )mm(14 .1～ 2 6.4mm )。星点位于横窦上缘上、横窦上 1/2、横窦下 1/2、横窦下缘下分别占 16.7%、2 6.7%、3 3 .3 %、2 3 .3 %。颧弓、乳突上嵴与其相对应的颅中窝底相平。结论 :颞底 -经小脑幕入路骨窗的关键孔 (孔 1) :圆心在乳突上嵴 ,孔后缘与顶乳突缝前角相切。孔 2 :于关键孔后方 ,下缘与颧弓延长线的距离为 15mm。孔 3 :于关键孔前方 ,下缘平颧弓。星点变异大 ,不易作为定位横窦的标志。     

经翼点入路鞍区手术间隙显微解剖研究

目的对鞍区的显微解剖研究,进一步掌握和熟悉鞍区内重要结构及其毗邻关系,为临床提供参考.方法 15例(30侧)福尔马林固定的成人头颅标本,模拟翼点入路双侧开颅,对鞍区手术常用的3个手术间隙及其内部结构进行解剖和测量.结果描述和测量了各间隙内血管和神经的毗邻、走行及直径、长度.间隙Ⅰ为视交叉间隙,垂体柄的形状呈上粗下细的近似圆锥形,与活体差异较大,翼点入路中通过间隙Ⅱ更能清楚地看见垂体柄;间隙Ⅱ为视神经、颈内动脉(ICA)和大脑前动脉(ACA)间隙,ICA床突上段分为眼段、交通段和脉络膜段;间隙Ⅲ为ICA、小脑幕游离缘间隙.AchA是视束的主要供血动脉之一.结论在鞍区显微手术中,间隙Ⅰ、Ⅱ是最常用的间隙,间隙Ⅲ、Ⅳ主要配合间隙Ⅰ、Ⅱ完成手术.间隙Ⅲ内进行手术操作时,动眼神经的识别和保护比较重要.垂体上动脉分支对视神经血供有非常重要的作用,熟悉这3个间隙的显微解剖是鞍区手术成功的关键.     

极外侧经髁入路的显微解剖研究

目的 为极外侧经髁入路的临床应用提供翔实的显微解剖学资料和参数，以利于术中重要血管、神经结构的识别和保护。方法 在10例干性颅骨标本上，对本入路相关的骨性结构进行观察、测量和拍照。模拟极外侧经髁入路，对10例尸头标本进行显微解剖，并对入路相关的重要解剖结构进行观察、测量和拍照，尤其关注枕下段椎动脉的识别和保护及枕髁的安全磨除。结果 本入路涉及众多的肌肉、血管、神经结构，它们的关系复杂；枕下段椎动脉行程曲折。结论 观察和测量的结果有助于术中重要血管、神经结构的识别和保护。     

颞下经下颌入路相关骨性结构解剖及其临床意义

目的研究与颞下经下颌入路相关的骨性结构解剖,为扩大手术暴露提供解剖学参考。方法选用成人尸头10例(20侧),经模拟手术后去除软组织,显露相关骨性结构,进行观察和测量。结果颧弓是暴露中颅底和颞下窝的关键,颧弓长度和下颌关节窝宽度分别为32.9±2.6mm和15.5±1.3mm;下颌孔位于下颌升支内侧面中央略偏后上方,下颌升支的斜行截骨安全且可以获得最佳的纵向暴露;颞下窝,翼腭窝和咽旁间隙骨性结构复杂,腔隙众多且互为交通;茎突是重要的解剖标志,其根部至颈静脉孔后缘仅2.95±0.25mm。结论颞下经下颌入路暴露充分,掌握相关骨性解剖对手术治疗侧颅底区沟通性肿瘤具有重要意义。     

经穹隆间第三脑室底锁孔入路的显微解剖

目的 探索经穹隆间第三脑室底锁孔入路的可行性和手术方法。 方法 设计经穹隆间第三脑室底锁孔入路(第三脑室底切口起自灰结节向后,经乳头体间,止于后穿质)。运用解剖学方法在导航辅助下在16例尸头标本上模拟经穹隆间第三脑室底锁孔入路手术,在手术显微镜下对手术显露进行观察,利用导航作解剖学测量。 结果 导航辅助下能顺利完成16例尸头标本的经穹隆间第三脑室底锁孔入路手术。冠状缝与矢状缝交点到室间孔上缘、丘脑间黏合、乳头体和中脑导水管上缘的距离分别为（68.4±4.6）mm、(66.3±6.0)mm、(86.3±5.3)mm、(82.0±7.6)mm,冠状缝与矢状缝交点到基底动脉末端分叉的操作距离为(91.8±5.0)mm。灰结节向后经乳头体间止于后穿质切开第三脑室底可获得长（9.5±2.6）mm的手术通道。术中经第三脑室底切口能清晰显露脚间池内的基底动脉末段、大脑后动脉P1段、P2段、小脑上动脉、后交通动脉以及它们的穿通支血管。向前解剖Liliequist膜可显露斜坡和鞍背,侧方可显露出动眼神经,向后显露出脚间窝。基底动脉末端分叉多偏于左侧（68.8%）,两侧大脑后动脉多向前外侧斜行（68.8%）。大部分大脑后动脉夹角上有1～4支小穿支血管自基底动脉末端分出。 结论 经穹隆间第三脑室底锁孔入路在技术上可行,深入研究可望应用于基底动脉末端动脉瘤的直接手术。     

垂体上动脉的显微外科解剖及其临床意义

目的：为探讨垂体上动脉在鞍区显微外科手术时的意义,以及与颈内动脉眼动脉段动脉瘤发生的关系。方法：研究了２４例颅脑４８侧颈内动脉发出的垂体上动脉的显微外科解剖。结果：垂体上动脉起自颈内动脉眼动脉段,有１～４支,可分为单支型（３７．５％）和多支型（６２．５％）。平均支数为２．２±１．０支,直径为０．２６±０．１（０．１６～０．４８）ｍｍ。起点在颈内动脉起点远侧５．８±２．０（３．６～１８．６）ｍｍ。该动脉起始后向内、后、上行至视交叉下前面,发出分支与对侧垂体上动脉和后交通动脉分支相互吻合,构成漏斗周围吻合网,分布至漏斗、垂体、视交叉。且有一恒定分支折返前行至视神经,它对视神经的血液供应起着非常重要的作用。结论：该动脉的显微解剖,对理解颈内动脉瘤的发生以及鞍区肿瘤的外科手术有重要的临床意义。     

后交通动脉池及相关蛛网膜的显微解剖研究及临床意义

目的　对后交通动脉池（PComA池）及相关蛛网膜的显微解剖特点进行描述并探讨其临床意义。 方法　在手术显微镜下,对10例(20侧)福尔马林固定的尸头标本进行显微解剖,观察PComA池及相关蛛网膜的膜显微特点。 结果　PComA池出现率60%（12侧）。组成PComA池前壁为后交通膜,若此膜缺失,则与与颈内动脉池（ICA池）相通;后壁为liliequist膜间脑叶和中脑叶;内侧壁为颈内动脉内侧膜以及liliequist膜中脑叶和间脑叶发出的纤维或束带;外侧壁前段为ICA外侧膜或颞叶内侧面,后段为liliequist膜中脑叶发出的许多附着于动眼神经和PComA上的蛛网膜小梁;上外壁为脚膜;底壁为颅底蛛网膜和liliequist膜间脑叶,各个膜的特点各不一样。 结论　明确了PComA池及相关的膜的组成和特点及临床意义。     

The microsurgical anatomy of the pancreas

70 prepared human pancreas were studied by methods of the three dimension sections, macro-microscopic preparation and duct injections were studied. Regularities of the first order lobules structure and peculiarities of duct system architecture were revealed. The presence of paraduodenal, paracholedochal, perivasal loose connective tissue, lobular organ structure and the presence of interlobular connective tissue septae and peculiarities of spatial distribution of the ducts are the anatomical basis of microsurgical interventions to the pancreas.     

健康体检成人基底动脉弯曲的磁共振血管成像影像解剖学特征

目的 探讨健康成人基底动脉弯曲的MR血管成像(MRA)表现及其解剖因素。方法 回顾性研究。2015年3月—2016年5月,北京丰台医院健康体检成人MRA检出基底动脉弯曲160例,其中男99例、女61例,年龄30~65岁。在基于MRA重建的最大密度投影(MIP)图像上观察基底动脉及椎动脉颅内段的形态、走行。应用SPSS 16.0软件,采用χ²检验比较健康人群基底动脉弯曲在椎动脉优势、椎动脉走行及汇合点变异间的分布差异性。结果 MRA检出基底动脉弯曲160例中,104例(65.0%)基底动脉右侧凸弯,56例(35.0%)基底动脉左侧凸弯,基底动脉右侧凸弯型占比多于左侧凸弯型。104例基底动脉右侧凸弯中84例(80.8%)为左优型椎动脉,56例基底动脉左侧凸弯中23例(41.1%)为右优型椎动脉,不同基底动脉弯曲类型间左优型与右优型椎动脉占比的差异有统计学意义(P＜0.017)。基底动脉右侧凸弯不伴左侧椎动脉优势型20例中,双侧椎动脉汇合前走行不对称者13例(65.0%)、对称者7例(35.0%),双侧椎动脉汇合点偏左侧8例(40.0%)、偏右2例(10.0%)、居中10例(50.0%);基底动脉左侧凸弯不伴右侧椎动脉优势型33例中,椎动脉汇合前走行不对称者23例(69.7%)、对称者10例(30.3%),双侧椎动脉汇合点偏左侧13例(39.4%)、偏右6例(18.2%)、居中14例(42.4%),两组间双侧椎动脉走行及汇合点位置差异均无统计学意义(P值均＞0.05)。结论 基底动脉弯曲的健康成人多伴发椎动脉优势变异;因其特殊的血流动力学特点,椎动脉优势可能是引发基底动脉弯曲的解剖学因素之一。     

Corpus callosum: microsurgical anatomy and MRI

The anatomy of the corpus callosum has received renewed interest during recent years due to the increasing number of callosotomies performed to treat intraventricular lesions, as well as some forms of generalized epilepsy. We have previously reported on the microsurgical anatomy of the corpus callosum and identified specific anatomical reference landmarks that can be used during surgery. In the present study we have continued the anatomical aspect of this earlier work in a larger number of cases, with in vitro observations (brain out of skull) being compared with the corresponding in vivo features seen in sagittal MRI slices. Fifty-three in vitro microsurgical callosotomies was performed and the data collected compared with a series of 57 in vivo normal MR callosal images. Callosal dimensions were measured on both the anatomical and MRI material, thus overcoming the problems associated with in vitro callosal deformation. Of the anatomical landmarks studied the distance from the genu of the corpus callosum to the bifurcation of the columns of the fornix was found to be useful for the intraoperative evaluation of the extent of rostral callosotomy, as it is not significantly changed in in vitro. The main microsurgical features of rostral callosotomy are presented.     

与上颌动脉结扎术有关的应用解剖

目的：为临床顽固性鼻后部出血经上颌窦后壁径路上颌动脉结扎止血提供解剖学基础。方法：解剖了４０侧上颌动脉并将上颌骨颞下面划分为四个区，结合１２０侧干燥颅骨，对照观察了该动脉翼腭部及主要分支的行程、管径大小、分支类型。结果：上颌动脉翼腭部行于上颌骨颞下面后上区内，并在该区发出上牙槽后动脉、眶下动脉、腭降动脉、蝶腭动脉四条主要分支；上颌动脉翼腭部的长度为１４．８±２．９ｍｍ，管径为２．５±０．６ｍｍ；蝶腭动脉管径为２．０±０．７ｍｍ，自发出至入翼上颌裂间的长度为５．８±２．１ｍｍ。结论：上颌窦开窗时应充分暴露上颌窦后壁的后上部，结扎部位宜选在紧贴上颌动脉翼腭部发出第一分支后缘处及蝶腭动脉的起始部位。     

Corpus callosum: microsurgical anatomy and MRI

Abstract: The anatomy of the corpus callosum has received renewed interest during recent years due to the increasing number of callosotomies performed to treat intraventricular lesions, as well as some forms of generalized epilepsy. We have previously reported on the microsurgical anatomy of the corpus callosum and identified specific anatomical reference landmarks that can be used during surgery. In the present study we have continued the anatomical aspect of this earlier work in a larger number of cases, with in vitro observations (brain out of skull) being compared with the corresponding in vivo features seen in sagittal MRI slices. Fifty-three in vitro microsurgical callosotomies was performed and the data collected compared with a series of 57 in vivo normal MR callosal images. Callosal dimensions were measured on both the anatomical and MRI material, thus overcoming the problems associated with in vitro callosal deformation. Of the anatomical landmarks studied the distance from the genu of the corpus callosum to the bifurcation of the columns of the fornix was found to be useful for the intraoperative evaluation of the extent of rostral callosotomy, as it is not significantly changed in in vitro. The main microsurgical features of rostral callosotomy are presented.     

Endovascular treatment of bilateral carotid artery occlusion with concurrent basilar apex aneurysm: a case report and literature review

We report a case of successful endovascular treatment of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. An elderly female patient with subarachnoid hemorrhage (SAH) onset was admitted to the hospital. Computed tomography (CT) and digital subtraction angiography (DSA) confirmed the presence of bilateral carotid artery occlusion with concurrent basilar apex aneurysm. Brain blood supply was provided by the bilateral vertebral artery through the basilar artery. We treated the aneurysm with the endovascular approach by embolizing the aneurysm with three coils. The patient recovered well after surgery and showed no recanalization of the aneurysm on a one-year follow-up DSA. We also reviewed six similar cases found with a PUBMED database search (1980-2010), including those with bilateral common carotid artery occlusion. In conclusion, by using the endovascular approach, bilateral carotid artery occlusion with concurrent basilar apex aneurysm was efficiently treated.     

The microsurgical anatomy of the hypoglossal canal

Background  The hypoglossal canal (HC) is a region of the skull base whose involvement in many pathological entities is often ignored. Adequate knowledge of the anatomy of the HC and its related bony, neural, and vascular structures is essential for surgery of lesions involving this area. Methods  Ten adult human cadaver heads from a US source fixed by formalin (20 sides) and 20 dry human skulls from Indian sources (40 sides) were used in this study. Various aspects of the anatomy of this region including the size, course and variation of the hypoglossal nerve and its relationship to the adjacent and canalicular course were recorded. Results  The left HC was located at 10 o’clock and the right HC at the 2 o’clock position with respect to the foramen magnum. The canal was surrounded superiorly by the jugular tubercle, superolaterally by the jugular foramen, laterally by the sigmoid sinus and inferiorly by the occipital condyle. All dry skulls were drilled in the horizontal plane at an axis of about 45° and directed slightly upwards. Conclusions  Detailed knowledge of the microsurgical anatomy of the region of the HC is crucial when performing surgery for lesions of the condylar region, the lower clivus, and ventral brain stem. This study provides the knowledge required to achieve accurate orientation and effective maneuvers during surgical procedures for treatment of the patient without injuring the vital neural and bony structures.