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。     

鞍隔孔区解剖学研究及其临床意义

目的 通过鞍隔孔区结构的解剖学研究,分析经蝶入路脑脊液漏的发生机制,以及空蝶鞍(ES)的形成原因. 方法 对8例胎儿标本进行组织学连续切片后,做HE和Masson染色,并在显微镜下对鞍隔孔附近结构进行观察;另取10例成人尸头标本,模拟经蝶入路手术,并在手术显微镜下观察鞍隔孔区解剖结构. 结果 鞍上蛛网膜在垂体柄上端和其表面的软脑膜紧密结合,并转折进入鞍内;同时在垂体上表面处,鞍隔从四周紧密包绕并和表面的软脑膜紧密结合,而难以从组织学切片上分辨二者的界限:鞍上蛛网膜池由于蛛网膜、软脑膜和鞍隔的束缚而终止于鞍隔孔上部. 结论 鞍隔、软脑膜和鞍上蛛网膜三者之间存在着严密的解剖学关系,其也是防止脑脊液漏和ES发生的关键因素.这三者的先天性缺损、生理性或者病理性破坏,尤其是在经蝶入路中对垂体腺瘤的过分牵拉,导致鞍上蛛网膜和软脑膜分离或者破裂,可能是造成术中脑脊液漏发生的重要原因;另外鞍隔、软脑膜和垂体上表面之间的分离也可能是造成ES的关键因素.     

垂体窝及其毗邻结构手术相关显微解剖学研究

目的为临床神经外科提供鞍区,尤其是垂体窝边界及其毗邻结构的解剖参数与观察研究。方法用20例汉族成人尸头湿标本、漂白干颅骨15例进行精确显微解剖测量、观察及拍照。结果两前床突间距为(25.2±0.58)mm(20.3～30.0mm);前后床突间距(12.5±1.21)mm(8.1～17.5mm);两后床突间距(12.8±0.87)mm(8.0～17.0mm)。颈内动脉内侧缘与垂体外侧缘间距为(3.8±1.25)mm(2.3～7.1mm)。海绵窦内侧壁为垂体硬膜囊袋的一部分。正常情况下约有20%的垂体侧面向其外侧的海绵窦膨出。结论该显微解剖学研究提供了垂体区的重要解剖参数及其重要毗邻间隙与结构,为临床鞍区肿瘤、尤其是垂体瘤及海绵窦肿瘤的术前诊断、入路选择提供参考。     

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。     

翼点入路的显微外科解剖

目的 掌握经翼点入路对下丘脑区结构显露的显微外科解剖和显微外科技术。方法 在15例(30侧)经颈内动脉灌注红色乳胶的成人尸体头颅上模拟翼点人路，借助手术显微镜在6—25倍下通过鞍区手术间隙对下丘脑区重要结构进行显微解剖。结果 经翼点入路，通过鞍区的手术间隙，可对颈内动脉床突上段及其分支、基底动脉顶端、终板、垂体柄、结节漏斗区等下丘脑区重要结构进行良好的显露。结论 经翼点入路对鞍区病变，特别是动脉瘤和颅咽管瘤显微手术时，需熟悉局部解剖结构，利用显微外科技术保护周围重要血管和神经组织。     

中颅窝鞍旁区相关结构的外科显微解剖研究

目的 提供中颅窝鞍旁区相关解剖学依据,为鞍旁区手术提供帮助.方法 对38例成人尸颅进行手术巨微解剖,测量鞍旁区的硬膜关系、神经与血管走行及相邻结构的关系,并进行组织学观察.结果 在中颅窝,动眼神经、滑车神经、展神经包裹着蛛网膜与硬脑膜深入中颅窝硬膜之间,Meckel腔、三叉神经节及其三个分支包裹着后颅窝蛛网膜与硬脑膜像三指手套深入中颅窝硬膜之间,颈内动脉及颅内、外静脉亦穿行于中颅窝硬膜间;上述结构与海绵窦在中颅窝鞍旁两层硬膜形成一个腔,即硬膜间腔.结论 提出鞍区形态学特点,为中颅窝鞍旁区手术提供解剖学依据.     

蝶鞍内蛛网膜囊肿

作者报告在358例垂体肿瘤与240例视交叉蛛网膜炎患者中,有6例为蝶鞍内蛛网膜囊肿,均诊断为垂体瘤而进行了手术。术中于鞍内见充满无色液体,有半透明薄壁的囊肿。垂体窝明显扩大,同时鞍膈或其成分常缺如,在鞍结节及前床突区囊肿之前部直接与周围蛛网膜相连。蛛网膜囊肿充满蝶鞍并向鞍上扩展,其上极可突出于前床突上3～10毫米,且由视交叉向前延伸。视神经明显向测方移位,视交叉有不同程度的变形,且     

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．     

海绵窦解剖学新概念

目的探讨海绵窦区解剖学新概念,为海绵窦区手术提供详实的解剖学依据。方法利用手术显微镜对经福尔马林固定、彩色乳胶灌注的国人成年尸颅21例进行手术观察、测量海绵窦区的硬膜关系、神经与血管走行及相邻结构的关系;利用组织化学技术对硬膜、神经及血管之间的关系进行组织学观察。结果中颅窝鞍旁两层硬膜形成一个腔,即鞍旁硬膜间腔;在鞍旁硬膜间腔内,硬脑膜结缔组织包裹动眼神经、滑车神经、外展神经、Meckel腔、三叉神经节及其三个分支组成一纵行板层样结构,我们称之为神经隔。颈内动脉及颅内、外静脉亦穿行于鞍旁硬膜间腔内;神经隔将海绵窦区分隔成硬膜间隙区、血液间隙区及床突间隙区。结论通过对海绵窦区显微外科解剖学研究,提出了该区构筑学新概念,为颅底手术经硬膜间隙侧壁入路提供了外科解剖学依据。     

空蝶鞍

空蝶鞍一词是由Bush于1951年首先提出,以前曾对这种病例应用了不同的名称如“鞍内蛛网膜憩室”、“鞍内囊肿”、“鞍隔缺损”和“鞍内池”等。Bush在尸检中发现,有些病例鞍隔孔扩大或鞍隔完全缺损,垂体腺位于鞍底成一窄小的圆边形。其后有不少文献报告,并将其分为原发性和续发性两种。原发     

Anatomic and histologic features of diaphragma sellae that effects the suprasellar extension

This study aimed to determine the anatomical and histological features of diaphragma sellae that affect the suprasellar extension of intrasellar tumours. Twenty-four fresh adult cadavers were dissected for the study. Diaphragma sellae and pituitary capsules with sellar structures were resected. The diaphragma sellae was anatomically reviewed in detail. Immunohistochemical staining was performed for collagen types I, II, III, and IV. We examined the suprasellar growth of 13 sellar tumours extending superiorly through the diaphragma sellae by performing a series of 2704 endoscopic transnasal operations to analyse the anatomic and histologic results of the study. The diameter of the foramen of diaphragma sellae varied between specimens. Of 24 specimens, the diaphragma sellae in five (21%) had a tight-type foramen and those in 19 (79%) were more spacious. An increased expression of collagen types I and IV was observed in the pituitary capsule and the diaphragma sellae. In this clinical series, we observed that all types of sellar tumours could expand through the foramen. We observed radiologically and intraoperatively that the diaphragma sellae was displaced laterally and formed a dome in two cases with an adenoma extending to the suprasellar area. Two types of suprasellar extension through the diaphragma sellae are possible: 1) The collagen structure of diaphragma sellae can be destroyed by invasive tumours; 2) The morphology of the foramen of the diaphragma sellae facilitates suprasellar tumoural extension. All sellar tumours, including non-invasive cystic tumours, may invade the suprasellar area by expanding through the foramen of the diaphragma sellae.     

Morphometric Study of the Korean Adult Pituitary Glands and the Diaphragma Sellae

Objective

To investigate the morphometric characteristics of the pituitary gland and diaphragma sellae in Korean adults.

Methods

Using the 33 formaline fixed adult cadavers (23 male, 10 female), the measurements were taken at the diaphragma sellae and pituitary gland. The authors investigated the relationship between dura and structures surrounding pituitary gland, morphometric aspects of pituitary gland and stalk, and morphometric aspect of central opening of diaphragma sellae.

Results

The boundary between the lateral surface of pituitary gland and the medial wall of cavernous sinus was formed by the thin dural layer and pituitary capsule. The pituitary capsule adherent tightly to the pituitary gland was observed to continue from the diaphragma sellae. Mean width, length, and height of the pituitary gland were 14.3 ± 2.1, 7.9 ± 1.3, and 6.0 ± 0.9 mm in anterior lobes, and 8.7 ± 1.7, 2.9 ± 1.1, and 5.8 ± 1.0 mm in posterior lobes, respectively. Although all dimensions of anterior lobe in female were slightly larger than those in male, statistical significance was noted in only longitudinal dimension. The ratio of posterior lobe to the whole length of pituitary gland was about 27%. The mean thickness of pituitary stalk was 2 mm. The diaphragmal opening was 5 mm or more in 26 (78.8%) of 33 specimen. The opening was round in 60.6% of the specimen, and elliptical oriented in an anterior-posterior or transverse direction in 39.4%.

Conclusion

These results provide the safe anatomical knowledge during the transsphenoidal surgery and may be helpful to access the possibility of the development of empty sella syndrome.     

翼点入路相关脑池的显微外科解剖及神经内镜解剖的研究

目的研究翼点入路相关脑池的显微解剖及内镜解剖，为内镜辅助下经翼点入路进行鞍区显微手术提供解剖学依据。方法在15例尸头上经翼点入路开颅后，交替使用显微镜和内镜，利用鞍区自然的解剖间隙对鞍区脑池及其内结构进行观察，并将两者观察的结果进行比较。结果利用内镜可以更广泛地显示对侧ICA内侧壁及其发出的分支及穿支，并从正面显示垂体柄及鞍隔；可以协助观察术侧的ICA内侧壁及其发出的分支及穿支，PcoA及其发出的穿支动脉，并从侧面观察到垂体柄的全长及其表面的穿支动脉；通过打开的Liliequist膜可以更清晰，更广泛地显示BA及分叉，双侧的PCA，SCA，动眼神经。利用成角的内镜可以清晰地显示PcoA和AchA下壁，AcoA发出的下丘脑穿支及三脑室底部结构。结论运用内镜可以消除经翼点入路进行鞍区显微手术的显微镜观察的死角，减少术中为暴露深部病变而对脑组织及重要颅底血管和神经的牵拉，从而提高鞍区手术的疗效。     

内镜经蝶手术治疗鞍区病变的视力保护简

目的探讨内镜经蝶手术治疗伴视觉障碍鞍区病变的手术操作技巧，提高治疗视觉障碍的疗效。方法回顾性分析68例内镜经蝶手术治疗伴视觉障碍鞍区病变病人的临床资料，分析术前病人的病史、体征和影像学资料，术中操作技巧和所见鞍膈形态。及术后视觉障碍改善情况。结果肿瘤全切除60例，次全切除8例。随访6-36个月，术前病人视力下降、视野缺损者，术后1个月均基本恢复；未发现肿瘤复发。结论对鞍区病变的视力保护，术前预估鞍膈的病理形态非常重要，术中避免直接对视神经及血管结构的操作，可减少手术并发症，促进病人视觉障碍恢复。     

Predicting Arachnoid Membrane Descent in the Chiasmatic Cistern in the Treatment of Pituitary Macroadenoma

ObjectivePreoperative prediction of the arachnoid membrane descent in pituitary surgery is useful for achieving gross total removal and avoiding cerebrospinal fluid leakage resulting from tearing of the arachnoid membrane in the chiasmatic cistern. In this study, we analyzed the patterns of arachnoid membrane descent during or after pituitary tumor surgery and identified the factors related to this descent. MethodsAnalysis was restricted to pituitary macroadenomas not extending into the third ventricle or over the internal carotid artery. To minimize confounding factors, patients who underwent revision surgery, those who had a torn arachnoid during operation or small medial diaphragma sellae (DS) opening, and subtotal resections were excluded. We enrolled 41 consecutive patients in this retrospective analysis. The degree of arachnoid descent was categorized using intraoperative videos. Preoperative magnetic resonance findings, including tumor height, suprasellar extension, and variables including DS area and medial opening size, tumor composition, and displacement of the pituitary stalk and gland were evaluated to determine their correlations with arachnoid membrane descent. ResultsArachnoid membrane descent was significantly correlated with DS area and medial opening size. Based on T2-weighted images (T2WI) magnetic resonance (MR) images, tumor composition was significantly associated with arachnoid membrane descent. Other factors were not significantly correlated with arachnoid membrane descent. ConclusionT2WI of tumor composition and preoperative MR imaging of DS area and medial opening provided valuable information regarding arachnoid membrane descent. These parameters may serve as fundamental measures to facilitate complete resection of pituitary macroadenomas.     

额外侧入路手术切除前颅窝底及鞍区肿瘤

目的 探讨经额外侧入路手术切除前颅窝底及鞍区肿瘤的方法及手术效果。方法 回顾性分析2015年1~12月经额外侧入路手术切除的48例前颅窝底及鞍区肿瘤的临床资料,其中嗅沟脑膜瘤5例,鞍结节脑膜瘤19例,垂体腺瘤10例,颅咽管瘤14例。结果 肿瘤全部切除36例,次全切除 12例,无手术死亡病例。结论 经额外侧入路可较好暴露并切除前颅窝底及鞍区肿瘤,效果满意。     

鞍区脑池的显微外科解剖

目的 了解鞍区脑池的界限和相互毗邻关系。方法 采用显微外科技术解剖并观察鞍区脑池。结果 鞍区脑池包括颈内动脉池、后交通动脉池、颈内动脉—后交通动脉池、视交叉池、垂体池、终板池、Sylvian池近侧端、嗅池、脚间池、脚池和动眼神经池，小梁蛛网膜分隔各池。结论 ①鞍区脑池环绕视交叉池有序排列。②不同的手术入路或同一入路到达不同部位，所涉及的脑池及其解剖的方向和次序均不相同。     

Current concepts and controversies in the management of non-functioning giant pituitary macroadenomas

Despite their histologically benign nature, giant and 'invasive' pituitary tumors are one of the most complex neurosurgical challenges. In the present article, we discuss the current approaches to the management of giant pituitary tumors. Giant non-functioning pituitary tumors are usually confined inferiorly by the sellar dura, superiorly by the elevated diaphragma sellae, and laterally by an intact medial wall of the cavernous sinus. If the anatomical extensions of the tumor are understood and a radical tumor resection is achieved, the visual and long-term outcome can be extremely rewarding. The goals of surgery are to make a pathologic diagnosis and since the majority of these tumors are endocrinologically silent, the second goal should be to decompress the neural tissue. With the increasing experience and better understanding of anatomy of these tumors, trans-sphenoidal approaches have now replaced craniotomy for the excision of these tumors.