侧脑室颞角显微解剖与相关手术入路的研究

目的 研究侧脑室颞角显微手术解剖.方法 结合侧脑室颞角手术入路对13个成人尸头进行侧脑审颞角及脉络膜裂显微镜下解剖,获取图像资料.结果 打开侧脑室颞角后海马及侧副隆起为主要标志.颞角脑室壁与丘脑、尾状核、胼胝体及穹窿等神经结构相关,进一步打开颞角脉络膜裂可暴露环池和大脑脚池内的脉络膜前动脉及脉络膜后外侧动脉.结论 组成颢角的神经结构重要,暴露颢角时应注意保护神经功能区,打开脉络膜裂可治疗累及颢叶内侧及环池的病变.     

岛叶形态结构特点、毗邻关系及相关入路的解剖学研究

目的 提供岛叶及其相邻结构的解剖数据以指导该区域的显微外科手术,以期更好的完成岛叶相关手术人路. 方法 对15具(30侧)经10%福尔马林同定的国人成年头颅标本进行研究,测量和描述岛叶自身解剖结构标志及其与周围相关结构的距离. 结果 岛叶是旁边缘结构的一部分,它构成大脑皮层的内陷部分,形成外侧裂的基底部.岛叶由额眶盖、额顶盖和颞盖共同围成的岛盖部包绕,内侧移行为钩状的最外囊即为岛叶皮质下的白质部分,向内与外囊、屏状核、内囊、豆状核、尾状核和背侧丘脑相邻,形成一个倒金字塔形的结构分隔端脑与边缘结构. 结论 熟悉岛叶及其周围结构的显微解剖,能指导术者经岛叶入路治疗基底节区脑出血、岛叶胶质瘤、颢叶癫痫等该区域的一系列神经外科的多发病与常见病.     

经外侧裂-岛叶与颞叶上回入路清除基底节区出血的疗效对比分析

目的分析经外侧裂-岛叶入路清除高血压基底节区脑出血的疗效。方法回顾分析49例单纯基底节区内囊以外的血肿患者,其中经外侧裂-岛叶入路显微手术治疗21例,经颞叶皮质入路手术治疗28例。从手术方法、血肿暴露、血肿清除难易、术中止血、术中脑组织损伤、术后复查、患者恢复方面进行对比分析。结果经外侧裂-岛叶与经颞上回入路清除高血压基底节区脑出血组比较,在72 h再出血率及术后3个月日常生活能力评分(ADL)中的Barthel指数评分比较,差异有统计学意义(均P0.05)。结论经外侧裂-岛叶入路清除高血压基底节区脑出血的效果优于经颞上回入路。     

经外侧裂-岛叶清除基底节血肿手术入路的解剖

目的探讨基底节脑出血手术中,经外侧裂岛叶入路的相关结构的解剖,做到既能彻底的清除血肿,又能最大程度地保护脑组织,减少术后并发症发生。方法对10例(20侧)成人尸头标本进行外侧裂、岛叶、岛盖、大脑中动脉、基底节的相关解剖。结果①外侧裂的表面有3个分支与岛盖关系密切,为暴露岛叶提供有利条件;②岛叶呈一个金字塔外形,表面由4～7个岛回组成,周围以环岛沟为界与额顶颞叶分隔开;③大脑中动脉的M1沿蝶骨嵴向外走形,多在岛顶前下方的岛阈附近分叉;M2段彼此""V"字形,或"网眼状",在岛叶表面向后上扇形展开,并发出许多微小的穿支血管供应岛叶皮层。④岛叶向内对应了基底节、内囊,丘脑等结构,本研究中发现,在岛叶的中部水平切面上,岛叶的中后短回,垂直向内对应了壳核最为宽阔的部分和内囊的膝部。结论熟悉外侧裂-岛叶手术入路中的解剖,有利于基底节血肿的清除。     

小骨窗-外侧裂手术入路的解剖研究

目的研究小骨窗一外侧裂手术入路的解剖,为其临床应用提供参考。方法应用10具（20侧）成人尸头模拟小骨窗一外侧裂手术人路进行解剖,显露骨窗下的最大术野,分离大脑中动脉分支及毗邻脑组织结构,在骨窗下观察并测量。结果该入路切口下方常起始于颞浅动脉主干分又上方,能减少颞浅动脉的损伤;骨窗位于翼点后方,直径平均3．5em;Rolandic下点与骨窗中心距离平均（1．15±0．44）cm;脑膜中动脉位于骨窗中央;打开硬脑膜后,可见外侧裂静脉、大脑中动脉分支和中央前、后回下端;本骨窗未能观察到Labbe静脉,4侧观察到Troland静脉;本骨窗还可暴露额下回三角部、外侧裂前点、岛回中央沟、岛顶等结构。结论该入路能避免损伤颞浅动脉和面神经的分支;经小骨窗能充分显露侧裂后支、岛叶部分及周围结构。     

经侧裂入路切除岛叶海绵状血管畸形

目的 探讨岛叶海绵状血管畸形(CMs)手术治疗方法与效果.方法 回顾性分析2007年12月至2013年8月手术治疗的4例岛叶CMs患者,采用术中B超(2例联合神经导航)辅助下经侧裂入路切除岛叶CMs,分析手术策略及术后神经功能状态.结果 4例岛叶CMs患者,均以癫痫发作为首发症状,经侧裂-经岛叶入路完整切除CMs.术后随访3～ 72个月(平均36.75个月),1例患者术后神经学恶化,永久神经学缺陷;1例出现语言缺陷,1周后逐渐恢复.Engel疗效分级,4例患者癫痫预后均为Ⅰ级.结论 经侧裂入路可安全可靠的暴露并切除岛叶CMs;神经导航、术中B超可为成功切除岛叶CMs提供指导.     

锥体束示踪成像技术在经侧裂岛叶肿瘤切除术中的应用

目的利用锥体束示踪成像技术指导经侧裂岛叶肿瘤切除手术。方法对18例岛叶肿瘤患者行经外侧裂岛叶肿瘤切除手术,分别在术前和术后两次进行磁共振弥散张量成像(diffusion tensor imaging,DTI),并应用白质纤维束示踪技术(fiber tracking)进行DTI原始影像数据后处理,得到锥体束示踪成像(tractography)。观察手术前后锥体束的形态、结构和空间位置的变化,通过测量其连续性、完整性以及空间位移以评估肿瘤占位效应及经侧裂岛叶肿瘤切除术对锥体束的影响。结果18例患者手术均行经侧裂岛叶肿瘤切除术,13例全切除,5例次全切除。手术前后均实现锥体束示踪成像,在锥体束示踪成像上可以精确测定有效锥体束条数。结论锥体束示踪成像可以清晰显示手术前后锥体束的形态、结构和空间位置及受肿瘤推移幅度,可用于指导经侧裂岛叶肿瘤手术的术前计划。     

小骨窗开颅显微手术治疗基底节区脑出血对脑神经功能的保护作用

目的 观察小骨窗开颅经侧裂-岛叶入路显微手术治疗基底节区脑出血的疗效及术中、术后对神经功能保护。方法 回顾分析254例基底节区脑出血患者行血肿清除术的临床资料。结果 230例患者经小骨窗开颅侧裂-岛叶入路显微手术清除,24例患者术中脑膨出明显改行大骨瓣经颞中回显微手术清除血肿,术后第1天行头颅CT复查,血肿清除量均在80%以上。住院期间死亡18例(7.1%)。6个月后随访194例患者,GOS评分Ⅴ分64例(34%),Ⅳ分88例(45%),Ⅲ分30例(16%),Ⅱ分12例(6%)。结论 小骨窗开颅经侧裂-岛叶入路显微手术,术中采取适当血管及神经功能的保护措施是治疗基底节区脑出血的一种安全、高效的手术方式。     

颞叶白质纤维束及相关结构的显微解剖学研究

目的 对颞叶白质纤维束及相关结构进行显微解剖学研究,分析其功能及临床意义.方法 选取100 g/L甲醛固定的国人成年尸体头颅标本10例(20侧大脑半球),在4～25倍手术显微镜辅助下,运用Klingler纤维剥离技术,解剖剥离大脑半球,观察颞叶白质纤维束及相关结构.结果 颞叶内存在大量复杂的白质纤维束,在侧脑室颞角周围尤为复杂.在颞角外侧由外向内依次有上纵束的垂直部、颞枕桥束、枕额下束、视辐射前中束.在颞角顶部上方由上向下依次有最外囊与外囊的颞盖部分、听辐射、钩状束、颞枕桥束出内囊的部分、部分枕额下束、前连合、视辐射前中束(包括Meyer's环)、脑脚袢、终纹.胼胝体放射组成侧脑室颞角外侧壁,其顶壁主要由尾状核尾及终纹构成,杏仁核组成颞角尖的前壁、上壁及内侧壁,海马构成侧脑室颞角的内侧壁.脑脚袢是侧脑室颞角内侧的一个重要结构.结论 颞叶内存在大量的白质纤维束,在侧脑室颞角尤为复杂,了解颞叶白质纤维束及相关结构的解剖特点,能够对颞叶部位的手术提供理论指导,减少手术并发症,降低手术致病率.     

磁共振弥散张量成像在岛叶胶质瘤诊疗中的应用进展

脑胶质瘤是颅内最常见的恶性肿瘤,岛叶是脑胶质瘤的好发部位之一,由于其位置深在,周围毗邻重要的血管和神经纤维束,与情感、记忆、内脏感觉与运动、语言等多种功能相关,同时脑胶质瘤本身具有极强的侵袭性,因此岛叶胶质瘤患者极易出现功能障碍。近年来,影像学检查技术发展较快,磁共振弥散张量成像(DTI)和弥散张量纤维束成像(DTT)在岛叶胶质瘤的诊治中应用较为广泛。本文对应用于岛叶胶质瘤的DTI相关研究进行综述,以期为临床诊治提供参考。     

小脑延髓裂入路相关显微解剖研究

目的 研究经小脑延髓裂(CMF)入路相关的显微解剖结构和毗邻关系,在不切开下蚓部情况下,分离CMF获得最充分的术野.方法 应用显微外科解剖技术,对经甲醛固定、血管乳胶灌注的5具成人湿性尸头标本,按不同手术入路逐层解剖,观察相关组织和血管的形态结构和毗邻关系,并做了测量和统计分析.结果 CMF入路不需切开下蚓部,可完全纵向显露从闩部至导水管下口,侧向显露从闩部至外侧孔的第四脑室底及脑桥背外侧区域.比较小脑下蚓部入路,CMF入路纵向显露距离差异无统计学意义(P＞0.05),侧向显露距离明显大于下蚓部入路(P＜0.05).结论 CMF入路可充分显露CMF、第四脑室周围、脑桥区域,比较下蚓部入路,显露充分,神经组织损伤小,手术安全性提高.     

Misinterpretation of Parahippocampal Herniation for a Posterior Fossa Tumor: Imaging and Intraoperative Findings

Tumors of the hippocampal and parahippocampal gyrus are not uncommon, nor are lesions of the cerebellopontine and ambient cisterns. Lesions in these areas include astrocytomas, meningiomas, gangliogliomas, hamartomas, neurilemomas, epidermoids, and dermoids. Preoperative imaging is an important tool that can help distinguish lesions, making surgical therapy more targeted and appropriate. The authors report a case of a 41-year-old man with right-sided atypical trigeminal neuralgia and a left ambient cistern abnormality that was radiologically interpreted as a mesial temporal lobe or extramedullary ambient cistern mass lesion. Surgical exploration for biopsy revealed an abnormal posterior fossa anatomy and a parahippocampal herniation into the perimesencephalic cistern. Biopsy confirmed the finding of normal brain.     

Microsurgical and tractographic anatomical study of insular and transsylvian transinsular approach

This study is to define the operative anatomy of the insula with emphasis on the transsylvian transinsular approach. The anatomy was studied in 15 brain specimens, among five were dissected by use of fiber dissection technique; diffusion tensor imaging of 10 healthy volunteers was obtained with a 1.5-T MR system. The temporal stem consists mainly of the uncinate fasciculus, inferior occipitofrontal fasciculus, Meyer’s loop of the optic radiation and anterior commissure. The transinsular approach requires an incision of the inferior limiting sulcus. In this procedure, the fibers of the temporal stem can be interrupted to various degrees. The fiber dissection technique is a very relevant and reliable method for neurosurgeons to study the details of brain anatomic features. The DTI fiber tracking technique can identify the fiber tracts of the temporal stem. Moreover, it will also help further functional study of human insula.     

The importance of preoperative planning to perform safely temporal lobe surgery

Neurosurgeons should know the anatomy required for safe temporal lobe surgery approaches. The present study aimed to determine the angles and distances necessary to reach the temporal stem and temporal horn in surgical approaches for safe temporal lobe surgery by using a 3.0 T magnetic resonance imaging technique in post-mortem human brain hemispheres fixed by the Klingler method. In our study, 10 post-mortem human brain hemisphere specimens were fixed according to the Klingler method. Magnetic resonance images were obtained using a 3.0 T magnetic resonance imaging scanner after fixation. Surgical measurements were conducted for the temporal stem and temporal horn by magnetic resonance imaging, and dissection was then performed under a surgical microscope for the temporal stem. Each stage of dissection was achieved in high-quality three-dimensional images. The angles and distances to reach the temporal stem and temporal horn were measured in transcortical T1, trans-sulcal T1–2, transcortical T2, trans-sulcal T2–3, transcortical T3, and subtemporal trans–collateral sulcus approaches. The safe maximum posterior entry point for anterior temporal lobectomy was measured as 47.16 ± 5.00 mm. Major white-matter fibers in this region and their relations with each other are shown. The distances to the temporal stem and temporal horn, which are important in temporal lobe surgical interventions, were measured radiologically, and safe borders were determined. Surgical strategy and preoperative planning should consider the relationship of the lesion and white-matter pathways.     

Transcortical selective amygdalohippocampectomy technique through the middle temporal gyrus revisited: An anatomical study laboratory investigation

The anterior temporal lobectomy (ATL) and selective amygdalohippocampectomy (SelAH) have been used for surgical treatment of mesial temporal lobe epilepsy. We examined the comprehensive white matter tract anatomy of the temporal lobe to gain an insight into the trans-middle temporal gyrus, a lateral approach which has been commonly used. The transmiddle temporal gyrus approach was performed in a stepwise manner on cadaveric human heads to examine the traversing white matter pathways through it and the structures located in the temporal horn. We reviewed the literature to compare the trans-middle temporal gyrus approach with other SelAH techniques based on surgical outcomes. There does not appear to be a significant difference in seizure outcome between SelAH and ATL. However, the SelAH provides a better neuropsychological outcomes than the ATL in selected patients. Each SelAH approach has individual advantages and disadvantages. Based on our anatomical study, in the transcortical amygdalohippocampectomy technique through the middle temporal gyrus the white matter pathways to be encountered. In the temporal horn, the collateral eminence, hippocampus, lateral ventricular sulcus, choroidal fissure, inferior choroidal point, choroid plexus, fimbria of the fornix, and amygdala are exposed. The subpial dissection is performed along the lateral ventricular sulcus from the collateral eminence on lateral side and from the choroidal fissure on medial side by microdissector for en bloc resection of the hippocampus proper. The trans-middle temporal gyrus approach is commonly used in treatment of mesial temporal lobe epilepsy patients. A better anatomical and functional understanding of the structures of the temporal lobe is crucial for safer and more accurate surgery.     

Pseudosubarachnoid haemorrhage in subdural haematoma

Two patients with large bilateral subdural haematomas with patterns of non-enhanced brain computed tomography (CT) falsely suggesting coexistent subarachnoid haemorrhage are presented. The CT images showed marked effacement of the basal cisterns with hyperdense signal along the tentorium, sylvian fissure, and the perimesencephalic cisterns. In both cases, the suspicion of subarachnoid haemorrhage led to the performance of angiographic studies to rule out vascular lesions. Thus, recognition of this radiological feature is important to avoid unnecessary testing and treatment delay.     

MRI线性测量局部脑萎缩对早期阿尔兹海默病的诊断意义

目的评价ＭＲＩ线性测量脑萎缩程度对阿尔兹海默病（Ａｌｚｈｅｉｍｅｒｄｉｓｅａｓｅ，ＡＤ）患者的早期诊断价值。方法应用ＭＲＩ线性定量测量对３０例轻度痴呆的ＡＤ患者、２０例多发脑梗塞性痴呆（ＭＩＤ）和２０名正常老年人进行局部额叶（双额指数、额叶半球间宽度）、中颞叶（海马钩回间距、中颞叶最小厚度）及海马结构（海马高度、脉络膜裂宽度、海马脑干间距及颞角宽度）等指标测量。结果颞角宽度指标是区别ＡＤ患者与ＭＩＤ患者及正常老年人的最敏感的指标；其敏感性达９０％，特异性达８５％。如结合脉络膜裂宽度、海马高度、海马与脑干间距及海马钩回间距，其敏感性达９３％，特异性达９５％。结论ＭＲＩ线性定量测量局部海马萎缩能够作为早期诊断ＡＤ的准确可靠性指标之一。     

Agenesis of corpus callosum and intraventricular lipomas.

Intracranial lipomas are rare and usually do not have clinical expression. They are located most commonly in the interhemispheric fissure and may also be found in the quadrigeminal, ambient, chiasmatic, interpeduncular, sylvian, and perimesencephalic cisterns. Interhemispheric lipomas may be associated with choroid plexus lipomas. The ultrasonography, computed tomography, and magnetic resonance imaging findings are reported in a neonate with lateral ventricular choroid plexus lipomas and interhemispheric lipoma associated with agenesis of the corpus callosum.     

Anatomy-computerized tomography correlations in transtentorial brain herniation

The diagnosis of transtentorial brain herniation has long relied on encephalography, then arteriography. Computerized tomography (CT) is a safer method which permits a more precise and earlier visualization of temporal and central herniations and herniation of the culmen cerebelli, which are the three varieties of transtentorial herniation. In an attempt to evaluate the reliability of CT images of herniation, the authors have conducted a study of anatomy-CT correlations, using autopsy specimens of brains with these three types of transtentorial herniation. Temporal herniation was well studied, irrespective of the CT reference plane. Direct visualization of temporal uncus herniation and filling of the homolateral perimesencephalic cistern was regularly obtained. Central herniation was better visualized when the occipito-temporal plane was used as reference. The disappearance of perimesencephalic cisterns on CT sections through the widest part of the tentorial incisura is the best element of diagnosis. Herniation of the culmen is easily studied on the conventional orbito-meatal plane. Provided CT scans are performed with the technique they recommend, the authors consider that this examination is reliable for the diagnosis of transtentorial herniation. Some variations in the anatomy of the incisura may explain why the clinical consequences of herniation are varied. CT perfectly shows the configuration of this notch and therefore may be helpful in predicting the prognosis.