岛叶动静脉的显微解剖学研究

目的 明确岛叶区域局部解剖、动脉供应及静脉引流,了解岛叶解剖及血管构成是成功进行此区显微外科手术的前提.方法 有色硅胶灌注10个福尔马林周定的成人尸头(20侧大脑半球),研究其岛叶解剖及血管构成.结果 岛盖包覆岛叶,环岛沟是其明确界线;大脑中动脉为岛叶提供惟一血供,其中主要由M2段为岛叶提供血供.岛叶动脉主要供应岛叶皮质、最外囊,偶尔供应屏状核和外囊,但不供应壳核、苍白球及内囊;岛叶主要有4条静脉,主要汇人大脑中深静脉,也常与侧裂浅静脉有联系.结论 理解岛叶复杂的血管构筑方式,熟悉岛叶解剖,将有助于完成此区域手术.     

岛叶胶质瘤的显微手术治疗

目的 探讨经侧裂入路切除岛叶胶质瘤手术中的切除范围及血管保护的术前评估方法和术中措施.方法 回顾性分析南京医科大学附属脑科医院神经外科2008年1月至2014年7月手术治疗的46例病灶主体位于岛叶胶质瘤患者的临床资料.经翼点或扩大翼点入路分离侧裂后显露大脑中动脉M2,处理M2发出的短穿支后分块切除肿瘤,内囊最外侧动脉不参与岛叶胶质瘤血供,为肿瘤切除内侧界.结果 显微镜下肿瘤近全切除并经术后影像学证实38例,大部切除8例,术后2例偏瘫,1例术后硬膜下出血.3例术后对侧肢体轻偏瘫,肌力Ⅳ级,1例短暂混合性失语.结论 手术前的影像学检查,尤其是肿瘤与血管的关系3D-TOF,对术中血管保护有重要指导作用.内囊最外侧动脉为肿瘤切除内侧界.     

大脑岛叶的显微外科解剖与临床意义

目的为大脑岛叶区域的手术操作提供显微解剖参数。方法对12例(24侧)成人尸头进行岛叶区域的显微解剖与测量。结果岛叶外形呈三角锥形,以前、上和下环岛沟为界。大脑中动脉是岛叶的唯一供血动脉,其分支在岛叶皮质表面形成血管屏障。岛叶与侧脑室、壳核、内囊关系密切。结论岛叶具有特殊的解剖特点,充分了解岛叶的显微解剖对该区域病变的手术切除以及避免术后并发症的发生具有重要的意义。     

大脑中动脉与岛叶的显微解剖

目的 熟悉大脑中动脉和岛叶的解剖,探讨岛叶胶质瘤手术与大脑中动脉的关系.方法 对10例(20侧)成人尸头标本进行大脑中动脉和岛叶的解剖与测量.结果 大脑中动脉的M2段,像一面动脉血管墙,躺在岛叶上.它发出的终末小穿支动脉是岛叶惟一的供血动脉,而它发出的长穿支动脉,则多在后岛叶上,向岛叶的后角方向走行,进人放射冠.最外侧豆纹动脉是岛叶的一个重要标记,距岛顶15.68 mm出现,在岛阈内侧进入前穿质,长约15.42 mm.结论 熟悉大脑中动脉的走行分布,有利于岛叶胶质瘤的切除,可减少重要动脉损伤引起的术后并发症.     

水分离技术在经侧裂岛叶手术治疗高血压壳核脑出血的应用

目的 探讨水分离技术在经侧裂岛叶手术治疗高血压壳核脑出血中的应用及体会.方法 2010 年1 月至2010 年11 月间11 例高血压壳核脑出血患者,超早期采用经侧裂岛叶清除血肿,术中应用水分离技术解剖侧裂和清除血肿.结果 11 例患者均术后24 h 内复查CT,9 例血肿清除完全,2 例血肿清除大于95%,11 例患者均随访3 月以上,ADL 评分为Ⅰ级2 例,Ⅱ级6 例,Ⅲ级3 例.结论 水分离技术是一种安全简便的分离技术,在经侧裂岛叶清除高血压壳核脑出血中能很好帮助解剖侧裂和清除血肿,且对脑组织损伤小,血肿清除彻底.     

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。     

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.     

经岛阈后入路治疗基底核出血合并脑疝(附12例分析)

1对象与方法我科2005年1月～2006年12月采用岛阈后入路治疗12例基底核出血合并脑疝病人,其中男8例,女4例;年龄45～66岁,平均56.2岁。术前瞳孔一侧散大10例,双侧散大2例。术前CT示血肿量均>60 ml。全麻,头偏向对侧60°、后仰20°。翼点入路开颅,先穿刺释放部分液态血肿,再打开硬膜。从外侧裂根部向后分开蛛网膜2.5～4.0 cm,将侧裂静脉分至额侧。显微镜下在近颞极动脉处环形切除颞上中回,形成2.5 cm×2.5 cm皮质瘘口,暴露大脑中动脉分叉部及岛阈。从岛阈后方1 cm近下方动脉处切开岛叶皮质,暴露血肿,沿下界边吸除血肿边寻找外侧豆纹动脉。破裂的豆纹动脉常与坚韧血凝块黏连紧密,仔细探查后处理。按顺序清除壳核前、后及上方血肿。反复冲水至无出血后,置入引流管,弃去骨瓣关颅。     

超早期小骨窗经外侧裂-岛叶入路显微手术治疗基底节脑出血

目的探讨超早期小骨窗经外侧裂岛叶入路显微手术治疗高血压性基底节脑出血的疗效。方法回顾性分析47例高血压性基底节脑出血6h内超早期手术,采用小骨窗开颅,显微镜下经外侧裂－岛叶入路,清除血肿。结果血肿完全清除36例,血肿清除〉95％11例。术后按日常生活能力分级法随访3～6个月,Ⅰ级9例,Ⅱ级14例,Ⅲ级15例,Ⅳ级6例,V级3例。结论超早期小骨窗经外侧裂－岛叶入路显微手术治疗高血压性基底节脑出血是一种创伤小的治疗方法。     

经外侧裂-岛叶入路显微外科治疗基底节区高血压脑出血

目的探讨经外侧裂-岛叶入路显微外科治疗基底节区高血压脑出血的疗效。方法回顾分析12例高血压基底节区脑内血肿患者在急性期接受经外侧裂-岛叶入路显微手术治疗。结果术后即刻复查CT示10例血肿基本清除,2例清除约70%。随访3个月时GOS评分:恢复良好8例,轻度残疾3,重度残疾1例,本组无植物生存及死亡病例。结论经外侧裂-岛叶入路显微外科治疗基底节区高血压脑出血具有微创的特点,能有效清除脑内血肿,并减少了颞叶皮层及血管的损伤,有益于改善患者的预后。     

Morphological responses of cerebral tissues to temporary ischemia.

The ultrastructural responses of cerebral tissue following temporary periods (1/2, 1,2,3, or 4 hour) of right, middle cerebral artery, (MCA) occlusion were studied acutely after a 3 day or 7 day interval following the removal of the MCA clip. Cortical and basal ganglia tissues for each ischemic duration were compared at 3 post-occlusive periods (acute, 3 days, 7 days). With the short periods of ischemic insult (1/2, 1, 2, 3, and 4 hour), the temporal and insular cortex contained no greater changes in the 7 day group than in the 3 day group. The basal ganglia were more susceptible to MCA occlusion as indicated by more marked cytological changes and/or necrosis in all intervals of ischemia.     

Changes in plasma catecholamine levels after insula damage in experimental stroke

The effect of permanent occlusion of the left middle cerebral artery (MCA) on plasma catecholamine levels was investigated in chloralose-anesthetized cats. Two-5 h after occulsion of the MCA the plasma levels of norepinephrine, epinephrine and dopamine were significantly elevated (33%, 44% and 28%, respectively) compared to preocclusion levels only in animals in which the cerebral infarction involved the insular cortex. No significant changes were observed in plasma catecholamine levels in animals in which either the infarction did not involve the insula or in sham-stroked animals. These data suggest that withdrawal of inhibitory inputs from the insula on central cardiovascular regulating centers after stroke results in an increase in the activity of the sympathoadrenal system.     

Neurogenic cardiac outcome in patients after acute ischemic stroke: The brain and heart connection

BackgroundNeurogenic cardiac impairment can occur after acute ischemic stroke (AIS), but the mapping of the neuroanatomic correlation of stroke-related myocardial injury remains uncertain. This study aims to identify the association between cardiac outcomes and middle cerebral artery (MCA) ischemic stroke, with or without insular cortex involvement, as well as the impact of new-onset atrial fibrillation (AF) after AIS on recurrent stroke.MethodsSerial measurements of high sensitivity troponin T (TnT), brain natriuretic peptide (BNP), electrocardiography (ECG), echocardiogram, and cardiac monitoring were performed on 415 patients with imaging confirmed MCA stroke, with or without insular involvement. Patients with renal failure, recent cardiovascular events, or congestive heart failure were excluded.ResultsOne hundred fifteen patients (28%) had left MCA infarcts with insular involvement, 122 (29%) had right MCA infarcts involving insular cortex, and 178 (43%) had no insular involvement. Patients with left MCA stroke with insular involvement tended to exhibit higher BNP and TnI, and transient cardiac dysfunction, which mimicked Takotsubo cardiomyopathy in 10 patients with left ventricular ejection fraction (LVEF) of 20-40%. Incidence of new-onset AF was higher in right MCA stroke involving insula (39%) than left MCA involving insula (4%). Nine out of fifty-three patients with new-onset AF were not on anticoagulant therapy due to various reasons; none of them experienced recurrent AF or stroke during up to a 3-year follow-up period. Statistically significant correlations between BNP or TnT elevation and left insular infarcts, as well as the incidence of AF and right insular infarcts, were revealed using linear regression analysis.ConclusionsThe present study demonstrated that acute left MCA stroke with insular involvement could cause transient cardiac dysfunction and elevated cardiac enzymes without persistent negative outcomes in the setting of health baseline cardiac condition. The incidence of new-onset AF was significantly higher in patients with right MCA stroke involving the insula. There was no increased risk of recurrent ischemic stroke in nine patients with newly developed AF who were not on anticoagulant therapy, which indicated a need for further research on presumed neurogenic AF and its management.     

Perforating branches of the middle cerebral artery. Microanatomy and clinical significance of their intracerebral segments

Perforating branches of the middle cerebral arteries (MCA) were examined on the forebrain hemispheres of fourteen human brains. It was noticed that their intracerebral segments arose from the MCA main trunk, and its terminal and collateral (cortical) branches. They terminated in certain parts of the basal ganglia and internal capsule. The course, direction, shape, diameters and branches of these segments were examined in detail. Classification of all the vessels was made according to caliber. It was concluded that the size of lacunar infarcts depends on the caliber and ramification zone extent of the occluded perforating vessels. Diameters of the intracerebral segments of vessels ranged from 80 to 840 microns, of their terminal branches from 80 to 780 microns, and of the collateral branches from 50 to 400 microns. The average size of the ramification zone was: 41.6 X 15.5 mm for the entire perforating artery; 37.9 X 15.5 mm for the intracerebral segment; 23 X 13 mm for the terminal branches; 8.9 X 5.5 mm for larger collateral branches; and 2.6 X 1.4 mm for the smallest branches.