动眼神经的显微解剖学研究及临床意义

目的 探讨动眼神经的走形以及与周围结构的关系并进行测量,指导临床手术.方法 对10例经血管内灌注染料的成人尸头,在手术显微镜下观察两侧20例动眼神经的形态、毗邻以及滋养血管情况,并测量与周边重要结构间距离.结果 动眼神经距离后床突5.13 mm±1.26 mm,动眼神经距离前床突2.42 mm±0.43 mm,动眼神经小脑幕入口与滑车神经人口距离为10.20 mm±2.71 mm,动眼神经起始部至上下支平均直径为2.41 mm±0.37 mm.结论 动眼神经各段毗邻神经血管结构复杂,在多种手术中易造成动眼神经损伤,了解动眼神经的相关毗邻,对指导临床手术有重要意义.     

磁共振血管造影联合3D-CISS序列在椎基底动脉延长扩张症诊断中的应用

目的探讨磁共振血管造影联合3D-CISS序列扫描在椎基底动脉延长扩张症诊断中的应用。方法回顾性分析8例VBD患者的MRA及3D-CISS序列图像资料。结果 8例患者的3D-CISS序列和MRA原始图像上除显示扩张迂曲的椎基底动脉外,还可见5例患者的基底动脉或其分支与脑池段颅神经的位置关系异常,其中基底动脉及左侧小脑上动脉压迫面神经脑池段各1例;基底动脉与三叉神经关系密切1例;基底动脉与动眼神经关系密切2例。结论磁共振血管造影联合3D-CISS序列扫描不但可以完整显示扩张、迂曲的椎基底动脉,且可以观察病变血管与脑池段脑神经的关系,为临床诊断和针对性治疗提供重要依据。     

动眼神经三角的显微解剖结构及临床应用

目的探讨动眼神经三角的显微解剖结构并讨论其临床意义,为术中动眼神经的保护提供解剖学参考。方法经血管灌注后观测10例(20侧)尸头的动眼神经三角及其毗邻结构。复习岩斜区三叉神经鞘瘤、脑膜瘤各5例,蝶骨嵴内侧脑膜瘤5例,后交通动脉瘤25例的手术录像并总结术中保护动眼神经的手术策略。结果动眼神经三角由前岩床突韧带、后岩床突韧带、床突间韧带三边构成。动眼神经由动眼神经三角中央处穿入海绵窦,动眼神经人海绵窦处距颈内动脉床突上段发起处后方约2～7 mm,平均5 mm。其外上方与脉络膜前动脉相邻,内上方与后交通动脉相邻。滑车神经从动眼神经后外侧进人海绵窦,在海绵窦外侧壁后方的动眼神经下方行走。40例手术患者中,后交通动脉瘤患者术前即有动眼神经损伤5例,其中2例动眼神经功能于术后3个月内恢复,另3例未恢复;余35例中术后有动眼神经损伤症状2例,但无动眼神经解剖性损伤,术后3个月内动眼神经功能损伤均恢复。结论动眼神经三角解剖结构毗邻结构复杂,前岩床突韧带、后岩床突韧带、后床突及颈内动脉床突上段发起处是手术中较好的解剖标志。存鞍区、鞍旁及岩尖等部位手术时应特别注意辨认和保护动眼神经。     

展神经颅内段显微外科解剖学研究

目的研究展神经颅内段的显微解剖结构。方法 对30个灌注红、蓝乳胶或硅橡胶的头颅标本进行解剖,观测颅内段展神经的位置、走行及重要毗邻关系。对岩斜段展神经进行苏木精-伊红染色,研究该段展神经硬膜鞘的构成。结果颅内段展神经分为脑池段、岩斜段和海绵窦段;共形成4个转角,分别为：穿硬脑膜处、岩尖、颈内动脉后曲或后升部外侧、海绵窦下动脉跨展神经处。脑池段展神经根腹面有小脑前下动脉、小脑后下动脉、脑桥下外侧动脉跨过,展神经根背面有小脑前下动脉、脑桥下外侧动脉跨过。岩斜段展神经与展神经硬膜鞘、Gruber韧带、Dorello管及脑膜背侧动脉关系密切。海绵窦下动脉在海绵窦段中部跨海绵窦段展神经,位置固定,交感神经出现在该动脉8mm范围内。结论脑池段展神经受血管压迫可导致展神经麻痹。岩斜段展神经与周围解剖结构毗邻关系复杂,熟知相关解剖关系,有助于岩斜段展神经受损的治疗。海绵窦下动脉是寻找海绵窦段展神经与交感神经的一个重要标志。     

动眼神经鞘的显微解剖及其临床意义

目的 为探讨动眼神经鞘的显微解剖及其临床意义。方法 在手术显微镜下观测30侧尸颅的动眼神经鞘及其毗邻结构,并用测微尺测量之。结果 46.7％(14/30)的动眼神经在跨越后床突和(或)后岩床皱襞处存在压迹。动眼神经鞘在水平切面和冠状面上均呈三角形,神经居于鞘腔内上角。结论 动眼神经鞘属于牵拉和固定结构。颞叶可直接压迫动眼神经,致瞳孔改变。该鞘缺乏血管,可安全切开。     

伴动眼神经麻痹的后交通动脉动脉瘤的血管内治疗

目的 探讨伴有动眼神经麻痹的后交通动脉动脉瘤的血管内栓塞治疗效果。方法 回顾性分析2010年1月至2015年12月采用血管内栓塞治疗的11例伴动眼神经麻痹的后交通动脉动脉瘤的临床资料。结果 术后随访12~24个月,平均18个月。术后DSA复查未见动脉瘤残留及复发,载瘤动脉均通畅,11例均完全栓塞。不完全性麻痹7例中,5例完全恢复,2例部分恢复;完全性麻痹4例中,1例完全恢复,3例部分恢复。发病14 d内栓塞治疗8例,其中动眼神经麻痹完全恢复5例,不完全恢复3例;大于14 d 3例中,完全恢复1例,不完全恢复2例。结论 血管内栓塞治疗对伴有动眼神经麻痹的后交通动脉动脉瘤,对于动眼神经恢复有良好的疗效,早期诊断及治疗对于动眼神经功能恢复极为重要。     

后交通动脉瘤所致动眼神经麻痹患者血管内栓塞治疗

目的探讨后交通动脉瘤所致的动眼神经麻痹患者血管内栓塞治疗的疗效。方法回顾性分析21例由后交通动脉瘤(PComAA)致动眼神经麻痹患者,均行后交通动脉血管内栓塞术,评估年龄、是否存在蛛网膜下腔出血、动脉瘤大小、术前动眼神经麻痹的严重程度和症状出现后至手术时间。结果治疗后动眼神经麻痹症状改善17例(80.9%),其中完全康复14例(66.7%),部分恢复3例(14.3%),4例无恢复(19.0%)。结论血管内栓塞术对治疗后交通动脉瘤所致的动眼神经麻痹患者有较好疗效。     

磁共振对因神经血管压迫致三叉神经痛的诊断价值

目的分析原发性三叉神经痛患者的MR表现，探讨MRI对因神经血管压迫致原发性三叉神经痛的诊断价值。方法回顾性分析12例三叉神经痛患者的MRI表现，就三叉神经和周围血管的关系与手术结果进行对照分析。结果12例三叉神经痛患者的MRI资料中，神经血管压迫、接触或可疑接触者11例，占91．7％；该12例患者均行手术，证实血管压迫或接触者12例；故与手术结果对照，MRI诊断三叉神经痛神经血管压迫或接触的敏感性为91．7％。结论MRI能清晰显示三叉神经脑池段与毗邻血管之间的关系，对三叉神经血管压迫或接触的诊断具有较高的敏感性，对提供术前评估和指导治疗有极其重要的意义。     

Liliequist膜的显微解剖研究

目的：探讨Lilequist膜的显微解剖及其手术意义。方法：在手术显微镜下观测15例尸头的Lilequist膜。结果：Lilequist膜是前切迹空间的网膜结构，鞍背、动眼神经、下丘脑及基底动脉是其主要附着结构，分下丘膜、间脑膜和中脑膜三类叶，伸向内上方、后上方及后（下）方，其大小、性状及附着均有较大差异，同垂体柄和后交通动脉等有纤维联系。结论：该膜可维系鞍后诸结构的空间位置，下丘膜分隔后交通动脉池与视交叉池，间脑膜主要分隔视交叉池与脚间池，中脑膜主要分隔脚间池与桥前池，均是重要的手术标志和界面。经幕上达到基底动脉尖或上斜坡，需经过该膜，可较安全地切开。     

经眶颧-海绵窦入路夹闭基底动脉瘤的应用解剖研究

目的 探讨在经眶颧-海绵窦入路手术中增加基底动脉上段显露的方法。方法在10例标本上模拟经眶颧-海绵窦入路，观察磨除前、后床突后对基底动脉上段的显露情况。结果磨除前床突后形成的间隙为床突间隙；前床突下颈内动脉与动眼神经间的膜为颈内动脉动眼神经膜。沿此膜可进入海绵窦；磨除后床突后，暴露鞍背、上斜坡，即可显露基底动脉上段。结论在经眶颧-海绵窦入路手术中磨除前床突和后床突，可增加对基底动脉上段的显露。     

Relationship between the posterior cerebral artery and the cisternal segment of the oculomotor nerve.

The aim of this study was to evaluate the relationship between the cisternal segment of the oculomotor nerve and the posterior cerebral artery and its branches. The oculomotor nerve and the posterior cerebral artery of 15 cadaver brains (30 hemispheres) were examined using a surgical microscope. The dorsal portion of the cisternal segment of the oculomotor nerve had a close relationship with the P(1) and P(2) segments of the posterior cerebral artery in 100% of cases, the thalamoperforating arteries in 97%, the collicular arteries in 97%, the short circumferential arteries in 33% and the posterior medial choroidal arteries in 20%. The proximal portion of the nerve had a close relationship with the P(1) segment of the posterior cerebral artery, the thalamoperforating arteries, the collicular arteries and the short circumferential arteries, whereas the distal portion had a close relationship with the P(2) segment of the posterior cerebral artery and the posterior medial choroidal arteries. The oculomotor nerve was perforated by various arteries in different portions. These arteries were the thalamoperforating arteries in 10% of the hemispheres, the collicular arteries in 16% and the short circumferential arteries in 11%. It can be concluded that the dorsal portion of the cisternal segment of the oculomotor nerve has a close relationship with the branches arising from the P(1) and P(2) segments of the posterior cerebral artery. These arteries supply the cisternal segment of the oculomotor nerve.     

Angiographic findings in herpes zoster arteritis

Four adults patients who experienced an ipsilateral hemispheric deficit 6 to 8 weeks after having developed herpes zoster ophthalmicus were seen during a six-month period. All four patients underwent full-circle angiography, including study of the extracranial arteries in the three older patients. Each examination demonstrated areas of segmental constriction of arteries on the ipsilateral side; two locations that were especially affected were the A2 segment of the pericallosal artery beneath the genu of the corpus callosum and the M4 segment of the middle cerebral artery. The cerebral arteries of the opposite hemisphere and the extracranial vessels did not contain demonstrable abnormalities. Pathological studies suggest that patients with this syndrome may have a necrotizing arteritis of ipsilateral blood vessels; in patients with disseminated zoster, a granulomatous angiitis of cerebral blood vessels has been found. We propose that the pattern of angiographic abnormalities described here is characteristic of herpes zoster arteritis; furthermore, the distribution pattern of the lesions suggests that the virus may spread to these arteries via branches of the ophthalmic division of the trigeminal nerve.     

Intra-axial involvement of the common oculomotor nerve in mesencephalic infarctions

Mesencephalic infarcts are rarely limited to the midbrain, and usually extend rostrally to the thalamus. This fact explains why an elective palsy of the oculomotor nerve is exceedingly uncommon in brainstem infarcts. We studied 4 cases with a unilateral infarct apparently restricted to the middle mesencephalon, with intra-axial involvement of the oculomotor nerve. In 2 cases with a fascicular lesion, there was a contralateral hemiparesis or hemi-ataxia, so that it is possible to term them Weber's syndrome and Claude's syndrome. In the 2 other cases, we suggest that a nuclear syndrome of the oculomotor nerve was present, because of bilateral involvement of the rectus superior in both cases, of the levator palpebrae in one case, and of the parasympathetic pupillary fibres in the other, although the infarct was unilateral. There are several clinical variants of the intra-axial syndrome of the oculomotor nerve which can be differentiated according to the uni or bilaterality of the oculomotor palsy, the pupillary disturbances, and the type of associated neurological dysfunction. The nuclear syndrome corresponds to an infarction of the median arterial area, which is directly supplied by the most distal part of the basilar artery. The fascicular syndromes correspond to infarction of the paramedian and intermediolateral areas supplied by the first part of the posterior cerebral artery (basilar communicating or mesencephalic artery). As the paramedian thalamic arteries also originate from the basilar communicating artery, most infarcts also involve the upper midbrain and the thalamus, producing supranuclear oculomotor disturbances.(ABSTRACT TRUNCATED AT 250 WORDS)     

Isolated Oculomotor Nerve Palsy Following Minor Head Trauma : Case Illustration and Literature Review

Isolated oculomotor nerve palsy (ONP) attributable to mild closed head trauma is a distinct rarity. Its diagnosis places high demands on the radiologist and the clinician. The authors describe this condition in a 36-year-old woman who slipped while walking and struck her face. Initial computed tomography did not reveal any causative cerebral and vascular lesions or orbital and cranial fractures. Enhancement and swelling of the cisternal segment of the oculomotor nerve was seen during the subacute phase on thin-sectioned contrast-enhanced magnetic resonance images. The current case received corticosteroid therapy, and then recovered fully in 13 months after injury. Possible mechanism of ONP from minor head injury is proposed and previous reports in the literature are reviewed.     

Transient oculomotor nerve palsy due to non-aneurysmal neurovascular compression

Acute oculomotor nerve palsy requires urgent exclusion of aneurysmal compression. We report a 62 year old man with a transient right third nerve palsy with pupillary involvement, who was found to have neurovascular compression of the cisternal oculomotor nerve as it curved over a duplicated superior cerebellar artery on high resolution MR imaging. Direct vascular compression should be considered in patients with isolated cranial neuropathies in whom other pathologies have been excluded.     

颈内动脉分叉上间隙的显微外科解剖

目的 探讨颈内动脉分叉上间隙的解剖特征及其手术意义。方法 在30侧尸体标本上观察该间隙的显微解剖。结果 该间隙狭小、深在，血管多，90％呈三角形、A1段为前下边，M1段为外下边，前穿质为上边。10％呈四边形，视交叉或视束构成其内侧边。间隙内常有Heubner回返动脉和大脑中深静脉等走行，经间隙可见下方的诸多小血管。结论 在至少1／3的间隙内容易展开显微操作，多数需慎重处理间隙内的小血管。     

Pathway of acetylcholinesterase containing nerves to the major cerebral arteries in rats

The pathway of nerves containing acetylcholinesterase (AChE) to the major cerebral arteries was investigated in the rat. In this species, the internal ethmoidal artery (IEA) arises from the anterior cerebral artery (ACA) and anastomoses with the external ethmoidal artery (EEA), forming the ethmoidal rete on the cribriform plate. The ethmoidal nerve (EN) and EEA enter the cranial cavity through the ethmoidal foramen. Densely distributed adventitial nerve plexi were present around the IEA, ethmoidal rete, and EEA. Many thick nerve bundles were found in the periadventitial layers in association with these vessels. Around the EN, just before it enters the ethmoid foramen, intensely staining nerve bundles were present that entered the cranial cavity with the EN. After unilateral section of the EN and EEA, a marked decrease of the nerve fibers was observed around the arteries of the anterior part of the circle of Willis on the operated side, whereas the basilar artery (BA) showed a moderate decrease in the AChE activity. After bilateral section of the EN and EEA, nerves disappeared from around all the major cerebral vessels including the BA. Section of the EEA alone did not produce any visible change of the cerebral perivascular innervation. The present study suggests that AChE-containing nerves on the cerebral arteries arise from the AChE-positive nerve bundles, which enter the cranial cavity with the EN through the ethmoid foramen; The anterior part of the circle of Willis is innervated unilaterally by the AChE-positive nerve bundles from the ethmoidal foramen, whereas the BA receives bilateral innervation.     

Painless abducens palsy disclosed by spontaneous dissection of the intracavernous internal carotid artery

A 63-year-old man presented suddenly and spontaneously an isolated painless oculomotor palsy of the nerve abducens. As no etiology could be suspected a head MRI was performed. It showed a T1 hypersignal of the intracavernous segment of the internal carotid artery with a double-lumen pattern typical of dissection. The patient was treated with aspirin and recovered from clinical symptoms in 10 weeks. A control MRI was performed 3 months after the onset of symptoms and showed the regression of the images of dissection. There was no ischemic lesion of the brain. This case underlines the diversity of the symptoms of spontaneous dissections of cervicocephalic arteries, especially absence of pain, palsies of cranial nerve that are not always limited to lower cranial nerve, and existence of dissections limited to the intracranial segment of the carotid artery. It suggests the interest of MRI in the diagnosis of isolated oculomotor nerve palsies.     

A patient with primary Sj?gren's syndrome featuring polyneuropathy and oculomotor paralysis and associated with asymptomatic left middle cerebral artery stenosis]

We report a case of primary Sj?gren's syndrome (primary SjS) with polyneuropathy and right oculomotor paralysis associated with middle cerebral artery stenosis. A 39-year-old woman developed progressive numbness and clumsiness of the limbs. Two months later, right third cranial palsy manifested itself and she was admitted to our hospital. A cranial MRA showed left middle cerebral artery stenosis confirmed by transcranial color doppler sonography. A nerve conduction study showed a decrease in the NCV and reduced CMAP, while sural nerve biopsy showed axonal degeneration and infiltration of inflammatory cells around the small blood vessel walls. The patient complained of dry mouth and a salivary gland biopsy revealed inflammatory changes, while salivary gland scintigraphy showed diminished secretion. These findings led to the diagnosis of Sj?gren's syndrome. Reports of primary SjS with involvement of large cerebral arteries are rare. In our case, polyneuropathy and oculomotor paralysis were the manifest symptoms, but middle cerebral artery stenosis was also observed. This indicates that, even in the absence of CNS symptoms, cerebral artery involvement may be present in primary SjS.