海绵窦区颅神经血供的显微解剖及临床应用研究

目的海绵窦区显微手术的不断开展，迫切需要海绵窦区颅神经血供的显微解剖资料。方法借助手术显微镜对40例福尔马林固定的成人头颅的颈内动脉（internal carotidartery，ICA）海绵窦段分支及颅神经血液供应进行了显微解剖研究。结果动眼神经和滑车神经的近段主要由小脑幕动脉供血、外展神经近段主要由脑膜背侧动脉分支供血。三者的远段主要由海绵窦下动脉前支供血；三叉神经半月神经节及远端分支主要由海绵窦下动脉供血。结论海绵窦下动脉是供应所有入眶颅神经最重要的供血动脉，在海绵窦区进行显微手术时，保护好各颅神经的血供是减少术后颅神经损伤、获得良好疗效的关键。     

经海绵窦颅神经与颈内动脉关系的应用解剖研究

目的为海绵窦区手术提供解剖学基础。方法在手术显微镜下对15例(30侧)成人尸头标本海绵窦内颅神经位置、走行及与颈内动脉海绵窦段的毗邻关系进行观测。结果海绵窦入口平面从上到下可见第Ⅲ、Ⅳ颅神经以及第Ⅴ颅神经第1、2分支,颈内动脉在海绵窦内分为5段,第Ⅲ、Ⅳ、Ⅴ1、Ⅵ颅神经在海绵窦内长度分别为(9.33±3.75)m m、(10.59±3.95)m m、(15.45±4.69)m m和(18.12±5.98)m m;滑车神经变异较大;滑车神经下缘与三叉神经眼支下缘组成Parkinson三角是经海绵窦外侧壁入路手术开颅最常用的间隙。结论掌握经海绵窦的颅神经的显微解剖对海绵窦的直接手术具有重要的意义。     

颈动脉海绵窦瘘

1 CCF有关神经、血管解剖 颈动脉经颈动脉孔入颅,在三叉神经半月节后上升进入海绵窦而后向前走行,在前床突下呈锐角向后内侧弯曲出海绵容窦进入蛛网膜下腔。颈动脉海绵窦段人为的分为5段,后升、后曲、水平、前曲、前升。此段有三个重要分支,其一脑膜垂体干,由后曲与水平段交接处发出,向后发出垂体、小脑幕及后床突支,其二为下外侧支干,由水平段近心端发出,其分支分别至海绵窦壁硬膜,三叉神经半月节,     

扩大经鼻蝶入路的海绵窦内颈内动脉和脑神经显微解剖研究

目的：研究扩大经鼻蝶入路海绵窦内颈内动脉和脑神经的显微解剖特点,为切除颈内动脉外侧肿瘤提供解剖形态学基础。方法：在7具成人尸头模拟扩大经鼻蝶手术入路,观察颈海绵窦段颈内动脉和脑神经的解剖关系,并测量相关解剖参数。结果：海绵窦段颈内动脉有两个重要分支：海绵窦下动脉和脑膜垂体干。海绵窦下动脉起源颈内动脉水平段中央外侧,垂体下动脉起源于脑膜垂体干。内展神经在海绵窦段颈内动脉的外侧,向眶上裂方向走行。颈内动脉与动眼神经、滑车神经、展神经和视神经入眶上裂处的平均距离分别为3.4 mm、3.4 mm、3.9 mm和4.5 mm。结论：熟悉展神经和海绵窦下动脉在海绵窦内的解剖关系,有助于经扩大经鼻蝶入路手术切除肿瘤时对其的保护。     

滑车神经的应用解剖学研究进展

滑车神经是唯一连于脑干背面的脑神经,外径细小,走行和毗邻复杂,其在颅脑外科手术,尤其是海绵窦、眶上裂、天幕裂孔侧方以及松果体区域手术时,极易损伤。随着神经外科显微技术的发展,目前对滑车神经的研究逐渐深入,为颅脑外科手术提供了越来越多的支持,本文就滑车神经应用解剖学研究进展综述如下。1与滑车神经相关的大体解剖滑车神经起于下丘下外方,继而向前外在环池中绕大脑脚,从小脑幕下缘穿入幕内,在幕中潜行后入海绵窦,在窦外侧壁,滑车神经介于动眼神经和眼神经之间。随后,滑车神经沿窦壁外侧前行至前床突下外方与动眼神经和眼神经紧密…     

颈内动脉海绵窦段显微解剖

本文介绍在手术显微镜下对100个(50例成人)海绵窦标本进行颈内动脉海绵窦段分支的研究,观察了分支的起点、分布、数目和吻合。主要结果如下:(1)颈内动脉海绵窦段分为五段:后升部、凸弯、水平部、凹弯、前升部;(2)脑膜垂体动脉是一支短干,它通常发出三个分支:小脑幕动脉、脑膜背侧动脉和垂体下动脉。依分支起始位置脑膜垂体动脉分为干型(64%)和非干型(36%)。(3)在凸弯上动脉分支的数目和起点变化颇大,脑膜背侧动脉起自海绵窦内颈内动脉者24%,天幕动脉为6%,垂体下动脉10%。(4)海绵窦下动脉在标本中出现95%,它们是起于颈内动脉海绵窦段的水平部;另外,起自脑膜垂体动脉者5%。幕缘动脉和眼动脉出现率14%和11%。垂体被膜动膜16%。文中对一些特殊变异提出了报告,供临床参考。     

经乳突后锁孔入路磨除部分岩骨显露中颅窝的内镜解剖学研究

目的探讨神经内镜下经乳突后锁孔入路密除部分岩骨显露中颅窝的范围、可行性及适应证。方法采用苏州大学附属第二院神经外科解剖实验室提供的不分性别、完整、无缺损的成人尸头标本8具（16侧）,模拟神经内镜下经乳突后锁孔入路磨除内听道上结节及岩尖显露中颅窝,观察最大的显露范围,标识Parkinson三角的边界,显露Meckel囊、海绵窦外侧壁包含的解剖结构,并测量乙状窦后缘中点至中颅窝各重要解剖结构的距离、Parkinson三角的边长。结果经乳突后锁孔入路可显露小脑脑桥角、脑干腹外侧、小脑幕切迹间隙、岩斜区及海绵窦外侧壁;可显露的中颅窝解剖标志包括：三叉神经节、滑车神经及外展神经海绵窦段、动眼神经岩床段、颈内动脉海绵窦后曲部及交通段、后交通动脉。乙状窦后缘中点至内听道上结节、三叉神经半月节、颈内动脉海绵窦后曲段的距离分别为（34．4±2．1）inin、（54．5±2．9）mm、（65．2±3．1）mm;Parkinson三角边长分别为（19．0±2．9）mm、（16．2±2．0）mm、（8．0±2．3）mm。结论神经内镜下经乳突后锁孔入路磨除部分岩骨增加中颅窝的有效显露,适合处理大部分后颅窝肿瘤、动脉瘤等病变,并能够完成主体位于后颅窝,小部分侵及中颅底病变的处理。     

蝶窦外侧壁和海绵窦内侧面观显微解剖研究

目的 为扩大经蝶手术和前方颅下手术提供蝶窦外侧壁和海绵窦内侧面观显微解剖参数。方法 对20具成人头颅标本，仿Janecka的标准面部移位入路切口(左侧)行两侧蝶窦外侧壁和海绵窦内侧面观显微解剖观察和测量。结果 蝶窦外侧壁的主要结构有视神经管隆起和颈内动脉隆起，而颈内动脉隆起缺失的出现率高达50％，此时，依照翼管-破裂孔-颈内动脉破裂孔段途径显露颈内动脉海绵窦段为一安全策略。内移颈内动脉海绵窦段，可以充分显露海绵窦外侧壁的颅神经。结论 掌握蝶窦外侧壁显微解剖和从内侧面显露、移动颈内动脉海绵窦段，有助于扩大经蝶手术和前方颅下手术对病变累及海绵窦的处理。     

海绵窦断层解剖研究及其临床意义

目的在水平、矢状和冠状3个方位上对海绵窦进行断层解剖研究,了解海绵窦断层解剖特点。方法采用低温铣切技术对3例头颅标本进行水平、矢状和冠状位的铣切,利用数码相机获取数字资料,观察海绵窦大小、形态、内部结构和毗邻结构。结果海绵窦及其毗邻结构在断层层面上可清晰显示:(1)海绵窦的外侧壁有两层膜性结构,外层为颅中窝硬脑膜的延续,而内层为动眼神经、滑车神经、三叉神经的分支构成的神经鞘膜。(2)外展神经穿过Dorello管后进入海绵窦内,与颈内动脉毗邻。(3)海绵窦内侧与垂体之间仅仅为疏松的膜性结构,是垂体腺瘤易于侵犯海绵窦的解剖学基础。结论海绵窦断层解剖研究对了解海绵窦断层解剖特点、指导海绵窦影像学诊断以及海绵窦区的手术治疗有指导意义。     

极外侧小脑上天幕下入路的显微解剖研究

目的探讨极外侧小脑上天幕下入路的手术方法及该入路可暴露的解剖范围。方法对10具动静脉灌注的头颅湿标本于导航辅助下模拟极外侧小脑上天幕下入路显微手术,观测手术全程及术野暴露范围。结果极外侧小脑上天幕下入路可以充分暴露天幕切迹侧方区域、环池、中脑背外侧、滑车神经及伴行的小脑上动脉、大脑后动脉（P2、P3段）、脉络膜后内侧动脉及后方的四叠体池外侧方,切开天幕可以显露海马旁回后部;轮廓化乙状窦和横窦有利于对脑干外侧及对应天幕切迹侧后区域的暴露。结论极外侧小脑上天幕下入路适合于脑干背外侧及与之相对应的天幕切迹区域病变手术。     

The antero-medial triangle: the risk for cranial nerves ischemia at the cavernous sinus lateral wall. Anatomic cadaveric study

OBJECTIVE: Vascular damage in the cavernous sinus can cause ischemic injury to the cranial nerves. An appropriate anatomical knowledge of the blood supply to the cranial nerves can help to reduce the morbidity associated with cavernous sinus surgery. MATERIAL AND METHODS: Three formalin-fixed and six adult cadaveric fresh heads, with common carotid arteries injected, were used for anatomical dissection in this study. A fronto-temporal craniotomy was performed and the cavernous sinus was explored according to the Dolenc technique. With microsurgical dissection and photographic documentation, we demonstrate the anatomy of the superior orbital fissure artery in the antero-medial triangle. RESULTS: The 12 explored cavernous sinuses demonstrated the presence of two principal branches directly from the intracavernous internal carotid artery that supply the cranial nerves: the infero-lateral trunk and the meningohypophyseal trunk. The artery of the Superior Orbital Fissure (SOF), originated more often from the infero-lateral trunk, and vascularized the III, IV, VI, and VI, and ophtalmic division of the trigeminal nerve (TGN VI) at their entry in the fissure. CONCLUSION: In this study we demonstrate that the superior orbital fissure artery is a branch from the infero-lateral trunk which runs immediately under the reticularis layer at the level of the anteromedial triangle in the lateral wall of the cavernous sinus. The blood supply to all cranial nerves in the SOF is at risk to injury when the lateral wall of the cavernous sinus is transgressed at the anteromedial triangle since the SOF-artery runs superficially at this level.     

Parasellar syndromes

The parasellar compartments are located lateral to and on either side of the sella turcica. The cavernous sinuses are the most prominent anatomic feature of the parasella. Each sinus consists of a plexus of veins through which runs the intracavernous portion of the internal carotid artery. Ocular motor nerves three and four travel within the dural covering of the cavernous sinus to the superior orbital fissure, and cranial nerve six travels through the carotid sinus itself, giving rise to parasellar syndromes, which have distinctive clinical features. Ophthalmoplegia occurs as a result of damage to these ocular motor nerves and variable involvement of oculosympathetic nerves. Facial pain, dysesthesia, and paraesthesia are caused by damage to one or more of the divisions of the fifth cranial nerve, travelling in the dural wall of the cavernous sinus. Tumors, such as meningiomas, frequently cause parasellar syndromes, as do aneurysms of the intracavernous portion of the internal carotid artery, carotid-cavernous fistulas, and cavernous sinus thrombosis. Inflammatory conditions such as Tolosa-Hunt syndrome, ischemia to small vessels supplying the cavernous portion of the cranial nerves, and infections can cause this syndrome. Magnetic resonance imaging is the investigation of choice and therapy is specific to the cause of the parasellar syndrome, but now includes more aggressive endoscopic and microsurgical intervention, and radiosurgery.     

A case of posterior ischemic optic neuropathy in a posterior-draining dural cavernous sinus fistula.

A 79-year-old woman presented with sudden unilateral visual loss after an ocular motor disturbance and pulsatile tinnitus. Neuro-ophthalmologic examination showed a presumed right posterior ischemic optic neuropathy (PION), oculosympathetic, and third, sensory fifth, and sixth cranial nerve pareses. Selective angiography of the right internal and external carotid arteries confirmed a posterior-draining dural carotid cavernous sinus fistula (CCF) fed by the right meningohypophyseal trunk and right middle meningeal artery. Angiography also showed an ophthalmic-middle meningeal arterial anastomosis. We postulate that the PION was caused by an arterial steal, because blood was drawn into the fistula and away from the intraorbital optic nerve.     

Painful ophthalmoplegia: the Tolosa-Hunt syndrome.

Painful ophthalmoplegia is characterized by unilateral involvement of the IIIrd, IVth and VIth cranial nerves, as well as supra- and retro-orbital pain, i.e. participation of the Vth cranial nerve. The pain is relieved within 48-72 h with steroid therapy. The paresis of the eye muscles in various combinations usually subsides gradually from within a few weeks to several months. The etiology is unknown. The few pathological examinations reported in the literature showed an unspecific inflammatory granulation tissue around the intracavernous portion of the carotid artery and on the dura mater in the vicinity of the cavernous sinus. Carotid arteriography may show stationary waves of this artery and narrowing of its intracavernous portion. With orbital phlebography the occlusion of the supraorbital vein and obstruction of the cavernous sinus are sometimes demonstrable. The syndrome is well defined and its etiology still unknown.     

虚拟现实技术在海绵窦手术入路定量分析中的作用

目的 探讨虚拟现实系统在海绵窦手术量化比较中的应用价值.方法 5例尸头行CT 和MRI扫描,影像数据输入Dextroscope虚拟现实系统构建海绵窦三维解剖模型.选取颅盖和颅底骨性标识点连线形成空间框架,模拟经外上、外下两个方向入路,测量解剖结构体积和手术窗口面积,进行比较分析.结果 在海绵窦三维解剖模型中成功模拟手术入路,操作空间中可清楚显示解剖结构,成功测量脑组织、脑神经、颈内动脉等体积和手术窗口面积数据并进行比较.结论 虚拟现实解剖模型模拟海绵窦手术入路清晰逼真,相关体积和面积数据测量有助于不同手术入路的比较研究.

Abstract：

Objective To evaluate the utility of virtual reality system in quantitative comparison for cavernous sinus surgical approach.Method Image data of CT and MRI scan performed in five adult cadaver heads was inputted into the Destroscope virtual reality system to build 3-D model of cavernous sinus.Surgical approaches for cavernous sinus from superolateral and inferolateral directions were simulated respectively in virtual reality system by lining landmark points selected on the calvaria and skull base to form special framework.Then,the two approaches were compared and analyzed according to the data measured for volume of anatomic structures and area of surgical entry.Results Images of anatomic structures related to cavernous sinus were displayed well in the operative space simulated successfully by the virtual reality system.The data measuring of volume for brain tissue, cranial nerves,intracavernous artery and area for operative entry was obtained and compared successfully.Conclusions Surgical approaches for cavernous sinus can be simulated in the virtual reality system with high fidelity.Data of correlative volume and area measuring is helpful for comparison between different surgical approaches.     

Anastomoses between the meningeal arteries and the cavernous sinus: the clinical picture, diagnosis and treatment

The findings of 106 patients with arteriosinus anastomoses formed by the meningeal arteries and cavernous sinus were analyzed. The clinical symptoms, the specific features of the course of this abnormality and the principle of its diagnosis are summarized. Based on angiographic data, 4 types of anastomoses were identified by X-ray and anatomic signs: 1) the anastomoses formed by the meningeal branches of the internal carotid and cavernous sinus (45.4%); 2) those formed by the branches of the external carotid and cavernous sinus (9.3%); 3) the branches of both the internal and external carotids are involved in anastomotic blood supply (38.1%); 4) a combination of carotid-cavernous and arteriosinus anastomoses (7.2%). According to the sources of blood supply, the patients received endovascular treatment (external carotid branch embolization, fistula balloon occlusion), radiation surgery or combined treatment. The differential approach to treating patients with arteriosinus anastomoses at the site of the cavernous sinus yielded good results in 78.9% of cases.     

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。     

Neural connections in and around the cavernous sinus in rat,with special reference to cerebrovascular innervation

There is a confluence in and around the cavernous sinus of neural pathways innervating the intracranial structures. To determine the patterns of innervation, particularly of the cerebral arteries, we stained whole-mount preparations of the cavernous sinus and adjacent regions of the rat for acetylcholinesterase. The cavernous nerve plexus, with several small ganglia, mainly occupied the lateral wall of the sinus and extended laterally above the ophthalmic and maxillary divisions of the trigeminal nerve, in relation to the oculomotor and trochlear nerves. The cavernous plexus was connected to the pterygopalatine ganglion, the trigeminal ganglion, and the abducens nerve. The elongated pterygopalatine ganglion consisted of an orbital part, from which parasympathetic fibers ran to the cerebral arteries, and a cavernous part. Nerves from the lateral extension of the cavernous plexus ran rostrally into the orbit along the oculomotor, trochlear, and ophthalmic nerves, and caudally to the pineal gland along the trochlear nerve. Several branches also ran over the dura mater. Caudal to the cavernous sinus, we found two large nerves and a number of small nerves that ran between the nerves surrounding the internal carotid artery and the abducens nerve. These nerves may represent additional parasympathetic and/or sensory pathways to the cerebral arteries. © 1996 Wiley-Liss, Inc.     

Meningiomas of the cavernous sinus: the surgical resectability and complications

The optimal management for patients with cavernous sinus meningiomas is to evacuate tumor without causing mortality or morbidity. The records of 16 patients, including 11 women and 5 men ranging in age from 31 to 63 years, underwent surgical treatment for this condition were reviewed. Completeness of tumor resection, cranial nerve morbidity, complications, mortality, the internal carotid artery encasement and outcome were studied. Total removal was achieved in six patients. Of ten patients who underwent subtotal resection there was one death and four were sent to radiotherapy. Morbidity was 24% for cranial nerves controlling extraocular motor function; trigeminal nerve function did not improve after surgical treatment. Symptomatic recurrence occurred in two patients who underwent subtotal tumor resection and in one who underwent complete tumor resection. The average follow-up period was of 26 months. According to our findings, we conclude: 1) the resectability of meningiomas of cavernous sinus depends on the degree of internal carotid artery involvement; 2) total resection of meningiomas confined in cavernous sinus is rare; 3) morbidity of the cranial nerves is significant; 4) subtotal resection is an effective mean to obtain control of the disease.     

Meningeal Layers Around Anterior Clinoid Process as a Delicate Area in Extradural Anterior Clinoidectomy : Anatomical and Clinical Study

Objective

Removal of the anterior clinoid process (ACP) is an essential process in the surgery of giant or complex aneurysms located near the proximal internal carotid artery or the distal basilar artery. An extradural clinoidectomy must be performed within the limits of the meningeal layers surrounding the ACP to prevent morbid complications. To identify the safest method of extradural exposure of the ACP, anatomical studies were done on cadaver heads.

Methods

Anatomical dissections for extradural exposure of the ACP were performed on both sides of seven cadavers. Before dividing the frontotemporal dural fold (FTDF), we measured its length from the superomedial apex attached to the periorbita to the posterolateral apex which connects to the anterosuperior end of the cavernous sinus.

Results

The average length of the FTDF on cadaver dissections was 7 mm on the right side and 7.14 mm on the left side. Cranial nerves were usually exposed when cutting FTDF more than 7 mm of the FTDF.

Conclusion

The most delicate area in an extradural anterior clinoidectomy is the junction of the FTDF and the anterior triangular apex of the cavernous sinus. The FTDF must be cut from the anterior side of the triangle at the periorbital side rather than from the dural side. The length of the FTDF incision must not exceed 7 mm to avoid cranial nerve injury.