终板池、终板相关显微解剖和临床应用研究

发布时间：2018-01-21 11:33

  本文关键词： 终板池 终板 终板外侧膜 终板内侧膜 终板间隙 终板入路　出处：《南方医科大学》2011年博士论文　论文类型：学位论文

【摘要】：背景和目的： 1.1664年Cerardus Blasius发现、描述并且命名了蛛网膜；1875年Key和Retzius首次对蛛网膜池进行细致描述；1976年Yasargil报道了手术中观察的终板池、终板相关显微解剖以及相关神经外科手术。终板池、终板相关解剖的研究方法和结果不尽相同,关于终板池的形态学特征、边界、内容物以及和周边脑池的关系尚有争议,在终板相关结构方面存在分歧。本研究是通过显微解剖人体尸头为基础,观察和测量终板池的形态学特征、边界、内容物以及和周边脑池的关系；终板的解剖学特征以及其周边的前交通动脉和穿支动脉等结构之间的关系；探讨终板池,终板相关形态学特征和数据在临床中的应用。 2.总结我科使用终板间隙进行手术切除三脑室前部肿瘤的临床资料,系统探讨终板间隙的使用方法,周边毗邻的大脑前动脉—前交通动脉复合体及其穿通支、前连合、视交叉、垂体柄、终板池以及三脑室前部等解剖结构在终板入路中的保护和利用,为处理该区域肿瘤提供依据。 研究方法： 1.选用10%福尔马林固定的国人成人头颅湿性标本20例,其中10例应用自制红色和蓝色乳胶分别灌注动、静脉系统。10例按翼点入路分两侧进行开颅,10例按前纵裂入路开颅。翼点入路解剖方法：尸头固定在操作台上,打开部分额骨和颞骨,尽量磨除蝶骨嵴直至蝶骨嵴的内侧,剪开硬脑膜,切除部分颞叶和额叶,向两侧牵拉暴露外侧裂。在6—-40倍手术显微镜下,模拟翼点入路逐层解剖,先分离外侧裂池,后暴露颈内动脉、视神经、视交叉,到达终板池侧方。前纵裂入路解剖方法：打开两侧部分额骨,扩大骨窗至前颅窝底,摘除眼球,于额极紧靠眶上马蹄形剪开硬脑膜,在6—-40倍手术显微镜下模拟前纵裂入路逐层解剖,逐层剔除额叶脑组织,沿纵裂方向进入鞍区,有目的的保留终板池相关的血管、软膜及蛛网膜,从胼胝体膝部水平沿大脑前动脉A2段向下解剖至终板池上方,再解剖至终板池底,到达终板和视交叉上表面。两种入路均观察终板池形态学特征、边界、内容物、膜性结构以及和相关血管、周边脑池的关系,明确终板、视隐窝、视交叉、前交通动脉及其穿支动脉、前联合、中间块、乳头体等相关结构,切开终板,模拟终板入路暴露三脑室前部和底部。使用数码相机拍照,摄录系统录像,采用电子游标卡尺对终板,视交叉,前交通动脉及其相关的和神经血管等进行测量,应用SPSS13统计软件分析处理。 2.临床病例来源于广州南方医院2008年1月至2010年12月间采用终板间隙的78例三脑室前部肿瘤患者,其中包括颅咽管瘤患者60例(未成年组≤16岁27例,成年组16岁33例),大型垂体腺瘤6例,下丘脑胶质瘤6例,脑膜瘤2例,生殖细胞瘤2例,非霍杰金淋巴瘤和非特异性肉芽肿各1例。临床主要表现包括颅内压增高征,视力障碍和视野缺损,垂体功能低下,多饮多尿,下丘脑损害症状,第二性征发育迟缓。根据CT和MR扫描明确肿瘤性质、大小、质地、累及部位等信息：MR扫描正中矢状位的主要观察指标包括：前交通动脉复合体位置及其与肿瘤的相对位置关系、肿瘤在矢状位上的高度、乳头体的移位方向,累及脚间窝甚至上中斜坡的程度及其与基底动脉顶端可能的关系等,评价前交通动脉复合体的血管构筑。根据肿瘤性质,大小,累及部位和三脑室关系不同分别选择额颞—经终板入路38例,前纵裂—经终板入路40例；这两种手术需解剖不同脑池,显露肿瘤的路径不同,但均需充分暴露和切开终板。经终板入路肿瘤的切除总体上包括两类：①完全经终板分离切除肿瘤：包括主体凸入三脑室的颅咽管瘤；②辅助使用终板手术：主要包括明显向鞍上池生长的颅咽管瘤、垂体腺瘤、下丘脑胶质瘤以及脑膜瘤等。术中辨别和保护周边的大脑前动脉—前交通动脉复合体及其穿通支、前连合、视交叉、垂体柄、中间块、乳头体、下丘脑等重要神经结构,术后影像学检查评价手术切除程度,病例随访 研究结果： 1.终板池是不成对的脑池,位于视交叉上方,终板前上方,上壁由终板内侧膜构成,向上延伸至胼胝体池,它在前方和外层蛛网膜相连,下壁由视交叉的上表面和终板构成,后缘是游离的,外侧壁由终板外侧膜构成,两侧终板外侧膜向上方延续至终板内侧膜。终板外侧膜附着在直回的后外侧边缘,下行到视交叉,视神经外侧方的上表面,分为稀疏型、致密型和缺如型。终板内侧膜不成对,由两侧直回后中部结合处向上延伸构成,分为凸起型和平坦稀疏型。终板池内容物包括双侧大脑前动脉A1段远端,A2段近端,前交通动脉,Heubner回返动脉的部分,大脑前动脉—前交通动脉复合体的部分穿支动脉,双侧额眶动脉,双侧大脑前静脉,前交通静脉。终板池上方为胼胝体池,终板内侧膜在胼胝体嘴部和胼胝体池前下部相交通；在前下方,终板池蛛网膜附着在视交叉前下方,视神经表面,并和视交叉池蛛网膜相连；在外侧方,终板外侧膜下行到视交叉外侧方和视神经的上表面,颈内动脉池内侧以颈动脉内侧蛛网膜附着在视交叉下部并向下延伸到外层蛛网膜,覆盖在鞍隔侧方和后床突,它与颈内动脉池相邻,以视交叉,视神经外侧方为界,无交通关系；在外侧前方,终板外侧膜的前方和嗅束下方延伸至直回的嗅神经蛛网膜汇合交通。 2.终板较薄,形态类似软膜组织,附着在视交叉上表面中部,呈弧线形向后上方止于前联合前下方,胼胝体嘴附近,占据视交叉上表面和胼胝体嘴之间的空间,终板起始部下方为比视交叉低的视隐窝。终板为三脑室最宽处,大多数为灰白色,其余为暗黄色和蓝黑色,终板按形态学分为隆起型和扁曲型,大多数终板中心部位透明隆起,为终板窗。视交叉和鞍结节的定位关系主要为：前置型、正常型和后置型。测量视隐窝长度6.35mm±1.22mm,视隐窝宽度为4.79mm±1.11mm。视交叉前缘到视隐窝前缘的距离为5.53mm±1.23mm,视交叉的前后径为11.33mm±1.55mm。终板长度为曲线距离,终板前缘(即视交叉上表面的中部)和前联合下缘的距离符合终板长度,为9.99mm±1.43mm,终板宽度为两侧视束内侧缘最大宽度,为11.23mm±2.23mm。终板切开至三脑室前部和底部,其中清晰辨别中间块15例,20例均观察到乳头体。测量视交叉前缘到中间块(丘脑间粘合)前下缘的距离28.66mm±2.24mm,视交叉前缘到乳头体间前缘的距离为20.10mm±1.90mm。 3.观察Heubner回返动脉从大脑前动脉Al远端距离前交通动脉6mm之内区域发出8例,从A2近端距离前交通动脉4mm之内域发出30例。前交通动脉是和终板联系最密切的血管结构,测量前交通动脉长度为2.52mm±0.76mm。前交通动脉下方中点距视交叉上表面中点的高度,符合前交通动脉到终板的距离为3.68mm±3.79mm。前交通动脉和视交叉的相对位置关系为前置型、中央型和后置型。前交通动脉的穿支动脉大多从上壁、后壁和下壁发出,少有从前壁发出,总数在几支到十几支不等,根据穿支动脉和终板池位置关系分为后穿支、内侧穿支和外侧穿支,其中有—支较为粗大后穿支,从前交通动脉后壁、下壁发出,经终板池后部,并向后上方发出分支分布在胼胝体下区和下丘脑区域,测量其平均直径为0.46mm。 4.主要向视交叉后三脑室内生长、具有典型特征的颅咽管瘤—般均可通过MR扫描判断肿瘤与三脑室底的关系,结合术前MR扫描判断分别选择额颞—经终板入路和前纵裂—经终板入路,手术切除均在三脑室腔内完成,三脑室底有时无法清晰辨认。术后78例行MR复查,同时或仅行CT复查53例,肿瘤切除程度均由术中录像和影像学检查证实,病理证实颅咽管瘤60例,垂体腺瘤6例,下丘脑视路胶质瘤6例,脑膜瘤2例,生殖细胞瘤2例,非霍杰金淋巴瘤和非特异性肉芽肿各1例。本组术中显微镜下所证实和术后影像学复查结果表明：颅咽管瘤病例全切除98.3%(59/60),近全切除1.3%(1/60)；大型垂体腺瘤全切除4例,近全切除1例,大部切除1例；下丘脑视路胶质瘤全切除2例,近全切除2例,大部切除2例；脑膜瘤2例全切除；生殖细胞瘤全切除1例,近全切除1例；淋巴瘤和肉芽肿性变各1例均得到全切除。本组颅咽管瘤选择经终板路径多数得到安全切除,术中肿瘤主要的粘连部位在垂体柄上端、三脑室前部和底部,垂体柄漏斗部容易部分损伤；肿瘤与垂体柄和三脑室底分离是手术难点,肿瘤切除后垂体柄连续性常常不能保留。在60例颅咽管瘤病例中,垂体柄给予保留者43例,为减少复发将垂体柄离断者9例,其他病变垂体柄均得到满意保留,部分患者术后复查时出现第三脑室底的部分缺损。颅咽管瘤患者术后多数合并垂体功能下降,不同程度垂体功能低下者90%；术后短期尿崩87%,长期随访尿崩发生率56%,需使用长效尿崩停控制；术前有视力障碍者19例,14例术后视力明显改善,3例无变化,2例加重,无并发脑脊液漏及颅内感染。 主要结论： 1.终板池上壁由终板内侧膜构成,下壁由视交叉的上表面和终板前部构成,后下壁为终板中后部,外侧壁由终板外侧膜构成。终板池和视交叉池,嗅池,胼胝体池,颈内动脉池联系紧密。首次将终板外侧膜按形态可分为稀疏型、致密型和缺如型；终板内侧膜按形态分为凸起型和平坦稀疏型。终板池的解剖特征以及和邻近的脑池的交通关系,可能影响前交通动脉瘤破裂后积血的位置。 2.终板大多数为灰白色,从形态学分为隆起型和扁曲型。终板长度为曲线距离,终板前缘和前联合下缘的距离为终板长度。终板切开选择在视交叉前缘后方5.5mm至11mm处的中线上。 3.前交通动脉和视交叉的相对位置关系为前置型、中央型和后置型。前交通动脉的穿通支和终板池关系分为后穿支、内侧穿支和外侧穿支。在经额颞或前纵裂—终板入路手术中,打开终板池和显露终板的方式是不同的,需按不同的次序处理前交通动脉外侧穿支、内侧穿支和后穿支,暴露前交通动脉和视交叉,进入终板区域。 4.经终板入路可以切除多种累及三脑室前部肿瘤,根据终板间隙的使用情况分为两类：①完全经终板入路②辅助使用终板入路。根据肿瘤的病理类型,大小,侵犯三脑室的不同方式,分别选择额颞—经终板入路和前纵裂—经终板入路,可以满足大多数累及三脑室前部病变的手术切除。 5.终板构成一个清晰,可以辨认的显微手术标志；分离终板池、前交通动脉及其穿通支可以暴露终板；术前MR和术中判别终板、前交通动脉复合体、前联合、垂体柄、乳头体、中间块等解剖标志,对安全使用终板手术空间有重要的临床意义。经终板间隙是处理鞍上凸入三脑室空间颅咽管瘤的重要手术路径,经该间隙可以全切除经典轴外路径难以充分暴露、手术难度较大的颅咽管瘤。
[Abstract]:Background and purpose:
1.1664 years Cerardus Blasius, described and named arachnoid; 1875 Key and Retzius for the first time to arachnoid pool a detailed description of the 1976 Yasargil report; endplate pool observation during the operation, and the related anatomical endplate microsurgical operation in the Department of neurosurgery. The endplate pool, end plate anatomy related research methods and results are not the same, morphological characteristics a pool of endplate, boundary, contents and neighboring cistern relationship remains controversial, there are differences in endplate related structures. This study is through the microscopic anatomy of human cadaveric head based on morphological characteristics, observation and measurement of endplate pool boundary, the relationship between the content and the surrounding brain cell; the relationship between anatomical characteristics the endplate and surrounding areas of anterior communicating artery and perforating artery structure; to explore the application of endplate pool, endplate related morphological characteristics and data in clinical practice.
2. summarize the clinical data of surgical use of endplate clearance three ventricle anterior tumor resection, using the method of system of endplate clearance, the surrounding adjacent anterior cerebral artery - anterior communicating artery complex and its perforating artery, anterior commissure, optic chiasm, pituitary stalk, and endplate pool to three ventricle anterior anatomical structure in the endplate into the protection and utilization of the road to provide the basis for the treatment of the tumor region.
Research methods:
1. using 10% formalin fixed adult cadaveric head specimens of 20 cases, including 10 cases of application of homemade red and blue latex perfusion respectively,.10 venous system with pterional approach on two sides to craniotomy, 10 cases by anterior interhemispheric approach craniotomy. Pterion approach methods: cadaveric heads fixed on the operating table on the open part of the frontal and temporal bone, medial sphenoid ridge to grind in until the sphenoid ridge, cutting the dura mater, resection of the temporal lobe and frontal part, on both sides to pull exposed lateral fissure. In 6, -40 under the microscope, simulating pterion approach to isolation layer by layer, lateral fissure, jugular after exposure artery, optic nerve, optic chiasm, reach the endplate pool. The lateral anterior interhemispheric approach anatomy: open the side of the frontal bone, expand the bone window to the anterior cranial fossa, removal of the eye in the frontal pole close to the supraorbital horseshoe cut dura, at 6 -40 under the microscope before simulation Interhemispheric approach anatomical layer, layer by layer from the frontal lobe, along the longitudinal direction of the saddle area, with the purpose of preserving endplate vascular pool related, pia mater and arachnoid, from the genu level along the A2 segment of anterior cerebral artery dissection down to endplate to endplate above the pool, then dissected the bottom of the pool, and arrived at the endplate the suprachiasmatic surface. Two approaches were observed in lamina terminalis cistern morphology, boundary, contents, and membrane structure and related vessels, between adjacent cisterns clear endplate, optic recess, optic chiasm, anterior communicating artery and its perforating artery, anterior commissure, middle block, mammillary body and other related structure, open lamina terminalis approach in simulation exposed three ventricle anterior and bottom. The use of digital camera and video recording system, using electronic vernier caliper on the endplate, optic chiasm, anterior communicating artery and its related and nerves and blood vessels were measured, using the SPSS13 statistical software division Analysis and treatment.
78 cases of the three ventricle anterior tumor patients 2. patients from Guangzhou Nanfang Hospital from January 2008 to December 2010 by the endplate clearance, including craniopharyngioma patients (60 cases of adult group under 16 years old in 27 cases, 16 year old adult group 33 cases), 6 cases of large pituitary adenoma, 6 cases of hypothalamic glioma, 2 cases meningioma, 2 cases of germ cell tumor, non Hochkin lymphoma and nonspecific granuloma in 1 cases. The clinical manifestations include intracranial hypertension, visual impairment and visual field defect, hypopituitarism, polyuria, hypothalamic injury symptoms, secondary education. According to the time delay clear tumor CT and MR scanning properties, size texture, information involving the location: the main observation indexes including sagittal MR scanning: the relative position of the anterior communicating artery complex and tumor position, tumor in the sagittal height, the direction of displacement of the mammillary body, involving The interpeduncular fossa or even slope degree and its possible relationship with top of the basilar artery, evaluate the anterior communicating artery complex angioarchitecture. According to the property of tumor size, involving the location and the three ventricle were selected by frontotemporal - endplate approach in 38 cases, and different anterior longitudinal translamina terminalis approach in 40 cases; this two surgical anatomic brain tumor revealed different path pool, but need to be fully exposed and cut the endplate. Trans lamina terminalis approach resection generally includes two types: 1. Complete resection of the tumor by plate separation: including the body into the three ventricle of the craniopharyngioma; auxiliary operation: the main use of endplate including the obvious growth to the suprasellar craniopharyngioma, pituitary adenoma, hypothalamic glioma and meningioma. Intraoperative identification and protection of the surrounding the anterior cerebral artery and anterior communicating artery complex and its perforating artery, anterior commissure, optic chiasm, Pituitary stalk, middle block, papilla body, hypothalamus, and other important nerve structures. Postoperative imaging examination to evaluate the degree of surgical excision, case follow up
The results of the study:
The 1. is the odd brain endplate pool pool, located above the optic chiasm, front upper endplate, on walls composed of endplate medial membrane, extended upward to the corpus callosum pool, which is connected to the front and outer arachnoid, inferior wall composed of the upper surface of the optic chiasm and endplate, posterior lateral wall which is free, the endplate membrane lateral, lateral to the top endplate membrane on both sides of the inner membrane. The endplate to endplate extension lateral membrane attached to the posterolateral edge straight back, down to the upper surface of the optic chiasm, lateral, divided into sparse, dense and absent type. The medial membrane endplate pairs, from both sides of the straight back after with a central extended upward, divided into convex type and flat type. The contents of sparse pool endplate including bilateral distal anterior cerebral artery A1 segment, A2 segment of the proximal, anterior communicating artery, Heubner recurrent arteries, anterior cerebral artery and anterior communicating artery complex part of perforating artery, 鍙屼晶棰濈湺鍔ㄨ剦,鍙屼晶澶ц剳鍓嶉潤鑴，

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