经蝶海绵窦内侧壁相关解剖和手术学研究

发布时间：2018-06-09 16:35

本文选题：经蝶手术 + 神经外科　；参考：《第一军医大学》2007年博士论文

【摘要】： 鞍区位于颅底中线处，是整个颅腔的中心位置，它包含垂体、两侧海绵窦(CS)、颈内动脉和Ⅲ～Ⅵ对颅神经等众多重要的解剖结构，几个世纪以来一直是神经外科医师和神经解剖学者不断研究的重要区域。对于该区域病变的手术治疗，尤其是向两侧鞍旁扩展并侵犯CS的病变，往往让神经外科医生望洋兴叹。而临床上，合并鞍旁扩展的巨大垂体腺瘤屡见不鲜，传统通过经颅手术处理该类病变时，往往由于重要的神经血管阻挡而无法达到满意的手术效果；近年来随着经蝶手术技巧的完善和手术器械的发展，使得经蝶手术由于距离短、创伤小和时间短等优点，而被广泛应用于垂体腺瘤的手术切除。更有学者通过扩展的经蝶入路来处理鞍旁、鞍上和上斜坡处的病变。而对于处理向两侧扩展的垂体腺瘤时，由于从内侧入路不存在各颅神经的阻挡，具有经颅手术无法比拟的优势，故如何能很好的利用经蝶手术宋处理该类病变具有重要意义。复习文献发现目前对于鞍区的解剖更多的是基于经颅手术视角，而对于经蝶手术下垂体、两侧CS和众多神经血管结构的解剖学形态未有详细和完善的报道，且对于该区域的解剖尚存在很多争论和理解误区，正基于此，本研究通过组织学切片和显微解剖两种方法，对胎儿和成人尸头进行形态学研究，并结合临床相关疾病，，探讨鞍区膜性结构和神经血管结构等的走形、分布和相互关系，以期为临床通过经蝶手术处理该区域病变提供组织学和解剖学依据。【目的】 1、本课题通过组织学切片和显微解剖的方法，系统的进行了经蝶入路下CS的解剖研究，并和传统的经颅入路对该区域的解剖学研究进行比较，对该区域解剖学系统化、完善化起到了很好的补充作用； 2、由于经蝶入路和经颅入路的手术角度，以及术野范围的不同，使这两种入路下垂体窝及两侧CS区域的解剖形态发生了很大变化，本课题的完成对于经蝶入路下该区解剖结构的变化进行了详细描述，为使用经蝶入路进行CS内侧壁手术操作起到了指导作用；【方法】 1、经蝶海绵窦相关膜性结构的解剖学研究取8例足月引产死胎，小心取出鞍区、两侧CS及部分中颅窝底、岩尖部，分别作冠状和矢状位连续切片，层厚8μm，使用常规HE和Masson’s法染色后，在显微镜下仔细观察鞍内和鞍上各层膜性结构的走行关系，并测量重要解剖区域的各模型结构的厚度；另取成人固定尸头标本10例(6男4女)，通过经蝶手术暴露鞍底和CS下壁，逐层切开各层膜性结构，对其走行和分布进行解剖学研究和测量。 2、经蝶海绵窦相关动脉结构的解剖学研究取仅动脉灌注的固定尸头标本10例20侧(6男4女)，通过经蝶手术暴露鞍旁段颈内动脉(PSICA)后，小心分离各动脉分支，对其进行解剖学描述，并和经颅手术中CS内血管结构进行对比研究。 3、经蝶海绵窦相关静脉结构的解剖学研究在胎儿标本中，取前、下、后海绵间窦和基底窦相关序列10张切片中的4张分别用常规HE和Masson's染色法染色，其结果在显微镜下观察。另取血管灌注的尸头标本10例(动脉和静脉分别灌注红色和蓝色乳胶)，通过经蝶入路暴露鞍底硬膜和CS下壁，切开二者后，确定前、下海绵间窦在鞍底的相对位置。对比经颅手术入路解剖，对CS各静脉腔隙进行观察和测量，分析在经蝶入路下可利用的静脉空间。【结果】 1、垂体表面有两层膜性结构覆盖：垂体固有膜和垂体囊，垂体囊的外侧部又构成了CS的内侧壁，该壁的下半部较之上半部为厚，其厚度甚至超过CS上壁和鞍隔，而其又可分为两层：纤维层和硬膜层。该纤维层还构成了CS各壁的内层，并且包绕在窦内各神经血管的鞘膜外，CS内侧壁的硬膜层向鞍隔孔附近延续并参与鞍隔的构成；而鞍上蛛网膜和软脑膜在视交叉腹侧、垂体柄上端处融合，并向下和垂体固有膜相延续。固有膜与垂体表面紧密联系，并深入垂体实质内，从而鞍上蛛网膜下腔在垂体柄处中止； 2、经蝶入路下，颈内动脉可分为鞍旁段颈内动脉(PSICA)和斜坡旁段颈内动脉(PCICA)，对于PSICA根据其形态可分为上、下水平部和垂直部。而脑膜垂体干源于PSICA下水平部末段内壁的9侧(45％)、顶壁4侧(20％)、外壁5侧(25％)、上水平部中段内壁2侧(10％)；海绵窦下动脉源于PSICA垂直部中段外壁16侧(80％)，下水平部中段1侧(5％)；另3侧(15％)源于脑膜垂体干；仅在5侧标本(25％)中发现McConnell's背囊动脉，其源于垂直部上段的内壁上，口径细小(0.85±0.21mm)； 3、所有胎儿标本的组织切片上，均发现在鞍结节下缘、腺垂体下方和鞍背处，均可见垂体囊和鞍底硬膜分离，从而形成了前、下和后海绵间窦；而在鞍背和上斜坡处，双层硬膜结构分离形成了基底窦。在10例尸体标本的显微解剖中，4例(40％)可见明显的前海绵间窦，5例(50％)有下海绵间窦，前海绵间窦位于视神经隆突下方，而下海绵间窦位于鞍底隆突向斜坡压迹转折处。CS分为内侧、下外侧和背外侧静脉腔，内侧和下外侧腔在经蝶手术中能方便使用，但背侧腔由于鞍旁段颈内动脉上水平部的阻挡，对经蝶入路影响较大。【结论】 1、由于CS内侧壁的结构特点，垂体腺瘤最易从囊上壁和上外侧壁向CS突出，包绕颈内动脉。在腺瘤向CS内膨胀生长的过程中，其间的膜性结构(垂体囊和固有膜)会发生适形性变化，使得肿瘤和CS之间保持毗邻关系，使得在垂体囊和固有膜之间存在一经蝶处理巨大垂体腺瘤的安全外科界线。而鞍隔孔附近膜性结构的生理或病理缺陷可能是空蝶鞍综合症的发病机制。 2、经蝶入路处理CS内侧壁相关病变时，在PSICA各分支中，垂体下动脉、McConnell's背囊动脉和手术关系最密切，是术中动脉出血的主要原因。同时由于肿瘤向外的推挤作用，脑膜垂体干(MHT)和海绵窦下动脉的起源位置也很有可能就暴露在术野中，从而造成分支或主干的损伤，因此在对靠下后内侧的肿瘤进行切除时，动作要轻柔，尽量避免钳夹。而术前进行血管造影，做好肿瘤和血管关系的良好预判，是术中防止出血，尽量全切肿瘤成功的关键。 3、经蝶入路下，由于手术空间狭小、位置深在，以及器械难以自由展开等特点，使得肿瘤切除，特别是术中止血变得非常困难，熟悉前、下海绵间窦在鞍底的解剖位置，明确CS各个静脉腔隙的形态特点和解剖结构，并在术前对病人影像学资料的仔细研究，对减少术中静脉性出血、神经血管的保护，以及增加肿瘤切除的安全性是非常有意义的。
[Abstract]:The saddle area, located at the middle of the skull base, is the central position of the whole skull. It contains many important anatomical structures, such as the pituitary, the bilateral cavernous sinus (CS), the internal carotid artery and the cranial nerves, which have been an important area for neurosurgeons and neuroanatomies for centuries. The surgical treatment of the lesions in this area is especially important. It is a disease that extends and invade CS on the side of the saddle and often makes neurosurgeons sigh. In clinical, the giant pituitary adenoma with paranella expansion is common. In the traditional way of transcranial surgery, it is often due to important neurovascular obstruction and no satisfactory surgical results. In recent years, with the transsphenoidal hand. The improvement of technique and the development of surgical instruments make transsphenoidal surgery widely used for the resection of pituitary adenomas because of the advantages of short distance, small trauma and short time. More scholars have treated the lesions near the saddle, suprasellar and upper clivus by extended transsphenoidal approach. For the treatment of pituitary adenomas extending to both sides, because of the expansion of the transsphenoidal approach, It is of great significance to use the transsphenoidal surgery song to deal with this kind of disease. It is found that more of the anatomy of the sellar region is based on the cranial operation perspective and the pituitary, both sides CS and many gods for transsphenoidal surgery. There are no detailed and perfect reports on the anatomical morphology of the vascular structure, and there are still a lot of controversy and misunderstanding about the anatomy of the region. It is based on this. In this study, the morphological study of fetal and adult cadavers was carried out by two methods of histological section and microdissection, and the membrane structure of the saddle region was discussed in combination with the clinical related diseases. In order to provide histological and anatomical basis for transsphenoidal surgery to treat lesions in this region, the distribution, relationship and distribution of neurovascular structures were discussed.
[Objective]
1, by means of histological section and microdissection, the anatomical study of CS under the transsphenoidal approach is carried out systematically and compared with the traditional transcranial approach to the anatomical study of the region, which is a good supplement for the systematization and perfection of this area.
2, due to the surgical angle of transsphenoidal approach and transcranial approach, as well as the differences in the scope of the operation, the anatomical morphology of the pituitary fossa and both sides of the CS region has been changed greatly in these two approaches, and the changes of the anatomical structure of the area under the transsphenoidal approach are described in detail, and the operation of the medial wall of the CS is performed by transsphenoidal approach. It has played a guiding role.
[method]
1, the anatomy of the cavernous sinus related membrane structures.
8 cases of full term induced abortion were taken to take out the saddle area carefully, both sides of CS and the bottom of the middle cranial fossa, the tip of the rock, respectively, the coronal and sagittal sections were sectioned and the thickness of the layer was 8 mu. After the routine HE and Masson 's staining, the relationship between the membranous structures of the suprasellar and suprasellar layers was carefully observed under the microscope, and the model structures of the important anatomical regions were measured. In addition, 10 adult cadaver specimens (6 men and 4 women) were exposed to the sella fundus and the lower CS wall through transsphenoidal surgery, and the membrane structures were cut by layer by layer, and their walking and distribution were anatomically studied and measured.
2, the anatomy of the transsphenoidal sinus related artery.
20 sides (6 men and 4 women) of fixed cadaver head specimens perfused with only arterial perfusion were carefully separated from the branches of the arteries after transsphenoidal exposure to the internal carotid artery (PSICA) of the sellar segment (PSICA), and the vascular structures in CS were compared with those in the craniotomy.
3, the anatomy of the transsphenoidal sinus related veins.
In the fetal specimens, 4 of the 10 slices of the related sequence of the inter cavernous sinus and the basilar sinus of Houhai were stained with conventional HE and Masson's staining. The results were observed under the microscope. Another 10 cadaver specimens perfused with blood vessels (arteries and veins were perfused with red and blue latex respectively) were exposed to the dural and CS of the saddle base through transsphenoidal approach. The relative position of the anterior and lower cavernous sinus in the saddle base was determined after the incision of the two sides. The venous lacunae of CS were observed and measured in contrast to the transcranial approach, and the venous space available under the transsphenoidal approach was analyzed.
[results]
1, the surface of the pituitary is covered with two layers of membranous structure: the hypophysis propria and the hypophyseal capsule, the lateral part of the hypophysis and the medial wall of the CS. The lower part of the wall is thicker than the upper half of the wall. The thickness of the wall is even more than the upper and saddle septum of the CS, and it can be divided into two layers: the fibrous layer and the dura layer. The fiber layer also forms the inner layer of the CS walls, and the package is wrapped. Outside the sheath of the nerve vessels in the sinus, the dural layer of the medial wall of the CS extends to the saddle septum and participates in the saddle septum, while the suprasellar arachnoid and the pia are fused at the intercruciate ventral side, the upper end of the pituitary stalk, and downward to the hypophyseal propria. The propria is closely linked to the pituitary surface and is deep in the pituitary parenchyma, thus saddle up. The subarachnoid cavity is discontinued at the pituitary stalk;
2, under the transsphenoidal approach, the internal carotid artery can be divided into the lateral saddle segment of the internal carotid artery (PSICA) and the lateral segment of the jugular artery (PCICA). For PSICA, it can be divided into upper, lower and vertical parts according to its morphology. The meningeal pituitary stem is derived from 9 sides (45%) of the inner wall of the end of the horizontal part of PSICA, the top wall of the wall (20%), the 5 side (25%) of the outer wall, and the 2 side of the middle segment of the upper level. 10%): the inferior cavernous sinus artery was derived from 16 sides of the outer wall of the middle part of the PSICA vertical part (80%), 1 sides of the middle segment of the horizontal part of the water (5%), and the other 3 sides (15%) originated from the meningeal hypophysis. Only the McConnell's dorsal capsule artery was found in the 5 side specimens (25%), which originated from the inner wall of the upper vertical part, and the diameter was fine (0.85 0.21mm).
3, on the tissue section of all fetal specimens, they were found in the lower margin of the saddle nodule, below the pituitary gland and the saddle back, and the hypophysis sac and the dura were separated from the saddle base, thus forming the anterior, lower and Houhai cavernous sinuses; and the basal sinus was separated from the double dura structure at the saddle back and the upper slope. In the microanatomy of 10 cadavers, 4 cases (40%) In 5 cases (50%), 5 cases (50%) have inferior cavernous sinus, and the cavernous sinus of Qianhai is located under the protuberance of the optic nerve. The inferior cavernous sinus is located in the medial, lower lateral and lateral vena cava at the turning point of the saddle bottom to the ramp, and the medial and lower lateral cavity can be easily used during transsphenoidal operation, but the dorsal cavity is due to the lateral saddle segment of the neck. The obstruction of the horizontal artery has great influence on the transsphenoidal approach.
1, due to the structural characteristics of the medial wall of the CS, pituitary adenomas are most likely to protruding from the upper and upper lateral walls of the capsule to the internal carotid artery. In the course of the expansion of the adenoma to CS, the membranous structure (the pituitary capsule and propria) changes conformable between the tumor and the CS, making the tumor and the CS adjacent to the hypophyseal capsule and the propria. There is a safe surgical boundary between the transsphenoidal treatment of giant pituitary adenomas, and the physiological or pathological defects of the membranous structure near the sella septum may be the pathogenesis of sella syndrome.
2, when transsphenoidal approach to CS medial wall related lesions, in the branches of the PSICA, the inferior hypophyseal artery, the McConnell's dorsal sac artery and the operation are most closely related, which are the main causes of intraoperative arterial hemorrhage. At the same time, the origin of the meningohypophysis (MHT) and the inferior cavernous sinus artery may also be exposed to the surgical field due to the external extrusion of the tumor. In this way, it causes the injury of the branch or the trunk, so when the tumor is removed, the action should be gentle and try to avoid the clamp. The key to prevent bleeding during the operation and to complete the success of the tumor is to do a good preoperative angiography and a good prediction of the relationship between the tumor and the blood vessel.
3, under the transsphenoidal approach, the resection of the tumor, especially the hemostasis in the operation, is very difficult because of the narrow space of the operation, the deep location and the difficulty of the free expansion of the instruments. The anatomical position of the cavernous sinus in the CS and the anatomical structure of the various venous lacunae is clear, and the imaging data of the patients before the operation are made. Careful study is of great significance in reducing intraoperative venous bleeding, neurovascular protection, and increasing the safety of tumor resection.
【学位授予单位】：第一军医大学
【学位级别】：博士
【学位授予年份】：2007
【分类号】：R651;R322

【参考文献】