颞叶内侧区显微解剖及手术入路研究

发布时间：2018-01-02 15:34

本文关键词：颞叶内侧区显微解剖及手术入路研究　出处：《天津医科大学》2009年博士论文　论文类型：学位论文

【摘要】： 目的1．研究颞叶内侧区解剖及其与周围结构的毗邻关系；2．研究到达颞叶内侧区的手术入路；3．研究颞叶内侧和邻近环池的血液供应。方法1、1 5个灌注有彩色硅胶的尸头标本和30侧大脑半球标本进行显微镜下解剖，观察颞叶内侧结构的组成及相互关系，颞叶内侧结构和颈内动脉、大脑中动脉、后交通动脉、脉络膜前动脉、大脑后动脉、基底静脉的解剖关系。2、根据通过下脉络点和四叠体水平的两条横线将颞叶内侧区分为前、中、后三部分，根据经过颞叶表面的不同将手术入路分为上、底、外、内四组，颞上组包括经侧裂—岛叶入路；内侧组包括前部经侧裂—脑池入路、后部经枕半球间入路、小脑上经小脑幕入路；颞底组指颞下入路；外侧组包括经颞外侧皮层入路和经颞沟入路，在15具尸头上模拟这些手术入路，研究各个手术入路的优缺点、观察颞叶桥静脉的走行、汇入点位置和形态特点以及其对手术入路的影响。结果 1、海马旁回通过侧副沟、鼻状沟和外侧的梭状回分界，30侧半球均存在侧副沟，从前向后连续走行，其前端6侧(5具尸头)与鼻状沟相连续，24侧(80％)二者不连续。大脑后动脉的颞下分支从海马旁回底面向外侧走行进入侧副沟，绕出后分布在颞叶底面，根据颞下分支可以确定侧副沟的位置。 2、海马和伞位于颞角底部内侧，海马长48．8mm±2．6mm，分为头、体、尾三部分，海马头横径19．24±2．3mm，前后径17．56±3．6mm，体长24．42±4．6mm，尾部横径7．88±2．4mm，前后径6．82±1．2mm。海马头表面有趾状突，表面无脉络丛，组成颞角前部的内侧壁。脉络丛覆盖于海马体尾部。 3、杏仁核后部向颞角上方膨出，90％和海马头前部相接，组成颞角的前上壁，完全在钩的范围内，杏仁核上方和苍白球无明显分界。 4、脑沟至颞角的距离，经侧副沟至颞角的距离最短，在钩尖水平为2．81±0．14mm，下脉络点水平为3．19±0．65mm；其次为下环岛沟，在钩尖和下脉络点水平至颞角的距离分别为6．08±1．32mm，，6．58±2．12mm。脑回至颞角的距离，海马旁回距离最短，在钩尖水平为6．80±2．16mm，下脉络点水平为12．32±2．92mm。 5、下脉络点位于海马头后部，对应钩后段的后界及最高点。下脉络点至颞极的距离为45．96±6．56mm，至海马头的距离为17．56±3．49mm，与钩尖的距离为10．88±2．34mm。 6、脉络膜前动脉池段前半部73％在钩前内侧面上1／3，9％在钩前内侧面中1／3，钩前内侧面下1／3占18％；脉络膜前动脉池段后半部和钩后段位置关系：91％在钩后内侧面上1／3，钩后内侧面下1／3占9％。大脑后动脉P2a段和钩后段相邻，P2a58％位于钩切迹水平，33％在钩切迹之上，9％在钩切迹之下。 7、共发现125支海马动脉，平均每侧4．2支(2—7支)，74．4％发自大脑后动脉主干及其分支；在大脑后动脉及其分支中，颞下前动脉最常发出海马动脉，25侧(83．3％)颞下前动脉发出26支(20．8％)海马动脉；6支钩—海马动脉发自颞下前动脉，供应海马体尾，齿状回。25侧(83．3％)半球共有32支(25．6％)海马动脉发自脉络膜前动脉，主要供应海马头，二者的海马动脉分支在钩后段下面形成吻合。 8、经侧裂—岛叶入路、经侧裂—脑池入路、经颞叶皮层或脑沟入路、颞下入路可暴露颞叶内侧区前部。颞下入路、经颞外侧入路可暴露颞叶内侧中部结构，中部病变需要根据病变的性质选择手术入路。后部入路包括经枕半球间入路和小脑上经小脑幕入路，可暴露颞叶内侧后部结构。 9、共发现32条Labb(?)静脉。每侧半球有2条Labb(?)静脉者2侧，有1条Labb(?)静脉者28侧。Labb(?)静脉在颞叶外侧面走行的位置在颞中静脉引流区和颞后静脉引流区，分别占40．6％和53．1％，颞前静脉分布区占6．3％。汇入点在横窦区20条，占62．5％，天幕前区和天幕后区各6条，占37．5％。距离窦硬膜点的距离左侧19．84±4．68mm(5．28～30．1 6mm)，右侧20．62±5．42mm(7．1 6～29．72mm)。颞下段的长度为15．86±1．34mm(15．20～16．72mm)，直径为2．68±0．86mm(1．46～4．32mm)。桥静脉汇入静脉窦的位置55％位于横窦区，天幕后区为30％，岩上窦区占9．4％，天幕前区占5．6％。汇入硬膜窦的形式集束型45％，成簇型30％，单支型25％。 10、钩回切除可以增加P2a的暴露范围。结论1、颞叶内侧和大脑后动脉、脉络膜前动脉池段、脑干、视束、基底静脉等重要结构毗邻，掌握颞叶内侧区解剖及其与毗邻结构的相互关系对于安全进行此部位的手术至关重要。下脉络点、脉络裂、杏仁核与海马头前部相接触的特点是经颞角手术治疗颞叶内侧区病变的重要解剖标志。2、对颞叶内侧区进行分区，不但有助于理解颞叶内侧区的解剖关系，而且对于选择合适的手术入路处理此区病变大有帮助。3、颞叶内侧区的每一个手术入路均有其优缺点，联合入路会弥补单个手术入路的不足。4、钩回部分切除可以作为增加暴露颞叶内侧区前部病变的手段之一。
[Abstract]:Objective 1. to study the anatomy of the medial temporal lobe and its adjacent relationship with the surrounding structures; 2., to study the operative approach to the medial temporal lobe, and 3. to study the blood supply of the medial temporal lobe and the adjacent cisterna.
1,1 5 perfusion method of cadaveric head color silica gel and 30 hemispheres were dissected under microscope, observe the composition of medial temporal lobe structures and the relationship between the medial temporal lobe structures and internal carotid artery, middle cerebral artery, posterior communicating artery, anterior choroidal artery, posterior cerebral artery, anatomy of the basal vein of.2 the two line, according to the context and the level of the quadrigeminal medial temporal lobe is divided into before, after the three part, according to the temporal surface of different surgical approach is divided into the upper and bottom, in four groups, including supertemporal group - transsylvian insular approach; the medial group including the anterior lateral cleft - cisternal approach, suboccipital posterior interhemispheric, superior cerebellar transtentorial approach; temporal base group refers to the subtemporal approach; lateral group including the temporal cortex lateral approach and temporal sulcus approach in 15 cadaveric heads into the surgical simulation on the road, each hand The advantages and disadvantages of the approach, the walk of the temporal lobe, the location of the remittance point and the morphological characteristics, and the effect on the surgical approach were observed.
Result
1, parahippocampal gyrus by collateral sulcus, sulcus lateral nasal and fusiform shaped back boundaries, all 30 hemispheres are the side ditch, continuous walking backwards, the front side of the 6 (5 cadaver heads) and the nose ditch, 24 sides (80%) the two brain is not continuous. After the artery branches from the parahippocampal gyrus, inferior temporal walking into the bottom of the outer side of the collateral sulcus in the temporal lobe distribution around the bottom surface, according to the temporal branch can determine the collateral sulcus position.
2, the hippocampus and temporal horn is located in the inner side of the bottom of the umbrella, in 48.8mm + 2.6mm, divided into head, body, tail three parts, head of hippocampus diameter anteroposterior diameter of 19.24 + 2.3mm, 17.56 + 3.6mm, 24.42 + 4.6mm tail length, transverse diameter of 7.88 + 2.4mm, 6.82 + 1.2mm. in diameter head surface of toe condyle surface, choroid plexus, the medial wall of the temporal horn. The composition of the front cover of choroid plexus in the hippocampus tail.
3, the posterior part of the amygdala protruded to the top of the temporal horn, and 90% connected with the anterior part of the horse head, forming the anterior superior wall of the temporal horn, which is completely within the hook range. There is no obvious boundary between the amygdaloid nucleus and the globus pallidus.
4, brain ditch to the temporal horn of the lateral distance, side ditch to the temporal horn of the shortest distance, the hook tip level was 2.81 + 0.14mm, under the context of level 3.19 + 0.65mm; followed by cerebral sulcus, the hook and choroidal point level to the temporal horn of the distance was 6.08 + 1.32mm 6.58 + 2.12mm., angular distance to the temporal gyrus, parahippocampal gyrus, the shortest distance, the hook tip level was 6.80 + 2.16mm, under the context of level 12.32 + 2.92mm.
5, the lower choroid point is located at the posterior part of the hippocampus, corresponding to the posterior border and the highest point of the posterior segment of the hook. The distance from the lower chord to the temporal pole is 45.96 + 6.56mm, the distance to the horse head is 17.56 + 3.49mm, and the distance from the hook tip to the hook tip is 10.88 + 2.34mm..
6, cisternal segment of the anterior choroidal artery in the former half of the 73% hook on the inner side of 1 / 3,9% in the inner side in the hook before 1 / 3, hook anteromedial of 1 / 3 accounted for 18%; the anterior choroidal artery cisternal segment of the back part and hook position relations: 91% side in 1 after the hook / 3, 1 / hook side accounted for 3 9%. posterior cerebral artery P2a segment and posterior segment of P2a58% located in the adjacent hook, hook notch, 33% in the top 9% in the hook hook notch and notch.
7, showed a total of 125 hippocampal arteries, 4.2 per side (2 - 7), 74.4% from the posterior cerebral artery and its branches; in the posterior cerebral artery and its branches in the anterior inferior temporal artery is most often a hippocampal artery, 25 sides (83.3%) temporal artery branch (20.8%) in issue 26 6 - hook artery; hippocampus artery originated from the anterior inferior temporal artery supply, hippocampus tail, dentate gyrus.25 side hemisphere (83.3%) a total of 32 (25.6%) of hippocampus artery originated from the anterior choroidal artery, the main supply of seahorse, hippocampus artery branch two formed on the hook after anastomosis below.
8, through lateral fissure - insular approach, through lateral fissure - cisternal approach, the temporal cortex or cerebral sulcus approach, subtemporal approach can expose the anterior medial temporal region. Subtemporal approach, the temporal lateral approach can expose the medial temporal lobe lesions according to the central structure, central the nature of the lesion to choose the surgical approach. The posterior part of the occipital including interhemispheric and cerebellar transtentorial approach can expose the medial temporal lobe, posterior structure.
9, found a total of 32 Labb (?) vein. Each hemisphere has 2 Labb (?) vein in 2 side, 1 Labb (?) vein in 28 side.Labb (?) vein in the temporal lobe lateral walking position in temporal vein drainage area and posterior temporal vein drainage area 40.6% and 53.1%, respectively, the temporal distribution of 6.3%. into the vein in the transverse area of 20, accounting for 62.5%, the front region and the region behind the day of the 6, accounting for 37.5%. distance the distance from the left sinus dural 19.84 + 4.68mm (5.28 ~ 30.1 6mm), on the right side of the 20.62 + 5.42mm (7.16 ~ 29.72mm). Infratemporal segment length was 15.86 + 1.34mm (15.20 ~ 16.72mm), the diameter was 2.68 + 0.86mm (1.46 ~ 4.32mm). The position of 55% bridge veins located in the transverse sinus area, area 30% days behind, sinus area accounted for 9.4% on the rock, before canopy area accounts for 45% 5.6%. to form a cluster of dural sinus the cluster type 30%, single Type 25%.
10, uncinate resection can increase the exposure range of P2a.
Conclusion 1, medial temporal lobe and posterior cerebral artery, anterior choroidal artery cisternal segment, brainstem, optic tract, adjacent to the basal vein and other important structures, grasp the relationship between the medial temporal region dissection and its neighbouring structure for this part of the operation is very important. Under the context, vein fissure, characteristics of the amygdala and the sea the front contact is the surgical treatment of temporal lobe lesions of the temporal horn of the medial region of the anatomical landmarks of.2, partitioning the medial temporal region, not only helps to understand the anatomy of the medial temporal region, and to select the appropriate surgical approach and the lesions are of great help.3, medial temporal lobe the area of each approach has its advantages and disadvantages, the combined approach will make up for lack of a single.4 surgical approach, hook back resection can be used as one of the exposure of the medial temporal lobe lesion area front means increased.

【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2009
【分类号】：R651.1;R322

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