内镜辅助眶颧入路对脚间池区的解剖研究
发布时间：2018-08-15 13:55
【摘要】：目的:大脑脚间池(interpeduncular cistern,IC)位置深在,基底动脉(basilarartery,BA)是此区重要结构。颅内动脉瘤中,椎—基底动脉(vertebral-basilar artery,VBA)动脉瘤较少见,约占3.8%～15%,而BA动脉瘤在VBA动脉瘤中占40%左右,由于位于颅后窝深部,可累及脑干、脑神经、穿支动脉等重要结构,一旦破裂预后较差,术后死亡率和病残率高于前循环动脉瘤。VBA系统的巨型动脉瘤(直径＞2cm)相对较多,据报道,VBA的巨型动脉瘤约占66%～87%,未经治疗的巨型动脉瘤在5年内80%以上出现严重的残疾甚至死亡(因脑干受压、严重的动脉栓塞等)。 BA动脉瘤的治疗手段目前主要有两种:一是血管内治疗,常用弹簧圈进行栓塞,为后循环动脉瘤首选治疗,但其适应证较窄。另一种为开颅动脉瘤夹闭术,由于病变位置深,多与脑神经、脑干等关系密切,显露困难,手术空间有限,手术难度明显增大。BA动脉瘤的手术入路文献报道已有不少,常用的有颞下、乙状窦后、翼点入路(pterional approach,PA)等,其共同缺点是脑牵拉较大,深部照明差,多数情况下操作空间较小,载瘤动脉的近端难以控制。而眶颧入路(orbitozygomatic approach,OZ)通过磨除部分颅底骨质,则可以明显增加对该区域的显露。OZ可暴露海绵窦、IC、岩骨尖、颞下窝等区域。对一些颅底的巨大肿瘤,复杂的血管病变,与其他入路相比,该入路无论在手术操作空间及视角上,还是在减少脑组织的牵拉上,都有无可替代的优势。然而OZ由于操作复杂,器械要求较高,难度较大而影响其推广应用。尤其重要的是,在显微镜下处理深部病变时,光线照明随深度增加而递减,病变周围组织不易暴露,可能出现手术死角。 无论是血管内介入,还是开颅手术夹闭颅内动脉瘤,其目的是将动脉瘤排除在脑的正常循环之外,以防止它破裂出血。而同时必须保护其载瘤动脉、重要的穿通支以及周围的重要解剖结构,BA动脉瘤手术死亡或致残的最重要原因是主要的穿支血管被夹闭。而内窥镜对深部照明很有帮助,其最大的优点是能显示动脉瘤背侧的信息,还可以显示分支、穿通支以及动脉瘤是否完全夹闭。然而内镜辅助眶颧入路(endoscope assisted orbitozygomatic approach,EAOZ)处理BA动脉瘤的研究甚少,解剖学研究也鲜有报道。 本实验提出了OZ新的眶颧骨瓣形成方法,以求简化操作,减小创伤。分别在显微镜和内窥镜下对国人IC区解剖结构进行了观察和研究,比较二者暴露的差异性,同时熟悉IC区显微镜及内窥镜下解剖关系,尤其是一些蛛网膜结构。为此区病变的手术治疗提供帮助。 方法:8例16侧经10%甲醛充分固定的成人头颅湿标本,动脉系统灌注红色乳胶,模仿实际手术操作将尸头固定于解剖头架上,准备好常规开颅器械。采用扩大PA的头皮切口,从耳屏前1cm颧弓下缘做弧形切口终止于对侧瞳孔中线与发际相交点。本研究采用改良后的两块骨瓣式OZ,首先形成额颞骨瓣,与传统PA骨瓣不同的是骨孔位置,引入了关键孔,此孔位于额蝶缝上颧突后1cm处,此孔恰好能暴露眶骨膜及颅前窝底硬膜。2号孔位于眶上孔外侧0.5cm,眶上缘1cm处。其余骨孔同PA。然后形成眶颧骨瓣:采用改良后的眶颧骨瓣形成术,在关键孔正上方2cm处眶顶上形成3号孔,用线锯依次连通关键孔-眶下裂,关键孔-3号孔,3号孔-2号孔,眶下裂眶内孔-眶下裂眶外孔,最后在颧弓中间部离断颧弓,形成眶颧骨瓣。按标准方式(C形切开基底朝前)剪开硬膜,由远端向近端打开侧裂。显露小脑幕切迹前间隙和BA末端,观察Liliequist膜(Liliequist's membrane,ML)及其分叶。打开ML,进入IC,小心分离蛛网膜,观察双侧后交通动脉(posteriorcommunicaing artery,PCoA)、大脑后动脉(posterior cerebral artery,PCA)、小脑上动脉SCA(superior cerebellar artery,SCA)显露的范围和重要血管分支。先后在显微镜及内窥镜下观察IC区解剖结构,测量所能观察到的BA及其分支的最远端。所测数据采用SPSS11.0统计软件进行处理,采用配对计量t检验进行统计学分析,以p＜0.05为有统计学意义。 结果:1.引入关键孔和3号孔后的改良OZ,降低了手术操作的难度,减小了创伤,切除的眶顶及眶外侧壁面积较传统术式有增加,有利于术后重建。 2.IC由浅部和深部两部分组成,浅部游离,深部为血管组织。与环池,桥前池,颈动脉池,桥小脑角池,动眼神经池相交通。 3.显微镜下观察到BA长度:16.34±3.16mm,内窥镜下观察观察所得BA长度:25.22±4.38mm。内窥镜下所视有明显提高(p＜0.05)。 4.同侧PCA所视长度在显微镜、内窥镜下无明显差别(p＞0.05),同侧、对侧SCA,对侧PCA所视长度在显微镜及内窥镜下有明显差别(p＜0.05)。 结论:1.运用了关键孔和3号孔后的改良OZ,其中关键孔的选位十分重要。 2.EAOZ对比显微镜,可以使BA及其分支的暴露范围明显增加,尤其是术野对侧暴露明显改善,内窥镜深部照明佳。 3.EAOZ对比显微镜,可以更加清晰地观察脑神经及细小穿支动脉的走行,有利于颅底深部操作。 4.应用神经内窥镜应重视内窥镜下IC区解剖关系,尤其应重视此区的蛛网膜结构。
[Abstract]:Objective: The position of interpeduncular cistern (IC) is deep, and the basilar artery (BA) is an important structure in this area. In intracranial aneurysms, vertebral-basilar artery (VBA) aneurysms are rare, accounting for about 3.8%-15%, while BA aneurysms account for about 40% of VBA aneurysms. Once ruptured, the mortality and disability rate are higher than those of anterior circulation aneurysms. There are more giant aneurysms (diameter > 2 cm) in VBA system. It is reported that about 66% ~ 87% of VBA giant aneurysms and more than 80% of untreated giant aneurysms have severe disabilities in 5 years. To death (due to brain stem compression, severe arterial embolism, etc.).
BA aneurysms have two main treatment methods: one is endovascular treatment, commonly used coil embolization, the first choice for the treatment of posterior circulation aneurysms, but its indications are narrow. The other is craniotomy aneurysm clipping surgery, because of the location of the lesion is deep, more closely related to the brain nerve, brain stem, difficult to expose, limited operating space, difficult to operate. Subtemporal, retrosigmoid, and pterional approach (PA) are common approaches for BA aneurysms. Their common drawbacks are large traction of the brain, poor deep illumination, small operating space in most cases, and difficulty in controlling the proximal end of the aneurysm-bearing artery. OZ can expose cavernous sinus, IC, petrous apex, infratemporal fossa and other areas. For some large tumors of the skull base, complex vascular lesions, compared with other approaches, this approach is not only in the operating space and visual angle, but also in reducing the traction of brain tissue. However, OZ is difficult to be popularized because of its complex operation, high equipment requirements and great difficulty. Especially important, when dealing with deep lesions under microscope, the light illumination decreases with the increase of depth, the surrounding tissues are not easy to expose, and the surgical dead angle may occur.
Whether it is endovascular intervention or craniotomy to clip intracranial aneurysms, the aim is to exclude aneurysms from the normal circulation of the brain in order to prevent them from rupturing and bleeding. At the same time, the parent artery, the important perforating branches and the important anatomical structures around it must be protected. The most important cause of death or disability in BA aneurysm surgery is the main reason. Endoscopy is very helpful for deep illumination. Its greatest advantage is that it can show the information of the aneurysm's dorsal side as well as the branches, perforating branches and whether the aneurysm is completely occluded. The study of anatomy is rarely reported.
In order to simplify the operation and reduce the trauma, a new method of orbitozygomatic bone flap formation in OZ was proposed in this study. The anatomical structure of IC region in Chinese was observed and studied under microscope and endoscope, and the differences of exposure between them were compared. At the same time, the anatomical relationship between IC region and endoscope was familiar, especially some arachnoid structures. Surgical treatment is helpful.
Methods: Sixteen adult wet cranial specimens were fixed by 10% formaldehyde in 8 cases. Red latex was perfused into the arterial system. The cadaveric head was fixed on the anatomical head frame and the conventional craniotomy instruments were prepared by imitating the actual operation. In this study, the frontotemporal bone flap was first formed with the modified two-piece bone flap type OZ. Different from the traditional PA bone flap, the key foramen was introduced. The foramen was located 1 cm behind the zygomatic process on the frontotemporal suture. The foramen 2 was located 0.5 cm outside the supraorbital foramen and 1 cm at the supraorbital margin. Formation of orbitozygozygomatic bone flap: A modified orbitozygozygozygozygomatic bone flap was used. A 3-hole was formed on the orbitaroof of the orbitaroof 2 cm above the key hole. The 3-hole was successively connected by wire saw to the key hole-suborbitbitbitbitbitbitbithole, the 3-hole, the 3-hole, the 3-2 hole, the 3-hole, the 2-hole, the intraororbitbitbitbithole-suborbitbitbitbitbitbitbitbitbitbitbitbitbitbitbitbitbitbithole-extraorbitbitbitbitbithole, and then the orbitozyzygomatic archwas cut off in the middle of the key hole above the key hole to form the orbitbitozygomatic arch.shape Open the dura mater and open the lateral fissure from the distal to the proximal. Expose the anterior tentorium notch space and the BA terminal. Observe the Liliequist membrane (ML) and its lobulation. Open the ML and enter the IC. Carefully separate the arachnoid membrane. Observe the posterior communicating artery (PCoA), posterior cerebra artery (PCoA). The scope and important branches of superior cerebellar artery (SCA) and superior cerebellar artery (PCA) were observed under microscope and endoscope, and the distal end of BA and its branches were measured. P < 0.05 was statistically significant.
Results: 1. The modified OZ with the key hole and the third hole reduced the difficulty of operation, reduced the trauma, and increased the area of the orbital roof and lateral orbital wall, which was beneficial to postoperative reconstruction.
2. IC consists of two parts: superficial and deep, free in the superficial part and vascular tissue in the deep part. It communicates with cistern annulus, anterior bridge, carotid artery, cerebellopontine angle and oculomotor nerve.
3. The length of BA observed under microscope was 16.34 [3.16 mm] and that under endoscope was 25.22 [4.38 mm]. The visual acuity under endoscope was significantly improved (p < 0.05).
4. The apparent length of ipsilateral PCA was not significantly different under endoscopy (p > 0.05). The apparent length of ipsilateral, contralateral SCA and contralateral PCA was significantly different under microscope and endoscopy (p < 0.05).
Conclusion: 1. the key hole and the modified OZ of No. 3 were used. The key hole selection is very important in Kong Hou.
2. EAOZ contrast microscope can increase the exposure range of BA and its branches, especially the contralateral exposure of operation field and endoscopic deep illumination.
3. EAOZ contrast microscope can observe the course of cerebral nerve and small perforator artery more clearly, which is beneficial for deep skull base operation.
4. The anatomical relationship of IC area should be emphasized under endoscope, especially the arachnoid structure.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2009
【分类号】：R322
本文编号：2184406
[Abstract]:Objective: The position of interpeduncular cistern (IC) is deep, and the basilar artery (BA) is an important structure in this area. In intracranial aneurysms, vertebral-basilar artery (VBA) aneurysms are rare, accounting for about 3.8%-15%, while BA aneurysms account for about 40% of VBA aneurysms. Once ruptured, the mortality and disability rate are higher than those of anterior circulation aneurysms. There are more giant aneurysms (diameter > 2 cm) in VBA system. It is reported that about 66% ~ 87% of VBA giant aneurysms and more than 80% of untreated giant aneurysms have severe disabilities in 5 years. To death (due to brain stem compression, severe arterial embolism, etc.).
BA aneurysms have two main treatment methods: one is endovascular treatment, commonly used coil embolization, the first choice for the treatment of posterior circulation aneurysms, but its indications are narrow. The other is craniotomy aneurysm clipping surgery, because of the location of the lesion is deep, more closely related to the brain nerve, brain stem, difficult to expose, limited operating space, difficult to operate. Subtemporal, retrosigmoid, and pterional approach (PA) are common approaches for BA aneurysms. Their common drawbacks are large traction of the brain, poor deep illumination, small operating space in most cases, and difficulty in controlling the proximal end of the aneurysm-bearing artery. OZ can expose cavernous sinus, IC, petrous apex, infratemporal fossa and other areas. For some large tumors of the skull base, complex vascular lesions, compared with other approaches, this approach is not only in the operating space and visual angle, but also in reducing the traction of brain tissue. However, OZ is difficult to be popularized because of its complex operation, high equipment requirements and great difficulty. Especially important, when dealing with deep lesions under microscope, the light illumination decreases with the increase of depth, the surrounding tissues are not easy to expose, and the surgical dead angle may occur.
Whether it is endovascular intervention or craniotomy to clip intracranial aneurysms, the aim is to exclude aneurysms from the normal circulation of the brain in order to prevent them from rupturing and bleeding. At the same time, the parent artery, the important perforating branches and the important anatomical structures around it must be protected. The most important cause of death or disability in BA aneurysm surgery is the main reason. Endoscopy is very helpful for deep illumination. Its greatest advantage is that it can show the information of the aneurysm's dorsal side as well as the branches, perforating branches and whether the aneurysm is completely occluded. The study of anatomy is rarely reported.
In order to simplify the operation and reduce the trauma, a new method of orbitozygomatic bone flap formation in OZ was proposed in this study. The anatomical structure of IC region in Chinese was observed and studied under microscope and endoscope, and the differences of exposure between them were compared. At the same time, the anatomical relationship between IC region and endoscope was familiar, especially some arachnoid structures. Surgical treatment is helpful.
Methods: Sixteen adult wet cranial specimens were fixed by 10% formaldehyde in 8 cases. Red latex was perfused into the arterial system. The cadaveric head was fixed on the anatomical head frame and the conventional craniotomy instruments were prepared by imitating the actual operation. In this study, the frontotemporal bone flap was first formed with the modified two-piece bone flap type OZ. Different from the traditional PA bone flap, the key foramen was introduced. The foramen was located 1 cm behind the zygomatic process on the frontotemporal suture. The foramen 2 was located 0.5 cm outside the supraorbital foramen and 1 cm at the supraorbital margin. Formation of orbitozygozygomatic bone flap: A modified orbitozygozygozygozygomatic bone flap was used. A 3-hole was formed on the orbitaroof of the orbitaroof 2 cm above the key hole. The 3-hole was successively connected by wire saw to the key hole-suborbitbitbitbitbitbitbithole, the 3-hole, the 3-hole, the 3-2 hole, the 3-hole, the 2-hole, the intraororbitbitbitbithole-suborbitbitbitbitbitbitbitbitbitbitbitbitbitbitbitbitbitbithole-extraorbitbitbitbitbithole, and then the orbitozyzygomatic archwas cut off in the middle of the key hole above the key hole to form the orbitbitozygomatic arch.shape Open the dura mater and open the lateral fissure from the distal to the proximal. Expose the anterior tentorium notch space and the BA terminal. Observe the Liliequist membrane (ML) and its lobulation. Open the ML and enter the IC. Carefully separate the arachnoid membrane. Observe the posterior communicating artery (PCoA), posterior cerebra artery (PCoA). The scope and important branches of superior cerebellar artery (SCA) and superior cerebellar artery (PCA) were observed under microscope and endoscope, and the distal end of BA and its branches were measured. P < 0.05 was statistically significant.
Results: 1. The modified OZ with the key hole and the third hole reduced the difficulty of operation, reduced the trauma, and increased the area of the orbital roof and lateral orbital wall, which was beneficial to postoperative reconstruction.
2. IC consists of two parts: superficial and deep, free in the superficial part and vascular tissue in the deep part. It communicates with cistern annulus, anterior bridge, carotid artery, cerebellopontine angle and oculomotor nerve.
3. The length of BA observed under microscope was 16.34 [3.16 mm] and that under endoscope was 25.22 [4.38 mm]. The visual acuity under endoscope was significantly improved (p < 0.05).
4. The apparent length of ipsilateral PCA was not significantly different under endoscopy (p > 0.05). The apparent length of ipsilateral, contralateral SCA and contralateral PCA was significantly different under microscope and endoscopy (p < 0.05).
Conclusion: 1. the key hole and the modified OZ of No. 3 were used. The key hole selection is very important in Kong Hou.
2. EAOZ contrast microscope can increase the exposure range of BA and its branches, especially the contralateral exposure of operation field and endoscopic deep illumination.
3. EAOZ contrast microscope can observe the course of cerebral nerve and small perforator artery more clearly, which is beneficial for deep skull base operation.
4. The anatomical relationship of IC area should be emphasized under endoscope, especially the arachnoid structure.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2009
【分类号】：R322
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