本文關鍵詞： 終板池 終板 終板外側膜 終板內側膜 終板間隙 終板入路　出處：《南方醫(yī)科大學》2011年博士論文　論文類型：學位論文

【摘要】：背景和目的： 1.1664年Cerardus Blasius發(fā)現(xiàn)、描述并且命名了蛛網膜；1875年Key和Retzius首次對蛛網膜池進行細致描述；1976年Yasargil報道了手術中觀察的終板池、終板相關顯微解剖以及相關神經外科手術。終板池、終板相關解剖的研究方法和結果不盡相同,關于終板池的形態(tài)學特征、邊界、內容物以及和周邊腦池的關系尚有爭議,在終板相關結構方面存在分歧。本研究是通過顯微解剖人體尸頭為基礎,觀察和測量終板池的形態(tài)學特征、邊界、內容物以及和周邊腦池的關系；終板的解剖學特征以及其周邊的前交通動脈和穿支動脈等結構之間的關系；探討終板池,終板相關形態(tài)學特征和數(shù)據(jù)在臨床中的應用。 2.總結我科使用終板間隙進行手術切除三腦室前部腫瘤的臨床資料,系統(tǒng)探討終板間隙的使用方法,周邊毗鄰的大腦前動脈—前交通動脈復合體及其穿通支、前連合、視交叉、垂體柄、終板池以及三腦室前部等解剖結構在終板入路中的保護和利用,為處理該區(qū)域腫瘤提供依據(jù)。 研究方法： 1.選用10%福爾馬林固定的國人成人頭顱濕性標本20例,其中10例應用自制紅色和藍色乳膠分別灌注動、靜脈系統(tǒng)。10例按翼點入路分兩側進行開顱,10例按前縱裂入路開顱。翼點入路解剖方法：尸頭固定在操作臺上,打開部分額骨和顳骨,盡量磨除蝶骨嵴直至蝶骨嵴的內側,剪開硬腦膜,切除部分顳葉和額葉,向兩側牽拉暴露外側裂。在6—-40倍手術顯微鏡下,模擬翼點入路逐層解剖,先分離外側裂池,后暴露頸內動脈、視神經、視交叉,到達終板池側方。前縱裂入路解剖方法：打開兩側部分額骨,擴大骨窗至前顱窩底,摘除眼球,于額極緊靠眶上馬蹄形剪開硬腦膜,在6—-40倍手術顯微鏡下模擬前縱裂入路逐層解剖,逐層剔除額葉腦組織,沿縱裂方向進入鞍區(qū),有目的的保留終板池相關的血管、軟膜及蛛網膜,從胼胝體膝部水平沿大腦前動脈A2段向下解剖至終板池上方,再解剖至終板池底,到達終板和視交叉上表面。兩種入路均觀察終板池形態(tài)學特征、邊界、內容物、膜性結構以及和相關血管、周邊腦池的關系,明確終板、視隱窩、視交叉、前交通動脈及其穿支動脈、前聯(lián)合、中間塊、乳頭體等相關結構,切開終板,模擬終板入路暴露三腦室前部和底部。使用數(shù)碼相機拍照,攝錄系統(tǒng)錄像,采用電子游標卡尺對終板,視交叉,前交通動脈及其相關的和神經血管等進行測量,應用SPSS13統(tǒng)計軟件分析處理。 2.臨床病例來源于廣州南方醫(yī)院2008年1月至2010年12月間采用終板間隙的78例三腦室前部腫瘤患者,其中包括顱咽管瘤患者60例(未成年組≤16歲27例,成年組16歲33例),大型垂體腺瘤6例,下丘腦膠質瘤6例,腦膜瘤2例,生殖細胞瘤2例,非霍杰金淋巴瘤和非特異性肉芽腫各1例。臨床主要表現(xiàn)包括顱內壓增高征,視力障礙和視野缺損,垂體功能低下,多飲多尿,下丘腦損害癥狀,第二性征發(fā)育遲緩。根據(jù)CT和MR掃描明確腫瘤性質、大小、質地、累及部位等信息：MR掃描正中矢狀位的主要觀察指標包括：前交通動脈復合體位置及其與腫瘤的相對位置關系、腫瘤在矢狀位上的高度、乳頭體的移位方向,累及腳間窩甚至上中斜坡的程度及其與基底動脈頂端可能的關系等,評價前交通動脈復合體的血管構筑。根據(jù)腫瘤性質,大小,累及部位和三腦室關系不同分別選擇額顳—經終板入路38例,前縱裂—經終板入路40例；這兩種手術需解剖不同腦池,顯露腫瘤的路徑不同,但均需充分暴露和切開終板。經終板入路腫瘤的切除總體上包括兩類：①完全經終板分離切除腫瘤：包括主體凸入三腦室的顱咽管瘤；②輔助使用終板手術：主要包括明顯向鞍上池生長的顱咽管瘤、垂體腺瘤、下丘腦膠質瘤以及腦膜瘤等。術中辨別和保護周邊的大腦前動脈—前交通動脈復合體及其穿通支、前連合、視交叉、垂體柄、中間塊、乳頭體、下丘腦等重要神經結構,術后影像學檢查評價手術切除程度,病例隨訪 研究結果： 1.終板池是不成對的腦池,位于視交叉上方,終板前上方,上壁由終板內側膜構成,向上延伸至胼胝體池,它在前方和外層蛛網膜相連,下壁由視交叉的上表面和終板構成,后緣是游離的,外側壁由終板外側膜構成,兩側終板外側膜向上方延續(xù)至終板內側膜。終板外側膜附著在直回的后外側邊緣,下行到視交叉,視神經外側方的上表面,分為稀疏型、致密型和缺如型。終板內側膜不成對,由兩側直回后中部結合處向上延伸構成,分為凸起型和平坦稀疏型。終板池內容物包括雙側大腦前動脈A1段遠端,A2段近端,前交通動脈,Heubner回返動脈的部分,大腦前動脈—前交通動脈復合體的部分穿支動脈,雙側額眶動脈,雙側大腦前靜脈,前交通靜脈。終板池上方為胼胝體池,終板內側膜在胼胝體嘴部和胼胝體池前下部相交通；在前下方,終板池蛛網膜附著在視交叉前下方,視神經表面,并和視交叉池蛛網膜相連；在外側方,終板外側膜下行到視交叉外側方和視神經的上表面,頸內動脈池內側以頸動脈內側蛛網膜附著在視交叉下部并向下延伸到外層蛛網膜,覆蓋在鞍隔側方和后床突,它與頸內動脈池相鄰,以視交叉,視神經外側方為界,無交通關系；在外側前方,終板外側膜的前方和嗅束下方延伸至直回的嗅神經蛛網膜匯合交通。 2.終板較薄,形態(tài)類似軟膜組織,附著在視交叉上表面中部,呈弧線形向后上方止于前聯(lián)合前下方,胼胝體嘴附近,占據(jù)視交叉上表面和胼胝體嘴之間的空間,終板起始部下方為比視交叉低的視隱窩。終板為三腦室最寬處,大多數(shù)為灰白色,其余為暗黃色和藍黑色,終板按形態(tài)學分為隆起型和扁曲型,大多數(shù)終板中心部位透明隆起,為終板窗。視交叉和鞍結節(jié)的定位關系主要為：前置型、正常型和后置型。測量視隱窩長度6.35mm±1.22mm,視隱窩寬度為4.79mm±1.11mm。視交叉前緣到視隱窩前緣的距離為5.53mm±1.23mm,視交叉的前后徑為11.33mm±1.55mm。終板長度為曲線距離,終板前緣(即視交叉上表面的中部)和前聯(lián)合下緣的距離符合終板長度,為9.99mm±1.43mm,終板寬度為兩側視束內側緣最大寬度,為11.23mm±2.23mm。終板切開至三腦室前部和底部,其中清晰辨別中間塊15例,20例均觀察到乳頭體。測量視交叉前緣到中間塊(丘腦間粘合)前下緣的距離28.66mm±2.24mm,視交叉前緣到乳頭體間前緣的距離為20.10mm±1.90mm。 3.觀察Heubner回返動脈從大腦前動脈Al遠端距離前交通動脈6mm之內區(qū)域發(fā)出8例,從A2近端距離前交通動脈4mm之內域發(fā)出30例。前交通動脈是和終板聯(lián)系最密切的血管結構,測量前交通動脈長度為2.52mm±0.76mm。前交通動脈下方中點距視交叉上表面中點的高度,符合前交通動脈到終板的距離為3.68mm±3.79mm。前交通動脈和視交叉的相對位置關系為前置型、中央型和后置型。前交通動脈的穿支動脈大多從上壁、后壁和下壁發(fā)出,少有從前壁發(fā)出,總數(shù)在幾支到十幾支不等,根據(jù)穿支動脈和終板池位置關系分為后穿支、內側穿支和外側穿支,其中有—支較為粗大后穿支,從前交通動脈后壁、下壁發(fā)出,經終板池后部,并向后上方發(fā)出分支分布在胼胝體下區(qū)和下丘腦區(qū)域,測量其平均直徑為0.46mm。 4.主要向視交叉后三腦室內生長、具有典型特征的顱咽管瘤—般均可通過MR掃描判斷腫瘤與三腦室底的關系,結合術前MR掃描判斷分別選擇額顳—經終板入路和前縱裂—經終板入路,手術切除均在三腦室腔內完成,三腦室底有時無法清晰辨認。術后78例行MR復查,同時或僅行CT復查53例,腫瘤切除程度均由術中錄像和影像學檢查證實,病理證實顱咽管瘤60例,垂體腺瘤6例,下丘腦視路膠質瘤6例,腦膜瘤2例,生殖細胞瘤2例,非霍杰金淋巴瘤和非特異性肉芽腫各1例。本組術中顯微鏡下所證實和術后影像學復查結果表明：顱咽管瘤病例全切除98.3%(59/60),近全切除1.3%(1/60)；大型垂體腺瘤全切除4例,近全切除1例,大部切除1例；下丘腦視路膠質瘤全切除2例,近全切除2例,大部切除2例；腦膜瘤2例全切除；生殖細胞瘤全切除1例,近全切除1例；淋巴瘤和肉芽腫性變各1例均得到全切除。本組顱咽管瘤選擇經終板路徑多數(shù)得到安全切除,術中腫瘤主要的粘連部位在垂體柄上端、三腦室前部和底部,垂體柄漏斗部容易部分損傷；腫瘤與垂體柄和三腦室底分離是手術難點,腫瘤切除后垂體柄連續(xù)性常常不能保留。在60例顱咽管瘤病例中,垂體柄給予保留者43例,為減少復發(fā)將垂體柄離斷者9例,其他病變垂體柄均得到滿意保留,部分患者術后復查時出現(xiàn)第三腦室底的部分缺損。顱咽管瘤患者術后多數(shù)合并垂體功能下降,不同程度垂體功能低下者90%；術后短期尿崩87%,長期隨訪尿崩發(fā)生率56%,需使用長效尿崩�？刂�；術前有視力障礙者19例,14例術后視力明顯改善,3例無變化,2例加重,無并發(fā)腦脊液漏及顱內感染。 主要結論： 1.終板池上壁由終板內側膜構成,下壁由視交叉的上表面和終板前部構成,后下壁為終板中后部,外側壁由終板外側膜構成。終板池和視交叉池,嗅池,胼胝體池,頸內動脈池聯(lián)系緊密。首次將終板外側膜按形態(tài)可分為稀疏型、致密型和缺如型；終板內側膜按形態(tài)分為凸起型和平坦稀疏型。終板池的解剖特征以及和鄰近的腦池的交通關系,可能影響前交通動脈瘤破裂后積血的位置。 2.終板大多數(shù)為灰白色,從形態(tài)學分為隆起型和扁曲型。終板長度為曲線距離,終板前緣和前聯(lián)合下緣的距離為終板長度。終板切開選擇在視交叉前緣后方5.5mm至11mm處的中線上。 3.前交通動脈和視交叉的相對位置關系為前置型、中央型和后置型。前交通動脈的穿通支和終板池關系分為后穿支、內側穿支和外側穿支。在經額顳或前縱裂—終板入路手術中,打開終板池和顯露終板的方式是不同的,需按不同的次序處理前交通動脈外側穿支、內側穿支和后穿支,暴露前交通動脈和視交叉,進入終板區(qū)域。 4.經終板入路可以切除多種累及三腦室前部腫瘤,根據(jù)終板間隙的使用情況分為兩類：①完全經終板入路②輔助使用終板入路。根據(jù)腫瘤的病理類型,大小,侵犯三腦室的不同方式,分別選擇額顳—經終板入路和前縱裂—經終板入路,可以滿足大多數(shù)累及三腦室前部病變的手術切除。 5.終板構成一個清晰,可以辨認的顯微手術標志；分離終板池、前交通動脈及其穿通支可以暴露終板；術前MR和術中判別終板、前交通動脈復合體、前聯(lián)合、垂體柄、乳頭體、中間塊等解剖標志,對安全使用終板手術空間有重要的臨床意義。經終板間隙是處理鞍上凸入三腦室空間顱咽管瘤的重要手術路徑,經該間隙可以全切除經典軸外路徑難以充分暴露、手術難度較大的顱咽管瘤。
[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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