【摘要】：背景幕上腦室系統(tǒng)包括側(cè)腦室和三腦室,該部位的腫瘤在顱內(nèi)發(fā)病率相對(duì)較低,其中側(cè)腦室腫瘤發(fā)病率約占顱內(nèi)腫瘤的0.75%-2.8%,三腦室腫瘤腫瘤約占顱內(nèi)腫瘤的3%。文獻(xiàn)報(bào)道側(cè)腦室、三腦室內(nèi)腫瘤性質(zhì)多為良性或低度惡性。隨著立體定向放射神經(jīng)外科的發(fā)展,對(duì)直徑3cm腫瘤可以選擇X刀、γ刀治療,但不能明確腫瘤性質(zhì),不利于后續(xù)治療,并且在腫瘤壞死期,可因組織脫落引起腦積水,手術(shù)切除是目前主要的治療方法。由于側(cè)腦室和三腦室位置較深,且腦室壁含有重要運(yùn)動(dòng)、感覺、視覺傳導(dǎo)通路、自主神經(jīng)、內(nèi)分泌等中樞。手術(shù)入路需經(jīng)過正常腦組織,既要做到最大程度切除腫瘤又要最大限度的保護(hù)周圍重要結(jié)構(gòu),使這一部位手術(shù)極具挑戰(zhàn)性。Tew等提出最佳的手術(shù)入路應(yīng)當(dāng)距離病變最近、能夠垂直顯露病變、腦組織牽拉最輕,且不經(jīng)過重要結(jié)構(gòu)。與皮質(zhì)入路相比經(jīng)胼胝體前部入路是經(jīng)自然裂隙進(jìn)行手術(shù),解剖標(biāo)志清楚,對(duì)腦組織牽拉較輕,手術(shù)并發(fā)癥相對(duì)較少,適用于切除側(cè)腦室額角、體部、三角區(qū)和第三腦室的腫瘤,該入路近幾年受到國內(nèi)外推崇；但是這一區(qū)域的顯微鏡手術(shù)具有一定的視野死角,而腦室系統(tǒng)具有天然的操作空間和水介質(zhì),在腦室內(nèi)運(yùn)用神經(jīng)內(nèi)鏡手術(shù)具有獨(dú)特的價(jià)值。內(nèi)鏡在腦室系統(tǒng)的應(yīng)用已有近百年歷史,早期的內(nèi)鏡照明不足,設(shè)備簡單,觀察、止血及操作困難,臨床使用受到限制；20世紀(jì)70年代以來,隨著科學(xué)技術(shù)的進(jìn)步,神經(jīng)內(nèi)鏡及其相關(guān)配套設(shè)備得到了很大的發(fā)展,目前神經(jīng)內(nèi)鏡具有橫截面小、深部照明好等優(yōu)點(diǎn),在狹窄的腔隙可進(jìn)行各個(gè)角度觀察,對(duì)微細(xì)結(jié)構(gòu)的觀察能力明顯增強(qiáng),可減輕對(duì)腦組織、神經(jīng)血管等重要結(jié)構(gòu)的牽拉,減少手術(shù)創(chuàng)傷、降低術(shù)后并發(fā)癥。1998年P(guān)erneczky和Fries提出神經(jīng)內(nèi)鏡輔助的顯微神經(jīng)外科手術(shù)(endoscope-assisted microneurosurgery, EAM)EAM是指手術(shù)同時(shí)使用顯微鏡及神經(jīng)內(nèi)鏡,神經(jīng)內(nèi)鏡主要用于解剖結(jié)構(gòu)復(fù)雜的病變區(qū)或顯微鏡視野死角,增加術(shù)野的顯露、避免病灶殘留、減輕對(duì)腦組織的牽拉、減少術(shù)后并發(fā)癥。因此熟悉經(jīng)胼胝體前部入路顯微鏡及神經(jīng)內(nèi)鏡下的解剖是進(jìn)行此入路手術(shù)的必要前提,本實(shí)驗(yàn)研究利用新鮮尸頭模擬經(jīng)胼胝體前部入路內(nèi)鏡輔助顯微鏡下觀察側(cè)腦室、三腦室解剖標(biāo)志,為臨床開展工作,內(nèi)窺鏡輔助顯微鏡更大程度的、微創(chuàng)的切除腫瘤,減少并發(fā)癥提供解剖學(xué)依據(jù)。 目的本實(shí)驗(yàn)利用新鮮尸頭模擬經(jīng)胼胝體前部入路神經(jīng)內(nèi)鏡輔助顯微鏡下觀察側(cè)腦室及三腦室解剖特點(diǎn),量化各重要解剖標(biāo)志之間的距離,探討該手術(shù)入路中相關(guān)解剖及術(shù)中注意事項(xiàng),為微侵襲手術(shù)切除側(cè)腦室、三腦室區(qū)域腫瘤,減少手術(shù)副損傷提供解剖學(xué)依據(jù)。 材料和方法5具新鮮成人未灌注尸頭標(biāo)本,在新鮮尸頭標(biāo)本上模擬神經(jīng)內(nèi)鏡輔助顯微鏡下經(jīng)胼胝體前部入路,通過手術(shù)顯微鏡及神經(jīng)內(nèi)鏡對(duì)側(cè)腦室、三腦室進(jìn)行解剖學(xué)觀察并測量相應(yīng)數(shù)據(jù)。 使用Mayfield三釘頭架固定新鮮尸頭標(biāo)本,面部朝上,前屈約20。。取右額發(fā)際內(nèi)馬蹄形切口,后界在冠狀縫后約1cm,向前約4cm,中線旁開約4cm,內(nèi)側(cè)到中線或過中線1cm,皮瓣翻向顳部,確認(rèn)冠矢點(diǎn)。于冠狀縫后中線旁開4cm顱骨鉆孔,銑刀形成約4*4cm骨瓣,內(nèi)側(cè)暴露矢狀竇,不留骨檐,剪開硬腦膜翻向矢狀竇側(cè)。記錄冠狀縫前引流靜脈的情況。顯微鏡前傾約20。,于冠狀縫前2cm,沿中線向兩外耳道假想連線垂直分離右側(cè)大腦半球,并導(dǎo)入神經(jīng)內(nèi)鏡觀察扣帶回、胼周動(dòng)脈、大腦前動(dòng)脈、胼胝體等結(jié)構(gòu)。測量各重要解剖標(biāo)志的距離。于兩胼周動(dòng)脈之間分離,或?qū)㈦葜軇?dòng)脈推向一側(cè),暴露胼胝體。以大腦鐮作為中線標(biāo)志,冠狀縫為后界,向前2cm為前界,于兩支胼周動(dòng)脈之間長約2cm,鈍性切開胼胝體。在顯微鏡和神經(jīng)內(nèi)鏡下觀察并測量側(cè)腦室內(nèi)結(jié)構(gòu)。經(jīng)胼胝體前部入路進(jìn)入三腦室目前常用入路主要有兩種,(1)經(jīng)穹窿間入路,即鈍性分離透明隔,于室間孔上方向后切開穹窿間2cm,剝離子做鈍性分離穹窿體部三腦室頂?shù)谝粚颖┞兜诙䦟?暴露大腦內(nèi)靜脈,于兩大腦內(nèi)靜脈之間分離,須注意保護(hù)大腦內(nèi)靜脈、脈絡(luò)膜后動(dòng)脈及其屬支。打開四層即進(jìn)入第三腦室。(2)經(jīng)室間孔入路,即切開同側(cè)穹窿柱擴(kuò)大室間孔進(jìn)入三腦室。在顯微鏡及內(nèi)窺鏡下觀察三腦室解剖標(biāo)志。將標(biāo)本沿眉弓與枕骨粗隆上方lcm水平連線鋸開顱骨,沿小腦幕水平切斷腦干,將端腦、間腦及部分中腦取出。數(shù)據(jù)測量：眉間距冠矢點(diǎn)距離、眉間距中央溝距離、中央溝距冠矢點(diǎn)距離、冠矢點(diǎn)前2cm下方扣帶回寬度、冠矢點(diǎn)前2cm下方扣帶回距大腦內(nèi)側(cè)面上緣、冠矢點(diǎn)前2cm下方胼胝體厚度及冠矢點(diǎn)下方胼胝體厚度、冠矢點(diǎn)前2cm距胼胝體上緣、室間孔上緣至穹窿胼胝體附著處、室間孔長徑、室間孔寬經(jīng)、透明隔前后徑、透明隔上下經(jīng)、乳頭體前緣至漏斗隱窩后緣、乳頭體前緣至視交叉、室間孔至乳頭體、乳頭體前緣至后聯(lián)合。統(tǒng)計(jì)學(xué)采用SPSS13.0統(tǒng)計(jì)軟件處理,每組數(shù)據(jù)側(cè)測量值以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示。 結(jié)果冠矢點(diǎn)(冠狀縫與矢狀縫交點(diǎn))位置相對(duì)固定,眉間距冠矢點(diǎn)距離為(127.17±9.38)mm,與眉間到枕外粗隆距離的1/4與3/4交點(diǎn)相吻合。中央溝距冠矢點(diǎn)距離為(45.20±2.89)m。冠狀縫前2cm,5例標(biāo)本雙側(cè)無引流靜脈；冠狀縫前4cm,5例標(biāo)本中,無引流靜脈2例,有一支引流靜脈2例,2支引流靜脈1例,直徑3mm；冠狀縫后引流到矢狀竇的靜脈較密集。顯露扣帶回,冠矢點(diǎn)前2cm扣帶回距大腦內(nèi)側(cè)面上緣為(24.25±4.59)mm,冠矢點(diǎn)前2cm下方扣帶回寬度為(13.57±2.16)mm。再向下分離,可見到表面光滑的白色胼胝體及其上方的胼周動(dòng)脈,5具標(biāo)本中有1例兩側(cè)胼周動(dòng)脈有橫向交通。打開胼胝體后,進(jìn)入右側(cè)腦室1例,進(jìn)入透明隔間腔3例,進(jìn)入左側(cè)腦室1例。進(jìn)入腦室后可觀察到丘紋靜脈、隔靜脈、脈絡(luò)叢,神經(jīng)內(nèi)鏡下脈絡(luò)叢、丘紋靜脈和隔靜脈呈“Y”形結(jié)構(gòu),室間孔長徑為(5.79±1.17)mm、室間孔寬徑(3.76±0.75)mm、透明隔前后徑(37.17±2.83)m、透明隔上下經(jīng)(12.06±1.18)mm。分離透明隔至穹窿,本組標(biāo)本中一例粘連緊密,分離困難,余分離較易,從室間孔上緣穹窿與胼胝體附著處的距離為(22.34±3.09)mm。中間帆內(nèi)可見大腦內(nèi)靜脈,大腦內(nèi)靜脈平行走形,兩者之間無靜脈相連,脈絡(luò)叢后內(nèi)側(cè)動(dòng)脈的分支在中間帆內(nèi)與其纏繞走形,分支纖細(xì)。分別經(jīng)穹窿間、擴(kuò)大室間孔進(jìn)入三腦室,可見中間塊,切斷中間塊,可見三腦室底；導(dǎo)入神經(jīng)內(nèi)鏡,在神經(jīng)內(nèi)鏡下可清楚的觀察到三腦室底解剖結(jié)構(gòu)從前向后依次是視交叉、漏斗隱窩、灰結(jié)節(jié)、乳頭體、中腦被蓋、中腦導(dǎo)水管。觀察測量前后聯(lián)合距離為(22.63±1.83)mm、乳頭體前緣至漏斗隱窩后緣(5.65±1.09)mm、乳頭體前緣至視交叉(7.40±1.04)mm、室間孔至乳頭體(14.26±2.62)mm、乳頭體前緣至后聯(lián)合(17.58±2.44)mm。 結(jié)論(1)神經(jīng)內(nèi)鏡輔助顯微鏡下經(jīng)胼胝體前部入路可暴露雙側(cè)側(cè)腦室體部、同側(cè)部分額角和部分枕角以及三腦室底,適用于侵犯側(cè)腦室額角、體部、三角區(qū)和第三腦室的腫瘤,向兩側(cè)側(cè)腦室內(nèi)發(fā)展的腫瘤可以作一期切除；(2)神經(jīng)內(nèi)鏡輔助顯微鏡下經(jīng)胼胝體前部入路,避免手術(shù)顯微鏡視野盲區(qū),提高手術(shù)安全性和精確性,降低并發(fā)癥；(3)神經(jīng)內(nèi)鏡輔助顯微鏡下經(jīng)胼胝體前部入路,通過自然裂隙分離大腦半球、切開胼胝體,解剖標(biāo)志清楚、垂直暴露病變、對(duì)周圍組織牽拉較輕,副損傷��；(4)神經(jīng)內(nèi)鏡輔助顯微鏡下經(jīng)胼胝體前部入路,通過室間孔進(jìn)入三腦室,受室間孔及中間塊大小的影響較大；通過穹窿間入路進(jìn)入三腦室,穹窿位置影響三腦室暴露,穹窿位置愈靠后,顯露三腦室愈充分；(5)經(jīng)胼胝體前部入路,癲癇發(fā)作機(jī)會(huì)小,與經(jīng)皮質(zhì)造瘺相比沒有腦皮層切口,即使切開胼胝體不減少癲癇發(fā)作,也不會(huì)誘發(fā)癲癇；(6)熟悉腦室及腦室周圍解剖結(jié)構(gòu)在顯微鏡及神經(jīng)內(nèi)鏡下的特點(diǎn),良好的顯微技巧是此入路的關(guān)鍵。
[Abstract]:The supratentorial system of the ventricle includes the lateral ventricle and the three ventricle. The incidence of tumors in the brain is relatively low. The incidence of lateral ventricle tumors is about 0.75%-2.8% of the intracranial tumor. The three ventricle tumor is about 3%. in the intracranial tumor, and the three ventricle is mostly benign or low-grade. To the development of the radiological department of Neurosurgery, the X knife and gamma knife can be selected for the diameter 3cm tumor, but it is not clear about the nature of the tumor and is not conducive to the follow-up treatment. In the period of the tumor necrosis, the hydrocephalus can be caused by the abscission of the tissue. The surgical removal is the main treatment now. The lateral ventricle and the three ventricle have a deep position and the ventricle wall contains important transport. The surgical approach needs to pass through the normal brain tissue, not only to maximize the resection of the tumor but also to maximize the protection of the surrounding important structures, so that the operation of this site is very challenging,.Tew and so on. It is suggested that the best way of hand operation should be closest to the lesion and can be exposed to the disease vertically. The anterior part of the corpus callosum is operated by the corpus callosum, clearly marked by the anterior corpus callosum, lighter in the brain tissue, and less in the surgical complications. It is suitable for the resection of the frontal horn of the lateral ventricle, the body part, the triangle area and the third ventricle in the lateral ventricle, which has received the country in recent years. However, the microscope surgery in this area has a certain angle of vision, while the ventricle system has a natural operating space and water medium, and the use of endoscopy in the ventricle has a unique value. Endoscopy has been used for nearly one hundred years in the ventricle system. Early endoscopic lighting is insufficient, equipment is simple, observation, and hemostasis are used. Since 1970s, with the progress of science and technology, the neuroendoscopy and related equipment have been greatly developed. At present, the neuroendoscopy has the advantages of small cross section, good deep illumination and so on. The narrow cavity can be observed at various angles and the ability to observe the micro structure is obvious. Enhancement, can reduce the traction of important structures such as brain tissue, neurovascular and other important structures, reduce surgical trauma, and reduce postoperative complications.1998 Perneczky and Fries neuroendoscopy assisted microsurgery (endoscope-assisted microneurosurgery, EAM) EAM is the operation of microscopical and neuroendoscopy, and neuroendoscopy is mainly used. It is necessary to be familiar with the anatomy of the anterior part of the corpus callosum and the dissection under the neuroendoscopy. The lateral ventricles of the lateral ventricle were observed under the anterior corpus callosum via endoscopy assisted microscopically, and the three ventricle anatomic markers were used for clinical work. Endoscopy assisted microscopically to a greater extent, minimally invasive resection of the tumor, and an anatomical basis for reducing complications.
Objective To observe the anatomical characteristics of the lateral ventricle and the three ventricle under the anterior approach of the corpus callosum via the anterior part of the corpus callosum, and to quantify the distance between the important anatomic markers, and to discuss the related anatomy and the cautions in the operation, and to remove the lateral ventricle, the three ventricle regional tumor and the reduction of hand for the minimally invasive hand operation. Anatomic basis was provided for the injury of the surgery.
Materials and methods 5 fresh adult cadaver head specimens were used to simulate the anterior part of the corpus callosum under the simulated neuroendoscopy assisted microscope on the fresh cadaver head specimens and to observe the lateral ventricles of the lateral ventricle and the three ventricle by surgical microscope and neuroendoscopy.
A Mayfield three nail head frame was used to fix the fresh cadaver head specimen, face up, and take 20.. To the right frontal internal horseshoe incision. The posterior boundary was about 1cm after the coronary seams, about 4cm, the middle line was about 4cm, the medial to the middle line or the middle line 1cm, the flap turned to the temporal region to confirm the crown sagittal point. In the middle of the coronal seam, the 4cm skull bore holes, and the milling cutters formed about 4*4c. M bone flap, the medial exposure of the sagittal sinus, without the eaves, and cut the dura to the sagittal sinus. Record the drainage vein before the coronal suture. The microscope leaned about 20. before the coronal 2cm and vertically separated the right hemisphere along the middle line to the two external auditory canal, and introduced the nerve endoscope to observe the cingulate gyrus, the corpus corpus of the corpus cerebral artery, the corpus callosum. The distance between the important anatomical marks was measured. The separation between the two pericorpus arteries, or the corpus callosum, was exposed to one side of the corpus callus, or the corpus callosum was exposed. The sickle of the cerebrum was marked by the middle line, the anterior 2cm was the anterior boundary, the two branches of the corpus callus were long about 2cm, and the corpus callosum was cut open blunt. Under microscope and endoscopy, the observation and measurement of the corpus callosum was observed and measured under the microscope and endoscopy. The intraventricular structure of the lateral ventricle. There are two main approaches to enter the three ventricle through the anterior corpus callosum approach. (1) the interfornix approach, the blunt separation of the transparent septum, the incision of the interfornix 2cm in the direction of the interventricular orifice, the exposure of the first layer of the three ventricle on the top of the fornix body, the exposure of second layers, the exposure of the internal cerebral veins, and the two cerebral statics. The internal vein, the posterior choroidal artery and its branch should be protected. Four layers were opened into the third ventricle. (2) through the interventricular hole into the three ventricle, the three ventricles of the three ventricles were observed under the microscope and endoscope. The specimens were connected along the eyebrow arch above the occipital trochanter. Sawing the skull, cutting the brain stem along the tentorial level and removing the end of the brain, mesoencephalon and partial mesencephalon. The data were measured: the distance from the crown to the crown, the distance between the central sulcus of the eyebrow distance, the distance from the central sulcus to the crown, the width of the cingulate gyrus below the crown sagittal 2cm, and the buckle below the crown of the sagittal 2cm, and the corpus callosum below the sagittal point before 2cm. Thickness of the corpus callosum below the crown sagittal point, the anterior 2cm of the crown sagittal point to the upper rim of the corpus callosum, the upper margin of the interventricular hole to the attachment of the corpus callosum of the fornix, the length of the interventricular hole, the width of the interventricular hole, the anterior and posterior translucent septum, the anterior margin of the papilla to the posterior margin of the funnel's recess, the anterior border of the papilla, the interventricular orifice to the nipple body, the anterior to the posterior connection of the nipple body. Statistics were processed by SPSS13.0 statistical software. The data measured on each side of the data were expressed by mean + standard deviation (x + s).
Results the location of the crown sagittal point (the intersection of the coronal and sagittal seams) was relatively fixed, the distance from the eyebrow to the crown was (127.17 + 9.38) mm, and the distance between the interoccipital and occipital protuberance was consistent with the intersection of 1/4 and 3/4. The distance between the central sulcus and crown sagittal point was (45.20 + 2.89) M. before the coronary suture, and 5 cases had bilateral non drainage veins; there were no drainage in 5 cases before the coronary seture. In 2 cases, there were 2 cases of drainage vein, 2 drainage veins in 1 cases, 3mm in diameter, and more dense in the sagittal sinus after coronary suture. The cingulate gyrus was exposed to the upper edge of the brain (24.25 + 4.59) mm, and the width of cingulate gyrus was (13.57 + 2.16) mm. below the crown sagittal 2cm, and the surface was smooth. In the white corpus callosum and the superior corpus corpus arteriae, there were 1 cases of lateral corpus callus in 5 specimens. After opening the corpus callosum, 1 cases entered the right ventricle, 3 cases entered the transparent compartment, and 1 cases entered the left ventricle. After entering the ventricle, the veins, septum, vein plexus, neuroendoscope choroid plexus, collaterals and septum veins were observed. The length and diameter of the interventricular pore was (5.79 + 1.17) mm, the width of the interventricular hole was (3.76 + 0.75) mm, the diameter of the septum was (37.17 + 2.83) m, and the transparent septum was separated to the fornix by (12.06 + 1.18) mm.. One of the specimens of this group was closely connected, difficult to separate and easy to separate, and the distance from the upper margin of the interventricular fornix to the corpus callosum was (22.). 34 + 3.09) mm. middle cerebral veins were seen in the middle cerebral sails. The internal cerebral veins were parallel in shape. There was no venous connection between the two. The branch of the posterior medial artery of the choroid plexus was shaped in the middle sail with its twining and slender. The interfornix, enlarged interventricular hole into the three ventricle, the middle block, the middle block, and the three ventricle; Endoscopy, under endoscopy, the anatomical structure of the three ventricle was clearly observed. The anterior and posterior anatomical structures of the ventricle were from the anterior and the back to the optic chiasm, the funnel's recess, the gray nodules, the papilla body, the mesencephalic tegmentum, the mesencephalic aqueduct. The joint distance was (22.63 + 1.83) mm before and after the observation, and the anterior margin of the papilla body to the posterior margin of the funnel's recess (5.65 + 1.09), and the anterior of the papilla body to the optic chiasma (7.40 + 1.). 04) mm, interventricular foramen to nipple body (14.26 + 2.62) mm, anterior border of nipple to posterior joint (17.58 + 2.44) mm.
Conclusions (1) the anterior approach of the corpus callosum under the aid of the neuroendoscope can expose the bilateral lateral ventricle body, the ipsilateral frontal and occipital horns and the three ventricle base. It is suitable for the tumor that invaded the frontal horn of the lateral ventricle, the body part, the triangle area and the third ventricle, and can be excised in the bilateral lateral ventricle, and (2) the neuroendoscopy is assisted. Under the microscope, the anterior corpus callosum was used to avoid the visual field blind area of the operation microscope, improve the safety and accuracy of the operation, and reduce the complications. (3) the anterior part of the corpus callosum through the neuroendoscopy assisted microscopically to separate the cerebral hemisphere through the natural fissure and cut the corpus callosum, and the dissection was clearly marked, the lesions were exposed vertically, and the surrounding tissue was pulled lighter. Secondary injuries were small; (4) neuroendoscopy assisted microscopically through the anterior corpus callosum through the corpus callosum to enter the three ventricle through the interventricular hole, influenced by the interventricular hole and the size of the middle block; through the interfornix entry into the three ventricle, the position of the fornix affected the three ventricle, the more the position of the fornix, the more fully the ventricles of the three brain; (5) the anterior part of the corpus callosum. The chance of epileptic seizures is small, and there is no cortical incision compared with the percutaneous corticostomy. Even if the incision of the corpus callosum does not reduce the seizures, it does not induce epilepsy. (6) familiarity with the anatomy of the ventricles and the ventricles of the brain under the microscope and neuroendoscopy is the key to this approach.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2012
【分類號(hào)】：R322

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