內(nèi)鏡輔助眶顴入路對(duì)腳間池區(qū)的解剖研究
發(fā)布時(shí)間：2018-08-15 13:55
【摘要】：目的:大腦腳間池(interpeduncular cistern,IC)位置深在,基底動(dòng)脈(basilarartery,BA)是此區(qū)重要結(jié)構(gòu)。顱內(nèi)動(dòng)脈瘤中,椎—基底動(dòng)脈(vertebral-basilar artery,VBA)動(dòng)脈瘤較少見(jiàn),約占3.8%～15%,而BA動(dòng)脈瘤在VBA動(dòng)脈瘤中占40%左右,由于位于顱后窩深部,可累及腦干、腦神經(jīng)、穿支動(dòng)脈等重要結(jié)構(gòu),一旦破裂預(yù)后較差,術(shù)后死亡率和病殘率高于前循環(huán)動(dòng)脈瘤。VBA系統(tǒng)的巨型動(dòng)脈瘤(直徑＞2cm)相對(duì)較多,據(jù)報(bào)道,VBA的巨型動(dòng)脈瘤約占66%～87%,未經(jīng)治療的巨型動(dòng)脈瘤在5年內(nèi)80%以上出現(xiàn)嚴(yán)重的殘疾甚至死亡(因腦干受壓、嚴(yán)重的動(dòng)脈栓塞等)。 BA動(dòng)脈瘤的治療手段目前主要有兩種:一是血管內(nèi)治療,常用彈簧圈進(jìn)行栓塞,為后循環(huán)動(dòng)脈瘤首選治療,但其適應(yīng)證較窄。另一種為開顱動(dòng)脈瘤夾閉術(shù),由于病變位置深,多與腦神經(jīng)、腦干等關(guān)系密切,顯露困難,手術(shù)空間有限,手術(shù)難度明顯增大。BA動(dòng)脈瘤的手術(shù)入路文獻(xiàn)報(bào)道已有不少,常用的有顳下、乙狀竇后、翼點(diǎn)入路(pterional approach,PA)等,其共同缺點(diǎn)是腦牽拉較大,深部照明差,多數(shù)情況下操作空間較小,載瘤動(dòng)脈的近端難以控制。而眶顴入路(orbitozygomatic approach,OZ)通過(guò)磨除部分顱底骨質(zhì),則可以明顯增加對(duì)該區(qū)域的顯露。OZ可暴露海綿竇、IC、巖骨尖、顳下窩等區(qū)域。對(duì)一些顱底的巨大腫瘤,復(fù)雜的血管病變,與其他入路相比,該入路無(wú)論在手術(shù)操作空間及視角上,還是在減少腦組織的牽拉上,都有無(wú)可替代的優(yōu)勢(shì)。然而OZ由于操作復(fù)雜,器械要求較高,難度較大而影響其推廣應(yīng)用。尤其重要的是,在顯微鏡下處理深部病變時(shí),光線照明隨深度增加而遞減,病變周圍組織不易暴露,可能出現(xiàn)手術(shù)死角。 無(wú)論是血管內(nèi)介入,還是開顱手術(shù)夾閉顱內(nèi)動(dòng)脈瘤,其目的是將動(dòng)脈瘤排除在腦的正常循環(huán)之外,以防止它破裂出血。而同時(shí)必須保護(hù)其載瘤動(dòng)脈、重要的穿通支以及周圍的重要解剖結(jié)構(gòu),BA動(dòng)脈瘤手術(shù)死亡或致殘的最重要原因是主要的穿支血管被夾閉。而內(nèi)窺鏡對(duì)深部照明很有幫助,其最大的優(yōu)點(diǎn)是能顯示動(dòng)脈瘤背側(cè)的信息,還可以顯示分支、穿通支以及動(dòng)脈瘤是否完全夾閉。然而內(nèi)鏡輔助眶顴入路(endoscope assisted orbitozygomatic approach,EAOZ)處理BA動(dòng)脈瘤的研究甚少,解剖學(xué)研究也鮮有報(bào)道。 本實(shí)驗(yàn)提出了OZ新的眶顴骨瓣形成方法,以求簡(jiǎn)化操作,減小創(chuàng)傷。分別在顯微鏡和內(nèi)窺鏡下對(duì)國(guó)人IC區(qū)解剖結(jié)構(gòu)進(jìn)行了觀察和研究,比較二者暴露的差異性,同時(shí)熟悉IC區(qū)顯微鏡及內(nèi)窺鏡下解剖關(guān)系,尤其是一些蛛網(wǎng)膜結(jié)構(gòu)。為此區(qū)病變的手術(shù)治療提供幫助。 方法:8例16側(cè)經(jīng)10%甲醛充分固定的成人頭顱濕標(biāo)本,動(dòng)脈系統(tǒng)灌注紅色乳膠,模仿實(shí)際手術(shù)操作將尸頭固定于解剖頭架上,準(zhǔn)備好常規(guī)開顱器械。采用擴(kuò)大PA的頭皮切口,從耳屏前1cm顴弓下緣做弧形切口終止于對(duì)側(cè)瞳孔中線與發(fā)際相交點(diǎn)。本研究采用改良后的兩塊骨瓣式OZ,首先形成額顳骨瓣,與傳統(tǒng)PA骨瓣不同的是骨孔位置,引入了關(guān)鍵孔,此孔位于額蝶縫上顴突后1cm處,此孔恰好能暴露眶骨膜及顱前窩底硬膜。2號(hào)孔位于眶上孔外側(cè)0.5cm,眶上緣1cm處。其余骨孔同PA。然后形成眶顴骨瓣:采用改良后的眶顴骨瓣形成術(shù),在關(guān)鍵孔正上方2cm處眶頂上形成3號(hào)孔,用線鋸依次連通關(guān)鍵孔-眶下裂,關(guān)鍵孔-3號(hào)孔,3號(hào)孔-2號(hào)孔,眶下裂眶內(nèi)孔-眶下裂眶外孔,最后在顴弓中間部離斷顴弓,形成眶顴骨瓣。按標(biāo)準(zhǔn)方式(C形切開基底朝前)剪開硬膜,由遠(yuǎn)端向近端打開側(cè)裂。顯露小腦幕切跡前間隙和BA末端,觀察Liliequist膜(Liliequist's membrane,ML)及其分葉。打開ML,進(jìn)入IC,小心分離蛛網(wǎng)膜,觀察雙側(cè)后交通動(dòng)脈(posteriorcommunicaing artery,PCoA)、大腦后動(dòng)脈(posterior cerebral artery,PCA)、小腦上動(dòng)脈SCA(superior cerebellar artery,SCA)顯露的范圍和重要血管分支。先后在顯微鏡及內(nèi)窺鏡下觀察IC區(qū)解剖結(jié)構(gòu),測(cè)量所能觀察到的BA及其分支的最遠(yuǎn)端。所測(cè)數(shù)據(jù)采用SPSS11.0統(tǒng)計(jì)軟件進(jìn)行處理,采用配對(duì)計(jì)量t檢驗(yàn)進(jìn)行統(tǒng)計(jì)學(xué)分析,以p＜0.05為有統(tǒng)計(jì)學(xué)意義。 結(jié)果:1.引入關(guān)鍵孔和3號(hào)孔后的改良OZ,降低了手術(shù)操作的難度,減小了創(chuàng)傷,切除的眶頂及眶外側(cè)壁面積較傳統(tǒng)術(shù)式有增加,有利于術(shù)后重建。 2.IC由淺部和深部?jī)刹糠纸M成,淺部游離,深部為血管組織。與環(huán)池,橋前池,頸動(dòng)脈池,橋小腦角池,動(dòng)眼神經(jīng)池相交通。 3.顯微鏡下觀察到BA長(zhǎng)度:16.34±3.16mm,內(nèi)窺鏡下觀察觀察所得BA長(zhǎng)度:25.22±4.38mm。內(nèi)窺鏡下所視有明顯提高(p＜0.05)。 4.同側(cè)PCA所視長(zhǎng)度在顯微鏡、內(nèi)窺鏡下無(wú)明顯差別(p＞0.05),同側(cè)、對(duì)側(cè)SCA,對(duì)側(cè)PCA所視長(zhǎng)度在顯微鏡及內(nèi)窺鏡下有明顯差別(p＜0.05)。 結(jié)論:1.運(yùn)用了關(guān)鍵孔和3號(hào)孔后的改良OZ,其中關(guān)鍵孔的選位十分重要。 2.EAOZ對(duì)比顯微鏡,可以使BA及其分支的暴露范圍明顯增加,尤其是術(shù)野對(duì)側(cè)暴露明顯改善,內(nèi)窺鏡深部照明佳。 3.EAOZ對(duì)比顯微鏡,可以更加清晰地觀察腦神經(jīng)及細(xì)小穿支動(dòng)脈的走行,有利于顱底深部操作。 4.應(yīng)用神經(jīng)內(nèi)窺鏡應(yīng)重視內(nèi)窺鏡下IC區(qū)解剖關(guān)系,尤其應(yīng)重視此區(qū)的蛛網(wǎng)膜結(jié)構(gòu)。
[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.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2009
【分類號(hào)】：R322
本文編號(hào)：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.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2009
【分類號(hào)】：R322
【參考文獻(xiàn)】
相關(guān)期刊論文 前10條
1 鐘東;支興剛;唐文淵;;單純神經(jīng)內(nèi)窺鏡手術(shù)治療三腦室內(nèi)囊性顱咽管瘤效果[J];第三軍醫(yī)大學(xué)學(xué)報(bào);2006年06期
2 王彥榮;;神經(jīng)內(nèi)窺鏡在脊柱疾病診治中的應(yīng)用與發(fā)展[J];國(guó)外醫(yī)學(xué)情報(bào);2006年10期
3 劉浩;張?zhí)煲?廖達(dá)光;王知非;;神經(jīng)內(nèi)鏡輔助下手術(shù)治療慢性硬膜下血腫[J];醫(yī)學(xué)臨床研究;2006年07期
4 鄭偉明,吳廣宇,魯祥和,諸葛啟釧,瞿宣興;內(nèi)窺鏡輔助下切除巨大斜坡膽脂瘤[J];浙江臨床醫(yī)學(xué);2004年03期
5 梁敏;湯樹洪;;神經(jīng)內(nèi)鏡輔助手術(shù)治療高血壓腦出血60例[J];右江醫(yī)學(xué);2008年04期
6 王鏞斐,江澄川;立體定向神經(jīng)內(nèi)窺鏡的應(yīng)用[J];中國(guó)臨床神經(jīng)外科雜志;2000年04期
7 劉建杰;神經(jīng)內(nèi)窺鏡手術(shù)的臨床應(yīng)用[J];中國(guó)醫(yī)療器械信息;2003年06期
8 馮東俠,Joseph M.Zabramski;應(yīng)用改良顱眶顴入路處理復(fù)雜性顱底病變[J];中華神經(jīng)外科雜志;2003年02期
9 王歡 ,劉學(xué)勇 ,李雷 ,陳衛(wèi)民 ,王海義;可調(diào)節(jié)斜位在顯微內(nèi)窺鏡腰椎間盤切除術(shù)中的應(yīng)用[J];中華外科雜志;2005年16期
10 黃李法;應(yīng)遠(yuǎn)峰;張昕;;神經(jīng)內(nèi)鏡治療慢性硬膜下血腫[J];浙江創(chuàng)傷外科;2006年02期
，本文編號(hào)：2184406
本文鏈接：http://sikaile.net/yixuelunwen/shiyanyixue/2184406.html
最近更新
教材專著
