【作者】 舒凯；

【导师】 雷霆；

【作者基本信息】 华中科技大学 ， 外科学， 2007， 博士

【摘要】 第一部分神经内镜应用解剖学研究一、神经内镜下鞍区应用解剖研究目的研究神经内镜下鞍区的解剖特点,探讨其临床应用价值。方法在2具新鲜尸头标本和6具10%甲醛固定尸头标本上采用常规翼点或扩大翼点入路,镜下解剖侧裂并以脑压板牵开额叶、颞叶,在不同角度神经内镜辅助下解剖鞍区并进行观察和测量。结果通过不同的观察角度与解剖间隙,能够在保全正常结构的前提下观察到鞍区各结构。1.1颈内动脉池:主要包含颈内动脉床突上段、PcoA、AchoA和钩动脉;1.2视交叉池:该池包绕视神经和视交叉,其下连接到漏斗和垂体柄,并与鞍隔相连,外侧与颈内动脉池相邻,后方与终板池下部连接,底部与脚间池共用一壁,即Liliquist膜;1.3终板池:位于终板前方,借室管膜和薄层终板与三脑室相隔;1.4脚间池:位于间脑下方,呈圆锥形,侧面与颞叶内面和海马旁回相邻,前下达斜坡,后下达桥脑上缘,后外侧与环池相接。2.1第一间隙:鞍结节后缘至视交叉前缘距离5.5±1.1mm,两侧视神经内侧缘间最大距离10.5±1.3mm;2.2第二间隙:其三边长度分别为6.5±0.6mm,6.8±0.8mm,4.1±0.3mm;2.3第三间隙:其三边长度分别为8.7±0.7mm,6.7±0.6mm,4.4±1.0mm;2.4第四间隙:ACA自ICA分叉处发出后,向内前方走行14.8±1.2mm后通过AcoA与对侧ACA相沟通,AcoA全长1.8±0.2mm。3.1颈内动脉:两侧ICA间距最短的部位75%在床突上,12.5%在海绵窦,12.5%在蝶窦内。3.2大脑中动脉:上、下干大小不一,上干为主者25%,下干为主者31.25%,两干口径相等者占18.75%,多支以及大小不等者占25%;3.3前交通动脉复合体:两侧相等者占43.75%,左侧大于右侧占37.5%,右侧大于左侧占18.75%。前交通动脉复合体变异较大,为动脉瘤的好发部位。3.4后交通动脉:一侧PcoA发达、管径大于或与PCA相当者占31.25%,伴有同侧PCA交通前段不发达。结论神经内镜可以多角度全景式观察,能绕过神经、血管,观察其深面的结构,临床应用可显著提高肿瘤全切率,并保护重要血管神经,减少手术并发症。二、神经内镜下经鼻蝶手术的应用解剖目的研究神经内镜下经鼻蝶入路解剖结构的特点,探讨神经内镜在经蝶入路鞍区病变切除术中的潜在价值。方法在2具新鲜尸头标本和6具10%甲醛固定成人尸头标本上采用鼻蝶入路,观察神经内镜下鼻蝶入路各解剖结构的特点及距离。结果鼻小柱根部到蝶窦开口距离64.3±3.2 mm,鼻根到蝶窦开口距离44.8±2.4 mm,蝶窦开口到蝶筛隐窝7.3±3.4 mm,鞍底到鼻小柱根部与中鼻甲下缘连线12.5±2.3 mm。蝶窦口纵径3.5±1.5 mm,蝶窦口横径1.2±0.5 mm,蝶窦口前上端距中线3.0±1.0 mm,蝶窦口下外端距中线3.9±1.2 mm。蝶窦口到同侧视神经11.6±1.8 mm,蝶窦口到同侧颈内动脉13.7±2.2 mm,蝶窦口到鞍结节15.6±3.0 mm,蝶窦口到鞍背22.6±3.2 mm。内窥镜在窦内可以看到颈内动脉隆突、视神经管隆突及鞍底前壁与视交叉前沟下方骨壁转折处的陷窝,转折处常为鞍底打开的中心。0°内镜难以达到满意的鞍内及鞍上暴露,30°镜头可获得理想的暴露,可清楚的看到垂体柄、海绵窦内侧壁、鞍隔、鞍隔孔、前后床突、视神经、视交叉、视交叉前沟、视交叉前间隙、漏斗等结构。讨论神经内镜独特的直观视角,结合专用器械,内镜下经单鼻孔入路可充分暴露蝶鞍区各解剖结构,术者必须熟悉各定位要点和解剖变异的内镜表现,方可避免正常结构的损害,达到安全有效地全切病变。三、神经内镜下侧脑室应用解剖研究目的研究神经内窥镜下脑室内结构在各视角下的表现及距离,为安全地脑室内操作提供有效参考资料。方法在2具新鲜尸头标本和6具10%甲醛固定的成人尸头标本上依侧脑室前后角不同的手术入路,观察并测量侧脑室内各解剖标志的特点及距离。结果侧脑室前角到室间孔为(30.3±2.2)mm;侧脑室在前角、室间孔及侧脑室体中部的顶宽及内、外侧壁的高度分别为(16.7±2.1 mm),(16.1±3.0)mm,(23.0±3.6)mm和(18.0±1.6)mm, (17.0±1.9)mm, (24.1±2.5)mm及(13.1±1.7)mm,(8.6±1.3)mm,(15.5±1.4)mm;侧脑室后角到前角、颞角及室间孔距离分别为( 86.5±6.3)mm,(59.6±6.4)mm,(56.3±5.2mm);由丘脑结构形成的脉络丛球与室间孔之间侧脑室底部的弓形隆起高度为(9.9±1.6)mm,侧脑室三角部的最大宽度为(9.3±2.1)mm,三角部上方侧脑室的宽度为(8.3±2.0)mm,三角部下方侧脑室的宽度为(9.4±1.8)mm;眉弓上方侧脑室手术穿刺点到脑室、室间孔距离分别为(29.6±2.5) mm, (55.6±2.4) mm,冠状缝前侧脑室手术穿刺点到脑室、室间孔距离分别为(29.4±2.8)mm、(55.4±3.0) mm。经额角入路观察侧脑室体部、枕角,三脑室底部、后部;经枕角观察到从颞角到额角的脉络丛。在侧脑室内观察的重要‘路标’是室间孔处的Y形结构。结论冠状缝前入路及纵裂入路对于室间孔区病变的暴露和操作有明显优势,操作距离相对较短,容易经室间孔向第三脑室前部推进。眉弓上方入路中由于神经内窥镜的轴线与侧脑室前部一致,有利于前角及体部病变的暴露和操作,且对脑功能的影响较小。侧脑室后角入路比较适合处理三角部及侧脑室体后部的病变。四、神经内镜下第三脑室应用解剖研究目的研究第三脑室系统结构在各手术入路的解剖距离及神经内镜下表现,为三脑室内病变神经内镜手术提供指导依据。方法在2具新鲜尸头标本和6具10%甲醛固定成人尸头标本上模拟内镜下经室间孔入路三脑室手术操作,观察并测量侧脑室及三脑室内各解剖标志并记录其内镜下表现。结果本组尸头标本中中间块出现率75%,长径为5.4±1.2(3.2-9.6)mm,短径为2.7±0.9(l.4-5.1) mm。经侧脑室前角入路进入侧脑室后可看到室间孔、脉络丛,进到三脑室内可看到中间块前缘、三脑室顶部的脉络丛结构及前联合、终板结构、视交叉隐窝、漏斗隐窝、中间帆后部、松果体隐窝、后联合、导水管上口。结论室间孔较小时可通过切断同侧穹隆柱扩大室间孔或通过脉络膜裂进入第三脑室;中间块缺如或较小时,工作镜多可顺利暴露三脑室下部及中间块后方结构;三脑室前、中部病变由于接近室间孔,可采用经室间孔入路;三脑室内中、后部病变可采用经脉络膜裂入路。五、神经内镜下桥小脑角区应用解剖研究目的研究神经内镜下桥小脑角区的解剖特点,探讨其临床应用价值。方法在6具12侧10%甲醛固定的成人尸头标本和2具4侧新鲜成人尸头标本上采用常规乙状窦后入路,内镜与显微镜结合,对该区血管神经关系进行解剖学研究。并对15例听神经瘤、6例胆脂瘤、5例三叉神经痛患者显微手术中应用内镜对该区行病理解剖观察。结果通过置入不同角度的内镜和变换不同的观察角度与解剖间隙,能够在不破坏正常解剖结构的前提下清晰地观察到CPA区所有的神经血管结构。不同角度的内镜在不同层面的观察中有其独特的价值,可为了解桥小脑角区解剖提供更多的信息。术中在内镜辅助下可提高肿瘤全切率。结论神经内镜和显微镜具有不同的视觉特点,神经内镜与显微镜下的解剖显示并不完全相同。只有全面了解神经内镜下的定位标志和重要结构解剖特点,才能在术中熟练地操作。内镜能越过浅层的阻挡结构,深入到桥小脑角的深部间隙,看到显微镜下显示不清的或不在直线视野内的显微解剖结构。在临床应用可提高肿瘤全切率,保全重要的血管神经结构,减少手术并发症的发生。第二部分神经内镜的临床应用一、内镜辅助经蝶垂体腺瘤切除及相关入路比较目的探讨神经内镜在不同经蝶入路垂体腺瘤切除术中的辅助作用及各手术入路的优缺点。方法对我院收治经蝶手术的500例垂体腺瘤病例的临床资料、手术过程、疗效预后进行回顾性分析,其中改良经口鼻蝶入路200例(内镜辅助20例),经鼻前庭-鼻中隔-蝶窦入路250例(内镜辅助20例),单鼻孔直接经蝶窦入路50例(内镜辅助10例)。结果经蝶手术并发症较少,各组均未出现术后感染等严重并发症,无死亡病例,辅助神经内镜后肿瘤全切率有所提高。结论神经内镜可观察到显微镜管状视野的盲区,提高肿瘤的全切率,为术者提供较显微镜更好的深部照明及图像放大,增加术者对蝶窦及鞍内、鞍上解剖结构的细致观察,为减少术后并发症提供有力的保障。二、内镜辅助显微手术切除颅内胆脂瘤目的探讨神经内镜辅助显微神经外科技术在颅内胆脂瘤手术治疗中的应用价值及手术技巧。方法应用神经内镜辅助显微神经外科技术治疗颅内胆脂瘤25例,单纯桥脑小脑角区17例,其中8例从桥脑小脑角延伸至幕上鞍区、斜坡、第三脑室或对侧桥脑小脑角区。手术采用乙状窦后入路17例、翼点入路4例、颞下入路3例、对应的半球入路1例,手术中显微镜下尽可能切除可见肿瘤,尔后再以神经内镜深入探查并切除残留肿瘤。结果所有病例在显微镜下切除满意后,神经内镜深入探查均发现不同程度的肿瘤残留,予以内镜下清除。术毕肿瘤全切23例(92%)。术后21(84%)例原有症状明显缓解,4(16%)例症状部分缓解。结论内镜辅助显微神经外科手术治疗颅内胆脂瘤,能够提高肿瘤全切率,提高手术安全性,减少临近结构损伤,减少术后并发症。更多还原

【Abstract】 Part 1 The Study of Neuroendoscopic Applied Anatomy1. endoscopic Anatomical study of the sella regionObjective To study the endoscopic anatomical characteristics of the sella region and to evaluate its clinical application value. Methods two fresh cadaver heads and six cadaver heads fixed by formalin were studied via pterion or enlarged pterion approach. Sylvian fissures were dissected under microscope and the sella region was observed and measured under endoscope and microscope. Results Through different anatomical fissures, with the help of endoscope we could observe all the cisterns around sella region and important anatomical structures in it without any destroy to normal tissues. 1.1 Carotid cistern: in it we could find supraclinoid portion of ICA, PCA, AchoA and uncus artery. 1.2 Optic chiasma cistern: It surrounds optic nerve and optic chiasma. Infundibulum, stalk hypophysial and diaphragma sellae were connected with its floor. Carotid cistern located on its lateral. Bottom of Cisterna lamina terminalis located on its posterior side. And it was separated from interpeduncular cistern by Liliquist membrane on the basalar portion. 1.3 Cisterna lamina terminalis: It seated anterior to the terminal lamina and was separated from the third ventricle by a layer of ependyma and a thin terminal lamina. 1.4 Interpeduncular cistern: It seats inferior to diencephalon and looks like a cop, and also it is close to the medial surface of temporal lobe and hippocampus, and usually entends to clivus at anterior-inferior side, and at posterior-inferior side it entends to superior side of the pons, and it is connected to ambient cistern on the posterior-lateral side. 2.1 The first interspace: The distance between tuberculum sellae and Optic chiasma is 5.5±1.1mm, and the biggest distance between the medial surface of two optic nerve is 10.5±1.3mm. 2.2 The second interspace: The length of three sides are 6.5±0.6mm,6.8±0.8mm,4.1±0.3mm. 2.3 The third interspace: The length of three sides are 8.7±0.7mm,6.7±0.6mm,4.4±1.0mm. 2.4 The fourth interspace: That is the terminal lamina fissure. 3.1 ICA: The closest site of bilateralis usually located at supraclinoid (75%), carvernous sinus (12.5%), and sphenoid sinus (12.5%). 3.2 MCA: The superior trunk and the inferior trunk are not always of the same size. Usually the superior trunk of 25% persons’are bigger, and at 31.25% persons the inferior trunk is bigger, and at 18.75% persons trunks of both side are of the same diameter. 3.3 The complex of AcoA: We observed that in about 43.75% persons calibers of the left side are equal to that of the right side, and in about 37.5% persons calibers of the left side artery are bigger than right side, and in the rest calibers of the left side are smaller than the right side. ACA of both sides are connected together by the AcoA. It has a lot of variation and aneurysms usually locate at this site. 3.4 PcoA: We found that in 31.25% persons calibers of PcoA and PCA are of the same size, and in these cases there must be some maldevelopment on PCA of the same side. Conclusions Neuroendoscope can be used to observe the hidden but important anatomic structures. Endoscope-assisted micro-neurosurgery may provide maximal removal of the lesions, maximal safety of patients, and minimal destruction to normal structures.2. applied anatomical study of endoscopic operation via trans-sphenoid sinus approachObjective To study the endoscopic characteristics of anatomic structures on trans-sphenoid sinus approach, and explore the potential values of endoscope in resection of masses on sella area via trans-sphenoid sinus approach.Methods :The anatomical structures and landmarks of 10 formalin-fixed cadaveric heads, were studied and measured under endoscope via trans-sphenoid sinus approach.Results :The distance from base of columella nasi to ostia of sphenoidal sinus was (64.3±3.2) mm, distance from radix nasi to ostia of sphenoidal sinus was (44.8±2.4) mm, distance from ostia of sphenoidal sinus to sphenoethmoidal recess was (7.3±3.4) mm,distance from root of sella downward to line through base of columella nasi and middle turbinate was (12.5±2.3) mm. The sagittal diameter of ostia of sphenoidal sinus was (3.5±1.5) mm,The transverse diameter was (1.2±0.5) mm. The distance from the anterio-superior and inferio-exterior end of ostia of sphenoidal sinus to the midline were (3.0±1.0) mm and (3.9±1.2) mm. The distance from the ostia of sphenoidal sinus to tuberculu sellae, internal carotid artery, optic nerve and dorsum sellae were (15.6±3.0) mm,(13.7±2.2) mm,(11.6±1.8) mm,and (22.6±3.2) mm. With the help of endoscope, we could see anatomical landmarks such as knob of ICA, optic canal, and lacune on break-over part of sella base, where is the center to open the sella base. We can not get sufficient exposure of structures in sella or upon sella under zero degree endoscope, but under 30 degree endoscope we can observe structures easily such as stalk hypophysial, medial wall of cavernous, sellae diaphragma, etc. conclusions under the direct visual angle of endoscope, with the specified equipment, anatomical landmarks on trans-sphenoid sinus approach could be exposed sufficiently. The surgeons should be familiar with the endoscopic characteristics of anatomical malformations and landmarks, then normal tissues can be avoided of destruction and masses can be resected safely and totally.3. endoscopic anatomical study of lateral cerebral ventricleObjective To study and measure the intra-ventricle structures under different view angles of endoscope, and collect effective reference for safe operation in ventricles. Methods : The anatomical structures and landmarks of 10 formalin-fixed cadaveric heads, were studied and measured under endoscope via different approach to frontal and occipital ventricle horn. Results The distance from frontal horn to interventricular foreman(monro) were (30.3±2.2) mm. The roof width, height of medial and lateral wall of frontal horn were (16.7±2.1)mm, (16.1±3.0)mm, (23.0±3.6)mm, and that at middle body of lateral ventricle and point of Monro’s foramen were (13.1±1.7)mm,(8.6±1.3)mm,(15.5±1.4)mm and (18.0±1.6)mm, (17.0±1.9)mm, (24.1±2.5)mm. The distance from occipital horn to frontal horn, temporal horn and Monro’s foreman were (86.5±6.3)mm, (59.5±6.4)mm and ( 56.3±5.2)mm. The height of arcuate bulge of lateral ventricular bottom between globe of choroids plexus and Monro’s foreman was (9.9±1.6)mm. The utmost width in trigone of ventricle was ( 9.3±2.1)mm. The width of lateral ventricle superior to trigone was (8.3±2.0)mm, and (9.4±1.8)mm at the inferior side. The distances from cortex-punctured point to lateral ventricle and Monro’s foreman in supra-eyebrow approach were (29.6±2.5) mm and (55.6±2.4) mm, and in fore-coronale approach were (29.4±2.8) mm and (55.4±3.0) mm. We observed the body of lateral cerebral ventricle occipital horn, bottom and posterior part of the third ventricle via frontal horn approach; and choroids plexus which extends from temporal horn to frontal horn via occipital horn approach. The most important landmark in ventricle was the“Y”shaped structure nearside Monro’s foramen. Conclusion there are obvious dominance in exposing and operating on the masses located around Monro’s foramen via fore-coronale approach and longitudinal split approach, and the working distance is not very long, and endoscope could be impelled into anterior part of third ventricle through Monro’s foramen easily. Supra-eyebrow approach is suitable for exposing and operating on masses located around frontal horn and body of lateral ventricle, and in this approach there is little destruction to normal neurofunction. Occipital horn approach is suitable for dealing with the masses located around triangular part and posterior part of lateral ventricular body.4. endoscopic anatomical study of the third ventricleObjective To study and measure the structures and landmarks in third ventricle under different view angles of endoscope via different operational approach. Methods :The anatomical structures and landmarks of 6 formalin-fixed and 2 fresh cadaveric heads, were studied and measured under endoscope via frontal ventricle horn, occipital ventricle horn and endoscopic Monro’s foramen approach. Results massa intermedia appeared in 75 % specimens. The sagittal and transverse diameter of interthalamic adhesion were (5.4±1.2)mm and (2.7±0.9)mm. We found Monro’s foramen, choroids plexus in lateral ventricle via frontal horn approach, and in third ventricle we found anterior border of massa intermedia, choroids plexus suspending on the roof of third ventricle, terminal plate, recessus infundibuli, rescessus pinealis, upper entrance of aqueduct, etc. Conclusions we can get into third ventricle through cutting off fornix collumn of the same side or choroids fissure when Monro’s foramen is not large enough. Working-scope can expose structures locating inferior to third ventricle and posterior to massa intermedia when massa intermedia is absent or not very large. Because masses locating at anterior third ventricle and middle third ventricle are close to Monro’s foramen, we may choose endoscopic Monro’s foramen approach, but in that locating near posterior third ventricle may choose choroid fissure approach.5. study of endoscopic anatomy of the cerebello-pontine angle RegionObjective Tr study the anatomic characteristics of the cerebellopontine angle region under the neuroendoscope and its clinical values. Methods We observed the related microdissection of the cerebellopontine angle region of 8 cadavers through retrosigmoid approach by operative microscope and neuroendoscope, in which 2 cadavers were fresh. We also studied the microdissection of the cerebellopontine angle region by operative microscope and neuroendoscope in 15 cases of acoustic neurilemoma, 6 cases of cholesteatoma and 5 cases of trigeminal neuralgia. Results The anatomy of important cerebral cisterns and operative fissures and vessels in the cerebellopontine angle region were observed by various neuroendoscope through various anatomic fissures with minimal invasiveness. Endoscope-assisted microneurosurgery can improve the resection rate of the tumor. Conclusions neuroendoscope has different visual angle from operative microscope. Endoscope can be used to inspect hidden but important anatomic structures in the cerebellopontine angle zone. This study supply the anatomical basis for microneurosurgery, also demonstrate that a good understanding of pathological microanatomy of tumor, as well as its relationship with adjacent neurovascular structures. The neuroendoscope will make up for the deficiencies of the microscope and be of important assistance to the microsurgical operating. Endoscope-assisted microneurosurgery may provide maximum efficiency to remove the lesion, maximum safety for the patient, and minimum invasiveness.Part 2 The Clinical Application of Neuroendoscope1. values of endoscope in microneurosurgical resection for pituitary adenomas via sphenoidal sinus approach and comparison of different correlated approachobjective to explore the assisted effect of endoscope in micro-resection for pituitary adenomas via different approach and the merit and defect of each approach. Methods analysis the clinical data, operational process and curative effect of 500 cases who suffered of different kinds of pituitary adenomas and treated in our department via trans-sphenoidal sinus approach, retrospectively. 200 of them were operated via improved mouth-nasal-sphenoidal sinus approach, and 20 of them were operated with the help of endoscope. 250 of them were operated via vestibulum nasi-nasal septum-sphenoidal sinus approach and 20 of them operated with help of endoscope. 50 of them were operated via direct transsphenoidal approach and 10 of them with the help of endoscope. Results there is little complications of operations via transsphenoidal approach. No post-operational infection and death appeared in each group. Total resection rate was improved with the help of endoscope. Conclusion with the help of endoscope we could see structures and masses in blind area of the microscopic tubular visual field, and rate of total resection was improved. Endoscope could provide good lighting of deep part and imaging amplification, which help surgeon get distinct observation of anatomical structures intra-sphenoidal sinus, intra-sella, or supra-sella.2. Endoscope-assisted microsurgical treatment of intracranial Epidermoid cystObjective To study the value of Endoscope-assisted Neurosurgery technique performed in surgical treatment of intracranial epidermoid cyst. Methods Endoscope-assisted Neurosurgery were applied in 25 cases of intracranial epidermoid cysts, in which 17 were Cerebellopontine Angle epidermoids, other 8 cases extended to sellar, clival, third ventricle or opposite CPA region. Craniotomy and surgical approach included suboccipital retrosigmoid (in 17 cases), pterion (in 4 cases), subtemporal (in 3 cases) and transcorticle approach (in 1 cases). Most part of tumors were resected under microscope, then explored and resected the remained tumors under neuroendoscope. Results In these all 25 cases,remained tumors were found under neuroendoscope after routine microsurgery and resected. Total removement rate was 92%(23/25 cases). 21/25 cases (84%) obviously recovered from former symptoms postoperation, 4/25 partially remission. Conclusions Endoscope-assisted neurosugery treatment of intracranial epidermoid cyst can increase total-resection rates, reduce surgery-ralated trauma, improve safety of the operation, reduce occurrence of complications, reduce length of stay.更多还原