内镜下经鼻扩大蝶窦入路至鞍上区的解剖及临床应用

目的 探讨神经内镜下经鼻扩大蝶窦入路手术切除鞍上区肿瘤的可行性和安全性.方法 选用10具灌注固定的正查尸头,模拟经鼻扩大蝶窦入路,内镜下观察鞍上区解剖结构,应用神经导航获取并分析解剖数据.采用神经内镜下经鼻扩大蝶窦入路切除鞍上区肿瘤12例,并以人工硬脑膜、明胶海绵和生物胶"三明治"式A结构重建颅底.结果 视神经一颈内动脉隐窝是丙镜下经鼻扩大蝶窦入路中恒定且关键的解剖标志.剪开硬脑膜后,可显露视交叉下间隙和上间隙,其中视交叉下间隙可见两侧颈内动脉、两侧垂体上动脉、垂体上部、垂体柄、视神经和视交叉,视交叉上间隙内可见大脑前动脉A1和A2段、前交通动脉以及直回.12例鞍上区肿瘤全切除10例,次全切除2例;随访12例,时间6～62个月,术后出现脑脊液鼻漏1例,再次行内镜下修补术后恢复.结论 神经内镜下经鼻扩大蝶窦入路切除鞍上区肿瘤是可行和安全的,熟练的内镜技术和可靠的颅底重建是手术成功的关键.     

神经内镜下经鼻蝶入路鞍上区域手术的应用解剖

目的探讨经鼻蝶入路和翼点入路对鞍上区暴露的差异,为内镜下经鼻蝶入路进入鞍上区的手术方法建立解剖学基础。方法在12例成人尸颅标本上,分别模拟经鼻蝶入路和翼点入路,暴露鞍上区,观察视神经、视交叉、垂体柄、颈内动脉及其分支。比较两个入路对于鞍上区重要结构的显露。结果翼点入路下,鞍结节后缘至视交叉前缘距离为5.35±1.38mm,两侧视神经内缘间距10.58±1.46mm,小脑幕游离缘长度6.73±0.84mm,后交通动脉长度16.52±2.98mm,前交通动脉长度2.11±0.35mm。神经内镜下经鼻蝶入路可以暴露视神经、视交叉、垂体柄、颈内动脉、大脑前动脉、大脑中动脉、前交通动脉、后交通动脉等结构,对于颈内动脉分叉以上结构暴露欠佳。结论经鼻蝶入路可以完全暴露第Ⅰ、Ⅱ间隙内的神经血管结构,对于第Ⅲ、Ⅳ间隙内结构显露较差,可以在微侵袭条件下部分代替翼点入路。     

视交叉池的膜性解剖结构及临床应用研究进展

<正>目前，经鼻入路神经内镜下手术治疗垂体腺瘤、鞍结节脑膜瘤、颅咽管瘤等颅底病变日益成熟^[1]。视交叉池是位于鞍区的一个不成对的幕上脑池，是经鼻入路神经内镜手术到达鞍上区域的门户，详细了解视交叉池膜性结构的解剖，是手术处理鞍区及鞍旁区域病变的基础。本文就视交叉池相关膜性结构的研究历史、研究现状、临床应用以及展望等几个方面进行综述，以深化对视交叉池膜性结构解剖的理解并促进相关研究的深入开展。     

经鼻-蝶窦入路的内镜鞍周解剖学研究

目的 通过经鼻蝶窦入路的内窥镜解剖学研究，为临床内镜经蝶手术提供形态学基础。方法 在10具已经动脉灌注染料的成人尸头上模拟扩大经鼻蝶窦手术入路，同时测量海绵窦内重要结构与鞍底的距离。结果 根据蝶窦后壁的骨性结构特征将蝶窦腔分为中间腔、旁中间腔及外侧腔5部分。扩大经蝶手术入路可清晰显示鞍底的骨膜、硬脑膜外层、海绵窦内侧壁，海绵窦内的颈内动脉及其分支血管、动眼神经、滑车神经、外展神经及眼神经等结构；打开堞骨平台可显示视神经、视交叉、垂体柄、鞍隔及视丘下部等解剖结构。结论 内窥镜扩大经鼻蝶手术入路可清晰显露蝶鞍周围的解剖结构，可适用于鞍旁、鞍上病变的手术治疗。     

扩大经鼻蝶入路海绵窦的内镜解剖研究

目的通过对扩大经鼻蝶窦入路的内镜解剖学研究,为临床应用提供形态学基础.方法在10具动脉灌注染料的成人尸头上模拟扩大经鼻蝶窦手术入路,测量海绵窦内重要结构与鞍底的距离.结果扩大经鼻蝶手术入路可清晰显示鞍底的骨膜、硬脑膜外层、海绵窦内侧壁,及海绵窦内的颈内动脉及其分支血管、动眼神经、滑车神经、展神经及视神经等结构.结论内镜下行扩大经鼻蝶手术入路可清晰显露海绵窦及其内的解剖结构,适用于鞍内病变侵犯海绵窦的外科治疗.     

内镜下扩大经鼻蝶入路至斜坡区的解剖学研究

目的探索内镜下经扩大鼻蝶入路显露斜坡区的可行性,为切除斜坡区病变提供解剖学参考。方法在10例成人头部固定标本上,内镜下模拟扩大经鼻蝶手术入路显露斜坡区,观察有关显微解剖标志。结果扩大经鼻蝶内镜入路可磨除从鞍后到斜坡、枕骨大孔前缘的骨性结构;可显露斜坡区腹侧硬膜下的椎基底动脉及其分支、后交通动脉及其与大脑后动脉汇合处、动眼神经、脑干腹侧等结构。此入路的手术标志主要包括:蝶筛隐窝、蝶窦开口、视神经隆突、颈内动脉隆突与颈内动脉视神经隐窝、咽结节、枕骨大孔前缘。结论内镜下扩大经鼻蝶手术入路可充分显露鞍后-斜坡区的腹侧硬膜下结构,适用于此区病变的手术治疗。     

内镜下经鼻-蝶窦入路蝶鞍周围解剖学研究

目的研究内镜下经鼻-蝶窦入路的解剖学,为临床内镜经蝶垂体病变手术提供形态学基础。方法选择10具经动脉灌注染料的成人尸体头部标本,男8具,女2具;模拟扩大经鼻-蝶窦手术入路,同时测量海绵窦内重要解剖结构与鞍底的距离。结果根据蝶窦后壁骨性结构特征将蝶窦腔分为中间腔、旁中间腔以及外侧腔等5个部分。扩大经鼻-蝶窦手术入路可清晰地显示鞍底的骨膜、硬脑膜外层、海绵窦内侧壁,海绵窦内的颈内动脉及其分支血管、动眼神经、滑车神经、外展神经及眼神经等重要解剖结构;打开蝶骨平台可显示视神经、视交叉、垂体柄、鞍膈及视丘下部等解剖结构。蝶鞍周围结构与鞍底中线的距离分别为视神经管隆起(5.72±1.56)mm,颈内动脉管隆起(5.42±1.38)mm,鞍膈(10.01±1.46)mm,视交叉(14.96±1.42)mm,海绵窦内颈内动脉(11.02±2.06)mm,海绵窦内动眼神经(13.75±1.79)mm,海绵窦内滑车神经(15.14±1.53)mm,海绵窦内外展神经(12.68±1.52)mm。结论内镜下扩大经鼻-蝶窦手术入路可清晰地显露蝶鞍周围的解剖结构,适用于鞍旁、鞍上病变的手术治疗。     

内镜下经鼻蝶窦入路至鞍上区的解剖与临床初步应用

目的研究内镜下扩大经鼻蝶窦入路至鞍区、鞍上区的显露范围，及手术入路中重要的解剖标志与其相互位置关系。结合该入路切除鞍结节脑膜瘤的临床应用体会，探讨内镜在此区域手术中面临的主要问题和解决办法。方法选择10例灌注尸头标本，采用显微镜解剖2例，其中冠状位和矢状位切开各1例；另8例标本模拟经鼻蝶窦入路。在内镜和显微镜下扩展显露鞍前及鞍上区的主要解剖标志，并研究其相互位置关系。对2例女性鞍结节脑膜瘤病人，采用神经导航经鼻蝶窦入路手术，肿瘤切除过程中和切除后分别应用成角内镜观察肿瘤周围结构及切除情况，肿瘤切除后以脂肪、人工硬膜及明胶海绵重建鞍底。结果内镜下在颅前窝向外侧显露的主要限制是两侧的眶内侧壁和视神经管；选择三个平面测量向侧方的显露范围，分别为筛骨鸡冠后缘平面（19．1±2．65）mm，鞍结节前方10mm的蝶骨平台平面（23．2±2．35）mm，两侧视神经管内口平面（13．1±2．18）mm。内镜下可清晰显示双侧视神经、视交叉、垂体柄、前交通动脉复合体等颅内结构。2例鞍结节脑膜瘤病人均达到肿瘤全切除，视力部分改善，术后均出现脑脊液漏，再次经原入路手术修补后痊愈。结论采用单纯内镜或内镜辅助的经鼻蝶窦入路可更直接达到鞍前及鞍上区病变，避免了经过重要的神经血管结构及对脑组织的牵拉。颅底骨质磨除位置和范围以及颅底的修补和重建是采用该入路需要解决的主要问题。     

内镜下经鼻蝶入路鞍区手术的应用解剖学研究

目的为经鼻蝶入路手术提供内镜解剖学依据。方法对23例成人尸头模拟经鼻蝶入路内镜下手术,进行内镜下的解剖观察和解剖测量。结果经鼻蝶窦入路内镜可达鞍膈以上,能清晰显示第三脑室底、视神经、视交叉及鞍旁结构等。鞍膈前后径为(5.5±1.9)mm,左右径为(6.0±1.4)mm;鞍膈孔与鞍结节的距离为(3.2±1.2)mm;两前床突间距离为(24.5±0.9)mm;前置型视交叉前缘到鞍结节的平均距离为2.1mm,后置型为3.5mm。结论内镜扩大经蝶入路能够清晰显示鞍区结构,可应用于各种鞍区肿瘤的手术。     

内镜下颞下锁孔入路至上岩斜区和鞍上区的解剖学研究

目的 观察经内镜下颞下锁孔入路至上岩斜区和鞍上区的解剖学特征,为临床运用提供解剖学资料. 方法 对10个经福尔马林固定的国人尸头,模拟颞下锁孔入路,分别在显微镜下和内镜下观察鞍上区和上岩斜区的显露结构和范围. 结果 (1)在不磨除颧弓上缘的情况下,内镜的引入使得颞下锁孔入路对该区域的暴露更为完全,可同时显露对侧的解剖结构,清晰显示深部穿支动脉.(2)动眼神经和后交通动脉间隙、脉络膜前动脉和后交通动脉间隙是非常重要的解剖间隙.(3)后床突和岩尖的磨除有利于术野的暴露.(4)内镜下定位应采用多种定位标识联合使用.包括骨性结构,例如内耳道口等. 结论 内镜下颞下锁孔入路至上岩斜区和鞍上区的视野暴露更完全,创伤更小,实用价值明显.     

美国《化学文摘》、《乌利希国际期刊指南》及波兰《哥白尼索引》正式收录本刊

美国《化学文摘》(Chemical Abstracts,CA)是世界最大的化学文摘库,也是目前世界上应用最广泛,最为重要的化学、化工及相关学科的检索工具。CA创刊于1907年,由美国化学协会化学文摘社(CAS)编辑出版,为国际六大著名检索期刊之一。     

Extended endoscopic endonasal transsphenoidal approach to the suprasellar region: anatomic study and clinical considerations

The extended endoscopic endonasal approach to the suprasellar region was performed on 10 fresh adult cadavers to describe the anatomic landmarks and key surgical steps for safe performance of the surgical approach. The anatomic features and relationships of the sphenoidal ostia, sphenoidal sinus, and optic-carotid recess are described, as are four intradural suprasellar neurovascular structural areas, including the suprachiasmatic, subchiasmatic, retrosellar and ventricular regions. Various anatomic conditions may influence the use of the extended endoscopic endonasal approach. This approach provides a straight, midline approach to the suprasellar region and offers a multi-angled and close-up view of the relevant neurovascular structures. For clinical use, the most important surgery-related complications concern the management of operative bleeding and the prevention of postoperative cerebrospinal fluid leakage.     

神经内镜下经鼻扩大入路至中颅底的解剖学研究

目的明确神经内镜下经鼻扩大入路至中颅底的各种重要解剖标志,探讨该入路临床应用的影响因素和手术特点。方法分别运用直径4 mm,长度18 cm的0°、30°和45°硬质内镜(Karl Storz),在动脉灌注后的成人尸头上模拟手术过程,神经导航的引导下经双侧鼻腔扩大入路对中颅底进行内镜解剖。测量各个解剖标志之间的距离。结果蝶窦后壁可分为鞍区、鞍上区、海绵窦区和斜坡区。在蝶窦后壁可见鞍底、后组筛房、蝶骨平台、鞍结节、斜坡、斜坡隐窝、海绵窦、颈内动脉隆起、视神经管隆起、颈内动脉-视神经隐窝。在蝶窦腔的外侧壁可见眶尖隆起、上颌神经隆起、下颌神经隆起和翼管神经,并分别形成视神经颈内动脉和动眼神经三角、V_1~V_2三角、V_2~V_3三角。两侧颈内动脉-视神经隐窝内侧距离为(11.3±1.2)mm,两侧垂体前部距离为(12.2±2.1)mm,两侧垂体中部距离为(21.5±2.5)mm,两侧垂体后部距离为(17.6±3.4)mm,垂体前后径为(9.1±2.9)mm。硬膜内的鞍上区又可分为视交叉上部、视交叉下部、鞍背后部和脑室部。在剪开海绵窦和垂体之间的硬膜后,海绵窦段的颈内动脉可分为三叉神经段、后曲段、下水平段、前曲段和上水平段。结论神经内镜经鼻扩大入路至中颅底可清晰显示鞍区、鞍上区和海绵窦区的解剖结构,为该区域的病变提供一条有价值微侵袭的手术方法。颈内动脉-视神经隐窝是该区域手术的关键性标志。     

Suprasellar pediatric craniopharyngioma resection via endonasal endoscopic approach

Purpose

Purely endoscopic endonasal approaches to surgical resection of pediatric suprasellar craniopharyngiomas are uncommonly performed. The aim of the study is to assess the feasibility and to describe the short-term outcomes of endonasal endoscopic approaches for the gross total resection of suprasellar craniopharyngiomas in the pediatric population.

Methods

A combined neurosurgical–otolaryngologic team performed gross total resection of craniopharyngiomas in seven pediatric patients (mean age 9.6 years) at The Children’s Hospital of Philadelphia over 2011–2012. Short-term outcomes were analyzed over a mean follow-up period of 6.3 months.

Results

All tumors involved the sellar and/or suprasellar space and contained some cystic component. The mean maximal tumor diameter was 31.5 mm (range 18.5–62.0 mm). Using a binostril approach, gross total tumor resection was obtained in all patients (100 %). All patients with preoperative visual dysfunction demonstrated improvement in visual acuity. New or stable panhypopituitarism was observed in all cases. All patients developed postoperative diabetes insipidus, and cerebrospinal fluid leak occurred in one patient (15 %).

Conclusions

Complete radiographic resection of pediatric craniopharyngioma can be achieved via a purely endoscopic endonasal approach. In particular, this approach can be performed safely using the “two-nostrils-four-hands” technique with intraoperative neuronavigation. This approach should be highly considered in patients with progressive visual dysfunction. Further studies are needed to characterize the long-term surgical and clinical outcome of pediatric patients treated with this surgical approach.     

Surgical outcome of the endoscopic endonasal approach for non-functioning giant pituitary adenoma

Pituitary adenomas with extensive suprasellar extension are a therapeutic challenge. The efficacy and safety of the endoscopic endonasal approach for non-functioning giant pituitary adenoma was evaluated retrospectively. A total of 43 consecutive patients with pituitary adenomas with a suprasellar extension of >20 mm underwent tumor resection with a purely endoscopic endonasal approach, and their surgical outcomes were analyzed. At surgery, irrespective of the size and shape of the adenoma, every effort was made to perform intracapsular resection under direct visual control using an angled-lens endoscope. Gross total removal was achieved in 20 out of 43 patients. Postoperatively, 42 patients showed varying improvement of both visual field defects and impaired visual acuity. In two patients who presented with gait disturbance and cognitive dysfunction due to obstructive hydrocephalus, these symptoms were completely resolved. There were no serious operative complications. The results indicate that intracapsular resection via the endoscopic approach can be a safe and effective treatment for giant pituitary adenomas.     

Cyst fenestration and Ommaya reservoir placement in endoscopic transcortical transventricular approach for recurrent suprasellar cystic craniopharyngioma without ventriculomegaly

The efficacy of the endoscopic transcortical transventricular approach (ETTA) for craniopharyngioma in the third ventricle with hydrocephalus has been reported focusing on its reduced invasiveness. On the other hand, suprasellar craniopharyngioma without ventriculomegaly is generally surgically managed by craniotomy or the endoscopic endonasal approach (EEA). Here, we report an elderly patient who received cyst fenestration and Ommaya reservoir placement in ETTA for recurrent suprasellar cystic craniopharyngioma without ventriculomegaly. The ETTA as a less invasive procedure is feasible in patients not only with intraventricular craniopharyngioma but also with suprasellar craniopharyngioma without hydrocephalus provided a navigational system is applied and the surgeon has ample experience with transcranial endoscopic procedures.     

导航引导下内镜扩大经鼻蝶窦入路切除鞍上区和第三脑室内颅咽管瘤

目的 探讨导航引导下完全内镜扩大经鼻蝶窦入路切除位于鞍上区和第三脑室内颅咽管瘤的可行性和有效性.方法 采用内镜扩大经鼻蝶窦入路、术中导航引导下切除3例位于鞍上区和第三脑室内的颅咽管瘤.结果 3例颅咽管瘤全切,手术效果好.术后随访10-14个月,患者生活正常,需要激素替代治疗.结论 内镜扩大经鼻蝶窦入路可以安全有效地切除位于鞍上区、第三脑室内的颅咽管瘤,这种手术方式不需要牵拉脑组织,并能完全暴露视交叉后、下方区域,在直视下操作,有利于对下丘脑、垂体柄及其他重要结构的保护.对于选择性的颅咽管瘤病例,内镜扩大经鼻蝶窦入路是切除肿瘤的一种新型微创手术入路.神经导航可以验证解剖标记点,引导手术方向,增加手术安全性.

Abstract：

Objective To investigate the feasibility and efficacy of image -guided extended endoscopic endonasal transsphenoidal approach(EEETA) for the removal of craniopharyngiomas in the suprasellar region and third ventricle. Method A pure EEETA with image -guided system was used. Three patients with a craniopharyngioma involving the suprasellar region and third ventricle were treated. Results Total craniopharyngioma removal was achieved in three cases. All the patients recovered uneventfully. The follow - up study was carried out for 10 to 14 months with good outcomes. Compensatory endocrine substitution therapy was needed in all of them. Conclusions The EEETA for removal of craniopharyngiomas in the suprasellar region and third ventricle is feasible and effective. It has the advantages of no needing for brain retraction,offering panoramic view of retrochiasmatic and infrachiasmatic regions,manipulating under direct vision and protecting hypothalamus,pituitary stalk and other vital structures. The EEETA is a novel and minimally invasive approach for selected cases of craniopharyngioma. Neuronavigation plays an important role in identifying anatomic landmarks,guiding surgical direction and increasing safety of the operations.