经眶颧额颞下入路显微切除中颅窝底肿瘤

经眶颧额颞下入路显微外科技术切除中颅窝底肿瘤２５例。脑膜瘤全切除１６例（８０％），次全切除４例。入侵海绵窦内巨大垂体腺瘤次全切除与大部切除各２例。骨巨细胞瘤全切除１例。无死亡。术后Ｋａｒｎｏｆｓｋｙ记分显著改善（９０．８±１３．２，Ｐ＜０．００１）。本入路因明显扩大了颅底显露角度，便于清除颅底病变骨质，明显缩短了肿瘤显露距离，最大限度地减少了脑牵拉，有利于切除鞍旁及海绵窦内肿瘤。     

额颞眶-颧弓开颅显露基底动脉及岩骨斜坡区显微外科解剖

目的：利用额颞眶颧弓（FTOZ）开颅，结合深部骨切除对基底动脉及岩骨斜坡区的显露进行研究。方法：利用10例尸体标本20侧FTOZ开颅，在手术显微镜下切除前后床突，用于显露基底动脉上部；切除岩骨前部用于显露岩骨斜坡区。结果：单纯FTOZ开颅可良好显露基底动脉顶端，结合前后床突切除，在10例标本16侧开颅均成功显露基底动脉中段以上；颞下硬膜外切除岩骨前部（Kawase三角）可由中颅窝显露桥脑前外侧的岩骨斜坡区；在50%(10侧)的情况下其显露可低至基底动脉下端及椎动脉汇合处。结论：FTOZ开颅较常规颞下开颅的手术方向更趋前后，正确选择开颅侧别，结合前后床突切除，FTOZ开颅可用于处理基底动脉中段以上的动脉瘤；结合岩骨前部切除可用于夹闭小脑前下动脉动脉瘤等；对同时累及海绵窦及后颅窝的肿瘤，FTOZ开颅也是全切肿瘤的良好选择。     

额颞眶颧入路切除颅中窝底肿瘤

目的 探讨额颞眶颧入路的特点及其切除颅中窝底肿瘤的手术技巧和适应证。方法 本入路是将额颞开颅颅骨切除的范围扩大到包括眶上缘、眶外测壁及颧弓,以增加肿瘤的暴露,有利于肿瘤的切除。采用该方法对２２例颅中窝底肿瘤进行手术,取得良好效果。其中脑膜瘤９例,垂体瘤８例,神经鞘瘤２例,脊索瘤２例海绵状血管瘤１例。结果 获得肿瘤全切除１３例,次全切除６例,大部分切除３例,无手术死亡和严重手术并发症结论 初步手术     

额颞眶颧入路在视神经管显微减压术中的应用

颅脑外伤合并视神经损伤致视力受损在临床上的发生率较低（0.3%～5%）,但传统的手术方式因术前的定位困难,很难做到全程视神经骨管探查减压,临床手术效果不理想.     

眶颧弓入路开颅术的临床应用

近年来我们采用眶颧弓入路开颅术处理颅底病变35例,效果良好,报告如下。1 临床资料和方法1.1 临床资料 男14例,女21例。年龄7～66岁,平均41.1岁。颅底脑膜瘤21例(其中颅眶沟通脑膜瘤2例,内侧型蝶骨嵴脑膜瘤15例,扁平型蝶骨嵴脑膜瘤2例,岩斜脑膜瘤1例,中颅底脑膜瘤1例);三叉神经鞘瘤4例(其中海绵窦三叉神经鞘瘤1例,哑铃状三叉神经鞘瘤3例);巨大颅咽管瘤、垂体瘤、脊索瘤和胆脂瘤各2例。肿瘤最大径3～11cm。另有脑动脉瘤2例,其中右颈内动脉眼动脉瘤和巨大后交通动脉瘤各1例。     

经额颞眶联合入路切除颅眶沟通肿瘤

颅眶沟通肿瘤包括颅眶型及眶颅型两类.我院自1988年10月～1995年10月采用额颞眶颧新联合入路,切除颅眶、中颅窝底肿瘤25例,效果满意,现报告如下.1 对象和方法一般资料 本组25例,男13例,女12例.平均年龄38.7(7～62)岁.临床表现 病程2个月至8年,其中1年以内10例,l～3年14例,7年后复发脑膜瘤1例.有不同程度突眼22例(单侧18例,双侧4例).复视、眼球固定及眼球活动障碍12例,视力下降20例,单侧视力下降14例,双侧6例,视乳头水肿15例,视神经萎缩5例.     

额颞颧入路海绵窦眶尖肿瘤切除及脑神经保护

目的探讨海绵窦眶尖肿瘤显微手术及脑神经保护的方法。方法回顾性分析8例海绵窦眶尖肿瘤临床资料,均采用额颞颧入路显微神经外科手术切除肿瘤及神经电生理检测保护脑神经,术后定期随访。结果肿瘤全切除4例,次全切2例,大部分切除1例,活检1例。脑神经继发损伤症状出现率22%,脑脊液漏1例,无脑内感染及死亡病例。结论掌握海绵窦眶尖区解剖及熟练的显微神经外科技术,再加上神经电生理检测保护脑神经,可提高肿瘤切除程度,减少脑神经继发损伤。     

额-颞-眶-颧弓入路的临床应用

近年来，随着颅底外科的发展，额颞眶颧弓人路日趋成熟及推广，今综述如下。     

部分去眶在额颞手术入路中的意义

额颞开颅是颅底外科常用的手术入路之一,眼眶上壁及外侧壁为额颞开颅入路的底边,其限制了手术视野,为了增加手术野暴露,衍生出了一些联合去眶的入路,部分去眶可以增加暴露角度,缩短手术视野工作距离,并减少对脑组织的牵拉。本文综述了各种改良去眶入路对额颞手术入路的意义并对各种入路加以比较。     

额颞经颧弓-颞下手术入路的显微解剖学研究

目的对额颞经颧弓-颞下手术入路进行显微外科解剖学研究,为手术入路提供解剖学基础。方法利用10例经福尔马林固定的国人成人尸头共20侧,15例头颅干标本共30侧,对额颞经颧弓-颞下手术人路相关解剖标志进行了详细地显微解剖、观察、拍摄、测量和统计。结果面神经额支与颧支存在变异的可能,离断颧弓的断端间距约30mm,颅板外缘至颧骨前后根夹角处距离约25mm,前后根交点与中颅窝底的夹角为-0．03±2．83(-5．0-4．0)°。与保留颧弓相比,离断颧弓后的骨窗下缘至颞底可缩短15mm左右的距离,与干标本测量颧弓宽度的数据14．76mm相当。海绵窦中段的截面、视神经管和眶上裂的解剖关系相对固定。结论额颞经颧弓-颞下手术入路适用于海绵窦-眶尖区病变,其手术空间和视角非常理想,应根据手术需要酌情采用。     

New orbitozygomatic approach by craniotomy

Introduction The orbitozygomatic extension technique described by Sekhar and Wright requires a temporal basal craniectomy that must be done in order to make osteotomy dissections. In the present work, a technique that includes the base and squamous temporal bone and a craniotomy instead of a craniectomy is shown.Method The temporal and masseter muscles are dissected and separated from the temporal and zygomatic bones to facilitate passing them through the zygomatic arch in a caudal direction, which allows a frontotemporal basal craniotomy. Intracranially, a trepan that communicates to the glenoid cavity is done, which permits a temporal basal cut using the pneumatic drill saw. This is done in order to join with the orbital wall osteotomies, which were done in this approach with the craniotomy.     

Reconstruction of pterional defects after frontotemporal and orbitozygomatic craniotomy using Medpor Titan implant: Cosmetic results in 98 patients

Objective

Reconstruction of pterional and temporal defects after frontotemporal (FT) and orbitozygomatic (OZ) craniotomy is important for avoidance of temporal hollowing, maintaining functional restoration, and achieving optimal cosmesis. The objective of this study is to describe our experience and cosmetic results with pterional reconstruction after FT and OZ craniotomy with the Medpor Titan implant.

Methods

Ninety-eight consecutive patients underwent reconstruction of pterional and temporal defects after FT and OZ craniotomy using the Medpor Titan implant. The implant was shaped to recreate the pterion to provide coverage for the cranial defect and to bolster the temporalis muscle to prevent temporal hollowing. The implant was then secured to the bone flap with titanium screws. Cosmetic evaluation was performed from both surgeon's and patient's perspective.

Results

Of 90 patients who underwent cosmetic assessment at the 3 month follow-up, temporalis asymmetry was noticed subjectively by three patients and noted in 7 patients by the surgeon. Orbital asymmetry was not noticed in any cases by either surgeon or patient. Overall patient satisfaction was found in 89 of 90 patients (98.9%). There were no cases of temporal hollowing. One patient had a delayed wound infection, and one had an inflammatory reaction that required removal of the implant.

Conclusions

Our technique using the Medpor Titan implant is a fast and effective method for pterional reconstruction after FT and OZ craniotomy with excellent cosmetic results and patient satisfaction. The implant combines the advantages of both porous polyethylene and titanium mesh, including easy custom-shaping without sharp edges, structural support and relatively lower cost.     

眶上裂区显微解剖学研究

目的　为手术治疗涉及眶上裂区肿瘤提供详尽的显微解剖及解剖参数。方法　应用２０ 例成人头颅湿标本, 在放大５ ×２５ 倍显微镜下, 对眶上裂区进行逐层显微解剖, 观察及测量。结果　眶上裂位于眶尖与海绵窦之间。被 Ｚｉｎｎ 腱环分为三部分： 外侧区、中央区和下侧区。滑车神经、额神经、泪腺神经及眼上静脉经外侧区穿行。动眼神经上、下支、外展神经、鼻睫神经及腱状神经节的交感根和感觉根均经中央区穿行。下侧区仅有眼下静脉穿行。本研究对穿行于上述各区域的神经及血管的行程及毗邻结构进行了显微解剖、观察和测量。结论　熟悉此区域的显微解剖, 术中可避免损伤重要的神经血管结构。     

Modified osteoplastic orbitozygomatic craniotomy in the pediatric population

Object  Anterior and anterolateral skull base approaches offer the advantages of improved visualization and minimal brain retraction for lesions involving the orbital apex, parasellar regions, and anterior and middle fossa floors. These approaches are seldom used in the pediatric population due to the perceived increase in morbidity and surgical complexity. We report the application of the previously described modified osteoplastic orbitozygomatic (OZ) craniotomy to pediatric neurosurgical cases. This approach offers a number of advantages and is technically straightforward. Materials and methods  The results from six pediatric cases are reported. Age ranged from 26 months to 15 years, with a follow-up period of 5 to 22 months. Pathology included craniopharyngioma (three), frontal epidural abscess–subdural empyema with intraorbital extension (one), hypothalamic hamartoma (one), and optic pathway glioma (one). No complications related to the surgical approach were noted. In all cases, good postoperative cosmesis was achieved with excellent realignment of the orbital rim. Temporalis muscle bulk was preserved and symmetric in all cases. Conclusion  The modified osteoplastic OZ craniotomy can be safely and effectively applied to the pediatric population. Advantages include: (1) ease of use; (2) superior exposure and therefore less brain retraction; (3) an easily replaced one-piece bone flap which obviates the need for plating–suturing at the orbital rim; (4) a vascularized bone flap less susceptible to infection; and (5) maintenance of normal temporalis muscle anatomy for improved cosmesis and function.     

眶上裂及海绵窦前部的显微外科解剖

目的为眶尖部肿瘤、眶颅沟通瘤和海绵窦内肿瘤的手术治疗提供解剖依据。方法应用15例成人干颅骨和15例福尔马林固定的成人头颅标本,在放大5~25倍显微镜下,对眶上裂区的骨性结构、分区、硬膜结构特征及海绵窦的前部进行逐层显微解剖、观察、测量及分析。结果从颞极硬膜索带外侧缘到眶上裂神经血管共同鞘的距离为5.52±1.09mm。可以通过两种方法切开Zinn腱环暴露眶上裂的中央区:(1)沿外直肌与上直肌和提上睑肌的起点间切开Zinn腱环;(2)沿外直肌和下直肌起点之间切开Zinn腱环。结论垂直于进入眶上裂硬膜的行走方向,紧贴眶上裂向着前床突方向剪开颞极硬膜索带(深度≤5mm),可以避免损伤在眶上裂外侧区行走的结构。切开颞极硬膜索带时应注意避免损伤泪腺神经。经上直肌与外直肌间切开腱环可充分显露眶上裂中央区的结构。翻开圆孔硬脑膜返折较卵圆孔处容易。     

额颞及额颞颧入路中面神经额颞支的保护

目的了解国人面神经额颞支在颞区的显微解剖。并结合此显微解剖学特点在临床额颞及额颞颧开颅中对面神经额颞支进行保护。方法应用国人成人头颅湿标本10例(20侧),模拟额颞颧入路进行面神经额颞支显微解剖学研究。对临床中24例利用筋膜间皮瓣技术进行额颞及额颞颧开颅的患者进行回顾分析。结果所有标本中,颞区均存在三层筋膜及三层脂肪垫。在颞区前下角的弧形区域内,颞浅筋膜与颞深筋膜浅层间存在粘连,失去了正常的疏松腱膜下组织层,而被粘连的纤维脂肪层所取代,面神经额颞支则穿行于此层。而在眶上外侧角水平以上,由于帽状腱膜完整且无粘连,面神经额颞支完全行走于帽状腱膜浅层。所有24例实施了筋膜间皮瓣技术的患者,术后均达到面神经额颞支功能保留。结论在额颞及额颞颧开颅时采用筋膜间皮瓣技术是进行面神经额颞支功能保护的有效方法。     

Optimal reconstruction of the bony defect after frontotemporal craniotomy with hydroxyapatite cement

Numerous procedures have been reported for reconstruction of the bony defect around the sphenoid ridge after a frontotemporal craniotomy. However, it is still often difficult to restore the defect because of the complex curvature. Here we describe a simple cranial reconstruction method using hydroxyapatite cement and gelatin sponges. This procedure has been used on six patients, and satisfactory reconstruction was confirmed in all with postoperative three-dimensional CT scans. Using this technique, the bony defect was completely reconstructed with an appropriate thickness and curvature.     

超早期小骨窗经侧裂入路微侵袭治疗基底节血肿

目的探讨超早期小骨窗经侧裂入路微侵袭治疗基底节血肿的效果。方法对53例基底节血肿的病人采取侧裂投影直切口,小骨窗经侧裂入路手术清除血肿。结果术后10h意识状况：42例神志清楚,7例较术前好转,4例无改善;24内复查CT,残余血肿量与术前比较。血肿清除80%以上有40例,50～80%者有9例,50%以下和超过原血肿量共3例,术后72h复查CT,脑水肿引起的占位效应与传统手术相比非常轻微;死亡7例,死亡率达13.21%;术后3～6个月随访,按ADL分级进行测评：Ⅰ级4例（7.55%）;Ⅱ级11例（20.75%）;Ⅲ级22例（41.51%）;Ⅳ级7例（13.21%）;Ⅴ级2例（3.77%）。结论超早期小骨窗经侧裂入路有视野好便于彻底清除血肿、创伤小、对脑组织损伤轻微和手术时间短等优点;术后脑水肿轻微,病人恢复快,明显提高预后。     

传统骨瓣开颅与小骨窗开颅微创治疗高血压脑出血患者的疗效分析

目的探讨传统骨瓣开颅与小骨窗微创手术治疗高血压脑出血患者的临床效果并对比分析。 方法选择高密市人民医院神经外二科自2016年5月至2018年3月收治的高血压脑出血患者72例,根据患者自身病情及家属意见进行手术分组,40例行小骨窗微创开颅（骨窗组）,32例行传统骨瓣开颅减压组（骨瓣组）。对比2组患者的术中手术时间、出血量、住院时间及术后6、24、72 h和1周的颅内压值,并于3个月后随访进行日常生活能力（ADL）评分。 结果骨窗组相对于骨瓣组术中出血量少、手术时间短;2组术后6、24 h颅内压力值比较,差异无统计学意义（P>0.05）;骨窗组72 h、1周颅内压力值高于骨瓣组,差异具有统计学意义（P<0.05）,但经脱水或释放部分脑脊液后,颅内压值均可控制在正常范围之内。术后3个月按照ADL评分：骨窗组Ⅰ~Ⅲ级良好率85.0%,骨瓣组Ⅰ~Ⅲ级良好率62.50%,差异具有统计学意义（P<0.05）。 结论与传统骨瓣开颅术相比,小骨窗微创术医源性创伤小,近期预后好,临床效果显著。