终板池、终板相关显微解剖和临床应用研究
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摘要
背景和目的：
1.1664年Cerardus Blasius发现、描述并且命名了蛛网膜；1875年Key和Retzius首次对蛛网膜池进行细致描述；1976年Yasargil报道了手术中观察的终板池、终板相关显微解剖以及相关神经外科手术。终板池、终板相关解剖的研究方法和结果不尽相同,关于终板池的形态学特征、边界、内容物以及和周边脑池的关系尚有争议,在终板相关结构方面存在分歧。本研究是通过显微解剖人体尸头为基础,观察和测量终板池的形态学特征、边界、内容物以及和周边脑池的关系；终板的解剖学特征以及其周边的前交通动脉和穿支动脉等结构之间的关系；探讨终板池,终板相关形态学特征和数据在临床中的应用。
2.总结我科使用终板间隙进行手术切除三脑室前部肿瘤的临床资料,系统探讨终板间隙的使用方法,周边毗邻的大脑前动脉—前交通动脉复合体及其穿通支、前连合、视交叉、垂体柄、终板池以及三脑室前部等解剖结构在终板入路中的保护和利用,为处理该区域肿瘤提供依据。
研究方法：
1.选用10%福尔马林固定的国人成人头颅湿性标本20例,其中10例应用自制红色和蓝色乳胶分别灌注动、静脉系统。10例按翼点入路分两侧进行开颅,10例按前纵裂入路开颅。翼点入路解剖方法：尸头固定在操作台上,打开部分额骨和颞骨,尽量磨除蝶骨嵴直至蝶骨嵴的内侧,剪开硬脑膜,切除部分颞叶和额叶,向两侧牵拉暴露外侧裂。在6—-40倍手术显微镜下,模拟翼点入路逐层解剖,先分离外侧裂池,后暴露颈内动脉、视神经、视交叉,到达终板池侧方。前纵裂入路解剖方法：打开两侧部分额骨,扩大骨窗至前颅窝底,摘除眼球,于额极紧靠眶上马蹄形剪开硬脑膜,在6—-40倍手术显微镜下模拟前纵裂入路逐层解剖,逐层剔除额叶脑组织,沿纵裂方向进入鞍区,有目的的保留终板池相关的血管、软膜及蛛网膜,从胼胝体膝部水平沿大脑前动脉A2段向下解剖至终板池上方,再解剖至终板池底,到达终板和视交叉上表面。两种入路均观察终板池形态学特征、边界、内容物、膜性结构以及和相关血管、周边脑池的关系,明确终板、视隐窝、视交叉、前交通动脉及其穿支动脉、前联合、中间块、乳头体等相关结构,切开终板,模拟终板入路暴露三脑室前部和底部。使用数码相机拍照,摄录系统录像,采用电子游标卡尺对终板,视交叉,前交通动脉及其相关的和神经血管等进行测量,应用SPSS13统计软件分析处理。
2.临床病例来源于广州南方医院2008年1月至2010年12月间采用终板间隙的78例三脑室前部肿瘤患者,其中包括颅咽管瘤患者60例(未成年组≤16岁27例,成年组>16岁33例),大型垂体腺瘤6例,下丘脑胶质瘤6例,脑膜瘤2例,生殖细胞瘤2例,非霍杰金淋巴瘤和非特异性肉芽肿各1例。临床主要表现包括颅内压增高征,视力障碍和视野缺损,垂体功能低下,多饮多尿,下丘脑损害症状,第二性征发育迟缓。根据CT和MR扫描明确肿瘤性质、大小、质地、累及部位等信息：MR扫描正中矢状位的主要观察指标包括：前交通动脉复合体位置及其与肿瘤的相对位置关系、肿瘤在矢状位上的高度、乳头体的移位方向,累及脚间窝甚至上中斜坡的程度及其与基底动脉顶端可能的关系等,评价前交通动脉复合体的血管构筑。根据肿瘤性质,大小,累及部位和三脑室关系不同分别选择额颞—经终板入路38例,前纵裂—经终板入路40例；这两种手术需解剖不同脑池,显露肿瘤的路径不同,但均需充分暴露和切开终板。经终板入路肿瘤的切除总体上包括两类：①完全经终板分离切除肿瘤：包括主体凸入三脑室的颅咽管瘤；②辅助使用终板手术：主要包括明显向鞍上池生长的颅咽管瘤、垂体腺瘤、下丘脑胶质瘤以及脑膜瘤等。术中辨别和保护周边的大脑前动脉—前交通动脉复合体及其穿通支、前连合、视交叉、垂体柄、中间块、乳头体、下丘脑等重要神经结构,术后影像学检查评价手术切除程度,病例随访
研究结果：
1.终板池是不成对的脑池,位于视交叉上方,终板前上方,上壁由终板内侧膜构成,向上延伸至胼胝体池,它在前方和外层蛛网膜相连,下壁由视交叉的上表面和终板构成,后缘是游离的,外侧壁由终板外侧膜构成,两侧终板外侧膜向上方延续至终板内侧膜。终板外侧膜附着在直回的后外侧边缘,下行到视交叉,视神经外侧方的上表面,分为稀疏型、致密型和缺如型。终板内侧膜不成对,由两侧直回后中部结合处向上延伸构成,分为凸起型和平坦稀疏型。终板池内容物包括双侧大脑前动脉A1段远端,A2段近端,前交通动脉,Heubner回返动脉的部分,大脑前动脉—前交通动脉复合体的部分穿支动脉,双侧额眶动脉,双侧大脑前静脉,前交通静脉。终板池上方为胼胝体池,终板内侧膜在胼胝体嘴部和胼胝体池前下部相交通；在前下方,终板池蛛网膜附着在视交叉前下方,视神经表面,并和视交叉池蛛网膜相连；在外侧方,终板外侧膜下行到视交叉外侧方和视神经的上表面,颈内动脉池内侧以颈动脉内侧蛛网膜附着在视交叉下部并向下延伸到外层蛛网膜,覆盖在鞍隔侧方和后床突,它与颈内动脉池相邻,以视交叉,视神经外侧方为界,无交通关系；在外侧前方,终板外侧膜的前方和嗅束下方延伸至直回的嗅神经蛛网膜汇合交通。
2.终板较薄,形态类似软膜组织,附着在视交叉上表面中部,呈弧线形向后上方止于前联合前下方,胼胝体嘴附近,占据视交叉上表面和胼胝体嘴之间的空间,终板起始部下方为比视交叉低的视隐窝。终板为三脑室最宽处,大多数为灰白色,其余为暗黄色和蓝黑色,终板按形态学分为隆起型和扁曲型,大多数终板中心部位透明隆起,为终板窗。视交叉和鞍结节的定位关系主要为：前置型、正常型和后置型。测量视隐窝长度6.35mm±1.22mm,视隐窝宽度为4.79mm±1.11mm。视交叉前缘到视隐窝前缘的距离为5.53mm±1.23mm,视交叉的前后径为11.33mm±1.55mm。终板长度为曲线距离,终板前缘(即视交叉上表面的中部)和前联合下缘的距离符合终板长度,为9.99mm±1.43mm,终板宽度为两侧视束内侧缘最大宽度,为11.23mm±2.23mm。终板切开至三脑室前部和底部,其中清晰辨别中间块15例,20例均观察到乳头体。测量视交叉前缘到中间块(丘脑间粘合)前下缘的距离28.66mm±2.24mm,视交叉前缘到乳头体间前缘的距离为20.10mm±1.90mm。
3.观察Heubner回返动脉从大脑前动脉Al远端距离前交通动脉6mm之内区域发出8例,从A2近端距离前交通动脉4mm之内域发出30例。前交通动脉是和终板联系最密切的血管结构,测量前交通动脉长度为2.52mm±0.76mm。前交通动脉下方中点距视交叉上表面中点的高度,符合前交通动脉到终板的距离为3.68mm±3.79mm。前交通动脉和视交叉的相对位置关系为前置型、中央型和后置型。前交通动脉的穿支动脉大多从上壁、后壁和下壁发出,少有从前壁发出,总数在几支到十几支不等,根据穿支动脉和终板池位置关系分为后穿支、内侧穿支和外侧穿支,其中有—支较为粗大后穿支,从前交通动脉后壁、下壁发出,经终板池后部,并向后上方发出分支分布在胼胝体下区和下丘脑区域,测量其平均直径为0.46mm。
4.主要向视交叉后三脑室内生长、具有典型特征的颅咽管瘤—般均可通过MR扫描判断肿瘤与三脑室底的关系,结合术前MR扫描判断分别选择额颞—经终板入路和前纵裂—经终板入路,手术切除均在三脑室腔内完成,三脑室底有时无法清晰辨认。术后78例行MR复查,同时或仅行CT复查53例,肿瘤切除程度均由术中录像和影像学检查证实,病理证实颅咽管瘤60例,垂体腺瘤6例,下丘脑视路胶质瘤6例,脑膜瘤2例,生殖细胞瘤2例,非霍杰金淋巴瘤和非特异性肉芽肿各1例。本组术中显微镜下所证实和术后影像学复查结果表明：颅咽管瘤病例全切除98.3%(59/60),近全切除1.3%(1/60)；大型垂体腺瘤全切除4例,近全切除1例,大部切除1例；下丘脑视路胶质瘤全切除2例,近全切除2例,大部切除2例；脑膜瘤2例全切除；生殖细胞瘤全切除1例,近全切除1例；淋巴瘤和肉芽肿性变各1例均得到全切除。本组颅咽管瘤选择经终板路径多数得到安全切除,术中肿瘤主要的粘连部位在垂体柄上端、三脑室前部和底部,垂体柄漏斗部容易部分损伤；肿瘤与垂体柄和三脑室底分离是手术难点,肿瘤切除后垂体柄连续性常常不能保留。在60例颅咽管瘤病例中,垂体柄给予保留者43例,为减少复发将垂体柄离断者9例,其他病变垂体柄均得到满意保留,部分患者术后复查时出现第三脑室底的部分缺损。颅咽管瘤患者术后多数合并垂体功能下降,不同程度垂体功能低下者90%；术后短期尿崩87%,长期随访尿崩发生率56%,需使用长效尿崩停控制；术前有视力障碍者19例,14例术后视力明显改善,3例无变化,2例加重,无并发脑脊液漏及颅内感染。
主要结论：
1.终板池上壁由终板内侧膜构成,下壁由视交叉的上表面和终板前部构成,后下壁为终板中后部,外侧壁由终板外侧膜构成。终板池和视交叉池,嗅池,胼胝体池,颈内动脉池联系紧密。首次将终板外侧膜按形态可分为稀疏型、致密型和缺如型；终板内侧膜按形态分为凸起型和平坦稀疏型。终板池的解剖特征以及和邻近的脑池的交通关系,可能影响前交通动脉瘤破裂后积血的位置。
2.终板大多数为灰白色,从形态学分为隆起型和扁曲型。终板长度为曲线距离,终板前缘和前联合下缘的距离为终板长度。终板切开选择在视交叉前缘后方5.5mm至11mm处的中线上。
3.前交通动脉和视交叉的相对位置关系为前置型、中央型和后置型。前交通动脉的穿通支和终板池关系分为后穿支、内侧穿支和外侧穿支。在经额颞或前纵裂—终板入路手术中,打开终板池和显露终板的方式是不同的,需按不同的次序处理前交通动脉外侧穿支、内侧穿支和后穿支,暴露前交通动脉和视交叉,进入终板区域。
4.经终板入路可以切除多种累及三脑室前部肿瘤,根据终板间隙的使用情况分为两类：①完全经终板入路②辅助使用终板入路。根据肿瘤的病理类型,大小,侵犯三脑室的不同方式,分别选择额颞—经终板入路和前纵裂—经终板入路,可以满足大多数累及三脑室前部病变的手术切除。
5.终板构成一个清晰,可以辨认的显微手术标志；分离终板池、前交通动脉及其穿通支可以暴露终板；术前MR和术中判别终板、前交通动脉复合体、前联合、垂体柄、乳头体、中间块等解剖标志,对安全使用终板手术空间有重要的临床意义。经终板间隙是处理鞍上凸入三脑室空间颅咽管瘤的重要手术路径,经该间隙可以全切除经典轴外路径难以充分暴露、手术难度较大的颅咽管瘤。
Background and objective:
1. Gerardus Blasius identified, described,and named the arachnoid membrane in1664. Key and Retzius provided the first detailed description of the arachnoid cisterns in1875. Yas.argil reported his intraoperative observations on the microsurgical anatomy of lamina terminalis cistern and lamina terminalis,and additional reports by neurosurgeons followed in1976.The research methods and results of microanatomy of lamina terminalis cistern and lamina terminalis are different. Moreover, the morphological features, borders and contents of LT cistern, the relationship between LT cistern and surrounding cerebral cistern, and the structure of LT are all in dispute. On the basis of microanatomy of human cadaveric heads, this study's objective is to observe and measure the morphological features, borders and contents of LT; the relationship between LT cistern and surrounding cerebral cistern; the anatomic features of LT cistern; the relationship between surrounding anterior communicating artery and perforating branches; and to discuss the clinical application of morphological features and data of lamina terminalis cistern and lamina terminalis.
2. To summarize the clinical data of the anterior third ventricle tumor resection through LT space in our hospital, and to discuss how to use the LT space. To study the anatomy structures of the surrounding ACA-AComA complex, perforating branches, anterior commissure, optic chiasm, pituitary stalk, LT cistern and the anterior third ventricle in the lamina terminalis approach, providing the basis on dealing with the anterior third ventricle tumor.
Method:
1.20Chinese cadaver heads fixed by10%formalin were chosen in this study, while the arterial and venous system of10heads were filled with one-time molding filling agents. In craniotomy,10heads were opened through pterional approach, while the other10heads were opened through anterior interhemispheric approach. The pterional approach:Cadaver head was fixed on the operating table. Then partial frontal bone and temporal bone were opened, and the sphenoidal crest was ground to its medial. Subsequently, dura mater was incised and partial temporal lobe and frontal lobe were removed. Finally the lateral fissure was in exposure by pulling toward both sides. Using the operating microscope with6to40times magnification, we simulated the pterional approach to dissect lateral fissure layer by layer. Sylvian cistern was firstly separated and exposed the medial carotid, optic nerve, optic chiasma in turn then the lateral LT cistern in the end. Anterior interhemispheric approach:both sides of partial frontal bone were opened and the bone window was enlarged to the anterior cranial fossa. Then the eyeballs were removed, and the dura mater was incised when the frontal pole closed to the supraorbital horseshoe. Using the operating microscope with6--40times magnification, we simulated the anterior interhemispheric approach approach to dissect lateral fissure layer by layer. Frontal lobe was removed layer by layer. Then we entered into the saddle area along the diastematocrania direction to keep the LT cistern related vessels, pia mater and arachnoid purposefully. Subsquently, we dissected downward from knee corpus callosum to the top of LT cistern along A2segment of anterior cerebral artery. Eventually, dissection reached to the bottom of LT cistern and and surface of LT and optic chiasma. These two approaches can both observed morphological characteristics, borders, contents and membrane structures of LT cistern, and the relationship between LT cistern and related vessels and surrounding cerebral cistern. Moreover, they can confirm the structures of LT, optic recess, optic chiasma, anterior communicating artery, perforating branches, anterior commissure, massa intermedia and corpus albicans, and stimulate lamina terminalis approach to expose the anterior and bottom third ventricle. A digital camera was used to take photographs and shoot video and an electronic vernier caliper was used to measure the length of LT, optic chiasma, anterior communicating artery and related vessels. SPSS13statistical software was used to analyze the data.
2. Clinical cases from78patients with the anterior third ventricle tumor received trans-LT resection in Guangzhou Nanfang Hospital from January2008to December2010, including craniopharyngioma60cases (27cases of teenagers≤16years old,33cases of adults>16years old), large pituitary adenomas6cases, hypothalamus glioma6cases, meningeoma2cases, germinoma2cases, non-Hodgkin's lymphoma1case and nonspecific granuloma1case. The main clinical manifestations included increased intracranial pressure, visual impairment, visual field defect, hypopituitarism, polyphagia, polyuria, hypothalamic lesion and secondary sexual characteristics retardation. CT and MR scans results disclosed the information on tumor's nature, size, texture, location involving. The observed index of MR scans on midsagittal images mainly included the relative position of the AComA complex and tumor, the height of tumor on sagittal image, shifting direction of corpus albicans, the degree of interpeduncal fossa involving, the relationship between interpeduncal fossa and basilar tip aneurysm and the vascular architecture of the AComA complex.38cases through frontotemporal-LT approach were chosen on the basis of tumor characteristic, size and involving parts, while40cases through the anterior interhemispheric-LT approach were chosen. These two surgeries needed to anatomize different cerebral cistern, and the approach of tumor exposure were different. However, it needed to expose and incise the LT completely. Tumor resection through LT approach included:(1) complete LT separation to remove tumor:mainly included craniopharyngioma burst into the third ventricle;(2) auxiliary application of LT approach:mainly included craniopharyngioma, pituitary adenomas, hypothalamus glioma, meningeoma which developed towards suprasellar cistern obviously. Then we discerned and protected the surrounding ACA-AComA complex, its perforating branches, anterior commissure, optic chiasma, pituitary stalk, corpus albicans, corpus albicans and hypothalamus in surgery. Finally, the tumor removal degree was evaluated by imaging after surgery, and cases follow-up were performed.
Result:
1. LT cistern was not an azygous cerebral cistern, which located on the top of optic chiasma and the upper front of LT. The superior wall consisted of medial LT membrane, extending upward to pericallosal cistern and connecting with arachnoid membrane forwardly. The interior wall comprised the upper surface of optic chiasma and LT, which was a free wall. The lateral wall was made of lateral LT membrane which both extended upward to medial LT membranes. The lateral LT membranes originated from posterolateral border of gyrus rectus, which extended downward to optic chiasma and the upper surface of optic nerve lateral border. It divided into sparse type, dense type and absent type. The medial LT membrane was azygous, consisting of both sides of gyrus rectus joint extending upward, which divided into convex type and flat sparse type. The contents of LT cistern included both of the A1 segments, the AComA, the proximal portions of the A2segments, partial Heubner artery, partial perforating branches of ACA-AComA complex, bilateral frontal orbitofrontal artery, bilateral the anterior cerebral veins and anterior communicating vein. The top of LT cistern was pericallosal cistern, and the medial LT membrane communicated between the rostrum of the corpus callosum and the inferior anterior of pericallosal cistern. Carotid membrane of LT cistern adhered to the inferior anterior of optic chiasma and the surface of optic nerve, connecting with the carotid membrane of optic chiasma. The lateral LT membrane extended downward to the lateral optic chiasma and the surface of optic nerve. The medial carotid cistern adhered to the inferior of the optic chiasma by the way of medial carotid membrane, extending downward to the lateral carotid membrane and covering the lateral saddle bed and posterior clinoid process. It was closed to the carotid cistern and bounded in lateral of optic chiasma and optic nerve, without communication. The anterior of lateral LT membrane and the inferior olfactory tract extended to gyrus rectus, communicating with the olfactory membrane.
2. The morphology of thin LT was similar to the soft membrane. LT adhered to the central upper surface of optic chiasma, archedly ending in the inferior-anterior anterior commissure and the neighborhood of the rostrum of the corpus callosum, and taking up the space of the upper surface of optic chiasma and the rostrum of the corpus callosum. The inferior initial part of LT was the optic recess which was lower than optic chiasma. LT was the widest place in the third ventricle, which was mostly grey white, while the other was dark yellow and black blue. LT was divided into-protruded type and flat song type by morphology. Most central LT was transparent and protruded fenestra laminae terminalis. The positioning between optic chiasm and the tuberculum sellae was pre-type, normal type and post type. The length of optic recess was6.35mm±1.22mm, while the width was4.79mm±1.11mm. The distance between the anterior optic chiasma and the anterior optic recess was5.53mm±1.23mm, while the anteroposterior diameter was11.33mm±1.55mm. The length of LT was a curve distance, and the distance between the anterior LT (namely the central upper surface of optic chiasma) and the inferior anterior commissure was9.99mm±1.43mm, which was correspondent with LT length. The width of LT was the largest distance between both sides of medial optic tracts, which was11.23mm±2.23mm. Dissecting LT to the anterior and bottom of third ventricle,15massa intermedias and20corpus albicans could be observed clearly. The distance between the anterior optic chiasm and the inferior anterior massa intermedia was28.66mm±2.24mm, while the distance between the anterior optic chiasm and the anterior corpus albican was20.10mm±1.90mm.
3.8cases of Heubner artery from the distal A1segments of ACA (the distance to AComA was within6mm) and30cases of Heubner artery from the proximal A1segments of ACA (the distance to AComA was within4mm) were observed. AComA was the vascular structure most closely connecting with LT. Its length was2.52mm±0.76mm. The height between the central inferior AComA and the central upper surface of optic chiasma was3.68mm±3.79mm, which was according with the distance between AComA and LT. The relative positioning between AComA and optic chiasm was pre-type, central type and post type. The perforating branches of AComA were mostly from superior wall, posterior wall and inferior wall, rarely from anterior wall, of which the total number ranged from several to dozens. The perforating branches were divided into posterior perforating branches, medial perforating branches and lateral perforating branches by the position of perforating branches and LT cistern. Hereinto, a relatively strong posterior perforating branch was from the posterior wall and inferior wall of AComA, via posterior LT cistern, and branched above the backward in the area subcallosa and hypothalamus. The average diameter was0.46mm.
4. Tumor developed into the third ventricle behind optic chiasma. The relationship between craniopharyngioma with typical characteristics and the bottom of third ventricle could be confirmed by MR scans. On the basis of MR scans results, the frontotemporal-LT approach and the anterior interhemispheric-LT approach were chosen in surgery. Resection was performed in the cavity of third ventricle, however, the bottom of third ventricle could not discern clearly sometimes. The tumor removal degree was evaluated by intraoperative video and imaging.78cases were reviewed routinely by MR scans following surgery. Meanwhile,53cases were only reviewed by CT scans. Pathological diagnosis confirmed60patients with craniopharyngioma,6patients with large pituitary adenomas,6patients with hypothalamus glioma,2patients with meningeoma,2patients with germinoma,1patient with non-Hodgkin lymphoma, and1patient with nonspecific granuloma. Results of operating microscope observation and imaging review demonstrated that98.3%of craniopharyngioma (59/60) were removed entirely, while1.3%of those (1/60) were removed almost completely;4cases of large pituitary adenomas were removed entirely, while1case of those was removed almost completely, and1cases were removed in a great measure;2cases of hypothalamus glioma were removed entirely, while2cases of those were removed almost completely, and2cases were removed in a great measure;2cases of meningeoma were removed entirely;1case of germinoma was removed entirely, while1case of those was removed almost completely; both of non-Hodgkin lymphoma and nonspecific granuloma were removed entirely. In this group, most craniopharyngioma was removed safely through LT approach. the adhering positions of tumor in surgery mainly located in the superior pituitary stalk, the anterior and bottom of third ventricle. The partial infundibulum of pituitary stalk could be easily damaged. Therefore, the separation of tumor from pituitary stalk and the bottom of third ventricle was much difficult in surgery, and the continuity of pituitary stalk after tumor resection could not be preserved frequently. Among60cases of craniopharyngioma,43cases kept the pituitary stalk, while10cases separated the pituitary stalk for less recurrence, and the other cases all kept the pituitary stalk. However, some patients had partial lesion in the third ventricle in case review.90%of patients with craniopharyngioma had a function decline of pituitary gland;87%of patients with craniopharyngioma had a short-term diabetes insipidus following surgery, while56%of those had a long-term diabetes insipidus in case follow-up, which needed to used injection vasopressin tannate to control it;19patients with craniopharyngioma had vision disorder before surgery, while14patients improved their vision after surgery,3patients had no change, and2patients aggravated. There were3patients died in this group, but no complications of cerebrospinal fluid leakage and intracranial infection.
Chief conclusion:
1. The superior wall consisted of medial LT membrane; the interior wall comprised the upper surface of optic chiasma and LT; the posterior-interior wall was the central posterior LT; and the lateral wall was made of lateral LT membrane. The LT cistern, pericallosal cistern and carotid cistern had a strong connection. In first time,the lateral LT membrane was divided into sparse type, dense type and absent type, while the medial LT membrane was divided into convex type and flat sparse type. The anatomy features of LT cistern and the communication with adjacent cerebral cistern mignt affect the position of anterior communicating aneurysms hematocele after-broken.
2. The color of LT was mostly grey white, which was divided into protruded type and flat song type by morphology. The length of LT was a curve distance, and the distance between the anterior LT (namely the central upper surface of optic chiasma) and the inferior anterior commissure was correspondent with LT length. LT was dissected in the central line distancing the posterior of anterior optic chiasma5.5mm--11mm.
3. The relative positioning between AComA and optic chiasm was pre-type, central type and post type. The perforating branches were divided into posterior perforating branches, medial perforating branches and lateral perforating branches. In the frontotemporal approach or interhemispheric-LT approach, the method of opening LT cistern and exposing LT were different. It should treat with the lateral, medial and posterior perforating branches of AComA in turns, to expose the AComA and optic chiasm and enter the LT area in the end.
4Diverse tumors involving anterior third ventrical chamber could be removed through Trans-lamina terminalis approach. It could be divided into two categories based on the application of LT space:(1) complete LT approach;(2) auxiliary extra-axial LT approach. Based on the pathological entities, size and ways of the third ventricle invasion of tumor, the frontotemporal-LT approach and the anterior interhemispheric-LT approach were chosen in surgery, which could meet the requirement of lesion resection involving the anterior third ventricle.
5LT was a clear and discernable landmark of anatomic surgery. The separation of LT cistern, AComA, anterior commissure and its perforating branches could expose LT. Preoperative MR scans and the determination of LT, AComA, anterior commissure, pituitary stalk, corpus albicans, corpus albicans and other anatomic landmark had a important clinical significance on safe application of LT space. The important approach of treating with craniopharyngioma burst invaginated into the third ventricle from suprasella space was LT approach. It could completely remove the craniopharyngioma which was difficult to be exposed through typical extra-axial approach.
1.1664年Cerardus Blasius发现、描述并且命名了蛛网膜；1875年Key和Retzius首次对蛛网膜池进行细致描述；1976年Yasargil报道了手术中观察的终板池、终板相关显微解剖以及相关神经外科手术。终板池、终板相关解剖的研究方法和结果不尽相同,关于终板池的形态学特征、边界、内容物以及和周边脑池的关系尚有争议,在终板相关结构方面存在分歧。本研究是通过显微解剖人体尸头为基础,观察和测量终板池的形态学特征、边界、内容物以及和周边脑池的关系；终板的解剖学特征以及其周边的前交通动脉和穿支动脉等结构之间的关系；探讨终板池,终板相关形态学特征和数据在临床中的应用。
2.总结我科使用终板间隙进行手术切除三脑室前部肿瘤的临床资料,系统探讨终板间隙的使用方法,周边毗邻的大脑前动脉—前交通动脉复合体及其穿通支、前连合、视交叉、垂体柄、终板池以及三脑室前部等解剖结构在终板入路中的保护和利用,为处理该区域肿瘤提供依据。
研究方法：
1.选用10%福尔马林固定的国人成人头颅湿性标本20例,其中10例应用自制红色和蓝色乳胶分别灌注动、静脉系统。10例按翼点入路分两侧进行开颅,10例按前纵裂入路开颅。翼点入路解剖方法：尸头固定在操作台上,打开部分额骨和颞骨,尽量磨除蝶骨嵴直至蝶骨嵴的内侧,剪开硬脑膜,切除部分颞叶和额叶,向两侧牵拉暴露外侧裂。在6—-40倍手术显微镜下,模拟翼点入路逐层解剖,先分离外侧裂池,后暴露颈内动脉、视神经、视交叉,到达终板池侧方。前纵裂入路解剖方法：打开两侧部分额骨,扩大骨窗至前颅窝底,摘除眼球,于额极紧靠眶上马蹄形剪开硬脑膜,在6—-40倍手术显微镜下模拟前纵裂入路逐层解剖,逐层剔除额叶脑组织,沿纵裂方向进入鞍区,有目的的保留终板池相关的血管、软膜及蛛网膜,从胼胝体膝部水平沿大脑前动脉A2段向下解剖至终板池上方,再解剖至终板池底,到达终板和视交叉上表面。两种入路均观察终板池形态学特征、边界、内容物、膜性结构以及和相关血管、周边脑池的关系,明确终板、视隐窝、视交叉、前交通动脉及其穿支动脉、前联合、中间块、乳头体等相关结构,切开终板,模拟终板入路暴露三脑室前部和底部。使用数码相机拍照,摄录系统录像,采用电子游标卡尺对终板,视交叉,前交通动脉及其相关的和神经血管等进行测量,应用SPSS13统计软件分析处理。
2.临床病例来源于广州南方医院2008年1月至2010年12月间采用终板间隙的78例三脑室前部肿瘤患者,其中包括颅咽管瘤患者60例(未成年组≤16岁27例,成年组>16岁33例),大型垂体腺瘤6例,下丘脑胶质瘤6例,脑膜瘤2例,生殖细胞瘤2例,非霍杰金淋巴瘤和非特异性肉芽肿各1例。临床主要表现包括颅内压增高征,视力障碍和视野缺损,垂体功能低下,多饮多尿,下丘脑损害症状,第二性征发育迟缓。根据CT和MR扫描明确肿瘤性质、大小、质地、累及部位等信息：MR扫描正中矢状位的主要观察指标包括：前交通动脉复合体位置及其与肿瘤的相对位置关系、肿瘤在矢状位上的高度、乳头体的移位方向,累及脚间窝甚至上中斜坡的程度及其与基底动脉顶端可能的关系等,评价前交通动脉复合体的血管构筑。根据肿瘤性质,大小,累及部位和三脑室关系不同分别选择额颞—经终板入路38例,前纵裂—经终板入路40例；这两种手术需解剖不同脑池,显露肿瘤的路径不同,但均需充分暴露和切开终板。经终板入路肿瘤的切除总体上包括两类：①完全经终板分离切除肿瘤：包括主体凸入三脑室的颅咽管瘤；②辅助使用终板手术：主要包括明显向鞍上池生长的颅咽管瘤、垂体腺瘤、下丘脑胶质瘤以及脑膜瘤等。术中辨别和保护周边的大脑前动脉—前交通动脉复合体及其穿通支、前连合、视交叉、垂体柄、中间块、乳头体、下丘脑等重要神经结构,术后影像学检查评价手术切除程度,病例随访
研究结果：
1.终板池是不成对的脑池,位于视交叉上方,终板前上方,上壁由终板内侧膜构成,向上延伸至胼胝体池,它在前方和外层蛛网膜相连,下壁由视交叉的上表面和终板构成,后缘是游离的,外侧壁由终板外侧膜构成,两侧终板外侧膜向上方延续至终板内侧膜。终板外侧膜附着在直回的后外侧边缘,下行到视交叉,视神经外侧方的上表面,分为稀疏型、致密型和缺如型。终板内侧膜不成对,由两侧直回后中部结合处向上延伸构成,分为凸起型和平坦稀疏型。终板池内容物包括双侧大脑前动脉A1段远端,A2段近端,前交通动脉,Heubner回返动脉的部分,大脑前动脉—前交通动脉复合体的部分穿支动脉,双侧额眶动脉,双侧大脑前静脉,前交通静脉。终板池上方为胼胝体池,终板内侧膜在胼胝体嘴部和胼胝体池前下部相交通；在前下方,终板池蛛网膜附着在视交叉前下方,视神经表面,并和视交叉池蛛网膜相连；在外侧方,终板外侧膜下行到视交叉外侧方和视神经的上表面,颈内动脉池内侧以颈动脉内侧蛛网膜附着在视交叉下部并向下延伸到外层蛛网膜,覆盖在鞍隔侧方和后床突,它与颈内动脉池相邻,以视交叉,视神经外侧方为界,无交通关系；在外侧前方,终板外侧膜的前方和嗅束下方延伸至直回的嗅神经蛛网膜汇合交通。
2.终板较薄,形态类似软膜组织,附着在视交叉上表面中部,呈弧线形向后上方止于前联合前下方,胼胝体嘴附近,占据视交叉上表面和胼胝体嘴之间的空间,终板起始部下方为比视交叉低的视隐窝。终板为三脑室最宽处,大多数为灰白色,其余为暗黄色和蓝黑色,终板按形态学分为隆起型和扁曲型,大多数终板中心部位透明隆起,为终板窗。视交叉和鞍结节的定位关系主要为：前置型、正常型和后置型。测量视隐窝长度6.35mm±1.22mm,视隐窝宽度为4.79mm±1.11mm。视交叉前缘到视隐窝前缘的距离为5.53mm±1.23mm,视交叉的前后径为11.33mm±1.55mm。终板长度为曲线距离,终板前缘(即视交叉上表面的中部)和前联合下缘的距离符合终板长度,为9.99mm±1.43mm,终板宽度为两侧视束内侧缘最大宽度,为11.23mm±2.23mm。终板切开至三脑室前部和底部,其中清晰辨别中间块15例,20例均观察到乳头体。测量视交叉前缘到中间块(丘脑间粘合)前下缘的距离28.66mm±2.24mm,视交叉前缘到乳头体间前缘的距离为20.10mm±1.90mm。
3.观察Heubner回返动脉从大脑前动脉Al远端距离前交通动脉6mm之内区域发出8例,从A2近端距离前交通动脉4mm之内域发出30例。前交通动脉是和终板联系最密切的血管结构,测量前交通动脉长度为2.52mm±0.76mm。前交通动脉下方中点距视交叉上表面中点的高度,符合前交通动脉到终板的距离为3.68mm±3.79mm。前交通动脉和视交叉的相对位置关系为前置型、中央型和后置型。前交通动脉的穿支动脉大多从上壁、后壁和下壁发出,少有从前壁发出,总数在几支到十几支不等,根据穿支动脉和终板池位置关系分为后穿支、内侧穿支和外侧穿支,其中有—支较为粗大后穿支,从前交通动脉后壁、下壁发出,经终板池后部,并向后上方发出分支分布在胼胝体下区和下丘脑区域,测量其平均直径为0.46mm。
4.主要向视交叉后三脑室内生长、具有典型特征的颅咽管瘤—般均可通过MR扫描判断肿瘤与三脑室底的关系,结合术前MR扫描判断分别选择额颞—经终板入路和前纵裂—经终板入路,手术切除均在三脑室腔内完成,三脑室底有时无法清晰辨认。术后78例行MR复查,同时或仅行CT复查53例,肿瘤切除程度均由术中录像和影像学检查证实,病理证实颅咽管瘤60例,垂体腺瘤6例,下丘脑视路胶质瘤6例,脑膜瘤2例,生殖细胞瘤2例,非霍杰金淋巴瘤和非特异性肉芽肿各1例。本组术中显微镜下所证实和术后影像学复查结果表明：颅咽管瘤病例全切除98.3%(59/60),近全切除1.3%(1/60)；大型垂体腺瘤全切除4例,近全切除1例,大部切除1例；下丘脑视路胶质瘤全切除2例,近全切除2例,大部切除2例；脑膜瘤2例全切除；生殖细胞瘤全切除1例,近全切除1例；淋巴瘤和肉芽肿性变各1例均得到全切除。本组颅咽管瘤选择经终板路径多数得到安全切除,术中肿瘤主要的粘连部位在垂体柄上端、三脑室前部和底部,垂体柄漏斗部容易部分损伤；肿瘤与垂体柄和三脑室底分离是手术难点,肿瘤切除后垂体柄连续性常常不能保留。在60例颅咽管瘤病例中,垂体柄给予保留者43例,为减少复发将垂体柄离断者9例,其他病变垂体柄均得到满意保留,部分患者术后复查时出现第三脑室底的部分缺损。颅咽管瘤患者术后多数合并垂体功能下降,不同程度垂体功能低下者90%；术后短期尿崩87%,长期随访尿崩发生率56%,需使用长效尿崩停控制；术前有视力障碍者19例,14例术后视力明显改善,3例无变化,2例加重,无并发脑脊液漏及颅内感染。
主要结论：
1.终板池上壁由终板内侧膜构成,下壁由视交叉的上表面和终板前部构成,后下壁为终板中后部,外侧壁由终板外侧膜构成。终板池和视交叉池,嗅池,胼胝体池,颈内动脉池联系紧密。首次将终板外侧膜按形态可分为稀疏型、致密型和缺如型；终板内侧膜按形态分为凸起型和平坦稀疏型。终板池的解剖特征以及和邻近的脑池的交通关系,可能影响前交通动脉瘤破裂后积血的位置。
2.终板大多数为灰白色,从形态学分为隆起型和扁曲型。终板长度为曲线距离,终板前缘和前联合下缘的距离为终板长度。终板切开选择在视交叉前缘后方5.5mm至11mm处的中线上。
3.前交通动脉和视交叉的相对位置关系为前置型、中央型和后置型。前交通动脉的穿通支和终板池关系分为后穿支、内侧穿支和外侧穿支。在经额颞或前纵裂—终板入路手术中,打开终板池和显露终板的方式是不同的,需按不同的次序处理前交通动脉外侧穿支、内侧穿支和后穿支,暴露前交通动脉和视交叉,进入终板区域。
4.经终板入路可以切除多种累及三脑室前部肿瘤,根据终板间隙的使用情况分为两类：①完全经终板入路②辅助使用终板入路。根据肿瘤的病理类型,大小,侵犯三脑室的不同方式,分别选择额颞—经终板入路和前纵裂—经终板入路,可以满足大多数累及三脑室前部病变的手术切除。
5.终板构成一个清晰,可以辨认的显微手术标志；分离终板池、前交通动脉及其穿通支可以暴露终板；术前MR和术中判别终板、前交通动脉复合体、前联合、垂体柄、乳头体、中间块等解剖标志,对安全使用终板手术空间有重要的临床意义。经终板间隙是处理鞍上凸入三脑室空间颅咽管瘤的重要手术路径,经该间隙可以全切除经典轴外路径难以充分暴露、手术难度较大的颅咽管瘤。
Background and objective:
1. Gerardus Blasius identified, described,and named the arachnoid membrane in1664. Key and Retzius provided the first detailed description of the arachnoid cisterns in1875. Yas.argil reported his intraoperative observations on the microsurgical anatomy of lamina terminalis cistern and lamina terminalis,and additional reports by neurosurgeons followed in1976.The research methods and results of microanatomy of lamina terminalis cistern and lamina terminalis are different. Moreover, the morphological features, borders and contents of LT cistern, the relationship between LT cistern and surrounding cerebral cistern, and the structure of LT are all in dispute. On the basis of microanatomy of human cadaveric heads, this study's objective is to observe and measure the morphological features, borders and contents of LT; the relationship between LT cistern and surrounding cerebral cistern; the anatomic features of LT cistern; the relationship between surrounding anterior communicating artery and perforating branches; and to discuss the clinical application of morphological features and data of lamina terminalis cistern and lamina terminalis.
2. To summarize the clinical data of the anterior third ventricle tumor resection through LT space in our hospital, and to discuss how to use the LT space. To study the anatomy structures of the surrounding ACA-AComA complex, perforating branches, anterior commissure, optic chiasm, pituitary stalk, LT cistern and the anterior third ventricle in the lamina terminalis approach, providing the basis on dealing with the anterior third ventricle tumor.
Method:
1.20Chinese cadaver heads fixed by10%formalin were chosen in this study, while the arterial and venous system of10heads were filled with one-time molding filling agents. In craniotomy,10heads were opened through pterional approach, while the other10heads were opened through anterior interhemispheric approach. The pterional approach:Cadaver head was fixed on the operating table. Then partial frontal bone and temporal bone were opened, and the sphenoidal crest was ground to its medial. Subsequently, dura mater was incised and partial temporal lobe and frontal lobe were removed. Finally the lateral fissure was in exposure by pulling toward both sides. Using the operating microscope with6to40times magnification, we simulated the pterional approach to dissect lateral fissure layer by layer. Sylvian cistern was firstly separated and exposed the medial carotid, optic nerve, optic chiasma in turn then the lateral LT cistern in the end. Anterior interhemispheric approach:both sides of partial frontal bone were opened and the bone window was enlarged to the anterior cranial fossa. Then the eyeballs were removed, and the dura mater was incised when the frontal pole closed to the supraorbital horseshoe. Using the operating microscope with6--40times magnification, we simulated the anterior interhemispheric approach approach to dissect lateral fissure layer by layer. Frontal lobe was removed layer by layer. Then we entered into the saddle area along the diastematocrania direction to keep the LT cistern related vessels, pia mater and arachnoid purposefully. Subsquently, we dissected downward from knee corpus callosum to the top of LT cistern along A2segment of anterior cerebral artery. Eventually, dissection reached to the bottom of LT cistern and and surface of LT and optic chiasma. These two approaches can both observed morphological characteristics, borders, contents and membrane structures of LT cistern, and the relationship between LT cistern and related vessels and surrounding cerebral cistern. Moreover, they can confirm the structures of LT, optic recess, optic chiasma, anterior communicating artery, perforating branches, anterior commissure, massa intermedia and corpus albicans, and stimulate lamina terminalis approach to expose the anterior and bottom third ventricle. A digital camera was used to take photographs and shoot video and an electronic vernier caliper was used to measure the length of LT, optic chiasma, anterior communicating artery and related vessels. SPSS13statistical software was used to analyze the data.
2. Clinical cases from78patients with the anterior third ventricle tumor received trans-LT resection in Guangzhou Nanfang Hospital from January2008to December2010, including craniopharyngioma60cases (27cases of teenagers≤16years old,33cases of adults>16years old), large pituitary adenomas6cases, hypothalamus glioma6cases, meningeoma2cases, germinoma2cases, non-Hodgkin's lymphoma1case and nonspecific granuloma1case. The main clinical manifestations included increased intracranial pressure, visual impairment, visual field defect, hypopituitarism, polyphagia, polyuria, hypothalamic lesion and secondary sexual characteristics retardation. CT and MR scans results disclosed the information on tumor's nature, size, texture, location involving. The observed index of MR scans on midsagittal images mainly included the relative position of the AComA complex and tumor, the height of tumor on sagittal image, shifting direction of corpus albicans, the degree of interpeduncal fossa involving, the relationship between interpeduncal fossa and basilar tip aneurysm and the vascular architecture of the AComA complex.38cases through frontotemporal-LT approach were chosen on the basis of tumor characteristic, size and involving parts, while40cases through the anterior interhemispheric-LT approach were chosen. These two surgeries needed to anatomize different cerebral cistern, and the approach of tumor exposure were different. However, it needed to expose and incise the LT completely. Tumor resection through LT approach included:(1) complete LT separation to remove tumor:mainly included craniopharyngioma burst into the third ventricle;(2) auxiliary application of LT approach:mainly included craniopharyngioma, pituitary adenomas, hypothalamus glioma, meningeoma which developed towards suprasellar cistern obviously. Then we discerned and protected the surrounding ACA-AComA complex, its perforating branches, anterior commissure, optic chiasma, pituitary stalk, corpus albicans, corpus albicans and hypothalamus in surgery. Finally, the tumor removal degree was evaluated by imaging after surgery, and cases follow-up were performed.
Result:
1. LT cistern was not an azygous cerebral cistern, which located on the top of optic chiasma and the upper front of LT. The superior wall consisted of medial LT membrane, extending upward to pericallosal cistern and connecting with arachnoid membrane forwardly. The interior wall comprised the upper surface of optic chiasma and LT, which was a free wall. The lateral wall was made of lateral LT membrane which both extended upward to medial LT membranes. The lateral LT membranes originated from posterolateral border of gyrus rectus, which extended downward to optic chiasma and the upper surface of optic nerve lateral border. It divided into sparse type, dense type and absent type. The medial LT membrane was azygous, consisting of both sides of gyrus rectus joint extending upward, which divided into convex type and flat sparse type. The contents of LT cistern included both of the A1 segments, the AComA, the proximal portions of the A2segments, partial Heubner artery, partial perforating branches of ACA-AComA complex, bilateral frontal orbitofrontal artery, bilateral the anterior cerebral veins and anterior communicating vein. The top of LT cistern was pericallosal cistern, and the medial LT membrane communicated between the rostrum of the corpus callosum and the inferior anterior of pericallosal cistern. Carotid membrane of LT cistern adhered to the inferior anterior of optic chiasma and the surface of optic nerve, connecting with the carotid membrane of optic chiasma. The lateral LT membrane extended downward to the lateral optic chiasma and the surface of optic nerve. The medial carotid cistern adhered to the inferior of the optic chiasma by the way of medial carotid membrane, extending downward to the lateral carotid membrane and covering the lateral saddle bed and posterior clinoid process. It was closed to the carotid cistern and bounded in lateral of optic chiasma and optic nerve, without communication. The anterior of lateral LT membrane and the inferior olfactory tract extended to gyrus rectus, communicating with the olfactory membrane.
2. The morphology of thin LT was similar to the soft membrane. LT adhered to the central upper surface of optic chiasma, archedly ending in the inferior-anterior anterior commissure and the neighborhood of the rostrum of the corpus callosum, and taking up the space of the upper surface of optic chiasma and the rostrum of the corpus callosum. The inferior initial part of LT was the optic recess which was lower than optic chiasma. LT was the widest place in the third ventricle, which was mostly grey white, while the other was dark yellow and black blue. LT was divided into-protruded type and flat song type by morphology. Most central LT was transparent and protruded fenestra laminae terminalis. The positioning between optic chiasm and the tuberculum sellae was pre-type, normal type and post type. The length of optic recess was6.35mm±1.22mm, while the width was4.79mm±1.11mm. The distance between the anterior optic chiasma and the anterior optic recess was5.53mm±1.23mm, while the anteroposterior diameter was11.33mm±1.55mm. The length of LT was a curve distance, and the distance between the anterior LT (namely the central upper surface of optic chiasma) and the inferior anterior commissure was9.99mm±1.43mm, which was correspondent with LT length. The width of LT was the largest distance between both sides of medial optic tracts, which was11.23mm±2.23mm. Dissecting LT to the anterior and bottom of third ventricle,15massa intermedias and20corpus albicans could be observed clearly. The distance between the anterior optic chiasm and the inferior anterior massa intermedia was28.66mm±2.24mm, while the distance between the anterior optic chiasm and the anterior corpus albican was20.10mm±1.90mm.
3.8cases of Heubner artery from the distal A1segments of ACA (the distance to AComA was within6mm) and30cases of Heubner artery from the proximal A1segments of ACA (the distance to AComA was within4mm) were observed. AComA was the vascular structure most closely connecting with LT. Its length was2.52mm±0.76mm. The height between the central inferior AComA and the central upper surface of optic chiasma was3.68mm±3.79mm, which was according with the distance between AComA and LT. The relative positioning between AComA and optic chiasm was pre-type, central type and post type. The perforating branches of AComA were mostly from superior wall, posterior wall and inferior wall, rarely from anterior wall, of which the total number ranged from several to dozens. The perforating branches were divided into posterior perforating branches, medial perforating branches and lateral perforating branches by the position of perforating branches and LT cistern. Hereinto, a relatively strong posterior perforating branch was from the posterior wall and inferior wall of AComA, via posterior LT cistern, and branched above the backward in the area subcallosa and hypothalamus. The average diameter was0.46mm.
4. Tumor developed into the third ventricle behind optic chiasma. The relationship between craniopharyngioma with typical characteristics and the bottom of third ventricle could be confirmed by MR scans. On the basis of MR scans results, the frontotemporal-LT approach and the anterior interhemispheric-LT approach were chosen in surgery. Resection was performed in the cavity of third ventricle, however, the bottom of third ventricle could not discern clearly sometimes. The tumor removal degree was evaluated by intraoperative video and imaging.78cases were reviewed routinely by MR scans following surgery. Meanwhile,53cases were only reviewed by CT scans. Pathological diagnosis confirmed60patients with craniopharyngioma,6patients with large pituitary adenomas,6patients with hypothalamus glioma,2patients with meningeoma,2patients with germinoma,1patient with non-Hodgkin lymphoma, and1patient with nonspecific granuloma. Results of operating microscope observation and imaging review demonstrated that98.3%of craniopharyngioma (59/60) were removed entirely, while1.3%of those (1/60) were removed almost completely;4cases of large pituitary adenomas were removed entirely, while1case of those was removed almost completely, and1cases were removed in a great measure;2cases of hypothalamus glioma were removed entirely, while2cases of those were removed almost completely, and2cases were removed in a great measure;2cases of meningeoma were removed entirely;1case of germinoma was removed entirely, while1case of those was removed almost completely; both of non-Hodgkin lymphoma and nonspecific granuloma were removed entirely. In this group, most craniopharyngioma was removed safely through LT approach. the adhering positions of tumor in surgery mainly located in the superior pituitary stalk, the anterior and bottom of third ventricle. The partial infundibulum of pituitary stalk could be easily damaged. Therefore, the separation of tumor from pituitary stalk and the bottom of third ventricle was much difficult in surgery, and the continuity of pituitary stalk after tumor resection could not be preserved frequently. Among60cases of craniopharyngioma,43cases kept the pituitary stalk, while10cases separated the pituitary stalk for less recurrence, and the other cases all kept the pituitary stalk. However, some patients had partial lesion in the third ventricle in case review.90%of patients with craniopharyngioma had a function decline of pituitary gland;87%of patients with craniopharyngioma had a short-term diabetes insipidus following surgery, while56%of those had a long-term diabetes insipidus in case follow-up, which needed to used injection vasopressin tannate to control it;19patients with craniopharyngioma had vision disorder before surgery, while14patients improved their vision after surgery,3patients had no change, and2patients aggravated. There were3patients died in this group, but no complications of cerebrospinal fluid leakage and intracranial infection.
Chief conclusion:
1. The superior wall consisted of medial LT membrane; the interior wall comprised the upper surface of optic chiasma and LT; the posterior-interior wall was the central posterior LT; and the lateral wall was made of lateral LT membrane. The LT cistern, pericallosal cistern and carotid cistern had a strong connection. In first time,the lateral LT membrane was divided into sparse type, dense type and absent type, while the medial LT membrane was divided into convex type and flat sparse type. The anatomy features of LT cistern and the communication with adjacent cerebral cistern mignt affect the position of anterior communicating aneurysms hematocele after-broken.
2. The color of LT was mostly grey white, which was divided into protruded type and flat song type by morphology. The length of LT was a curve distance, and the distance between the anterior LT (namely the central upper surface of optic chiasma) and the inferior anterior commissure was correspondent with LT length. LT was dissected in the central line distancing the posterior of anterior optic chiasma5.5mm--11mm.
3. The relative positioning between AComA and optic chiasm was pre-type, central type and post type. The perforating branches were divided into posterior perforating branches, medial perforating branches and lateral perforating branches. In the frontotemporal approach or interhemispheric-LT approach, the method of opening LT cistern and exposing LT were different. It should treat with the lateral, medial and posterior perforating branches of AComA in turns, to expose the AComA and optic chiasm and enter the LT area in the end.
4Diverse tumors involving anterior third ventrical chamber could be removed through Trans-lamina terminalis approach. It could be divided into two categories based on the application of LT space:(1) complete LT approach;(2) auxiliary extra-axial LT approach. Based on the pathological entities, size and ways of the third ventricle invasion of tumor, the frontotemporal-LT approach and the anterior interhemispheric-LT approach were chosen in surgery, which could meet the requirement of lesion resection involving the anterior third ventricle.
5LT was a clear and discernable landmark of anatomic surgery. The separation of LT cistern, AComA, anterior commissure and its perforating branches could expose LT. Preoperative MR scans and the determination of LT, AComA, anterior commissure, pituitary stalk, corpus albicans, corpus albicans and other anatomic landmark had a important clinical significance on safe application of LT space. The important approach of treating with craniopharyngioma burst invaginated into the third ventricle from suprasella space was LT approach. It could completely remove the craniopharyngioma which was difficult to be exposed through typical extra-axial approach.
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[1]Sanan A, van Loveren HR:The arachnoid and the myth of Arachne. Neurosurgery 45:152-157,1999.
[2]Lii J, Zhu XL:Characteristics of distribution and configuration of intracranial arachnoid membranes. Surg Radiol Anat 27:472-481,2005.
[3]Matsuno H, Rhoton AL Jr, Peace D:Microsurgical anatomy of the posterior fossa cisterns. Neurosurgery 23:58-80,1988.
[4]Brasil AV, Schneider FL:Anatomy of Liliequist's membrane. Neurosurgery 32:956-961,1993.
[5]Vinas FC, Panigrahi M:Microsurgical anatomy of the Liliequist's membrane and surrounding neurovascular territories. Minim Invasive Neurosurg 44:104-109,2001.
[6]LiliequistB.The anatomy of the subarachnoid cistenrs.Acts Radiol,1956, 46:61-71.
[7]Arutiunov Al, Baron MA, Majorova NA. The role of mechanical factors in the pathogenesis of short-term and prolonged spasm of the cerebral arteries.J Neurosurg,1974,40(4):459-472.
[8]Yas.argil MG:Microneurosurgery. New York, Thieme Stratton,1984, vol 1, pp 5-53.
[9]Yas.argil MG, Kasdaglis K, Jain KK, Weber HP:Anatomical observations of the subarachnoid cisterns of the brain during surgery. J Neurosurg 44:298-302,1976.
[10]Froelich SC, Abdel Aziz KM, Cohen PD, van Loveren HR, Keller JT: Micro-surgical and endoscopic anatomy of Liliequist's membrane:A complex and variable structure of the basal cisterns. Neurosurgery 63 [Suppl 1]:ONS1-ONS9,2008.
[11]Lu J, Zhu XI:Microsurgical anatomy of Liliequist's membrane. Minim Invasive Neurosurg 46:149-154,2003.
[12]Lu J, Zhu XL:Cranial arachnoid membranes:Some aspects of microsurgical anatomy. Clin Anat 20:502-511,2007.
[13]Martins C, Yasuda A, Campero A, Rhoton AL Jr:Microsurgical anatomy of the oculomotor cistern. Neurosurgery 58 [Suppl 2]:ONS-220-ONS-228,2006.
[14]Rhoton AL Jr:The posterior fossa cisterns. Neurosurgery 47 [Suppl 3]:S287-S297,2000.
[15]Zhang M, An PC:Liliequist's membrane is a fold of the arachnoid mater:Study using sheet plastination and scanning electron microscopy. Neurosurgery 47:902-909,2000.
[16]Wang SS, Zheng HP, Zhang X, Zhang FH, Jing JJ, Wang RM:Microanatomy and surgical relevance of the olfactory cistern. Microsurgery 28:65-70,2008.
[17]Vinas FC, Fandino R, Dujovny M, etal. Microsurgical anatomy of the Supratentorial arachnoidal trabecular membranes and cisterns. Neurological Res,1994,16(12):417-424.
[18]Vinas FC,Dujovny M,Fandino R, etal.Microsurgical anatomy of the in fratentorial trabecular membranes and subarachnoidcisterns.Neurological Res,1996,18(4):117-125.
[19]Vinas FC,Dujovny M,Fandino R, etal.Microsurgical anatomy of the arachnoidal trabecular membranes and ciaterns at the level of the tentorium-Neurological Res,1996,18(8):305-312.
[20]Cavallo LM, de Divitiis O, Aydin S, Messina A, Esposito F, Iaconetta G, Talat K, Cappabianca P, Tschabitscher M:Extended endoscopic endonasal transsphenoidal approach to the suprasellar area:Anatomic considerations-Part1.Neurosurgery62[Suppl 3]:1202-1212,2008.
[21]De Divitiis E, Esposito F, Cappabianca P, Cavallo LM, de Divitiis O, Esposito I: Endoscopic transnasal resection of anterior cranial fossa meningiomas. Neurosurg Focus 25:E8,2008.
[22]Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R:Expanded endo-nasal approach:Fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratem-poral fossa. Neurosurg Focus 19:E6,2005.
[23]Kassam AB, Prevedello DM, Thomas A, Gardner P, Mintz A, Snyderman C, Carrau R:Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery 62:57-74,2008.
[24]Tanriover N, Rhoton AL Jr, Kawashima M, Ulm AJ, Yasuda A:Microsurgical anatomy of the insula and the sylvian fissure. J Neurosurg 100:891-922,2004.
[25]Gibo H, Carver CC, Rhoton AL Jr, Lenkey C, Mitchell RJ:Microsurgical ana-tomy of the middle cerebral artery. J Neurosurg 54:151-169,1981.
[26]Rosner SS, Rhoton AL Jr, Ono M, Barry M:Microsurgical anatomy of the anterior perforating arteries. J Neurosurg 61:468-485,1984.
[27]Gibo H, Lenkey C, Rhoton AL Jr:Microsurgical anatomy of the supraclinoid portion of the internal carotid artery. J Neurosurg 55:560-574,1981.
[28]Rhoton AL Jr:The supratentorial arteries. Neurosurgery 51 [Suppl 4]:S53-S120, 2002.
[29]Kohei Inoue,Askin Seker, L.Rhoton,etal Microsurgical and endoscopic anatomy of the supratentorial arachnoidal membranes and cisterns. Neurosurgery 65:644-665,2009.
[30]Ulm AJ, Tanriover N, Kawashima M, Campero A, Bova FJ, Rhoton A Jr: Microsurgical approaches to the perimesencephalic cisterns and related segments of the posterior cerebral artery:Comparison using a novel application of image guidance. Neurosurgery 54:1313-1328,2004.
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[33]Perlmutter D, Rhoton AL Jr:Microsurgical anatomy of the distal anterior cerebral artery. J Neurosurg 49:204-228,1978.
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[35]Rhoton AL Jr:Tentorial incisura. Neurosurgery 47 [Suppl 3]:S131-S153,2000.
[36]Rhoton AL Jr:The cerebellar arteries. Neurosurgery 47 [Suppl 3]: s29-s68,2000.
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[1]Sanan A, van Loveren HR:The arachnoid and the myth of Arachne. Neurosurgery 45:152-157,1999.
[2]Lii J, Zhu XL:Characteristics of distribution and configuration of intracranial arachnoid membranes. Surg Radiol Anat 27:472-481,2005.
[3]Matsuno H, Rhoton AL Jr, Peace D:Microsurgical anatomy of the posterior fossa cisterns. Neurosurgery 23:58-80,1988.
[4]Brasil AV, Schneider FL:Anatomy of Liliequist's membrane. Neurosurgery 32:956-961,1993.
[5]Vinas FC, Panigrahi M:Microsurgical anatomy of the Liliequist's membrane and surrounding neurovascular territories. Minim Invasive Neurosurg 44:104-109,2001.
[6]LiliequistB.The anatomy of the subarachnoid cistenrs.Acts Radiol,1956, 46:61-71.
[7]Arutiunov Al, Baron MA, Majorova NA. The role of mechanical factors in the pathogenesis of short-term and prolonged spasm of the cerebral arteries.J Neurosurg,1974,40(4):459-472.
[8]Yas.argil MG:Microneurosurgery. New York, Thieme Stratton,1984, vol 1, pp 5-53.
[9]Yas.argil MG, Kasdaglis K, Jain KK, Weber HP:Anatomical observations of the subarachnoid cisterns of the brain during surgery. J Neurosurg 44:298-302,1976.
[10]Froelich SC, Abdel Aziz KM, Cohen PD, van Loveren HR, Keller JT: Micro-surgical and endoscopic anatomy of Liliequist's membrane:A complex and variable structure of the basal cisterns. Neurosurgery 63 [Suppl 1]:ONS1-ONS9,2008.
[11]Lu J, Zhu XI:Microsurgical anatomy of Liliequist's membrane. Minim Invasive Neurosurg 46:149-154,2003.
[12]Lu J, Zhu XL:Cranial arachnoid membranes:Some aspects of microsurgical anatomy. Clin Anat 20:502-511,2007.
[13]Martins C, Yasuda A, Campero A, Rhoton AL Jr:Microsurgical anatomy of the oculomotor cistern. Neurosurgery 58 [Suppl 2]:ONS-220-ONS-228,2006.
[14]Rhoton AL Jr:The posterior fossa cisterns. Neurosurgery 47 [Suppl 3]:S287-S297,2000.
[15]Zhang M, An PC:Liliequist's membrane is a fold of the arachnoid mater:Study using sheet plastination and scanning electron microscopy. Neurosurgery 47:902-909,2000.
[16]Wang SS, Zheng HP, Zhang X, Zhang FH, Jing JJ, Wang RM:Microanatomy and surgical relevance of the olfactory cistern. Microsurgery 28:65-70,2008.
[17]Vinas FC, Fandino R, Dujovny M, etal. Microsurgical anatomy of the Supratentorial arachnoidal trabecular membranes and cisterns. Neurological Res,1994,16(12):417-424.
[18]Vinas FC,Dujovny M,Fandino R, etal.Microsurgical anatomy of the in fratentorial trabecular membranes and subarachnoidcisterns.Neurological Res,1996,18(4):117-125.
[19]Vinas FC,Dujovny M,Fandino R, etal.Microsurgical anatomy of the arachnoidal trabecular membranes and ciaterns at the level of the tentorium-Neurological Res,1996,18(8):305-312.
[20]Cavallo LM, de Divitiis O, Aydin S, Messina A, Esposito F, Iaconetta G, Talat K, Cappabianca P, Tschabitscher M:Extended endoscopic endonasal transsphenoidal approach to the suprasellar area:Anatomic considerations-Part1.Neurosurgery62[Suppl 3]:1202-1212,2008.
[21]De Divitiis E, Esposito F, Cappabianca P, Cavallo LM, de Divitiis O, Esposito I: Endoscopic transnasal resection of anterior cranial fossa meningiomas. Neurosurg Focus 25:E8,2008.
[22]Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R:Expanded endo-nasal approach:Fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratem-poral fossa. Neurosurg Focus 19:E6,2005.
[23]Kassam AB, Prevedello DM, Thomas A, Gardner P, Mintz A, Snyderman C, Carrau R:Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery 62:57-74,2008.
[24]Tanriover N, Rhoton AL Jr, Kawashima M, Ulm AJ, Yasuda A:Microsurgical anatomy of the insula and the sylvian fissure. J Neurosurg 100:891-922,2004.
[25]Gibo H, Carver CC, Rhoton AL Jr, Lenkey C, Mitchell RJ:Microsurgical ana-tomy of the middle cerebral artery. J Neurosurg 54:151-169,1981.
[26]Rosner SS, Rhoton AL Jr, Ono M, Barry M:Microsurgical anatomy of the anterior perforating arteries. J Neurosurg 61:468-485,1984.
[27]Gibo H, Lenkey C, Rhoton AL Jr:Microsurgical anatomy of the supraclinoid portion of the internal carotid artery. J Neurosurg 55:560-574,1981.
[28]Rhoton AL Jr:The supratentorial arteries. Neurosurgery 51 [Suppl 4]:S53-S120, 2002.
[29]Kohei Inoue,Askin Seker, L.Rhoton,etal Microsurgical and endoscopic anatomy of the supratentorial arachnoidal membranes and cisterns. Neurosurgery 65:644-665,2009.
[30]Ulm AJ, Tanriover N, Kawashima M, Campero A, Bova FJ, Rhoton A Jr: Microsurgical approaches to the perimesencephalic cisterns and related segments of the posterior cerebral artery:Comparison using a novel application of image guidance. Neurosurgery 54:1313-1328,2004.
[31]Zeal AA, Rhoton AL Jr:Microsurgical anatomy of the posterior cerebral artery. J Neurosurg 48:534-559,1978.
[32]Perlmutter D, Rhoton AL Jr:Microsurgical anatomy of the anterior cerebral-anterior communicating-recurrent artery complex. J Neurosurg 45:259-272,1976.
[33]Perlmutter D, Rhoton AL Jr:Microsurgical anatomy of the distal anterior cerebral artery. J Neurosurg 49:204-228,1978.
[34]Hardy DG, Peace DA, Rhoton AL Jr:Microsurgical anatomy of the superior cerebellar artery. Neurosurgery 6:10-28,1980.
[35]Rhoton AL Jr:Tentorial incisura. Neurosurgery 47 [Suppl 3]:S131-S153,2000.
[36]Rhoton AL Jr:The cerebellar arteries. Neurosurgery 47 [Suppl 3]: s29-s68,2000.
[37]Epstein BS. The rote of artansverse arachnoidal membrane within the interpeduncular cistern in the passage of Pantopaque into the cranialc avity. Radiology,1965,85:914-920.
[38]Fushimi Y, Miki Y, Ueba T, Kanagaki M, Takahashi T, Yamamoto A, Haque TL, Konishi J, Takahashi JA, Hashimoto N, Konishi J:Liliequist membrane:Three-dimensional constructive interference in steady state MR imaging. Radiology 229:360-365,2003.