頸靜脈孔區(qū)解剖

1、頸靜脈孔的應(yīng)用解剖,陳立華CHINA-INI,頸靜脈孔由顳骨巖部和枕骨頸突圍成。顳骨和枕骨向孔內(nèi)的突起分別被稱(chēng)為顳突和枕突，二者以纖維或骨橋連接，構(gòu)成孔內(nèi)神經(jīng)和血管的分隔。由顳突下方沿頸靜脈球內(nèi)側(cè)緣伸向后方的骨性隆起稱(chēng)為頸內(nèi)嵴，舌咽神經(jīng)行于其內(nèi)側(cè)。頸靜脈孔為一自顱后窩通向前、外、下方的骨性管道 。頸靜脈管（jugular canal）。,osseous relationships, superior view,,osseous

2、relationships, posterosuperior view. The jugular foramen is best seen in a posterosuperior view oriented perpendicular to the clivus.,the jugular foramen is located between the temporal and occipital bones sigmoid groo

3、ve descends along the mastoid and crosses the occipitomastoid suture , turns forward on the upper surface of the jugular process , enters the foramen,from posterior and superior shows the shape of the foramen,,hypoglossa

4、l canal passes above the middle third of the occipital condyle and opens laterally into the interval between the jugular foramen and carotid canal stylomastoid foramen is located lateral and the anterior half of the occ

5、ipital condyle medial to the jugular foramen,,anterior and backward reveals the shape of the jugular foramen,,larger lateral part, the sigmoid part, which receives the drainage of the sigmoid sinus, and a smaller medial

6、part, the petrosal part, which receives the drainage of the inferior petrosal sinus,,enlarged view,,intrajugular process projects into the interval between the sigmoid and petrosal parts of the foramen intrajugular ridg

7、e, extends forward from the intrajugular process along the medial side of the jugular bulb,,cochlear aqueduct opens above the petrosal part of the foramen , where the glossopharyngeal nerve enters the intrajugular part o

8、f the foramen on the medial side of the intrajugular process. the vestibular aqueduct opens onto the posterior surface of the temporal bone superolateral to the jugular foramen,,The inferior petrosal sinus extends along

9、 the petroclival fissure and enters the petrosal part of the foramen,,posterosuperior view of the intrajugular process and ridge, which separate the sigmoid and petrosal parts of the jugular foramen,Rembrandt van Rijn (D

10、utch, 1606-1669). This painting is called "The Anatomy Lecture of Dr. Nicolaes Tulp", painted in 1632,頸靜脈孔的硬膜結(jié)構(gòu)及分部,Hovelacque將頸靜脈孔分為前內(nèi)側(cè)的神經(jīng)部和后外側(cè)的血管部?jī)刹糠?。Katsuta根據(jù)通過(guò)頸靜脈孔的結(jié)構(gòu)將其分為巖部、頸內(nèi)部（或神經(jīng)部）和乙狀竇部。神經(jīng)部的硬膜形成舌咽道和迷走道，分

11、別有舌咽神經(jīng)和迷走神經(jīng)及副神經(jīng)穿過(guò)。舌咽道和迷走道位于頸內(nèi)突內(nèi)側(cè),二者間隔以0.5-4.9mm寬的硬膜。神經(jīng)部上外側(cè)緣的硬膜返折增厚并伸向下內(nèi)覆于舌咽道和迷走道上方，稱(chēng)頸靜脈孔硬膜返折,是辨認(rèn)顱神經(jīng)的重要標(biāo)志。,,,,,sigmoid sinus descends in the sigmoid sulcus , sharp anterior turn to enter the jugular foramen. The jugular

12、bulb extends upward under the petrous temporal bone toward the internal acoustic meatus,nerves penetrate the dura on the medial side of the intrajugular process, intrajugular ridge extends forward along the medial side o

13、f the jugular bulb,glossopharyngeal nerve passes forward along the medial side of the intrajugular ridgevagus and accessory nerves, on the medial side of the intrajugular process,vagus and accessory nerves pass lateral

14、to the osseous bridge and the inferior petrosal sinus descends below the bridge to open into the internal jugular vein,hypoglossal canal and joins the glossopharyngeal, vagus, and accessory nerves below the jugular foram

15、en in the interval between the internal carotid artery and internal jugular vein,arachnoid opened to expose the glossopharyngeal, vagus, and accessory nerves entering the dura and passing through the intrajugular part of

16、 the foramen. A dural septum separates the glossopharyngeal nerve from the upper vagal rootlets at the site at which the nerve enters the intrajugular portion of the foramen. The jugular dural fold projects over the nerv

17、es as they penetrate the dura,,,upper portion of the cerebellopontine angle, including the trigeminal nerves, has been exposed,,A bridging vein passes from the medulla to the jugular bulb. The posteroinferior cerebellar

18、artery passes behind the hypoglossal nerve and between the accessory rootlets,頸靜脈孔區(qū)神經(jīng)定位,舌咽神經(jīng)的根絲位于小腦絨球和Luschka孔脈絡(luò)叢的前方，且位置關(guān)系相對(duì)恒定。因此，可將小腦絨球和Luschka孔脈絡(luò)叢復(fù)合體作為辨認(rèn)舌咽神經(jīng)腦池段起始部的解剖標(biāo)志，并據(jù)此初步判斷迷走神經(jīng)、副神經(jīng)腦干端。 Lachman N研究發(fā)現(xiàn)副神經(jīng)沒(méi)有顱根，僅由脊髓根構(gòu)成

19、，頸靜脈孔內(nèi)副神經(jīng)和迷走神經(jīng)間無(wú)任何連接。均可在顯微鏡下縱行切開(kāi)神經(jīng)鞘膜，將神經(jīng)束彼此分開(kāi)。,A： Lateral view of the normal anatomy of the jugular foramen. B： Axial cut (dotted line in A) viewed from inferior to the normal anatomy. Note that the perforations connect

20、ing the inferior petrosal sinus to the jugular vein run between the lower cranial nerves.,,在頸靜脈孔內(nèi)口，舌咽神經(jīng)根絲匯合后經(jīng)單獨(dú)的硬膜通道（舌咽道）入頸靜脈孔，迷走神經(jīng)和副神經(jīng)則經(jīng)迷走道入頸靜脈孔。頸靜脈孔神經(jīng)部上外側(cè)緣的硬膜返折增厚并唇樣伸向下內(nèi)覆于舌咽道和迷走道上方，即頸靜脈孔硬膜返折，是于頸靜脈孔內(nèi)口辨認(rèn)腦神經(jīng)的標(biāo)志。,,,,,神經(jīng)血管結(jié)

21、構(gòu)的位置關(guān)系,小腦后下動(dòng)脈行程迂曲，與Ⅸ、Ⅹ、Ⅺ及Ⅻ對(duì)腦神經(jīng)根關(guān)系復(fù)雜，其穿行腦神經(jīng)根絲的形式，大致可分為四種：發(fā)自第一齒狀韌帶周?chē)男∧X后下動(dòng)脈穿副神經(jīng)根絲；起自舌下神經(jīng)孔周?chē)叽┟宰呱窠?jīng)和副神經(jīng)根絲或之間；起自舌下神經(jīng)孔與橋延溝之間者穿迷走神經(jīng)根；起自基底動(dòng)脈者勾繞舌咽神經(jīng)和頸靜脈孔。小腦后下動(dòng)脈或/和迂曲的椎動(dòng)脈壓迫舌咽神經(jīng)根被認(rèn)為是引起舌咽神經(jīng)痛的原因之一；小腦后下動(dòng)脈或/和迂曲的椎動(dòng)脈壓迫延髓左側(cè)可能引起血壓升高，壓迫延髓右側(cè)

22、可引起血糖升高。,,,,,,,頸靜脈孔區(qū)不同性質(zhì)腫瘤的生長(zhǎng)方式及特點(diǎn)，對(duì)術(shù)前正確診斷、確定合理的治療方案及術(shù)中保護(hù)神經(jīng)功能具重要意義,頸靜脈孔診斷,神經(jīng)鞘瘤,神經(jīng)鞘瘤起源于舌咽神經(jīng)、迷走神經(jīng)、副神經(jīng)或頸交感干，沿其起源的神經(jīng)生長(zhǎng)。神經(jīng)鞘瘤因壓迫性溶骨致頸靜脈孔擴(kuò)大，表現(xiàn)為扇貝樣改變而骨皮質(zhì)完好。邊緣常是光滑的，瘤邊界清楚。 容易發(fā)生囊變/壞死，腫瘤質(zhì)地不均勻，內(nèi)部多有短T1長(zhǎng)T2的片狀影。ＭＲＩ增強(qiáng)后腫瘤實(shí)質(zhì)部分可強(qiáng)化，但不如腦膜

23、瘤和化學(xué)感受器瘤明顯。瘤內(nèi)無(wú)流空的血管影可同化學(xué)感受器瘤鑒別，而ＭＲＩ上可顯示面聽(tīng)神經(jīng)也可同聽(tīng)神經(jīng)瘤相鑒別。,腦膜瘤,起源于頸靜脈球或鄰近靜脈竇部的蛛網(wǎng)膜顆粒 。Sekhar將頸靜脈孔區(qū)腦膜瘤定義為附著于頸靜脈孔硬膜或起源于延髓小腦角伴或不伴向顱外生長(zhǎng)。 CT為高密度腫瘤。MRI缺乏象化學(xué)感受器那樣的瘤內(nèi)血管流空影。增強(qiáng)后Ｔ1像明顯強(qiáng)化，其程度較化學(xué)感受器瘤更為明顯，并?？梢?jiàn)腦膜尾征。 腦膜瘤典型的表現(xiàn)為“離心性”擴(kuò)張和“匍匐狀”

24、生長(zhǎng)，并有浸潤(rùn)顱神經(jīng)和血管外膜的傾向。其對(duì)鄰近骨質(zhì)的破壞表現(xiàn)為廣泛浸潤(rùn)板障而骨結(jié)構(gòu)和骨密度得以保留，頸靜脈孔邊緣因皮質(zhì)遭破壞而不規(guī)則。邊緣往往有骨質(zhì)增生或硬化的表現(xiàn)。,頸靜脈球瘤,頸靜脈孔骨質(zhì)不規(guī)則的破壞、擴(kuò)大，無(wú)骨質(zhì)增生。MRI平掃頸靜脈孔區(qū)腫塊呈等Ｔ1，長(zhǎng)Ｔ2像，輪廓不規(guī)則。瘤內(nèi)可見(jiàn)點(diǎn)狀，迂曲條狀低信號(hào)影，腫瘤實(shí)質(zhì)的高信號(hào)與低信號(hào)相間，稱(chēng)為“椒鹽”征，這些條狀的低信號(hào)影是流空的血管影，代表了腫瘤內(nèi)扭曲擴(kuò)張的血管，是該腫瘤的特征性表現(xiàn)

25、。ＭＲＩ增強(qiáng)后Ｔ1像上明顯不均勻強(qiáng)化，邊界清晰。,頸靜脈球體瘤Fisch分型法(1978),頸靜脈球體瘤Glasscock-Jackson分型法(1981),Intracranial growth pattern of glomus jugulare tumors into the inferior petrosal sinus,glomus jugularmeningioma (M)schwannoma (S). Section

26、 A is at the level of the dome of the jugular bulb, section B is at the midlevel of the jugular foramen, section C is at the exit of the skull base,,“微創(chuàng)”理念---要求對(duì)頸靜脈孔區(qū)的解剖境界和特征更精確的理解和認(rèn)識(shí)。Rhoton等學(xué)者將到達(dá)頸靜脈孔區(qū)的主要手術(shù)入路分為顳下耳前顳下窩入

27、路、耳后經(jīng)顳入路、枕下及遠(yuǎn)外側(cè)入路三組。,頸靜脈孔區(qū)腫瘤手術(shù)入路,1. 側(cè)方入路： 通過(guò)乳突切除到達(dá)術(shù)區(qū)，又稱(chēng)迷路下入路。需移位面神經(jīng)并可能損及內(nèi)耳結(jié)構(gòu)，卻對(duì)延伸至顱內(nèi)的腫瘤顯露不充分。2. 后方入路：包括枕下乙狀竇后入路、遠(yuǎn)外側(cè)及經(jīng)髁入路等。該組入路便于切除延伸到后顱窩的腫瘤，但卻對(duì)顳下窩腫瘤顯露有限，經(jīng)髁入路還增加了舌下神經(jīng)、椎動(dòng)脈損傷和出現(xiàn)寰枕關(guān)節(jié)不穩(wěn)定的風(fēng)險(xiǎn)。3. 前方入路： Sekhar提出的顳下耳前顳下窩入路為該組最主要

28、的手術(shù)入路，頸內(nèi)動(dòng)脈前移后可顯露頸靜脈孔的前緣，進(jìn)一步磨除Kawase三角可顯露中上斜坡，該入路聯(lián)合側(cè)方經(jīng)顳即為Fisch顳下窩入路。對(duì)橋腦小腦角和延髓小腦角的顯露卻極為有限 。,經(jīng)頸靜脈孔入路（transjugular foramen）是極外側(cè)經(jīng)髁入路的亞型，通過(guò)枕下開(kāi)顱、切除枕髁后1/3、頸靜脈突和枕大孔后壁，自后下方顯露頸靜脈孔。遠(yuǎn)外側(cè)經(jīng)髁入路有利于面神經(jīng)功能和聽(tīng)力的保護(hù)，且能對(duì)下外側(cè)顱底和顳下窩提供較充分的顯露，有助于一期切除

29、頸靜脈孔區(qū)顱內(nèi)外溝通性腫瘤，但需進(jìn)行枕髁、頸靜脈結(jié)節(jié)切除和椎動(dòng)脈移位。經(jīng)髁旁入路切除頸靜脈孔區(qū)腫瘤，通過(guò)切除寰椎橫突、移位椎動(dòng)脈、切除部分枕髁及髁旁、髁上骨質(zhì)、頸靜脈結(jié)節(jié)等實(shí)現(xiàn)自后下方顯露頸靜脈孔。,Anatomic landmarks on the cranium,1: asterion , junction of the transverse and sigmoid sinuses.2: mastoid foramen, con

30、veys the mastoid emissary vein, indicates the posterior margin of the middle portion of the sigmoid sinus.,3: posterior end of the incisura mastoidea 4:condylar fossa5:posterior condylar foramen 6:occipital condyle 7

31、:mastoid process , grossly corresponds to the level of the internal acoustic meatus. The bony opening for the infratentorial lateral supracerebellar approach should be made above this level.,,,,operative view of the tran

32、scond-ylar fossa approach,1:glossopharyngeal nerve ;2: the PICA ; 3: vagal nerve;4: accessory nerve ; 5: the vertebral artery ; 6: posterior condylar emissary vein; 7: AICA ; 8:choroid plexus.,Surgical technique of expos

33、ing the neural component of the jugular foramen,A: Normal view of the jugular foramen. Also shown are Cranial Nerves V, VII, and VIII. B: An intracranial meningioma with jugular foramen involvement is depicted. the tumo

34、r is posterior to the nerve roots (the most favorable situation). C: Drilling of the neural component of the jugular foramen is performed. D:Tumor within the jugular foramen can then be microdissected out.,transcondyla

35、r approach Angle of surgical approach,pre, ASA to clivus before OC resection post, ASA to JT after OC resection. the far lateral transcondylar exposure was 17 ± 1 mm.,transcondylar approach，the jugular tubercle o

36、bstructs the anterior portion of the PICA aneurysm. B ：gentle retraction of the spinal accessory nerve revealing the neck of the aneurysm, which is covered partially by the jugular tubercle. C： the dura covering the ju

37、gular tubercle is incised and reflected posterior before drilling.,D ：drilling jugular tubercle, improved exposure of the anterior aspect of the aneurysm. The suction tip is used to retract and protect the spinal accesso