海绵窦的内镜解剖以及手术入路

Transnasal endoscopic anatomy and approaches to the cavernous sinus

目的 探讨内镜下海绵窦的解剖特点以及手术入路.方法 6例（12侧）新鲜尸头,有色硅胶灌注血管.行内镜经鼻-蝶入路和经筛-翼-蝶入路,完成蝶窦开放,蝶窦后壁切除,翼突部分切除和蝶窦外侧壁切除.充分暴露海绵窦及其周围结构.应用Stroz Image l高清系统采集图像.结果 颈内动脉海绵窦段穿行海绵窦将海绵窦分为5个部分,即内侧海绵窦、外侧海绵窦、海绵窦后上腔隙、海绵窦后下腔隙和海绵窦前下腔隙.海绵窦段颈内动脉的分支包括：脑膜垂体干、McConnell包膜动脉和下外侧干.颅神经Ⅲ、Ⅳ走行于海绵窦外侧壁的上部；颅神经Ⅴ1自Meckel腔向眶上裂斜行；颅神经Ⅵ自海绵窦后下腔隙底部从颈内动脉后膝部的内侧绕行到外侧,穿过海绵窦窦腔,向外上前至眶上裂.内镜经鼻海绵窦手术入路分为经蝶-鞍-内侧海绵窦入路（颈内动脉内侧入路）和经筛-翼-蝶-外侧海绵窦入路（颈内动脉外侧入路）.前者可以暴露海绵窦段颈内动脉的内侧部,部分海绵窦后上、后下腔隙.后者可以暴露海绵窦前下腔隙、外侧海绵窦以及外侧壁的颅神经.结论 海绵窦的解剖非常复杂,颈内动脉以及颅神经Ⅲ、Ⅳ、Ⅴ1、Ⅵ穿行其内,与周同重要静脉窦相交通.熟悉掌握内镜下海绵窦解剖以及手术入路对于内镜下处理海绵窦以及海绵窦相关的病变有重要意义.

Objective The goal of the current study is to describe the transnasal endoscopic anatomy of the cavernous sinus and to provide the surgical approaches to this area.Methods Six siliconinjected adult cadaveric heads （12 sides） were dissected through endoscopic endonasal approach.The cavernous sinus and adjacent structures were exposed; detailed anatomies were demonstrated.High-quality pictures were produced.Results The cavernous sinus had four walls,namely medial,lateral,posterior and superior walls.Five venous spaces within the sinus were identified by their relation to the carotid artery;those were the medial,lateral,posterosuperior,posteroinferior and anterolateral compartments.Three branches arising from the cavernous segment of internal carotid artery from proximal to distal were meningohypophyseal trunk,inferolateral trunk and McConnell capsular artery.Cavernous sinuses communicated each other by intercavernous sinuses,as well as basilar sinus in middle line,and connected with superior and inferior petrosal sinuses.The third and fourth nerves coursed in superior part of the lateral wall of the cavernous sinus; Meckel＇s cave located in the posteroinferior part of the lateral wall of the cavernous sinus; Ⅴ1 sloped to the superior orbital fissure along the lateral wall; the sixth nerve entered the posteroinferior compartment then passed through the internal carotid artery and reached to superior orbital fissure.The approaches to the cavernous sinus included trans-sphenoid-sellar-medial cavernous sinus （medial to the internal carotid artery） and trans-ethmoid-pterygoid-sphenoid-lateral cavernous sinus （lateral to the internal carotid artery）.Trans-sphenoid-sellar-medial cavernous sinus approach was able to expose medial compartment and posterosuperior compartment and part of posteroinferior compartment.Transethmoid-pterygoid-sphenoid-lateral cavernous sinus approach was able to expose anterioinferior compartment,lateral cavernous sinus and cranial nerves in lateral wall.Conclusion An understanding of the complex relationships of the cavernous segment of internal carotid artery and cranial nerves in cavernous sinus is paramount for surgically dealing with the disease involved cavernous sinus and adjacent region.