Thieme图解｜脑干丘脑等解剖

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Fig.2.1Thalamus.(a)Medialview.Thethalamusformsthesuperiorpartofthelateralwallofthethirdventricle.Thehypothalamicsulcusistheborderbetweenthethalamusaboveandhypothalamusbelow.(b)Superolateralviewofthepositionofthethalamusinthelateralventricle.Thethalamusislocatedinthecenterofthelateralventricleattheupperendofthebrainstem.Theanteriorthalamicnucleus(tubercle)formstheposterioredgeoftheforamenofMonro.(c)Superiorview.Theuppermarginofthethalamusformsthelateralpartsofthefloorofthelateralventricle.Thestriaterminalisandthalamostriateveinrunalongthestriathalamicsulcus.(d)Thefornixwrapsaroundthemedialedgeofthethalamus,andthecaudatenucleuswrapsaroundthelateraledgeofthethalamus.(e)Posterolateralview.Theleftthalamuswasremovedtoexposethesubthalamicnucleusandrednucleus.Thepulvinaristheposterolateralpartofthethalamus.(f,g)Superiorandlateralviewsofthearterialsupplyofthethalamus.(h,i)Superiorandlateralviewsofthevenousanatomyofthethalamus.Theventricularveinsaredividedintomedialandlateralgroups.TheventricularveinsdrainintotheinternalcerebralandbasalveinsandtheveinofGalen.Thelateralgroupconsistsoftheanteriorcaudateveininthefrontalhorn;thethalamostriate,posteriorcaudate,andthalamocaudateveinsinthebody;thelateralatrialveinsintheatriumandoccipitalhorn;andtheinferiorventricularandamygdalarveinsinthetemporalhorn.Themedialgroupisformedbytheanteriorseptalveininthefrontalhorn,theposteriorseptalveinsinthebody,themedialatrialveinsintheatrium,andthetransversehippocampalveins(notshown)inthetemporalhorn.Thetransversehippocampalveinsdrainintotheanteriorandposteriorlongitudinalhippocampalveins.Thesuperiorchoroidalveinsdrainintothethalamostriateandinternalcerebralveins,andtheinferiorchoroidalveindrainsintotheinferiorventricularvein.TheveinofGalendrainsintothestraightsinus.Abbreviations:Ant.thal.nucl.,anteriorthalamicnucleus;call.,callosum;Caud.,caudate;Chor.,choroid;Collat.,collateral;Corp.,corpus;fiss.,fissure;For.,foramen;Front.,frontal;gl.,gland;Hypothal.,hypothalamic;Lat.vent.,lateralventricular;nucl.,nucleus;pell.,pellucidum;plex.,plexus;Quad.,quadrigeminal;Sept.,Septum;STN.,subthalamicnucleus;Str.,stria;Str.thal.sulc.,striathalamicsulcus;sulc.,sulcus;term.,terminalis;vent.,ventricle.(Fig.2.1a-edissectionswerepreparedbyKaanYağmurlu,MD.ReproducedwithpermissionfromtheRhotonCollection(http://rhoton.ineurodb.org),CCBY-NC-SA4.0(http://creativecommons.org/licenses/by-nc-sa/4.0).Fig.2.1f-i

Fig.2.2Anatomicalrelationshipofthepinealregiontosurroundingstructures.(a)Righthemisphereshowingtherelationshipbetweenthetentoriumandfalxcerebriandthestraightsinus,whichliesbetweenthem.(b)Medialviewshowingexposureofthepinealregionandsurroundingstructures.(c)EnlargedviewofFig.2.2b.ThepinealglandispositionedinferiortotheveinofGalen.TheinternalcerebralveinsrunningthroughtheveluminterpositumandthebasalveinsofRosenthalcometogethertoformtheveinofGaleninthesubsplenialarea.(d)Superiorview.Thebodyofthefornixandthehippocampalcommissurehavebeensplittoexposetheinternalcerebralveinandmedialposteriorchoroidalarteryintheveluminterpositum.(e)Posteriorview.Thepinealglandanditsrelationshiptodeepvenousstructures.Abbreviations:A.,artery;Cer.,cerebral;Chor.,choroidal;Gl.,gland;Int.,internal;Lat.,lateral;Med.,medial;Post.,posterior;S.,Sinus;Sag.,sagittal;Sup.,superior;Occ.,occipital;V.,vein;Vent.,ventricle;Verm.,vermian.(DissectionspreparedbyKaanYağmurlu,MD.ReproducedwithpermissionfromtheRhotonCollection(http://rhoton.ineurodb.org),CCBYNC-SA4.0(http://creativecommons.org/licenses/by-nc-sa/4.0).)

Fig.2.3Surgicalapproachestothepinealregionandthalamus.Thesurgicalroutestothepinealregion(yellowlines)orthalamus(dashedgreenarrows)canbeclassifiedasfromabove,frombelow,andfromlateral(transcortical).Insetsindicatepatientorheadpositioningandcraniotomyoptionsforthefourindicatedsurgicalapproaches.(DissectionpreparedbyKaanYağmurlu,MD.ReproducedwithpermissionfromtheRhotonCollection(http://rhoton.ineurodb.org),CCBY-NC-SA4.0(http://creativecommons.org/licenses/by-nc-sa/4.0).InsetsareusedwithpermissionfromBarrowNeurologicalInstitute,Phoenix,Arizona.)

Fig.2.4Cranialnerves.(a)Superolateralview.Thecourseofthecranialnerves(CNs)throughtheskullbasewasexposed,showingthelocationswhereCNsIIIthroughXIIariseinorexitfromthebrainstem.(b)AnteriorviewofthebrainstemshowingtheoriginsofCNsIIthroughXII(CNIVnotshown).(DissectionspreparedbyKaanYağmurlu,MD.ReproducedwithpermissionfromtheRhotonCollection(http://rhoton.ineurodb.org),CCBY-NC-SA4.0(http://creativecommons.org/licenses/by-nc-sa/4.0).)

Fig.2.5Bloodsupplyofthebrainstem.(a)Anteriorviewofthebrainstemwithoutvessels.(b)Anteriorview.Theposteriorinferiorcerebellararteries(PICAs)arisefromthevertebralarteries(VAs)atthemedullarylevelandcoursealongsidetheglossopharyngeal(cranialnerve[CN]IX),vagus(CNX),spinalaccessory(CNXI),andhypoglossal(CNXII)nerves.ThetwoVAscometogethertoformthebasilarartery(BA),frequentlyatthelevelofthepontomedullaryjunction.TheBAgivesoffthebasilarperforatorsthatsupplytheventralpons,anditgivesofftheanteriorinferiorcerebellarartery(AICA)incloseproximitytotheabducens(CNVI),facial(CNVII),andvestibulocochlear(CNVIII)nerves.(c)Thesuperiorcerebellarartery(SCA)arisesatthemidbrainlevelandencirclesthebrainstemnearthepontomesencephalicjunction.TheSCAcoursesinferiortotheoculomotor(CNIII)andtrochlear(CNIV)nervesandsuperiortothetrigeminal(CNV)nerve.TheSCAcoursesalongthemidbrain,cerebellomesencephalicfissure,superiorcerebellarpeduncle,andtentorialsurfaceofthecerebellum.TheAICAliesincloseproximitytothepons,middlecerebellarpeduncle,cerebellopontinefissure,andpetrosalsurfaceofthecerebellum.ThePICAliesincloseproximitytothemedulla,inferiorcerebellarpeduncle,cerebellomedullaryfissure,andsuboccipitalsurfaceofthecerebellum.(d)Medialview.TheSCAcoursesalongthesuperiorhalfoftheroofofthefourthventricle;thePICAcoursesalongtheinferiorhalfoftheroof;andtheAICAisintimatelyrelatedtothelateralrecessandtheforamenofLuschka.Abbreviations:Cerebellomed.,cerebellomedullary;Cerebellomes.,cerebellomesencephalic;ICP,inferiorcerebellarpeduncle;MCP,middlecerebellarpeduncle;PCA,posteriorcerebralartery;Pontomed.,pontomedullary;Pontomes.,pontomesencephalic;Sulc.,sulcus;Tr.,tract.(DissectionspreparedbyKaanYağmurlu,MD.ReproducedwithpermissionfromtheRhotonCollection(http://rhoton.ineurodb.org),CCBY-NC-SA4.0(http://creativecommons.org/licenses/by-nc-sa/4.0).)

Fig.2.6Thelongtractsofthebrainstem.(a)Lateralview.Themediallemniscus(ML)andmediallongitudinalfasciculus(MLF)wereexposed.TheMLascendsfromthegracileandcuneatetuberclestothethalamus.Inthemidbrain,itascendsdorsaltothecerebralpeduncleandsubstantianigra,ventrolateraltotherednucleus,andlateraltothesubthalamicnucleus,toterminateinthethalamus.Inthemedulla,theMLFislocatedjustbehindthepyramidsformedbythecorticospinaltractsthatdescendintheventralmedulla.TheMLFcurvesventrallyattheloweredgeofthefacialcolliculusandpassesventraltothehypoglossaltriangle.ItcrossestheMLatthelevelofthegracileandcuneatetuberclesanddescendsintheventralfuniculusofthespinalcord.TheoliveislocatedlateraltotheML.(b)Anteriorviewdemonstratingtherelationshipsbetweenthecerebralpeduncle,ML,andcorticospinaltractinthepons.TheventralfibertractsinthelefthalfoftheponshavebeenremovedtoexposetheML.(c)Posteriorviewofthedorsalpontinetracts:theMLF,trigeminalmesencephalictract(TMT),andtrigeminalspinaltract(TST).TheMLFcoursesadjacenttothemidlinenearthefloorofthefourthventricleandpassesmedialtotheabducensnucleusandintrapontinesegmentofthefacialnerve.ThetrigeminalnervedividesintotherostrallydirectedTMTandthecaudallydirectedTST.(d)Posteriorview.Thepartsofthedorsalponsandmidbrainhavebeenremoved,leavingtherightcentraltegmentaltract(CTT),whichconnectstherednucleusandtheolive.Inthemidbrain,theCTToriginatesfromthedorsomedialpartoftherednucleusanddescendsipsilaterallybetweenthesuperiorcerebellarpedunclelaterally,theMLFmedially,andtheMLventrally.Atthelevelofthefacialcolliculus,theCTTcoursesmedialtotheintrapontinesegmentsofthefacialnerveandcourseslateraltotheintrapontinesegmentoftheabducensnervetoterminateintheolive.Abbreviations:CN,cranialnerve;Corticospin.,corticospinal;Frontopon.,frontopontine;Hypogl.,hypoglossal;Lemn.,lemniscus;Med.,medial;Nucl.,nucleus;Pontomed.,pontomedullary;SCP,superiorcerebellarpeduncle;Spin.,spinal;Subst.,substantia;Sup.,superior;TPOPon.,temporoparieto-occipitopontine;Tr.,tract;Tub.,tubercle.(DissectionspreparedbyKaanYağmurlu,MD.ReproducedwithpermissionfromtheRhotonCollection(http://rhoton.ineurodb.org),CCBY-NC-SA4.0(http://creativecommons.org/licenses/by-nc-sa/4.0).)

Fig.2.7Surface,internalanatomy,safeentryzones,andsurgicalexposuresofthemidbrain.(a)Leftlateralview.Theupperandlowerlimitsofthemidbrainhavebeenexposed.(b)Theventralanddorsalpartsofthemidbrain,mediallemniscus(ML)andlateralmesencephalicsulcus(LMS,thickyellowline)havebeenexposed.TheLMSextendsalongthelateraledgeoftheML.(c)Midbrainaxialsection.EntryintotheLMSatarightangle(dashedgreenarrow)tothetectalsurface(dashedwhitelines)reachesthedorsalmidbrain.Angling45°forward(dashedbluearrow)willreachtheML.ThesubstantianigraislocatedalongtheanteriorsurfaceoftheML.(d)ThesubtemporalexposureoftheLMS.Insetshowslocationofthecraniotomy(yellowrectangle).(e)ThelateralinfratentorialsupracerebellarexposureoftheLMS.Insetshowslocationofcraniotomy(yellowcircle).(f)Posteriorviewofthetectalplateandthesupracollicular,infracollicular,andintercollicularsafeentryzones(yellowlines).(g)Posteriorview.Furtherdissectionofthetectalplate.Thesuperiorandinferiorcolliculihavebeenremovedontherightsidetoexposetheaqueduct,animportantlandmarkattheventrallimitofthesupracollicular,infracollicular,andintercollicularapproaches.Thenucleiofthesuperiorandinferiorcolliculihavebeenexposedontherightside.(h)Posteriorviewafterremovalofthethalami.Inthemidbrain,theMLascendsventrolateraltotherednucleusandlateraltothesubthalamicnucleustoenterthethalamus.Therednucleusextendsfrommidleveloftheinferiorcolliculustothelateralwallofthethirdventricle.Thesubthalamicnucleusislocatedjustventraltotherednucleusanddorsomedialtotheinternalcapsule.(i)Paramedianinfratentorialsupracerebellarapproachtothedorsalmidbrainandcollicularsafeentryzones.Yellowlinesindicatethesupracollicular,infracollicular,andintercollicularsafeentryzones.Insetshowslocationofcraniotomywithduraexposed.(j)Anteriorviewofthemidbrain.Theperioculomotorandinterpeduncularfossasafeentryzones(yellowovals)havebeenexposed.(k)Theperioculomotorzoneisborderedsuperiorlybytheposteriorcerebralartery(PCA),andinferiorlybythesuperiorcerebellarartery(SCA).(l)Superiorview.Thecontralateralorbitozygomatictrajectory(dashedgreenarrow)tothelesion(redsquare)locatedinthecentromedianmidbrainandtheipsilateralorbitozygomaticroute(dashedyellowarrow)forreachingtheperioculomotorzoneareshown.(m)Theorbitozygomaticormini-orbitozygomaticexposureoftheperioculomotorzone(yellowoval).Insetindicatesheadposition.(n)Thecontralateraltrajectoryforreachingtheinterpeduncularzonepassesthroughtheopticocarotidtriangle(insetindicatesheadposition)(o)Afterpassingthroughtheopticocarotidtriangle,theinterpeduncularfossaisreachedbetweenthebasilartipandmammillarybody.Abbreviations:A.,artery;Cer.,cerebri;CN,cranialnerve;Coll.,colliculus;Contralat.,contralateral;Corticospin.,corticospinal;Gen.,geniculate;Gl.,gland;ICA,internalcerebralartery;Inf.,inferior;Interped.,interpeduncular;Ipsilat.,ipsilateral;Lat.,lateral;Lemn.,lemniscus;Mamm.,mammillary;Med.,medial;Mes.,mesencephalic;Nucl.,nucleus;Periocc.,perioculomotor;Pontomes.,pontomesencephalic;Post.Perf.Subs.,posteriorperforatedsubstance;Sulc.,sulcus;Sup.,superior;STN,subthalamicnucleus;Temp.,temporal;Tr.,tract;V.,vein.(DissectionspreparedbyKaanYağmurlu,MD.ReproducedwithpermissionfromtheRhotonCollection(http://rhoton.ineurodb.org),CCBY-NC-SA4.0(http://creative-commons.org/licenses/by-nc-sa/4.0).)

Fig.2.8Surface,internalanatomy,safeentryzones,andsurgicalexposuresofthepons.(a)Lateralsurfaceofthepons.Thesupratrigeminalentryzone(blueoval),peritrigeminalentryzone(yellowoval),andmiddlecerebellarpeduncleentryzone(greenoval)areshown.(b)Criticalstructuresattheperitrigeminalandsupratrigeminalsafeentryzonesareexposedbyfurtherdissectionoftheleftventralpons.(c)Axialsectionofthepons.Themiddlecerebellarpedunclezonecanbeeasilyreachedbysplittingthepetrosalfissureofthecerebellum(greenarrow)toremovethecentralpontinelesion(yellowcircle).Theredarrowindicatestheroutetothecentralponswithoutsplittingthepetrosalfissurethatrequiresmorecerebellarretraction.(d)Rightretrosigmoidviewasseenwhenthepatientisinasittingposition.Insetshowsheadpositionwithverticallinemarkingskinincision.(e)Thetechniqueforsplittingthepetrosalfissuretoexposethemiddlecerebellarpeduncle(greenoval)isshown.(f)Leftretrosigmoidapproachtotheperitrigeminalzone,asseenwhenthepatientisinasittingposition.Insetshowsheadpositionwithskinincisionmarkedforthecraniotomy.(g)Theleftpresigmoidapproachcanbeusedtoexposetheperitrigeminalzone(yellowoval).Insetshowsheadpositionwithcraniotomymarked(yellowrectangle).(h)Leftsubtemporaltranstentorialapproachforexposureofthesupratrigeminal(greenoval)andperitrigeminal(yellowoval)zones.Insetshowsheadpositionwithcraniotomymarked(yellowrectangle).(i)Leftanteriorpetrosectomy(Kawaseapproach)forexposureofthesupratrigeminal(greenoval)andperitrigeminal(yellowoval)zones.Insetshowsheadpositionwithcraniotomymarked(yellowrectangle).(j)Dorsalponsandfloorofthefourthventricle.Whitedashedcircleindicatesextentoflateralrecess.WhitedashedVshapeindicatestheborderofthemedullarypartofthefourthventricle.(k)Posteriorviewofthefacialcolliculi.(l)Posterolateralviewofthefacialcolliculi.Thefacialcolliculusoverliestheabducensnucleusandtheintrapontinesegmentsofthefacialnerve.(m)Thesuperiorfoveatriangle.Thesuperolateraledgeofthesuperiorfoveatriangleisalandmarkforthedeeplocationofthetrigeminalmotorandmainsensorynuclei(yellowcircle).Theapexofthesuperiorfoveatriangle(greendashedtriangle)islocatedatthesametransverselevelastherostraledgeofthefacialcolliculus(bluedashedline).Thelowerhalfofthesuperiorfoveatrianglemaybeincisedtoremovealesionlocatedatthelevelofthefacialcolliculus.(n)Thesuperiorfoveatriangle(yellowoval)andthesuprafacialandinfrafacialapproaches(greenareas)andtheirpositioninrelationtothefacialcolliculusareshown.(o)Themediansuboccipitalapproachisusedtoreachthefloorofthefourthventricle.(p)Thetelovelarincision(greendashedline)isperformedtoexposethefloorofthefourthventricle.(q)Thefacialcolliculusfrequentlymakesaprominenceonthefloor.(o-q)Insetsshowpatientpositioningandcraniotomylocation.Abbreviations:AICA,anteriorinferiorcerebellarartery;Aud.,auditory;Cerebellopont.,cerebellopontine;CN,cranialnerve;coll.,colliculus;Corticospin.,corticospinal;CTT,centraltegmentaltract;Ext.external;Fiss.,fissure;Flocc.,flocculus;Hypogl.,hypoglossal;Inf.,inferior;Intermed.,intermediate;Junct.,junction;Lat.,lateral;Lemn.,lemniscus;limit.,limitans;MCP,middlecerebellarpeduncle;Med.,medial,median;MLF,mediallongitudinalfasciculus;Nucl.,nucleus;Pontomed.,pontomedullary;Pontomes.,pontomesencephalic;rec.,recess;SCP,superiorcerebellarpeduncle;Sulc.,sulcus;Sup.,superior;TMT,trigeminalmesencephalictract;Tr.,tract;TST,trigeminalspinaltract;V.ofCPF,veinofcerebellopontinefissure;Vest.,vestibular.(DissectionspreparedbyKaanYağmurlu,MD.ReproducedwithpermissionfromtheRhotonCollection(http://rhoton.ineurodb.org),CCBYNC-SA4.0(http://creativecommons.org/licenses/by-nc-sa/4.0).Fig.2.8d,f,o-qinsetsareusedwithpermissionfromBarrowNeurologicalInstitute,Phoenix,Arizona.)

Fig.2.9Surface,internalanatomy,safeentryzones,andsurgicalexposuresofthemedulla.(a)TheanterolateralsulcussafeentryzonemakesuseofthedecussationofthecorticospinaltractbetweentherootletsofthehypoglossalnerveandtheC1nerveasapointofentry.Similarly,attheleveloftheolives(yellowoval)ontheanterolateralsurfaceofthemedulla,asafeentryzonelimitedmediallybytheanterolateralsulcus(yellowdashedline)andthepyramidsandposteriorlybytheposterolateralsulcuscanbeusedtoenterthemedullafordeeplesionsthatdonotreachapialsurface.Thelateralmedullaryzone(LMZ;yellowrectangle)throughtheinferiorcerebellarpedunclecanalsobeusedasasafeentryzone.(b)Theleftfarlateralviewtotheventralmedullaryentryzones.(c)ThedorsalmedullarysulciandtheLMZ(lightredareas)havebeenusedasentryzones.Abbreviations:CN,cranialnerve;ICP,inferiorcerebellarpeduncle;inter.,intermediate;lat.,lateral;med.,median;PICA,posteriorinferiorcerebellarartery;Post.,posterior;Sulc.,sulcus;VA,vertebralartery.(DissectionspreparedbyKaanYağmurlu,MD.ReproducedwithpermissionfromtheRhotonCollection(http://rhoton.ineurodb.org),CCBY-NC-SA4.0(http://creativecommons.org/licenses/by-nc-sa/4.0).)