圖2.1。在後窩的三個神經血管複叢中，每一個都包括三條小腦動脈中的一條，腦幹的三個部分中的一個，三個小腦梗中的一個，三個小腦麵中的一個，腦幹和小腦之間的三個裂隙中的一個，以及三組腦神經中的一組。上麵的複合體與SCA有關，中間的複合體與AICA有關，下麵的複合體與PICA有關。上部複合體包括SCA、中腦、小腦上梗、小腦後裂、小腦幕麵、動眼神經、滑車神經和三叉神經。中間複群包括異食癖、橋腦、小腦中梗、橋小腦裂、岩麵、外展神經、麵神經和前庭耳蝸神經。下複叢包括異食癖、髓質、小腦下梗、小腦髓裂、枕下麵，以及舌咽神經、迷走神經、副神經和舌下神經。SCA被分為四個節段:前側橋腦(綠色)、側橋腦(橙色)、小腦(藍色)和皮質(紅色)。每個段可以由一個或多個主幹組成，這取決於主幹線的分支級別。AICA分為四個部分:橋前(綠色)、橋髓外側(橙色)、絮凝結節(藍色)和皮質(紅色)。PICA被分為五個部分:前髓質(綠色)，側髓質(橙色)，扁桃體髓質(藍色)，端速扁桃體(黃色)和皮質(紅色)。 A.I.C.A., anteroinferior cerebellar artery; CN, cranial nerve; Fiss., fissure; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery.

圖2.2。A，腦幹和小腦動脈的前視圖。B，顱底後視圖，保留了顱神經和動脈。A和B, SCA出現在中腦水平，並環繞
腦幹附近的橋腦連接。SCA位於動眼神經和滑車神經下方，三叉神經上方。SCA在B處比在a處更靠近三叉神經。AICA在橋腦水平出現，經過外展神經、麵神經和前庭耳蝸神經。在A區，兩個aica通過外展神經的下方。在B區，左側外展神經經過AICA前麵，右側外展神經經過AICA後麵。pica起源於椎動脈髓質水平，與舌咽神經、迷走神經、副神經和舌下神經有關。sca的起源從一側到另一側是相當對稱的。 There is slight asymmetry in the level of origin of the AICAs and marked asymmetry in the level of the origin of the PICAs, especially in A. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; CN, cranial nerve; P.C.A., posterior cerebral artery; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery; Sp., spinal; Vert., vertebral.

圖2.3。小腦動脈的關係。A，後視圖，左小腦和部分右腦被切除。B，側位圖，切除左小腦，露出第四腦室。SCAs(黃色)與第四腦室頂上半部和小腦後腦裂密切相關;aica(橙色)與橋小腦裂和側隱窩密切相關;PICAs(紅色)與屋頂尾半部和小腦延髓裂密切相關。骶髂韌帶在三叉神經上方繞過中腦，分為吻側幹和尾側幹。這些主幹的分支深入小腦後腦裂，並發出小腦前動脈，這些動脈沿著小腦上梗延伸到齒狀核。PICAS起源於椎動脈，通過舌咽神經、迷走神經和副神經之間到達小腦髓裂。 After passing near the caudal pole of the tonsils, where they form a caudal loop, they ascend through the cerebellomedullary fissure, where they are intimately related to the caudal part of the ventricular roof. They pass around the rostral pole of the tonsil and through the telovelotonsillar cleft, where they form a cranial loop. In their course around the tonsils, they divide into medial and lateral trunks. They give off branches to the dentate nuclei near the superior pole of the tonsils. The AICAs arise from the basilar artery and pass near or between the facial and vestibulocochlear nerves and are intimately related to the cerebellopontine fissures, the flocculi, and the lateral recesses. The AICAs divide into rostral and caudal trunks before reaching the facial and vestibulocochlear nerves. The rostral trunk passes between the nerves and along the middle cerebellar peduncle near the cerebellopontine fissure. The caudal trunk passes below the nerves and near the lateral recess to supply the lower part of the petrosal surface. The AICA and the PICA give rise to the choroidal arteries, which supply the tela choroidea and attached choroid plexus. (From, Matsushima T, Rhoton AL Jr, Lenkey C: Microsurgery of the fourth ventricle: Part I—Microsurgical anatomy. Neurosurgery 11:631–667, 1982 [35].) A., artery; A.I.C.A., anteroinferior cerebellar artery; B., basilar; Ca., caudal; Cer., cerebellar; Cer. Med., cerebellomedullary; Cer. Mes., cerebellomesencephalic; Ch., choroid, choroidal; Coll., colliculus; Dent., dentate; F., foramen; Inf., inferior; Lat., lateral; Med., medial, medullary; Mid., middle; Nucl., nucleus; P.C.A., posterior cerebral artery; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Pl., plexus; Ro., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tr., trunk; V., vein; V.A., vertebral artery; Vel., velum.

圖2.4。模擬。小腦動脈，腦幹，小腦-腦幹裂。後外側的視圖。SCA繞過中腦進入小腦後腦裂，在那裏它發送穿孔分支進入中腦後側，位於上丘和下丘之間的一條線上，並沿上椎梗向下到達齒狀核。AICA環繞小葉、麵神經和前庭耳蝸神經。左異食癖穿過進入頸靜脈孔的神經根之間，在左側扁桃體的下極(已被切除)周圍尾側轉彎，然後上升，在扁桃體的上極與腦室頂下半部分交界處形成顱環。B,另一個標本。左小腦被切除了。SCA在周圍池和四頭池的下部繞過PCA下方的中腦，進入小腦後腦裂，並在裂的後唇盤旋，供應腦幕表麵。 The PICA arises from the vertebral artery, passes around the medulla, crosses the inferior cerebellar peduncle, and enters the cerebellomedullary fissure, where it passes along the inferior half of the ventricular roof, and exits the fissure to supply the suboccipital surface. The AICA passes laterally around the pons and above the flocculus. C, enlarged oblique view. The right PICA loops around the caudal and rostral poles of the tonsil. The left PICA dips below the level of the foramen magnum. D, posterior view after removing all of the cerebellum except for the right tonsil and dentate nucleus. A., artery; A.I.C.A., anteroinferior cerebellar artery; Caud., caudal; Cer. Med., cerebellomedullary; Cer. Mes., cerebellomesencephalic; Chor., choroid; CN, cranial nerve; Cran., cranial; Dent., dentate; Fiss., fissure; Flocc., flocculus; Inf., inferior; Mid., middle; Nucl., nucleus; P.C.A., posterior cerebral artery; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Plex., plexus; S.C.A., superior cerebellar artery; Sup., superior; Vent., ventricle; Vert., vertebral.

圖2.4。E和F.
小腦動脈，腦幹，
和小腦-腦幹裂。E, SCA穿過
三叉神經並進入小腦後腦裂，在那裏它將
分支沿上
神經梗向下發送到
齒狀核。異食癖在迷走神經和
副神經之間通過
，並在下足梗上經過
至
，到達小腦延髓
裂。F，
側隱窩的放大視圖。
小葉和脈絡膜叢
從
Luschka孔的
緣向外側投射到
橋小腦角，
在舌咽部
和迷走神經後麵，
在PICA上麵。舌下
小根起源於舌咽神經和迷走神經前麵的髓質，穿過椎動脈的後表麵。有些舌下根在異食癖起源的上方通過，有些在異食癖起源的下方通過。

圖2.5。模擬。小腦動脈。優越的觀點。A，兩個sca作為中腦水平的重複動脈出現並伴隨腦幹周圍的基底靜脈進入小腦後腦裂。它們經過動眼神經和滑車神經下麵三叉神經上麵。SCA幹與腦幹後外側滑車神經纏繞在一起。B，腦幹部分已經向下延伸到腦橋。雙側骶管的吻側和尾側幹直接從基底動脈的一側發出，並在三叉神經的外側上方通過。
C，腦幹部分已經延伸到中腦橋。將三叉神經、動眼神經和滑車神經分開，以便腦幹向後反射，暴露AICA和麵神經和前庭耳蝸神經。 Both AICAs pass below the abducens nerves and loop laterally toward the internal acoustic meatus. The left PICA loops upward in front of the pons between the facial and vestibulocochlear nerves and the AICA before turning downward to encircle the medulla. D, enlarged view. The right AICA loops laterally into the porus of the internal acoustic meatus, as occurs in approximately half of cases. The AICA has a premeatal segment that passes toward the meatus, a meatal segment that loops into the porus in about half of cerebellopontine angles, and a postmeatal segment that loops back to the brainstem. The vestibulocochlear nerve has been retracted to expose the nervus intermedius, which arises at the brainstem along the anterior surface of the vestibulocochlear nerve, has a free segment in the cerebellopontine angle, and joins the facial nerve as it proceeds laterally toward the meatus. The AICA gives rise to a recurrent perforating branch to the brainstem. A., artery; A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Bridg., bridging; Cer. Mes., cerebellomesencephalic; CN, cranial nerve; Fiss., fissure; Flocc., flocculus; Intermed., intermedius; Meat., meatal; Mes., mesencephalic; Nerv., nervus; P.C.A., posterior cerebral artery; Ped., peduncle; Perf., perforating; P.I.C.A., posteroinferior cerebellar artery; Premeat., premeatal; Rec., recurrent; S.C.A., superior cerebellar artery; Seg., segment; V., vein; Vent., ventrical; Vert., vertebral.

圖2.5。情況。小腦動脈。E,放大視圖。左耳鼻喉管起於基底動脈，向外側穿過內聽道孔，然後在麵神經和前庭耳蝸神經之間轉向內側。彎曲的異食癖在AICA和麵神經之間向上循環，然後向下轉動。F, AICA和進入內聽道的神經被分開了。異食癖先向上循環，然後向尾側旋轉，穿過迷走神經和副神經的細根。舌下神經起源於橄欖前的腦幹。舌下神經的其中一根細根在異食癖起源處盤旋向上，然後向下在舌下管處與其他細根彙合。 A bridging vein passes from the medulla to the jugular bulb. G, the section has been extended downward to the level of the medulla to show the perforating branches of the vertebral and basilar arteries entering the medullary pyramids and the lateral medulla. The glossopharyngeal, vagus, and accessory nerves arise dorsal to the olives. The hypoglossal nerve arises ventral to the olives and passes behind the vertebral arteries. H, the medullary section has been extended caudally. The level of the PICA origins from the vertebral arteries are asymmetric. The right PICA intermingles with multiple rootlets of the hypoglossal nerve, while the left PICA, which arises at a higher level, has only the upper hypoglossal rootlet stretched around it. The PICAs encircle the medulla and appear on the dorsal surface behind the fourth ventricle. The left is larger than the right vertebral artery.

圖2.6。SCA，小腦-後腦裂，和腦幕麵。優越的觀點。A, sca穿過中腦進入小腦後腦裂，在裂內經過一係列發夾狀轉彎後，繞過裂後唇到達腦幕表麵。四頭腦池的下部延伸至小腦後腦裂。帳篷的表麵從裂縫後麵的頂端向下傾斜。B,前上的觀點。左側SCA發生在一條重複動脈上。在最初的過程中，SCAs在腦幕邊緣下方橫向循環，但進一步向後，它們在腦幕邊緣下方內側進入小腦後裂。C,另一個小腦。 The SCAs loop into the cerebellomesencephalic fissure, where they undergo a series of hairpin turns before exiting the fissure to supply the tentorial surface. D, the posterior lip of the fissure has been retracted to expose the branches of the SCA within the fissure. Cer. Mes., cerebellomesencephalic; Cist., cistern; CN, cranial nerve; Coll., colliculus; Dup., duplicate; Fiss., fissure; Inf., inferior; P.C.A., posterior cerebral artery; Pet., petrosal; Quad., quadrigeminal; S.C.A., superior cerebellar artery; Str., straight; Sup., superior; Tent., tentorial; V., vein.

圖2.7。SCA的關係。A, SCA左側側麵視圖，切除部分小腦，顯示小腦上梗在齒狀核的終止。SCA主幹經過動眼神經和滑車神經下方和三叉神經上方，分為吻側幹和尾側幹。視神經束和旋短動脈環繞腦幹。小腦前動脈起源於小腦後腦裂，供應鄰近的小腦和下丘，並沿小腦上梗向齒狀核發出分支。上丘主要由異食癖供血。吻側和尾側主幹分裂為蚓動脈和外側動脈、內側動脈和中間半球動脈。B，切除小腦後腦裂上唇，顯示裂內分支。旋狀穿通動脈止於下丘和小腦上、中末梢交界處。 The precerebellar branches pass along the superior cerebellar peduncles to the dentate nucleus. The right half of the vermis is supplied by a large vermian artery and the hemispheric surface is supplied by medial, intermediate, and lateral hemispheric arteries. (From, Hardy DG, Peace DA, Rhoton AL Jr: Microsurgical anatomy of the superior cerebellar artery. Neurosurgery 6:10–28, 1980 [19].) A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; B., basilar; Bo., body; Ca., caudal; Cer., cerebellar; Circ., circumflex; Co., communicating; Coll., colliculus; Dent., dentate; Gen., geniculate; He., hemispheric; Inf., inferior; Int., intermediate; L., long; Lat., lateral; Med., medial; Nucl., nucleus; O., optic; P., posterior; P.C.A., posterior cerebral artery; Ped., peduncle; Ro., rostral; S., short; Sup., superior; Tr., trunk; V., ventricle or vertebral; Ve., vermian.

圖2.8。SCA關係。第一，左SCA是一條重複動脈。尾側重複幹在進入小腦後裂之前穿過三叉神經的吻側麵。B，右SCA在到達小腦後腦裂前緣之前不分為吻側幹和尾側幹。C，靠近原點處，SCA在動眼神經下方，遠端靠近進入小腦後裂的入口處，通過滑車神經下方。D,另一個SCA。一個大主幹直接從腦幹一側到腦半球表麵，而不進入腦裂，盡管它也向腦裂發出一些較小的分支。E，小腦後裂的後唇被切除第四腦室頂部的上半部分被打開。SCA產生穿過小腦上梗的穿孔分支，為齒狀核供血。 F, oblique posterior view of the SCA branches within the cerebellomesencephalic fissure and the quadrigeminal cistern. The SCA supplies the cisternal walls below the sulcus between the superior and inferior colliculi, and the PCA supplies the wall above this level. A.I.C.A., anteroinferior cerebellar artery; Br., branch; Caud., caudal; Cer. Mes., cerebellomesencephalic; Cist., cistern; CN, cranial nerve; Coll., colliculus; Fiss., fissure; Inf., inferior; Mid., middle; P.C.A., posterior cerebral artery; Ped., peduncle; Pet., petrosal; Quad., quadrigeminal; Rost., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tent., tentorial; Tr., trunk; Vent., ventricle.

圖2.9。A，右SCA起源於基底動脈作為一條雙動脈。喙側重複幹產生蚓部分支，提供蚓部和半球的鄰近部分。尾部的重複幹產生半球形的分枝。B,放大圖。在閉塞和分割三叉神經周圍的岩上靜脈時需要小心，因為SCA的分支可能與靜脈的支流交織在一起，如本例所示。足靜脈通常流入基底靜脈，與外側中腦靜脈彙合，並流入岩上竇。C，裂縫的邊緣已被收回，露出SCA的主幹和分支。D，小腦後裂的後唇被切除了。在裂隙內，SCA分支向下延伸至小腦上梗。 Some SCA branches pass above and some below the trochlear nerve. The SCA gives rise to a marginal branch that supplies some of the petrosal surface bordering the tentorial surface. Br., branch; Caud., caudal; Cer. Mes., cerebellomesencephalic; CN, cranial nerve; Fiss., fissure; Hem., hemispheric; Lat., lateral; Marg., marginal; Mes., mesencephalic; Ped., peduncle; Pet., petrosal; Rost., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tent., tentorial; Tr., trunk; V., vein; Verm., vermian.

圖2.10。SCA的樹幹。A, SCA的主幹在三叉神經上麵分叉形成吻側幹和尾側幹。主幹在滑車神經和腦幕邊緣的前外側經過，而遠端吻側幹在滑車神經和腦幕邊緣的上方通過，尾側幹在滑車神經和腦幕邊緣的下方通過。B、去掉幕邊後查看。三叉神經痛中最常見的壓迫三叉神經的是位於主幹與吻側主幹和尾側主幹交界處的SCA，在本例中位於三叉神經上方。在到達腦幕表麵之前，兩根主幹都深入小腦後腦裂。C，這個岩上靜脈有多個支流，它們與SCA的分支纏繞在一起。這些靜脈在到達三叉神經時通常需要凝固和分裂。除非小心翼翼地將動脈幹與靜脈支分開，否則在凝固岩上靜脈支的過程中SCA可能被清除。 D, this SCA has a duplicate origin in which both the rostral and caudal trunks arise directly from the basilar artery. Both trunks, at the anterolateral brainstem, pass below the tentorial edge and trochlear nerve and above the trigeminal nerve. At the posterolateral margin of the brainstem, the rostral trunk loops above the level of the trochlear nerve and tentorial edge. The caudal trunk rests against the posterior trigeminal root as the nerve passes below the anterior edge of the tentorium to enter Meckel’s cave. E, another SCA. The main trunk passes above the trigeminal nerve before bifurcating into rostral and caudal trunks. The main trunk courses below the trochlear nerve, but the rostral trunk loops upward medial to the nerve. The caudal trunk divides into a large hemispheric branch that supplies the tentorial surface and a marginal branch, which supplies some of the upper part of the petrosal surface. F, another SCA. The artery bifurcates below the oculomotor nerve. Both trunks pass below the trochlear nerve at the anterolateral margin of the brainstem and above the trochlear nerve distally at the entrance into the cerebellomesencephalic fissure. A., artery; Bas., basilar; Br., branch; Caud., caudal; Cer. Mes., cerebellomesencephalic; CN, cranial nerve; Fiss., fissure; Hem., hemispheric; Marg., marginal; Pet., petrosal; Rost., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tent., tentorial; Tr., trunk; V., vein.

圖2.11。AICA關係。腦幹和右側岩狀小腦表麵的前外側視圖。右耳蝸脊經過外展肌下方，在麵神經和前庭耳蝸神經之間，然後到達橋小腦裂和小腦岩麵。B，右髂脊起於椎基底連接處上方，穿過橋髓連接處下方，然後向上延伸至小腦中踝表麵。它穿過絮凝體上方，沿著橋小腦裂到達岩麵。C和D，小腦和腦幹被切除，以顯示aica與顱神經和內聽道的關係。C，左鼻翼間區經過外展神經的上方和麵神經和前庭耳蝸神經的下方，在那裏形成腦幹的循環穿孔支。SCA穿過三叉神經後根上方。D，右耳蝸袢進入入口孔，在麵神經和前庭耳蝸神經之間。 E, another brainstem and cerebellum. The right vertebral artery is a duplicate artery and gives rise to duplicate PICAs. The AICAs arise from the lower part of the basilar artery. The left AICA is larger than the right. The rostral duplicate PICA loops upward into the cerebellopontine angle. The left vertebral artery loops upward into the left cerebellopontine angle. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Caud., caudal; Cer. Pon., cerebellopontine; CN, cranial nerve; Dup., duplicate; Fiss., fissure; Flocc., flocculus; For., foramen; Mid., middle; P.C.A., posterior cerebral artery; Ped., peduncle; Perf., perforating; P.I.C.A., posteroinferior cerebellar artery; Pon., pontine; Rec., recurrent; Rost., rostral; S.C.A., superior cerebellar artery; Sp., spinal; Tent., tentorial; Vert., vertebral.

圖2.12。AICA關係。前視圖。切除斜坡及鄰近的枕骨和顳骨，露出腦幹前部、椎動脈和基底動脈、右側內聽道的麵神經和前庭耳蝸神經，以及右側舌下管中的舌下神經。左鼻竇袢進入入口孔。B，右側橋小腦角放大圖。AICA通過麵神經和前庭耳蝸神經之間。舌下神經在椎動脈的後表麵周圍伸展。椎動脈向上彎入橋小腦角，異食癖發生於此，與麵神經根出口區密切相關，是麵肌痙攣的常見表現。一個迷宮般的動脈起源於AICA。 C, another enlarged view of the right cerebellopontine angle. The labyrinthine artery passes laterally with the facial nerve. The PICA loops upward and contacts the lower margin of the facial nerve. The vein of the cerebellopontine fissure ascends to empty into the superior petrosal sinus. D, the left AICA passes below the abducens, facial, and vestibulocochlear nerves and loops into the porus where it gives off two labyrinthine branches. Some of the hypoglossal rootlets are stretched over the PICA. The posterior trigeminal nerve was divided behind Meckel’s cave. The proximal stump arises from the midpons and the distal portion enters Meckel’s cave. A., artery; Ac., acoustic; A.I.C.A., anteroinferior cerebellar artery; Cer. Pon., cerebellopontine; CN, cranial nerve; Fiss., fissure; Labyr., labyrinthine; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; Prox., proximal; S.C.A., superior cerebellar artery; Sup., superior; V., vein; Vert., vertebral.

圖2.13。右CPA中A、AICA關係經乙狀竇後法分析。AICA在麵神經和前庭耳蝸神經之間橫向穿過，並向內側轉向，沿小腦中梗和橋小腦裂前進。三叉神經後方有一條巨大的岩上靜脈，有多條支流，包括橋三叉神經、橋橫靜脈和橋小腦裂靜脈。小葉隱藏了麵神經和前庭耳蝸神經與腦幹的連接處。B，小葉和脈絡膜叢，從Luschka孔突出，已經被抬起，暴露麵神經和前庭耳蝸神經與腦幹的連接處，在那裏麵神經在前庭耳蝸神經下麵。AICA分支由弓下動脈和迷宮動脈組成。C，解剖器抬高前庭耳蝸神經以更清楚地確定麵神經與腦幹的交界處。麵神經與腦幹的連接處較容易暴露於前庭耳蝸神經下方而非上方。D口後壁已被切除露出了口內壁的硬腦膜。 E, the meatal dura has been opened and the vestibulocochlear nerve displaced downward to expose the facial nerve coursing anterior and superior within the meatus. The nervus intermedius, which arises on the anterior surface of the vestibulocochlear nerve and passes laterally to join the facial nerve, is composed of several rootlets, as is common. F, the cleavage plane between the superior and inferior vestibular nerves has been developed. The cochlear nerve is located anterior to the inferior vestibular nerve. A., artery; A.I.C.A., antero- inferior cerebellar artery; Cer. Mes., cerebellomesencephalic; Cer. Pon., cerebellopontine; Chor., choroid; CN, cranial nerve; Coch., cochlear; Fiss., fissure; Flocc., flocculus; Inf., inferior; Intermed., intermedius; Labyr., labyrinthine; N., nerve; Nerv., nervus; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; Plex., plexus; Pon., pontine; S.C.A., superior cerebellar artery; Subarc., subarcuate; Sup., superior; Trans., transverse; Trig., trigeminal; V., vein; Vest., vestibular.

圖2.14。神經相關動脈與橋小腦角神經的關係圖。神經的方向如圖腦幹右側中央圖所示。三叉神經起源於腦橋。麵神經、前庭耳蝸神經和中間神經的方向如圖所示。上動脈、前上動脈等術語是指動脈和神經的關係。在50名注冊會計師中發現的動脈和動脈節段的數量是根據它們與神經的位置關係列出的。最常見的部位為口前段、下前段;道的段差;posteroinferior postmeatal段; internal auditory artery origin and course, inferior and anteroinferior; recurrent perforating artery origin, inferior and anteroinferior, and course, superior and between; and subarcuate artery origin, posterior, and course, posterosuperior. (From, Martin RG, Grant JL, Peace DA, Theiss C, Rhoton AL Jr: Microsurgical relationships of the anterior inferior cerebellar artery and the facial-vestibulocochlear nerve complex. Neurosurgery 6:483–507, 1980 [34].) c., course; I.A.A., internal auditory artery; Mea., meatal; o., origin; R.P.A., recurrent perforating artery; S.A., subarcuate artery; Seg., segment.

圖2.15。A和b異食癖的片段。劣質的視圖。左側扁桃體在扁桃體梗的水平被切除，扁桃體梗與腦半球其餘部分的連接位置。髓前段(綠色)從椎動脈起點延伸到下橄欖。這段位於舌下神經的細根的吻側或尾側或之間。外側髓段(橙色)從橄欖樹最突出的部分延伸到舌咽神經、迷走神經和副神經的根的水平。扁桃體髓段(藍色)從扁桃體尾半部分周圍的後端神經水平延伸，常形成尾側凸環。端速扁桃體段(黃色)從扁桃體中段延伸到位於脈絡膜背、上下髓質膜和下扁桃體上極之間的裂口出口。皮質段(紅色)從動脈及其分支出扁桃體、蚓部和腦半球之間的裂隙處延伸至皮質表麵。 The bifurcation of the main trunk into medial and lateral trunks is often located at the level of the tonsillomedullary or the telovelotonsillar segments. The medial trunk gives rise to median and paramedian vermian arteries. The lateral trunk gives rise to lateral, intermediate, and medial hemispheric and tonsillar arteries. B, enlarged posterior view. The left and part of the right halves of the cerebellum was removed to show the relationship of the PICA to the roof of the fourth ventricle. The dentate nucleus wraps around the superior pole of the tonsil. The telovelotonsillar fissure is below the inferior half of the roof of the fourth ventricle between the tonsil, tela choroidea, and inferior medullary velum. The caudal loop of the PICA is near the caudal pole of the tonsil, and the cranial loop is above the rostral pole of the tonsil. A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; B.A., basilar artery; Cer., cerebellar; Ch., choroid; Coll., colliculus; F., foramen; Fiss., fissure; He., hemispheric; Inf., inferior; Int., intermediate; Lat., lateral; Med., medial, medullary; Mid., middle; Nucl., nucleus; Paramed., paramedian; P.C.A., posterior cerebral artery; Ped., peduncle; Pl., plexus; S.C.A., superior cerebellar artery; Seg., segment; Sup., superior; Ton., tonsillar; Tr., trunk; V.A., vertebral artery; Ve., vermian; Vel., velum.

圖2.15。C和d異食癖的片段。C,側麵圖。髓前段經過舌下神經吻側。側髓段通過附屬細枝之間。扁桃體髓段在扁桃體下極附近形成一個顱凸環。端速扁桃體段形成顱凸環，並在其末端附近分叉為內側主幹和外側主幹。皮質段橫跨枕下表麵。D,矢部分。扁桃體髓和端速扁桃體段將脈絡膜分支送入脈絡膜叢。 The telovelotonsillar segment ascends between the nodule and uvula medially and the tonsil laterally. (From, Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery 10:170–199, 1982 [30].)

圖2.16。異食癖的關係。A，異食癖穿過髓質，進入小腦髓裂，並從裂出供應枕下表麵。裂縫向上延伸在一側的小腦扁桃體和另一側的髓質和腦室頂下半部分之間。pica常在小腦扁桃體的下極形成尾狀環。B,放大圖。左側扁桃體被切除，以暴露異食癖在小腦髓裂內的過程。pica通常繞著扁桃體吻端向上循環，在扁桃體吻端(下側)和脈絡膜端(上側)和下髓膜之間運動。C，切除扁桃體和雙側小葉的相鄰部分，暴露異食癖幹。pica分為內側幹和尾幹，內側幹提供蚓部和半球的鄰近部分，尾幹環繞扁桃體提供半球表麵的最大部分。 Choroidal branches pass to the tela choroidea and choroid plexus in the roof. The vein of the cerebellomedullary fissure crosses the tela and velum and passes above the flocculus to join the veins in the cerebellopontine angle that empty into the superior petrosal sinus. D, another dissection showing the relationship of the cranial loop of the PICA to the tonsils and inferior medullary velum. Both tonsils and the nodule and uvula have been preserved. The inferior medullary velum has been preserved on the right side. The left half of the inferior medullary velum has been removed to expose the supratonsillar loop of the PICA, which courses between the velum and the tonsil. The velum stretches laterally from the nodule across the rostral pole of the tonsil to blend into the flocculus. A., artery; A.I.C.A., antero- inferior cerebellar artery; Br., branch; Cer. Med., cerebellomedullary; Cer. Mes., cerebellomesencephalic; Chor., choroidal; CN, cranial nerve; Fiss., fissure; Flocc., flocculus; Inf., inferior; Lat., lateral; Med., medial, medullary; Mes., mesencephalic; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery; Tr., trunk; V., vein; Vel., velum; Vent., ventricle; Verm., vermian; Vert., vertebral.

圖2.17。異食癖分岔的位置，與扁桃體和枕骨大孔相關的尾側環，以及顱環。A，與扁桃體相關的分叉部位。異食癖的主幹可在扁桃體邊緣的任何部位分叉。下外側分支(紅色):外側幹向扁桃體外側向上穿過，到達半腦，內側幹沿扁桃體前內側緣穿過。內下分支(綠色):外側幹上外側穿過扁桃體後緣到達半球表麵，內側幹沿扁桃體前內側緣向上穿過。超內側分支(藍色):外側幹向後穿過扁桃體內側表麵，內側幹向上提供蚓部。上外側分支(黃色):外側幹從扁桃體和腦半球之間的裂隙中出來，並向前延伸至腦半球表麵，內側幹向上提供蚓部。B，尾袢與扁桃體的位置。扁桃體髓段在穿過髓質後表麵時，常形成尾側凸環(藍色、橙色、綠色)。 This caudal part of the tonsillomedullary segment was located between 10.0 mm inferior and 13.0 mm superior (average, 1.6 mm superior) to the caudal tip of the tonsil. This loop could be found superior to (orange), inferior to (green), or at the level of (blue) the caudal tip of the tonsil. In some cases (yellow), the PICA ascended from the vertebral artery (V.A.) or took another course to reach the medial surface of the tonsil without forming a caudal loop. C, relation of the caudal loop to the foramen magnum. Most caudal loops were superior to the foramen magnum (yellow), but they could be inferior to (red) or at the level of (green) the foramen magnum. The caudal loop was located between 7.0 mm inferior and 18.0 mm superior (average, 6.9 mm superior) to the foramen magnum. D, relationship of the cranial loop (arrow) to the superior pole of the tonsil and the trunks of the PICA. The right tonsil was removed at the level of the tonsillar peduncle to expose the inferior medullary velum and the tela choroidea. The telovelotonsillar segment often formed a cranially convex loop. below the fastigium. The cranially convex loop could be formed by either the main (green), medial (yellow), or lateral (blue) trunk. On the left (blue), the lateral trunk (arrow) forms a cranially convex loop over the superior pole of the tonsil and the medial trunk ascends straight to the vermis. In the center (yellow), the medial trunk (arrow) forms a cranially convex loop at the superior pole of the tonsil and the lateral trunk courses around the medial surface of the tonsil. On the right (green), the cranial loop is formed by the main trunk (arrow) and lies in the telovelotonsillar fissure anterior to the superior pole of the tonsil. (From, Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery 10:170–199, 1982 [30].) Inf., inferior; Lat., lateral; Med., medial, medullary; Ped., peduncle; Ton., tonsillar; Tr., trunk; V.A., vertebral artery; Vel., velum.

圖2.18。異食癖的關係。第一，小腦的右半部分被切除。右異食癖通過迷走神經和副神經的細根之間到達小腦下梗的表麵。左異食癖，由於它在扁桃體的吻端附近移動，被小舌剩下的左半邊所掩蓋。SCA穿過腦幹，在動眼神經下麵，三叉神經上麵。B，小舌的部分和扁桃體內側的結節已經被切除，暴露PICAs通道通過小腦髓裂和扁桃體周圍。動脈常在扁桃體下緣形成尾側袢，並在扁桃體吻側極周圍形成顱側或扁桃體上袢。C，扁桃體被切除，暴露異食癖通過小腦髓裂的循環過程。D，下髓質膜，它橫跨扁桃體的吻端，向下折疊露出齒狀結節，齒狀核下的齒狀突起。 The lateral recess is also exposed. The telovelotonsillar segment of the PICA courses in the cerebellomedullary fissure between the tela and velum on one side and the tonsil on the other side. Cer. Med., cerebellomedullary; Cer. Mes., cerebellomesencephalic; CN, cranial nerve; Cran., cranial; Dent., dentate; Fiss., fissure; Inf., inferior; Lat., lateral; Med., median, medullary; Mid., middle; Nucl., nucleus; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery; Sulc., sulcus; Sup., superior; Vel., velum.

圖2.19。腦幹和小腦的下視圖(上)顯示了椎動脈周長(右下)上50個小腦半球中42個pica起源的位置。右下圓對應椎動脈的周長。50個小腦半球中有8個沒有異食癖。異食癖最常發生於椎動脈的後、後外側或外側表麵，但也有少數起源於動脈的前半部分或內半部分。(來自，Lister JR, Rhoton AL JR, Matsushima T, Peace DA:小腦後下動脈的顯微外科解剖。神經外科10:17 - 199,1982[30]。

圖2.20。橋腦、髓質、椎動脈和基底動脈的前上(上)和前(下)視圖顯示了異食尼卡起始節段所采取的方向。在我們檢查的50個小腦半球中發現了42個pica。箭頭是開的，並定義pica的初始段所采取的方向，直接遠端於其原點。外展神經、麵神經和前庭耳蝸神經在橋髓連接處出現。舌咽神經、迷走神經和副神經起於下橄欖的後方，舌下神經起於下橄欖的前方。最初節段最常指向後、外側上、後外側或後內側。少數PICAS定向於上外側、下外側、前外側、後下、上內側、下內側或前。(來自，Lister JR, Rhoton AL JR, Matsushima T, Peace DA:小腦後下動脈的顯微外科解剖。神經外科10:17 - 199,1982[30]。 Ant., anterior; B.A., basilar artery; Inf., inferior; Lat., lateral; Med., medial; Post., posterior; Sup., superior; V.A., vertebral artery.

圖2.21。起源於硬膜外的雙側PICAs。A，兩種pica都發生在硬腦膜外，因為椎動脈經過寰枕關節後方。pica在背外側髓質水平進入硬腦膜，沒有前髓質或完整的外側髓質段。左異食癖在寰椎後弓前向下循環。B,放大圖。左側異食癖發出腦膜後動脈，通過椎動脈周圍的硬腦膜套穿過硬腦膜，在副神經和C1和C2根後向下循環，然後上升進入小腦髓裂。右側異食癖穿過硬腦膜，沿副神經細根前的髓質側行。C，左側異食癖伴椎動脈和C1神經根穿透硬腦膜套。副神經通過椎動脈和異食癖後方。 The rostral attachment of the dentate ligament ascends between the PICA and the vertebral artery to attach to the dura at the level of the foramen magnum. D, the C1 nerve root passes through the dural cuff with the vertebral artery and the PICA. The accessory nerve ascends posterior to both the vertebral artery and PICA. A small posterior spinal artery arises from the PICA and courses along the dorsolateral aspect of the spinal cord. A., artery; Atl., atlanto; CN, cranial nerve; Dent., dentate; Lig., ligament; Men., meningeal; Occ., occipital; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Sp., spinal; Suboccip., suboccipital; Vert., vertebral.

圖2.22。異食癖的關係。A，左側異食癖比右側大。兩種pica進入小腦延髓裂，繞過扁桃體，然後從裂出供應枕下表麵。右扁桃體和雙側小葉之間的天然裂口已經打開。扁桃體通過扁桃體梗與小腦的其餘部分相連，扁桃體梗是一個沿著扁桃體上外側邊緣的白質束。扁桃體的其他邊緣都是遊離邊緣。B,放大圖。左雙腹小葉被抬高，露出從側隱窩邊緣突出的小葉。C，扁桃體向外側收縮，暴露在小腦髓裂中的PICAs。 The right PICA bifurcates into medial and lateral trunks before reaching the cerebellomedullary fissure. The left PICA bifurcates within the fissure. The medial trunks supply the vermis and adjacent part of the hemisphere and the lateral trunks supply the remainder of the hemisphere. D, the right tonsil has been removed to expose the lateral recess and bifurcation of the right PICA into medial and lateral trunks. E, both tonsils and the tela have been removed to expose the ventricular floor and walls. The left PICA divides into its trunks within the cerebellomedullary fissure. The inferior medullary velum has been preserved, but is a thin layer that can be opened, if needed, to increase the exposure of the fourth ventricle. F, enlarged view showing the relationship of the PICAs to the fourth ventricle. The PICAs, after passing between the rootlets of the accessory rootlets course along the caudolateral margin of the fourth ventricle on the inferior cerebellar peduncle before entering the cerebellomedullary fissure. The left PICA has been reflected laterally. The facial colliculus is in the upper and hypoglossal and vagal nuclei are in the lower part of the floor. Bivent., biventral; Br., branch; Cer. Med., cerebellomedullary; CN, cranial nerve; Coll., colliculus; Fiss., fissure; Flocc., flocculus; Hem., hemispheric; Hypogl., hypoglossal; Inf., inferior; Lat., lateral; Med., medial, medullary; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Suboccip., suboccipital; Tr., trunk; Trig., trigeminal; V., vein; Vel., velum; Vent., ventricle; Verm., vermian.

圖2.23。A.後窩脈絡膜動脈示意圖。上側:後位或枕下位。脈絡膜叢由兩個內側段和兩個外側段組成。每個內側節分為吻側(結節狀)和尾側(扁桃體)部分。每個側段被分為內側，或梗，和外側，或絮凝，部分。髓質，第四腦室，椎動脈和PICAs的起源如下。脈絡膜動脈起源於PICA、SCA和AICA。脈絡膜叢與脈絡膜端相連，脈絡膜端沿著第四腦室底部的邊界與帶絛蟲相連。低:前外側的觀點。 The choroid plexus is seen through the brainstem. The AICA arises from the basilar artery and sends branches that enter the choroid plexus near the flocculus. The SCA may also send choroidal branches to the floccular part of the choroid plexus. Right Center: Diagram showing subdivision of the choroid plexus into medial and lateral segments. The medial segments have nodular and tonsillar parts and the lateral segments have peduncular and floccular parts. The floccular parts protrude through the foramina of Luschka, and the tonsillar parts extend through the foramen of Magendie. B. Schematic illustrations of the choroid plexus of the posterior fossa showing the different patterns of blood supply. Upper: Orienting diagram. The PICA and its plexal area of supply are shown in blue, the AICA in red, and the SCA in green. The PICA divides into vermian and tonsillohemispheric branches. Lower diagrams (A--D): The size of the area supplied by the arteries arising from the AICA, PICA, and SCA is shown. Each half of the schematic diagrams shows a different pattern. Colors used to show plexal areas of supply of the different cerebellar arteries are as follows: red: ipsilateral AICA; orange: contralateral AICA; blue: ipsilateral PICA; yellow: contralateral PICA; and green: ipsilateral SCA. (From, Fujii K, Lenkey C, Rhoton AL Jr: Microsurgical anatomy of the choroidal arteries: Fourth ventricle and cerebellopontine angles. J Neurosurg 52:504–524, 1980 [15].) A., artery; A.I.C.A., anteroinferior cerebellar artery; B.A., basilar artery; Ch., choroidal; F., foramen; fl., floccular; He., hemispheric; L., lateral; M., medial; Med., medulla; no., nodular; pe., peduncular; P.I.C.A., posteroinferior cerebellar artery; Pl., plexus; S.C.A., superior cerebellar artery; to., tonsillar; To., tonsillo; V.A., vertebral artery; Ve., vermian.

圖2.24。右側腦幹側位麵顯示異食癖的起源位置與下橄欖和舌下神經的小根有關。在我們檢查的50個小腦半球中發現了42個pica。舌咽神經、迷走神經和副神經的細根在橄欖的後方出現。舌咽神經和迷走神經出現在橄欖樹上三分之一的水平。附屬細枝生長在橄欖樹下三分之二及以下的水平。舌下神經的細根位於橄欖下三分之二的前方和略下方。兩個PICAS出現在橄欖的吻端三分之一處，12個出現在中間三分之一處，16個出現在尾部三分之一處，12個出現在橄欖的下方。橄欖樹前有二十棵，橄欖樹旁有二十二棵。椎動脈和位於橄欖樹旁的異食性骨骺端將舌下小根向後伸展，因為舌下小根總是在椎動脈後方通過。 (From, Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery 10:170–199, 1982 [30].)

圖2.25。異食癖與舌咽神經、迷走神經和副神經的細根的關係。A，插圖B到f的方向。插圖顯示頭皮皮瓣和顱骨切除術的位置。大圖顯示了小腦的收縮和麵神經，前庭耳蝸，舌咽神經，迷走神經，副神經和舌下神經。舌咽根、迷走根和附屬根在橄欖的後方生長，舌下根在橄欖的前方生長。脈絡叢和小葉延伸到橋小腦角在舌咽神經和迷走神經的後麵。異食癖起源於椎動脈，經過下(B和C)、上(E和F)或舌下神經根(D)之間。在50個小腦半球發現的42個pica中，16個通過副神經根(B)之間，13個通過迷走神經和副神經根(C)之間，
10個通過迷走神經根(D)之間，
2個通過舌咽神經和前庭耳蝸神經(E)之間，1在舌咽神經和迷走神經之間(F)。曲曲性異食性耳咽癌可能上行至舌咽神經和迷走神經的前方，壓迫和扭曲麵神經和前庭耳蝸神經，然後再後移至舌咽神經、迷走神經和副神經(E和F)之間。(來自，Lister JR, Rhoton AL JR, Matsushima T, Peace DA:小腦後下動脈的顯微外科解剖。)神經外科10:17 - 199,1982[30]。