圖4.1。右側橋小腦角的乙狀竇後神經暴露。A，前庭耳蝸神經通過AICA的一個迷路分支進入內聽道。異食癖發生在舌咽神經、迷走神經和副神經周圍。外展神經在腦橋前麵上升。弓形下動脈在入口孔上外側進入弓形下窩。脈絡膜叢在舌咽神經和迷走神經後麵伸入橋小腦角。B，內聲道的後壁已經被移除。由前庭上神經形成的上束和由前庭下神經和耳蝸神經形成的下束之間的解理平麵從外側開始，神經在耳底附近分離，並向內側延伸。中間神經起於前庭耳蝸神經的前表麵，在腦池和/或耳道有遊離段，並在遠端與麵神經相連。 The facial nerve is located anterior to the superior vestibular nerve and the cochlear nerve is anterior to the inferior vestibular nerve.
C, the cleavage plane between the cochlear and inferior vestibular nerves, which is well developed in the lateral end of the internal acoustic meatus, has been extended medially. Within the cerebellopontine angle, the superior vestibular nerve is posterior and superior, the facial nerve anterior and superior, the inferior vestibular nerve posterior and inferior, and the cochlear nerve anterior and inferior. D, the superior and inferior vestibular nerves have been divided to expose the facial and cochlear nerves. A labyrinthine branch of the PICA enters the internal meatus. A., artery; A.I.C.A., anteroinferior cerebellar artery; Chor. Plex., choroid plexus; CN, cranial nerve; Coch., cochlear; Flocc., flocculus; Inf., inferior; Intermed., intermedius; Labyr., labyrinth; N., nerve; Nerv., nervus; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; Subarc., subarcuate; Sup., superior; V., vein; Vest., vestibular.

圖4.2。側麵圖，右三叉神經。A, Meckel 's洞穴，池，它從後窩沿著三叉神經後根向前延伸到神經節中部，通過移除洞穴的外側硬腦膜壁暴露出來。運動根起源於感覺根的吻側，穿過後感覺根和神經節內側的Meckel 's穴。第二，硬腦膜被切除露出後根和神經節以及三叉神經的三個分支。在神經節後方的小根之間有彌漫性吻合。C, mekel’s cave區域彌漫性吻合的放大視圖。D，在感覺根的吻側邊緣周圍出現的四個運動根被抬高以暴露運動根和感覺根之間的吻合口。小腦唇向前突出，可能隱藏感覺根與乙狀結腸後入路腦橋的連接處。E，一個解理麵已經在前麵開始，並向後延伸到後根的水平。 The first-division fibers are rostromedial within the posterior root and the third-division fibers caudolateral with the second division being in an intermediate location. Cav., cavernous; Cereb., cerebellar; CN, cranial nerve; Gang., ganglion; Post., posterior; V., vein.

圖4.3。12張三叉神經圖顯示三叉神經感覺根、運動小根和進入腦橋部位的異常感覺小根之間的關係。中心圖是定位圖，顯示了感覺根的橢圓截麵。大橢圓(A-F)代表感覺根，其方向與中心圖中的感覺根相同。動力根的起源部位為黑色。上半身:右側神經。B中僅有5個運動小根，f中有13個。異常的感覺小根由中心清晰的深色輪廓所示。在C和E中，一些異常的細根比一些運動細根出現在離感覺根更遠的地方。下麵，左邊的神經。A中僅有4個運動小根，而B和c中有10個運動小根。 None are present in B and C. In A, D, E, and F, some aberrant rootlets arise farther from the sensory root than some of the motor rootlets. Lines through the oval representing the main sensory root show portions of the nerve from each of the three divisions. In all diagrams, the rostromedial portion is from the first division, the caudolateral portion is from the third division, and the second division is in an intermediate position. In all these nerves, except A and B in the left nerve, the second division fibers make up a greater portion of the medial than the lateral portion of the sensory root. Small arteries or veins coursing between the rootlets at the level of entry into the pons are shown in all diagrams of both nerves, except D in the right nerve (upper). (From, Gudmundsson K, Rhoton AL Jr, Rushton JG: Detailed anatomy of Surgical approach, the intracranial portion of the trigeminal nerve. J Neurosurg 35:592–600, 1971 [12].)

圖4.4。腦橋三叉神經橢圓截麵最長軸(虛線)與身體縱軸(實線)的變異性。大多數神經的長軸與身體的縱軸成40- 50度角(a);然而，這可以從10度(C)到80度(B)不等。在B區，第三區幾乎直接位於第一區的橫向，而在C區，它幾乎直接位於尾側。(From, Gudmundsson K, Rhoton AL Jr, Rushton JG:三叉神經顱內部分的詳細解剖。神經外科雜誌35:59 - 600,1971 [12]

圖4.5。左側三叉神經的側麵圖。神經鉤位於大的異常感覺根和主感覺根之間。異常的小根起源於腦橋，直接位於感覺根的外側，在距腦幹約1厘米處與感覺根相連。感覺根上方可見四個運動小根。(From, Gudmundsson K, Rhoton AL Jr, Rushton JG:三叉神經顱內部分的詳細解剖。神經外科雜誌35:59 - 600,1971 [12]

圖4.6。與主感覺根相關的異常感覺根的起源。大而清晰的橢圓形表示感覺根在進入腦橋水平的橫截麵。異常小根的起源是純黑色的。實線左側的所有神經都來自右側，其方向與圖4.3(上)所示的神經相同。線右邊的是左邊的，方向如圖4.3(下)所示。圖中F(右)下方箭頭所示的根原點與感覺根G相關，M(左)下方箭頭所示的根原點與感覺根o相關。圖中根的吻側緣在上，尾側緣在下。主感覺根尾側無異常感覺根。(From, Gudmundsson K, Rhoton AL Jr, Rushton JG:三叉神經顱內部分的詳細解剖。神經外科雜誌35:59 - 600,1971 [12]

圖4.7。右三叉神經與橋腦橋交界處的側麵圖。箭頭指向運動根和感覺根之間的中間纖維群。B，同樣的三叉神經。箭頭指向中間的纖維組，證明是一個運動根，當追蹤遠端。這說明了分辨中間的一組纖維是運動的還是感覺的困難，除非這些神經束可以分開並單獨檢查。(From, Gudmundsson K, Rhoton AL Jr, Rushton JG:三叉神經顱內部分的詳細解剖。神經外科雜誌35:59 - 600,1971 [12]

圖4.8。乙狀結腸後入路至三叉神經行微血管減壓手術。A，(左上)，患者俯臥四分之三位。外科醫生坐在桌子的頭。桌子是傾斜的，這樣腳就比心髒低。B，垂直中位切口穿過星號。開顱手術的上外側緣位於橫竇和乙狀竇的交界處。C，小腦的上外側邊緣被輕輕地抬高用一個從底部10毫米到頂端3或5毫米的錐形腦鏟來暴露三叉神經進入腦橋的位置。腦鏟向前並與岩上竇平行排列。滑車神經位於暴露的上緣，麵神經和前庭耳蝸神經位於下緣。 The dura is tacked up to the adjacent muscles to maximize the exposure along the superolateral margin of the cerebellum. The main trunk of the SCA loops down into the axilla of the trigeminal nerve. (From, Rhoton AL Jr: Microsurgical anatomy of decompression operations on the trigeminal nerve, in Rovit RL, Murali R, Jannetta PJ (eds): Trigeminal Neuralgia. Baltimore, Williams & Wilkins, 1990, pp 165–200 [34].) S.C.A., superior cerebellar artery; Sig., sigmoid; Sup., superior; Trans., transverse.

圖4.9。腦鏟在橋小腦角各間室手術中的應用方向。A，橋小腦角中部病變的外側暴露，如聽神經瘤。橫竇下方和乙狀竇內側的開顱手術切除聽神經瘤或其他累及多個神經血管複合體的病變。打開貯水池，取出腦脊液，小腦放鬆後，刮刀保護小腦外側表麵。在切除大型腫瘤時，通常使用從底部20或25mm逐漸變細到尖端15或20mm的腦鏟，而切除小型腫瘤時則使用底部15mm逐漸變細到尖端10mm的腦鏟。B、三叉神經痛顯微血管減壓術中使用刮刀暴露上神經血管複叢。一般選用從底部10毫米到頂部3或5毫米的錐形刮刀。將刮刀與上岩竇平行放置。C，應用牽開器暴露下神經血管複合體。 This approach also is used in hemifacial spasm because the facial nerve root exit zone is located only a few millimeters above the glossopharyngeal nerve and the PICA is commonly a compressing vessel. A brain spatula tapered from 10 mm at the base to 3 or 5 mm at the tip is commonly used for operations for hemifacial spasm. (From, Rhoton AL Jr: Instrumentation, in Apuzzo MLJ (ed): Brain Surgery: Complication Avoidance and Management. New York, Churchill-Livingstone, 1993, vol 2, pp 1647–1670 [36].)

圖4.10。三叉神經與SCA的關係。A，三叉神經後根，神經節，和三個分支通過從Meckel 's cave外側壁和海綿竇移除硬腦膜暴露出來。後根在SCA下方進入中橋，與岩上靜脈的分支纏繞在一起。B, SCA向下循環，在吻側主幹和尾側主幹的連接處，在橋橋連接處與三叉神經後根接觸。小腦唇向前突出，可能阻塞乙狀結腸後入路三叉神經和腦橋的連接處。C, SCA早期分叉。吻側幹向下彎曲，壓入三叉神經的上表麵。D，另一個SCA繞過腦橋，在三叉神經根進入區上方分叉進入吻側和尾側主幹。一個,動脈; A.I.C.A., anteroinferior cerebellar artery; Car., carotid; Caud., caudal; Cav., cavernous; Cereb., cerebellar; CN, cranial nerve; Pet., petrosal; Post., posterior; Rost., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tr., trunk; V., vein.

圖4.11。三叉神經的動脈受壓部位。方位如圖中所示。一、中央圖。右三叉神經被彎曲的基底動脈壓迫，左三叉神經被SCA主幹壓迫。B, SCA在到達三叉神經之前分成吻側和尾側幹。神經被尾幹壓迫了。C, SCA遠端分叉到神經。神經被主幹壓迫了。D, SCA在到達神經之前分叉。 The nerve is compressed by both the rostral and caudal trunks. E, the nerve is compressed by a large pontine artery. F, the nerve is compressed by an AICA that has a high origin and loops upward into the medial surface of the nerve. The SCA passes around the brainstem above the nerve. (From, Rhoton AL Jr: Microsurgical anatomy of decompression operations on the trigeminal nerve, in Rovit RL, Murali R, Jannetta PJ (eds): Trigeminal Neuralgia. Baltimore, Williams & Wilkins, 1990, pp 165–200 [34].) A., artery; A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Ca., caudal; Ro., rostral; S.C.A., superior cerebellar artery; Tr., tract; V., vein.

圖4.12。枕下開顱術所見三叉神經動脈受壓部位。一、中央圖。皮膚切口(實線)和開顱切口(斷續線)的位置顯示在插入物中。輕輕收縮小腦上外側緣，露出三叉神經和SCA。腦鏟向前平行於岩上竇。滑車神經位於暴露的上緣，麵神經和前庭耳蝸神經位於下緣。三叉神經被下垂到神經腋窩的SCA的一個環壓迫。動脈受壓部位位於主幹與吻側主幹和尾側主幹的交界處。第二，神經被尾幹壓迫了。 C, the nerve is compressed by the main trunk. D, compression by both the rostral and caudal trunks. E, compression by a pontine branch of the basilar artery. F, compression by the AICA. G, compression by a tortuous basilar artery. A., artery; A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Ca., caudal; Ro., rostral; S.C.A., superior cerebellar artery; Sup., superior; Tr., trunk; V., vein. (From, Rhoton AL Jr: Microsurgical anatomy of decompression operations on the trigeminal nerve, in Rovit RL, Murali R, Jannetta PJ (eds): Trigeminal Neuralgia. Baltimore, Williams & Wilkins, 1990, pp 165–200 [34].)

圖4.13。三叉神經靜脈受壓部位。一、中央圖。前視圖。通常壓迫三叉神經的靜脈是岩上靜脈的支流。彙聚並可能壓迫神經的支流是橋橫靜脈和橋三叉神經靜脈以及橋小腦裂靜脈和小腦中梗靜脈。橋橋橫靜脈橫過橋橋。小腦中梗的靜脈起於麵神經和前庭耳蝸神經區域，上升至腦橋。橋小腦裂的靜脈沿著橋腦橋和小腦之間的裂縫向上延伸到三叉神經後麵。三叉腦橋靜脈起於腦橋上部，經過三叉神經上方。 B, a transverse pontine vein compresses the lateral side of the nerve and joins the veins of the middle cerebellar peduncle and cerebellopontine fissure to empty into a superior petrosal vein. C, the medial side of the nerve is compressed by a tortuous transverse pontine vein. D, the lateral side of the nerve is compressed by the junction of the transverse pontine vein with
the veins of the middle cerebellar
peduncle and the
cerebellopontine fissure. E, the
nerve is compressed on the
medial side by the vein of the middle cerebellar peduncle and on the lateral side by the vein of the cerebellopontine fissure. F, the lateral side of the nerve is compressed by the vein of the cerebellopontine fissure. (From, Rhoton AL Jr: Microsurgical anatomy of decompression operations on the trigeminal nerve, in Rovit RL, Murali R, Jannetta PJ (eds): Trigeminal Neuralgia. Baltimore, Williams & Wilkins, 1990, pp 165–200 [34].) Cer., cerebellar; Cer. Pon., cerebellopontine; Fiss., fissure; Mid., middle; Ped., peduncle; Pon., pontine; Sup., superior; Trans., transverse; Trig., trigeminal; V., vein.

圖4.14。乙狀結腸後開顱術所見三叉神經靜脈受壓部位。A，插入片顯示頭皮切口(實線)和開顱手術(斷續線)的位置。小腦被抬高以暴露三叉神經與腦橋的連接處。岩上靜脈流入岩上竇。滑車神經位於上緣，麵神經和前庭耳蝸神經位於下緣。開顱術暴露了乙狀竇和橫竇的交界處。三叉神經被橋橫靜脈和小腦中踝靜脈與岩上靜脈的連接處壓迫。橋小腦裂的靜脈在神經後麵上升而橋三叉靜脈在神經上麵通過。B，三叉神經的內側被橋橫靜脈壓迫外側被小腦中梗靜脈壓迫。 C, the lateral side of the nerve is compressed by a transverse pontine vein. D, the medial side of the nerve is compressed by the junction of a transverse pontine vein with the veins of the middle cerebellar peduncle and cerebellopontine fissure. E, the lateral side of the nerve is compressed by the junction of the transverse pontine vein with the veins of the middle cerebellar peduncle and cerebellopontine fissure. F, the medial side of the nerve is compressed by the vein of the middle cerebellar peduncle. G, the lateral side of the nerve is compressed by the vein of the cerebellopontine fissure. (From, Rhoton AL Jr: Microsurgical anatomy of decompression operations on the trigeminal nerve, in Rovit RL, Murali R, Jannetta PJ (eds): Trigeminal Neuralgia. Baltimore, Williams & Wilkins, 1990, pp 165–200 [34].) Cer., cerebellar; Cer. Pon., cerebellopontine; Fiss., fissure; Mid., middle; Ped., peduncle; Pon., pontine; Sig., sigmoid; Sup., superior; Trans., transverse; Trig., trigeminal; V., vein.

圖4.15。乙狀結腸後入路的上齶變異。第一，小腦被抬高以暴露小腦橋腦角的神經。一個大的岩靜脈阻斷了到顱上區的通路。B，岩上靜脈被切開，露出位於內聽道孔上方和三叉神經外側的口上結節。C，晶狀體上結節上的硬腦膜已被切除，準備鑽孔。D, removing the
suprameatal bone, including the tubercle, extends the exposure along the posterior trigeminal root by approximately 1 cm and increases access to the front of the brainstem and clivus. A.I.C.A., anteroinferior cerebellar artery; CN, cranial nerve; Flocc., flocculus; Pet., petrosal; S.C.A., superior cerebellar artery; Sup., superior; Suprameat., suprameatal; V., vein.

圖4.16。上齶入路進入梅克爾氏洞後部。A，右橋小腦角。口上結節位於內口孔的上方。一個大的岩下靜脈通過迷走神經的後麵。B，移除顱上結節，打開前向Meckel 's穴延伸的硬腦膜，沿三叉神經後根提供1cm的額外暴露。此外，通往斜坡一側的通道也得到了改善。C，晶狀體上結節的上位視圖。結節位於三叉神經外側，岩上靜脈下方，內聽道、麵神經和前庭耳蝸神經上方。D，移除孔上結節和穿過梅克爾氏洞孔的上岩竇段後的側位圖。 This improves the length of the posterior trigeminal root exposed by 8 to 10 mm, compared with the exposure before drilling the tubercle. Bridg., bridging; CN, cranial nerve; Flocc., flocculus; P.C.A., posterior cerebral artery; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery; Sup., superior; Suprameat., suprameatal; Tent., tentorium; V., vein.

圖4.17。離開retrosigmoid曝光。第一，小腦被抬高了。一個大的AICA循環進入內入口的孔。麵神經與腦幹的連接處位於前庭耳蝸神經的下方略前方。B，前庭耳蝸神經被抬高以提供更多的麵神經暴露。C，脈絡膜叢從盧氏孔伸出到橋小腦角在舌咽神經和迷走神經後麵。在菱形唇內放置了一個神經鉤，這是一個神經組織袋，沿側隱窩的前緣附著，並在舌咽神經和迷走神經後麵向外側延伸。D，菱形唇的放大視圖。A.I.C.A，小腦前下動脈; Chor. Plex., choroid plexus; CN, cranial nerve; Flocc., flocculus; Pet., petrosal; Sup., superior; V., vein.

圖4.18。f。左小腦橋腦角。A, AICA通過麵神經和前庭耳蝸神經之間。頸靜脈孔處的硬腦膜隔將舌咽神經和迷走神經分開。B，前庭耳蝸神經和小葉被抬高以暴露麵神經與腦幹的連接處。在乙狀竇後入路中，前庭耳蝸神經下麵的麵神經與腦幹的連接處可以暴露出來。C，內聽道的後壁被切除。前庭上神經與下庭神經之間的解理麵尤為明顯。D，內襯內聽道的硬腦膜已經打開。 The transverse crest separates the superior vestibular and facial nerves above from the inferior vestibular and cochlear nerves below. E, enlarged view of the nerves within the meatus. The cochlear nerve is partially hidden anterior to the inferior vestibular nerve. F, the cleavage plane between the superior and inferior vestibular and cochlear nerves has been started laterally and extended medially to expose the individual nerve bundles. A., artery; A.I.C.A., anteroinferior cerebellar artery; Arc., arcuate; CN, cranial nerve; Coch., cochlear; Emin., eminence; Endolymph., endolymphatic; Flocc., flocculus; Inf., inferior; Intermed., intermedius; Jug., jugular; Labyr., labyrinth; N., nerve; Nerv., nervus; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Subarc., subarcuate; Sup., superior; Trans., transverse; Vert., vertebral; Vest., vestibular.

圖4.18。G-J。左小腦橋腦角。G，垂直和橫脊暴露於口底。小腿和上、後根管的相鄰部分已經暴露出來。內淋巴管和囊位於內聽道的下外側。H，另一個解剖顯示了後上根管和總小腿到入口的連接關係。內淋巴管從前庭向下向後延伸，進入內淋巴囊，內淋巴囊位於硬腦膜下，在入口的下方和外側。通過內淋巴囊內側的骨可見頸靜脈球。第一，左內聽道眼底。 The transverse crest separates the superior vestibular area and facial canal above from the inferior vestibular and cochlear areas below. The vertical crest separates the superior vestibular area from the entrance into the facial canal. The multiple cochlear nerve filaments penetrating the tiny openings in the lamina cribrosa at the meatal fundus can easily be torn with traction on the nerve from lateral to medial, therefore, we try to direct the strokes of dissection from medial to lateral when there is an opportunity to preserve hearing. J, closure after removing the posterior wall of the internal acoustic meatus. Bone wax on a microdissector is carefully placed into open air cells in the posterior meatal lip and then a pledget of crushed subcutaneous abdominal fat is laid over the drilled meatal area. This has prevented cerebrospinal fluid leaks after removal of the posterior wall of the internal acoustic meatus in more than 200 consecutive operations for acoustic neuroma by the author.

圖4.19。右耳內聽道，切除後唇，顯示聽神經瘤引起麵神經移位的不同方向。第一，正常的神經關係第八神經在外側入口分為三個部分。麵神經和前庭上神經在橫冠的上麵耳蝸神經和前庭下神經在橫冠的下麵。麵神經占據外側入口的前上象限。第二，麵神經直接向前移位。這是聽神經瘤常見的移位方向。C，另一個常見的麵神經移位方向是前上神經。D，麵神經在前方和下方被腫瘤移位，腫瘤侵蝕神經上方的入口上壁生長到神經上方的區域，將神經移位到下方。(來自，Rhoton AL Jr:內部聲學通道的顯微外科。 Surg Neurol 2:311–318, 1974 [32].)

圖4.20。聽神經瘤腦幹側的神經血管關係。
右橋小腦角的前外側視圖。一、神經
關係。麵神經和前廳耳蝸神經起於腦幹
附近的橋髓溝外側端，位於從
Luschka孔伸出的脈絡膜
叢的前上方，位於小葉前部，
吻側至沿著舌咽部、迷走神經、
和副神經與腦幹的
根連接處的一條線，
起於下橄欖樹吻側極
稍後。橋小腦裂由小腦
包圍
腦橋外側和小腦中足梗形成，有
的上肢通過
三叉神經上方，以及
的下肢延伸到Luschka孔下方。小腦髓質裂
在
髓質和小腦之間向上延伸，在
Luschka孔區域與橋小腦裂
相通。B,動脈的關係。AICA發源於基底動脈
，分為吻側
和尾側幹。吻側幹
通常是兩個
幹中較大的一個，經過麵神經和前庭耳蝸神經的下方，然後在
小葉的上方到達
小腦中梗的表麵。 The PICA
arises from the vertebral artery and
passes first between the hypoglossal
rootlets, and then between the vagus
and accessory nerves on its way to the
cerebellar hemisphere. The SCA passes
above the trigeminal nerve. The cerebellar arteries give rise to hemispheric
branches. C, venous relationships. The
veins that converge on the junction of the facial and vestibulocochlear nerves with the brainstem are the veins of the pontomedullary sulcus, cerebellomedullary fissure, middle cerebellar peduncle, and the retro-olivary and lateral medullary veins. The vein of the cerebellopontine fissure, which passes above the flocculus on the middle cerebellar peduncle, is formed by the anterior hemispheric veins that arise on the cerebellum. Transverse pontine and transverse medullary veins cross the pons and medulla. The median anterior medullary and median anterior pontomesencephalic veins ascend on the anterior surface of the medulla and pons. The veins of the middle cerebellar peduncle and the cerebellopontine fissure and a transverse pontine vein join to form a superior petrosal vein, which empties into the superior petrosal sinus. A bridging vein passes below the vagal rootlets toward the jugular foramen. D, neurovascular relationships of an acoustic neuroma. The tumor arises from the vestibulocochlear nerve and displaces the facial nerve anteriorly, the trigeminal nerve superiorly, and the vagus and glossopharyngeal nerves inferiorly. The facial nerve, even though displaced by the tumor, enters the brainstem along the lateral margin of the pontomedullary sulcus, rostral to the glossopharyngeal and vagus nerves, anterior to the flocculus, and rostral to the choroid plexus protruding from the foramen of Luschka. The rostral trunk of the AICA, after passing below the tumor, returns to the surface of the middle cerebellar peduncle above the flocculus. The veins displaced around the medial side of the tumor are the veins of the middle cerebellar peduncle, cerebellomedullary fissure, cerebellopontine fissure, and pontomedullary sulcus, and the retro-olivary and lateral medullary veins. (From, Rhoton AL Jr: Microsurgical anatomy of the brainstem surface facing an acoustic neuroma. Surg Neurol 25:326–339, 1986 [33].) A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Br., bridging; Ca., caudal; Cer., cerebellar; Cer. Pon., cerebellopontine; Chor., choroid; F., foramen; Fiss., fissure; Hem., hemispheric; Lat., lateral; Med., medial, medullary; Mid., middle; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Pon., pontine; Pon. Med., pontomedullary; Pon. Mes., pontomesencephalic; Ro., rostral; S.C.A., superior cerebellar artery; Sulc., sulcus; Sup., superior; Tr., trunk; Trans., transverse; V., vein; Vert., vertebral.

圖4.21。通過枕下開顱術看到的Luschka孔和第四腦室側隱窩與麵神經和前庭耳蝸神經與腦幹交界處的關係。A，插入物顯示方位、皮膚切口(實線)和開顱術(斷續線)。Luschka孔在舌咽神經和迷走神經
後方進入橋小腦角。脈絡膜叢從Luschka孔突出，在麵部神經和前庭耳蝸神經略低於和後麵，在舌咽神經和迷走神經
後麵。小葉伸入小腦橋腦角，位於Luschka孔上方。副神經位於迷走神經的下方。舌下細根在橄欖的腹側出現。三叉神經在暴露的上部交叉。B，右小腦扁桃體通過分裂扁桃體梗被切除以顯示側隱窩與麵神經和前庭耳蝸神經的關係。 The flocculus and choroid plexus protrude in the cerebellopontine angle behind the junction of the facial and vestibulocochlear nerves with the brainstem. The inferior medullary velum stretches from the lateral side of the vermis to the flocculus and is all that remains of the connection between the flocculus and the nodulus, which form the flocculonodular lobe of the cerebellum. The inferior medullary velum stretches laterally to form the peduncle of the flocculus. The tela choroidea forms the caudal part of the roof of the fourth ventricle and has the choroid plexus attached to its inner surface. The facial and vestibulocochlear nerves enter the brainstem at the lateral end of the pontomedullary sulcus. C, the tela choroidea has been opened, but the choroid plexus, which arises on the inner surface of the tela in the fourth ventricle, has been preserved. The fringelike choroid plexus extends through the foramen of Luschka slightly below and behind the junction of the facial and vestibulocochlear nerves with the brainstem. The inferior cerebellar peduncle ascends on the dorsolateral margin of the medulla. D, relationships of an acoustic neuroma. The facial nerve is displaced anteriorly and superiorly in the cerebellopontine angle and enters the brainstem at the lateral end of the pontomedullary sulcus, anterosuperior to the choroid plexus protruding from the foramen of Luschka, and near where the flocculus is attached along the margin of the lateral recess. The tumor displaces the trigeminal nerve upward and the glossopharyngeal and vagus nerves downward. The AICA gives rise to a subarcuate artery, which enters the subarcuate fossa in the posterior wall of the internal acoustic meatus and bifurcates into a rostral and a caudal trunk. The rostral trunk courses above the flocculus to reach the surface of the middle cerebellar peduncle. (From, Rhoton AL Jr: Microsurgical anatomy of the brainstem surface facing an acoustic neuroma. Surg Neurol 25:326–339, 1986 [33].) Br., bridging; Ca., caudal; Cer. Med., cerebellomedullary; Cer. Pon., cerebellopontine; Chor. choroid; F., foramen; Fiss., fissure; Inf., inferior; Jug., jugular; Lat., lateral; Med., medial, medullary; Mid., middle; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Pon. Med., pontomedullary; Ro., rostral; Subarc., subarcuate; Sulc., sulcus; Tr., trunk; V., vein; Vel., velum.

圖4.22。
聽神經瘤腦幹側的神經血管關係。前上的
視圖。神經的關係。
大腦和小腦幕
被切除，三叉神經、滑車神經和動眼神經
被分割，以便腦幹向後移位到
從上麵露出橋小腦角
。麵神經和前庭耳蝸神經起於橋髓溝
側
小葉前，
舌咽神經、迷走神經和副神經的吻端，以及從Luschka
孔伸出的
脈絡叢的前上。橋小腦裂由
小腦包裹在橋腦外側
側和中小腦
梗處形成，有上肢和下肢
。Luschka孔打開
進入下肢，靠近麵部
和前庭蝸神經。B,動脈的關係。AICA發源於基底動脈
，經過
麵神經和前庭耳蝸神經
下麵，產生弓形下動脈
，並分為吻側幹和尾側幹
。 The rostral trunk passes
above the flocculus to course on the
middle cerebellar peduncle, and the
caudal trunk supplies the area below the flocculus. C, venous relationships. The veins converging on the junction of the facial nerve with the brainstem are the lateral medullary and retro-olivary veins, and the veins of the pontomedullary sulcus, cerebellomedullary fissure, and middle cerebellar peduncle. The median anterior pontomesencephalic vein ascends on the anterior surface of the brainstem, and the transverse pontine and transverse medullary veins cross the pons and medulla. The vein of the cerebellopontine fissure passes above the flocculus. The transverse pontine vein and the veins of the middle cerebellar peduncle and cerebellopontine fissure join to form one of the superior petrosal veins that empty into the superior petrosal sinus. A bridging vein passes from the side of the brainstem to the jugular foramen. The anterolateral marginal vein crosses the anterolateral margin of the cerebellum. The vein of the pontomesencephalic sulcus courses in the pontomesencephalic sulcus below the oculomotor nerve. D, neurovascular relationships of an acoustic neuroma. The tumor arises from the vestibulocochlear nerve and displaces the facial nerve anteriorly, the trigeminal nerve superiorly, and the glossopharyngeal and vagus nerves inferiorly. The vestibulocochlear nerve disappears into the tumor. The facial nerve enters the brainstem along the lateral margin of the pontomedullary sulcus, rostral to the glossopharyngeal nerve, anterior to the flocculus, and rostral to the choroid plexus protruding from the foramen of Luschka. The AICA is usually displaced around the lower margin of the tumor. The veins displaced around the medial side of the tumor are the veins of the pontomedullary sulcus, middle cerebellar peduncle, and cerebellomedullary fissure, and the lateral medullary and retro-olivary veins. (From, Rhoton AL Jr: Microsurgical anatomy of the brainstem surface facing an acoustic neuroma. Surg Neurol 25:326–339, 1986 [33].) A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Br., bridging; Ca., caudal; Cer., cerebellar; Cer. Pon., cerebellopontine; Chor., choroid; F., foramen; Fiss., fissure; Inf., inferior; Jug., jugular; Lat., lateral; Marg., marginal; Med., medial, medullary; Mid., middle; Ped., peduncle; P.I.C.A., posteroinferior cerebellar artery; Pon., pontine; Pon. Med., pontomedullary; Pon. Mes., pontomesencephalic; Ro., rostral; S.C.A., superior cerebellar artery; Subarc., subarcuate; Sulc., sulcus; Sup., superior; Tr., trunk; Trans., transverse; V., vein; Vert., vertebral.

圖4.23。聽神經瘤周圍AICA移位方向的後視圖。左上角的插入顯示了視圖的方向。口前節段和口後節段都位於腫瘤下緣周圍最常見的位置。口前段從前下頜骨接近入口，口後段從後下頜骨接近腫瘤。SCA和三叉神經位於腫瘤上方，PICA和舌咽神經、迷走神經和脊髓副神經位於腫瘤下方。脈絡膜叢伸入腫瘤內側的橋小腦角。切除內聽道後壁，露出橫脊和前庭上神經和前庭下神經。前庭神經消失在腫瘤內;然而，耳蝸和麵神經在腫瘤前緣周圍移位。 A subarcuate artery arises from the premeatal segment, and a recurrent perforating artery arises from the postmeatal segment. Center right, in a less common pattern of displacement of the AICA, the premeatal and postmeatal segments are above the tumor. The internal auditory arteries arise from the meatal segment. Bottom left, both the premeatal and the postmeatal segments are displaced anteriorly to the tumor. This occurs if the AICA courses between the vestibulocochlear and facial nerves. The tumor arises in the vestibular nerves, and tumor growth displaces both the premeatal and the postmeatal segments anteriorly. (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 [25].) Ch. Pl., choroid plexus; Co., cochlear; I.A.A., internal auditory (labyrinthine) artery; I.V., inferior vestibular; Mea., meatal; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; R.P.A., recurrent perforating artery; S.A., subarcuate artery; S.V., superior vestibular; S.C.A., superior cerebellar artery; Seg., segment; Tent., tentorium.

圖4.24。聽神經瘤腦幹側神經血管
關係
。通過乙狀竇後
開顱術
後側視圖。神經的關係。的orientation, skin incision (solid
line), and craniotomy site
(interrupted line) are shown in the
insert. The retractor is on the
petrosal surface of the cerebellum.
The facial and vestibulocochlear
nerves arise at the lateral end of the
pontomedullary sulcus, anterior to
the flocculus, rostral to the
glossopharyngeal, vagus, and
accessory nerves, and anterosuperior
to the choroid plexus protruding
from the foramen of Luschka. The
cerebellopontine fissure, formed
where the cerebellum wraps around
the lateral side of the pons and
middle cerebellar peduncle, has
superior and inferior limbs. B,
arterial relationships. The AICA
arises from the basilar artery and
divides into a rostral trunk, which
passes above the flocculus to reach
the surface of the middle cerebellar
peduncle, and a caudal trunk, which
supplies the area below the
flocculus. The PICA arises from the
vertebral artery and passes dorsally
between the vagus and accessory
nerves. The SCA courses above the
trigeminal nerve. C, venous
relationships. The veins that join
near the junction of the facial and
vestibulocochlear nerves with the
brainstem are the lateral medullary
veins and the veins of the
cerebellomedullary fissure,
pontomedullary sulcus, and middle
cerebellar peduncle. The vein of the cerebellopontine fissure passes above the flocculus along the superior limb of the cerebellopontine fissure and joins the vein of the middle cerebellar peduncle and a transverse pontine vein to form a superior petrosal vein, which empties into the superior petrosal sinus. A bridging vein passes behind the vagus nerve. The lateral anterior pontomesencephalic vein ascends on the pons. D, neurovascular relationships of an acoustic neuroma. The tumor arises from the vestibulocochlear nerve and displaces the facial nerve anteriorly, the trigeminal nerve superiorly, and the glossopharyngeal and vagus nerves inferiorly. The vestibulocochlear nerve disappears into the tumor. The facial nerve enters the brainstem at the lateral margin of the pontomedullary sulcus anterior to the flocculus and rostral to the choroid plexus protruding from the foramen of Luschka. The rostral trunk of the AICA courses below the tumor and above the flocculus to reach the surface of the middle cerebellar peduncle. The veins displaced around the medial side of the tumor are the lateral medullary veins and the veins of the middle cerebellar peduncle, cerebellomedullary fissure, and pontomedullary sulcus. The vein of the cerebellopontine fissure passes above the tumor. A recurrent perforating branch of the AICA passes across the tumor and supplies the brainstem. (From, Rhoton AL Jr: Microsurgical anatomy of the brainstem surface facing an acoustic neuroma. Surg Neurol 25:326–339, 1986 [33].) A., artery; A.I.C.A., anteroinferior cerebellar artery; Ant., anterior; Bas., basilar; Br., bridging; Ca., caudal; Cer., cerebellar; Cer. Pon., cerebellopontine; Chor., choroid; F., foramen; Fiss., fissure; Lat., lateral; Med., medial, medulla; Mid., middle; Ped., peduncle; Perf., perforating; P.I.C.A., posteroinferior cerebellar artery; Pon., pontine; Pon. Med., pontomedullary; Rec., recurrent; Ro., rostral; S.C.A., superior cerebellar artery; Sulc., sulcus; Sup., superior; Tr., trunk; V., vein; Vert., vertebral.

圖4.25。A.乙狀結腸後入路切除小或中型聽神經瘤。A，病人俯臥四分之三位，外科醫生在頭後。插入片(右)顯示頭皮切口(連續線)和骨開口(斷續線)的位置。抵扣。乙狀結腸後入路切除小或中型聽神經瘤。B，用衝洗鑽去除內耳道後壁。AICA沿腫瘤下緣走行。C，腫瘤囊內內容物已被移除。腫瘤囊與腦橋和
麵神經和腦幹鄰近的前庭耳蝸神經部分的後表麵分離。 The superior and inferior vestibular nerves are seen at the lateral end of the internal auditory canal. The trigeminal nerve and SCA are above the tumor and the glossopharyngeal and vagus nerves and the PICA are below the tumor. D, the dissection along the eighth nerve is done in a medial to lateral direction (arrows) to avoid tearing the tiny filaments of the cochlear nerve in the lateral end of the canal where they pass through the lamina cribrosa. The transverse crest separates the superior and inferior vestibular nerves in the lateral end of the canal. E, cerebellopontine angle and internal auditory canal after tumor removal. The facial and vestibulocochlear nerves have been preserved. A.I.C.A., anteroinferior cerebellar artery; Inf., inferior; Int., internal; N., nerve; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery; Sup., superior; Vest., vestibular. (From, Rhoton AL Jr: Microsurgical anatomy of acoustic neuromas, in Sekhar LN, Janecka IP (eds): Surgery of Cranial Base Tumors. New York, Raven Press, 1993, pp 687–713 [37].)

圖4.26。麵肌痙攣時麵部動脈壓迫部位
神經。前上的視圖。麵部神經和前庭耳蝸神經在與腦幹的連接處被aica的右前段和左後段扭曲。B,前視圖。右麵神經和前庭耳蝸神經與腦幹的連接處被彎曲的椎動脈壓迫。左側的神經被異食癖壓迫。(來自，Martin RG, Grant JL, Peace DA, Theiss C, Rhoton AL Jr:小腦前下動脈與顏麵-前庭耳蝸神經複合物的顯微外科關係。神經外科:483 - 507,1980[25]。A.I.C.A，小腦前下動脈; Ch. Pl., choroid plexus; Mea., meatal; P.C.A., posterior cerebral artery; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; S.C.A., superior cerebellar artery; Seg., segment; V.A., vertebral artery.

圖4.27。A，異食癖起源於
椎動脈，通過
舌下神經的細根之間，在
舌咽神經和迷走神經的細根之間經過後下方，然後在迷走神經的細根和脊髓副神經之間向上循環。椎動脈向後延伸舌下神經的細根。AICA袢位於麵神經和前庭耳蝸神經的後方。B，彎曲異食癖起源於椎動脈，並向耳庭耳蝸和麵神經的側方向通過。在前庭耳蝸神經水平，它在舌咽神經和迷走神經的前麵向下循環，並在迷走神經和脊髓副神經之間通過。異食癖壓迫舌咽部和迷走神經起源前的髓質。脈絡膜叢從舌咽神經後的Luschka孔突出。小腦梗在第四腦室側隱窩的上方。C，椎動脈移位並延伸舌下細根到很遠的後方它們與脊副神經的細根混合。 The PICA descends between the rootlets of the spinal accessory nerve. (From, Lister JR, Rhoton AL Jr, Matsushima T, Peace DA: Microsurgical anatomy of the posterior inferior cerebellar artery. Neurosurgery 10: 170–199, 1982 [24].) A., artery; A.I.C.A., anteroinferior cerebellar artery; Cer., cerebellar; Ch. Pl., choroid plexus; F., foramen; Lat., lateral; Ped., peduncle; Perf., perforating; P.I.C.A., posteroinferior cerebellar artery; V.A., vertebral artery.

圖4.28。麵肌痙攣時麵神經暴露。A，插入的
顯示了沿著小腦下外側緣
的入路。小腦被
抬高以暴露右側小腦橋腦角。腦幹
的麵部
神經出口區沿著前庭耳蝸神經
的下緣可見。
AICA通過麵神經和
前庭蝸神經之間。一個巨大的
彎曲異食癖在麵部神經和前庭耳蝸神經前麵和三叉神經後麵向上循環，然後向下轉
到達髓質。
小葉和脈絡膜
叢從孔
Luschka突出，經常隱藏
麵神經和前庭耳蝸
腦幹神經的交界處。在本例中，
小葉被輕輕抬高，以暴露
這些神經與腦幹的連接處。B,
放大視圖。從腦幹
暴露麵部
神經出口區是通過沿著小腦下外側緣
在舌咽神經
以上和小葉下緣以下的區域進行暴露來促進的。 C, the vestibulocochlear nerve
has been depressed. This exposes
the distal segment of the facial
nerve, but does not provide access
to the junction of the facial nerve
with the brainstem, which should
be visualized in dealing with hemifacial spasm. D, the vestibulocochlear nerve has been gently elevated. This exposes both the rostral
and caudal margins of the facial
nerve at the brainstem. A rootlet of
the nervus intermedius is also exposed. The vein of the middle cerebellar peduncle passes between the
facial and vestibulocochlear nerve.
A., artery; A.I.C.A., anteroinferior
cerebellar artery; Cer., cerebellar;
Chor. Plex., choroid plexus; CN, cranial nerve; Flocc., flocculus; Inf., inferior; Intermed., intermedius; Mid., middle; Nerv., nervus; Ped., peduncle; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; V., vein; Vert., vertebral.

圖4.29。a - f，通過乙狀竇後開顱術觀察麵肌痙攣時麵神經的動脈壓迫，患者俯臥四分之三位。A，上圖顯示了切口的位置(直線)和開顱手術的位置(折線)。下圖顯示了用這種方法獲得的手術暴露。AICA和麵神經和前庭耳蝸神經位於暴露的中間部分。下麵是椎動脈、異食癖神經、舌咽神經、迷走神經和脊髓副神經。B，小腦被抬高以暴露麵部和前庭耳蝸神經以及AICA的出生前，出生前，出生前和出生前的節段。小葉和脈絡膜叢擋住了麵神經和前庭耳蝸神經與腦幹的連接處。C，小葉和脈絡膜叢被抬高，暴露出麵神經和前庭耳蝸神經的根進出區。口前段壓迫腦橋和髓質連接處的神經。 D, the nerve root entry/ exit zone is compressed by the postmeatal segment. E, a tortuous PICA loops upward to compress the nerves at their junction with the brainstem before turning inferiorly to pass between the glossopharyngeal and vagus nerves. F, a tortuous vertebral artery compresses the nerve root entry/exit zone. A., artery; A.I.C.A., anteroinferior cerebellar artery; Chor. Plex., choroid plexus; Labyrin., labyrinthine; Mea., meatal; P.I.C.A., posteroinferior cerebellar artery; Post., posterior; Seg., segment; Subarc., subarcuate; Vert., vertebral.

圖4.30。從上麵看橋小腦角，顯示中間神經與麵神經和前庭耳蝸神經的關係。一，最常見的關係。中間神經與前庭耳蝸神經的腹表麵連接在腦幹附近幾毫米處，然後在橋小腦角有一個遊離段，當它與麵部運動根連接時。B, 20%的被研究神經都有這種模式。遊離段完全在入口。C，中間神經由三個自由節段組成:兩個是角，一個在入口。A段中間神經可以在不鑽開入口後唇的情況下暴露在角度內。在B組中，遊離段不在角度處，僅在入口處。(來自Rhoton AL Jr:聽神經瘤的顯微外科解剖，在Jackler RK (ed):北美耳鼻喉科診所。 Philadelphia, W.B. Saunders Co., 1992, pp 257–294 [35].)

圖4.31。左側腦幹的側麵圖，由折線所示。B，注意舌咽神經和迷走神經的腹側和背側根。可見一個舌咽部腹側小根和兩個迷走神經腹側小根。(來自Rhoton AL Jr, Buza R:頸靜脈孔的顯微外科解剖。神經外科雜誌(英文版):541 - 550,1975

圖4.32。腦幹外側表麵的折線勾勒出了每張圖中所示的區域，展示了腦幹的起源和舌咽神經、迷走神經和脊髓副神經的小根大小的變化。大的卵形結構為下橄欖。虛線圈勾勒出麵神經和前庭耳蝸神經的起源。最頭側的陰影圈表示舌咽部小根的起源，中間的開放圈表示迷走神經小根的起源，尾側的黑色圈表示脊髓副小根的起源。舌咽神經通常起源於一個大的小根，迷走神經起源於一係列大大小小的小根，脊髓副起源於一係列小的小根。上，注意A、B、C處舌咽神經的腹側小根，A處舌咽神經和迷走神經之間的腹側小根。除D處外，舌咽根均大於迷走神經的吻側根，其中吻側迷走神經的根大於舌咽神經。底部，注意C的舌咽神經和迷走神經的起源，C的舌咽神經的腹側小根，A的舌咽神經和迷走神經的腹側小根。舌咽神經比A和d的迷走神經上根小。(來自，Rhoton AL Jr, Buza R:頸靜脈孔的顯微外科解剖。神經外科雜誌(英文版):541 - 550,1975

圖4.33。腫瘤涉及多個神經血管複合體。A，在顱神經之間的路徑可以暴露並切除位於內側並累及多根顱神經的腫瘤。患者取四分之三俯臥位。插入片(左上)顯示垂直頭皮切口和開顱的位置。位於神經內側的病理通路可以在上麵的滑車神經和下麵的三叉神經之間引導(箭頭);在上麵的三叉神經和下麵的麵神經和前庭耳蝸神經之間;在上麵的麵神經和前庭耳蝸神經和下麵的舌咽神經之間;舌咽神經和迷走神經之間;在迷走神經和附屬細根之間; and between the widely separated rootlets of the accessory nerve. A tumor located medial to the nerves will often widen the intervals between the nerves, depending on the site of origin of the tumor. Choroid plexus protrudes from the foramen of Luschka. B, meningioma attached lateral to the trigeminal nerve in the region of the superior petrosal sinus. The trochlear nerve is elevated, the trigeminal nerve is pushed medially, and the facial and vestibulocochlear nerves are stretched below the tumor. C and D. Tumors involving multiple neurovascular complexes. C, the tumor has been removed. The thin distorted nerves have been preserved, and the remaining dural attachment is removed or cauterized with bipolar coagulation. The basilar artery and abducens nerve are exposed. D, a large meningioma arising from the clivus in the region of the inferior petrosal sinus with involvement of the fourth through the eleventh nerves. The nerves are displaced laterally around the tumor. The tumor is removed by working through the intervals between the nerves. Tumors involving multiple neurovascular complexes. E, the meningioma has been removed. The dural attachment has been partially removed and the base is being cauterized. F, meningioma arising medial to the jugular bulb in the region of the jugular tubercle and involving the lower cranial nerves. G and H. Tumors involving multiple neurovascular complexes. G, the tumor was removed by operating through the intervals between the facial and vestibulocochlear nerves above and the glossopharyngeal nerve below and between the glossopharyngeal and vagus nerves (round insert). H, a large epidermoid tumor being removed by working through the intervals between the nerves. A., artery; A.I.C.A., anteroinferior cerebellar artery; Bas., basilar; Ch. Plex., choroid plexus; Pet., petrosal; P.I.C.A., posteroinferior cerebellar artery; S.C.A., superior cerebellar artery; Sig., sigmoid; Sup., superior; Tent., tentorium; Vert., vertebral.