圖1所示。鞍區優越的視野。A，視神經和交叉向前反射，露出眼動脈。垂體上動脈起源於左髂內動脈的脊狀肌上段。左側ICA已向外側縮回，露出頸動脈洞，其延伸至遠端硬腦膜環以下，進入頸動脈頸和動脈壁之間的空間。一個垂體上動脈出現在洞穴的上部。B，頸動脈腔放大圖。C，切除前床突形成的右側床突間隙的上視圖。床突空間近端由硬腦膜形成的頸動脈動眼膜定義，硬腦膜將床突下表麵與動眼神經隔開，並向內側延伸環繞頸動脈形成近端硬腦膜環，遠端由硬腦膜從環繞頸動脈的床突上表麵向內側延伸形成遠端硬腦膜環。從前到後，床突空間內的結構包括視神經支柱、圍繞ICA的頸動脈頸圈(近端環和遠端環之間)和海綿竇頂的前部。 D, the right carotid artery has been retracted laterally to expose the carotid cave. A., artery; Car., carotid; Cav., cavernous; Clin., clinoid; CN, cranial nerve; Dist., distal; Hyp., hypophyseal; Memb., membrane; Oculo., oculomotor; Ophth., ophthalmic; Pit., pituitary; Prox., proximal; Seg., segment; Sup., superior; ICA, internal carotid artery. (Images courtesy of AL Rhoton, Jr.)

圖2。A，頸動脈洞穴的骨關係，上位視圖。頸內動脈的床突段，即穿過前床突內側的段，幾乎被外側的前床突、前方的視神經支柱和內側的蝶骨頸動脈溝所包圍。頸動脈腔位於ICA壁，麵向頸動脈溝。前突基部外側附著於由蝶小翼形成的蝶脊內側端，內側附著於蝶小翼的前、後根。小翼前根從前突基部向內側延伸至蝶骨體，形成視神經管的頂部。後根，稱為視神經支柱，向視神經下方內側延伸至蝶骨體，形成視神經管的底部。B、放大上位視圖。交叉溝是一對視神經管之間的淺凹陷，後麵是鞍結節，前麵是蝶平麵。鞍結節位於中線，沿脊形成交叉溝的後緣。 The middle clinoid process projects upward on the medial side of the terminal part of the carotid sulcus toward the tip of the anterior clinoid process. An osseous bridge may extend from the middle clinoid to the anterior clinoid, thus creating a bony ring, referred to as a caroticoclinoidal foramen, through which the ICA passes. The dura lining the upper margin of the anterior clinoid extends medially above the optic nerve to form the falciform ligament (blue arrow) and slightly downward to line the upper margin at the optic strut and form the anterior part of the distal dural ring (green line). The margins of the left carotid sulcus are shown (interrupted lines). C, oblique posterior view. The carotid sulcus (interrupted lines) begins below and lateral to the dorsum sella, turns forward in a shallow groove below the lateral edge of the sellar floor, and turns upward to end medial to the anterior clinoid process. D, oblique posterior view of the right optic strut, the bridge of the bone that extends from the inferomedial aspect of the base of the anterior clinoid to the body of the sphenoid bone and separates the optic canal from the superior orbital fissure. The clinoid segment of the ICA rests against the posterior margin of the strut. The dura lining the upper margin of the anterior clinoid extends medial above the optic nerve to form the falciform ligament (blue arrow) and slightly downward to line the upper margin at the optic strut and form the anterior part of the distal dural ring (green arrow). The posterior surface of the strut widens as it slopes medially. E, superior view. The lesser sphenoid wing and the base of the left anterior clinoid, have been removed to unroof the optic canal and upper and posterior margin of the optic strut. The posterior margin of the optic strut is shaped to accommodate the anterior surface of the anterior bend of the intracavernous carotid. The pneumatization of the sphenoid sinus may extend through the strut into the anterior clinoid. The lateral wall of the sphenoid sinus forms the medial wall of the optic canal. F, superior view of specimen with bilateral caroticoclinoidal foramen and interclinoidal osseus bridges. An osseous bridge connects the tips of the anterior and middle clinoid processes bilaterally, thus creating a bony ring around the artery called a caroticoclinoidal foramen, on each side. There are also interclinoidal osseus bridges connecting the anterior and posterior clinoid processes on both sides. Ant., anterior; Car., carotid; Car. Clin., caroticoclinoidal; Chiasm., chiasmatic; Clin., clinoid; Fiss., fissure; For., foramen; Inf., inferior; Interclin., interclinoidal; Lac., lacerum; Less., lesser; Mid., middle; Orb., orbital; Plan., planum; Post., posterior; Rotund., rotundum; Sphen., sphenoid, sphenoidale; Sup., superior; Tuberc., tuberculum; ICA, internal carotid artery. (Images courtesy of AL Rhoton, Jr.)

圖3。鞍上區上方視圖。A，頸動脈通過前床突的內側進入顱腔並在視神經下方。位於前突上表麵的硬腦膜向內側延伸，向兩個方向延伸:上伸展部穿過視神經上方，在蝶骨小翼前根處形成鐮狀韌帶;下延伸略微向下延伸到視神經支柱的上邊緣形成硬腦膜遠端環的前部。B，視神經管頂部的硬腦膜和前凸肌被切除。鐮狀韌帶沿小翼前根後緣延伸至視神經上方，向內側與覆蓋蝶平麵的硬腦膜融合。C，視神經和交叉被抬高，暴露垂體柄、眼動脈和垂體上動脈。頸動脈動眼膜已被切除以顯露頸動脈動眼膜由位於頸動脈下緣的硬腦膜形成，它將頸動脈下突與動眼神經分開並向內側延伸形成近端硬腦膜環。硬腦膜從前凸突的上表麵向內側延伸到視神經支柱的上表麵，也形成了遠端硬腦膜環的前部，遠端硬腦膜環定義了ICA的上緣。 This dura forming the proximal ring slopes downward as it proceeds medially, so that the medial part of the distal dural ring actually lies at the level of the lower rather than the upper surface of the anterior clinoid. The lateral part of the distal ring near the origin of the ophthalmic artery tightly adheres to the lateral wall of the ICA. D, the clinoid segment of the ICA, located between the proximal and distal dural rings, has been exposed by removing the anterior clinoid. The ICA between the proximal and distal ring is enclosed in a thin layer of dura referred to as the carotid collar. The proximal ring is loosely applied to the clinoid segment and allows the clinoid venous plexus, a thin venous plexus that courses inside the carotid collar and outside the carotid wall, to communicate inside the ring with the anterior part of the cavernous sinus. E, the right ICA has been retracted laterally to expose the carotid cave. The dura along the posterior edge of the carotid cave contains the anterior intercavernous sinus. F, the clinoid segment has been retracted anteriorly to expose the part of the cave adjacent the diaphragm sellae. G, oblique anterior superior view. The roof of the sphenoid sinus has been removed to expose the medial side of the right ICA. A green piece has been inserted into the carotid cave. The cave, the short downward directed pouch inside the carotid collar, extends below the level of the distal dural ring between the arterial wall and the carotid collar. H, the distal dural ring and the carotid collar have been divided and the dural flaps retracted with white silk to expose the carotid cave, the space between the carotid collar and the outer carotid wall that opens upward into the intradural space. A., artery; Ant., anterior; Br., branch; Car., carotid; Ch., choroidal; Clin., clinoid; CN, cranial nerve; Comm., communicating; Diaph., diaphragma; Dist., distal; Falc., falciform; Hyp., hypophyseal; Intercav., intercavernous; Lent. Str., lenticulostriate; Lig., ligament; Memb., membrane; Oculo., oculomotor; Ophth., ophthalmic; P., posterior; Perf., perforating; Pit., pituitary; Plex., plexus; Prox., proximal; Rec., recurrent; Seg., segment; Sphen., sphenoid; Subst., substance; Sup., superior; ICA, internal carotid artery. (Images courtesy of AL Rhoton, Jr.)

圖4。A，鞍區優越的視角。硬腦膜頂、前臥突、視神經管和右側海綿竇外側壁被切除。右上垂體動脈殘端被保存下來。膈肌缺失暴露垂體的上緣。B，鐮狀韌帶下方的解剖器進入視神經管。C，在保留頸動脈動眼膜和硬腦膜近端和遠端環的情況下，切除前床突。在切除前凸突所形成的空間中暴露出視神經支柱和側突段。硬腦膜形成近端環和遠端環在動脈外壁連接形成硬腦膜頸圈，頸動脈頸圈，環繞ICA。頸動脈腔位於ICA的內側和後部，向下延伸至遠端硬腦膜環和頸動脈頸和動脈外壁之間。 D, posterior superior view. The proximal and distal dural rings converge as they extend along the posterior margin of the carotid where they blend into a single layer forming the diaphragm sellae. E, lateral view of the proximal and dural rings. The proximal and distal dural rings converge posteriorly where both rings blend into the dural layer forming the diaphragm sellae. The clinoid segment of the carotid artery is surrounded by the carotid collar. F, lateral view of the cavernous sinus and the proximal and dural rings. The distal dural ring is formed by the dura extending medially from the upper surface of the anterior clinoid process. The proximal ring is formed by the dura that separates the lower margin by the anterior clinoid from the oculomotor nerve and extends medially around the ICA. In this specimen, the mucosa lining the sphenoid sinus extends into the optic strut, and in some cases, the sinus may pneumatize through the strut into the anterior clinoid process. A., artery; Ant., anterior; Car., carotid; Clin., clinoid; CN, cranial nerve; Dist., distal; Falc., falciform; Hyp., hypophyseal; Lig., ligament; Memb., membrane; Oculo., oculomotor; Ophth., ophthalmic; Pit., pituitary; Prox., proximal; Sup., superior; Tent., tentorial; ICA, internal carotid artery. (Images courtesy of AL Rhoton, Jr.)

圖5。A，前視圖。蝶鞍和視交叉前的冠狀麵。遠端硬腦膜環已被保留。蝶竇壁被切除，露出蝶鞍前壁和ICAs。視頸隱窩延伸到視神經支柱。右側硬腦膜近端環向內側延伸至頸動脈隱窩下方，在動脈內側不像遠端環那樣形成明顯的近端環。基底靜脈叢是海綿竇之間最大的交流通道。B，右側鞍旁區和延伸至視神經支柱的視頸隱窩的放大視圖。硬腦膜沿視神經支柱的下緣向後延伸形成近端硬腦膜環。 The dura on the upper surface of the optic strut extends around the ICA to form the distal dural ring. The abducens nerve passes around the lateral surface of the carotid and ascends medial to the ophthalmic nerve in the cavernous sinus. C, enlarged view after removing the dura in the sellar region and along the medial wall of the right cavernous sinus. The opticocarotid recess, a pneumatized diverticulum of the sphenoid sinus extends laterally into the optic strut, which separates the optic nerve in the optic canal from the nerves passing through the superior orbital fissure. The dura forming the proximal dural ring does not form as distinct a ring on the medial side of the artery adjacent the carotid sulcus as it does along the anterior and lateral surface of the artery. D, enlarged view. The distal dural ring encases the carotid artery just below the level of the origin of the ophthalmic artery. The proximal ring blends into the dura surrounding the artery on the side of the carotid sulcus. E, a triangular piece of green material has been inserted into the carotid cave located between the dura forming the collar around the artery and the outer wall of the ICA. The proximal ring is not as distinct on the medial side of the artery as is the distal ring. F, the distal dural ring and upper medial part of the carotid collar has been incised and retracted with black sutures to expose the arterial wall in the carotid cave. G, transnasal exposure of the left parasellar region in another specimen. One superior hypophyseal artery arises in the carotid cave proximal to the distal ring and ascends to exit the cave and pass to the pituitary stalk. Another superior hypophyseal artery arises above the level of the distal dural ring. A triangular piece of green material has been placed inside the cave. H, the carotid collar, below the level of the distal ring, has been opened to expose the origin of the superior hypophyseal artery in the carotid cave. The proximal ring is not as distinct on the medial side of the ICA as is the distal ring. A., artery; Bas., basilar; Car., carotid; Cav., cavernous; CN, cranial nerve; Dist., distal; For., foramen; Gyr., gyrus; Lac., lacerum; Med., medial; Ophth., ophthalmic; Opticocar., opticocarotid; Pit., pituitary; Prox., proximal; Rec., recess; Seg., segment; ICA, internal carotid artery. (Images courtesy of AL Rhoton, Jr.)

圖6。右頸動脈洞穴動脈瘤的上外側切麵。動脈瘤頸位於遠端硬腦膜環下方的洞穴中就在垂體上動脈起源的上方。前臥突被切除，形成遠端環的外側和前緣的硬腦膜被打開。B，這種類型動脈瘤最常見的夾應用是從動脈瘤頸的遠端到近端的角度開孔夾。洞穴的邊緣已被收回，露出動脈瘤頸。夾正在向動脈瘤頸部推進。需要注意避免阻塞起源於ICA的眼動脈、上垂體、後交通、前脈絡膜和穿通動脈的起源。C，夾已經閉合動脈瘤已經放氣。在夾層前環包圍動脈的水平上，ICA上有一個陰影。 A., artery; A.Ch.A., anterior choroidal artery; Car., carotid; CN, cranial nerve; P.Comm.A., posterior communicating artery; Dist., distal; Hyp., hypophyseal; Prox., proximal; Sup., superior; ICA, internal carotid artery.