圖1．CS內側壁測量圖(定義見表1)。V2，三叉神經的第二分支;V3，三叉神經的第三分支。(圖片由AL Rhoton, Jr.提供)

圖2。腦下垂體和腦下皮質的冠狀麵圖。硬腦膜被分為腦膜層(橙色)和髓膜層(綠色)。這兩層在顱中窩底緊密粘附，但在第二三叉神經區(V2)的上緣，即CS的最下端，它們分離為兩層。腦膜層向上延伸形成腦脊膜外側壁和頂板的外層和膈鞍的上層。在上頜神經上緣水平的內切層分為兩層。一層向上延伸構成頸動脈外側壁和鞍底的內層，另一層緊貼蝶骨，覆蓋頸動脈溝和鞍底。從膈膜的遊離邊緣，一層薄薄的硬腦膜向下延伸包裹，但很容易與腦垂體分離。我們的解剖顯示腦膜層形成了內側壁的鞍部，內膜層(綠色層)形成了內側壁的蝶竇部。A，下海綿間竇連接成對的海綿竇。 These intercavernous sinuses extend across the midline between the meningeal dural layer covering the inferior aspect of the pituitary gland and the endosteal layer covering the osseous sellar floor. B, no inferior intercavernous sinus, and the meningeal and endosteal layers of dura fuse into a single layer on the sellar floor. C, the ease of separating the meningeal layer covering the inferior aspect of the pituitary gland from the endosteal layer covering the bony sellar floor. D, the intracavernous carotid indenting and deforming the lateral surface of the pituitary gland to create protrusion of the gland above the artery. E, lateral tongue-like protrusions of the pituitary gland extending above the intracavernous carotid. F, an empty sella. The superior portion of the sellar part of the medial wall, formed by the meningeal layer (orange), separates the contents of the CS from the extension of the chiasmatic cistern into the sella. A., artery; Car., carotid; CN, cranial nerve; Inf., inferior; Intercav., intercavernous; Pit., pituitary; Sphen., sphenoid; V1, first division of the trigeminal nerve; V2, second division of the trigeminal nerve; V3, third division of the trigeminal nerve; III, oculomotor nerve; IV, trochlear nerve. (Images courtesy of AL Rhoton, Jr.)

圖3。照片顯示左腦脊骨逐步剝離。左顱底上外側視圖。切除左側前凸突以暴露視神經支柱。骶髂脊位於眶上裂後方，三叉神經第二段上緣和蝶骨舌部上方，鞍膈下方，鞍背前方。蝶骨上與CS相關的骨結構為(虛線):前臥突、視神經支柱、頸動脈溝、舌、鞍背和後臥突。B, CS外側壁從穹幕邊緣向下延伸並與覆蓋Meckel 's洞穴和中窩的硬腦膜融合。動眼神經和滑車神經進入CS的頂部。頸動脈在前床突的內側出CS。C，硬腦膜的外層(腦膜層)已經從腦脊膜的側壁剝離，薄薄的內層(神經內膜層)保存了下來。 The lateral wall of Meckel’s cave and the anterior clinoid process have been removed to expose the clinoidal segment of the carotid artery. This exposes the oculomotor, trochlear, and ophthalmic nerves in the roof and lateral wall of the CS and passing forward through the superior orbital fissure. The thin layer covering Meckel’s cave consists in part of the arachnoid membrane extending forward from the posterior fossa and surrounding the trigeminal nerve to the level of the trigeminal ganglion. D, the thin inner layer of dura covering the lateral wall (endosteal layer) has been removed. The oculomotor, trochlear, and ophthalmic nerves converge on the superior orbital fissure. The optic strut separates the optic canal and superior orbital fissure. The dura extending medially off the upper surface of the anterior clinoid forms the upper dural ring around the internal carotid artery, and the dura lining the lower margin of the clinoid extends medially to form the lower dural ring. The clinoidal segment of the carotid artery, located between the upper and lower dural ring, is enclosed in a dural sheath, referred to as the carotid collar. E, the ophthalmic nerve has been depressed to expose the abducens nerve, which courses medial to the ophthalmic nerve. The oculomotor nerve splits into superior and inferior divisions just behind the level of the superior orbital fissure. F, the ophthalmic and abducens nerves have been depressed to expose the venous space of the cavernous sinus and the cavernous segment of the internal carotid artery. G, the cranial nerves have been displaced, and the intracavernous carotid has been removed to expose the sellar and sphenoidal parts of the medial wall. The superior and inferior margins of the removed segment of the carotid artery that coursed along all the pituitary gland are shown (yellow dotted line). H, another specimen in which the sellar part of the medial wall of the left CS has been opened and reflected away from the capsule of the pituitary gland. The sellar part of the medial wall separates easily from the pituitary capsule that is attached to the gland. A., artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; Clin., clinoid, clinoidal; CN, cranial nerve; Div., division; Fiss., fissure; For., foramen; Gang., ganglion; Gr., greater; Inf., inferior; Lat., lateral; M., muscle; Ophth., ophthalmic; Orb., orbital; Pet., petrosal; Pit., pituitary; Post., posterior; Rec., rectus; Seg., segment; Sphen., sphenoidal; Sup., superior; V, trigeminal nerve. (Images courtesy of AL Rhoton, Jr.)

圖4。照片顯示右側脊髓脊髓的階梯式剝離。A，前臥位和動眼神經的後部，眼神經和上頜神經都被切除了。CS向下延伸到海綿內頸動脈和蝶骨體上的頸動脈溝的下方並延伸到上頜神經的上緣。硬腦膜從前凸肌上表麵向內延伸形成頸內動脈周圍的硬腦膜上環，位於前凸肌下緣的硬腦膜向內延伸形成下硬腦膜環。頸動脈的斜位段位於硬腦膜上環和下環之間。B，海綿內頸動脈水平段上方的靜脈空間已經被清空。通過內側竇壁可觀察到垂體。下外側幹起於海綿內頸動脈水平段中部的外側並從外展神經的上方和外側穿過。C，海綿狀內頸動脈，下外側幹起點遠端，已被切除以暴露內側壁和內靜脈空間。 The posterior clinoid and dorsum sellae also have been removed to expose the posterior lobe of the pituitary gland. The inferior hypophyseal and dorsal meningeal arteries arise from the meningohypophyseal trunk. D, the part of the intracavernous carotid above the level of the superior edge of the abducens nerve has been removed to expose the sphenoidal part of the medial wall. The inferior hypophyseal artery runs in the dura that covers the posterior inferior part of the anterior lobe and pierces the pituitary capsule at the level of the posterior lobe. The superior and inferior margins of the intracavernous carotid are marked (yellow dotted line). In this case, the horizontal segment of the intracavernous carotid courses below the level of the sellar floor and the pituitary gland. E, enlarged view of the medial wall. In this specimen, the intercavernous sinuses are located along the anterior and inferior margins of the pituitary gland. The dorsum sellae has been removed. The sellar part of the medial wall (dotted line) covers the lateral surface of the anterior lobe but not the posterior lobe, which sits in the concavity of the dorsum sellae behind the sellar part of the medial wall. F, the pituitary gland and the sellar part of the medial wall have been removed from the sella. The sellar part of the medial wall (outer margin, yellow dotted line) does not extend lateral to the posterior lobe but blends into the lateral margin of the dorsum in front of the posterior lobe, which sits in the concavity of the dorsum. A., artery; Ant., anterior; Car., carotid; Cav., cavernous; Clin., clinoid, clinoidal; CN, cranial nerve; Diaph., diaphragm; Dors., dorsal; Hyp., hypophyseal; Inf., inferior; Lat., lateral; Lig., ligament; Men., meningeal; Ophth., ophthalmic; Petroling., petrolingual; Pit., pituitary; Post., posterior; Seg., segment; Tr., trunk; V, trigeminal nerve. (Images courtesy of AL Rhoton, Jr.)

圖5。顯示顳下頜關節內側壁的照片。A，內側壁鞍部與垂體外表麵接觸;內側壁的蝶骨部分覆蓋在上頜神經上緣上方的蝶骨體。海綿內頸動脈的後垂直和水平段被切除，但外展神經被保留。B，一個微型解剖器通過鞍膈放置，在內側壁的鞍部和垂體之間。C，放置了三個微型解剖器。一個放置在內側壁鞍部與垂體之間，另一個放置在垂體上方，傾斜的微解剖器與覆蓋鞍背凹麵的內膜層接觸，並與鞍底的內膜層混合。垂體後葉位於鞍背前凹麵，位於內側壁與鞍背外側緣連接點的後麵。D，內側壁的鞍部被打開了葉子從腺體中縮回。 The pituitary capsule is tightly attached to the gland and is a separate structure from the medial wall of the CS. E, superolateral view. The pituitary gland and the diaphragm sellae have been retracted to show the sellar part of the right medial wall. A., artery; Car., carotid; Clin., clinoid; CN, cranial nerve; Diaph., diaphragm; Ophth., ophthalmic; Pit., pituitary; Post., posterior; Sphen., sphenoidal; VI, abducens nerve; V1, first division of the trigeminal nerve; V2, second division of the trigeminal nerve. (Images courtesy of AL Rhoton, Jr.)

圖6。照片顯示從內側到外側的階梯夾層。A，中線水平的矢狀切麵。部分鼻中隔被切除了。蝶竇位於蝶骨體內。貝殼被保存了下來。B，垂體和蝶竇的放大視圖。蝶竇的粘膜被切除了。C，垂體被切除，露出內側壁的鞍部。通過內側壁的鞍部可以觀察到海綿狀內頸動脈內側靜脈空間和神經叢的藍色。 The anterior intercavernous sinus crosses anterosuperior to the pituitary gland and the basilar sinus crosses posterior to the gland and dorsum. D, the bone forming the lateral wall of the sphenoid sinus has been removed to expose the sphenoidal part of the medial wall (yellow dotted line). A rectangular window of dura has been removed to show the venous space inside the CS (yellow arrow) that separates the intracavernous carotid from the dura forming the sphenoidal part of the medial wall. The posterior vertical segment of the intracavernous carotid can be observed through the dura of the medial wall. The horizontal segment of the intracavernous carotid courses lateral to the venous space. A., artery; Ant., anterior; Car., carotid; CN, cranial nerve; Diaph., diaphragm; Eust., Eustachian; Inf., inferior; Intercav., intercavernous; Mid., middle; Pit., pituitary; Post., posterior; Seg., segment; Sphen., sphenoid; Sup., superior; Vert., vertical. (Images courtesy of AL Rhoton, Jr.)

圖7。顱腦內側壁照片。A，側壁和頂部、前、後側凸、一段顱神經和部分海綿狀頸內動脈被切除，暴露出與腦脊膜內壁直接接觸的靜脈空間。靜脈腔最厚的部分位於頸動脈溝的上緣和下緣附近。B，海綿內頸動脈內側的靜脈空間已經部分被清空以暴露內側壁的鞍部和蝶部。海綿內頸動脈的上緣和下緣(黃色虛線)沿著垂體腺的下三分之一。C-F，另一個標本的左內側壁。C，內側壁鞍部側麵放大圖。頸動脈外側壁、顱神經和海綿內頸動脈已被切除。靜脈腔內的物質向下收縮以顯示內側壁的鞍部(黃色虛線)。 Intercavernous sinuses cross the anterior and posterior margins of the pituitary gland and connect both CS (yellow arrows). D, the material in the venous space has been removed to expose the sellar and sphenoidal parts of the medial wall. E, the sellar part of the medial wall is located at the area lateral to the anterior lobe but not the posterior lobe because the posterior lobe sits in the concavity of the anterior surface of the dorsum sellae behind the medial wall. The inferior hypophyseal artery runs in the posterior inferior part of the sellar part of the medial wall to pierce the pituitary capsule at the level of the posterior lobe. F, the endosteal layer of the dura lining the sellar floor (red arrows) separates easily from the meningeal layer that forms the sellar part of the medial wall (yellow arrows) and extends below the pituitary gland. The intercavernous sinuses cross the midline between the meningeal and endosteal layers of dura to communicate the paired CS. A., artery; Ant., anterior; Car., carotid; Cav., cavernous; Clin., clinoid; CN, cranial nerve; Hyp., hypophyseal; Inf., inferior; Intercav., intercavernous; Ophth., ophthalmic; Pit., pituitary; Post., posterior; Seg., segment; Sphen., sphenoidal. (Images courtesy of AL Rhoton, Jr.)

圖8。三個標本的照片。海綿內頸動脈(綠色箭頭)上方的垂體雙側突起標本的後上位視圖。頸動脈外側壁，前斜突，顱神經，頸動脈斜突段和頸動脈脊上段都被切除。B，另一標本左骶管上外側視圖，蝶鞍部分空(黃色箭頭)。左側海綿內頸動脈，靜脈腔內的物質，以及顱神經都被切除了。通過內側壁觀察到對側(右)頸動脈海綿狀內動脈。交叉池延伸到鞍區(黃色箭頭)，靠在鞍區內側壁的上半部分。C，巨大的前海綿間竇穿過鞍壁的硬腦膜層。內側壁的鞍部與交叉池的下延伸部直接接觸，進入部分空鞍區(黃色箭頭)。 D, lateral view of the right medial wall of the specimen shown in C. This specimen presents a large anterior intercavernous sinus with extension of the chiasmatic cistern into the partial empty sella (yellow arrow). Ant., anterior; Cav., cavernous; CN, cranial nerve; Intercav., intercavernous; Pit., pituitary; Seg., segment. (Images courtesy of AL Rhoton, Jr.)

圖9。右側頸動脈側位圖顯示了海綿內頸動脈和內側壁鞍部之間的不同關係。A，海綿內頸動脈在頸動脈溝上，與內側壁鞍部沒有任何接觸。B，海綿內頸動脈在腺下三分之一和內側壁的外側。C，海綿狀內頸動脈延伸到腺體中部和下三分之一部分和內側壁的外側。D，海綿內頸動脈在腺體的三分之一和內側壁的外側。一個,動脈;螞蟻。前;的車。, carotid; Cav., cavernous; Clin., clinoid; Fiss., fissure; For., foramen; Orb., orbital; Pit., pituitary; Post., posterior; Seg., segment; Sphen., sphenoidal; Sup., superior. (Images courtesy of AL Rhoton, Jr.)

圖10。圖示經蝶竇入路至蝶鞍後硬腦膜開口。第一，在鞍前角使用刀切開硬腦膜應避免暴露因為海綿內頸動脈會壓進腺體或腫瘤的外側可能在硬腦膜外側切開時被刀損壞。B，高級作者(ALR)從中線處的一個短垂直切口開始打開硬腦膜。一個小的，鈍的，直角環形刮匙通過小的垂直硬腦膜開口插入，將硬腦膜與腺體和腫瘤分開。取出硬腦膜後，用一把45度角的剪刀從一個角到另一個角以x形切口將硬腦膜切開。用插入硬腦膜內的剪刀將硬腦膜從腺體抬高，這樣就可以通過硬腦膜觀察到硬腦膜刀片，以確保沒有其他結構被切割。(圖片由AL Rhoton, Jr.提供)