圖。1。通過中線、中線、外側和遠外側小腦小幕下路徑測量鬆果體的深度和小腦小幕麵角度。A:橫竇和乙狀竇拐角水平的軸向CT圖像(A平麵，穿過橫竇和乙狀竇交界處的軸向平麵)。在檢查不同的小腦上幕下入路時，小齒輪和乙狀竇之間的距離被分成三份。中線路線沿中線(藍色箭頭)，旁正中路線沿中間三分之二交界處(黃色箭頭)，外側路線沿中間和外側三分之二交界處(綠色箭頭)，遠外側路線沿小腦上方毗鄰橫竇和乙狀竇交界處(紅色箭頭)。B:小腦上幕下鬆果體手術入路右後外側視圖。圖示中線(藍色箭頭)、中線(黃色箭頭)、側線(綠色箭頭)和遠側線(紅色箭頭)。版權所有Satoshi Matsuo。已獲授權發布。C:重建的CT矢狀麵圖像，垂直於A麵板所示平麵(平麵A)，與鬆果體(紅圈)和中線路線接近點(藍圈)相交。 The approach point was defined as the point just below the sigmoid sinus on the inner surface of the occipital bone. The distance between the pineal gland (red circle) and the approach point (blue circle) was defined as the depth of the pineal gland. The angle of the tentorial surface of the cerebellum was defined as the angle between the orbitomeatal plane and the line through the approach point (blue circle) and the highest point of the tentorial surface of the cerebellum (yellow circle). D: Reconstructed sagittal CT image perpendicular to Plane A and intersecting the pineal gland (red circle) and the approach point (blue circle) of the paramedian route. E: Reconstructed sagittal CT image perpendicular to Plane A and intersecting the pineal gland (red circle) and the approach point (blue circle) of the lateral route. F: Reconstructed sagittal CT image perpendicular to Plane A and intersecting the pineal gland (red circle) and the approach point (blue circle) of the far-lateral route. Gl. = gland; Infratent. = infratentorial; Lat. = lateral; Mid. = midline; Paramed. = paramedian. (Images courtesy of AL Rhoton, Jr.)

圖。2。後切口間隙的神經血管關係。A:左幕切骨側位圖。左大腦半球被切除了。小幕切骨位於小幕邊緣之間。小腦門板相對於腦幹分為前、中、後間隙。後切膜間隙，鬆果體的位置，位於中腦後和幕尖之間。腦後動脈和小腦上動脈起於前壁間隙，並繞腦幹到達後壁間隙。腦內靜脈穿過腦間膜，基底靜脈起源於前切口間隙，環繞中腦，在後切口間隙彙合，最後流入Galen靜脈。鬆果體位於第三腦室後方，Galen靜脈前方，脾前部下方，丘板上方。 B: Superior view of the left tentorial incisura after removal of all of the left cerebral hemisphere except the temporal lobe. The roof of the temporal horn and part of the parahippocampal gyrus have been removed. The basal vein, which originates in the anterior incisural space at the union of the anterior cerebral and deep middle cerebral veins, and internal cerebral vein join in the posterior incisural space and empty into the vein of Galen. C: Superior view of the tentorial incisura and cerebellum. The cerebral hemispheres and tentorium have been removed to expose the tentorial surface of the cerebellum. The distal part of the posterior cerebral artery has been removed to expose the course of the superior cerebellar artery. The superior cerebellar artery, which usually arises below the oculomotor nerve as a single trunk from the basilar artery, arises on the right side as a duplicated trunk. The superior cerebellar artery courses below the trochlear nerve and above the trigeminal nerve, to reach the cerebellomesencephalic fissure, which extends downward between the midbrain and the cerebellum. The superficial part of the posterior lip of the fissure is formed by the culmen in the midline and the quadrangular lobule laterally. After leaving the fissure, the superior cerebellar artery gives rise to the branches to the tentorial surface of the cerebellum. D: Posterolateral view of the left posterior incisural space and tentorial surface of the cerebellum. The right occipital, parietal, and temporal lobes have been removed at the level of the body of the lateral ventricle. The right tentorium has been removed to expose the tentorial surface of the cerebellum. The superior and inferior hemispheric veins drain the tentorial surface of the cerebellum and join before emptying into the tentorial sinuses. The posterior pericallosal vein, which drains the posterior part of the cingulate gyrus, empties around the splenium into the vein of Galen in the quadrigeminal cistern. E: Enlarged view. The internal cerebral, posterior pericallosal, basal, and superior vermian veins empty into the vein of Galen. The superior and inferior colliculi are located posterior and inferior to the pineal gland. The medial posterior choroidal artery courses beside the pineal gland and enters the velum interpositum in the roof of the third ventricle. The lateral posterior choroidal artery, which arises from the posterior cerebral artery, enters into the lateral ventricle through the choroidal fissure. A. = artery; A.C.A. = anterior cerebral artery; Ant. = anterior; Bas. = basilar; Calc. = calcarine; Car. = carotid; Cent. = central; Cer. = cerebral, cerebellar; Cer. Mes. = cerebellomesencephalic; Chor. = choroidal; Cing. = cingulate; Cist. = cistern; CN = cranial nerve; Coll. = colliculus; dup. = duplicate; Fiss. = fissure; For. = foramen (of); Gyr. = gyrus; Hem. = hemispheric; Incis. = incisural; Inf. = inferior; Int. = internal; Interpos. = interpositum; M.C.A. = middle cerebral artery; Med. = medial, medullary; Mid. = middle; Occip. = occipital; P.C.A. = posterior cerebral artery; P. Comm. = posterior communicating; Par. = parietal; Parahippo. = parahippocampal; Ped. = peduncle; Pericall. = pericallosal; Post. = posterior; Quad. = quadrigeminal, quadrangular; S.C.A. = superior cerebellar artery; Sag.= sagittal; Str. = straight; Sulc. = sulcus; Sup. = superior; Sylv. = sylvian; Temp. = temporal; Tent. = tentorium, tentorial; V. = vein (of); Vel. = velum; Vent. = ventricle; Verm. = vermian. (Images courtesy of AL Rhoton, Jr.)

圖。3。後切口間隙的神經關係。A:切除左腦半球、小腦和腦幹後切牙間隙的矢狀麵。後切間隙的前壁由鬆果體、上、下丘和蚓舌組成。後切口空間的屋頂由脾下表麵和穹窿體後部組成。後切間隙的底部由蚓部的頂部和中央小葉組成。後切間隙向下延伸至小腦腦裂。B:右半腦幹在上丘水平切除後的右後上視圖。韁肌和後連肌形成了腺體與第三腦室後部的連接。枕骨、穹窿小腿和海馬旁回構成後切口空間的側壁。 C: Inferior view of the medial temporal lobe and lateral wall of the posterior incisural space. The brainstem and cerebellum have been removed. The pulvinar, located just lateral to the pineal body, and the crus of the fornix, located posterior to the pulvinar, form the lateral wall of the posterior incisura space. Cer. Mes. = cerebellomesencephalic; Coll. = colliculus; Comm. = commissure; Hab. = habenular; Hippo. = hippocampal; Mam. = mammillary; Tr. = tract. (Images courtesy of AL Rhoton, Jr.)

圖。4。中線(A和B)和右中線(C和D)小幕下小腦上顯微手術和內鏡入路到鬆果體。A:鬆果體顯微中線入路。打開四叉神經池，可以看到蚓上靜脈、枕內靜脈、基底靜脈、腦內靜脈和Galen靜脈。在中線入路中，可能需要收縮或犧牲蠕蟲上靜脈以暴露鬆果體區。B:內窺鏡中線入路。C:鬆果體右側旁位顯微外科入路。在蚓上靜脈和腦內靜脈之間可暴露鬆果體和上、下丘，而不犧牲靜脈。腺體的離中線視圖打開了腺體周圍大靜脈之間的視角。D:內鏡輔助入路。 The pineal gland can be exposed between the galenic tributaries. Retracting the cerebellum can provide access to the superior and inferior colliculi. Coll. = collicular, colliculus; Med. = medial; Tent. = tentorial, tentorium. (Images courtesy of AL Rhoton, Jr.)

圖。5。右側(A和B)和遠側(C和D)小幕下小腦上顯微外科和內窺鏡入路到鬆果體。A:鬆果體右側顯微外科入路。注意，中線外入路允許暴露在半球靜脈之間，在淺層流入幕竇，在Galen靜脈水平前於蚓上靜脈。B:內窺鏡側入路。C:鬆果體右側遠側顯微手術入路。進路向外側移動得越遠，蚓上靜脈與腦內靜脈之間的進路就越寬。D:內鏡遠側入路。Cer。=腦; Cer. Mes. = cerebellomesencephalic; Coll. = collicular, colliculus; Tent. = tentorial, tentorium. (Images courtesy of AL Rhoton, Jr.)

圖。6。小腦上幕下鬆果體顯微手術入路。A:小腦枕下表麵。扁桃體後靜脈上行與蚓下靜脈彙合，蚓下靜脈沿蚓半球裂隙上行並流入橫竇靠近眼眶和中線。下半球靜脈上升進入幕內靜脈竇。右下半球靜脈與扁桃體後靜脈吻合。B:帳篷下方的後視圖。蚓下靜脈引流扁桃體、蚓下和半球的鄰近部分，並流入中線附近的橫竇。上、下半球靜脈引流枕下麵和小腦幕麵，並流入幕下竇，其可流入直竇(C)或橫竇(D)。兩組半球橋靜脈之間的離中線幕下入路通常可進入鬆果體，而不損害任何橋靜脈。而中線入路通常需要明顯的回縮或閉塞這些橋靜脈。 C: Posterior view beneath the right half of the tentorium. The superior and inferior hemispheric veins drain the suboccipital and tentorial cerebellar surfaces and empty into a tentorial sinus, which empties into the straight sinus in the posterior fossa. D: Posterior view beneath the left half of the tentorium. The superior and inferior hemispheric veins drain the suboccipital and tentorial cerebellar surfaces and empty into a tentorial sinus that empties into the transverse sinus. E: Superior view of the tentorium. The cerebral hemispheres have been removed while preserving the tentorium. Each half of the tentorium has 2 tentorial sinuses. The medial tentorial sinuses (yellow arrows) course medially to empty into the straight sinus near the junction of the straight and transverse sinuses. The lateral tentorial sinuses (red arrows), formed by the union of veins from the basal and lateral surfaces of the temporal and occipital lobes, including the vein of Labbé and temporobasal and occipital veins, course laterally to empty into the terminal portion of the transverse sinus. F: Superior view of the tentorial cerebellar surface. The tentorium has been removed while preserving the tentorial edges and the tentorial, superior petrosal, straight, and transverse sinuses. The medial tentorial sinuses formed by the union of the superior and inferior hemispheric veins course medially to empty into the torcula or straight sinus. P.I.C.A. = posterior inferior cerebellar artery; Pet. = petrosal; Retrotons. = retrotonsilar; Tent. = tentorial, tentorium; Trans. = transverse.