圖5.1。幕的切跡。第一，左腦半球被切除。腦幕切骨位於腦幕邊緣之間，是腦幕上和腦幕下空間後麵唯一的交流部位。幕頂位於蓋倫靜脈和直竇的交界處。帳篷的邊緣從頂部向下傾斜。遊離邊沿腦幹一側向前進入硬腦膜覆蓋岩尖和前、後床突。門骨，相對於中腦，分為前、中、後三個空間。前切口空間在視交叉上方延伸至終板，在視交叉和第三室底下方延伸至踝間窩。中切膜位於中腦和腦幕邊緣之間，向上延伸至周圍池和腳池，向下延伸至小腦後腦裂的前部。 The posterior incisural space, located between the posterior midbrain and the tentorial apex, encompasses the quadrigeminal cistern, which extends into the cerebellomesencephalic fissure and along the outer surface of the upper part of the fourth ventricular roof. The anterior incisural space, located below the frontal horn, contains the basilar bifurcation. The PCA and SCA arise in the anterior and pass around the brainstem to reach the middle and posterior incisural spaces. The branches of the PCA and SCA pass through the lateral part of the posterior incisural space, and the large venous structures converging on the vein of Galen course in the medial part of the posterior incisural space. B, part of the left central hemisphere and all of the left thalamus have been removed, while preserving the fornix and choroid plexus. The frontal horn and anterior part of the third ventricle is located above the anterior incisural space. The middle incisural space is located medial to the temporal horn, between the temporal lobe and midbrain. The posterior incisural space is located between the tentorial apex and posterior midbrain surface. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Bas., basilar; Car., carotid; Chor., choroid; CN, cranial nerve; Front., frontal; Gyr., gyrus; Incis., incisural; Mid., middle; Parahippo., parahippocampal; Ped., peduncle; Plex., plexus; Post., posterior; Temp., temporal; Tent., tentorial; V., vein; Vent., ventricle.

圖5.2。前庭切口，視野優越。A，左大腦，在腦梗上方，被切除以暴露前，中，後切口空間。丘腦是側腦室體的底部，位於腦幕切骨中央的正上方。右側腦室和側裂下壁被保留。除去幕幕邊緣的左半部分，露出幕幕小腦表麵。額角位於前切口上方。位於額角以下的前切口空間的結構包括視神經和交叉、頸內動脈和基底動脈的上部及其分支。中切骨間隙位於中腦和腦幕邊緣之間，向上延伸至腳和周圍池，向下延伸至小腦後腦裂的前部。後切骨間隙位於中腦和腦幕尖之間，包括四頭腦池區域，並向小腦後腦裂的中央部分開放。 The atrium of the lateral ventricle is situated lateral to the posterior incisural space. B, view of the tentorial incisura after removing the cerebrum. The tentorial edges sweep along the lateral margin of the cerebral peduncle. The oculomotor nerve passes medial to the anterior edge of the tentorium and enters the cavernous sinus by passing through a triangular patch of dura called the oculomotor trigone. C, superior view of the tentorial incisura before removing the left temporal lobe. The crural cistern is located between the cerebral peduncle and uncus. The ambient cistern opens upward between the midbrain and the medial surface of the temporal lobe formed by the parahippocampal and dentate gyri. The thalamus and the genu of the internal capsule are located above the central part of the tentorial incisura. D, enlarged view after removing the temporal lobe. The internal capsule and the lentiform nucleus are located above the middle incisural space. The genu of the internal capsule abuts on the lateral ventricular wall at the level of the foramen of Monro. A., artery; Ant., anterior; Cap., capsule; Car., carotid; Caud., caudate; Cist., cistern; CN, cranial nerve; For., foramen; Front., frontal; Incis., incisural; Int., internal; Lent., lentiform; Mid., middle; Nucl., nucleus; P.C.A., posterior cerebral artery; Ped., peduncle; Post., posterior; Quad., quadrigeminal; Tent., tentorial; Trig., trigone.

圖5.3。逐步剝離腦幕切骨上方的神經結構。A，右半球的冠狀部分垂直穿過丘腦和外側膝狀體橫切麵穿過腦梗。打開右側顳角，露出海馬體和杏仁核。第三腦室的底部在中線露出來。左半球的冠狀部分穿過丘腦前方，靠近門羅孔和內囊膝。前切骨間隙從蹠間窩，圍繞交叉，延伸到視交叉上區。第二，切除了右側丘腦，但保留了穹窿，穹窿包裹著丘腦形成了位於丘腦和穹窿之間的脈膜裂隙的外緣。中切口空間向上延伸到周圍池和腳池。腳池位於鉤椎和腦踝之間。 The ambient cistern in located between the parahippocampal and dentate gyri and the fimbria of the fornix laterally and the midbrain medially. The posterior part of the tentorial edge is exposed. The quadrigeminal cistern is located in the posterior incisural space between the tentorial apex and the pineal. The atrium is located lateral to the quadrigeminal cistern and posterior incisural space. C, enlarged view. The coronal section through the left hemisphere has been extended backward to the level of the thalamus and posterior limb of the internal capsule. The left temporal horn is exposed below the basal ganglia. The optic nerves, chiasm, and tracts, and the oculomotor nerves cross the anterior incisural space. The middle incisural space extends into the ambient and crural cisterns, and the posterior incisural space, located in front of the tentorial apex, contains the quadrigeminal cistern. D, the upper parts of the anterior and middle incisural spaces have been exposed by removing the thalami on both sides. The tentorial edges extend forward from the apex, located at the posterior margin of the pineal region, along the side of the midbrain to attach to the petrous ridge and clinoid processes. E, the temporal lobe has been sectioned in a coronal plane and the third ventricular floor has been removed. The lateral wall of the ambient cistern is formed by the parahippocampal and dentate gyri and the fimbria of the fornix. F, enlarged view. The rounded medial edge of the parahippocampal gyrus, the site of the subiculum, which blends into the hippocampus, joins the dentate gyri and fimbria to form the lateral wall of the ambient cistern. The fimbria arises on the hippocampal surface. A., artery; Amyg., amygdaloid; Ant., anterior; Cap., capsule; Car., carotid; Chor., choroid; Cist., cistern; CN, cranial nerve; Coll., colliculus; Dent., dentate; Front., frontal; Gen., geniculate; Gyr., gyrus; Incis., incisural; Int., internal; Lat., lateral; Lent., lentiform; Nucl., nucleus; Parahippo., parahippocampal; Ped., peduncle; Plex., plexus; Quad., quadrigeminal; Sulc., sulcus; Temp., temporal; Tent., tentorial; Vent., ventricle.

圖5.4。神經關係
上幕切骨。
從下麵
看到的逐步解剖。A，前切骨
間隙從第三腦室
底下的
足間窩和圍繞視交叉的
向前延伸到
終板。中間的
切口空間向上延伸
進入位於
的腳池(位於鉤椎和大腦
足梗之間)和位於外側
中腦和顳葉之間的周圍池(
)。
後切口空間
位於中腦後方，
包括四頭池
和鬆果體區。前
部分的幕邊緣有
溝鉤。B，切除海馬旁
回的內側
邊緣，露出
周圍池
的頂部，由
丘腦的下表麵和膝曲
體形成。視束在
底池頂部向後延伸
，終止於位於周圍池
頂部前部的外側膝狀體

。
齒狀回和
穹窿的齒狀脊位於
海馬旁回上方的周圍
腦池的
側緣。C，顳角下海馬旁回
的
部分被切除
，同時保留穹窿的
纖維。位於顳角的脈絡膜
叢
沿著位於
絨毛膜和丘腦之間的脈絡膜
裂連接。 D, all but the upper part of the left temporal lobe and fimbria has been removed. The optic tract extends posteriorly through the crural cistern to the anterior part of the ambient cistern where it terminates in the lateral geniculate body. The posterior incisural space between the midbrain and the tentorial apex borders the atrium laterally. Amyg., amygdaloid; Ant., anterior; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Dent., dentate; Fiss., fissure; Gen., geniculate; Gyr., gyrus; Interped., interpeduncular; Lat., lateral; Med., medial; Nucl., nucleus; Olf., olfactory; Parahippo., parahippocampal; Ped., peduncle; Perf., perforated; Pit., pituitary; Plex., plexus; Quad., quadrigeminal; Subst., substance; Temp., temporal; Tent., tentorial; Tr., trunk.

圖5.5。幕的切跡。A，從下麵看與幕切鄰近的池。中切口空間向上打開進入位於鉤椎和足梗之間的底腦池和位於海馬旁回和腦幹外側表麵之間的周圍腦池。pca通過腳和周圍池到達後切骨間隙，即四頭池的位置。基底靜脈在腳和周圍池的上部伴著PCA，並流入四叉池的Galen靜脈。內側後脈絡膜動脈繞腦幹走行，位於pca的內側，有長長的回旋的穿支。B，右顳葉的內側部分被切除露出顳角。穹窿的絲膜，出現在海馬體的上表麵，形成脈絡膜裂隙的下緣，被保存了下來。丘腦、膝狀體和視道位於腳和周圍池的頂部。 C, the right PCA has been removed. The basal vein passes backward above the PCA and empties into the vein of Galen with the internal cerebral and internal occipital veins. The lower surface of the thalamus, the geniculate bodies, and the optic tract form the roof of the crural and ambient cisterns. The anterior choroidal artery passes posteriorly above the uncus and through the choroidal fissure to supply the choroid plexus in the temporal horn. D, both PCAs have been removed to expose the roof of the middle incisural space on both sides and the basal veins, which drain the neural structures in the region. A., artery; Ant., anterior; Car., carotid; Cer., cerebral; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Fiss., fissure; Gen., geniculate; Gyr., gyrus; Incis., incisural; Int., internal; Lat., lateral; Med., medial; Mid., middle; Occip., occipital; Parahippo., parahippocampal; P.C.A., posterior cerebral artery; Plex., plexus; Post., posterior; Quad., quadrigeminal; Temp., temporal; V., vein.

圖5.6。前，中，後切口空間的優越視圖。A和B來自一個標本，C來自另一個標本。首先，通過切除丘腦和除枕葉和顳葉以外的所有左腦半球，我們可以看到腦幕切骨區域的基底池。顳角的頂部被移除了。與前切膜間隙相關的結構，位於鞍結節前方、中腦後方和幕前邊緣外側之間，包括視神經和交叉、頸內動脈、基底動脈、小腦上動脈和多腦動脈。前切口向後打開進入中切口，中切口延伸到腳和周圍池。底腦池位於腦足和鉤椎之間，周圍腦池位於外側中腦和顳葉內側表麵之間。周圍池向後打開，進入後切口空間，其中包含四叉池。基底靜脈、PCA和SCA在中切口間隙繞過中腦，到達後切口間隙和四叉腦池。 B, enlarged view. The preserved tentorial edge is exposed between the basal vein and trochlear nerve. C, superior view of the middle and posterior incisural space in another specimen. The basal vein courses through the crural and ambient cisterns. The upper lip of the calcarine sulcus has been removed but the lower lip of the sulcus has been preserved. The calcarine branch of the PCA loops laterally into the calcarine sulcus, which extends so deeply into the medial part of the hemisphere that it forms a prominence, the calcar avis, in the lower part of the medial wall of the atrium. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Car., carotid; Calc., calcarine; Cer., cerebral; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Comm., communicating; Gyr., gyrus; Incis., incisural; Int., internal; Interped., interpeduncular; M.C.A., middle cerebral artery; Mid., middle; Parahippo., parahippocampal; P.C.A., posterior cerebral artery; Plex., plexus; Post., posterior; Quad., quadrigeminal; Sulc., sulcus; Temp., temporal; Tent., tentorial; V., vein.

圖5.7。模擬。前正中切口間隙。第一，右顳葉被抬高了。中切口空間位於中腦外側表麵和腦幕邊緣之間，向上打開進入周圍池，在那裏PCA和基底靜脈經過。頸內動脈暴露在中腦前麵的前切口空間。B，前切口和中切口交界處的放大視圖。頸內動脈、視神經和顱底分支位於前切口間隙。動眼神經在PCA和SCA之間向前移動。C，顳下回和梭狀回已經被切除暴露出海馬旁回的外側邊緣在正中切口上方。 The opening into the temporal horn exposes the choroid plexus attached along the choroidal fissure. The veins draining the roof of the temporal horn empty into the basal vein. D, the choroidal fissure has been opened by detaching the choroid plexus from the fimbria of the fornix. Opening the fissure exposes the upper part of the ambient cistern and the branches of the PCA and basal vein. A., artery; Ant., anterior; Bas., basilar; Br., branch; Car., carotid; Chor., choroid, choroidal; Cist., cistern; CN, cranial nerve; Comm., communicating; Coll., colliculus; Fiss., fissure; Gen., geniculate; Gyr., gyrus; Inf., inferior; Lat., lateral; Med., medial; Mes., mesencephalic; Parahippo., parahippocampal; P.C.A., posterior cerebral artery; Ped., peduncle; Plex., plexus; Post., posterior; S.C.A., superior cerebellar artery; Sup., superior; Temp., temporal; Tent., tentorial; V., vein; Vent., ventricular.

圖5.7。情況。E，前正中切口間隙，放大視圖。通過脈絡膜裂的開口暴露了基底靜脈和周圍池上部的PCA分支。PCA向脈絡膜叢發出許多分支，包括一個大的脈絡膜後外側動脈。F，海馬體和顳葉的內側部分，包括海馬旁回，已經被移除，露出中切口空間的上部。PCA和基底靜脈穿過海馬旁回內側的中間切口空間，已經被切除了。脈絡膜叢沿著位於脈絡膜和丘腦下表麵之間的脈絡膜裂隙相連。下心室靜脈從顳角頂部流出並流入基底靜脈。G，切除PCA的分支以暴露基底靜脈，基底靜脈起源於前穿孔物質的下方，向後方通過中切口空間，進入後切口空間和四叉神經池。 The pulvinar and lower surface of the thalamus, including the geniculate bodies, are in the upper margin of the exposure. H, the basal vein has been removed. This exposes the lateral aspect of the cerebral peduncle and the tegmental part of the midbrain, which are separated by the lateral mesencephalic sulcus. The medial and lateral geniculate bodies protrude downward from the lower surface of the thalamus.

圖5.8。前和中顳下暴露的前和相鄰部分的中切口空間。A，開顱瓣和硬腦膜開口暴露了顳葉和中顱窩底。插入片顯示頭皮切口的位置。B，顳葉被抬高暴露出前和中切口空間的PCA和SCA。PCA在動眼神經上方，SCA在動眼神經下方。SCA分支與滑車神經一起沿腦幹側行。C, PCA被壓下暴露基底動脈。脈絡膜前動脈起於切口前間隙，穿過腦梗和鉤椎之間，在切口中部進入腳池。D，幕被劃分在岩脊後麵暴露出SCA以及三叉神經和滑車神經在中切口區域。 The SCA sends branches above the trigeminal nerve and into the anterior part of the cerebellomesencephalic fissure. The medial posterior choroidal artery also passes around the lateral side of the brainstem. A., artery; Ant., anterior; Bas., basilar; Br., branch; Car., carotid; Chor., choroidal, CN, cranial nerve; Comm., communicating; Fiss., fissure; M.C.A., middle cerebral artery; Med., medial; P.C.A., posterior cerebral artery; Ped., peduncle; Post., posterior; S.C.A., superior cerebellar artery; Temp., temporal; Tent., tentorial.

圖5.9。f。額顳開顱術暴露前切口空間。A，插入物顯示了開顱手術的位置。額葉和顳葉被縮回以暴露視神經和動眼神經以及前、中大腦和後交通動脈。B，視神經三角，位於視神經、頸動脈和大腦前動脈之間，已被輕輕打開，露出基底尖和同側動眼神經向前穿過PCA和SCA之間。C，暴露被定向到視神經交叉上方以暴露前交通動脈區域。D，額葉被抬高暴露了對側頸動脈和大腦前動脈和中動脈。E，頸動脈被抬高通過頸動脈和動眼神經之間的間隔暴露基底動脈頂端。後床突阻斷了基底動脈的通路。 F, the anterior clinoid process and the roof of the cavernous sinus have been removed to provide access to the posterior clinoid process. The upper dural ring is located at the level of the upper margin of the anterior clinoid process. A., artery; A.C.A., anterior cerebral artery; Ant., anterior; Bas., basilar; Car., carotid; Cav., cavernous; Clin., clinoid; CN, cranial nerve; Comm., communicating; Contra., contralateral; Ipsi., ipsilateral; Lam., lamina; M.C.A., middle cerebral artery; P.C.A., posterior cerebral artery; Post., posterior; S.C.A., superior cerebellar artery; Term., terminalis; V1., first ophthalmic branch, trigeminal nerve.

圖5.9。G-J。額顳開顱術暴露前切口空間。G，後床突被切除以增加基底動脈上部的通路。H幕邊緣的前部已經被切除，暴露出三叉神經後根在Meckel 's洞穴的上邊緣，並增加進入後窩前上部的通道。在開幕邊緣前部保留滑車神經。I，另一種剝離術，切除前床突和海綿竇頂，暴露前頸動脈和後動眼器之間的後床突。J，切除後床突以增加基底動脈上部的通路。

圖5.10。f。四頭池和第三後腦室中線、中位經小腦上幕下、枕部幕後入路的比較。A-D，第三腦室和四腦池的視圖。A，從上麵看第三心室。穹窿體將側腦室體與第三腦室頂分開。穹窿體向後與穹窿小腿混合，穹窿小腿位於第三腦室後部上方。脈絡膜裂是脈絡膜叢的附著部位，位於穹窿和丘腦之間。B，穹窿在柱的水平處被分割，就在Monro孔的後麵，向後反射，暴露出後連合、鬆果體和四頭池的相鄰部分。C，四腦池位於鬆果體和丘的後麵，在枕核之間。 It extends into the cerebellomesencephalic fissure. The trochlear nerves arise below the inferior colliculi. D, view similar to C, except that the vessels have been preserved. The internal cerebral and basal veins join the vein of Galen behind the pineal. The PCA and SCA exit the ambient cistern to enter the lateral part of the quadrigeminal cistern. Both the infratentorial supracerebellar and occipital transtentorial approaches are directed to this area. E and F, midline infratentorial supracerebellar approach. E, the venous complex emptying into the vein of Galen blocks access to the pineal region. This complex includes the internal occipital, basal and internal cerebral veins, and the vein of the cerebellomesencephalic fissure. A tentorial branch of the SCA crosses the exposure. F, the vein of Galen has been retracted to expose the splenium. The vein of the cerebellomesencephalic fissure has been retracted to expose the pineal. A., artery; Bridg., bridging; Cer., cerebral; Cer. Mes., cerebellomesencephalic; Chor., choroidal; Cist., cistern; CN, cranial nerve; Coll., colliculus; Comm., communicating; Fiss., fissure; For., foramen; Inf., inferior; Int., internal; Lat., lateral; Med., medial; Occip., occipital; P.C.A., posterior cerebral artery; Ped., peduncle; Plex., plexus; Post., posterior; Quad., quadrigeminal; Sag., sagittal; S.C.A., superior cerebellar artery; Str., straight; Sup., superior; Temp., temporal; Tent., tentorial; Trans., transverse; V., vein; Ve., vermian; Vent., ventricle.

圖5.10。G-L。G和H，中線幕下小腦上入路。G，左側腦基底靜脈和內靜脈被抬高，小腦後腦裂靜脈被蚓上靜脈連接，已向右縮回，露出上丘、鬆果體和脾。H，附著在鬆果體上表麵的脈留膜末梢被打開，露出第三腦室的後部。I-L，幕下小腦上入路的中位變體。在這種變體中，腦幕表麵的收縮從蚓部和腦幕尖移至半球的中端。該入路的中位變體可進入四頭池的外側部分和周圍池的後部，此外，與蚓尖上方中線入路相比，該入路能更好地觀察小腦後裂的中央和同側半部分。第一，中側入路的後收已移至蚓部左側。J，左腦內和枕內靜脈被縮回，露出脾後部，鬆果體和上、下丘，以及從周圍池出的PCA和SCA分支。 K, enlarged view. The exposure has been shifted to where the PCA exits the ambient cistern. L, the paramedian approach provides easier access to the superior and inferior colliculi and requires less retraction than is needed to expose these structures in the approach directed in the midline above the apex of the tentorial cerebellar surface.

圖5.10。先生。枕transtentorial方法。M，枕骨幕後區沿著枕骨葉的內側表麵在羔羊骨縫線下麵。在羔羊骨縫合下方的枕葉通常沒有通往上矢狀竇的橋靜脈，因此它是枕骨幕前入路的合理路徑。N，枕葉後6cm與上矢狀竇之間沒有大的橋靜脈。第一個靜脈是枕內靜脈它從枕內葉的前部到蓋倫靜脈。噢，蓋倫靜脈已被收回從上麵露出脾和鬆果體。P，在直竇的外側打開幕，蓋倫靜脈移至左側暴露鬆果體和上、下丘。Q，抬高Galen靜脈的分支可以很好地觀察到四叉腦池，與小腦幕下小腦上入路相比，可以更好地觀察到小腦間裂。 R, the exposure has been directed laterally along the side of the brainstem to the ambient cistern where the lateral margin of the cerebral peduncle is exposed.

圖5.11。幕下小腦上、枕部幕下及幕下聯合入路的比較。幕下小腦上入路。入路在幕下表麵和幕小腦表麵之間。進入Galen靜脈的大靜脈複合體位於暴露的中央，PCA和SCA橫向暴露。小腦後裂的一條大靜脈阻斷了鬆果體的通路，限製了小腦後裂的通路。這種入路適用於位於Galen靜脈下方中線且不深入橋小腦裂的病變。環繞小腦後腦裂唇的SCA分支可能向上延伸並限製進入鬆果體區。B，小腦後腦裂的靜脈必須分開以露出鬆果體。內側後脈絡膜動脈與該區域的靜脈交織在一起。 C, the occipital transtentorial approach has been directed along the medial side of the right occipital lobe. The tentorium behind the quadrigeminal cistern has been divided. The approach provides access to the splenium and the upper part of the cerebellomesencephalic fissure and has been extended forward to the lateral surface of the cerebral peduncles. Both the superior and inferior colliculi can be exposed and the arteries can be followed forward into the ipsilateral ambient cistern. In addition, the veins joining the vein of Galen can be elevated to expose the pineal. The trochlear nerve is exposed just distal to its brainstem exit below the inferior colliculus. D, combined supra and infratentorial exposure with the division of the transverse sinus and tentorium. Division of the transverse sinus, if it is small and well collateralized, provides an exposure that combines both the supra- and infratentorial approaches. A., artery; Cer., cerebral; Cer. Mes., cerebellomesencephalic; Chor., choroidal; CN, cranial nerve; Coll., colliculus; Fiss., fissure; Inf., inferior; Int., internal; Med., medial; Occip., occipital; P.C.A., posterior cerebral artery; Ped., peduncle; Post., posterior; S.C.A., superior cerebellar artery; Sup., superior; Temp., temporal; V., vein.