额眶颧入路的临床应用额眶颧入路的临床应用赵元立赵元立北京天坛医院神经外科北京天坛医院神经外科2003.09.192003.09.19额眶颧入路的历史额眶颧入路的历史 Yasargil Yasargil Yasargil Yasargil 经典的额颞开颅经典的额颞开颅经典的额颞开颅经典的额颞开颅 - - - - 翼点入路翼点入路翼点入路翼点入路 JaneJaneJaneJane（1982198219821982）打开部分眶顶打开部分眶顶打开部分眶顶打开部分眶顶 Al-Al-Al-Al-MeftyMeftyMeftyMefty（1983198319831983）打开眶上壁和外侧壁打开眶上壁和外侧壁打开眶上壁和外侧壁打开眶上壁和外侧壁额眶颧开颅：额眶颧开颅：额眶颧开颅：额眶颧开颅： PellerinPellerinPellerinPellerin（1984198419841984）颅眶沟通肿瘤颅眶沟通肿瘤颅眶沟通肿瘤颅眶沟通肿瘤 HakubaHakubaHakubaHakuba（1986198619861986）鞍旁海绵窦肿瘤及基底动脉瘤鞍旁海绵窦肿瘤及基底动脉瘤鞍旁海绵窦肿瘤及基底动脉瘤鞍旁海绵窦肿瘤及基底动脉瘤 SpetzlerSpetzlerSpetzlerSpetzler（1992199219921992）前、中颅底及斜坡上前、中颅底及斜坡上前、中颅底及斜坡上前、中颅底及斜坡上1/31/31/31/3的的的的 肿瘤、动脉瘤及海绵状血管瘤肿瘤、动脉瘤及海绵状血管瘤肿瘤、动脉瘤及海绵状血管瘤肿瘤、动脉瘤及海绵状血管瘤颅底手术概念的演变颅底手术概念的演变强调通过打开骨性结构，减少脑组织的牵强调通过打开骨性结构，减少脑组织的牵拉，以取得满意的显露拉，以取得满意的显露眶颧入路眶颧入路 去除眶上壁和外侧壁以及颧去除眶上壁和外侧壁以及颧弓，显露海绵窦及上斜坡弓，显露海绵窦及上斜坡增加骨质的去除增加骨质的去除 增加并发症，延长手术时间增加并发症，延长手术时间得失的平衡？得失的平衡？是否真的扩大了显露是否真的扩大了显露医生的经验，个人手术风格医生的经验，个人手术风格对额眶颧入路的基本评价对额眶颧入路的基本评价额眶颧入路及其改良额眶颧入路及其改良标准翼点入路标准翼点入路 Standard Pterional approach Standard Pterional approach去除眶缘，眶顶，眶外侧壁及颧弓的一部分去除眶缘，眶顶，眶外侧壁及颧弓的一部分 Rim, roof and lateral wall of the orbit, Rim, roof and lateral wall of the orbit, as well as the Zygomatic archas well as the Zygomatic arch安全及美容安全及美容 SafeSafe & & Cosmetic Cosmetic 面神经额支的保护面神经额支的保护避免颞肌萎缩避免颞肌萎缩充分显露，较少咬除骨组织，免于颅底重建充分显露，较少咬除骨组织，免于颅底重建缩短工作距离，扩大术野及视角，改善照明缩短工作距离，扩大术野及视角，改善照明Narrow space Narrow space Wide portal Wide portal额眶颧入路的优点额眶颧入路的优点SupineSupine30-6030-60 to to the the side side opposite opposite to to the the surgical incisionsurgical incisionMalar eminence Malar eminence superior point superior pointHead fixationHead fixation额眶颧入路额眶颧入路 体位和切口体位和切口耳耳屏屏( (TragusTragus) )前方前方1-21-2cmcm，颧弓下缘颧弓下缘弧形切口弧形切口curvilinear mannercurvilinear manner对侧瞳孔中点延长线与发际相交处对侧瞳孔中点延长线与发际相交处注意：必须保留颞浅动脉后支注意：必须保留颞浅动脉后支切切口口向向下下延延长长不不要要超超过过下下颌颌关关节节平平面面，避免损伤面神经避免损伤面神经额眶颧入路额眶颧入路 体位和切口体位和切口帽状腱膜下脂肪垫帽状腱膜下脂肪垫 subgaleal fat padsubgaleal fat pad注意面神经额支的走行及保护注意面神经额支的走行及保护骨膜下分离颞肌骨膜下分离颞肌 subperiosteal techniquesubperiosteal technique慎用单极，避免颞肌萎缩慎用单极，避免颞肌萎缩硬膜悬吊硬膜悬吊 dural tacking suturesdural tacking sutures摆动锯摆动锯 reciprocating sawreciprocating saw额眶颧入路额眶颧入路 体位和切口体位和切口标准翼点骨瓣，注意眶上神经的保护（眶上孔）标准翼点骨瓣，注意眶上神经的保护（眶上孔）六步法六步法 眶颧眶颧 RemovalRemoval颧突根部，切断颧弓颧突根部，切断颧弓颧突平面上横断颧骨，直达眶下裂颧突平面上横断颧骨，直达眶下裂眶上缘和眶顶（眶上神经孔外侧眶上缘和眶顶（眶上神经孔外侧1-21-2mm)mm)眶上裂和眶下裂之间眶上裂和眶下裂之间硬膜切口硬膜切口针对一些特殊病变的改良，如磨除前床突针对一些特殊病变的改良，如磨除前床突额眶颧入路额眶颧入路 骨性部分骨性部分术野显露过程术野显露过程硬膜翻转硬膜翻转锐性分离视神经和颈内动脉周围的蛛网膜锐性分离视神经和颈内动脉周围的蛛网膜脑脊液引流脑脊液引流 脑室穿刺脑室穿刺 VentriculostomyVentriculostomy腰穿腰穿Lumbar drainLumbar drain终板造瘘终板造瘘 Lamina terminales exposeLamina terminales exposeBony approach + Brain relaxationBony approach + Brain relaxation病例病例 1 基底动脉瘤基底动脉瘤病例病例 1 基底动脉瘤基底动脉瘤病例病例 1 基底动脉瘤基底动脉瘤病例病例 1 基底动脉瘤基底动脉瘤入路选择要素入路选择要素对对出血的有效控制出血的有效控制 Vascular control Vascular control保留穿通动脉保留穿通动脉 Preservation of perforating arteryPreservation of perforating artery牺牲骨性结构牺牲骨性结构 Maximize bone removal Maximize bone removal减少脑组织牵拉减少脑组织牵拉 Less brain retraction Less brain retraction扩大显露范围扩大显露范围 Improve exposure Improve exposure对出血的控制对出血的控制切除部分直回切除部分直回 Gyrus RectusGyrus Rectus打开纵裂打开纵裂Recurrent arteries of HeubnerRecurrent arteries of HeubnerTemporary clipTemporary clipRemoval of hematomaRemoval of hematomaSelf-retaining retractor blades ?Self-retaining retractor blades ?手术的目的手术的目的动脉瘤动脉瘤 exclude it from the circulationexclude it from the circulation TCD monitoring TCD monitoringAneurysm Aneurysm trapping trapping with with or or without without distal distal revascularizationrevascularizationSide-to-side A2-to-A2 anastomosesSide-to-side A2-to-A2 anastomoses辅助手段辅助手段术中脑血管造影术中脑血管造影Intraoperative AngiographyIntraoperative Angiography术中脑血流监测术中脑血流监测 Intraoperative MonitoringIntraoperative Monitoring巴比妥麻醉巴比妥麻醉Barbiturate AdministrationBarbiturate Administration术中轻低温术中轻低温Mild hypothermia 33-35Mild hypothermia 33-35 C C锐性分离锐性分离Sharp dissectionSharp dissection避免术中低血压避免术中低血压No HypotensionNo Hypotension补充说明补充说明标准翼点入路标准翼点入路 + + 良好的牵开器良好的牵开器血管变异血管变异 Vascular anomaliesVascular anomaliesCT CT angiographyangiography严密缝合硬膜严密缝合硬膜骨瓣复位骨瓣复位无需额外的颅骨重建无需额外的颅骨重建注意解剖复位，层次对合注意解剖复位，层次对合额眶颧入路额眶颧入路 关颅关颅并发症并发症眶周瘀肿眶周瘀肿Periorbital bruising and swellingPeriorbital bruising and swelling （Tarsorrhaphy Tarsorrhaphy 眼睑缝合术）眼睑缝合术）搏动性突眼搏动性突眼 Pulsatile exophthalmusPulsatile exophthalmus额额神经损伤神经损伤 Frontalis nerve injuryFrontalis nerve injury眼球内陷眼球内陷 EnophthalmosEnophthalmos，Orbital entrapmentOrbital entrapment复视复视 Diplopia Diplopia 失明失明 BlindnessBlindnessZygomatic separationZygomatic separation，Bone reabsorption Bone reabsorption Cerebrospinal fluid fistulasCerebrospinal fluid fistulas，InfectionInfection病例病例 2 基底动脉瘤基底动脉瘤病例病例 2 基底动脉瘤基底动脉瘤病例病例 2 基底动脉瘤基底动脉瘤病例病例 2 基底动脉瘤基底动脉瘤病例病例 3 眼动脉段动脉瘤眼动脉段动脉瘤病例病例 3 眼动脉段动脉瘤眼动脉段动脉瘤参考文献参考文献Joseph M. Zabramski, Talat Kiris, Suresh K. Sankhla, et al. Orbitozygomatic craniotomy. Journal of Neurosurgery, Vol. 89, August, 1998: 336-341L. Fernando Gonzalez, Neil R. Crawford, Michael A. Horgan, et al. Working area and angle of attack in three cranial base approaches: pterional, orbitozygomatic, and maxillary extension of the orbitozygomatic approach. Neurosurgery, Vol. 50, No. 3, March 2002: 550-557Howard A. Riina, G. Michael Lemole Jr., Robert F. Spetzler. Anterior communicating artery aneurysms. Neurosurgery, Vol. 51, No. 4, October 2002: 993-996谢谢 谢谢 ！谢谢 谢谢 ！