1、颈静脉孔的应用解剖,陈立华CHINA-INI,颈静脉孔由颞骨岩部和枕骨颈突围成。颞骨和枕骨向孔内的突起分别被称为颞突和枕突，二者以纤维或骨桥连接，构成孔内神经和血管的分隔。由颞突下方沿颈静脉球内侧缘伸向后方的骨性隆起称为颈内嵴，舌咽神经行于其内侧。颈静脉孔为一自颅后窝通向前、外、下方的骨性管道 。颈静脉管（jugular canal）。,osseous relationships, superior view,osseous relationships, posterosuperior view. The jugular foramen is best seen in a posterosup
2、erior view oriented perpendicular to the clivus.,the jugular foramen is located between the temporal and occipital bones sigmoid groove descends along the mastoid and crosses the occipitomastoid suture , turns forward on the upper surface of the jugular process , enters the foramen,from posterior an
3、d superior shows the shape of the foramen,hypoglossal canal passes above the middle third of the occipital condyle and opens laterally into the interval between the jugular foramen and carotid canal stylomastoid foramen is located lateral and the anterior half of the occipital condyle medial to the
4、jugular foramen,anterior and backward reveals the shape of the jugular foramen,larger lateral part, the sigmoid part, which receives the drainage of the sigmoid sinus, and a smaller medial part, the petrosal part, which receives the drainage of the inferior petrosal sinus,enlarged view,intrajugular
5、process projects into the interval between the sigmoid and petrosal parts of the foramen intrajugular ridge, extends forward from the intrajugular process along the medial side of the jugular bulb,cochlear aqueduct opens above the petrosal part of the foramen , where the glossopharyngeal nerve enter
6、s the intrajugular part of the foramen on the medial side of the intrajugular process. the vestibular aqueduct opens onto the posterior surface of the temporal bone superolateral to the jugular foramen,The inferior petrosal sinus extends along the petroclival fissure and enters the petrosal part of
7、the foramen,posterosuperior view of the intrajugular process and ridge, which separate the sigmoid and petrosal parts of the jugular foramen,Rembrandt van Rijn (Dutch, 1606-1669). This painting is called The Anatomy Lecture of Dr. Nicolaes Tulp, painted in 1632,颈静脉孔的硬膜结构及分部,Hovelacque将颈静脉孔分为前内侧的神经部和
8、后外侧的血管部两部分。Katsuta根据通过颈静脉孔的结构将其分为岩部、颈内部（或神经部）和乙状窦部。神经部的硬膜形成舌咽道和迷走道，分别有舌咽神经和迷走神经及副神经穿过。舌咽道和迷走道位于颈内突内侧,二者间隔以0.5-4.9mm宽的硬膜。神经部上外侧缘的硬膜返折增厚并伸向下内覆于舌咽道和迷走道上方，称颈静脉孔硬膜返折,是辨认颅神经的重要标志。,sigmoid sinus descends in the sigmoid sulcus , sharp anterior turn to enter the jugular foramen. The jugular bulb extends upwa
9、rd under the petrous temporal bone toward the internal acoustic meatus,nerves penetrate the dura on the medial side of the intrajugular process, intrajugular ridge extends forward along the medial side of the jugular bulb,glossopharyngeal nerve passes forward along the medial side of the intrajugula
10、r ridgevagus and accessory nerves, on the medial side of the intrajugular process,vagus and accessory nerves pass lateral to the osseous bridge and the inferior petrosal sinus descends below the bridge to open into the internal jugular vein,hypoglossal canal and joins the glossopharyngeal, vagus, an
11、d accessory nerves below the jugular foramen in the interval between the internal carotid artery and internal jugular vein,arachnoid opened to expose the glossopharyngeal, vagus, and accessory nerves entering the dura and passing through the intrajugular part of the foramen. A dural septum separates
12、 the glossopharyngeal nerve from the upper vagal rootlets at the site at which the nerve enters the intrajugular portion of the foramen. The jugular dural fold projects over the nerves as they penetrate the dura,upper portion of the cerebellopontine angle, including the trigeminal nerves, has been e
13、xposed,A bridging vein passes from the medulla to the jugular bulb. The posteroinferior cerebellar artery passes behind the hypoglossal nerve and between the accessory rootlets,颈静脉孔区神经定位,舌咽神经的根丝位于小脑绒球和Luschka孔脉络丛的前方，且位置关系相对恒定。因此，可将小脑绒球和Luschka孔脉络丛复合体作为辨认舌咽神经脑池段起始部的解剖标志，并据此初步判断迷走神经、副神经脑干端。 Lachman N研
14、究发现副神经没有颅根，仅由脊髓根构成，颈静脉孔内副神经和迷走神经间无任何连接。均可在显微镜下纵行切开神经鞘膜，将神经束彼此分开。,A： Lateral view of the normal anatomy of the jugular foramen. B： Axial cut (dotted line in A) viewed from inferior to the normal anatomy. Note that the perforations connecting the inferior petrosal sinus to the jugular vein run between
15、 the lower cranial nerves.,在颈静脉孔内口，舌咽神经根丝汇合后经单独的硬膜通道（舌咽道）入颈静脉孔，迷走神经和副神经则经迷走道入颈静脉孔。颈静脉孔神经部上外侧缘的硬膜返折增厚并唇样伸向下内覆于舌咽道和迷走道上方，即颈静脉孔硬膜返折，是于颈静脉孔内口辨认脑神经的标志。,神经血管结构的位置关系,小脑后下动脉行程迂曲，与、及对脑神经根关系复杂，其穿行脑神经根丝的形式，大致可分为四种：发自第一齿状韧带周围的小脑后下动脉穿副神经根丝；起自舌下神经孔周围者穿迷走神经和副神经根丝或之间；起自舌下神经孔与桥延沟之间者穿迷走神经根；起自基底动脉者勾绕舌咽神经和颈静脉孔。小脑后下动脉或/
16、和迂曲的椎动脉压迫舌咽神经根被认为是引起舌咽神经痛的原因之一；小脑后下动脉或/和迂曲的椎动脉压迫延髓左侧可能引起血压升高，压迫延髓右侧可引起血糖升高。,颈静脉孔区不同性质肿瘤的生长方式及特点，对术前正确诊断、确定合理的治疗方案及术中保护神经功能具重要意义,颈静脉孔诊断,神经鞘瘤,神经鞘瘤起源于舌咽神经、迷走神经、副神经或颈交感干，沿其起源的神经生长。神经鞘瘤因压迫性溶骨致颈静脉孔扩大，表现为扇贝样改变而骨皮质完好。边缘常是光滑的，瘤边界清楚。 容易发生囊变/坏死，肿瘤质地不均匀，内部多有短T1长T2的片状影。增强后肿瘤实质部分可强化，但不如脑膜瘤和化学感受器瘤明显。瘤内无流空的血管影可同化学感
17、受器瘤鉴别，而上可显示面听神经也可同听神经瘤相鉴别。,脑膜瘤,起源于颈静脉球或邻近静脉窦部的蛛网膜颗粒 。Sekhar将颈静脉孔区脑膜瘤定义为附着于颈静脉孔硬膜或起源于延髓小脑角伴或不伴向颅外生长。 CT为高密度肿瘤。MRI缺乏象化学感受器那样的瘤内血管流空影。增强后1像明显强化，其程度较化学感受器瘤更为明显，并常可见脑膜尾征。 脑膜瘤典型的表现为“离心性”扩张和“匍匐状”生长，并有浸润颅神经和血管外膜的倾向。其对邻近骨质的破坏表现为广泛浸润板障而骨结构和骨密度得以保留，颈静脉孔边缘因皮质遭破坏而不规则。边缘往往有骨质增生或硬化的表现。,颈静脉球瘤,颈静脉孔骨质不规则的破坏、扩大，无骨质增生。
18、MRI平扫颈静脉孔区肿块呈等1，长2像，轮廓不规则。瘤内可见点状，迂曲条状低信号影，肿瘤实质的高信号与低信号相间，称为“椒盐”征，这些条状的低信号影是流空的血管影，代表了肿瘤内扭曲扩张的血管，是该肿瘤的特征性表现。增强后1像上明显不均匀强化，边界清晰。,颈静脉球体瘤Fisch分型法(1978),颈静脉球体瘤Glasscock-Jackson分型法(1981),Intracranial growth pattern of glomus jugulare tumors into the inferior petrosal sinus,glomus jugularmeningioma (M)schw
19、annoma (S). Section A is at the level of the dome of the jugular bulb, section B is at the midlevel of the jugular foramen, section C is at the exit of the skull base,“微创”理念-要求对颈静脉孔区的解剖境界和特征更精确的理解和认识。Rhoton等学者将到达颈静脉孔区的主要手术入路分为颞下耳前颞下窝入路、耳后经颞入路、枕下及远外侧入路三组。,颈静脉孔区肿瘤手术入路,1. 侧方入路： 通过乳突切除到达术区，又称迷路下入路。需移位面神
20、经并可能损及内耳结构，却对延伸至颅内的肿瘤显露不充分。2. 后方入路：包括枕下乙状窦后入路、远外侧及经髁入路等。该组入路便于切除延伸到后颅窝的肿瘤，但却对颞下窝肿瘤显露有限，经髁入路还增加了舌下神经、椎动脉损伤和出现寰枕关节不稳定的风险。3. 前方入路： Sekhar提出的颞下耳前颞下窝入路为该组最主要的手术入路，颈内动脉前移后可显露颈静脉孔的前缘，进一步磨除Kawase三角可显露中上斜坡，该入路联合侧方经颞即为Fisch颞下窝入路。对桥脑小脑角和延髓小脑角的显露却极为有限 。,经颈静脉孔入路（transjugular foramen）是极外侧经髁入路的亚型，通过枕下开颅、切除枕髁后1/3、颈
21、静脉突和枕大孔后壁，自后下方显露颈静脉孔。远外侧经髁入路有利于面神经功能和听力的保护，且能对下外侧颅底和颞下窝提供较充分的显露，有助于一期切除颈静脉孔区颅内外沟通性肿瘤，但需进行枕髁、颈静脉结节切除和椎动脉移位。经髁旁入路切除颈静脉孔区肿瘤，通过切除寰椎横突、移位椎动脉、切除部分枕髁及髁旁、髁上骨质、颈静脉结节等实现自后下方显露颈静脉孔。,Anatomic landmarks on the cranium,1: asterion , junction of the transverse and sigmoid sinuses.2: mastoid foramen, conveys the ma
22、stoid emissary vein, indicates the posterior margin of the middle portion of the sigmoid sinus.,3: posterior end of the incisura mastoidea 4:condylar fossa5:posterior condylar foramen 6:occipital condyle 7:mastoid process , grossly corresponds to the level of the internal acoustic meatus. The bony o
23、pening for the infratentorial lateral supracerebellar approach should be made above this level.,operative view of the transcond-ylar fossa approach,1:glossopharyngeal nerve ;2: the PICA ; 3: vagal nerve;4: accessory nerve ; 5: the vertebral artery ; 6: posterior condylar emissary vein; 7: AICA ; 8:c
24、horoid plexus.,Surgical technique of exposing the neural component of the jugular foramen,A: Normal view of the jugular foramen. Also shown are Cranial Nerves V, VII, and VIII. B: An intracranial meningioma with jugular foramen involvement is depicted. the tumor is posterior to the nerve roots (the
25、most favorable situation). C: Drilling of the neural component of the jugular foramen is performed. D:Tumor within the jugular foramen can then be microdissected out.,transcondylar approach Angle of surgical approach,pre, ASA to clivus before OC resection post, ASA to JT after OC resection. the far
26、lateral transcondylar exposure was 17 1 mm.,transcondylar approach，the jugular tubercle obstructs the anterior portion of the PICA aneurysm. B ：gentle retraction of the spinal accessory nerve revealing the neck of the aneurysm, which is covered partially by the jugular tubercle. C： the dura covering
27、 the jugular tubercle is incised and reflected posterior before drilling.,D ：drilling jugular tubercle, improved exposure of the anterior aspect of the aneurysm. The suction tip is used to retract and protect the spinal accessory nerve. E ： clip the aneurysm neck, with improved visualization and after reduction of the jugular tubercle. CI , continuous irrigation; JT , jugular tubercle; VA , vertebral artery,
