| Objective:To study the anatomy of sellar region and upper slope. Determine the operation approach through exposure range by different operation approach to sellar region and slope, and considering the location, size, growth direction of top of the basilar artery aneurysm and posterior clinoid process,which provide the anatomical basis for the selection of operation approach.Methods:The brain abnormalities or pathological changes were not found on adult cadaveric head specimens fixed with Faure Marin6(12sides). We lavage vascular with warm wate from neck over and over again to removal the intravascular thrombosis before dissecting. After drying cadaveric heads, pour into red silica gel curing agent through the carotid artery and vertebral artery, and pour into blue silica gel curing agent through jugular vein.1. Temporal pole approach:this approach can protect the temporal branch of facial nerve through interfascial approach. Remove the zygomatic bone, ligate and interrupt bridging veins ligation into sphenoparietal sinus, and cut the dura mater "S" shaped around the lateral fissure frontal lobe, in order to expose the frontal lobe, temporal lobe and the lateral fissure fully. Uplift the frontal lobe after separating the lateral fissure and pull the temporal pole lateral and backward to reveale skull base upslope and its surrounding structures, carefully separate the arachnoid in this region. After uplift posterior communicating artery and internal carotid artery, open Lilieguist membrane into the interpeduncular cistern between the posterior communicating artery and internal carotid artery and oculomotor to expose basilar artery bifurcation. In the meantime, we observe how the perforating artery from posterior cerebral artery and basilar artery to walk, measure the distance of exposure sellar region slope and surrounding through this approach.In order to further expand the exposure range, the temporal pole approach to expose on the basis of slope and surrounding tissue structure, carefully scissor the tentorium around the posterior clinoid process to expose the posterior clinoid process at the basis of exposure of upslope and its surrounding tissue via temporal pole approach, grind the posterior clinoid process using the high speed drill carefully to increase the exposure range. Observe how the perforating artery from posterior cerebral artery and basilar artery to walk, measure the distance of exposure sellar region slope and surrounding through this approach again.2.The subtemporal petrous bone approach:Scalp skin tempus incision,temporal craniotomy, separate dura mater of skull, disconnect middle meningeal artery by electric coagulation, expose the trigeminal ganglion, protect the greater superficial petrosal nerve, make the brain to physiological and anatomical position via grinding kaease triangle under temporal bone, cut the dura mater outside of the temporal dura mater in the shape of horseshoe.Uplift the temporal lobe, ligate and disconnect superior petrosal sinus, cut tentorium in the position where tentorial in trochlear nerve into the rear in "T" shape, free cerebral dura mater around the position where trigeminal nerve penetrates into the middle cranial fossa, oppress the trigeminal nerve to increase the operative field.At the same time to observe how the perforating artery from posterior cerebral artery and basilar artery to walk, measure the distance of exposure sellar region slope and surrounding through this approach.3. Expanded temporal pole approach:The scalp incision was from the zygomatic arch near the tragus1cm, vertical upward to the root of auricle and backwards to the ear2~3cm, curved forward and inward to the midline, across the midline aside1~2cm, ending in the hair. Uplift the frontal lobe, pull the temporal pole lateral and backward, observe the walking of perforating artery from oposterior cerebral artery and basilar artery through lateral fissure, measure the distance of exposure sellar region slope and surrounding through this approach. Removal Kawase triangle, uplift the temporal lobe, scissor the tentorium, observe the walking of perforating artery from oposterior cerebral artery and basilar artery under the temporal, measure the distance of exposure sellar region slope and surrounding through this approach.Results:Distance of exposure sellar region slope through temporal pole approach:(12.46±1.51) mm.Distance of exposure sellar region slope through temporal pole and grinding the posterior clinoid process approach:(17.31±2.03) mmDistance of exposure sellar region slope through the subtemporal petrous bone approach:(23.92±1.64) mmThree different surgical approach for exposing sellar region slope were significant statistically, the difference exist indeed.Conclusion:1. Top of the basilar artery aneurysm located at posterior clinoid process within5mm and rear of the saddle area can employed the temporal pole approach to fully expose and clip, when necessary, cut tentorium wrapping posterior clinoid process and grind the posterior clinoid process, to increase the exposure range.2. Top of the basilar artery aneurysm under posterior clinoid process should adopt the subtemporal petrous bone approach for clipping.3. The perforating artery from bilateral posterior cerebral artery and basilar artery tip can be observed via the temporal pole approach, which can prevent the error clamp of perforating arterie in aneurysm clippings. Through the subtemporal petrous bone approach we can not see the contralateral perforating artery clearly. Clip perforating artery mistakenly can lead to serious top of the basilar artery syndrome, accordingly affect the long-term prognosis effect or even death.4. If the growth of basilar artery aneurysm towards the rear part, part of perforating artery sometimes maybe from aneurysm or difficult to separate with aneurysm, which greatly increase the difficulty of operation. In this case, it is difficult to clearly distinguish the relationship between perforator artery and aneurysm through temporal pole ahead, while through the subtemporal petrous bone approach we can see the perforating artery clearly, effectively prevent the intraoperative error clamp of perforating artery.It is a great advantage for such aneurysm clipping.5. Both sides diameter of the aneurysms located at the bifurcation of basilar artery tend to be wider than the anteroposterior diameter frequently. Aneurysm clip almost parallel to the top of basilar artery through the subtemporal petrous bone approach when clipping performed. At the same time, it can reduce twist and stenosis of the basilar artery and posterior cerebral artery when clipping, thus ensure the vascular patency.6. To expose visual operative field fully is a prerequisite for the smooth operation. Expanding the approach to the temporal pole in the treatment of top of the basilar artery aneurysm can see bilateral perforating artery clearly back from the anterior temporal pole lateral fissure, as well as the rear lateral infratemporal and its rear in order to reduce the risk of error clamp. And for the high or low tip of the basilar artery aneurysm, this approach can be effective clipping, sequentially improve the success rate of operation. |
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