頸靜脈孔的應(yīng)用解剖1頸靜脈孔的應(yīng)用解剖1頸靜脈孔由顳骨巖部和枕骨頸突圍成。顳骨和枕骨向孔內(nèi)的突起分別被稱為顳突和枕突，二者以纖維或骨橋連接，構(gòu)成孔內(nèi)神經(jīng)和血管的分隔。由顳突下方沿頸靜脈球內(nèi)側(cè)緣伸向后方的骨性隆起稱為頸內(nèi)嵴，舌咽神經(jīng)行于其內(nèi)側(cè)。頸靜脈孔為一自顱后窩通向前、外、下方的骨性管道。頸靜脈管（jugularcanal）。2頸靜脈孔由顳骨巖部和枕骨頸突圍成。顳骨和枕骨向孔內(nèi)的突起分別osseousrelationships,superiorview

3osseousrelationships,superioosseousrelationships,posterosuperiorview.Thejugularforamenisbestseeninaposterosuperiorvieworientedperpendiculartotheclivus.4osseousrelationships,posterothejugularforamenislocatedbetweenthetemporalandoccipitalbonessigmoidgroovedescendsalongthemastoidandcrossestheoccipitomastoidsuture,turnsforwardontheuppersurfaceofthejugularprocess,enterstheforamen5thejugularforamenislocatedfromposteriorandsuperiorshowstheshapeoftheforamen6fromposteriorandsuperiorshhypoglossalcanalpassesabovethemiddlethirdoftheoccipitalcondyleandopenslaterallyintotheintervalbetweenthejugularforamenandcarotidcanalstylomastoidforamenislocatedlateralandtheanteriorhalfoftheoccipitalcondylemedialtothejugularforamen7hypoglossalcanalpassesaboveanteriorandbackwardrevealstheshapeofthejugularforamen8anteriorandbackwardrevealslargerlateralpart,thesigmoidpart,whichreceivesthedrainageofthesigmoidsinus,andasmallermedialpart,thepetrosalpart,whichreceivesthedrainageoftheinferiorpetrosalsinus9largerlateralpart,thesigmoenlargedview10enlargedview10intrajugularprocessprojectsintotheintervalbetweenthesigmoidandpetrosalpartsoftheforamenintrajugularridge,extendsforwardfromtheintrajugularprocessalongthemedialsideofthejugularbulb11intrajugularprocessprojectscochlearaqueductopensabovethepetrosalpartoftheforamen,wheretheglossopharyngealnerveenterstheintrajugularpartoftheforamenonthemedialsideoftheintrajugularprocess.thevestibularaqueductopensontotheposteriorsurfaceofthetemporalbonesuperolateraltothejugularforamen12cochlearaqueductopensaboveTheinferiorpetrosalsinusextendsalongthepetroclivalfissureandentersthepetrosalpartoftheforamen13Theinferiorpetrosalsinusexposterosuperiorviewoftheintrajugularprocessandridge,whichseparatethesigmoidandpetrosalpartsofthejugularforamen14posterosuperiorviewoftheiRembrandtvanRijn(Dutch,1606-1669).Thispaintingiscalled"TheAnatomyLectureofDr.NicolaesTulp",paintedin1632

15RembrandtvanRijn(Dutch,160頸靜脈孔的硬膜結(jié)構(gòu)及分部Hovelacque將頸靜脈孔分為前內(nèi)側(cè)的神經(jīng)部和后外側(cè)的血管部?jī)刹糠帧atsuta根據(jù)通過(guò)頸靜脈孔的結(jié)構(gòu)將其分為巖部、頸內(nèi)部（或神經(jīng)部）和乙狀竇部。神經(jīng)部的硬膜形成舌咽道和迷走道，分別有舌咽神經(jīng)和迷走神經(jīng)及副神經(jīng)穿過(guò)。舌咽道和迷走道位于頸內(nèi)突內(nèi)側(cè),二者間隔以0.5-4.9mm寬的硬膜。神經(jīng)部上外側(cè)緣的硬膜返折增厚并伸向下內(nèi)覆于舌咽道和迷走道上方，稱頸靜脈孔硬膜返折,是辨認(rèn)顱神經(jīng)的重要標(biāo)志。16頸靜脈孔的硬膜結(jié)構(gòu)及分部Hovelacque將頸靜脈孔分為17171818sigmoidsinusdescendsinthesigmoidsulcus,sharpanteriorturntoenterthejugularforamen.Thejugularbulbextendsupwardunderthepetroustemporalbonetowardtheinternalacousticmeatus19sigmoidsinusdescendsinthenervespenetratetheduraonthemedialsideoftheintrajugularprocess,intrajugularridgeextendsforwardalongthemedialsideofthejugularbulbglossopharyngealnervepassesforwardalongthemedialsideoftheintrajugularridgevagusandaccessorynerves,onthemedialsideoftheintrajugularprocess

20nervespenetratetheduraontvagusandaccessorynervespasslateraltotheosseousbridgeandtheinferiorpetrosalsinusdescendsbelowthebridgetoopenintotheinternaljugularvein

hypoglossalcanalandjoinstheglossopharyngeal,vagus,andaccessorynervesbelowthejugularforamenintheintervalbetweentheinternalcarotidarteryandinternaljugularvein21vagusandaccessorynervespas2222arachnoidopenedtoexposetheglossopharyngeal,vagus,andaccessorynervesenteringtheduraandpassingthroughtheintrajugularpartoftheforamen.Aduralseptumseparatestheglossopharyngealnervefromtheuppervagalrootletsatthesiteatwhichthenerveenterstheintrajugularportionoftheforamen.Thejugularduralfoldprojectsoverthenervesastheypenetratethedura23arachnoidopenedtoexposethe2424upperportionofthecerebellopontineangle,includingthetrigeminalnerves,hasbeenexposed25upperportionofthecerebellAbridgingveinpassesfromthemedullatothejugularbulb.Theposteroinferiorcerebellararterypassesbehindthehypoglossalnerveandbetweentheaccessoryrootlets26Abridgingveinpassesfromth頸靜脈孔區(qū)神經(jīng)定位舌咽神經(jīng)的根絲位于小腦絨球和Luschka孔脈絡(luò)叢的前方，且位置關(guān)系相對(duì)恒定。因此，可將小腦絨球和Luschka孔脈絡(luò)叢復(fù)合體作為辨認(rèn)舌咽神經(jīng)腦池段起始部的解剖標(biāo)志，并據(jù)此初步判斷迷走神經(jīng)、副神經(jīng)腦干端。LachmanN研究發(fā)現(xiàn)副神經(jīng)沒(méi)有顱根，僅由脊髓根構(gòu)成，頸靜脈孔內(nèi)副神經(jīng)和迷走神經(jīng)間無(wú)任何連接。均可在顯微鏡下縱行切開(kāi)神經(jīng)鞘膜，將神經(jīng)束彼此分開(kāi)。27頸靜脈孔區(qū)神經(jīng)定位舌咽神經(jīng)的根絲位于小腦絨球和LuschkaA：Lateralviewofthenormalanatomyofthejugularforamen.B：Axialcut(dottedlineinA)viewedfrominferiortothenormalanatomy.Notethattheperforationsconnectingtheinferiorpetrosalsinustothejugularveinrunbetweenthelowercranialnerves.28A：Lateralviewofthenormal在頸靜脈孔內(nèi)口，舌咽神經(jīng)根絲匯合后經(jīng)單獨(dú)的硬膜通道（舌咽道）入頸靜脈孔，迷走神經(jīng)和副神經(jīng)則經(jīng)迷走道入頸靜脈孔。頸靜脈孔神經(jīng)部上外側(cè)緣的硬膜返折增厚并唇樣伸向下內(nèi)覆于舌咽道和迷走道上方，即頸靜脈孔硬膜返折，是于頸靜脈孔內(nèi)口辨認(rèn)腦神經(jīng)的標(biāo)志。29在頸靜脈孔內(nèi)口，舌咽神經(jīng)根絲匯合后經(jīng)單獨(dú)的硬膜通道（舌咽道）30303131神經(jīng)血管結(jié)構(gòu)的位置關(guān)系

小腦后下動(dòng)脈行程迂曲，與Ⅸ、Ⅹ、Ⅺ及Ⅻ對(duì)腦神經(jīng)根關(guān)系復(fù)雜，其穿行腦神經(jīng)根絲的形式，大致可分為四種：發(fā)自第一齒狀韌帶周圍的小腦后下動(dòng)脈穿副神經(jīng)根絲；起自舌下神經(jīng)孔周圍者穿迷走神經(jīng)和副神經(jīng)根絲或之間；起自舌下神經(jīng)孔與橋延溝之間者穿迷走神經(jīng)根；起自基底動(dòng)脈者勾繞舌咽神經(jīng)和頸靜脈孔。小腦后下動(dòng)脈或/和迂曲的椎動(dòng)脈壓迫舌咽神經(jīng)根被認(rèn)為是引起舌咽神經(jīng)痛的原因之一；小腦后下動(dòng)脈或/和迂曲的椎動(dòng)脈壓迫延髓左側(cè)可能引起血壓升高，壓迫延髓右側(cè)可引起血糖升高。32神經(jīng)血管結(jié)構(gòu)的位置關(guān)系

小腦后下動(dòng)脈行程迂曲，與Ⅸ、Ⅹ、Ⅺ及3333

頸靜脈孔區(qū)不同性質(zhì)腫瘤的生長(zhǎng)方式及特點(diǎn)，對(duì)術(shù)前正確診斷、確定合理的治療方案及術(shù)中保護(hù)神經(jīng)功能具重要意義

頸靜脈孔診斷

34頸靜脈孔區(qū)不同性質(zhì)腫瘤的生長(zhǎng)方式及神經(jīng)鞘瘤

神經(jīng)鞘瘤起源于舌咽神經(jīng)、迷走神經(jīng)、副神經(jīng)或頸交感干，沿其起源的神經(jīng)生長(zhǎng)。神經(jīng)鞘瘤因壓迫性溶骨致頸靜脈孔擴(kuò)大，表現(xiàn)為扇貝樣改變而骨皮質(zhì)完好。邊緣常是光滑的，瘤邊界清楚。容易發(fā)生囊變/壞死，腫瘤質(zhì)地不均勻，內(nèi)部多有短T1長(zhǎng)T2的片狀影。ＭＲＩ增強(qiáng)后腫瘤實(shí)質(zhì)部分可強(qiáng)化，但不如腦膜瘤和化學(xué)感受器瘤明顯。瘤內(nèi)無(wú)流空的血管影可同化學(xué)感受器瘤鑒別，而ＭＲＩ上可顯示面聽(tīng)神經(jīng)也可同聽(tīng)神經(jīng)瘤相鑒別。35神經(jīng)鞘瘤神經(jīng)鞘瘤起源于舌咽神經(jīng)、迷走神經(jīng)、副神經(jīng)或頸交腦膜瘤起源于頸靜脈球或鄰近靜脈竇部的蛛網(wǎng)膜顆粒。Sekhar將頸靜脈孔區(qū)腦膜瘤定義為附著于頸靜脈孔硬膜或起源于延髓小腦角伴或不伴向顱外生長(zhǎng)。CT為高密度腫瘤。MRI缺乏象化學(xué)感受器那樣的瘤內(nèi)血管流空影。增強(qiáng)后Ｔ1像明顯強(qiáng)化，其程度較化學(xué)感受器瘤更為明顯，并常可見(jiàn)腦膜尾征。腦膜瘤典型的表現(xiàn)為“離心性”擴(kuò)張和“匍匐狀”生長(zhǎng)，并有浸潤(rùn)顱神經(jīng)和血管外膜的傾向。其對(duì)鄰近骨質(zhì)的破壞表現(xiàn)為廣泛浸潤(rùn)板障而骨結(jié)構(gòu)和骨密度得以保留，頸靜脈孔邊緣因皮質(zhì)遭破壞而不規(guī)則。邊緣往往有骨質(zhì)增生或硬化的表現(xiàn)。36腦膜瘤起源于頸靜脈球或鄰近靜脈竇部的蛛網(wǎng)膜顆粒。Sekha頸靜脈球瘤

頸靜脈孔骨質(zhì)不規(guī)則的破壞、擴(kuò)大，無(wú)骨質(zhì)增生。MRI平掃頸靜脈孔區(qū)腫塊呈等Ｔ1，長(zhǎng)Ｔ2像，輪廓不規(guī)則。瘤內(nèi)可見(jiàn)點(diǎn)狀，迂曲條狀低信號(hào)影，腫瘤實(shí)質(zhì)的高信號(hào)與低信號(hào)相間，稱為“椒鹽”征，這些條狀的低信號(hào)影是流空的血管影，代表了腫瘤內(nèi)扭曲擴(kuò)張的血管，是該腫瘤的特征性表現(xiàn)。ＭＲＩ增強(qiáng)后Ｔ1像上明顯不均勻強(qiáng)化，邊界清晰。37頸靜脈球瘤頸靜脈孔骨質(zhì)不規(guī)則的破壞、擴(kuò)大，無(wú)骨質(zhì)增生。頸靜脈球體瘤Fisch分型法(1978)38頸靜脈球體瘤Fisch分型法(1978)38頸靜脈球體瘤Glasscock-Jackson分型法(1981)39頸靜脈球體瘤Glasscock-Jackson分型法(198Intracranialgrowthpatternofglomusjugularetumorsintotheinferiorpetrosalsinus

40Intracranialgrowthpatternofglomusjugularmeningioma(M)schwannoma(S).SectionAisatthelevelofthedomeofthejugularbulb,sectionBisatthemidlevelofthejugularforamen,sectionCisattheexitoftheskullbase41glomusjugular41“微創(chuàng)”理念---要求對(duì)頸靜脈孔區(qū)的解剖境界和特征更精確的理解和認(rèn)識(shí)。Rhoton等學(xué)者將到達(dá)頸靜脈孔區(qū)的主要手術(shù)入路分為顳下耳前顳下窩入路、耳后經(jīng)顳入路、枕下及遠(yuǎn)外側(cè)入路三組。42“微創(chuàng)”理念---要求對(duì)頸靜脈孔區(qū)的解剖境界和特征更精確的頸靜脈孔區(qū)腫瘤手術(shù)入路1.側(cè)方入路：通過(guò)乳突切除到達(dá)術(shù)區(qū)，又稱迷路下入路。需移位面神經(jīng)并可能損及內(nèi)耳結(jié)構(gòu)，卻對(duì)延伸至顱內(nèi)的腫瘤顯露不充分。2.后方入路：包括枕下乙狀竇后入路、遠(yuǎn)外側(cè)及經(jīng)髁入路等。該組入路便于切除延伸到后顱窩的腫瘤，但卻對(duì)顳下窩腫瘤顯露有限，經(jīng)髁入路還增加了舌下神經(jīng)、椎動(dòng)脈損傷和出現(xiàn)寰枕關(guān)節(jié)不穩(wěn)定的風(fēng)險(xiǎn)。3.前方入路：Sekhar提出的顳下耳前顳下窩入路為該組最主要的手術(shù)入路，頸內(nèi)動(dòng)脈前移后可顯露頸靜脈孔的前緣，進(jìn)一步磨除Kawase三角可顯露中上斜坡，該入路聯(lián)合側(cè)方經(jīng)顳即為Fisch顳下窩入路。對(duì)橋腦小腦角和延髓小腦角的顯露卻極為有限。43頸靜脈孔區(qū)腫瘤手術(shù)入路43經(jīng)頸靜脈孔入路（transjugularforamen）是極外側(cè)經(jīng)髁入路的亞型，通過(guò)枕下開(kāi)顱、切除枕髁后1/3、頸靜脈突和枕大孔后壁，自后下方顯露頸靜脈孔。遠(yuǎn)外側(cè)經(jīng)髁入路有利于面神經(jīng)功能和聽(tīng)力的保護(hù)，且能對(duì)下外側(cè)顱底和顳下窩提供較充分的顯露，有助于一期切除頸靜脈孔區(qū)顱內(nèi)外溝通性腫瘤，但需進(jìn)行枕髁、頸靜脈結(jié)節(jié)切除和椎動(dòng)脈移位。經(jīng)髁旁入路切除頸靜脈孔區(qū)腫瘤，通過(guò)切除寰椎橫突、移位椎動(dòng)脈、切除部分枕髁及髁旁、髁上骨質(zhì)、頸靜脈結(jié)節(jié)等實(shí)現(xiàn)自后下方顯露頸靜脈孔。44經(jīng)頸靜脈孔入路（transjugularforamen）是Anatomiclandmarksonthecranium1:asterion,junctionofthetransverseandsigmoidsinuses.2:mastoidforamen,conveysthemastoidemissaryvein,indicatestheposteriormarginofthemiddleportionofthesigmoidsinus.45Anatomiclandmarksonthecran3:posteriorendoftheincisuramastoidea4:condylarfossa5:posteriorcondylarforamen6:occipitalcondyle7:mastoidprocess,grosslycorrespondstotheleveloftheinternalacousticmeatus.Thebonyopeningfortheinfratentoriallateralsupracerebellarapproachshouldbemadeabovethislevel.463:posteriorendoftheincisu47474848operativeviewofthetranscond-ylarfossaapproach

1:glossopharyngealnerve;2:thePICA;3:vagalnerve;4:accessorynerve;5:thevertebralartery;6:posteriorcondylaremissaryvein;7:AICA;8:choroidplexus.49operativeviewofthetransconSurgicaltechniqueofexposingtheneuralcomponentofthejugularforamen50SurgicaltechniqueofexposingA:Normalviewofthejugularforamen.AlsoshownareCranialNervesV,VII,andVIII.B:Anintracranialmeningiomawithjugularforameninvolvementisdepicted.thetumorisposteriortothenerveroots(themostfavorablesituation).C:Drillingoftheneuralcomponentofthejugularforamenisperformed.D:Tumorwithinthejugularforamencanthenbemicrodissectedout.51A:Normalviewofthejugulartranscondylarapproach

Angleofsurgicalapproach

pre,ASAtoclivusbeforeOCresection

post,ASAtoJTafterOCresection.thefarlateraltranscondylarexposurewas17±1mm.52transcondylarapproach

Angletranscondylarapproach，thejugulartubercleobstructstheanteriorportionofthePICAaneurysm.

B：gentleretractionofthespinalaccessorynerverevealingtheneckoftheaneurysm,whichiscoveredpartiallybythejugulartubercle.

C：

theduracoveringthejugulartubercleisincisedandreflectedposteriorbeforedrilling.53transcondylarapproach，thejugD：drillingjugulartubercle,improvedexposureoftheanterioraspectoftheaneurysm.Thesuctiontipisusedtoretractandprotectthespinalaccessorynerve.

E：cliptheaneurysmneck,withimprovedvisualizationandafterreductionofthejugulartubercle.

CI,continuousirrigation;JT,jugulartubercle;VA,vertebralartery54D：drillingjugulartubercle,頸靜脈孔的應(yīng)用解剖55頸靜脈孔的應(yīng)用解剖1頸靜脈孔由顳骨巖部和枕骨頸突圍成。顳骨和枕骨向孔內(nèi)的突起分別被稱為顳突和枕突，二者以纖維或骨橋連接，構(gòu)成孔內(nèi)神經(jīng)和血管的分隔。由顳突下方沿頸靜脈球內(nèi)側(cè)緣伸向后方的骨性隆起稱為頸內(nèi)嵴，舌咽神經(jīng)行于其內(nèi)側(cè)。頸靜脈孔為一自顱后窩通向前、外、下方的骨性管道。頸靜脈管（jugularcanal）。56頸靜脈孔由顳骨巖部和枕骨頸突圍成。顳骨和枕骨向孔內(nèi)的突起分別osseousrelationships,superiorview

57osseousrelationships,superioosseousrelationships,posterosuperiorview.Thejugularforamenisbestseeninaposterosuperiorvieworientedperpendiculartotheclivus.58osseousrelationships,posterothejugularforamenislocatedbetweenthetemporalandoccipitalbonessigmoidgroovedescendsalongthemastoidandcrossestheoccipitomastoidsuture,turnsforwardontheuppersurfaceofthejugularprocess,enterstheforamen59thejugularforamenislocatedfromposteriorandsuperiorshowstheshapeoftheforamen60fromposteriorandsuperiorshhypoglossalcanalpassesabovethemiddlethirdoftheoccipitalcondyleandopenslaterallyintotheintervalbetweenthejugularforamenandcarotidcanalstylomastoidforamenislocatedlateralandtheanteriorhalfoftheoccipitalcondylemedialtothejugularforamen61hypoglossalcanalpassesaboveanteriorandbackwardrevealstheshapeofthejugularforamen62anteriorandbackwardrevealslargerlateralpart,thesigmoidpart,whichreceivesthedrainageofthesigmoidsinus,andasmallermedialpart,thepetrosalpart,whichreceivesthedrainageoftheinferiorpetrosalsinus63largerlateralpart,thesigmoenlargedview64enlargedview10intrajugularprocessprojectsintotheintervalbetweenthesigmoidandpetrosalpartsoftheforamenintrajugularridge,extendsforwardfromtheintrajugularprocessalongthemedialsideofthejugularbulb65intrajugularprocessprojectscochlearaqueductopensabovethepetrosalpartoftheforamen,wheretheglossopharyngealnerveenterstheintrajugularpartoftheforamenonthemedialsideoftheintrajugularprocess.thevestibularaqueductopensontotheposteriorsurfaceofthetemporalbonesuperolateraltothejugularforamen66cochlearaqueductopensaboveTheinferiorpetrosalsinusextendsalongthepetroclivalfissureandentersthepetrosalpartoftheforamen67Theinferiorpetrosalsinusexposterosuperiorviewoftheintrajugularprocessandridge,whichseparatethesigmoidandpetrosalpartsofthejugularforamen68posterosuperiorviewoftheiRembrandtvanRijn(Dutch,1606-1669).Thispaintingiscalled"TheAnatomyLectureofDr.NicolaesTulp",paintedin1632

69RembrandtvanRijn(Dutch,160頸靜脈孔的硬膜結(jié)構(gòu)及分部Hovelacque將頸靜脈孔分為前內(nèi)側(cè)的神經(jīng)部和后外側(cè)的血管部?jī)刹糠帧atsuta根據(jù)通過(guò)頸靜脈孔的結(jié)構(gòu)將其分為巖部、頸內(nèi)部（或神經(jīng)部）和乙狀竇部。神經(jīng)部的硬膜形成舌咽道和迷走道，分別有舌咽神經(jīng)和迷走神經(jīng)及副神經(jīng)穿過(guò)。舌咽道和迷走道位于頸內(nèi)突內(nèi)側(cè),二者間隔以0.5-4.9mm寬的硬膜。神經(jīng)部上外側(cè)緣的硬膜返折增厚并伸向下內(nèi)覆于舌咽道和迷走道上方，稱頸靜脈孔硬膜返折,是辨認(rèn)顱神經(jīng)的重要標(biāo)志。70頸靜脈孔的硬膜結(jié)構(gòu)及分部Hovelacque將頸靜脈孔分為71177218sigmoidsinusdescendsinthesigmoidsulcus,sharpanteriorturntoenterthejugularforamen.Thejugularbulbextendsupwardunderthepetroustemporalbonetowardtheinternalacousticmeatus73sigmoidsinusdescendsinthenervespenetratetheduraonthemedialsideoftheintrajugularprocess,intrajugularridgeextendsforwardalongthemedialsideofthejugularbulbglossopharyngealnervepassesforwardalongthemedialsideoftheintrajugularridgevagusandaccessorynerves,onthemedialsideoftheintrajugularprocess

74nervespenetratetheduraontvagusandaccessorynervespasslateraltotheosseousbridgeandtheinferiorpetrosalsinusdescendsbelowthebridgetoopenintotheinternaljugularvein

hypoglossalcanalandjoinstheglossopharyngeal,vagus,andaccessorynervesbelowthejugularforamenintheintervalbetweentheinternalcarotidarteryandinternaljugularvein75vagusandaccessorynervespas7622arachnoidopenedtoexposetheglossopharyngeal,vagus,andaccessorynervesenteringtheduraandpassingthroughtheintrajugularpartoftheforamen.Aduralseptumseparatestheglossopharyngealnervefromtheuppervagalrootletsatthesiteatwhichthenerveenterstheintrajugularportionoftheforamen.Thejugularduralfoldprojectsoverthenervesastheypenetratethedura77arachnoidopenedtoexposethe7824upperportionofthecerebellopontineangle,includingthetrigeminalnerves,hasbeenexposed79upperportionofthecerebellAbridgingveinpassesfromthemedullatothejugularbulb.Theposteroinferiorcerebellararterypassesbehindthehypoglossalnerveandbetweentheaccessoryrootlets80Abridgingveinpassesfromth頸靜脈孔區(qū)神經(jīng)定位舌咽神經(jīng)的根絲位于小腦絨球和Luschka孔脈絡(luò)叢的前方，且位置關(guān)系相對(duì)恒定。因此，可將小腦絨球和Luschka孔脈絡(luò)叢復(fù)合體作為辨認(rèn)舌咽神經(jīng)腦池段起始部的解剖標(biāo)志，并據(jù)此初步判斷迷走神經(jīng)、副神經(jīng)腦干端。LachmanN研究發(fā)現(xiàn)副神經(jīng)沒(méi)有顱根，僅由脊髓根構(gòu)成，頸靜脈孔內(nèi)副神經(jīng)和迷走神經(jīng)間無(wú)任何連接。均可在顯微鏡下縱行切開(kāi)神經(jīng)鞘膜，將神經(jīng)束彼此分開(kāi)。81頸靜脈孔區(qū)神經(jīng)定位舌咽神經(jīng)的根絲位于小腦絨球和LuschkaA：Lateralviewofthenormalanatomyofthejugularforamen.B：Axialcut(dottedlineinA)viewedfrominferiortothenormalanatomy.Notethattheperforationsconnectingtheinferiorpetrosalsinustothejugularveinrunbetweenthelowercranialnerves.82A：Lateralviewofthenormal在頸靜脈孔內(nèi)口，舌咽神經(jīng)根絲匯合后經(jīng)單獨(dú)的硬膜通道（舌咽道）入頸靜脈孔，迷走神經(jīng)和副神經(jīng)則經(jīng)迷走道入頸靜脈孔。頸靜脈孔神經(jīng)部上外側(cè)緣的硬膜返折增厚并唇樣伸向下內(nèi)覆于舌咽道和迷走道上方，即頸靜脈孔硬膜返折，是于頸靜脈孔內(nèi)口辨認(rèn)腦神經(jīng)的標(biāo)志。83在頸靜脈孔內(nèi)口，舌咽神經(jīng)根絲匯合后經(jīng)單獨(dú)的硬膜通道（舌咽道）84308531神經(jīng)血管結(jié)構(gòu)的位置關(guān)系

小腦后下動(dòng)脈行程迂曲，與Ⅸ、Ⅹ、Ⅺ及Ⅻ對(duì)腦神經(jīng)根關(guān)系復(fù)雜，其穿行腦神經(jīng)根絲的形式，大致可分為四種：發(fā)自第一齒狀韌帶周圍的小腦后下動(dòng)脈穿副神經(jīng)根絲；起自舌下神經(jīng)孔周圍者穿迷走神經(jīng)和副神經(jīng)根絲或之間；起自舌下神經(jīng)孔與橋延溝之間者穿迷走神經(jīng)根；起自基底動(dòng)脈者勾繞舌咽神經(jīng)和頸靜脈孔。小腦后下動(dòng)脈或/和迂曲的椎動(dòng)脈壓迫舌咽神經(jīng)根被認(rèn)為是引起舌咽神經(jīng)痛的原因之一；小腦后下動(dòng)脈或/和迂曲的椎動(dòng)脈壓迫延髓左側(cè)可能引起血壓升高，壓迫延髓右側(cè)可引起血糖升高。86神經(jīng)血管結(jié)構(gòu)的位置關(guān)系

小腦后下動(dòng)脈行程迂曲，與Ⅸ、Ⅹ、Ⅺ及8733

頸靜脈孔區(qū)不同性質(zhì)腫瘤的生長(zhǎng)方式及特點(diǎn)，對(duì)術(shù)前正確診斷、確定合理的治療方案及術(shù)中保護(hù)神經(jīng)功能具重要意義

頸靜脈孔診斷

88頸靜脈孔區(qū)不同性質(zhì)腫瘤的生長(zhǎng)方式及神經(jīng)鞘瘤

神經(jīng)鞘瘤起源于舌咽神經(jīng)、迷走神經(jīng)、副神經(jīng)或頸交感干，沿其起源的神經(jīng)生長(zhǎng)。神經(jīng)鞘瘤因壓迫性溶骨致頸靜脈孔擴(kuò)大，表現(xiàn)為扇貝樣改變而骨皮質(zhì)完好。邊緣常是光滑的，瘤邊界清楚。容易發(fā)生囊變/壞死，腫瘤質(zhì)地不均勻，內(nèi)部多有短T1長(zhǎng)T2的片狀影。ＭＲＩ增強(qiáng)后腫瘤實(shí)質(zhì)部分可強(qiáng)化，但不如腦膜瘤和化學(xué)感受器瘤明顯。瘤內(nèi)無(wú)流空的血管影可同化學(xué)感受器瘤鑒別，而ＭＲＩ上可顯示面聽(tīng)神經(jīng)也可同聽(tīng)神經(jīng)瘤相鑒別。89神經(jīng)鞘瘤神經(jīng)鞘瘤起源于舌咽神經(jīng)、迷走神經(jīng)、副神經(jīng)或頸交腦膜瘤起源于頸靜脈球或鄰近靜脈竇部的蛛網(wǎng)膜顆粒。Sekhar將頸靜脈孔區(qū)腦膜瘤定義為附著于頸靜脈孔硬膜或起源于延髓小腦角伴或不伴向顱外生長(zhǎng)。CT為高密度腫瘤。MRI缺乏象化學(xué)感受器那樣的瘤內(nèi)血管流空影。增強(qiáng)后Ｔ1像明顯強(qiáng)化，其程度較化學(xué)感受器瘤更為明顯，并常可見(jiàn)腦膜尾征。腦膜瘤典型的表現(xiàn)為“離心性”擴(kuò)張和“匍匐狀”生長(zhǎng)，并有浸潤(rùn)顱神經(jīng)和血管外膜的傾向。其對(duì)鄰近骨質(zhì)的破壞表現(xiàn)為廣泛浸潤(rùn)板障而骨結(jié)構(gòu)和骨密度得以保留，頸靜脈孔邊緣因皮質(zhì)遭破壞而不規(guī)則。邊緣往往有骨質(zhì)增生或硬化的表現(xiàn)。90腦膜瘤起源于頸靜脈球或鄰近靜脈竇部的蛛網(wǎng)膜顆粒。Sekha頸靜脈球瘤

頸靜脈孔骨質(zhì)不規(guī)則的破壞、擴(kuò)大，無(wú)骨質(zhì)增生。MRI平掃頸靜脈孔區(qū)腫塊呈等Ｔ1，長(zhǎng)Ｔ2像，輪廓不規(guī)則。瘤內(nèi)可見(jiàn)點(diǎn)狀，迂曲條狀低信號(hào)影，腫瘤實(shí)質(zhì)的高信號(hào)與低信號(hào)相間，稱為“椒鹽”征，這些條狀的低信號(hào)影是流空的血管影，代表了腫瘤內(nèi)扭曲擴(kuò)張的血管，是該腫瘤的特征性表現(xiàn)。ＭＲＩ增強(qiáng)后Ｔ1像上明顯不均勻強(qiáng)化，邊界清晰。91頸靜脈球瘤頸靜脈孔骨質(zhì)不規(guī)則的破壞、擴(kuò)大，無(wú)骨質(zhì)增生。頸靜脈球體瘤Fisch分型法(1978)92頸靜脈球體瘤Fisch分型法(1978)38頸靜脈球體瘤Glasscock-Jackson分型法(1981)93頸靜脈球體瘤Glasscock-Jackson分型法(198Intracranialgrowthpatternofglomusjugularetumorsintotheinferiorpetrosalsinus

94Intracranialgrowthpatternofglomusjugularmeningioma(M)schwannoma(S).SectionAisatthelevelofthedomeofthejugularbulb,sectionBisatthemidlevelofthejugularforamen,sectionCisattheexitoftheskullbase95glomusjugular41“微創(chuàng)”理念---要求對(duì)頸靜脈孔區(qū)的解剖境界和特征更精確的理解和認(rèn)識(shí)。Rhoton等學(xué)者將到達(dá)頸靜脈孔區(qū)的主要手術(shù)入路分為顳下耳前顳下窩入路、耳后經(jīng)顳入路、枕下及遠(yuǎn)外側(cè)入路三組。96“微創(chuàng)”理念---要求對(duì)頸靜脈孔區(qū)的解剖境界和特征更精確的頸靜脈孔區(qū)腫瘤手術(shù)入路1.側(cè)方入路：通過(guò)乳突切除到達(dá)術(shù)區(qū)，又稱迷路下入路。需移位面神經(jīng)并可能損及內(nèi)耳結(jié)構(gòu)，卻對(duì)延伸至顱內(nèi)的腫瘤顯露不充分。2.后方入路：包括枕下乙狀竇后入路、遠(yuǎn)外側(cè)及經(jīng)髁入路等。該組入路便于切除延伸到后顱窩的腫瘤，但卻對(duì)顳下窩腫瘤顯露有限，經(jīng)髁入路還增加了舌下神經(jīng)、椎動(dòng)脈損傷和出現(xiàn)寰枕關(guān)節(jié)不穩(wěn)定的風(fēng)險(xiǎn)。3.前方入路：Sekhar提出的顳下耳前顳下窩入路為該組最主要的手術(shù)入路，頸內(nèi)動(dòng)脈前移后可顯露頸靜脈孔的前緣，進(jìn)一步磨除Kawase三角可顯露中上斜坡，該入路聯(lián)合側(cè)方經(jīng)顳即為Fisch顳下窩入路。對(duì)橋腦小腦角和延髓小腦角的顯露卻極為有限。97頸靜脈孔區(qū)腫瘤手術(shù)入路43經(jīng)頸靜脈孔入路（transjugularforamen）是極外側(cè)經(jīng)髁入路的亞型，通過(guò)枕下開(kāi)顱、切除枕髁后1/3、頸靜脈突和枕大孔后壁，自后下方顯露頸靜脈孔。遠(yuǎn)外側(cè)經(jīng)髁入路有利于面神經(jīng)功能和聽(tīng)力的保護(hù)，且能對(duì)下外側(cè)顱底和顳下窩提供較充分的顯露，有助于一期切除頸靜脈孔區(qū)顱內(nèi)外溝通性腫瘤，但需進(jìn)行枕髁、頸靜脈結(jié)節(jié)切除和椎動(dòng)脈移位。經(jīng)髁旁入路切除頸靜脈孔區(qū)腫瘤，通過(guò)切除寰椎橫突、移位椎動(dòng)脈、切除部分枕髁及髁旁、髁上骨質(zhì)、頸靜脈結(jié)節(jié)等實(shí)現(xiàn)自后下方顯露頸靜脈孔。98經(jīng)頸靜脈孔入路（transjugularforamen）是Anatomiclandmarksonthecranium1:asterion,junctionofthetransverseandsigmoidsinuses.2:mastoidforamen,conveysthemastoidemissaryvein,indicatestheposteriormarginofthemiddleportionofthesigmoidsinus.99Anatomiclandmarksonthecran3:posteriorendoftheincisuramastoidea4:condylarfossa5:posteriorcondylarforamen6:occipitalcondyle7:mastoidprocess,grossly