| Objective:1.We simulated the Kawase approach(the anterior-subtemporal transanterior petrosal approach),cranio-orbito-zygomatic approach combined with Dolenc approach in the surgical treatment of basilar artery bifurcation aneurysm under the microscope,to measure the data of related anatomical structures during the operation,discusse the main points of surgical operation and important anatomical markers,clarify the surgical indications between the two surgical approaches,in order to improve the individualized treatment of basilar aneurysm,provide a microanatomical basis for improving the surgical technique and postoperative effect and reducing the occurrence of complications.2.To provide guidance for surgery,we observed and measured the shape,size,distance and anatomical relationship of anterior clinoid process,superior orbital fissure,optic strut,petrous bone and adjacent structures.3.To provide an anatomical basis for opening the cavernous sinus and treating lesions through the cavernous sinus,we observed and measured the anatomical structures of the cavernous sinus the top wall,the lateral wall triangle and surrounding,familiarize with the anatomical relationship between the cavernous sinus structure and adjacent structures.Methods:1.We selected 5 cases(10 sides)head specimens,exposed under the microscope and observed they anatomical structures.Two anatomical approaches were simulated on the specimen to observe and measure the exposure range of each surgical approach to the basilar artery,the local microanatomy involved in the surgical operation,the anatomical difficulties and the indications for the selection of the surgical approach.2.The anterior clinoid process,superior orbital fissure,optic strut,petrous bone and other anatomical markers of dry skull specimens were observed and measured.3.When the surgical simulation finishied,we removed telencephalon,and observed the top wall,lateral wall and adjacent anatomical structures of the cavernous sinus.4.The measurement data obtain in this study(measured 3 times and averaged)were analyzed by SPSS 26.0 statistical software,and the results were expressed as meanz±standard deviation(X±S)and minimum value(Min)-maximum value(Max)to represent.Results:1.Anterior clinoid process: The anterior clinoid process was a bony structure formed at the medial end of the sphenoid winglet,which was conical and located at the posterior medial end of the sphenoid ridge.Together with the lesser sphenoid wing,it formed the anterior part of the roof of the cavernous sinus and the superior orbital fissure.There were 2 sides that had bone bridge that was formed between the anterior clinoid processes and middle clinoid processes.There was 1 sides that had the anterior clinoid process that communicated with the sphenoid sinus.Based on the posterior edge of the sphenoid platform(jugum sphenoidale),the length of the anterior bedprocess was 9.84±1.33(7.61-12.43)mm,the total width was12.80±2.64(8.78-17.54)mm,and the total thickness was 5.71±1.68(3.44-9.52)mm,the half length was 6.12±1.65(3.20-9.15)mm,the half width was 6.71±1.84(4.42-10.56)mm,the half thickness was 4.61±1.16(2.48-6.80)mm,the length of the optic strut was 5.11±1.15(2.92-6.82)mm,and the width of the optic strut was 2.51±0.65(1.15-3.24)mm.2.Clinoid space: Clinoid space was located in the Clinoid triangle and between the two layers of dura mater.It was the surgical operation space formed after anterior clinoid process resection,which was conical.The length of the inner side of the Clinoid space measure on the wet specimen was 8.38±1.25(6.88-10.56)mm,the length of the inner lower side was 11.46±1.61(8.98-13.74)mm,the length of the outer side was 9.88±1.24(8.13-11.87)mm,the root width was 5.45±1.04(3.76-6.91)mm,the root depth was 8.62±1.22(6.92-10.68)mm,and the top width was 2.42±0.95(1.19-4.02)mm.3.Cavernous sinus triangle: There were four triangles on the top wall of cavernous sinus.The measured data were as follows: Dolenc triangle: medial border was 9.56 ± 0.90(8.31-11.01)mm,lateral border was 10.41±1.48(8.87-13.07)mm,and base was 7.72±1.85(5.11-10.62)mm;Hakuba triangle: medial border was 7.83±1.89(5.26-10.91)mm,lateral border was 6.97±1.87(4.32-9.97)mm,base was 4.33±1.83(1.96-7.40)mm;Internal carotid triangle: medial border was 12.00±2.03(8.95-15.08)mm,lateral border was 11.09±2.00(7.98-14.00)mm,base was 10.60±2.28(6.95-13.81)mm;Oculomotor triangle: medial border was 11.09±2.00(7.98-14.00)mm,lateral border was 19.55±1.06(17.89-21.05)mm,and base was 13.40±2.06(10.37-16.53)mm.There were two triangles on the lateral wall of cavernous sinus.The measured data were as follows: the supratrochlear triangle was not measured because it was very narrow;Parkinson’s Triangle: medial border was 15.47±1.98(12.23-18.06)mm,lateral border was 17.48±2.33(13.32-20.06)mm,and base was 7.62±2.01(4.95-10.96)mm.There were four triangles in the middle cranial fossa.The measured data were as follows: Mullan triangle: medial border was 16.60±1.67(14.03-19.06)mm,lateral border was 12.87±1.69(10.05-15.03)mm,base was 8.91±1.95(6.16-12.01)mm;Anterolateral triangle: medial border was 13.06±1.49(10.56-15.06)mm,lateral border was6.68±1.71(4.74-9.72)mm,base was 8.87±1.66(7.37-11.95)mm;Glasscock triangle:medial border was 11.63 ± 1.55(9.26-13.96)mm,lateral border was 13.09 ± 1.25(10.94-14.61)mm,and base was 7.09±1.43(5.04-9.37)mm;Kawase triangle: medial border was 14.17±1.25(12.22-16.06)mm,lateral border was 11.63±1.55(9.26-13.96)mm,and base was 11.69±1.41(9.33-13.60)mm.4.During Kawase approach,it was necessary to identify important anatomical markers such as spinous foramen,middle meningeal artery,trigeminal foramen,arcuate eminence and greater superficial petrosal nerve,which were mainly used to locate the anatomical structures such as peripheral nerves and blood vessels.5.In the orbital zygomatic approach,maccarty’s key hole was the key to craniotomy.Most of them were located on the frontal sphenoid suture behind the junction of frontal bone,zygomatic bone and sphenoid bone.Conclusion:1.The cranial nerves and blood vessels adjacent to the anterior clinoid process were complex,and the operation space was small.After excision of the anterior clinoid process,the internal carotid artery and optic nerve were exposed,and the scope of the operation field and operation space were enlarged.Resection of the anterior clinoid process in the Dolenc approach was a key step,and the scope of resection should be limited to the clinoid triangle.The gasification and bone bridge of the anterior clinoid process should be understood before surgery.2.The clinoid space was the surgical conical operation cavity formed after the excision of the anterior clinoid process,and its size was closely related to the anterior clinoid process and adjacent anatomical structures.The clinoid segment of the internal carotid artery,the anterior curvature and the anterior ascending part of C3(the cavernous sinus segment),and the origin of the ophthalmic artery could be exposed through it.3.Almost all the anatomical structures and parts in the cavernous sinus could be exposed through the lateral wall of the cavernous sinus Parkinson’s triangle and the medial triangle.Clinical application of these two triangles to deal with cavernous sinus lesions.Being familiar with the anatomical composition of the lateral wall and top wall of the cavernous sinus could reduce the probability of damaging important structures in the treatment of cavernous sinus lesions through the cavernous sinus approach.4.The cranio-orbito-zygomatic approach expanded the scope of the bone window by removing the skull,reduced the traction on the brain tissue,expanded the surgical field and operation space,and reduced the probability of intraoperative injury to cranial nerves and arteriovenous vessels.Combined with the Dolenc approach,it could fully expose the bifurcation of the basilar artery.5.The Dolenc approach was suitable for the proximal posterior cerebral artery aneurysm with anterior and superior aneurysm protrusion and the basilar artery bifurcation aneurysm with higher bifurcation.It could be exposed by grinding the posterior clinoid process and part of the dorsum of the saddle.For basilar artery and posterior cerebral artery aneurysms,especially high basilar artery bifurcation aneurysms,the Kawase approach could increase the exposure of the surgical field by removing part of the petrous part of the temporal bone,but the exposure of the aneurysm require elevation of the temporal lobe,which would cause brain tissue damage.6.In the Kawase approach,the petrous part of the temporal bone was anatomically marked with spinous foramen,middle meningeal artery,greater superficial petrosal nerve and trigeminal foramen,which could be used as a basis for localization.Understanding and familiarity with anatomical markers and the relationship between them could protect the cochlea,internal carotid artery,facial acoustic nerve and other structures during the operation,and reduce the injury.Kawase approach was suitable for basilar artery bifurcation aneurysms with low bifurcation.This approach could reach the ventrolateral side of the pons,expose the middle trunk of the basilar artery,and reduce the traction with the cerebellum during the operation,but it required the operator to be familiar with the anatomical structure of the petrous part of the temporal bone,otherwise it would cause serious consequences.7.For the treatment of basilar artery bifurcation aneurysms,the relationship between basilar artery bifurcation and posterior clinoid process,dorsal Sellar process and the characteristics of aneurysms should be fully understood before operation,and an appropriate surgical approach should be made. |
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