目的:选择合适的显微外科手术方法治疗丘脑病变目前在很大程度上是主观的。这项研究的目的是为手术导航提供结构化的制图图,以治疗涉及丘脑不同表面的神经胶质瘤。
方法:15福尔马林固定,解剖注射硅胶的尸体(30面),和10个成人脑标本(20侧)用于说明使用Klingler纤维解剖技术的丘脑显微外科解剖。使用来自健康受试者的MR数据转换为表面渲染的3D虚拟大脑模型,描绘了六种最常见的显微外科手术方法的暴露和轨迹。此外,用所有六种方法暴露的丘脑表面在虚拟3D模型上进行颜色映射,并在360°视图中与先前报道的显微外科手术方法并排比较。然后将这些3D模型与地形数据结合使用,以指导尸体解剖步骤。
结果:丘脑病变有两种一般手术途径:蛛网膜下经胸骨途径和经皮质途径。经胸骨入路包括以下三种入路:1)半球前经can入路,暴露前丘脑和上丘脑;2)后半球间经call骨入路,暴露了上丘脑后;和3)小脑上幕下入路,它暴露了后内侧脑池丘脑,并可以通过切割肌腱横向延伸以接近后外侧丘脑。三种经皮质入路为1)上顶叶小叶入路,暴露后上丘脑,在脑积水的情况下特别有利;2)经脑回入路,暴露了下外侧丘脑;和3)跨体跨岛入路,它暴露了外侧丘脑(稍微更上方和后方),并且有利于横向延伸到花梗中的病理,豆状核,或岛。
结论:丘脑胶质瘤的显微外科手术方法仍然具有挑战性。尽管如此,安全有效的胸腔,心室,皮质走廊可以通过周密的规划来开发,解剖学理解,以及对优势的了解,风险,以及每种方法的局限性。在某些情况下,将这些方法与分阶段的程序结合起来是明智的,正如作者在第2部分中所证明的那样。在这个由两部分组成的系列的第1部分中,他们讨论了丘脑显微外科解剖学,并说明了所有六种方法的轨迹和暴露,以指导决策。第2部分讨论了他们的丘脑神经胶质瘤显微外科病例系列,利用这些显微外科手术方法。
OBJECTIVE: The selection of appropriate microsurgical approaches to treat thalamic pathologies is currently largely subjective. The objective of this study was to provide a structured cartography map for surgical navigation to treat gliomas involving different surfaces of the thalamus.
METHODS: Fifteen formalin-fixed, silicone-injected cadavers (30 sides) were dissected, and 10 adult brain specimens (20 sides) were used to illustrate thalamic microsurgical anatomy using the Klingler fiber dissection technique. Exposures and trajectories for the six most common microsurgical approaches were depicted using MR data from healthy subjects converted into surface-rendered 3D virtual brain models. Additionally, thalamic surfaces exposed with all six approaches were color mapped on the virtual 3D model and compared side-by-side in 360° views with previously reported microsurgical approaches. These 3D models were then used in conjunction with topographic data to guide cadaveric dissection steps.
RESULTS: There are two general surgical routes to thalamic lesions: the subarachnoid transcisternal and transcortical routes. The transcisternal route consists of the following three approaches: 1) anterior interhemispheric transcallosal approach, which exposes the anterior and superior thalamus; 2) posterior interhemispheric transcallosal approach, which exposes the posterosuperior thalamus; and 3) supracerebellar infratentorial approach, which exposes the posteromedial cisternal thalamus and can be extended laterally to approach the posterolateral thalamus by cutting the tentorium. The three transcortical approaches are the 1) superior parietal lobule approach, which exposes the posterosuperior thalamus and is particularly advantageous in the setting of hydrocephalus; 2) transtemporal gyrus approach, which exposes the inferolateral thalamus; and 3) transsylvian transinsular approach, which exposes the lateral thalamus (slightly more superiorly and posteriorly) and is advantageous for pathologies extending laterally into the peduncle, lenticular nucleus, or insula.
CONCLUSIONS: Microsurgical approaches to thalamic gliomas continue to be challenging. Nonetheless, safe and effective cisternal, ventricular, and cortical corridors can be developed with thoughtful planning, anatomical understanding, and knowledge of the advantages, risks, and limitations of each approach. In some cases, it is wise to combine these approaches with staged procedures, as the authors demonstrate in Part 2. In Part 1 of this two-part series, they discuss thalamic microsurgical anatomy and illustrate the trajectory and exposures of all six approaches to guide decision-making. Part 2 discusses their thalamic glioma microsurgical case series, which utilizes these microsurgical approaches.