颈静脉孔区解剖

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Ｔ1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。
• 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
• upper portion of the cerebellopontine angle, including the trigeminal nerves, has been exposed
• 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
• 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Ⅸ、Ⅹ、Ⅺ及Ⅻ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/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。
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。
osseous relationships, superior view
• osseous relationships, posterosuperior view. The jugular foramen is best seen in a posterosuperior view oriented perpendicular to the clivus.
• from posterior and 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 jugular foramen
• The inferior petrosal sinus extends along the petroclival fissure and enters the petrosal part of the foramen
• posterosuperior view of the intrajugular process and ridge, which separate the sigmoid and petrosal parts of the jugular foramen
• 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
颈静脉孔诊断
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
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。ＭＲＩ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 受器瘤鉴别，而ＭＲＩ上可显示面听神经也 可同听神经瘤相鉴别。
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。
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）。
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, and accessory nerves below the jugular foramen in the interval between the internal carotid artery and internal jugular vein
• sigmoid sinus descends in the sigmoid sulcus , sharp anterior turn to enter the jugular foramen. The jugular bulb extends upward under the petrous temporal bone toward the internal acoustic meatus
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 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
• cochlear aqueduct opens above the petrosal part of the foramen , where the glossopharyngeal nerve enters 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