颞底经天幕经岩入路在岩斜区手术中的解剖及临床应用研究
摘要
第一部分岩斜区的显微解剖研究
目的：对颞骨外表面、岩斜区及岩骨内部重要骨性结构进行解剖学研究，探索各重要解剖结构的定位方法，为开展颞底经天幕经岩手术入路提供解剖基础。
方法：干性成人漂白颅骨标本10例(20侧)。观察测量颞骨外表面外耳孔、颞骨颧突起始部、顶乳突缝前角、乳突上嵴等结构之间的距离，观察测量岩斜区特征性骨性结构破裂孔、弓状隆起最高点、岩斜裂、三又神经半月节压迹、内耳孔等结构之间的距离。测量岩骨内部上半规管、后半规管，总脚、耳蜗，面神经迷路段、鼓室部之间的距离。
结果：外耳孔前缘至颧弓根处平均距离为13.80±1.33mm，上缘至其上方骨性隆起的距离为6.18±1.20 mm，后缘至项乳缝前角的距离为26.18±3.90mm。破裂孔外缘至弓状隆起最高点距离为32.74±1.79mm，至三又神经岩尖压迹中心距离为6.62±1.66 mm。面神经管裂孔至弓状隆起最高点的距离为14.15±2.93mm，至岩骨嵴的距离为11.79±1.00 mm。内耳孔后缘至弓状隆起最高点的距离为14.56±3.48 mm。内听道位于弓状隆起和岩浅大神经央角平分线上(或弓状隆起成60°)，或与岩骨嵴的长轴成约45°。内听道上壁口至底距离为8.28±1.64 mm。岩骨内结构总脚至内听道口后缘距离为9.30±0.58mm，耳蜗底圈至岩骨嵴距离为8.00±1.07mm，后半规管上肢中点至岩骨嵴距离为4.30±0.60mm。颈动脉管上缘至岩骨嵴距离为10.47±1.34 mm。
结论：通过外耳孔与颧弓根、外耳孔上方的骨性隆起及顶乳突缝前角之间的距离来定位外耳孔以免损伤。乳突上嵴后端隆起部的后方约1cm处可定位横窦乙状窦转角的部位。为了避免损伤膝状神经节和面神经膝部，在颞底经天幕经岩入路中将面神经管裂口作为岩骨前表面硬膜剥除的前界，剥除的范围为距岩骨嵴10mm以内。磨除颈动脉管和耳蜗上方的岩骨时，磨除的深度分别不能超过10mm和8mm；磨处外侧部半规管区域的岩嵴时，磨除深度控制在4mm之内。
第二部分Labbé静脉的显微解剖和CT静脉造影对Labbé静脉位置判断的研究
目的：研究后颞部Labbé静脉的解剖形态和位置。探讨通过CT静脉造影(CTV)的方法来判断Labbé静脉的形态和位置，为术前决定是否适合应用颞底经天幕经岩手术入路提供帮助。
方法：成人湿头颅标本共10例(20侧)。观察头颅标本Labbé静脉形态，测量其与静脉窦角(横窦乙状窦岩上窦交界，STP)的距离。5例志愿者和7例岩斜肿瘤患者术前行CTV检查，测量CTV中Labbé静脉汇入静脉窦点与STP之间的距离，然后根据术中实际观察测量到的Labbé静脉形态和位置来验证CTV对Labbé静脉位置判断的准确程度。
结果：20侧Labbé静脉可分为单根型、双根型和多根型三种类型，1侧Labbé静脉缺如。单根型Labbé静脉占40％，双根型占35％，多根型占20％。Labbé静脉静脉窦汇入点和STP的距离平均距离为22.91±8.09mm。Labbé静脉汇入点和STP的距离小于10mm(前置型)的共2例，占10％。术前CTV所显示的Labbé静脉形态与术中实际观察Labbé静脉的形态完全一致。CTV中测量Labbé静脉汇入点至STP的距离和术中实际测量距离基本一致，无显著差异。
结论：Labbé静脉的解剖形态及其回流到静脉窦的位置是决定颞底经天幕经岩入路术中颞叶能否牵开的关键因素，对于Labbé静脉前位引流这种类型不适合应用颞底经天幕经岩手术入路。相对于MRV和DSA，CTV检查可以术前更方便准确的判断Labbé静脉位置。岩斜区肿瘤的患者术前有必要进行CTV检查以明确Labbé静脉的位置，从而决定是否适合运用颞底经天幕经岩手术入路。底经天幕经岩入路对岩斜区结构的暴露改善情况。对术后头颅标本进行CT颅底超薄扫描，比较两种手术入路在暴露内听道下方、中脑腹侧中点时所需对颞叶牵拉的程度。
结果：以内听道为中心分中间部、内侧部、外侧部来磨除岩骨。中间部内听道上方的岩骨磨除深度5mm见内听道上壁，磨除长度8mm后可暴露到内听道底。内侧部岩骨嵴向前方磨除宽度10.47±1.34mm及8.00±1.07mm可分别暴露岩骨颈内动脉水平段和耳蜗。内侧部后半规管距离岩嵴最近的距离为4.30±0.60mm，总脚距离内听道后缘的距离为9.30±0.58mm，磨除总脚与内听道后缘之间的骨质深度约5mm后接近内听道底部。通过磨除适当范围的岩骨，颞底经天幕经岩入路可以暴露出外展神经进入Doller's孔部；面听神经及伴随的小脑前下动脉襻进入内听道口的部位；内听道口周围和岩斜裂周围的岩骨。颞底经岩经天幕入路磨除内听道上唇和其上方岩嵴后，暴露内听道下方岩骨只需要抬起颞底24.5±4.59°；颞底经天幕经岩入路磨除内侧部岩骨后，对于中脑腹侧中点的暴露几乎可以不用抬起颞底就能观察到。
结论：颞底经天幕入路中对于多数岩骨后颅窝面的观察仍然受到阻挡。颞底经天幕经岩入路从硬膜下磨除适度范围的岩骨可以明显改善对岩骨后颅窝面及邻近结构的暴露，并减少对颞底的牵拉。以内听道为中心，将岩骨磨除区域分为中间部、内侧部和外侧部三个区域。中间部分安全磨除范围长度为8mm，深度为5mm，宽度为5mm(内听道底为2mm)；内侧部分磨除范围深度为10mm(靠近内听道前壁的深度在8mm以内)，长度为15mm；外侧部分磨除的范围在以内听道、弓状隆起、总脚与内耳口之间岩嵴为三条边的近似三角形区域中，长度为9mm，深度为5mm，磨除三角形区域以外的岩骨时深度不能超过4mm。
第四部分应用颞底经天幕经岩入路切除岩斜区脑膜瘤
目的：在对岩斜区结构显微解剖研究的基础上，临床运用颞底经天幕经岩手术入路治疗该区域的脑膜瘤，探讨这一手术入路对岩斜区脑膜瘤手术切除的优点和注意点。
方法：从2002年4月至2006年2月间收治岩斜区(骑跨中后颅窝)脑膜瘤和三叉神经鞘瘤21例，分别运用颞底经天幕和颞底给天幕经岩入路手术进行肿瘤切除，重点对比分析两种手术入路对岩斜脑膜瘤的治疗效果。
结果：7例三叉神经神经鞘瘤采用颞底经天幕手术入路均获肿瘤全切除，手术全切除率100％。14例脑膜瘤中采用颞底经天幕“经岩”手术入路4例均达到SimpsonⅠ类全切除，采用未磨除岩骨的颞底经天幕手术入路9例中无1例取得SimpsonⅠ类全切除，取得SimpsonⅡ令切除的6例，肿瘤次全切除3例，分别占采用该手术入路的66.7％和33.3％。19例患者获得随访，7例三叉神经鞘瘤术后恢复良好，遗留面部麻木1例(占14％)，经常性角膜炎1例(占14％)。12例脑膜瘤患者中，运用颞底经天幕经岩手术4例患者术后均恢复良好，现都生活自理且已重新工作，遗留面部麻木和复视1例；运用颞底经天幕入路手术患者1例于术后13个月时出现严重肺部感染最后死亡(占8.3％)，1例一侧肢体肌力差行走不便(占8.3％)，其余患者均生活基本正常。
结论：颞底经天幕入路中由于岩嵴的阻挡使得对岩骨后颅窝面等部位暴露仍然存在死角，采用颞底经天幕经岩入路通过在岩骨安全区域中适当磨除岩骨，消除了岩嵴对岩斜脑膜瘤基底“帽檐样”阻挡，在直视下铲除肿瘤基底，达到SimpsonⅠ类全切除，运用该手术入路术后并发症少，手术效果满意。
Part I Microsurgical Anatomy of Petroclival Region
Objective: To explore the way to locate the important anatomical structures of temporal bone and petroclival region to gain the orientation regarding with temporal base transpetrosal transtentorial approach.
Materials and methods: Ten dried skulls for a total of 20 sides were used to explore the morphometric relationships with ×2 to ×16 magnification. The anatomical relationships and the distance among the external auditory foramen, foramen lacerum, hiatus canalis facialis, internal auditory foramen, internal carotid canal, cochlea, semicircular canal and the adjacent bone structures were studied and measured.
Results: The distance between the anterior border of the external auditory foramen and the root of zygoma, superior border and the bone tuberositas above external auditory foramen, posterior border and the anterior angle of parietomastoid sutures, were 13.80±1.33mm, 6.18±1.20 mm , and 26.18±3.90mm; the distance between the foramen lacerum and the zenith of arcuate eminence, or the petrous apex impression by trigeminal nerve were 32.74±1.79mm and 6.62±1.66 mm; the distance between the hiatus canalis facialis and petrous ridge was 11.79±1.00 mm; the distance between posterior border of the internal auditory foramen and the zenith of the arcuate eminence was 14.56±3.48 mm. The location of the internal auditory canal was on the
angular bisector of the angle form by the arcuate eminence and the nervus petrosus superficialis major. The gap from the common crus to posterior border of the internal auditory foramen was 9.30±0.58mm; from cochlea to petrous ridge was 8.00± 1.07mm; from the posterior semicircular canal to the petrous ridge was 4.30±0.60 mm; and from the internal carotid canal to the petrous ridge was 10.47±1.34 mm.
Conclusions: The external auditory foramen can be located by the root of zygoma, the bone tuberositas above external auditory foramen and the anterior angle of parietomastoid sutures. To avoid injurying of the geniculater ganglion and the genu of facial nerve, the dura of the front petrous bone should be dissect within the boundary formed by the hiatus canalis facialis,which is about 11.79±1.00 mm from the petrosal ridge. When resectting the petrous bone above the internal carotid canal, the cochlea and the semicircular canal in the temporal base transpetrosal transtentorial approach to the petroclival region, the depth should be less than 10mm, 8mm and 4mm respectively.
Part II Microsurgical Anatomy of the vein of Labbé and Locating vein of Labbé by CTV
Objective: The anatomical shape and location of the the vein of Labbé were investigated to protect this vein during temporal base transpetrosal transtentorial approach, and the CTvenography (CTV) was used to identify and locate the the vein of Labbé preoperation for the apply of the temporal base transpetrosal transtentorial approach.
Materials and methods: Ten cadaver heads for a total of 20 sides were
examined, using ×2 to ×16 magnification after perfusing the arteries and veins with colored latex. The anatomical shape of the the vein of Labbé and the distance between the endpoint of the the vein of Labbé and STP (the conjunction of the transverse sinus, sigmoid sinus and superior petrosal sinus) were noted. 5 volunteer and 7 patients with tumor in petroclival region received CTV examination to investigate the shape and locating of the vein of Labbé before operation. The outcome of the CTV examination for the vein of Labbé was checked by the operation.
Results: The vein of Labbé can be divided into three configurations, including single independent type 40%(8 sides), double indepentend type 35%(7 sides) and multiple indepentend type 20%(4 sides). The distance between the terminations of the the vein of Labbé and STP was 22.91±8.09mm, with less than 10mm in 10%. The shape of the vein of Labbé displayed by CTV was clear and same as the shape displayed in operation, and the distance between the terminations of the vein of Labbé and STP measured by CTV was also same with the value measured in the operation.
Conclusions: The vein of Labbé is believed to be the most important vein in the temporal base transpetrosal transtentorial approach, for the location of the vein of Labbé can greatly effect the degree of the temporal base retraction. "Anterior drainage of the vein of Labbé" is a special type of the vein of Labbé, which will significantly limited the temporal base retraction or operative exposure, and the temporal base transpetrosal transtentorial approach is not suitable to be applied in this situation. Comparing with MRV and DSA, CTV examination can locate the vein of Labbé more easily and exactly preoperation, and it should be performed and scrutinized carefully before planning the temporal base transpetrosal transtentorial approach.
Part III Applied Anatomical Study of the Temporal Base Transpetrosal Transtentorial Approach
Objective: To explore the anatomical structure and identify the "safe resecting region" in the temporal base transpetrosal transtentorial approach, and compare the extended exposed area in the temporal base transpetrosal transtentorial approach with that in the temporal base transtentorial approach.
Materials and methods: Ten adult cadaver heads for a total of 20 sides were firstly performed by the temporal base transtentorial approach, and the microsurgical anatomy and the exposed field of this approach were examined. Then the temporal base transpetrosal transtentorial approach was simulated and identify the "safe resecting region" in this approach. The area which cann't be observed in the temporal base transtentorial approach was evaluated in the temporal base transpetrosal transtentorial approach. All specimens received ultrathin-slice CT scan when the temporal base transpetrosal transtentorial approach were completed in one side to compare the angle of temporal base retraction when exposing the same structure of petroclival region in the two approaches.
Results: To resect the petrosal bone safely, the petrosal bone can be divided into three parties by the internal acoustic canal including the medial, intermediate and lateral part in the temporal base transpetrosal transtentorial approach. In the medial part, after resecting 5mm deep petrosal bone above the internal acoustic canal, the roof of the internal acoustic canal will be exposed; and after resecting 8mm wide petrosal bone, the bottom of the internal acoustic canal can be nearly reached. In the intermediate part, the distance between the internal carotid artery in the petrosal bone and petrosal ridge was 10.47 ± 1. 34mm, the cochlea and petrous ridge was 8.00±1.07mm. In the lateral part, the distance between the common crus and petrosal ridge and posterior border of the internal auditory foramen were 4.30 ± 0. 60mm and 9.30±0.58mm. By resecting the petrosal bone which hinder the visual field of the most part of the
the petrosal bone's posterior surface, the part of CNVI entering doller's hole, the part of CNVII-VIII and anterior inferior cerebellar artery entering the internal acoustic canal, the region near the petroclival fissure and the internal acoustic canal can be totally exposed in the temporal base transpetrosal transtentorial approach. Further more, after deleted the hindrance of the petrosal bone in this new approach, the angle which the temporal base need to be retracted to for exposing the inferior area of the internal acoustic foramen and the middle area of the mesencephal were about 24.5±4.59° and 0°, while in the temporal base transtentorial approach these were 66.5±6.53° and 10° respectively.
Conclusions: There still exists blind area of the posterior surface of the petrosal bone which is dodged by the petrosal ridge in the temporal base transtentorial approach. The temporal base transpetrosal transtentorial approach can significantly improve the visual field above-mentioned and reduce the degree of the temporal base retraction. The safe area when resecting petrosal ridge can be divided into three parts: the medial part is about 15mm(length) × 8-10mm(width), the intermediate part is about 8mm(length) × 5mm(width) × 2-5mm(depth), and lateral part is about 9mm(length) × 5mm(width).
Part IV Temporal Base Transpetrosal Transtentorial Approach to the Meningioma in Petroclival region
OBJECTIVE: To investigate temporal base transpetrosal transtentorial approach for the meningioma in petroclival region.
METHODS: The clinical data of 21 consecutive patients with the tumors, including 14 meningioma and 7 trigeminal neurinoma in petroclival region (bestriding middle and posterior fossae), operated with the temporal base
transpetrosal transtentorial approach or the temporal base transtentorial approach from March 2002 to February 2006, were reviewed.
RESULTS: To the trigeminal neurinoma, gross total resection (GTR) were achieved in all 7 patients (100%). To the meningioma, SimpsonI resection were achieved in all 4 patients in the temporal base transpetrosal transtentorial approach; in the temporal base transtentorial approach, SimpsonII resection were achieved in 6 patients (66.7%) and subtotal total resection (STR) in 3 patients (33.3%), but no patients get SimpsonI resection in this approach. Patients have been followed up for 2-48 months (mean 21.1 months). The postoperation neurological deficits in the patients with petroclival meningioma consisted of two patients facial numbness (16.6%), two patients diplopia (16.6%). All 4 patients who received the temporal base transpetrosal transtentorial approach recover well postoperatively, they have lived independent and resumed their occupation now. In the patients who received the temporal base transtentorial approach, 3 patients postoperative neurologic status deteriorated, 2 of them improved after theraphy, and 1 patient died 13 months after operation for the reason of the deadly pneumonia, and the mortality was 8.3%. To the tumor received SimpsonII resection, following-up MR imaging revealed no evidence of tumor recurrence till now, and to the tumor received STR, the residual tumor didn't get larger in the most recent follow-up visit.
CONCLUSION: The temporal base transtentorial approach can eliminate the visual hindrance by the petrosal redge, and resect the base of the petroclival meningioma to achieve the SimpsonI resection. This new approach is effective and can get the satisfied therapy outcome for the petroclival meningioma
目的：对颞骨外表面、岩斜区及岩骨内部重要骨性结构进行解剖学研究，探索各重要解剖结构的定位方法，为开展颞底经天幕经岩手术入路提供解剖基础。
方法：干性成人漂白颅骨标本10例(20侧)。观察测量颞骨外表面外耳孔、颞骨颧突起始部、顶乳突缝前角、乳突上嵴等结构之间的距离，观察测量岩斜区特征性骨性结构破裂孔、弓状隆起最高点、岩斜裂、三又神经半月节压迹、内耳孔等结构之间的距离。测量岩骨内部上半规管、后半规管，总脚、耳蜗，面神经迷路段、鼓室部之间的距离。
结果：外耳孔前缘至颧弓根处平均距离为13.80±1.33mm，上缘至其上方骨性隆起的距离为6.18±1.20 mm，后缘至项乳缝前角的距离为26.18±3.90mm。破裂孔外缘至弓状隆起最高点距离为32.74±1.79mm，至三又神经岩尖压迹中心距离为6.62±1.66 mm。面神经管裂孔至弓状隆起最高点的距离为14.15±2.93mm，至岩骨嵴的距离为11.79±1.00 mm。内耳孔后缘至弓状隆起最高点的距离为14.56±3.48 mm。内听道位于弓状隆起和岩浅大神经央角平分线上(或弓状隆起成60°)，或与岩骨嵴的长轴成约45°。内听道上壁口至底距离为8.28±1.64 mm。岩骨内结构总脚至内听道口后缘距离为9.30±0.58mm，耳蜗底圈至岩骨嵴距离为8.00±1.07mm，后半规管上肢中点至岩骨嵴距离为4.30±0.60mm。颈动脉管上缘至岩骨嵴距离为10.47±1.34 mm。
结论：通过外耳孔与颧弓根、外耳孔上方的骨性隆起及顶乳突缝前角之间的距离来定位外耳孔以免损伤。乳突上嵴后端隆起部的后方约1cm处可定位横窦乙状窦转角的部位。为了避免损伤膝状神经节和面神经膝部，在颞底经天幕经岩入路中将面神经管裂口作为岩骨前表面硬膜剥除的前界，剥除的范围为距岩骨嵴10mm以内。磨除颈动脉管和耳蜗上方的岩骨时，磨除的深度分别不能超过10mm和8mm；磨处外侧部半规管区域的岩嵴时，磨除深度控制在4mm之内。
第二部分Labbé静脉的显微解剖和CT静脉造影对Labbé静脉位置判断的研究
目的：研究后颞部Labbé静脉的解剖形态和位置。探讨通过CT静脉造影(CTV)的方法来判断Labbé静脉的形态和位置，为术前决定是否适合应用颞底经天幕经岩手术入路提供帮助。
方法：成人湿头颅标本共10例(20侧)。观察头颅标本Labbé静脉形态，测量其与静脉窦角(横窦乙状窦岩上窦交界，STP)的距离。5例志愿者和7例岩斜肿瘤患者术前行CTV检查，测量CTV中Labbé静脉汇入静脉窦点与STP之间的距离，然后根据术中实际观察测量到的Labbé静脉形态和位置来验证CTV对Labbé静脉位置判断的准确程度。
结果：20侧Labbé静脉可分为单根型、双根型和多根型三种类型，1侧Labbé静脉缺如。单根型Labbé静脉占40％，双根型占35％，多根型占20％。Labbé静脉静脉窦汇入点和STP的距离平均距离为22.91±8.09mm。Labbé静脉汇入点和STP的距离小于10mm(前置型)的共2例，占10％。术前CTV所显示的Labbé静脉形态与术中实际观察Labbé静脉的形态完全一致。CTV中测量Labbé静脉汇入点至STP的距离和术中实际测量距离基本一致，无显著差异。
结论：Labbé静脉的解剖形态及其回流到静脉窦的位置是决定颞底经天幕经岩入路术中颞叶能否牵开的关键因素，对于Labbé静脉前位引流这种类型不适合应用颞底经天幕经岩手术入路。相对于MRV和DSA，CTV检查可以术前更方便准确的判断Labbé静脉位置。岩斜区肿瘤的患者术前有必要进行CTV检查以明确Labbé静脉的位置，从而决定是否适合运用颞底经天幕经岩手术入路。底经天幕经岩入路对岩斜区结构的暴露改善情况。对术后头颅标本进行CT颅底超薄扫描，比较两种手术入路在暴露内听道下方、中脑腹侧中点时所需对颞叶牵拉的程度。
结果：以内听道为中心分中间部、内侧部、外侧部来磨除岩骨。中间部内听道上方的岩骨磨除深度5mm见内听道上壁，磨除长度8mm后可暴露到内听道底。内侧部岩骨嵴向前方磨除宽度10.47±1.34mm及8.00±1.07mm可分别暴露岩骨颈内动脉水平段和耳蜗。内侧部后半规管距离岩嵴最近的距离为4.30±0.60mm，总脚距离内听道后缘的距离为9.30±0.58mm，磨除总脚与内听道后缘之间的骨质深度约5mm后接近内听道底部。通过磨除适当范围的岩骨，颞底经天幕经岩入路可以暴露出外展神经进入Doller's孔部；面听神经及伴随的小脑前下动脉襻进入内听道口的部位；内听道口周围和岩斜裂周围的岩骨。颞底经岩经天幕入路磨除内听道上唇和其上方岩嵴后，暴露内听道下方岩骨只需要抬起颞底24.5±4.59°；颞底经天幕经岩入路磨除内侧部岩骨后，对于中脑腹侧中点的暴露几乎可以不用抬起颞底就能观察到。
结论：颞底经天幕入路中对于多数岩骨后颅窝面的观察仍然受到阻挡。颞底经天幕经岩入路从硬膜下磨除适度范围的岩骨可以明显改善对岩骨后颅窝面及邻近结构的暴露，并减少对颞底的牵拉。以内听道为中心，将岩骨磨除区域分为中间部、内侧部和外侧部三个区域。中间部分安全磨除范围长度为8mm，深度为5mm，宽度为5mm(内听道底为2mm)；内侧部分磨除范围深度为10mm(靠近内听道前壁的深度在8mm以内)，长度为15mm；外侧部分磨除的范围在以内听道、弓状隆起、总脚与内耳口之间岩嵴为三条边的近似三角形区域中，长度为9mm，深度为5mm，磨除三角形区域以外的岩骨时深度不能超过4mm。
第四部分应用颞底经天幕经岩入路切除岩斜区脑膜瘤
目的：在对岩斜区结构显微解剖研究的基础上，临床运用颞底经天幕经岩手术入路治疗该区域的脑膜瘤，探讨这一手术入路对岩斜区脑膜瘤手术切除的优点和注意点。
方法：从2002年4月至2006年2月间收治岩斜区(骑跨中后颅窝)脑膜瘤和三叉神经鞘瘤21例，分别运用颞底经天幕和颞底给天幕经岩入路手术进行肿瘤切除，重点对比分析两种手术入路对岩斜脑膜瘤的治疗效果。
结果：7例三叉神经神经鞘瘤采用颞底经天幕手术入路均获肿瘤全切除，手术全切除率100％。14例脑膜瘤中采用颞底经天幕“经岩”手术入路4例均达到SimpsonⅠ类全切除，采用未磨除岩骨的颞底经天幕手术入路9例中无1例取得SimpsonⅠ类全切除，取得SimpsonⅡ令切除的6例，肿瘤次全切除3例，分别占采用该手术入路的66.7％和33.3％。19例患者获得随访，7例三叉神经鞘瘤术后恢复良好，遗留面部麻木1例(占14％)，经常性角膜炎1例(占14％)。12例脑膜瘤患者中，运用颞底经天幕经岩手术4例患者术后均恢复良好，现都生活自理且已重新工作，遗留面部麻木和复视1例；运用颞底经天幕入路手术患者1例于术后13个月时出现严重肺部感染最后死亡(占8.3％)，1例一侧肢体肌力差行走不便(占8.3％)，其余患者均生活基本正常。
结论：颞底经天幕入路中由于岩嵴的阻挡使得对岩骨后颅窝面等部位暴露仍然存在死角，采用颞底经天幕经岩入路通过在岩骨安全区域中适当磨除岩骨，消除了岩嵴对岩斜脑膜瘤基底“帽檐样”阻挡，在直视下铲除肿瘤基底，达到SimpsonⅠ类全切除，运用该手术入路术后并发症少，手术效果满意。
Part I Microsurgical Anatomy of Petroclival Region
Objective: To explore the way to locate the important anatomical structures of temporal bone and petroclival region to gain the orientation regarding with temporal base transpetrosal transtentorial approach.
Materials and methods: Ten dried skulls for a total of 20 sides were used to explore the morphometric relationships with ×2 to ×16 magnification. The anatomical relationships and the distance among the external auditory foramen, foramen lacerum, hiatus canalis facialis, internal auditory foramen, internal carotid canal, cochlea, semicircular canal and the adjacent bone structures were studied and measured.
Results: The distance between the anterior border of the external auditory foramen and the root of zygoma, superior border and the bone tuberositas above external auditory foramen, posterior border and the anterior angle of parietomastoid sutures, were 13.80±1.33mm, 6.18±1.20 mm , and 26.18±3.90mm; the distance between the foramen lacerum and the zenith of arcuate eminence, or the petrous apex impression by trigeminal nerve were 32.74±1.79mm and 6.62±1.66 mm; the distance between the hiatus canalis facialis and petrous ridge was 11.79±1.00 mm; the distance between posterior border of the internal auditory foramen and the zenith of the arcuate eminence was 14.56±3.48 mm. The location of the internal auditory canal was on the
angular bisector of the angle form by the arcuate eminence and the nervus petrosus superficialis major. The gap from the common crus to posterior border of the internal auditory foramen was 9.30±0.58mm; from cochlea to petrous ridge was 8.00± 1.07mm; from the posterior semicircular canal to the petrous ridge was 4.30±0.60 mm; and from the internal carotid canal to the petrous ridge was 10.47±1.34 mm.
Conclusions: The external auditory foramen can be located by the root of zygoma, the bone tuberositas above external auditory foramen and the anterior angle of parietomastoid sutures. To avoid injurying of the geniculater ganglion and the genu of facial nerve, the dura of the front petrous bone should be dissect within the boundary formed by the hiatus canalis facialis,which is about 11.79±1.00 mm from the petrosal ridge. When resectting the petrous bone above the internal carotid canal, the cochlea and the semicircular canal in the temporal base transpetrosal transtentorial approach to the petroclival region, the depth should be less than 10mm, 8mm and 4mm respectively.
Part II Microsurgical Anatomy of the vein of Labbé and Locating vein of Labbé by CTV
Objective: The anatomical shape and location of the the vein of Labbé were investigated to protect this vein during temporal base transpetrosal transtentorial approach, and the CTvenography (CTV) was used to identify and locate the the vein of Labbé preoperation for the apply of the temporal base transpetrosal transtentorial approach.
Materials and methods: Ten cadaver heads for a total of 20 sides were
examined, using ×2 to ×16 magnification after perfusing the arteries and veins with colored latex. The anatomical shape of the the vein of Labbé and the distance between the endpoint of the the vein of Labbé and STP (the conjunction of the transverse sinus, sigmoid sinus and superior petrosal sinus) were noted. 5 volunteer and 7 patients with tumor in petroclival region received CTV examination to investigate the shape and locating of the vein of Labbé before operation. The outcome of the CTV examination for the vein of Labbé was checked by the operation.
Results: The vein of Labbé can be divided into three configurations, including single independent type 40%(8 sides), double indepentend type 35%(7 sides) and multiple indepentend type 20%(4 sides). The distance between the terminations of the the vein of Labbé and STP was 22.91±8.09mm, with less than 10mm in 10%. The shape of the vein of Labbé displayed by CTV was clear and same as the shape displayed in operation, and the distance between the terminations of the vein of Labbé and STP measured by CTV was also same with the value measured in the operation.
Conclusions: The vein of Labbé is believed to be the most important vein in the temporal base transpetrosal transtentorial approach, for the location of the vein of Labbé can greatly effect the degree of the temporal base retraction. "Anterior drainage of the vein of Labbé" is a special type of the vein of Labbé, which will significantly limited the temporal base retraction or operative exposure, and the temporal base transpetrosal transtentorial approach is not suitable to be applied in this situation. Comparing with MRV and DSA, CTV examination can locate the vein of Labbé more easily and exactly preoperation, and it should be performed and scrutinized carefully before planning the temporal base transpetrosal transtentorial approach.
Part III Applied Anatomical Study of the Temporal Base Transpetrosal Transtentorial Approach
Objective: To explore the anatomical structure and identify the "safe resecting region" in the temporal base transpetrosal transtentorial approach, and compare the extended exposed area in the temporal base transpetrosal transtentorial approach with that in the temporal base transtentorial approach.
Materials and methods: Ten adult cadaver heads for a total of 20 sides were firstly performed by the temporal base transtentorial approach, and the microsurgical anatomy and the exposed field of this approach were examined. Then the temporal base transpetrosal transtentorial approach was simulated and identify the "safe resecting region" in this approach. The area which cann't be observed in the temporal base transtentorial approach was evaluated in the temporal base transpetrosal transtentorial approach. All specimens received ultrathin-slice CT scan when the temporal base transpetrosal transtentorial approach were completed in one side to compare the angle of temporal base retraction when exposing the same structure of petroclival region in the two approaches.
Results: To resect the petrosal bone safely, the petrosal bone can be divided into three parties by the internal acoustic canal including the medial, intermediate and lateral part in the temporal base transpetrosal transtentorial approach. In the medial part, after resecting 5mm deep petrosal bone above the internal acoustic canal, the roof of the internal acoustic canal will be exposed; and after resecting 8mm wide petrosal bone, the bottom of the internal acoustic canal can be nearly reached. In the intermediate part, the distance between the internal carotid artery in the petrosal bone and petrosal ridge was 10.47 ± 1. 34mm, the cochlea and petrous ridge was 8.00±1.07mm. In the lateral part, the distance between the common crus and petrosal ridge and posterior border of the internal auditory foramen were 4.30 ± 0. 60mm and 9.30±0.58mm. By resecting the petrosal bone which hinder the visual field of the most part of the
the petrosal bone's posterior surface, the part of CNVI entering doller's hole, the part of CNVII-VIII and anterior inferior cerebellar artery entering the internal acoustic canal, the region near the petroclival fissure and the internal acoustic canal can be totally exposed in the temporal base transpetrosal transtentorial approach. Further more, after deleted the hindrance of the petrosal bone in this new approach, the angle which the temporal base need to be retracted to for exposing the inferior area of the internal acoustic foramen and the middle area of the mesencephal were about 24.5±4.59° and 0°, while in the temporal base transtentorial approach these were 66.5±6.53° and 10° respectively.
Conclusions: There still exists blind area of the posterior surface of the petrosal bone which is dodged by the petrosal ridge in the temporal base transtentorial approach. The temporal base transpetrosal transtentorial approach can significantly improve the visual field above-mentioned and reduce the degree of the temporal base retraction. The safe area when resecting petrosal ridge can be divided into three parts: the medial part is about 15mm(length) × 8-10mm(width), the intermediate part is about 8mm(length) × 5mm(width) × 2-5mm(depth), and lateral part is about 9mm(length) × 5mm(width).
Part IV Temporal Base Transpetrosal Transtentorial Approach to the Meningioma in Petroclival region
OBJECTIVE: To investigate temporal base transpetrosal transtentorial approach for the meningioma in petroclival region.
METHODS: The clinical data of 21 consecutive patients with the tumors, including 14 meningioma and 7 trigeminal neurinoma in petroclival region (bestriding middle and posterior fossae), operated with the temporal base
transpetrosal transtentorial approach or the temporal base transtentorial approach from March 2002 to February 2006, were reviewed.
RESULTS: To the trigeminal neurinoma, gross total resection (GTR) were achieved in all 7 patients (100%). To the meningioma, SimpsonI resection were achieved in all 4 patients in the temporal base transpetrosal transtentorial approach; in the temporal base transtentorial approach, SimpsonII resection were achieved in 6 patients (66.7%) and subtotal total resection (STR) in 3 patients (33.3%), but no patients get SimpsonI resection in this approach. Patients have been followed up for 2-48 months (mean 21.1 months). The postoperation neurological deficits in the patients with petroclival meningioma consisted of two patients facial numbness (16.6%), two patients diplopia (16.6%). All 4 patients who received the temporal base transpetrosal transtentorial approach recover well postoperatively, they have lived independent and resumed their occupation now. In the patients who received the temporal base transtentorial approach, 3 patients postoperative neurologic status deteriorated, 2 of them improved after theraphy, and 1 patient died 13 months after operation for the reason of the deadly pneumonia, and the mortality was 8.3%. To the tumor received SimpsonII resection, following-up MR imaging revealed no evidence of tumor recurrence till now, and to the tumor received STR, the residual tumor didn't get larger in the most recent follow-up visit.
CONCLUSION: The temporal base transtentorial approach can eliminate the visual hindrance by the petrosal redge, and resect the base of the petroclival meningioma to achieve the SimpsonI resection. This new approach is effective and can get the satisfied therapy outcome for the petroclival meningioma
引文
01 Ozveren MK, Uchida K, Aiso S: Meningovenous structures of petroclival region: Clinical importance for surgery and intravascular surgery. Neurosurgery 2002, 50(4):829-836
02 Iaconetta G, Fusco M, Samii M: The sphenopetroclival venous gulf: a microanatomy study. J Neurosurgery 2003 99:366-375
03 Horgan MA, Anderson GJ, Kellogg JX, et al: Classification and quantification of the petrosal approach to the petroclival region. J Neurosurgery 2000,93:108-112
04 Sekhar LN, Schessel DA, Bucur SD, et al: Partial labyrinthectomy petrous apiectomy approach to neoplastic and vascular lesions of the petroclival area. Neurosurgery 1999, 44(3): 537-552
05 张俊庭，王忠诚，贾桂军，等。岩斜区脑膜瘤的显微外科治疗。中华神经外科杂志，2000，16(5)：292-294
06 Taha JM, Tew JM, van Loveren HR, et al: Comparison of conventional and skull base surgical approaches for the excision of trigeminal neurinomas. J Neurosurgerv 1995,82:719-725
07 徐启武，车晓明，杨伯捷，等。中、后颅窝型三叉神经鞘瘤的诊断与治疗。中国神经精神疾病杂志，2002，28(6)：443-445
08 Smith ER, Chapman PH, Ogilvy CS. Far posterior subtemporal approach to the dorsolateral brainstem and tentorial ring: technique and clinical experience. Neurosurgery. 2003,52(2):364-9.
09 施炜 徐启武 车晓明，等。应用颞底-经天幕入路治疗中后颅窝肿瘤。中华外科学杂志，2006，44(2)：126-128
1 Day JD, Kellogg JX,Fukushima,T, et al. Microsurgical anatomy of the inner surface of the petrous bone: neuroradiological and morphometric analysis as an adjunct to the retrosigmoid transmeatal approach. Neurosurgy, 1994, 34(5):1003—1007.
2 Uz A, Ugur HC, Tekdemir I. Is the asterion a reliable landmark for the lateral approach to posterior fossa? J Clin Neurosci, 2001, 8(2): 146-147.
3 李泽福，徐启武，车晓明，等．颞底-经小脑幕手术入路的应用解剖学．中国临床解剖学杂志，2004，22(2)：159-161．
4 梁树立，漆松涛，彭林，等．国人乙状窦沟的应用解剖学研究．广东医学，2001，22(2)：113-115．
5 Iaconetta G, Fusco M, Samii M. The sphenopetroclival venous gulf: a microanatomy study. J Neurosurgery, 2003, 99(3): 366-375.
6 罗滨，邹连生，彭韶平，等．经幕上、下联合进路岩斜区的显微外科解剖．解剖学杂志，2005，28(1)：74-75．
7 Rhoton AL, Pulec JL, Hall GM, et al. Absence of bone over the genitulate ganglion. J Neurosurgery, 1968, 28(1): 84-89.
8 AL-mefty O. Comments on"Anterior transpetrosaltranstentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients". Neurosurgery, 1991, 28(6):876-881.
9 Macros Tagagiba Samii M. The significance for postoperative hearing of preserving the labyrinth in acoustic neurinoma surgery.J Neurosurgery, 1992, 77(11):677-684.
1. Barrels RH, van-Overbeeke JJ. Charles Labbé(1851-1889). J Neurosurg, 1997, 87(3): 477-480.
2. Morita A, Sekhar L. Reconstruction of the vein of Labbé by using a short saphenous vein bypass graft technical note. J Neurosurg, 1998, 89(6): 671-675.
3. Rhoton AL Jr. The cerebral vein. Neurosurgery, 2002, 51(S1): 51-167.
4. Koperna TH, Tshabitscher M, Knosp E. The termination of the vein of Labbé and its microsurgical significance. Acta Neurochir, 1992, 118(7): 172-175.
5. Guppy KH , Origitano TC , Reichman OH , et al. Venous drainage of the inferolateral temporal lobe in relationship to transtemporal/transtentorial aooroaches to the cranial base. Neurosurgery, 1997,41 (3) : 615-620.
6．刘庆良，王忠诚，张俊廷．颞枕入路Labbé静脉术中结扎术后失语分析．中华神经外科杂志，1997，13(2)：95-97．
7. Schmid-Elsaesser R , Steiger HJ , Yousry T , et al. Radical resection of meningiomas and arteriovenous fistulas involving critical dural sinus segments: experience with intraoperative sinus pressure monitoring and elective sinus reconstruction in 10 patients. Neurosurgery, 1997,41 (5) : 1005-1018.
8. Kawase T, Shiobara, Toya S. Anterior transpetrosal transtentoial approach for sphenopetroclival meningiomas: surgical results in 10 patients. Neurosurgery, 1991, 28:869-876
9．张力伟，王忠诚，于春江，等．Labbé静脉的显微解剖学研究．中华神经外科杂志，2003，19(6)，456-458．
10．张岩松，常义，惠国桢，等．颞叶桥静脉引流形式的显微外科解剖研究．中华神经外科杂志，2005 21(1)，9-12．
11. Jones BV.Case 62: Lobar Hemorrhage from thrombosis of the Vein of Labbé′. Radiology, 2003; 228:693-696
12. Cho CW, AI-Mefty O. Combined petrosal approach to petroclival meningiomas. Neurosurgery 2002, 51 (10):708-718.
13．魏群，郑文济，沈春森，等．颞下经小脑幕入路中Labbé静脉的保留与离断．临床神经外科杂志．1998，3(2)：65-67．
14. Sakata K, Al-Mefty O, Yamamoto I. Venous consideration in petrosal approach: microsurgerical anatomy of temporal bridging vein. Neurosurgery, 2000, 47(1):153-161.
15. Miabi Z, Midia R, Rohrer SE, et al. Delineation of Lateral Tentorial Sinus with Contrast-Enhanced MR Imaging and Its Surgical Implications. AJNR Am J Neuroradiol, 2004, 25(3): 1181-1188.
16. Kirchhof K, Welzel T, Jansen O, et al. More reliable noninvasive visualization of the cerebral veins and dural sinuses: comparison of three MR angiographic techniques. Radiology, 2002, 224(7):804-810.
17. Matsumoto M, Endo Y, Sato M, Sato S, et al. Acute aneurysm surgery using three-dimensional CT angiogrphy without conventional catheter angiography. Fukushima J Med Sci. 2002, 48(2):63-73.
18. Casey SO, Alberico RA, Patel M, et al. Cerebral CT venography. Radiology, 1996, 198(2):163-170.
19. Veber G, Andrew M, Adams C, et al. Cerebral Sinovenous Thrombosis in Children. N. Engl. J. Med, 2001, 345(13): 417-423.
1．徐启武，车晓明，杨伯捷，等。中、后颅窝型三叉神经鞘瘤的诊断与治疗。中国神经精神疾病杂志，2002，28(6)：443-445
2. Smith ER, Chapman PH, Ogilvy CS. Far posterior subtemporal approach to the dorsolateral brainstem and tentorial ring: technique and clinical experience. Neurosurgery. 2003,52(2):364-369.
3．施炜，徐启武，车晓明，等。应用颞底-经天幕入路治疗中后颅窝肿瘤。中华医学杂志 2005，46(85)：3293-3295．
4. Kawase T, Toya S, Shiobara R, et al. Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg, 1985, 63(5):857-861.
5. Kawase T, Shiobara R, Toya S. Anterior transpetrosal tanstentorial approach for sphenonpetroclival meningioma: surgical methods and results in 10 patients. Neurosurgey, 1991, 28(6):869-875.
6. Arriaga MA, Brackmann DE. Extended middle fossa resection of petroclival and cavernous sinus neoplasms. Layngoscope, 1993,103(6):693-697.
7. Harsh GR, Sekhar LN. Subtemporal,tanscavernous,anterior transprtrosal approach to the upper brain stem and clivus. J Neurosurg,1992, 77(5):709-715.
8. Sen CN, Sekhar LN. The subtemproal and preauricular infrotemporal approach to intradrual structure ventral to the brain stem. J Neurosurg,1990, 73(3):345-350.
9. Al-mefty O. Comments on "Anterior transpetrosaltranstentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients." Neurosurg, 1991, 28(6): 876-880.
10．刘清明，赵华盛，朱世杰，等。颅中窝经路内耳道手术有关的应用解剖。中国临床应用解剖学杂志，1990，8(4)：217—220．
11. Pialoux P, Freyss G, Narch P, et al . Contributional anatomie stereotaxique du conduit auditif interne et de la premiere portion du facial. Ann Otolaryngol Chir Cervecofac, 1972,89(5): 141-142.
12. Catalano PJ , Eden AR, et al. An external reference to internal auditory canal in middle fossa. Otolaryngol Huvg, 1993, 108(5):111—116.
13．李士庭、周良辅、郭欢欢，等。颞骨岩部的应用解剖。解剖学杂志，1997，20(4)：313—317．
14．丁锡平，袁贤瑞，曹美鸿，等。颞下经岩尖—小脑幕入路手术的显微解剖研究。中国耳鼻喉颅底外科杂志，2003，9(1)：10—12．
15．曹焕军，鞠学红，李翠花，等。内听道的解剖学研究及其临床意义。中国解剖与临床，2001，6(2)：79—80．
16. Cokkeser Y, Aristegui M, Naguib MB, et al. Identification of internal acoustic canal in the middle cranial fossa approach: a safe technique. Laryngoscope, 1998,108(8):1190-1194.
17．黄素群，李兴国，傅希玥，等。颞骨岩尖部及其邻近结构的应用解剖学研究。局解手术学杂志，2003，12(4)：264—267．
18．罗滨，邹连生，彭韶平，等。经幕上、下联合入路岩斜区的显微外科解剖。解剖学杂志，2005，28(1)：74—75．
19. Giorgio Iaconetta, Mario Fusco, Madjid Samii. The sphenopetroclival venous gulf: a microanatomy study. J Neurosurgery 2003 99:366-375.
20. Day JD, Fukushima T, Giannotta SL. Microanatomical study of the extradural middle fossa approach to the petroclival and posterior cavernous sinus region : description of the rhomboid contruct. Neurosurgery, 1994,34 (6): 1009-1016.
21. Abdel Aziz KM, van loveren HR, Tew JMJ r, et al. The kawase approach to retrosellar and upper clival basilar aneurysms. Neurosurgery, 1999,44 (6): 1225-1236.
22．刘军，王克强，张天宇，等。颞骨岩部的临床应用解剖研究。中国局部手术学杂志，2000，9(2)：102—105．
23. Marcos Tatagiba Sammii M. The significance for postoperative hearing of preserving the labyrinth in acoustic neurinoma surgery. J Neurosurg,1992, 77(11):677-684.
1. Samii M, Carvalho GA, Tatagiba M, et al. Surgical management of meningiomas originating in Meckel's cave. Neurosurgery, 1997, 41(4):767-774.
2. Samii M, Migliori MM, Tatagiba M, et al. Surgical treatment of approach for sphenopetroclival meningiomas: surgical method and result in 10 patients. Neurosurgery, 1995, 82(5):711-718.
3. Mehmet Faik Ozveren, Koichi Uchida, Sadakazu Aiso. Meningovenous structures of petroclival region: Clinical importance for surgery and intravascular surgery. Neurosurgery, 2002, 50(4):829-836.
4. Ozveren MF, Uchida K, Aiso S. Meningovenous structures of petroclival region: Clinical importance for surgery and intravascular surgery. Neurosurgery, 2002, 50(4):829-836.
5. Khaled M. Abdel A, Abhay S, Harry R VL; John M. Jr. T; Jeffrey T. K; Myles L. P: Petroclival Meningiomas: Predictive Parameters for Transpetrosal Approaches. Neurosurgery,47(1):139-152.
6. Chang Weon C, Ossama A:Combined Petrosal Approach to Petroclival Meningiomas. Neurosurgery, 2002, 51(3):708-718.
7. Amitabha Chanda, Anil Nanda: Partial labyrinthectomy petrous apiectomy approach to the petroclival region: an anatomic and technical study. Neurosurgery 2002, 51(1):147-160
8. McCormick CP, Bello JA, Post KD: Trigeminal schwannoma. Surgical series of 14 cases with review of the literature. J Neurosurg, 1988, 69(6): 850-860
9. Jamal M. Taha, John M Tew, Harry R. van Loveren, et al: Comparison of conventional and skull base surgical approaches for the excision of trigeminal neurinomas. J Neurosurgery, 1995, 82(5):719-725.
10．施炜 徐启武 车晓明，等。应用颞底-经天幕入路治疗中后颅窝肿瘤。中华外科学杂志，2006，44(2)：126-128
11. Taniguchi M, Perneczky A. Subtemporal keyhole approach to the superasellar and petroclival region: microanatomic considerations and clinical application. Neurosurgery, 1997, 41(3): 592-601.
12．李泽福，徐启武，车晓明，等 中后颅窝型三叉神经鞘瘤的手术治疗。中国临床神经科学，2004，12(1)：54-55
13．徐启武，车晓明，杨伯捷等 三叉神经鞘瘤的诊断和手术入路选择。中华神经外科疾病研究杂志，2002，1(4)：320-323
14．兰青，钱志远，陈坚，等 锁孔入路显微切除后颅窝肿瘤的疗效分析。中华医学杂志，2005，85(4)：219-223．
15. Smith ER, Chapman PH, Ogilvy CS. Far posterior subtemporal approach to the dorsolateral brainstem and tentorial ring: technique and clinical experience. Neurosurgery,2003, 52(2):364-369.
16. Ammerman JM, Lonser RR, Oldfield EH. Posterior subtemporal transtentorial approach to intraparenchymal lesions of the anteromedial region of the superior cerebellum. J Neurosurg. 2005, 103(5):783-788.
17. Kawase T, Toya S, Shiobara R, et al. Transpetrosal app roach for aneurysms of the lower basilar artery. J Neurosurg, 1985, 63: 857-861.
18. Madjid Samii, Marcos Tatagiba, Gustavo A, et al: Retrosigmoid intradural suprameatal approach to Meckel's cave and middle fossa: surgical technique and outcome. J Neurosurgery 2000, 92:235-241.
19．徐启武，车晓明，杨伯捷，等。中、后颅窝型三叉神经鞘瘤的诊断与治疗。中国神经精神疾病杂志，2002，28(6)：443-445
20. Simpson D. The recurrence of intracranial meningiomas after surgical treatment.J Neurol Neurosurg Psychiatry,1957,20(1):22-39.
21. Wilson CB. Meningiomas: genetics, malignancy, and the role of radiation in induction and treatment. The Richard C. Schneider Lecture. J Neurosurg, 1994,81(5):666-75.
22. Sepehrnia A, Knopp U. The combined subtemporal-suboccipital approach: a modified surgical access to the clivus and petrous apex. Minim Invasive Neurosurg, 2002,45(2): 102-1044.
23．刘开东，耿晓增，程刚，等。颞叶桥静脉的显微解剖及临床意义。中国临床解剖学杂志，2005，32(2)：149-152
24．宫剑，于春江，关树森，等。改良岩斜区手术入路的解剖研究。中国微侵袭神经外科杂志，2005，10(1)：26-29
25. TedeschiH, RhotonAl. Lateral approaches to the petroclival region. SurgNeurol, 1994, 41(3): 180-216.
26. Miller RS, Pensak ML. The superior petrosal triangle as a constant anatomical landmark for subtemporal middle fossa orientation. Laryngoscope. 2003, 113(8): 1327-1331.
27. Bassiouni H, Hunold A, Asgari S, et al. Meningiomas of the posterior petrous bone: functional outcome after microsurgery. J Neurosurg. 2004, 100(6): 1014-1024.
28. Rhoton AL, Pulec JL, Hall GM, et al. Absence of bone over the genitulate ganglion. Neurosurg, 1998, 43(1): 84-89
29．丁锡平，袁贤瑞，曹美鸿，等 颞下经岩尖—小脑幕入路手术的显微解剖研究。中国耳鼻咽喉颅底外科杂志，2003，9(1)：10—12
30. Al-mefty O. Comments on "Anterior transpetrosaltranstentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients." Neurosurg, 1991,28(6): 876-880
31．徐启武，杨伯捷。手术治疗岩斜区脑膜瘤。中华神经外科杂志，2002，18(2)：71-73
32. Little KM, Friedman AH, Sampson JH, et al. Surgical management of petroclival meningiomas: defining resection goals based on risk of neurological morbidity and tumor recurrence rates in 137 patients. Neurosurgery. 2005,56(3):546-59.
1. Mehmet Faik Ozveren, Koichi Uchida, Sadakazu Aiso: Meningovenous structures of petroclival region: Clinical importance for surgery and intravascular surgery. Neurosurgery 2002, 50(4):829-836.
2. Giorgio Iaconetta, Mario Fusco, Madjid Samii: The sphenopetroclival venous gulf: a microanatomy study. J Neurosurgery 2003, 99:366-375.
3. Morrison AW, King TT: Experiences with a translabyrinthine-transtentorial approach to the cerebellopontine angle. Technical note. J Neurosurg, 1973, 38: 382-390.
4. Madjid Samii, Marcos Tatagiba, Gustavo A, et al: Retrosigmoid intradural suprameatal approach to Meckel's cave and middle fossa: surgical technique and outcome. J Neurosurgery 2000, 92:235-241.
5. Hakuba A, Nishimura S, Tanaka K, et al: Clivus meningioma: Six cases of total removal. Neurol Med Chir(Tokyo), 1977,17: 63-77.
6. House WF, de al Cruz A, Hitselberger WE: Surgery of the skull base: Transcochlear approach to the petrous apex and clivus. Otolaryngology, 1978, 86:770-779.
7. Jenkins HA, Fisch U: The transotic approach to rection of difficult acoustic tumors of the cerebellopontine angle. Am J Otol, 1980, 2:70-76.
8. Al-Mefty O, Fox JL, Smith RR: Petrosal approach for petroclival meningiomas. Neurosurgery, 1988, 22:410-414.
9. McElveen JT Jr, Wilkins RH, Erwin AC, et al: Modifying the translabyrinthine approach to preserve hearing during acoustic tumor surgery. J Laryngol Otol, 1991, 105:34-37.
10. Hirsch BE, Cass SP, Sekhar LN, et al: Translabyrinthine approach to skull base tumors with hearing preservation. Am J Otol, 1993, 14: 533-543.
11. Laligam N. Sekhar, David A. Schessel, Sorin D. Bucur, et al:: Partial labyrinthectomy petrous apiectomy approach to neoplastic and vascular lesions of the petroclival area. Neurosurgery, 1999, 44(3): 537-552.
12. Horrgan MA, Delashaw JB, Schwaitz MS, et al: Transcrusal approach to the petroclival region with hearing preservation: Technical note and illustrative cases. J Neurosurg, 2001, 94: 660-666.
13. Bochenek Z, Kukwa A: An extended approach through the middle cranial fossa to the internal auditory meatus and the cerebello-pontine angle. Acta Otolaryngol(Stockh), 1975,80:410-414.
14. Kawase T, Toya S, Shiobara R, et al: Transpetrosal approach for aneurysm of the lower basilar artery. J Neurosurg, 1985, 63:857-861.
15. Amitabha Chanda, Anil Nanda: Partial labyrinthectomy petrous apiectomy approach to the petroclival region: an anatomic and technical study. Neurosurgery, 2002, 51(1):147-160.
16. Michael A, Horgan, Gregory J, Anderson, Jordi X. Kellogg, et al: Classification and quantification of the petrosal approach to the petroclival region. J Neurosurgery, 2000,93: 108-112.
17. Jamal M. Taha, John M Tew, Harry R. van Loveren, et al: Comparison of conventional and skull base surgical approaches for the excision of trigeminal neurinomas. J Neurosurgery, 1995,82:719-725.
18. Jongkees LB: On function of the labyrinth after destruction of the horizontal canal. Acta Otolaryngol(Stockh), 1950, 38: 505-510.
19. Chang Weon Cho, Ossama Al-Mefty: Combined petrosal approach to petroclivial meningiomas. Neurosurgery, 2002, 51(3):708-718.
02 Iaconetta G, Fusco M, Samii M: The sphenopetroclival venous gulf: a microanatomy study. J Neurosurgery 2003 99:366-375
03 Horgan MA, Anderson GJ, Kellogg JX, et al: Classification and quantification of the petrosal approach to the petroclival region. J Neurosurgery 2000,93:108-112
04 Sekhar LN, Schessel DA, Bucur SD, et al: Partial labyrinthectomy petrous apiectomy approach to neoplastic and vascular lesions of the petroclival area. Neurosurgery 1999, 44(3): 537-552
05 张俊庭，王忠诚，贾桂军，等。岩斜区脑膜瘤的显微外科治疗。中华神经外科杂志，2000，16(5)：292-294
06 Taha JM, Tew JM, van Loveren HR, et al: Comparison of conventional and skull base surgical approaches for the excision of trigeminal neurinomas. J Neurosurgerv 1995,82:719-725
07 徐启武，车晓明，杨伯捷，等。中、后颅窝型三叉神经鞘瘤的诊断与治疗。中国神经精神疾病杂志，2002，28(6)：443-445
08 Smith ER, Chapman PH, Ogilvy CS. Far posterior subtemporal approach to the dorsolateral brainstem and tentorial ring: technique and clinical experience. Neurosurgery. 2003,52(2):364-9.
09 施炜 徐启武 车晓明，等。应用颞底-经天幕入路治疗中后颅窝肿瘤。中华外科学杂志，2006，44(2)：126-128
1 Day JD, Kellogg JX,Fukushima,T, et al. Microsurgical anatomy of the inner surface of the petrous bone: neuroradiological and morphometric analysis as an adjunct to the retrosigmoid transmeatal approach. Neurosurgy, 1994, 34(5):1003—1007.
2 Uz A, Ugur HC, Tekdemir I. Is the asterion a reliable landmark for the lateral approach to posterior fossa? J Clin Neurosci, 2001, 8(2): 146-147.
3 李泽福，徐启武，车晓明，等．颞底-经小脑幕手术入路的应用解剖学．中国临床解剖学杂志，2004，22(2)：159-161．
4 梁树立，漆松涛，彭林，等．国人乙状窦沟的应用解剖学研究．广东医学，2001，22(2)：113-115．
5 Iaconetta G, Fusco M, Samii M. The sphenopetroclival venous gulf: a microanatomy study. J Neurosurgery, 2003, 99(3): 366-375.
6 罗滨，邹连生，彭韶平，等．经幕上、下联合进路岩斜区的显微外科解剖．解剖学杂志，2005，28(1)：74-75．
7 Rhoton AL, Pulec JL, Hall GM, et al. Absence of bone over the genitulate ganglion. J Neurosurgery, 1968, 28(1): 84-89.
8 AL-mefty O. Comments on"Anterior transpetrosaltranstentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients". Neurosurgery, 1991, 28(6):876-881.
9 Macros Tagagiba Samii M. The significance for postoperative hearing of preserving the labyrinth in acoustic neurinoma surgery.J Neurosurgery, 1992, 77(11):677-684.
1. Barrels RH, van-Overbeeke JJ. Charles Labbé(1851-1889). J Neurosurg, 1997, 87(3): 477-480.
2. Morita A, Sekhar L. Reconstruction of the vein of Labbé by using a short saphenous vein bypass graft technical note. J Neurosurg, 1998, 89(6): 671-675.
3. Rhoton AL Jr. The cerebral vein. Neurosurgery, 2002, 51(S1): 51-167.
4. Koperna TH, Tshabitscher M, Knosp E. The termination of the vein of Labbé and its microsurgical significance. Acta Neurochir, 1992, 118(7): 172-175.
5. Guppy KH , Origitano TC , Reichman OH , et al. Venous drainage of the inferolateral temporal lobe in relationship to transtemporal/transtentorial aooroaches to the cranial base. Neurosurgery, 1997,41 (3) : 615-620.
6．刘庆良，王忠诚，张俊廷．颞枕入路Labbé静脉术中结扎术后失语分析．中华神经外科杂志，1997，13(2)：95-97．
7. Schmid-Elsaesser R , Steiger HJ , Yousry T , et al. Radical resection of meningiomas and arteriovenous fistulas involving critical dural sinus segments: experience with intraoperative sinus pressure monitoring and elective sinus reconstruction in 10 patients. Neurosurgery, 1997,41 (5) : 1005-1018.
8. Kawase T, Shiobara, Toya S. Anterior transpetrosal transtentoial approach for sphenopetroclival meningiomas: surgical results in 10 patients. Neurosurgery, 1991, 28:869-876
9．张力伟，王忠诚，于春江，等．Labbé静脉的显微解剖学研究．中华神经外科杂志，2003，19(6)，456-458．
10．张岩松，常义，惠国桢，等．颞叶桥静脉引流形式的显微外科解剖研究．中华神经外科杂志，2005 21(1)，9-12．
11. Jones BV.Case 62: Lobar Hemorrhage from thrombosis of the Vein of Labbé′. Radiology, 2003; 228:693-696
12. Cho CW, AI-Mefty O. Combined petrosal approach to petroclival meningiomas. Neurosurgery 2002, 51 (10):708-718.
13．魏群，郑文济，沈春森，等．颞下经小脑幕入路中Labbé静脉的保留与离断．临床神经外科杂志．1998，3(2)：65-67．
14. Sakata K, Al-Mefty O, Yamamoto I. Venous consideration in petrosal approach: microsurgerical anatomy of temporal bridging vein. Neurosurgery, 2000, 47(1):153-161.
15. Miabi Z, Midia R, Rohrer SE, et al. Delineation of Lateral Tentorial Sinus with Contrast-Enhanced MR Imaging and Its Surgical Implications. AJNR Am J Neuroradiol, 2004, 25(3): 1181-1188.
16. Kirchhof K, Welzel T, Jansen O, et al. More reliable noninvasive visualization of the cerebral veins and dural sinuses: comparison of three MR angiographic techniques. Radiology, 2002, 224(7):804-810.
17. Matsumoto M, Endo Y, Sato M, Sato S, et al. Acute aneurysm surgery using three-dimensional CT angiogrphy without conventional catheter angiography. Fukushima J Med Sci. 2002, 48(2):63-73.
18. Casey SO, Alberico RA, Patel M, et al. Cerebral CT venography. Radiology, 1996, 198(2):163-170.
19. Veber G, Andrew M, Adams C, et al. Cerebral Sinovenous Thrombosis in Children. N. Engl. J. Med, 2001, 345(13): 417-423.
1．徐启武，车晓明，杨伯捷，等。中、后颅窝型三叉神经鞘瘤的诊断与治疗。中国神经精神疾病杂志，2002，28(6)：443-445
2. Smith ER, Chapman PH, Ogilvy CS. Far posterior subtemporal approach to the dorsolateral brainstem and tentorial ring: technique and clinical experience. Neurosurgery. 2003,52(2):364-369.
3．施炜，徐启武，车晓明，等。应用颞底-经天幕入路治疗中后颅窝肿瘤。中华医学杂志 2005，46(85)：3293-3295．
4. Kawase T, Toya S, Shiobara R, et al. Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg, 1985, 63(5):857-861.
5. Kawase T, Shiobara R, Toya S. Anterior transpetrosal tanstentorial approach for sphenonpetroclival meningioma: surgical methods and results in 10 patients. Neurosurgey, 1991, 28(6):869-875.
6. Arriaga MA, Brackmann DE. Extended middle fossa resection of petroclival and cavernous sinus neoplasms. Layngoscope, 1993,103(6):693-697.
7. Harsh GR, Sekhar LN. Subtemporal,tanscavernous,anterior transprtrosal approach to the upper brain stem and clivus. J Neurosurg,1992, 77(5):709-715.
8. Sen CN, Sekhar LN. The subtemproal and preauricular infrotemporal approach to intradrual structure ventral to the brain stem. J Neurosurg,1990, 73(3):345-350.
9. Al-mefty O. Comments on "Anterior transpetrosaltranstentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients." Neurosurg, 1991, 28(6): 876-880.
10．刘清明，赵华盛，朱世杰，等。颅中窝经路内耳道手术有关的应用解剖。中国临床应用解剖学杂志，1990，8(4)：217—220．
11. Pialoux P, Freyss G, Narch P, et al . Contributional anatomie stereotaxique du conduit auditif interne et de la premiere portion du facial. Ann Otolaryngol Chir Cervecofac, 1972,89(5): 141-142.
12. Catalano PJ , Eden AR, et al. An external reference to internal auditory canal in middle fossa. Otolaryngol Huvg, 1993, 108(5):111—116.
13．李士庭、周良辅、郭欢欢，等。颞骨岩部的应用解剖。解剖学杂志，1997，20(4)：313—317．
14．丁锡平，袁贤瑞，曹美鸿，等。颞下经岩尖—小脑幕入路手术的显微解剖研究。中国耳鼻喉颅底外科杂志，2003，9(1)：10—12．
15．曹焕军，鞠学红，李翠花，等。内听道的解剖学研究及其临床意义。中国解剖与临床，2001，6(2)：79—80．
16. Cokkeser Y, Aristegui M, Naguib MB, et al. Identification of internal acoustic canal in the middle cranial fossa approach: a safe technique. Laryngoscope, 1998,108(8):1190-1194.
17．黄素群，李兴国，傅希玥，等。颞骨岩尖部及其邻近结构的应用解剖学研究。局解手术学杂志，2003，12(4)：264—267．
18．罗滨，邹连生，彭韶平，等。经幕上、下联合入路岩斜区的显微外科解剖。解剖学杂志，2005，28(1)：74—75．
19. Giorgio Iaconetta, Mario Fusco, Madjid Samii. The sphenopetroclival venous gulf: a microanatomy study. J Neurosurgery 2003 99:366-375.
20. Day JD, Fukushima T, Giannotta SL. Microanatomical study of the extradural middle fossa approach to the petroclival and posterior cavernous sinus region : description of the rhomboid contruct. Neurosurgery, 1994,34 (6): 1009-1016.
21. Abdel Aziz KM, van loveren HR, Tew JMJ r, et al. The kawase approach to retrosellar and upper clival basilar aneurysms. Neurosurgery, 1999,44 (6): 1225-1236.
22．刘军，王克强，张天宇，等。颞骨岩部的临床应用解剖研究。中国局部手术学杂志，2000，9(2)：102—105．
23. Marcos Tatagiba Sammii M. The significance for postoperative hearing of preserving the labyrinth in acoustic neurinoma surgery. J Neurosurg,1992, 77(11):677-684.
1. Samii M, Carvalho GA, Tatagiba M, et al. Surgical management of meningiomas originating in Meckel's cave. Neurosurgery, 1997, 41(4):767-774.
2. Samii M, Migliori MM, Tatagiba M, et al. Surgical treatment of approach for sphenopetroclival meningiomas: surgical method and result in 10 patients. Neurosurgery, 1995, 82(5):711-718.
3. Mehmet Faik Ozveren, Koichi Uchida, Sadakazu Aiso. Meningovenous structures of petroclival region: Clinical importance for surgery and intravascular surgery. Neurosurgery, 2002, 50(4):829-836.
4. Ozveren MF, Uchida K, Aiso S. Meningovenous structures of petroclival region: Clinical importance for surgery and intravascular surgery. Neurosurgery, 2002, 50(4):829-836.
5. Khaled M. Abdel A, Abhay S, Harry R VL; John M. Jr. T; Jeffrey T. K; Myles L. P: Petroclival Meningiomas: Predictive Parameters for Transpetrosal Approaches. Neurosurgery,47(1):139-152.
6. Chang Weon C, Ossama A:Combined Petrosal Approach to Petroclival Meningiomas. Neurosurgery, 2002, 51(3):708-718.
7. Amitabha Chanda, Anil Nanda: Partial labyrinthectomy petrous apiectomy approach to the petroclival region: an anatomic and technical study. Neurosurgery 2002, 51(1):147-160
8. McCormick CP, Bello JA, Post KD: Trigeminal schwannoma. Surgical series of 14 cases with review of the literature. J Neurosurg, 1988, 69(6): 850-860
9. Jamal M. Taha, John M Tew, Harry R. van Loveren, et al: Comparison of conventional and skull base surgical approaches for the excision of trigeminal neurinomas. J Neurosurgery, 1995, 82(5):719-725.
10．施炜 徐启武 车晓明，等。应用颞底-经天幕入路治疗中后颅窝肿瘤。中华外科学杂志，2006，44(2)：126-128
11. Taniguchi M, Perneczky A. Subtemporal keyhole approach to the superasellar and petroclival region: microanatomic considerations and clinical application. Neurosurgery, 1997, 41(3): 592-601.
12．李泽福，徐启武，车晓明，等 中后颅窝型三叉神经鞘瘤的手术治疗。中国临床神经科学，2004，12(1)：54-55
13．徐启武，车晓明，杨伯捷等 三叉神经鞘瘤的诊断和手术入路选择。中华神经外科疾病研究杂志，2002，1(4)：320-323
14．兰青，钱志远，陈坚，等 锁孔入路显微切除后颅窝肿瘤的疗效分析。中华医学杂志，2005，85(4)：219-223．
15. Smith ER, Chapman PH, Ogilvy CS. Far posterior subtemporal approach to the dorsolateral brainstem and tentorial ring: technique and clinical experience. Neurosurgery,2003, 52(2):364-369.
16. Ammerman JM, Lonser RR, Oldfield EH. Posterior subtemporal transtentorial approach to intraparenchymal lesions of the anteromedial region of the superior cerebellum. J Neurosurg. 2005, 103(5):783-788.
17. Kawase T, Toya S, Shiobara R, et al. Transpetrosal app roach for aneurysms of the lower basilar artery. J Neurosurg, 1985, 63: 857-861.
18. Madjid Samii, Marcos Tatagiba, Gustavo A, et al: Retrosigmoid intradural suprameatal approach to Meckel's cave and middle fossa: surgical technique and outcome. J Neurosurgery 2000, 92:235-241.
19．徐启武，车晓明，杨伯捷，等。中、后颅窝型三叉神经鞘瘤的诊断与治疗。中国神经精神疾病杂志，2002，28(6)：443-445
20. Simpson D. The recurrence of intracranial meningiomas after surgical treatment.J Neurol Neurosurg Psychiatry,1957,20(1):22-39.
21. Wilson CB. Meningiomas: genetics, malignancy, and the role of radiation in induction and treatment. The Richard C. Schneider Lecture. J Neurosurg, 1994,81(5):666-75.
22. Sepehrnia A, Knopp U. The combined subtemporal-suboccipital approach: a modified surgical access to the clivus and petrous apex. Minim Invasive Neurosurg, 2002,45(2): 102-1044.
23．刘开东，耿晓增，程刚，等。颞叶桥静脉的显微解剖及临床意义。中国临床解剖学杂志，2005，32(2)：149-152
24．宫剑，于春江，关树森，等。改良岩斜区手术入路的解剖研究。中国微侵袭神经外科杂志，2005，10(1)：26-29
25. TedeschiH, RhotonAl. Lateral approaches to the petroclival region. SurgNeurol, 1994, 41(3): 180-216.
26. Miller RS, Pensak ML. The superior petrosal triangle as a constant anatomical landmark for subtemporal middle fossa orientation. Laryngoscope. 2003, 113(8): 1327-1331.
27. Bassiouni H, Hunold A, Asgari S, et al. Meningiomas of the posterior petrous bone: functional outcome after microsurgery. J Neurosurg. 2004, 100(6): 1014-1024.
28. Rhoton AL, Pulec JL, Hall GM, et al. Absence of bone over the genitulate ganglion. Neurosurg, 1998, 43(1): 84-89
29．丁锡平，袁贤瑞，曹美鸿，等 颞下经岩尖—小脑幕入路手术的显微解剖研究。中国耳鼻咽喉颅底外科杂志，2003，9(1)：10—12
30. Al-mefty O. Comments on "Anterior transpetrosaltranstentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients." Neurosurg, 1991,28(6): 876-880
31．徐启武，杨伯捷。手术治疗岩斜区脑膜瘤。中华神经外科杂志，2002，18(2)：71-73
32. Little KM, Friedman AH, Sampson JH, et al. Surgical management of petroclival meningiomas: defining resection goals based on risk of neurological morbidity and tumor recurrence rates in 137 patients. Neurosurgery. 2005,56(3):546-59.
1. Mehmet Faik Ozveren, Koichi Uchida, Sadakazu Aiso: Meningovenous structures of petroclival region: Clinical importance for surgery and intravascular surgery. Neurosurgery 2002, 50(4):829-836.
2. Giorgio Iaconetta, Mario Fusco, Madjid Samii: The sphenopetroclival venous gulf: a microanatomy study. J Neurosurgery 2003, 99:366-375.
3. Morrison AW, King TT: Experiences with a translabyrinthine-transtentorial approach to the cerebellopontine angle. Technical note. J Neurosurg, 1973, 38: 382-390.
4. Madjid Samii, Marcos Tatagiba, Gustavo A, et al: Retrosigmoid intradural suprameatal approach to Meckel's cave and middle fossa: surgical technique and outcome. J Neurosurgery 2000, 92:235-241.
5. Hakuba A, Nishimura S, Tanaka K, et al: Clivus meningioma: Six cases of total removal. Neurol Med Chir(Tokyo), 1977,17: 63-77.
6. House WF, de al Cruz A, Hitselberger WE: Surgery of the skull base: Transcochlear approach to the petrous apex and clivus. Otolaryngology, 1978, 86:770-779.
7. Jenkins HA, Fisch U: The transotic approach to rection of difficult acoustic tumors of the cerebellopontine angle. Am J Otol, 1980, 2:70-76.
8. Al-Mefty O, Fox JL, Smith RR: Petrosal approach for petroclival meningiomas. Neurosurgery, 1988, 22:410-414.
9. McElveen JT Jr, Wilkins RH, Erwin AC, et al: Modifying the translabyrinthine approach to preserve hearing during acoustic tumor surgery. J Laryngol Otol, 1991, 105:34-37.
10. Hirsch BE, Cass SP, Sekhar LN, et al: Translabyrinthine approach to skull base tumors with hearing preservation. Am J Otol, 1993, 14: 533-543.
11. Laligam N. Sekhar, David A. Schessel, Sorin D. Bucur, et al:: Partial labyrinthectomy petrous apiectomy approach to neoplastic and vascular lesions of the petroclival area. Neurosurgery, 1999, 44(3): 537-552.
12. Horrgan MA, Delashaw JB, Schwaitz MS, et al: Transcrusal approach to the petroclival region with hearing preservation: Technical note and illustrative cases. J Neurosurg, 2001, 94: 660-666.
13. Bochenek Z, Kukwa A: An extended approach through the middle cranial fossa to the internal auditory meatus and the cerebello-pontine angle. Acta Otolaryngol(Stockh), 1975,80:410-414.
14. Kawase T, Toya S, Shiobara R, et al: Transpetrosal approach for aneurysm of the lower basilar artery. J Neurosurg, 1985, 63:857-861.
15. Amitabha Chanda, Anil Nanda: Partial labyrinthectomy petrous apiectomy approach to the petroclival region: an anatomic and technical study. Neurosurgery, 2002, 51(1):147-160.
16. Michael A, Horgan, Gregory J, Anderson, Jordi X. Kellogg, et al: Classification and quantification of the petrosal approach to the petroclival region. J Neurosurgery, 2000,93: 108-112.
17. Jamal M. Taha, John M Tew, Harry R. van Loveren, et al: Comparison of conventional and skull base surgical approaches for the excision of trigeminal neurinomas. J Neurosurgery, 1995,82:719-725.
18. Jongkees LB: On function of the labyrinth after destruction of the horizontal canal. Acta Otolaryngol(Stockh), 1950, 38: 505-510.
19. Chang Weon Cho, Ossama Al-Mefty: Combined petrosal approach to petroclivial meningiomas. Neurosurgery, 2002, 51(3):708-718.