Juan C. Fernandez-Miranda, MD教授
内镜鼻内入路的海绵窦隔室：腺瘤手术的
解剖学深思和手术相关性
目的
OBJECTIVE Tumors with cavernous sinus (CS) invasion represent a neurosurgical challenge. Increasing application of the endoscopic endonasal approach (EEA) requires a thorough understanding of the CS anatomy from an endonasal perspective. In this study, the authors aimed to develop a surgical anatomy–based classification of the CS and establish its utility for preoperative surgical planning and intraoperative guidance in adenoma surgery.
目的 侵袭海绵窦（CS）的肿瘤是神经外科的挑战。内镜经鼻入路（EEA）的广泛应用需要从鼻内的角度对CS解剖结构进行全面的了解。在本研究中，作者旨在阐述一种基于手术解剖的CS分类，并确定其在腺瘤手术的术前手术计划和术中指导中的实用性。
方法
METHODS Twenty-five colored silicon–injected human head specimens were used for endonasal and transcranial dissections of the CS. Pre- and postoperative MRI studies of 98 patients with pituitary adenoma with intraoperatively confirmed CS invasion were analyzed.
方法 对25例彩色硅胶注射人体头部标本的CS进行经鼻和经颅解剖。对98例经术中证实垂体腺瘤侵袭CS的患者进行术前和术后MRI的分析。
结果
RESULTS Four CS compartments are described based on their spatial relationship with the cavernous ICA: superior, posterior, inferior, and lateral. Each compartment has distinct boundaries and dural and neurovascular relationships: the superior compartment relates to the interclinoidal ligament and oculomotor nerve, the posterior compartment bears the gulfar segment of the abducens nerve and inferior hypophyseal artery, the inferior compartment contains the sympathetic nerve and distal cavernous abducens nerve, and the lateral compartment includes all cavernous cranial nerves and the inferolateral arterial trunk. Twenty-nine patients had a single compartment invaded, and 69 had multiple compartments involved. The most commonly invaded compartment was the superior (79 patients), followed by the posterior (n = 64), inferior (n = 45), and lateral (n = 23) compartments. Residual tumor rates by compartment were 79% in lateral, 17% in posterior, 14% in superior, and 11% in inferior.
结果 根据其与海绵窦段ICA的空间关系，描述了4个CS隔室：上、后、下和外侧隔室。每个隔室都有不同的边界以及硬膜和神经血管的关系：上隔室与床突间韧带和动眼神经有关，后隔室承载外展神经的gulfar段和垂体下动脉，下隔室包含交感神经和外展神经海绵窦内远端，外侧隔室包括所有海绵窦段脑神经和下外侧动脉干。29例患者仅侵袭单一隔室，69例患者侵袭多个隔室。最常见受侵袭的是上隔室（79例患者），其次是后隔室（n=64）、下隔室（n=45）和外侧隔室（n=23）。按隔室划分的残余肿瘤发生率分别为外侧隔室79%，后隔室17%，上隔室14%，下隔室11%。
结论
CONCLUSIONS The anatomy-based classification presented here complements current imaging-based classifications and may help to identify involved compartments both preoperatively and intraoperatively.
结论 本文提出的基于解剖学的分类补充了当前基于影像学的分类，可能有助于在术前和术中识别受累的隔室。
Pituitary and skull base tumors with cavernous sinus (CS) invasion represent a neurosurgical challenge. The surgical anatomy, safe-entry zones, and corresponding surgical routes to the CS have been studied by several authors. Transcranial skull base approaches have accessed the CS through its superior and lateral walls, where 4 different triangles (clinoidal and oculomotor for the superior wall, supratrochlear and infratrochlear for the lateral wall) were described to facilitate understanding of the intracavernous anatomy and neurovascular structures at risk. In contrast, the transsphenoidal microscopic technique was, until recently, standard for pituitary surgery and included drawbacks such as a limited lateral view toward the medial wall of the CS and difficulty removing tumor tissue compressing or invading the space of the CS.
侵袭海绵窦（CS）的垂体和颅底肿瘤是神经外科的一大挑战。一些作者已经对CS的手术解剖、安全进入区和相应的手术路径进行了研究。经颅颅底入路通过其上壁和外侧壁进入CS，那里描述了4个不同的三角（上壁的床突三角和动眼神经三角，外侧壁的滑车上三角和滑车下三角）以促进对海绵窦内解剖和处于危险中的神经血管结构的理解。相比之下，经蝶窦显微技术直到最近才成为垂体手术的标准技术，并包括一些缺点，如对CS内侧壁有限的侧方视野，以及难以去除压迫或侵入CS间隙的肿瘤组织。
The endoscopic endonasal approach (EEA) has opened new routes to the ventral skull base, including the CS. The wider view provided by the endoscope enables the surgeon to inspect the medial wall and the inside of the CS directly using a medial-to-lateral trajectory. In addition, significant advances in endonasal surgical anatomy and technique also allow direct access into the CS using an anterior-to-posterior trajectory. In contrast to the transcranial and transsphenoidal microscopic approaches, the endonasal route provides access through the medial (sellar) and/or anterior (sphenoidal) walls of the CS. Similarly, the previously described CS triangles have limited utility when approaching CS lesions endonasally, and previous radiological classifications of CS invasion, while useful from the prognostic point of view, are not helpful for understanding the surgical anatomy of the different compartments within the CS.
内镜经鼻入路（EEA）开辟了通往腹侧颅底包括CS在内的新途径。内镜提供的更宽视野使外科医生能够直接使用从内到外的轨迹来探查CS的内侧壁及其内部。19此外，鼻内手术解剖和技术的显著进步也允许使用从前到后的轨迹直接进入CS。与经颅和经蝶窦显微镜入路相比，鼻内入路提供了通过CS的内侧壁（鞍）和/或前壁（蝶）的通路。同样，先前描述的CS三角在鼻内接近CS病变时的效用有限，并且以前的侵袭CS的放射学分类，虽然从预后的角度来看是有用的，但对理解CS内不同隔室的手术解剖没有帮助。
In this study we propose a practical and surgically relevant endonasal classification scheme for different compartments of the CS in relation to the intracavernous internal carotid artery (ICA). The classification proposed here is partially modified from the venous spaces (“compartments”) described by Harris and Rhoton in 1976, where they differentiated posterosuperior, anteroinferior, and medial venous spaces in relation to the ICA.
在本研究中，我们针对与海绵窦内颈内动脉(ICA)相关的CS不同隔室提出了一种实用且与手术相关的鼻内分类方案。这里提出的分类是根据Harris和Rhoton于1976年描述的静脉间隙（“隔室”）进行了部分改良，他们分为了与ICA相关的后上、前下和内侧静脉间隙。
Furthermore, we describe the distinct boundaries and dural and neurovascular relationships of each compartment. Based upon these findings and our extensive surgical experience, we then highlight the surgically relevant technical nuances for approaching these CS compartments.This classification scheme was retrospectively applied for radiological evaluation of patients with pituitary adenomas and surgically confirmed CS invasion to ascertain patterns of involvement of single or multiple compartments. We thereby aim to establish the potential utility of this anatomical classification for preoperative surgical planning and intraoperative guidance.
此外，我们描述了每个隔室的不同边界以及硬膜和神经血管的关系。基于这些发现和我们丰富的手术经验，我们随后强调了接近这些CS隔室的手术相关技术的细节。回顾性地将该分类方案应用于垂体腺瘤和经手术证实的CS受侵袭患者的放射学评估，以确定单个或多个隔室的受累模式。因此，我们的目标是建立这种解剖分类在术前手术计划和术中指导中的潜在效用。
方法
Anatomical Study
解剖学研究
Twenty-five lightly embalmed, colored silicon–injected human postmortem head specimens were prepared for dissection. The research was approved by the Committee for Oversight of Research Involving the Dead at the University of Pittsburgh. Endoscopic endonasal dissections were performed using rod lens endoscopes (Hopkins II, 4-mm diameter ×18-cm length, 0° and 45°, Karl Storz) attached to a high-definition camera. Heads were positioned supine on the dissection table and a Mayfield head holder was used to maintain an almost neutral position.
准备了25个经过轻微防腐处理、注射有色硅胶的人类死后头部标本进行解剖。这项研究得到了匹兹堡大学死者研究监督委员会的批准。使用附有高清摄像机的柱状透镜内镜（Hopkins II，直径4mm×长度18cm，0°和45°，Karl Storz）进行内镜鼻内解剖。将头部仰卧于解剖台上，并使用Mayfield头架来保持几乎中立位。
An EEA was performed in all specimens. Wide bilateral sphenoidotomies were performed to expose the posterior wall of the sphenoid sinus. The bone overlying the sellar and parasellar region was removed to allow access to the medial and anterior walls of the CS. We described 4 compartments in the CS based on their spatial relationship with the cavernous ICA: superior, posterior, inferior, and lateral compartments. The following were inspected thoroughly within each compartment: dural structures and layers, cranial nerves (CNs), and branches of the ICA. In selected specimens, the pituitary gland and the intracavernous ICA were removed to better expose and study the lateral wall of the CS. Three additional heads were bisected in a sagittal plane using a high-speed electric saw, which allowed for stepwise dissection and inspection of the CS sequentially from medial to lateral. A comparative transcranial approach to the CS was performed in all heads after the endonasal dissection with the aid of 4–24 magnification (Olympus OME 8000 surgical microscope). This comparative approach was performed for correlation of the endonasal findings.
对所有标本均进行了EEA。进行双侧蝶骨扩大切开术以暴露蝶窦后壁。移除鞍区和鞍旁区上的骨质以便进入CS的内侧壁和前壁。根据CS与其内ICA的空间关系，我们描述了CS的4个隔室：上隔室、后隔室、下隔室和外侧隔室。在每个隔室内全面检查以下内容：硬膜结构及其层次、颅神经（CNs）和ICA分支。在选定的标本中，切除垂体和海绵窦段ICA，以更好地暴露和研究CS的外侧壁。使用高速电锯在矢状面上将另外3个头部对半分开，这样可以从内侧到外侧依次对CS进行逐步解剖和检查。在4-24倍数放大（Olympus OME 8000 手术显微镜）的帮助下进行鼻内解剖后，对所有头部进行CS经颅入路的比较。这种比较方法是为了鼻内检查结果的相关性而进行的。
Clinicoradiological Study
临床放射学研究
From January 2010 to July 2015, 384 patients underwent an EEA for pituitary adenoma by 2 neurosurgeons (J.C.F.M. and P.A.G.). Of these patients, 144 demonstrated CS invasion based on intraoperative findings. When the medial wall was not detectable (or was not intact) and/or intracavernous structures were visible (venous compartments, intracavernous ligaments, cavernous ICA adventitia, CNs), invasion was deemed to be present. The medial wall alone was invaded in 46 patients (32%), with 5 patients having bilateral medial wall invasion. These invasion determinations were based on careful intraoperative endoscopic observation and not on histological confirmation or MRI findings. This subgroup of patients with only medial wall invasion was excluded from this
study, as tumor did not extend into any CS compartment. For the remaining 98 patients, preoperative MRI studies were used to identify the involved compartments, because a significant number of operative notes were not sufficiently detailed to accurately discern patterns of invasion. Adequate pre- and postoperative MRI studies were available in all cases. Postcontrast T1-weighted axial, sagittal, and coronal sequences (1.25-, 3-, and 3-mm thicknesses, respectively) through the parasellar region were carefully studied. The surgical anatomy–based classification described in this study was applied to interpret the patterns of CS invasion, namely the CS compartments potentially invaded by tumor.
从2010年1月到2015年7月，2名神经外科医生（JCFM和PAG）对384名垂体腺瘤患者进行了EEA。在这些患者中，基于术中检查结果，证实144例有CS侵袭。当内侧壁不可发现（或不完整）和/或可见海绵窦内结构（静脉隔室、海绵窦内韧带、海绵度段ICA外膜、CNs）时，认为存在侵袭。46例患者（32%）仅侵袭了内侧壁，其中5例患者双侧内侧壁受侵袭。这些侵袭的确定是基于术中仔细的内镜观察，而非组织学证实或MRI结果。该亚组仅内侧壁侵袭的患者被排除在本研究之外，因为肿瘤没有延伸到任何一个CS隔室。其余的98名患者，由于大量手术记录不够详细以准确识别侵袭的模式，采用术前MRI研究来识别受累的隔室。所有病例均进行了充分的术前和术后MRI研究。仔细研究了通过鞍旁区域对比增强后的T1加权轴向、矢状和冠状位序列（厚度分别为1.25mm、3mm和3mm）。本研究中描述的基于手术解剖学的分类用于解释CS侵袭的模式，即可能被肿瘤侵袭的CS隔室。
结果
Parasellar ICA
鞍旁ICA
Understanding the parasellar ICA anatomy is essential for understanding the anatomy of the CS from an endonasal
perspective. The parasellar ICA is divided into 2 segments:
cavernous and paraclinoidal. The subsegments of the cavernous ICA from proximal to distal are the short vertical (continuation of paraclival ICA), horizontal, and anterior genu. The posterior genu is located between the short vertical and horizontal subsegments. The paraclinoidal ICA is a continuation of the anterior genu of the cavernous ICA as it emerges from the CS. It is located within the clinoidal space at the roof of the CS and is limited by the proximal and distal dural rings. It is bounded
superolaterally by the lateral optic-carotid recess (or optic strut; Fig. 1). The middle clinoid, when present, marks the transition between the cavernous and paraclinoidal ICA, while the medial opticocarotid recess at the lateral aspect of the tuberculum sella is located just medial to the paraclinoidal-supraclinoidal ICA transition.
理解鞍旁ICA解剖对于从鼻内角度理解CS的解剖至关重要。鞍旁ICA分为2段：海绵窦段和床突旁段。海绵窦段ICA由近至远的亚段是短垂直（斜坡旁段ICA的延续）、水平和前膝。后膝位于短垂直和水平亚段之间。床突旁段ICA是当海绵窦段ICA从CS中出来时前膝的延续。它位于CS顶部的床突间隙内，并受到近和远硬脑膜环的限制。它的上外侧边界是视神经-颈动脉外侧隐窝（或视柱；图1）。中床突（当存在时）标志着海绵窦段和床突旁段ICA之间的过渡，而位于鞍结节外侧面的视神经-颈动脉内侧隐窝正好位于床突旁段-床突上段ICA过渡区的内侧。
FIG. 1. Representation of the segments of the ICA. The parasellar ICA is divided into cavernous and paraclinoidal (Paraclin.) segments. Cavernous ICA subsegments from proximal to distal are: short vertical (continuation of paraclival ICA), horizontal, and anterior genu (Ant. Genu). The posterior (Post.) genu marks the transition between the short vertical and the horizontal segments of the cavernous ICA. The paraclinoidal ICA is a continuation of the anterior genu of the cavernous ICA and is within the clinoidal triangle in the roof of the CS; proximal (Prox.) and distal dural rings demarcate its extent. The yellow lines from caudal to rostral define the boundaries of the paraclival, cavernous, and paraclinoidal ICA. The vidian nerve (N.) can be followed to the lacerum ICA.
图1. ICA各段的表示。鞍旁ICA分为海绵窦段和床突旁(Paraclin.)段。由近至远的海绵窦段ICA的亚段有：短垂直（斜坡旁段ICA的延续）、水平和前膝（Ant. Genu）。后膝(Post.)标志着海绵窦段ICA的短垂直和水平段之间的过渡。床突旁段ICA是海绵窦段ICA前膝的延续，位于CS顶壁的床突三角内；近（Prox.）和远硬脑膜环界定了其范围。从尾侧到头侧的黄线定义了斜坡旁段、海绵窦段和床突旁段ICA的边界。翼管神经（Vidian N.）可以延伸至破裂孔段颈内动脉(lacerum ICA)。
Ant.Genu 前膝；Cavernous ICA海绵窦段颈内动脉；CS 海绵窦；Distal Ring 远环；Horizontal 水平的；Lacerum ICA 破裂孔段颈内动脉；Paracin.ICA 床突旁段颈内动脉；Paraclivai lCA斜坡旁段颈内动脉；Post.Genu 后膝；Prox.Ring 近环；Short Vertical 短垂直的；Vidian N.翼管神经
FIG. 2. Location of the CS compartments in relation to the segments of the ICA as visualized in a left sagittal section (medial-to-lateral view). The superior compartment (Sup. Comp.) is located superior and posterior to the horizontal and anterior (Ant.) genu segments of the cavernous ICA. The oculomotor nerve (CN III) is in the lateral wall of this compartment in the oculomotor triangle (Tr.). The interclinoidal ligament (Interclin. Lig.) is an important landmark, with CN III lateral to it. The posterior compartment (Post. Comp.) is located posterior to the short vertical cavernous ICA and anterior to the lateral petroclival dura forming the posterior wall of the CS. The interdural segment of the abducens nerve (CN VI) can be seen in this compartment above the petrous (Petr.) apex. The meningohypophyseal trunk (Men-Hyp.) can be seen coming off the posterior ICA genu. The inferior compartment (Inf. Comp.) is located inferior to the horizontal and anterior genu subsegments of the ICA and anterior to the short vertical subsegment. Key structures including the sympathetic nerve (Symp. N.), and the distal segment of CN VI medial to CN V1 (ophthalmic nerve) can be seen in this compartment. Max. St. = maxillary strut; Opt. St. = optic strut; V2= maxillary nerve.
图2. 左矢状切面（由内向外视图）显示CS隔室的位置与ICA各段的关系。上隔室(Sup. Comp.)位于海绵窦段ICA的水平段和前膝（(Ant.）的上后方。动眼神经（CN III）位于该隔室动眼神经三角(Tr.)的外侧壁中。床突间韧带（Interclin. Lig.）是一个重要的标志，CN III位于其外侧。后隔室(Post. Comp.) 位于海绵窦段ICA短垂直段的后方和形成CS后壁岩斜侧硬脑膜的前方。外展神经（CN VI）的硬膜间段可以在该隔室岩（Petr.）尖的上方看到。可见脑膜垂体干（Men-Hyp.）从ICA后膝发出。下隔室（Inf. Comp.）位于ICA水平段和前膝亚段的下方、短垂直亚段的前方。在该隔室中可以看到的关键结构包括交感神经（Symp.N.）和CN V1（眼神经）内侧的CN VI的远侧段。
Ant.Genu 前膝；CN III 动眼神经；CN V1 眼神经；CN V2 上颌神经；CN VI 外展神经；Distal Ring 远环；Horizontal 水平的；Inf.Comp 下隔室；Interclin.Lig 床突间韧带；Max. St.=上颌柱；Men-Hyp.Trurk 脑膜垂体干；Oculo-Motor Tr 动眼神经三角；Opt. St.=视柱；Paraclival ICA 斜坡旁段颈内动脉；Petr. Apex 岩尖；Post.Comp 后隔室；Short Vertical 短垂直的；Sup.Comp.上隔室；Symp. N. 交感神经
FIG. 3. Coronal (A), sagittal (B, D, and F) and axial (C and E) MR images of sellar and parasellar regions showing case examples of single-compartment invasion: superior compartment (Sup. Comp.) invasion (A and B), posterior (Post.) compartment invasion (C and D), and inferior (Inf.) compartment invasion (E and F)
图3. 鞍区和鞍旁区的冠状（A）、矢状（B、D和F）和轴位（C和E）MR图像显示了单一隔室侵袭的病例
示例：上隔室（Sup. Comp.）侵袭（A和B）、后隔室（Post.）侵袭（C和D）以及下隔室（Inf.）侵袭(E和F）。
Inf.Comp. 下隔室；Post.Comp. 后隔室；Sup. Comp. 上隔室
FIG. 4. Neurovascular relationships in the superior compartment (Sup. Comp.; A–D). A: Medial view (sagittal) section of the right CS. The oculomotor nerve (CN III) can be seen lateral to the interclinoidal ligament (Interclin. Lig.) in the oculomotor triangle (Tr.) and in the lateral wall of the superior compartment. Paraclin. = paraclinoidal. B: This oculomotor nerve segment (defined as the interdural segment) travels in between 2 layers of the dura and as such is relatively protected in this location at the posterior aspect of the superior compartment. C and D: Mediolateral mobilization of the parasellar ICA allows inspection of the interclinoidal ligament and its relationship to the oculomotor nerve and the paraclinoidal ICA. The dura of the oculomotor triangle forms the posterolateral aspect of the superior compartment, while the paraclinoidal ICA occupies the anteromedial aspect. Ant. = anterior. E and F: Coronal (E) and sagittal (F) MR images demonstrate the presence of a pituitary adenoma with evidence of supra-and parasellar extension. Note that there is evidence of invasion of the superior and inferior (Inf.) compartments as ascertained in relation to the horizontal cavernous ICA.
图4.上隔室神经血管关系（Sup. Comp.；A-D）。A：右侧CS的内侧视图（矢状面）。动眼神经三角（Tr.）内的床突间韧带（Interclin. Lig.）外侧以及上隔室外侧壁内可见动眼神经（CN III）。Paraclin.=paraclinoidal. 床突旁的。B：该段动眼神经（定义为硬膜间段）在硬膜的两层之间行进，因此在上隔室后部的这个位置受到相对保护。C和D：鞍旁段ICA的侧方移位可以检查床突间韧带及其与动眼神经和床突旁段ICA的关系。动眼神经三角的硬膜形成上隔室的后外侧，而床突旁段颈内动脉占据其前内侧。Ant. = anterior.
前面的。E和F：冠状（E）和矢状（F）面MR图像显示存在的垂体腺瘤向鞍上和鞍旁扩展的情况。值得注意的是，就海绵窦段ICA而言，有证据表明上隔室和下隔室（Inf.）受到侵袭。
Ant.Genu 前膝；CN III 动眼神经；Horizontal
ICA水平段颈内动脉；Inf.Comp. 下隔室；Interclin.
Lig床突间韧带；Interdural CN III动眼神经硬膜间段；Oculo-Motor. Tr.动眼神经三角；Paraclin. ICA床突旁段颈内动脉；Sup. Comp. 上隔室
Superior Compartment of the CS
CS上隔室
Boundaries
The superior compartment of the CS lies superior to the horizontal cavernous ICA and posterior to the anterior genu. It is limited by the roof of the CS superiorly and laterally: the ventral surface of the paraclinoidal ICA anterolaterally (which corresponds to the clinoidal triangle), and the dura of the oculomotor triangle posterolaterally (Figs. 2, 3A, 3B, and 4).
边界
CS上隔室位于海绵窦段ICA水平段的上方和前膝的后方。它在上方受到CS顶壁的限制，外侧受到的限制为：前外侧的床突旁段ICA的腹侧面（对应于床突三角）和后外侧的动眼神经三角硬膜（图2、3A、3B和4）。
Key Structures
The oculomotor nerve runs in the lateral wall of this compartment, which correlates with the oculomotor triangle or posterior roof of the CS. This oculomotor nerve segment travels between 2 layers of dura in the oculomotor triangle and is thus defined as the interdural segment, but it is also defined as the oculomotor cistern because CSF accompanies the nerve along this interdural segment. As the nerve travels anteriorly, it is incorporated into the most superior aspect of the lateral wall of the CS. The entry point of the oculomotor nerve into the lateral wall of the CS is just lateral to the anterior genu of the ICA. The interclinoidal ligament is a key landmark to be identified within the roof of the superior compartment of the CS. This ligament is a very well-defined dural band—which can be mistaken for the oculomotor nerve—that extends from the posterior to the anterior clinoid process and separates the clinoidal triangle from the oculomotor triangle. The paraclinoidal ICA runs medial and anterior to the interclinoidal ligament, and the oculomotor nerve runs just lateral and posterior.
关键结构
动眼神经在该隔室的外侧壁内走行，与动眼神经三角或CS的后顶壁相关。该动眼神经段在动眼三角的2层硬膜之间行进，因此被定义为硬膜间段，但它也被定义为动眼神经池，因为脑脊液沿着硬膜间段伴随该神经。随着该神经向前行进，其被并入CS外侧壁的最上部。动眼神经进入CS外侧壁的入口点正好位于ICA前膝的外侧。床突间韧带是在CS上隔室顶壁内需要识别的关键标志。该韧带是一条非常清晰的硬膜带，可被误认为是动眼神经，它从后床突延伸到前床突并将床突三角与动眼神经三角分开。床突旁段ICA走行于床突间韧带的内前方，而动眼神经则走行于床突间韧带的外后方。
Surgical Nuances
To explore the superior compartment, the bone covering the paraclinoidal ICA and anterior wall of the CS is removed. This allows lateral displacement of the ICA for direct surgical dissection within this region. The superior compartment is accessed through the medial wall of the CS and tumors invading this compartment typically destroy the medial wall, making the access easier. As recently pointed out by Micko et al., the superior compartment is often compressed and not invaded, in which case the medial wall of the CS is displaced laterally but still covers the cavernous ICA and interclinoidal ligament. For cases with true invasion, gentle medial-to-lateral ICA mobilization is performed with the suction shaft while a second surgical instrument is used to remove tumor. The majority of this dissection can be performed with 0° endoscopes, but the use of angled scopes is required to maximize visualization, especially of the dorsal aspect of the anterior genu of the ICA. The interdural segment of the oculomotor nerve is protected as long as the lesion does not invade and extend beyond the roof and lateral wall of the CS. The most vulnerable portion of the oculomotor nerve is located just lateral to the anterior genu of the ICA, an area that is not easily accessible from a medial to lateral trajectory. Our electrophysiological studies have typically shown a positive response for CNs III and IV at high amperage (2 mA) only when stimulating posteriorly but a positive response at low amperage (0.5–1 mA) when stimulating more anteriorly just behind the genu of the ICA. This finding is explained by the inner dural layer of the oculomotor triangle becoming thinner as CN III travels anteriorly. The interclinoidal ligament is identified repeatedly during surgery and acts as a landmark for the oculomotor nerve (located lateral to the ligament).
手术细节
移除覆盖床旁段ICA和CS前壁的骨质以探查上隔室。这就允许ICA的侧向移位以便在该隔室内直接进行手术分离。通过CS的内侧壁进入上隔室，侵入该隔室的肿瘤通常会破坏内侧壁，使得更容易进入。正如Micko等人最近指出的，上隔室经常被挤压而不被侵袭，在这种情况下，向外侧移位CS内侧壁，但仍覆盖海绵窦段ICA和床突间韧带。对于真正侵袭的病例，使用吸引器柄轻柔地由内向外进行ICA移位，同时使用第二种手术器械去除肿瘤。这种分离的大部分可以用0°内镜进行，但需要使用成角内镜来最大限度地可视化，尤其是ICA前膝的背侧。只要病变不侵袭CS的顶壁和外侧壁并延伸到其之外，动眼神经硬膜间段就受到保护。动眼神经最脆弱的部分就位于ICA前膝的外侧，从内侧到外侧的轨迹不容易到达该区域。我们的电生理学研究通常显示，仅当以高电流（2 mA）向后刺激时，CNs III和IV才会有阳性反应，而在ICA膝部正后方，当以低电流（0.5–1 mA）往前刺激时，CNs III和IV才会有阳性反应。这一发现的解释是，随着CN III向前走形，动眼神经三角的硬膜内层变得更薄。术中反复识别床突间韧带并作为动眼神经的一个标志（位于韧带的外侧）。
FIG. 5. Neurovascular relationships in the posterior compartment (Post. Comp.). A: The posterior compartment is located posterior to the short vertical cavernous ICA and anterior to the lateral petroclival dura forming the posterior wall of the CS. The posterior (Post.) ICA genu marks the transition between the superior and posterior compartments. The meningohypophyseal trunk (Men-Hyp.) is seen arising from the posterior wall of the posterior genu of the ICA at this transitional level. Note the intimate relationship of this compartment to the abducens nerve (CN VI). The interdural (Interd.) or inferior petrosal segment can be seen. Prox. Cav. = proximal cavernous. B: The gulfar or superior petrosal segment (below the dissector and above the petrous apex) of CN VI is located at the most inferior portion of this compartment as it passes under the petro-sphenoidal (Petro-Sph.) ligament to enter the CS. C: Note the location of the gulfar segment of CN VI above the petrous (Petr.) apex. The proximal cavernous segment of CN VI, usually not visible from this angle due to its paracarotid location, can be seen due to forward mobilization of the short vertical ICA. The nerve sits at the confluence of the inferior (Inf.) and superior (Sup.) petrosal sinuses (Petr. Sin.). D: A case example (sagittal MR image) shows evidence of a pituitary adenoma with extension into the posterior and inferior compartments. Note the presence of the tumor in relation to the short vertical segment of the ICA.
图5. 后隔室神经血管关系（Post. Comp.）。A：后隔室位于海绵窦段ICA短垂直段的后方和形成CS后壁的岩斜侧硬膜的前方。ICA后膝（Post.）标志着上隔室和后隔室之间的过渡。在该过渡水平可见脑膜垂体干（Men-Hyp.）自ICA后膝的后壁发出。请注意该隔室与外展神经（CN VI）的密切关系。可以看到硬膜间段（Interd.）或岩下段。Prox. Cav. =proximal cavernous.海绵窦近端。B：CN VI穿过岩蝶（PetroSph.）韧带下方进入CS时，其gulfar段或岩骨上段（解剖器下方和岩尖上方）位于该隔室的最下部。C：注意岩（Petr.）尖上方CN VI gulfar段的位置。CN VI海绵窦段的近端由于其旁颈动脉的位置，通常从这个角度看不到，但向前移位ICA的短垂直段，则可以看到。该神经位于岩下（Inf.）窦和岩上（Sup.）窦的交汇处（Petr. Sin.）。D：一个病例（矢状面MR图像）显示了存在的垂体腺瘤延伸至后隔室和下隔室的情况。注意肿瘤的存在与ICA短垂直段的相对位置。
CN VI(Interd.) 硬膜间段外展神经；CN VI(Prox.Cav.) 海绵窦近端外展神经；Horizontal ICA水平段颈内动脉；Inf.Comp. 下隔室；Inf.Petr.Sin. 岩下窦；Men-Hyp.Trunk 脑膜垂体干；Paraclival ICA 斜坡旁段颈内动脉；Petr. Apex 岩尖；Petr. Sin. 岩窦；Petro-Sph.Lig. 岩蝶韧带；Post. Comp. 后隔室；Post.Genu后膝；Shor:Vertical 短垂直的；Sup.Petr.Sin. 岩上窦
Posterior Compartment of the CS
CS后隔室
Boundaries
The posterior compartment of the CS is located posterior to the short vertical cavernous ICA and anterior to the lateral petroclival dura, forming the posterior wall of the CS. The transition between the short vertical and horizontal subsegments of the cavernous ICA (posterior cavernous ICA genu) marks the transition between the superior and posterior compartments (Figs. 2, 3C, 3D, and 5).
边界
CS的后隔室位于海绵窦段ICA短垂直段的后方和形成CS后壁的岩斜硬膜外侧的前部。海绵窦段ICA的短垂直亚段和水平亚段之间的过渡（海绵窦段ICA后膝）标志着上隔室和后隔室之间的过渡（图2、3C、3D和5）。
Key Structures
The meningohypophyseal trunk arises from the posterior wall of the posterior genu of the ICA at this transitional level. The inferior hypophyseal artery has a lateromedial trajectory toward the dura of the sellar floor, while the dorsal meningeal artery has a posterior and inferomedial trajectory toward the dura of the dorsum sella. These 2 arteries, along with the tentorial artery, may arise together from the meningohypophyseal trunk or as independent branches directly from the ICA. The gulfar segment of the abducens nerve is located at the most inferior portion of this compartment as it passes through Dorello’s canal to enter the CS, just behind the ICA. This nerve segment is above the most medial aspect of the petrous apex and is bounded posteriorly by the petro-sphenoidal or Gruber’s ligament. It is critical to note that the abducens nerve sits at the confluence (or gulf) of the inferior and superior petrosal sinuses with the basilar plexus as they enter the CS. Once it enters the CS, the nerve does not have any dural layer protecting it.
关键结构
脑膜垂体干起源于此过渡水平的ICA后膝后壁。垂体下动脉具有朝向鞍底硬膜的外内侧轨迹，而脑膜背侧动脉则具有朝向鞍底硬膜的后下内侧轨迹。这2条动脉，连同小脑幕动脉，可能共同起源于脑膜垂体干，也可能作为独立的分支直接起源于ICA。外展神经gulfar段，当其穿过Dorello管就在ICA后面进入CS时，位于该隔室的最下部。该段神经位于岩尖最内侧的上方，向后以岩蝶韧带或Gruber韧带为界。值得注意的是，外展神经位于岩下窦和岩上窦与基底丛的交汇处（或湾）并进入CS。一旦进入CS，该神经就没有任何硬膜层的保护。
Surgical Nuances
Surgical access behind the short vertical subsegment of the cavernous ICA requires extensive bone removal to uncover the anterior wall of the CS and to expose the entrance of the ICA into the CS. This entrance point corresponds with the end of the paraclival ICA. The floor of the sella (typically an expanded sella) is followed and drilled from medial to lateral until the carotid entrance is identified. To gain access posterior to the cavernous ICA, gentle lateral mobilization of the short vertical subsegment and posterior ICA genu is needed. This may necessitate coagulation and transection of the inferior hypophyseal artery to safely advance toward the posterior compartment. The short vertical ICA is the best landmark to locate the abducens nerve, which will be more or less evident depending on the degree of tumor expansion of this compartment. Electrostimulation will confirm the presence of the abducens nerve at the floor of this compartment just behind the ICA. Venous bleeding from the inferior and superior petrosal sinuses is commonly encountered behind and above the abducens nerve, respectively, and its management requires careful hemostatic technique to prevent nerve damage from excessive packing or unnecessary coagulation.
手术细节
海绵窦段ICA短垂直亚段后方的手术入路需要广泛的骨质去除，以显露CS的前壁并暴露ICA进入CS的入口。该入口点对应于斜坡旁段ICA的末端。沿着蝶鞍底（通常是一扩大的蝶鞍）从内侧向外侧进行磨除，直到识别出颈动脉入口。为了进入海绵窦段ICA后部，需要轻轻侧向移动ICA短垂直亚段和后膝。这可能需要电凝并横断垂体下动脉，以安全地向后隔室行进。短垂直亚段ICA是定位外展神经的最佳标志，其将或多或少地取决于该隔室肿瘤的扩展程度。电刺激将确认外展神经在该隔室底部ICA后方的存在。岩下窦和岩上窦的静脉出血通常会分别发生在外展神经的后面和上方，其处理需要仔细的止血技术，以防止过度填塞或不必要的凝血造成的神经损伤。
FIG. 6. Neurovascular relationships in the inferior compartment (Inf. Comp.). A: The anterior (Ant.) wall of the CS is continuous with the periosteal layer of the dura surrounding the pituitary gland, while the medial wall is continuous with the meningeal layer surrounding the gland. The medial wall attaches to the carotid via the caroticoclinoidal ligament. Note the blue silicone representing the CS. B: Note the location of the paraclinoidal (Paraclin.) ICA at the roof of the CS. The inferior compartment can be seen. C: Medial view of the left CS. The inferior compartment is located inferior to the horizontal and anterior genu
subsegments of the ICA and anterior to the short vertical segment. The sympathetic nerve (Symp. N.) or plexus is located around the ICA with the distal cavernous (Dis. Cav.) segment of the abducens nerve (CN VI), inferolateral to the horizontal ICA. Note the oblique trajectory of the sympathetic nerve compared with the horizontal trajectory of CN VI. D: The dural floor of the CS denotes the transition from the parasellar region dura to the middle cranial fossa dura. Note that the maxillary nerve (CN V2) is outside the dural envelope surrounding the CS, and therefore is not part of the CS.
图6. 下隔室神经血管关系（Inf. Comp.）。A：CS的前壁（Ant.）与垂体周围的硬膜骨膜层相延续，而内侧壁与垂体周围的脑膜层相延续。内侧壁通过颈动脉床突韧带连接至颈动脉。注意蓝色硅胶代表CS。B：注意床突旁段（Paraclin.）ICA在CS顶壁的位置。可以看到下隔室。C：左侧CS的内侧视图。下隔室位于ICA水平段和前膝亚段的下方，短垂直段的前方。交感神经（Symp. N.）或丛位于外展神经（CN VI）海绵窦段远端（Dis. Cav.）的ICA周围、ICA水平段的下外侧。请注意与CN VI的水平轨迹相比，交感神经的倾斜轨迹。D：CS的硬膜底表示从鞍旁区硬膜向中颅窝硬膜的过渡。请注意，上颌神经（CN V2）位于CS周围的硬膜包膜外，因此不是CS的一部分。
Ant.Wall 前壁；CN V2 上颌神经；CN VI(Dis:Cav)外展神经（海绵窦段远端）；Floor 底；Inf.Comp. 下隔室；Medial Wall 内侧壁；Horizontal ICA水平段颈内动脉；Paraclin.ICA床突旁段颈内动脉；Short Vertical短垂直的；Symp.N. 交感神经
Inferior Compartment of the CS
CS 下隔室
Boundaries
The inferior compartment of the CS is located inferior to the horizontal and anterior genu subsegments of the ICA and anterior to the short vertical subsegment. The anterior wall of this compartment is the anterior wall of the CS. It continues laterally with the lateral compartment (Figs. 2, 3D, 3F, and 6).
边界
CS下隔室位于ICA水平亚段和前膝亚段的下方，以及短垂直亚段的前方。该隔室的前壁是CS的前壁。它在外侧面与外侧隔室相连（图2、3D、3F和6）。
Key Structures
The sympathetic nerve or plexus is in this compartment around the ICA as it travels from the short vertical ICA to the horizontal ICA. The distal cavernous segment of the abducens nerve is just inferior and lateral to the horizontal ICA subsegment, at the transition between the inferior and lateral compartments. The sympathetic nerve is located medially in relation to the abducens nerve and has an oblique trajectory, running from the surface of the ICA to join the abducens nerve, which has a more horizontal trajectory at this segment.
关键结构
当交感神经或丛从ICA短垂直亚段行进到水平亚段时，它位于该隔室的ICA周围。外展神经海绵窦段远端正好在ICA水平亚段的下外侧，即下隔室和外侧隔室之间的过渡处。就外展神经而言，交感神经位于内侧并具有倾斜的轨迹，走形于ICA表面直至加入外展神经，后者在此段具有更水平的轨迹。
Surgical Nuances
Using a transpterygoid supravidian approach with vidian nerve preservation, the lateral recess of the sphenoid sinus is widely opened to provide full access to the lateral wall of the sphenoid sinus. Surgery in the inferior compartment requires removal of the bone that covers the anterior wall of the CS. This is extended laterally to the cavernous ICA up to the lateral dural fold, marking the transition between the middle cranial fossa dura and the parasellar region dura, and may be facilitated by identification of the maxillary nerve entering the foramen rotundum. This identification enables extending the opening of the dura laterally and inferior to the anterior genu and horizontal ICA, and in front of the short vertical ICA subsegment. Tumor occupies the space between the short vertical ICA and the dura of the anterior wall of the CS, making this dural opening feasible. The intraoperative use of a Doppler ultrasonography device is very valuable toward confirming the ICA trajectory before opening this dura. A right-angled knife with a blunt tip is used to perform this dural cut. The first nerve to be encountered in this compartment is the sympathetic nerve, which runs medial to the abducens nerve. Electrical stimulation in this compartment will facilitate identification of the abducens nerve lateral, inferior, and parallel to the horizontal ICA and will enable its distinction from the sympathetic nerve.
手术细节
使用保留翼管神经的经翼突翼管上入路，广泛打开蝶窦外侧隐窝，以提供至蝶窦外侧壁完全通道。下隔室内的手术需要去除覆盖CS前壁的骨质。这向外侧扩展至海绵窦段ICA，直至外侧的硬膜反折，其标志着中颅窝硬膜和鞍旁区硬膜之间的过渡，它可以通过进入圆孔的上颌神经的识别来促进。这种识别能够将硬膜的开口向外侧扩展，向下至ICA前膝和水平亚段的下方，以及ICA短垂直亚段的前方。肿瘤占据ICA短垂直段和CS前壁硬膜之间的空间，使得这种硬膜开口可行。术中使用多普勒超声设备对于在打开硬脑膜之前确认ICA轨迹非常有价值。使用钝尖的直角刀进行硬膜切开。在该隔室中遇到的第1个神经是交感神经，走形在外展神经的内侧。该隔室的电刺激将有助于识别ICA水平段外侧、下方和与其平行的外展神经，并将其与交感神经区分开来。
FIG. 7. Neurovascular relationships in the lateral compartment (Lat. Comp.). A: The upper limit of this compartment is formed by the proximal (Prox.) dural ring that covers the inferior surface of the optic strut. The maxillary strut (Max. St.) separates the superior orbital fissure from the foramen rotundum and marks the inferior limit of the lateral compartment along with the V2 prominence. The optic and maxillary struts are ideal landmarks for the superior and inferior extent of the exposure, respectively. The dura is opened in front of the anterior genu of the ICA starting from the inferior compartment (Inf. Comp.) and advancing superiorly and anteriorly. Mid. Clin. = middle clinoid; Paraclin. = paraclinoidal; Vid. N. = vidian nerve. B: The arterial branches of the inferolateral (Inf-Lat.) trunk can be identified running from medial to lateral where they distribute along the lateral wall of the CS. To mobilize (from lateral to medial) the horizontal (Horiz.) cavernous ICA, the lateral aspect of the proximal (Prox.) ring (extending between the paraclinoidal ICA and lower aspect of the optic strut) requires partial sectioning. Dis. Cav. = distal cavernous; Symp. N. = sympathetic nerve. C: The inferolateral trunk has been transected to facilitate access to the lateral compartment. D: This compartment contains the third and fourth CNs and the first division of the trigeminal nerve, which are located at the lateral wall of the CS. The distal cavernous segment of the abducens nerve is located at the transition between inferior and lateral compartments. E: Intraoperative view of the case shown in panel F. Tumor from the lateral compartment has been removed by extending the exposure from the proximal dural ring to V2 to gently mobilize the horizontal ICA. F: Coronal MRI showing invasion of all CS compartments.
图7. 外侧隔室神经血管关系（Lat. Comp.）。A：该隔室的上界由覆盖视柱下表面的近端（Prox.）硬膜环形成。上颌柱（Max. St.）将眶上裂与圆孔分开，并标明了沿V2突起的外侧隔室下界。视柱和上颌柱分别是上、下显露范围的理想标志。硬膜在ICA前膝部前方打开，从下隔室（Inf. Comp.）开始并向上向前推进。Mid. Clin. = middle clinoid 中床突; Paraclin. = paraclinoidal 床突旁的; Vid. N. = vidian nerve 翼管神经。B：可以识别由内向外走形沿CS外侧壁分布的下外侧（Inf-Lat.）干动脉分支。为了移位（由外向内）海绵窦段ICA水平段（Horiz.），近（Prox.）环的外侧（在床突旁段ICA和视柱下面之间延伸）需要部分切开。Dis. Cav. = distal cavernous 海绵窦远段; Symp. N. = sympathetic nerve 交感神经。C：下外侧干已被横断，以便于进入外侧隔室。D：该隔室包含第三和第四脑神经以及三叉神经第一分支，均位于CS的外侧壁。外展神经海绵窦段的远段位于下隔室和外侧隔室之间的过渡处。E：如图F所示病例的术中视图。通过从近端硬膜环至V2的扩大显露以轻轻地移动ICA水平段，切除了来自外侧隔室的肿瘤。F：显示所有CS隔室受侵袭的冠状位MRI。
CN III 动眼神经；CN IV 滑车神经；CN V1眼神经；CN V2 上颌神经；CN VI外展神经；cut 切断；Dis.Cav. 海绵窦远段；Horiz.ICA水平段颈内动脉；Inf.Comp. 下隔室；Inf-Lat.Trunk 下外侧干；Lat. Comp. 外侧隔室；Max.St.上颌柱；Mid.Clin. 中床突；Paraclin.ICA床突旁段颈内动脉；Prox. Ring 近环；Symp.N. 交感神经；Vid. N. 翼管神经
Lateral Compartment of the CS
CS外侧隔室
Boundaries
The lateral compartment of the CS lies lateral to the anterior genu and horizontal ICA subsegments. The upper limit of this compartment is formed by the proximal dural ring that covers the inferior surface of the optic strut. The maxillary strut separates the superior orbital fissure from the foramen rotundum and marks the inferior limit of the lateral compartment along with the V2 prominence. At the anterior limit of the optic and maxillary struts, the CNs have entered the superior orbital fissure and exited the CS (Figs. 2 and 7).
边界
CS外侧隔室位于ICA前膝亚段和水平亚段的外侧。该隔室的上界由覆盖视柱下表面的近端硬膜环形成。上颌柱将眶上裂与圆孔分开，跟V2突起一起标明了外侧隔室的下界。在视柱和上颌柱的前界，CNs已进入眶上裂并离开CS（图2和7）。
Key Structures
This compartment contains the third and fourth CNs,and the first division of the trigeminal nerve, which are located at the lateral wall of the CS. As mentioned above, the distal cavernous segment of the abducens nerve is located at the transition between inferior and lateral compartments. The arterial branches of the inferolateral trunk (arising from the inferior surface of the horizontal cavernous ICA) can be identified in this region running from medial to lateral where they distribute along the lateral wall of the CS.
关键结构
该隔室包含第3和第4 CNs，以及三叉神经的第1分支，均位于CS的外侧壁。如上所述，外展神经海绵窦段远端位于下隔室和外侧隔室之间的过渡处。可在该隔室中识别由内向外走形并沿着CS的外侧壁分布的下外侧干动脉分支（源自海绵窦段ICA水平段的下表面）。
Surgical Nuances
Direct surgery into this compartment is performed only in select cases to avoid the risk of CN injury. Surgical access requires full exposure of the anterior genu and paraclinoidal ICA and anterior wall of the CS laterally up to the superior orbital fissure. The optic and maxillary struts are ideal landmarks for the superior and inferior extent of the exposure, respectively. The dura is opened in front of the anterior genu of the ICA starting from the inferior compartment and advancing superiorly and anteriorly with a blunt tip, right-angled knife. Superiorly, the dura becomes adherent to the ICA as the dural rings meet the anterior clinoid process to form the clinoidal space. The use of a Doppler device and precise neuronavigation enables accurate mapping of the carotid artery.
仅在选定的病例中才对该隔室进行直接手术，以避免CN损伤的风险。手术入路需要完全暴露ICA前膝和床突旁段以及外侧的CS前壁直至眶上裂。视柱和上颌柱分别是上、下暴露程度的理想标志。用一钝尖直角刀从下隔室开始，在ICA前膝前方打开硬膜并向上和向前推进。在上部，当硬膜环与前床突相遇形成床突间隙时，硬膜就会粘附在ICA上。使用多普勒设备和精确的神经导航可以准确地了解颈动脉。
手术细节
A surgical corridor needs to be developed between the anterior genu/horizontal ICA and the CNs in the lateral wall of the CS. This is typically facilitated by tumor invasion that separates the ICA from the CNs in the lateral wall of the CS. The abducens nerve is an exception because it does not run in the wall of the sinus and may be embedded within the tumor, although it can be displaced laterally against the lateral wall, which facilitates tumor resection. To mobilize (from lateral to medial) the cavernous ICA and paraclinoidal ICA, the lateral aspect of the proximal ring (extending between the paraclinoidal ICA and lower aspect of the optic strut) requires partial sectioning. The arterial branches of the inferolateral trunk are encountered while developing this lateral corridor, and therefore careful coagulation and division are required. Tumor can be carefully removed between the cavernous ICA and CNs with the assistance of electrostimulation to identify the oculomotor, trochlear, and especially abducens nerves. Unfortunately, tumors in the lateral compartment commonly involve the lateral wall of the CS, in which case complete resection is not feasible without CN injury.
需要在ICA前膝/水平段和CS外侧壁的CN之间建立手术通道。这通常是由将ICA与CS外侧壁CNs分开的侵袭肿瘤来促成的。由于外展神经不在窦壁中走形，因此它是一个例外，并可能嵌入肿瘤内，尽管可以靠着外侧壁将它向外侧移位从而利于肿瘤切除。近环的外侧部分（在床突旁段ICA和视柱下面之间延伸）需要部分切开，以移位（由外向内）海绵窦段和床突旁段ICA。下外侧干的动脉分支会在形成该外侧通道的同时而遇到，因此需要仔细电凝并分开。在电刺激的帮助下识别动眼神经、滑车神经，尤其是外展神经，可以在海绵窦段ICA和CNs之间小心地切除肿瘤。遗憾的是，外侧隔室肿瘤通常累及CS外侧壁，在这种情况下，没有CN的损伤并完全切除肿瘤是不可行的。
Clinicoradiological Results
临床放射学结果
Patterns of CS Invasion
CS侵袭的模式
Twenty-nine patients had only a single compartment invaded, with the superior compartment invaded 14 times, and the inferior and posterior compartments invaded 11 and 4 times, respectively. There was no invasion of the lateral compartment in isolation. The remaining 69 patients had multiple compartments involved, 18 of whom had bilateral invasion. The most commonly invaded compartment was again the superior (65 patients, 4 with bilateral invasion), followed by the posterior (60 patients, 6 with bilateral involvement), inferior (34 patients, 7 exhibiting bilateral involvement), and lateral compartments (23 patients, 1 with bilateral invasion; Table 1). With tumors that invaded multiple compartments, the most common pattern was the superior/posterior (n=32) followed by the inferior/superior/posterior/lateral (n=17), inferior/superior/posterior (n=14), superior/lateral (n=11), inferior/posterior (n=9), posterior/superior/lateral (n=7), inferior/superior/lateral (n=7), and finally, inferior/superior (n = 6). There were no patients who had growth into the inferior/posterior/lateral compartments without superior compartment invasion.
29例患者仅单隔室受侵袭，其中上隔室侵袭14次，下隔室和后隔室分别侵袭11次和4次。没有单独的外侧隔室侵袭。其余69例患者有多个隔室侵袭，其中18例为双侧侵袭。最常被侵袭的隔室同样是上隔室（65例患者，4例双侧侵袭），其次是后隔室（60例患者，6例双侧侵袭），下隔室（34例患者，7例出现双侧侵袭）和外侧隔室（23例患者，1例双侧侵袭；表1）。对于侵袭多个隔室的肿瘤，最常见的模式是上/后（n=32），其次是下/上/后/外侧（n=17），下/上/后（n=14），上/外侧（n=11），下/后（n=9），后/上/外侧（n=7），下/上/外侧（n=7），最后是下/上（n=6）。没有长入到下/后/外侧隔室而不侵袭上隔室的患者。
Resection Rates by Compartments
按隔室划分的切除率
Thirty-seven (38%) of 98 patients had residual tumor after the initial operation. The most common location for residual tumor was in the lateral compartment (n =19, 79%), followed by posterior (n =12, 17%), superior (n =12, 14%), and inferior (n =6, 11%; Table 2) compartments. These values were determined by subsequent postoperative imaging rather than intraoperative assessment. Two patients underwent further resection with subsequent complete tumor resection: 1 had residual
adrenocorticotropic hormone–secreting tumor in the posterior compartment that grew on imaging, and the other patient had residual nonsecreting tumor in the inferior compartment that was re-explored with complete resection. Twenty-seven (74%) of those with residual tumor were treated with radiosurgery.
98例患者中有37例(38%)在初次手术后有肿瘤残留。残留肿瘤最常见的位置是外侧隔室(n=19, 79%)，其次是后(n=12, 17%)、上(n=2, 14%)和下(n=6, 11%；表2)隔室。这些值是通过随后的术后影像而不是术中评估来确定的。两例患者接受了进一步切除，随后将肿瘤完全切除：其中1例患者在后隔室有残留的促肾上腺皮质激素肿瘤，在影像学上有生长，另1例患者在下隔室有残留的非分泌性肿瘤，通过重新探查完全切除。27例（74%）有残留肿瘤的患者接受了放射外科治疗。
Complications by Compartments
按隔室划分的并发症
No patient developed oculomotor or trochlear nerve palsies. Two patients had immediate complete abducens nerve palsies: 1 of these patients was believed to have excessive Surgifoam placed in the CS, and improved spontaneously in 2 weeks, whereas the other patient had bilateral invasion of multiple compartments and the abducens nerve was believed to be injured while working in the lateral compartment. Diplopia resolved completely at 3 months after surgery. Three patients suffered from postoperative hematomas that caused worsening of vision acuity (secondary to optic chiasm compression) immediately during the postoperative period and had to be taken back to the operative theater for evacuation; the locations of tumor invasion in these patients were inferior/superior, superior/posterior, and in all 4 compartments. In 2 of these patients, vision improved significantly immediately after the clot evacuation, and both of these patients returned to their preoperative visual baseline by the first postoperative visit. The third patient suffered from bitemporal hemianopsia up to 6 months after her surgery that was still worse than it was preoperatively. One patient (1/144) suffered from ICA injury during growth hormone tumor dissection from the cavernous ICA wall; bleeding was controlled with local packing, but intraoperative somatosensory evoked potential recording showed a significant drop in potentials, suggesting ischemia and high risk of stroke if the vessel were to be sacrificed. Successful vessel preservation was accomplished using covered stents and the patient did not develop any neurological sequelae postoperatively.
没有患者出现动眼神经或滑车神经麻痹。2例患者立即出现完全性外展神经麻痹：其中1例患者被认为在CS中放置了过量的可吸收明胶海绵，并在2周内自行改善，而另1例患者侵袭双侧多个隔室，外展神经被认为是在外侧隔室操作时损伤。术后3个月复视完全消失。3例患者术后出现血肿，导致术后视力立即下降（继发于视交叉受压），不得不返回手术室清除；这些患者的肿瘤侵袭的位置为下/上、上/后以及所有4个隔室。其中2例患者的视力在血肿清除后立即显著改善，并且这2例患者在术后第一次就诊时均恢复到术前视力基线。第3例患者在她术后6个月内出现双颞侧偏盲，比术前还更严重。1例患者（1/144）在从海绵窦段ICA壁上分离生长激素肿瘤时发生ICA损伤；通过局部填塞控制出血，但术中体感诱发电位记录显示电位显著下降，表明如果牺牲血管，则会出现缺血和卒中的高风险。使用覆膜支架成功保留血管，患者术后未出现任何神经系统后遗症。
Discussion
讨论
In this study, we propose a classification of the CS in anatomical compartments from an endonasal perspective that has proven useful both for surgical purposes and for imaging-based presurgical planning. The adoption of endoscopic endonasal surgery requires shifting the concept of accessing the CS through anatomical triangles bounded by CNs to accessing the CS through anatomical compartments defined by the course of the intracavernous ICA. In fact, incorporating the EEA into the skull base armamentarium allows for 360° access to the CS; while transcranial approaches enter the sinus through the lateral and superior walls, the endonasal route accesses the sinus through the medial and anterior walls.
在本研究中，我们建议从鼻内的角度对CS的解剖隔室进行分类，这已被证明对手术目的和基于影像的术前计划都很有用。内镜鼻内手术的采用需要将通过以CNs为界的解剖三角进入CS的概念转变为通过由海绵窦内ICA走形定义的解剖隔室进入CS。事实上，将EEA纳入到颅底医疗设备中可以360°进入CS；经颅入路通过外侧壁和上壁进入海绵窦，而鼻内通道通过内壁和前壁进入海绵窦。
Every attempt to classify a complex anatomical region, such as the CS, has the risk of introducing arbitrary divisions and boundaries. With that in mind, however, we believe that the classification proposed here helps the surgeon to better understand the endoscopic surgical anatomy of the CS by dividing it into separate venous compartments that are selectively invaded by tumor and contain different neurovascular structures at risk. As a consequence, the surgeon will be able to predict structures to be exposed and readily identify them once exposed within each different compartment. Importantly, this classification is entirely based on the course of the intracavernous ICA, and similarly, surgery within the CS has to be based on a thorough understanding of the course of the ICA to prevent inadvertent vascular injury when performing tumor removal.
每次尝试对复杂的解剖区域（例如CS）进行分类，都存在引入任意划分和边界的风险。然而，考虑到这一点，我们认为本文提出的分类，通过将海绵窦划分为被肿瘤选择性地侵袭的单独的静脉隔室，有助于外科医生更好地理解CS的内镜手术解剖以及包含有风险的不同神经血管结构。因此，外科医生将能够预测要暴露的结构，并且一旦暴露，就能在每个不同的隔室内轻松识别它们。重要的是，这种分类完全基于海绵窦内ICA的走形，同样，CS内的手术必须基于对ICA走形的全面了解，以防止在进行肿瘤切除时造成无意的血管损伤。
When comparing this classification with Harris and Rhoton venous spaces, there are 3 major differences: the absence of a medial compartment, and the existence of lateral and posterior compartments. In our opinion, the medial compartment does not have clinical utility because the medial venous space, as described by Harris and Rhoton, is frequently obliterated by the ICA, and when tumor penetrates the CS it will invade into 1 of the compartments located above, below, or behind the ICA. In cases in which just the medial wall is invaded (46 cases in this study), we prefer to classify them as medial wall invasion rather than medial compartment invasion, because they require medial wall removal rather than medial compartment tumor removal. The description of relevant surgical anatomy and nuances for medial wall removal is currently an ongoing project. Harris and Rhoton described the potential existence of a lateral venous compartment, but they stated that “the lateral space is so narrow that the sixth nerve which passes through it is adherent to the carotid on its medial side and to the sinus wall on its lateral side.” This narrow compartment, however, is greatly expanded by tumor invasion, which will cause separation of the ICA from the lateral wall of the CS. The posterior and superior compartments are considered together, as the posterior space, in the description by Harris and Rhoton and are not taken into account in radiological classifications, such as that of Knosp (see below). We believe that the separation of superior and posterior compartments is important from the clinical point of view because the posterior compartment can be invaded in isolation (4 cases) or in combination with inferior compartment invasion (9 cases). As a consequence, understanding the surgical anatomy and nuances when accessing the posterior compartment becomes surgically relevant.
当将此分类与Harris和Rhoton静脉间隙进行比较时，有3个主要的区别：没有内侧隔室，以及存在外侧和后隔室。我们认为，内侧隔室不具有临床实用性，因为正如Harris和Rhoton所描述的，内侧静脉间隙经常被ICA所闭塞，并且当肿瘤穿透CS时，它会侵入位于ICA上方、下方或后面的1个隔室。对于仅侵袭内侧壁的病例（本研究中为46例），我们倾向于将其归类为内侧壁侵袭而不是内侧隔室侵袭，因为它们需要切除内侧壁而不是切除内侧隔室肿瘤。对内侧壁切除的相关手术解剖结构和细节的描述是一个目前正在进行的项目。Harris和Rhoton描述了外侧静脉隔室的潜在存在，但他们表示，“外侧间隙非常狭窄，以至于穿过它的第六神经在其内侧粘附于颈动脉，在其外侧粘附于窦壁”。然而，这个狭窄的隔室由于肿瘤的侵袭而大大扩大，将导致ICA与CS外侧壁分离。在Harris和Rhoton的描述中，后隔室和上隔室被一起考虑为后间隙，而在放射学分类中不被考虑，例如Knosp分类（见下文）。我们认为，从临床角度来看，将上隔室和后隔室分开很重要，因为后隔室可能单独受侵袭（4例）或合并下隔室受侵袭（9例）。因此，了解进入后隔室时的手术解剖和细节就变得与手术相关。
The classification proposed here is not based on MRI studies but on relevant surgical anatomy, and as such it is not intended to have predictive or prognostic value. To avoid confusion, it is important to note that here we first selected patients with intraoperatively confirmed CS invasion and then retrospectively analyzed their MRI studies to correlate surgical anatomy findings with imaging findings, rather than trying to predict CS invasion based on MRI studies. We acknowledge that our report might overestimate the incidence of CS invasion per compartment, especially when multiple compartments are invaded, because imaging studies cannot always differentiate compression from true invasion of the CS.
In any case, we believe that this classification helps in analyzing imaging studies with greater detail to identify the potential location of CS invasion and therefore facilitates planning the surgical approach to each involved compartment.
这里提出的分类不是基于MRI研究，而是基于相关的手术解剖，因此，它不具有预测或预后价值。为了避免混淆，需要注意的是，我们首先选择了术中确诊为侵袭CS的患者，然后回顾性分析研究了他们的MRI，以将手术解剖结果与影像学结果相关联，而不是试图基于MRI研究预测CS侵袭。我们承认，我们的报告可能高估了CS每个隔室侵袭的发生率，特别是当多个隔室被侵袭时，因为影像学研究不能总是区分CS受压和真正侵袭。无论如何，我们认为这种分类有助于更详细地分析影像学研究，以确定CS侵袭的潜在位置，从而有助于规划每个受累隔室的手术入路。
In 1993, Knosp et al. proposed a widely used MRI-based classification that describes 5 grades (0–4) of parasellar growth based on the intercarotid line and has predictive and prognostic intentions. The same group has recently reevaluated their MRI-based classification in an excellent article showing that the direct endoscopic view confirmed the low rate of invasion of Knosp Grade 1 adenomas but showed significantly lower rates of invasion in Knosp Grade 2 and 3 adenomas than those previously found using the microscopic technique. Consistent with the surgical anatomy–based classification proposed here, the Knosp group in 2015 suggested the addition of Grades 3A and 3B to distinguish adenomas invading the superior CS compartment from those invading the inferior CS compartment, respectively. Interestingly, they have shown that in their MRI-based classification the rate of true invasion in Grade 3A (equivalent to the superior compartment) was 26.5%, while in Grade 3B (equivalent to the inferior compartment), the rate of surgically observed invasion was 70.6%. This is probably explained by the existence of a stronger medial wall at the superior compartment than at the inferior compartment.
Knosp et al. have also shown that, in their experience, the resection rates at the superior compartment were higher than those at the inferior one, with this difference becoming much more evident when comparing functional tumors. This difference could also be explained by the direct connection between inferior and lateral compartments, as shown in our study, which decreases the possibility of endocrinological remission for tumors invading the inferior but not the superior compartment. It could also reflect ease of access to the superior compartment, which merely requires lateral extension of the sellar exposure, whereas the inferior compartment often requires clival drilling, wider exposure, and opening of the anterior wall of the CS in front of the cavernous ICA.
1993年，Knosp等人提出了一种广泛使用的基于MRI的分类，该分类根据颈动脉间线描述了鞍旁生长的5个等级(0-4)，并具有预测和预后意图。同一个小组最近在一篇优秀的文章中重新评估了他们基于MRI的分类结果表明，直接内镜检查证实了Knosp 1级腺瘤的侵袭率较低，但与之前使用显微镜技术发现的结果相比，Knosp 2级和3级腺瘤的侵袭率明显较低。与本文提出的基于手术解剖的分类一致，Knosp小组于2015年建议增加3A和3B级，以区分分别侵袭CS上隔室的腺瘤和侵袭CS下隔室的腺瘤。有趣的是，他们已经表明，在他们基于MRI的分类显示，3A级（相当于上隔室）的真实侵袭率为26.5%，而手术观察到的3B级（相当于下隔室）的侵袭率为70.6%。这可能是由于上隔室比下隔室存在更强的内侧壁。Knosp等人还表明，根据他们的经验，上隔室的切除率高于下隔室的，在比较功能性肿瘤时，这种差异变得更加明显。这种差异也可以通过下隔室和外侧隔室之间的直接联系来解释，正如我们的研究所示，这降低了肿瘤侵袭下隔室而不是上隔室的内分泌缓解的可能性。它也可以反映出易于进入上隔室，仅需要鞍区暴露的外侧延伸，而下隔室通常需要斜坡磨除，更广泛的暴露，以及在海绵窦段颈内动脉前方打开CS前壁。
Here we have also intended to correlate potential adverse outcomes with the compartments where pathology was found. This was not intended as an outcomes paper, but nevertheless, we wanted to investigate the risk of CN and vascular injury when performing surgery within different compartments. Remarkably, our surgical results show that with appropriate surgical anatomical knowledge and extensive experience, good resection rates can be obtained with very low morbidity. The abducens nerve is, as expected, the one at the highest risk, but usually with good recovery. The low rate of abducens nerve palsy correlates with the high rate of residual tumor in the lateral compartment, but also suggests that surgery in the inferior and posterior compartments is safe in most instances. The risk of postoperative hematoma, on the other hand, is potentially higher in tumors with CS invasion because of venous oozing, cavernous ICA branches, and general invasiveness of tumors with greater likelihood of residual.
在这里，我们还打算将潜在的不良后果与发现病变的隔室相关联。本文无意作为结果文件，但尽管如此
，我们还是想调查在不同隔室内进行手术时CN和血管损伤的风险。值得注意的是，我们的手术结果表明，凭借适当的手术解剖知识和丰富的经验，可以获得良好的切除率和非常低的发病率。正如预期的那样，外展神经是风险最高的神经，但通常恢复良好。外展神经麻痹的低发生率与外侧隔室内肿瘤残留的高发生率相关，但也表明在大多数情况下，下隔室和后隔室的手术是安全的。另一方面，由于侵袭CS肿瘤的静脉渗出、海绵窦段ICA分支和肿瘤普遍侵袭的残留可能性更大，术后血肿的风险可能更高。
Limitations and Future Directions
局限性和未来方向
Operative notes and preoperative MRI studies were analyzed to identify patterns of CS invasion. The Knosp group found a 16% incidence of true CS invasion among all pituitary adenomas, while here we describe a higher incidence of 37%. However, if we discount the cases of exclusive medial wall invasion, the incidence drops to 23% and is more consistent with previous descriptions. We agree with the Knosp group when they state that the endoscopic technique is the best available method for distinguishing between invasion and compression of the CS, but there remains a potential error of perception when describing intraoperatively the presence of CS invasion. Regardless, the primary aim of this work is to present a practical and surgically relevant classification of CS compartments based on meticulous surgical anatomy studies and extensive surgical experience with radiological correlation to facilitate both preoperative assessment and intraoperative performance. Even in cases in which there is compression without true invasion of the CS, it is important to identify the potentially involved compartments both in preoperative imaging studies and intraoperatively, for which the surgical anatomy–based classification presented here might be useful. This identification will help to ensure complete tumor removal when feasible. Further prospective studies are needed to elucidate the true intraoperative incidence of CS invasion per compartment as well as to evaluate the predictive and prognostic value of the classification proposed here when evaluating MRI studies.
分析手术记录和术前MRI研究，以确定CS侵袭的模式。Knosp小组发现，所有垂体腺瘤中真正CS侵袭
的发生率为16%，而我们在此描述的发生率更高，为37%。然而，如果我们不计入单纯内侧壁侵袭的病例，发生率下降至23%，与之前的描述更加一致。Knosp小组认为内镜技术是区分CS侵袭和受压的最佳可用方法，我们同意他们的观点，但在术中描述存在CS侵袭时，仍存在潜在的感知错误。无论如何，这项工作的主要目的是基于细致的手术解剖研究和具有放射学相关性丰富的手术经验以促进术前评估和术中表现，进而对CS隔室提出一种实用且有手术相关性的分类。无论是在术前影像学研究中，还是在术中应用本文提出的基于手术解剖的分类，对于识别潜在受累的隔室都是很重要的，即使是在CS受压但没有真正侵袭的情况下。这一识别将有助于确保在可行的情况下完全切除肿瘤。每个隔室CS侵袭的真实术中发生率，以及本文在评估MRI研究时所提出分类的预测和预后价值，需要进一步的前瞻性研究来阐明并评估。
Conclusions
结论
We present a modified compartmental description of the CS through an EEA and include the relevant descriptive anatomy for surgical decision-making. Using the intracavernous ICA as the reference point, the CS is easily divided into 4 compartments with specific boundaries, neurovascular structures, and important landmarks. This anatomical-based classification complements current imaging-based classifications. As use of the EEA continues to increase, the surgical anatomy and relevant clinical correlations provided here may serve as a guide to others utilizing this corridor to access tumors invading the CS, in particular invasive pituitary adenomas.
我们通过EEA提出了一种改良后的CS隔室的描述，并包括用于手术决策的相关描述性解剖。使用海绵窦
内ICA作为参考点，CS易于分为4个具有明确边界、神经血管结构和重要标志的隔室。这种基于解剖学的分类补充了当前的基于影像学的分类。随着EEA的使用不断增加，本文提供的手术解剖和有关的临床相关性可以为利用该通道进入侵袭CS肿瘤的其他人提供指导，尤其是侵袭性垂体腺瘤。
参考文献：略
附：
国内洪涛教授团队2021年发表的文章，概述了102例Knosp 4级垂体腺瘤（PA）患者接受内镜经蝶手术的手术结果和经验。这是迄今为止对Knosp 4级PA进行的最大规模的研究，也是第一项专门针对功能性和非功能性4级PA的研究。这研究的优势之一是，这项研究中的所有手术都是由同一位手术医生洪涛教授进行，消除了变异性并使得研究结果更加可信。海绵窦内ICA的处理能力为4级PA的手术切除带来一些挑战。为了解决这一问题，术前要详细评估ICA、CS肿瘤和CS不同隔室之间的个体空间关系，并相应地采用不同的CS入路。
FIGURE 1 This shows the common location of the horizontal ICA in Knosp grade 4 PAs and the main surgical approaches. When the horizontal ICA was inferior to the tumor (A1), it caused the horizontal ICA to sink due to the oppression of the tumor, resulting in a larger posterosuperior compartment and a smaller anteroinferior compartment within the CS. The medial approach, often combined with the superior-lateral approach was mainly used to remove the tumor (C1, D1). Postoperative MRI revealed a subtotal resection of the tumor (B1).When the horizontal ICA was superior to the tumor (A2), it caused the horizontal ICA to be raised by the tumor, leading to a smaller posterosuperior compartment and a larger anteroinferior compartment within the CS. The anteroinferior approach was mainly used to remove the tumor (C2, D2). Postoperative MRI revealed a total resection of the tumor (B2).When the horizontal ICA was in the middle of the CS tumor (A3), which was a combination of the two conditions, then the medial, superior-lateral, and anteroinferior approaches could be used (C3, D3). Postoperative MRI revealed a total resection of the tumor (B3).
The red, thick arrow ‘M’ represents the medial approach, the orange-yellow, thick arrow ‘SL’ represents the superior-lateral approach, and the blue, thick arrow ‘A’ represents the anteroinferior approach.
图1上图显示了Knosp 4级垂体腺瘤（PA）中水平段ICA的常见位置和主要手术入路。当水平段ICA在肿瘤下方（A1）时，由于肿瘤的压迫，引起水平段ICA下降，导致CS内的后上隔室较大，前下隔室较小。内侧入路，通常与上外侧入路相联合，主要用于切除肿瘤（C1，D1）。术后MRI显示肿瘤次全切除（B1）。当水平段ICA在肿瘤上方（A2）时，水平段ICA被肿瘤抬高，导致CS内的后上隔室较小，前下间隔较大。主要采用前下入路切除肿瘤（C2、D2）。术后MRI显示肿瘤完全切除（B2）。当水平段ICA位于CS肿瘤的中间时（A3），即两种情况的结合，则可以使用内侧、上外侧和前下入路（C3，D3）。术后MRI显示肿瘤完全切除（B3）。
红色粗箭头“M”表示内侧入路，橙黄色粗箭头“SL”表示上外侧入路，蓝色粗箭头“A”表示前下入路。
FIGURE 2 This was a 32-year-old male patient who was admitted to hospital after the accidental discovery of a pituitary tumor due to trauma. The preoperative visual examination was normal, and the preoperative PRL and ACTH hormones were increased. A preoperative MRI (A, B) showed that the tumor was in Knosp grade 4 and was mainly distributed in both posterosuperior and anteroinferior compartments of the CS. Intraoperatively, various compartments (G) and nerves (H) in the CS could be observed after total tumor resection. Postoperative MRI (E, F) also confirmed total tumor resection. The yellow dotted circle indicated entry into the CS from above (C) and below (D) the horizontal ICA. The pathological examination of the tumor was mixed pituitary adenoma. The visual and endocrine function of the patient were all normal three months after the operation.
Post., posterior compartment; Med., medial compartment; Lat., lateral compartment; Inf., inferior compartment; ICA, internal carotid artery; III, oculomotor nerve; IV, trochlear nerve; V1, first branch of the trigeminal nerve; VI, abducens nerve.
图2 这是一名32岁的男性患者，因外伤偶然发现垂体腺瘤后入院。术前视力检查正常，术前PRL和ACTH激素升高。术前MRI（A，B）显示肿瘤为Knosp 4级，主要位于CS的后上和前下两个隔室。术中，在肿瘤全切除后，可以观察到CS内的不同隔室（G）和神经（H）。术后MRI（E，F）也证实了肿瘤全切除。黄色虚线圆圈表示从水平段ICA的上方（C）和下方（D）进入CS。肿瘤病理检查为混合性垂体腺瘤。患者的视力和内分泌功能在术后3个月时均正常。
Post.，后隔室；Med.，内侧隔室；Lat.，外侧隔室；Inf.，下隔室；ICA，
颈内动脉；III，动眼神经；IV，滑车神经；V1，三叉神经第一支；VI，外展神经。
译者简介
罗宗晚 主任医师
湖南省脑科医院（湖南省第二人民医院）
神经外科一病区，从事神经外科32年，善长颅底肿瘤、垂体瘤、颅咽管瘤、脑膜瘤、听神经瘤、脊髓肿瘤的诊断与手术治疗，并在脑外伤、脑出血、脑动脉瘤、脑和脊髓血管畸形、脑梗塞的手术与介入治疗方面有较高造诣。
张卫民 主任医师
湖南省脑科医院（湖南省第二人民医院）
神经外科一病区，曾先后至美国Mayo Clinic及UCLA、德国
University Medicine Griefswald神经外科中心访问学习
神经疾病、解剖及手术翻译爱好者
严于术前 精于术中 勤于术后
相识是缘
医院介绍
湖南省脑科医院（湖南省第二人目医院）始建于1950年，是直属于湖南省卫生健康委的一所非营利性大型三甲医院，是湖南中医药大学附属医院、湖南中医药大学临床医学院，拥有博士后科研流动工作站、临床医学硕士专业学位授权点、临床医学一级学科硕士学位授权点，开放床位1823张，设有48个临床科室、8个医技科室、12个教研室，1个重症医学科和4个专科 ICU ( NICU 、 CICU 、 RICU 及NSICU )。
神经外科为湖南省临床重点专科，2023年入选国家临床重点专科培育项目，已经成为湖南省内亚专科最齐全的知名神经外科中心，设五个病区即神外一病区（肿瘤）、神外二病区（创伤+神经重症）、神外三病区（功能）、神外四病区（脑血管病）及神外五病区（癫痫中心）。分7个亚专业医疗组即功能神经外科组、神经肿瘤组、脑血管病组、神经重症组、颅脑创伤组、癫痫外科组、精神外科组；一个神经重症病房（NSICU）和神经电生理监测室。六个诊疗中心，即脑血管病诊疗中心、神经调控中心、颅脑创伤中心、癫痫诊疗中心、精神外科中心、帕金森全病程管理诊疗中心。
专科始终医、教、研并举，坚持以临床能力建设为中心，以提高手术质量为核心，践行“除人类之病痛、助健康之完美”的宗旨，为建设国内一流的神经外科中心而不懈奋斗。
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