学习笔记——ribas教授的手术定位
神经系统手术定位对每位神经外科医生来说至关重要。具有一双“透视眼”是我梦寐以求的事情。感谢Ribas教授的精彩讲解视频和精美的图解。感谢上海交通大学附属新华医院神经外科唐寅达博士的无私分享和指导。有幸接处并学习Ribas教授的这套视频。在日常工作中经常用到还经常遗忘，所以我就花了一些时间整理了各关键点的一些图，并进行了翻译和编排。水平有限，翻译可能有很多错误，望朋友们多多批评指正。
Ribas教授的定位法：
在功能区附近，宜采用软膜下subpial甚至直接经脑回transgyral切除技术；如果在非功能区，应根据详尽的定位信息，采用最大范围的脑沟-脑沟间sulcal-to-sulcal切除的技术。
While the coronal sutures are usually palpablelaterally andabove the superior temporal lines, distances from the nasion tothebregma, and from the bregma to the lambda vary roughlyfrom 12 to 14 cm inadults (Ribat al., 2006). This knowledgeis very helpful for the localizationof the two importantcraniometric points along the midline.虽然冠状缝通常可从侧面和颞上线以上触及，但在成人中，从鼻根点到冠矢点和从冠矢点到人字点的距离大致为12厘米到14厘米不等(Ribat al.，2006)。这些知识对于沿着中线的这两个重要的颅骨测量点的定位非常有帮助。
所以，只需记住13这个数字，此为平均值，因人略有增减。因此对于开颅定位，13是个好数字。【Na（nasion）—13cm—Br（bregma）—13cm—La（lambda）—2-4cm—
OpCr（opisthocranion）—3-4cm—In（inion）】
触摸枕外隆突的方法：沿枕后两侧肌肉之间向上直到触及颅骨。
枕后点是枕骨最突向后方的点。
只需触到枕后点，记住13加13就可以定位所有的脑沟关键点了。
1、额颞开颅
前侧裂点anterior sylvianfissure point——鳞状缝squamous suture起点
下中央沟点inferior Rolandicpoint——鳞状缝squamous suture顶点
额下沟/中央前沟交点inferior frontal sulcus and precentral sulcus meetingpoint——冠状点stephanion后1-2cm
2、额上部开颅
上中央沟点superior Rolandicpoint——前囟点Brins风简笔画
egma后5cm
额上沟/中央前沟交点superior frontal sulcus and precentral sulcus meetingpoint——中线旁
3cm、冠状缝coronal suture后1.5cm
3、顶部开颅
颅阔点euryon——缘上回Supramarginal Gyrus前上部
顶内沟/中央后沟交点(The Intraparietal and Postcentral Sulci Meeting Point)——中线旁5cm、人字点lambda前6cm
4、枕部开颅
顶枕沟上端/顶枕切迹the parieto-occipital incisure——矢状线和每条人字缝之间的交角theanglebetween the sagittal and each lambdoidsuture
距状裂后端distal extremity ofthe calcarine fissure——枕后点opisthocranion
5、颞后开颅
颞上沟后端The PosteriorExtremity of the Superior Temporal Sulcus——鳞状缝和顶乳缝交汇点上方3cm处the cranial arealocated 3 cm above the evident squamosal and parietomastoid suture meetingpoint
6、岩骨上（颞下）开颅
岩骨外侧面——耳前压迹ThePreauricular Depression---鳞状缝与顶乳缝交点The Parietomastoid and Squamosal SutureMeeting Point
星点The Asterion——顶乳缝、人字缝和枕乳缝交点the meeting point of the
lambdoid,occipitomastoid, and parietomastoid sutures.
颅骨表面缝、点等结构与脑表面关键点的对应关系：
1、额盖的定位：通过额盖关键点Fronto-OpercularKey Points（前侧裂点——鳞状缝的起点；下中央沟点——鳞状缝最高点；额下沟与中央前沟的交汇点——冠状点稍后方）来定位额盖。前侧裂点anterior sylvian point：侧裂点是froriep于19世纪末提出的。如今已被称为前侧裂
点，yasargil教授命名了另一个后侧裂点。前侧裂点实质上是侧裂的局部扩大，因为额下回的三角部通
常较为内陷。因此总是存在这个大小不一的侧裂扩大部。眶部始终膨出。盖部则位于后方，内含中央前沟。在前侧裂点的正下方恰是岛叶尖部所在区域。前侧裂点位于三角部下方，盖部的前方。前侧裂点恰位于鳞状缝的最前端，即翼点的H形骨缝后部的鳞状缝起始段，偏差小于1cm。
下中央沟点inferior rolandic point：位于Heschl回前方，中央后回始终位于Heschl回的上方。下中央沟点恰位于鳞状缝最高点的深面。这里需要用到所谓的耳前压迹，位于颞部，耳屏前方。在成人，从耳前压迹向上约4cm即可到达鳞状缝的最高点。此处正是中央沟投射至侧裂的交点。
额下沟与中央前沟的交点The Inferior Frontal andPrecentral Sulci Meeting Point：额下沟永远是无法全程辨认，但当其到达中央前沟时，通常会形成局部扩大的蛛网膜下腔，是额下回盖部的上界。这在优势半球对应于Broca区的上界。另一重要意义在于，在该点下方的中央前回运动皮层存在双侧支配。该点在颅骨的投影恰在冠状点的稍后方。冠状点即为冠状缝与颞上线的交点。额下沟与中央前沟的交点则在冠状点后方约1-2cm或稍远处。
2、额上和中央关键点：SuperiorFrontal and Central Key Points：
额上沟与中央前沟交点The Superior Frontal and PrecentralSulci Meeting Point：中央前沟总呈断续状，额中回是最大的额叶脑回。该关键点还指向Omega区，就是中央前回中的一个Omega 形脑回。Omega区是手部运动的皮质中枢。该点的颅骨定位是中线旁开3cm、冠状缝后方
1.5cm（不超过2cm）处。
Given its usual constancy, straightness, depth, and itsreliable relationship with the underlying ventricular frontal horn, thesuperior frontal sulcus constitutes an important microneurosurgical corridor(Harkeyet al., 1989). Its posterior extremity, which usually joins or lies veryclo to the precentral sulcus, is an important key point which 1) delineatesanteriorly the precentral gyrus at the level of the omega region whichcorresponds to the hand motor activation area (Boling et al., 1999; Yousry etal., 1995) and which 2) limits the superior frontal sulcus opening posteriorly(Figure 3.18A).
鉴于额上沟通常恒定、陡直、深在，并与下方的侧脑室前角关系可靠，额上沟构成了一个重要的显微神经外科手术通路(Harkeyet al.，1989)。额上沟的后端，通常连接或非常靠近中央前沟，这是一个重要的关键点。 1) 它在与手部运动功能区相对应的中央前回的OMEGA区前方。2）界定了额上沟后方的开口（图3.18A）。
上中央沟点The Superior Rolandic Point：上中央沟点的颅骨定位由Broca提出，位于前囟点后方5cm处。
The superiorextremity of the central sulcus (CS) is alwayslocated on the medial surface ofeach cerebral hemisphere,and its projection on the superior margin of thecerebral hemisphere, which corr
esponds to the interction of the CS withthesuperior margin of the interhemispheric fissure (IHF), isusually designated asthe Superior Rolandic point (SRP)(Taylor and Haughton, 1900 apud Uematsu etal., 1992)(Figure 3.19c).In relation to the skull surface, the SRP is locatedroughly5 cm behind the bregma.
中央沟(CS)的上端总是位于大脑半球的内侧表面，其投影在大脑半球的上缘，对应于中央沟CS 与半球间裂(IHF)上缘的交叉点，通常称为上中央沟点Pont(SRP)(Taylor和Haughton，1900
apud Uematsu等，1992)(图3.19c)。相对于颅骨表面，上中央沟点SRP位于冠矢点后约5cm 处。
Exposure of theSuperior Frontal Gyrus and Sulcus, and of the Interhemispheric Fissure额上回、沟和半球间裂的显露。
Regardingthe craniotomy placement, a few very important anatomical features should beconsidered关于开颅术的定位，应该考虑一些非常重要的解剖学特征:
1) The meetingpoi西兰花的吃法
nt of the superior frontal sulcus with the precentral sulcus, hence theanterior aspect of the precentral gyrus, is located approximately 3 cm lateralto the sagittal suture and 2 cm posterior to the coronal suture .额上沟与中央前沟的交点位于中央前回的前面，位于矢状缝外侧约3cm，冠状缝后约2cm。
2) The centralsulcus reaches the midline (superior Rolandic point) about 5 cm posterior tothe bregma.中央沟到达中线(上中央沟点)，大约在冠矢点后5厘米处。
3) The lesionshould always be understood in relation to the coronal suture, which is knownto be related to the interventricular foramina of Monro along the coronal planeof its midline point and which trancts the corpus callosum just anteriorly toits half length.始终认为病变与冠状缝相关时，经monro室间孔的冠状切面的中线点与冠状缝相对应，在此横切胼胝体正好为胼胝体前半部。
4) The corticalveins which drain into the superior sagittal sinus are more numerous and morerelevant over the central area, hence from 2 cm posteriorly to the coronalsuture.引流入上矢状窦的皮质静脉比中央区更多更重要，因此应从冠状缝后2cm开始。
5) The craniotomyshould always expo the superior sagittal sinus to allow comfortableinterhemispheric handling; a bony bar of only 1 cm covering the sinus will becovering almost half of the superior frontal gyrus longitudinally.开颅手术应始终暴露上矢状窦，以便进行舒适的半球间操作；仅覆盖窦的1cm骨棒就可纵向覆盖几乎一半的额上回。
6) A ratherextensive disction of the interhemispheric fissure along the midline, alwaysprerving the central draining veins, enlarges the surgical exposure andfacilitates any surgic
al maneuver.
沿中线对半球间裂进行相当广泛的解剖，始终保留中央引流静脉，扩大了手术暴露，便于任何手术操作。
It isntial to bear in mind that a transcallosal approach more than 2 cmposteriorly to the coronal suture would require dealing with central
veins,retraction of the paracentral lobule, and, since the atriums are away from andlateral to the midline, a more posteriorly callosal opening implies the risk ofreaching the pineal cistern and not the ventricular cavity. 必须牢记，在冠状缝后2厘米以上的经胼胝体入路需要处理中央静脉、中央旁小叶的缩回，并且由于侧脑室房部旁开于中线并且远离中线，所以更后方的胼胝体开口意味着到达的是松果体池而不是脑室。Since the medial surface of the superior frontal gyrus facesthe falx, this cortical surface (superior
frontal gyrus) can be easilyparated from this dural surface (falx), but both cingulate gyri can be morefirmly attached to each other along the inferior margin of the falx, requiringcareful paration in order to prerve their pial surfaces.由于额上回的内面面向大脑镰，所以该皮质表面(额上回)可以容易地与硬脑膜表面(镰)分离，但是两个扣带回可以沿着大脑镰的下缘更牢固地彼此连接，需要仔细分
离以保存它们的软脑膜。
Koutsarnakis et al. studied the sulcal and thesubcortical anatomy related to the superior frontal sulcus (SFS), and foundthat the 5 cms of the SFS immediately anterior to the Precentral Sulcus alwa山的成语
ysoverlie the body and the anterior horn of the lateral ventricle, with thedistance from the fundus of the sulcus to the ventricular cavity varying from1.3 to 2.5 足球俱乐部排名
cm fibers between its fundus and the ventricle. Koutsarnakis等人研究了额上沟(SFS)的沟和皮质下解剖，发现位于中央前沟前方的5cms的额上沟SFS总是覆盖侧脑室体和前角，指向脑室腔的额上沟底与脑室之间有1.3～
2.5cm不等的纤维。
3、顶部关键点ParietalKey Points：The parietal keypoints are 1) the intraparietal and postcentralsulci meeting point(IPS/PostCS), 2) the euryon (Eu), and 3)the parieto-occipital incisure (POInc).
l 顶间沟与中央后沟交点The Intraparietal and PostcentralSulci Meeting Point：
According to thestudies about its morphology, the intraparietal sulcus is predominantlyparallel to the interhemispheric fissure in about 90 percent of humans, beingthentransver in only about 10 perce
nt, and is continuous withthe postcentralsulcus in about 80 percent of humans (Ebelingand Steinmetz, 1995b; Ono et al.,1990; Steinmetz et al., 1990;Ribas et al., 2006; Ribas, 2005b).Theintraparietal/postcentral sulci meeting point
(IPS/PostCS) then corresponds tothe connection or transitionpoint between the two sulci, or to thepostcentral sulcuspoint more particularly related to the most anterior aspectofthe intraparietal sulcus level (projection site of the intraparietalsulcusinto the postcentral sulcus). When the two sulci are notcontinuous, theIPS/PostCS constitutes an important neurosurgical key point 1) since it is anevident point that delineatesposteriorly the
postcentral gyrus, 2) becau itcan be utilized asa safe starting point for the microsurgical opening of thesulci,and 3) due to its deep relationship with the ventricular atriumortrigone. (Figure 3.29).根据对其形态学的研究，大约90%的人的顶内沟主要平行于半球间裂隙，然后只有大约10%的人是横向的，大约80%的人与中央后沟是连续的（E.ng和Steinmetz，1995b；Ono 等人，1990；Steinmetz等人1990年；Ribas等人，2006年；Ribas，2005b）。然后，顶内/中央后沟交汇点(IPS/PostCS)对应于这两个沟之间的连接点或过渡点，或者与中央后沟点相对应，中央后沟点更特别地与顶内沟水平的最前方(顶内沟向中央后沟的投影位置)相关。当这两个沟不连续时，IPS/PostCS构成重要的神经外科关键点1)因为它是描绘中枢后回的标志点，2)因为它可以作为这些沟的显微外科开口的安全起点，3)
由于它与侧脑室房部或三角部有很深的关系。 (图3.29)。
颅阔点与缘上回The Euryon and the Supramarginal Gyrus：
The euryon (Eu)is the craniometric point that corresponds to the center of the parietaltuberosity (Gusmo et al., 2000; Broca, 1876b; Pernkoff, 1980), and is veryeasily palpated as the most prominent cranial parietal area (Figure 3.30). TheEu is usually located immediately superiorly to the superior temporal line(STL), and also corresponds to the area of interction of the STL with avertical line that pass thr秋翁
ough the posterior aspect of the mastoid tip andthrough the meeting point of the squamous and parietomastoid
sutures(PaMaSut/SqSut) (Ribat al., 2006; Ribas, 2005b). In relation to the corticalsurface, the Eu always lies over the superior aspect of the supramarginalgyrus, more frequently over its posterior half, hence always posteriorly to thepostcentral sulcus (PostCS) (average distance: 1.5– 3.0 cm), laterally to theintraparietal sulcus (IPS) (average distance: 1–3 cm), and anteriorly to theintermediary sulcus of Jenn (the distal part of superior temporal sulcunters inside the angular,the superior one parates the supramarginal from theangular, intermediary sulcus of jenn.) (ISJ) (average distance: 1–2 cm),which parates the supramarginal gyrus (SMG) from the幽默搞笑段子精选
angular gyrus (AG). Th
eposterior Sylvian point (PSP) is then always anterior and inferior to the Eu(average distance 2–3 cm) (Ribat al., 2006; Ribas, 2005b). In the dominanthemisphere, the cortical area underneath the Eu is particularly related to theparietal speech zone, has its epicenter roughly located 1–4 cm above theSylvian fissure and from 2 to 4 cm behind the postcentral sulcus.
颅阔点 (Eu)是对应于顶结节中心的颅骨测量点，并且在顶骨区最突出的部位很容易被触及(图3.30)。Eu通常直接位于上颞线(STL)的上方，并且还对应于STL与穿过乳突尖端后部和通过鳞状和顶乳突缝(PaMaSut/SqSut)的会合点的垂直线的交汇区域(Ribatal.，2006；Ribas，2005b)关于皮质表面，Eu总是位于边缘上回的上方，更多情况位于其后半部，因此总是位于中央后沟(PostCS)的后方(平均距离：1.5-3.0cm)、顶内沟(IPS)的侧面(平均距离：1-3cm)和Jenn中间内侧沟(颞上沟的远侧支进入角回内，上支则分隔缘上回和角回，即所谓的Jenn中间沟)(ISJ)的前方 (平均距离：1-2cm)，Jenn中间沟将缘上回(SMG)和角回(AG)分开。然后后侧裂点（PSP）总是位于颅阔点Eu的前下部（平均距离2-3cm）（Ribat等人，2006；Ribas，2005b）。尤其在优势半球，颅阔点（Eu）下方的皮质区与顶部语言区有关，其中心位于侧裂上方1-4厘米处和中央后沟后2-4厘米处。
顶枕切迹和人字点The Parieto-Occipital Incisure and theLambda：
Theparieto-occipital sulcus is a very deep sulcus which runs along the medialsurface of the brain he
misphere parating the precuneus from the cuneus, andits depth appears transversally and very evidently on the medial aspect of thehemispheric superolateral surface as the parieto-occipital incisure (POInc).The parieto-occipital incisure (POInc) lies on the medial aspect of thesuperolateral surface of the brain, transversally to the interhemisphericlongitudinal fissure. It is always inside an also very evident U-shapedconvolution currently called the parieto-occipital arcus (Petrides, 2012)(POArc) and classically known as the first or superior parieto-occipitalconnection of Gratiolet (Testut and Jacob, 1932) (Figure 3.31).Since, in the past, the parieto-occipital sulcus was also denominated theinternal occipital fissure due to its perpendicularity in relation to thecalcarine fissure, the POInc was formerly known as the external occipitalfissure (Broca, 1876b). The POInc corresponds to the most superior point of theparieto-occipital sulcus and constitutes a uful surgical landmark since itdefines the position of the parieto-occipital sulcus, and hence the posterioraspect of the precuneus along the interhemispheric fissure (IHF) (average longitudinalextent of the precuneus along the IHF: 3.5–4.05 cm) . As with otherwell-developed sulci, it is not uncommon to have a vein running along t检讨书格式模板
hePOInc. Regarding its cranial relationships, each POInc lies underneath eachparamedian area that corresponds to the angle between the sagittal and eachlambdoid suture (La/Sa) (Figure 3.31C). 顶枕沟是一个非常深的沟，它沿着大脑半球的内表面延伸，将楔前叶和楔叶分开，顶枕沟在半球背外侧面的内侧缘上形成非常明显的横向的顶枕切迹(POInc)。顶枕切迹（POInc）位于大脑上外侧表面的
内侧面，横向于半球间纵裂。它总是位于一个非常明显的U形卷积内部，现称此卷积为顶枕弓（Petrides，2012）（POArc），传统上称为Gratiolet第一或上顶枕连接（Testut和
Jacob，1932）（图3.31）。过去，顶枕沟由于垂直于距状裂，也称为枕内裂，因此顶枕切迹
