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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3644_Библиотеки_им_академика_М_И_Перельмана
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18.12 Hematological Disorders and Coagulopathies . . . . . . 892
18.13 Metabolic Disorders . . . . . . . . . . . . . . . . . . . . 893
18.14 Proliferative Angiopathy . . . . . . . . . . . . . . . . . . 893
18.15 PHACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899
18.16 Hereditary Hemorrhagic Telangiectasia,
or Rendu-Osler-Weber Disease . . . . . . . . . . . . . . . 899
18.17 Spinal Cord Strokes . . . . . . . . . . . . . . . . . . . . . 899
18.18 Treatment and Management . . . . . . . . . . . . . . . . 905
19 References . . . . . . . . . . . . . . . . . . . . . . . . . 909
Subject Index . . . . . . . . . . . . . . . . . . . . . . . 967
ContentsXX
1.1 Preliminary Remarks 1
1.2 Leptomeninges 21
1.3 Subpial Space 22
1.3.1 Anatomy 22
1.3.2 Relationships of the Subpial Space 23
1.3.3 Pathology 23
1.3.3.1 Inflammation 23
1.3.3.2 Tumor 24
1.1 Preliminary Remarks
In this section we have collected illustrations that are relevant to the
basic principles described in the various chapters of this book.
Vascularization of dural covers in the fetus, particularly the venouslike channels, points to the role that they may play before granulation
maturation. This rich vascularization contrasts with the rarity of true
dural arteriovenous malformation in clinical practice. On the other hand,
it may also constitute a reservoir for the sometimes dramatic response of
the dural covers to angiogenic stimulation (Figs. 1.1,1.2).
C. Larroche and N. Girard have allowed us to reproduce some of their
work; we have used fetal brain sections published by Larroche in an atlas
that is no longer in print (Figs. 1.3–1.8) and magnetic resonance imaging
(MRI) evaluation by Girard of myelinization in the perinatal period
(Figs. 1.9–1.18). These pictures are not intended to formally establish
what constitutes a normal appearance, but rather to help visualize the
path that the myelinization process follows in neonates and infants.
The subpial space has been extensively studied by various authors.
We ller (1992; Nicholas and Weller 1988) has contributed to the better understanding of both the anatomy and the role of the subpial space. The
following text and images illustrate this particular meningeal space
(Figs. 1.19–1.25). An understanding of meningeal relationships in terms
of the biology of the barrier that they constitute should explain why hemorrhage in one space gives rise to a spasm,but a few millimeters after a
transpial passage the same vessel does not show a spastic reaction to the
same abluminal stimuli. On the venous side, in neonates subpial congestion gives rise to multiple trophic changes,which are very mild if the congestion occurs only in the subarachnoid space.
The responses to inflammatory diseases certainly account for the
transdural contributions and indicate that several cellular proliferative
reactions can cross this barrier very easily.
1Embryological and Anatomical Introduction
1Embryological and Anatomical Introduction2
Fig. 1.1A–F. Anatomic preparation of neonatal
dural coverings. AAxial section showing the
occipital lobe,the falx cerebri and the striate
sinus. Note the multiple vascular spaces contained in the torcular region.B Higher horizon-
tal section above the torcular showing the
parietal suture and the superior sagittal sinus.
Note the bilobed appearance of the superior
sagittal sinus (see the sinus malformations
illustrated in Chap.4). Many vascular channels
can be seen within the dura. C Horizontal
section showing the straight sinus and the
tentorium at the torcular level. Highly vascularized dural spaces can still be seen. D Ver t i c a l
section demonstrating the straight sinus and
two additional venous channels in the falx.
The arachnoid covers can be clearly seen.
E Parasagittal section showing the lateral sinus
and the marginal sinus at the lower edge of
the occipital bone. The cerebellum and the tentorium are easily recognizable. F Ver t ical
section demonstrating a superior sagittal sinus
in its mid-third portion. Multiple venous
channels are seen surrounding the sinus itself.
The arachnoid and pia mater can be clearly
seen. v,Vascular spaces. (Courtesy of P. Kherli
and C. Maillot, unpublished data).
E–F see p.3
3Preliminary Remarks
Fig. 1.1 (continued). E Parasagittal section showing the lateral sinus and the marginal
sinus at the lower edge of the occipital bone. The cerebellum and the tentorium are
easily recognizable. F Ve r t i c al section demonstrating a superior sagittal sinus in its
mid-third portion. Multiple venous channels are seen surrounding the sinus itself.
The arachnoid and pia mater can be clearly seen. v,Vascular spaces. (Courtesy of P.
Kherli and C.Maillot, unpublished data)
1Embryological and Anatomical Introduction4
Fig. 1.2A,B. Injected newborn specimen. A Medial face of the dural tentorium,
demonstrating the arterial capillary network and a converging drainage in a perforating vein, joining the external surface of the dura mater (arrows).B Arterial capillary
network on the tentorium cerebelli. The arrow points to the free margin of the tentorium.(Courtesy of C. Maillot, unpublished data)
5Preliminary Remarks
Fig. 1.4A–F. A 40-g fetus. A Horizontal section for a gestational age of 12–13 weeks.
The germinal matrix is well demonstrated. The choroid plexus fills the lateral ventricle entirely. B On the frontal section, the choroid plexus of the third ventricle can be
clearly seen. A corpus callosum has not developed yet. C Mid-sagittal view. 1,Corpus
callosum; 2,fornix; 3,lamina comissuralis; 4,olfactory bulb;5,infundibulum; 6, mesencephalic aqueduct; 7,quadrigeminal plate; 8,fourth ventricle; 9,cerebellum.
D Superior view. 1,Longitudinal fissure of the cerebrum; 2,cerebellum;3,fourth ven-
tricle; 4,medulla oblongata; 5,medulla spinalis. E Basal view. 1,Olfactory bulb;
2,optic chiasm;3,infundibulum;4,lateral fossa; 5,transverse fissure of the cerebrum;
6,pons;7,cerebellum;8,medulla oblongata;9,medulla spinalis. F Lateral view.1,Lat-
eral fossa; 2,cerebellum;3,medulla oblongata; 4,medulla spinalis. (Reprinted from
Fess-Higgins and Larroche 1987, with permission) C–F see p. 6
Fig. 1.3. Fronto-oblique section
passing through the frontal lobe
and the olfactory nerve, the
optic and infundibula recesses,
the pons and trigeminal nerve,
and the large fourth ventricle
in a 13-week-old fetus.
(Reprinted from Fess-Higgins
and Larroche 1987, with
permission)
1Embryological and Anatomical Introduction6
Fig. 1.4 C–F (continued). C Mid-sagittal view. 1,Corpus callosum; 2,fornix; 3, lamina
comissuralis; 4,olfactory bulb;5,infundibulum;6, mesencephalic aqueduct;
7,quadrigeminal plate; 8,fourth ventricle; 9,cerebellum.D Superior view. 1,Longitu-
dinal fissure of the cerebrum; 2,cerebellum;3,fourth ventricle; 4,medulla oblongata;
5,medulla spinalis. E Basal view. 1,Olfactory bulb;2,optic chiasm; 3,infundibulum;
4,lateral fossa; 5,transverse fissure of the cerebrum; 6,pons;7,cerebellum;8,medul-
la oblongata; 9,medulla spinalis. F Lateral view. 1,Lateral fossa; 2,cerebellum;
3,medulla oblongata; 4,medulla spinalis.(Reprinted from Fess-Higgins and Larroche
1987, with permission)
Fig. 1.5. A Frontal section of a 280-g fetus, 19–20 weeks of gestation. The deep nuclei
are clearly demonstrated,in particular the thalamic and amygdaloid complex. B The
trigeminal matrix and cells that have migrated toward the cortical surface can be
clearly seen. (Reprinted from Fess-Higgins and Larroche 1987, with permission)
7Preliminary Remarks
Fig. 1.6. A Axial and B frontal section of a 1,140-g embryo, 28weeks of gestation,
showing the development of the corpus callosum and the cortical layers. The matrix
cannot be seen very well. The choroid plexus is reduced in size.Note the subarachnoid
and pial spaces filled with small vessels. (Reprinted from Fess-Higgins and Larroche
1987, with permission)
Fig. 1.7. Mid-sagittal section
of a 2,600-g embryo, 36weeks
of gestation, showing the
choroid fissure. The same
aspect is demonstrated Fig. 1.8.
(Reprinted from Fess-Higgins
and Larroche 1987, with
permission)
1Embryological and Anatomical Introduction8
Fig. 1.8. Frontal view of 2,510-g
embryo,37 weeks of gestation.
(Reprinted from Fess-Higgins
and Larroche 1987, with permission)
Fig. 1.9A–C. Axial T1-weighted images (T1WI) in a
23-week-old fetus. C Axial T2-weighted image (T2WI) in
a 21-week-old fetus.A The brain is agyric and the sylvian
fissures are wide open, as they should be at this stage.
The lateral ventricles are large; this feature corresponds
to the relative hydrocephalus of the fetus.The cortical
ribbon has a high signal, as do the germinal matrix and
the migrant cells, which results in a multilayered pattern.
High signal intensity is observed in the basal ganglia,
corresponding to the high cellularity. B This is also the
case in the posterior part of the brain stem as a result
of myelination. C The cortical ribbon has low signal
intensity on T2WI.(Courtesy of N. Girard)
9Preliminary Remarks
Fig. 1.10A–H. Coronal T1-weighted images (T1WI) in a 29-week-old fetus.
T2-weighted images (T2WI) in a 28-week-old fetus in C axial and D sagittal planes.
E, G Axial T1WI and F, H axial T2WI of a 28-week-old premature newborn. A, B The
cortical ribbon can still be seen as high signal intensity,while the migrant cells are no
longer as visible. A,C The ventricles are now thinner than in Fig. 1.9. C The cortical
ribbon can be seen as low signal intensity that is well delineated from the white
matter and the subarachnoid spaces, which appear as high signal intensity.Moreover,
early gyration can be seen and is better depicted on T2WI. The brain stem appears
as B high signal intensity on T1WI and D low signal intensity on T2WI secondary to
the completion of myelination. In the 28-week-old premature newborn, the cortical
ribbon shows G high signal intensity on T1WI and H low signal intensity on T2WI
E–H see p. 10
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