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Case Reports Case 1. A 24-year-old man came to the hospital on July 7, 1965, complaining of pain in the left eye and double vision which had begun after a fall 3 weeks earlier. Two years previously the patient had sustained fractures of the left facial bones and was operated upon for depression of the floor of the left orbit; afterwards diplopia was present intermittently. When he fell he struck his head on the ground, but remained conscious. After this he noticed a bruit, and the diplopia became constant. Examination. Conjunctival edema, exophthalmos, and a bruit were present on the left. The left retinal veins were distended, but vision was normal. A left carotid arteriogram demonstrated a left carotid cavernous fistula (Fig. 1). The contrast medium left the cavernous sinus via the superior petrosal sinus, the superior ophthalmic vein, the Sylvian vein, and the basal vein of Rosenthal. A right carotid arteriogram with compression of the left carotid artery demonstrated the anterior and middle cerebral arteries bilaterally and the fistula. Operation. A left frontal craniotomy was performed, and the common, internal, and external carotid arteries were exposed in the neck. An electromagnetic flow meter was

AAnNHCJ 3 introduced a new operation for the treatment of trigeminal neuralgia in 195~. His procedure consisted of intradural decompression of the gasserian ganglion and posterior root of the fifth cranial nerve. In this operation the posterior root is not sectioned, and consequently sensation in the face is not sacrificed. Love, 1 in 195~, modified Taarnh0j's operation and carried out an extradural approach to the gasserian ganglion and posterior root of the fifth cranial nerve. During the period from June, 195~ to 1V[arch, 1954, we and our associates have treated 100 patients with trigeminal neuralgia by decompression of the gasserian ganglion and posterior root of the fifth cranial nerve. The procedure employed in each of these cases is the modification of Taarnh0j's procedure devised by Love, 2 which may be described briefly as follows. PROCEDURE Through a small subtemporal craniectomy opening the middle meningeal artery is ligated and divided. The dura mater is stripped from the foramen ovale upward and backward to expose the intracranial portion of the third branch of the trigeminal nerve, the gasserian ganglion and the dura propria over the adjacent portion of the posterior root of this ganglion. The dura mater underneath the temporal lobe is then incised posteriorly, parallel to the posterior root of the ganglion, and the tentorium overlying the posterior root in the posterior fossa is also incised. By this technic the posterior root of the gasserian ganglion is thoroughly decompressed. POSTOPERATIVE COMPLICATIONS From Table 1 it is evident that the procedure of decompression as employed in this series is a safe one. The 1 death occurred in a patient who had, from all clinical signs, recovered from the operation. Only in 1 case did palsy of the third cranial nerve result, and in this instance the palsy was slight and cleared up completely in a month. There were no instances of palsy of the fourth cranial nerve. Bleeding from the superior petrosal sinus has not been a problem; it is usually controlled easily by the application of absorbable gelatin sponge (gelfoam). In only a few instances has clipping of the sinus been necessary.

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Twelve meningiomas situated in the region of the asterion have been operated upon over the past 18 years at Walter Reed General Hospital. These tumors invaded the transverse sinus at its junction into the sigmoid sinus. The superior petrosal sinus which enters the transverse sinus in this area had to be ligated separately only in two instances. However, most of these tumors did extend from the middle into the posterior fossa and required a combined temporal-suboccipital craniectomy. In Fig. 299 an anatomical drawing outlines the relationships of the tumor to the skull, dura, dural sinus, and tentorium. The temporal lobe, the cerebellum, the tumor and its invasion into the transverse sigmoid sinus are seen in a coronal section (Fig. 300). The main blood supply to the asterion meningioma comes from the middle meningeal artery and the occipital artery. The richness of this blood supply demonstrated angiographically will help decide if ligation of the external carotid artery should be done prior to removal of the tumor.

WHILE IN THIS day and age this topic would ordinarily be considered unusual, nevertheless, the gravity of this clinical entity, whenever it does occur,1demands the utmost of the clinician's comprehension and skill. Therefore, lest complacency supervene, a timely review including a case report may not be entirely amiss. Anatomy and Pathological Physiology The cavernous sinus is a composite system of numerous intercommunicating endothelial-lined compartments on both sides of the sella turcica, which functions as a venous blood conduit in that it drains the upper lip, nose, paranasal sinuses, nasopharynx, pharynx, and orbits and channels this blood into the jugular vein by the inferior petrosal sinus and into the lateral sinus by the superior petrosal sinus. These compartments resemble honeycomb cells. By thrombosis is meant intravascular coagulation in any part of the circulatory system. Normally, the blood remains in a fluid condition, owing to some interaction between it and

Anomalies of the cranial venous sinuses when encountered unexpectedly at the operating table may be the cause of hesitation and confusion to the surgeon. If, however, the possibility of such an occurrence has been brought to his attention previously, he will be at least partially prepared with technical procedures to cope with the situation. After the first presentation of a case of congenital absence of the sigmoid sinus found at operation, reported in the literature by one of us (Williams 1 ) in 1930, Hoople, 2 in 1936, presented a similar case. In the first case, the descending portion of the sigmoid sinus was absent and the lateral sinus reduced to the size of a thread. A large vein following the course of the superior petrosal sinus left the skull by way of the foramen for the emissary vein of the mastoid process. In Hoople's case, in which the findings were confirmed by

1. A case is described in which meningitis terminated an apparently convalescent case of acute otitis media and mastoiditis. 2. At necropsy a partly organized, partly septic thrombus was found in the superior petrosal sinus adjacent to the involved tympanic cavity, but no direct connection was found between the primary infection and either the thrombosis or the meningitis. 3. No case of otitis media or mastoiditis is free from the possibility of cerebral complication until it is entirely healed 4. It is suggested that the physical signs which were interpreted as those of brain abscess were possibly due to irritation of the cranial nerves which lay close to the inflammed region, and that this irritation was caused by the same inflammatory process which produced the thrombosis of the superior petrosal sinus.

We experienced the following two cases of otogenous thrombosis of the superior longitudinal sinus.Case 1. Age, 8, female.Preceding otitis: O.m.p.chr. cholesteatom. sin.Characteristic symptoms: Increased intracranial pressure.Kernig's reaction (+). Edematous painful swelling of the scalp.Autopsy findings: Thrombosis of the left lateral, the superior longitudinal sinus and the left jugular vein. Hemorrhage in the cerebral cortex. Fibrino-purulent meningitis.Cause of death: Septico-pyemia and metastasis in the pulmonary circulation.Case 2. Age 9, male.Preceding otitis: O.m.p.chr. cholesteatom. sin.Characteristic symptoms: Increased intracranial pressure.Babinski's reflex (+). Kernig's reaction (+). Edematous painful swelling.Autopsy findings: Thrombosis of the bilateral transverse sinus. the superior longitudinal, the superior petrosal sinus and the jugular vein. Cerebral edema.Cause of death: Metastasis in the pulmonary circulation.Examining available literature, further 43 cases of this disease were considered together with the author's two cases. Victims are mostly, 13 cases among 45, small children under 10. The preceding otitis is mostly on the right side and oftener of the acute nature.In both of the present cases, the sculp developed the edematous, painful swelling, i. e. Gradanigo's symptom. This can be regarded as the sole symptom peculiar to this disease, though it may not always occur, being on record in 8 cases among 45.Intra-cranial syndrom, observed in many cases indeed, is not, however, characteristic exclusively of this disease, being common to the intra-cranial circulatory disturbance cerebral edema, hemorrhage or abscess, and secondary softening, etc.

Hemorrhage from the superior petrosal sinus exists as a possibility in operations on the lateral sinus despite the fact that, with one exception, no mention is made of it in any of the literature published on mastoid or lateral sinus operations. Since attention has now been called to it there is little to add except to show briefly how the complication occurs, and how its results are frequently unfavorable to the patient. The superior petrosal sinus is described in the various textbooks on anatomy as being one of the terminal divisions of the cavernous sinus, running in a small groove in the superior border of the petrous portion of the temporal bone in the attached margin of the tentorium cerebelli and terminating in the lateral sinus at the point where the sigmoid portion of that vessel begins. While this termination is usually described as being through a single opening in