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BACKGROUND Despite increasing use of craniofacial access for complex intracranial and skull base pathology, there have been no reports detailing the impact of improved access on clinical outcome. METHODS Orbitozygomatic access was used in 32 patients with an aneurysm of the basilar bifurcation, superior cerebellar, or posterior cerebral arteries over a 9-year period. RESULTS Operative mortality was 0%, overall management mortality 9% and management morbidity was 9%. This approach was selected for these patients because of the anatomy of the aneurysm and its relationship to the terminal basilar complex and the dorsum sellae/posterior clinoid process. The flexibility achieved by the access allowed intraoperative use of multiple corridors of access. Morbidity directly attributable to the use of orbitozygomatic access was minimal. CONCLUSIONS While management outcome after aneurysmal subarachnoid hemorrhage relates directly to the severity of the initial hemorrhage, rather than the surgical approach chosen, in selected patients we recommend the use of this approach as a valuable adjunct to the armamentarium of the vascular neurosurgeon.

Three patients with a meningioma involving the bone around the orbit are presented. The need for a complete resection and immediate reconstruction is emphasized. The principles of a 3-D orbital reconstruction are discussed.

Lymphatic malformations of the head and neck, also known as lymphangiomas or cystic hygromas, are a diverse group of lesions. They can be small and superficial or large and extensive, and management can be a challenge. Surgically they can be difficult to remove completely because of their poorly defined borders and the potential for damaging neighbouring structures. We review the dilemmas posed in diagnosis and treatment, and discuss the contemporary management of these interesting entities including sclerotherapy, which is gaining popularity.

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Dissection deep within the orbit is a cause for concern to surgeons because of the perceived risks of injuring critical structures such as the contents of the superior orbital fissure and the optic nerve. Although "safe distances" (those distances within which it is considered safe to dissect within the orbit) have been described, these are of limited value if the orbit is severely disrupted or is congenitally shallow. In addition, traumatic defects in the orbital floor, in particular, often extend beyond these distances. Reliable landmarks based on the relations between anatomical structures within the orbit, rather than absolute distances, are described that permit safe dissection within the orbit. We present the concept of the deep orbit and describe its relevance to repair of injuries.

Despite the availability of effective photocoagulation treatment, diabetic retinopathy remains the main cause of blindness in persons aged between 20 and 64 years. We have examined the effectiveness of the referral chain for retinopathy by auditing medical records for a representative sample being 226 diabetic patients (35% of attenders) referred to a special photocoagulation clinic. Patients were classified as 'late' or 'not late' by using an algorithm which accounted for the state of retinopathy at referral and the previous frequency of eye examination. Forty-four patients (19%) were considered to have been referred late. These were mainly younger onset patients, aged between 30 and 40, and not attending a diabetic clinic. Patients not attending any other outpatient clinic were 27 times more likely to be referred late.

Sunmary.4G males were administered the lPAT Anxiety Scale and the obtained sten scores were correlated with the number of neutral auditory stimuli required to reach habituation. Habituation was defined by the absence of digital vasoconstriction (a component of the orientation reaction) to the stimuli. The Spearman rho was .788. The results were interpreted in terms of activation theory and the hypothesis was forwarded that the high arousal level of the anxious S interferes with the recording of the properties of the stimulus and thus subsequent identical stimuli are perceived as being novel. To any qualitative, intensive or temporal change in stimulation, a number of physiological alterations, collectively called the orientation reaction (O.R.) are brought about that serve to enhance the discriminatory power of the receptors. The components of the O.R. comprise skeletal, sensory, autonomic, and electroencephalographic changes. Thus as one part of the O.R. vasoconstriction occurs in the extremities and vasodilatation in the head (Lynn, 1966). If a stimulus that at one time had efficacy for initiating the O.R. is repeatedly presented, the components habituate. The ne~lrophysiological basis for this habituation has been hypothesized in Sokolov's ( 1960) two stage model. Stimulus input is appraised in the cortex and if the stimulus is novel the O.R. is generated at a reticular level. On the other hand, if the stimulus is judged not to be novel the O.R. is inhibited at the behest of the cortex, at a pre-reticular level. Malmo (1957) has suggested that anxiety may represent a "disease of overarousal" and be based "on reduced central inhibition." If this be the case, it is reasonable to expect that the anxious person should require more stimulus presentations to reach habituation than the non-anxious Ss. In the form of a null hypothesis: there is no significant correlation between psychometrically assessed anxiety and the number of neutral auditory stimuli necessary to reach a defined level of habituation. METHOD Forty-six males, with a mean chronological age of 21.30, all of whom but two attended university, were Ss. Anxiety levels were gauged by the IPAT Anxiety Scale (Cattell & Scheier, 1957) and the scores were converted into stens. A test-retest reliability coefficient for 29 Ss with a 3- to 4-wk. interval was .94. Digital blood volume was measured by a Photoelectric Pulse Pick-up (E & M Instrument Co.) on a Physiograph "Four." Vasomotor fluctuations were re