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We report a supine lateral retromastoid approach for computed tomography-guided stereotactic aspiration of hematomas of the posterior fossa. The method involves horizontal insertion of the aspiration needle at the suboccipital region with the patient in a supine position with the head turned 30 to 40° away from the lesion and with slight forward flexion of the neck. Eleven hematomas have been removed through this approach thus far, nine cerebellar and two pontine. With this technique, general anesthesia is not needed and operative invasion is minimal, allowing hematoma aspiration in patients in whom operation would previously not have been indicated. An additional merit is the suitability of this method for elderly patients.

A group of venous sacculations associated wth a system of glomerular arteriovenous anastomoses and numerous nerves lies adjacent to the vertebral artery. As thin walled extensions of a dural sinus, these ampullae are structurally capable of responding to changes in venous pressure. The function of their glomerular connections to branches of the vertebral artery is not apparent.

✓ A case of ectopic extraspinal meningioma is reported which presented as a tumor at the back of the neck of a 51-year-old woman. This neoplasm was of considerable size and arose extradurally in the region of the C-2 nerve root, with its main bulk lying almost totally outside the spinal canal in the right suboccipital region. Total resection was accomplished in two stages, with no evidence of recurrence after 1 year. The rarity of such cases prompted this report.

✓ The authors describe the occurrence of proatlantal artery as an incidental angiographic observation in a young Indian soldier. This primitive anastomotic channel is seen extending from near the origin of the external carotid artery to the suboccipital region, traversing the foramen magnum and coursing beyond like a vertebral artery. The developmental and roentgenological aspects of carotid-basilar and carotid-vertebral anastomosis are discussed, along with a review of four similar cases reported previously.

Between 1966 and 1976, postmortem examinations revealed significant intracranial birth trauma in 17 infants delivered breech first and in ten infants delivered head first; separation of the squamous and lateral parts of the occipital bone (occipital osteodiastasis) was found in five of the infants who died after breech delivery. The finding of the lesions in these infants is attributed to the adoption, since 1971, of a postmortem technique involving dissection of the suboccipital region before opening the skull. Review of earlier necropsy reports suggests that the lesion was sometimes missed. Analysis of the fresh stillbirths and neonatal deaths occurring in the 477 vaginal breech deliveries at the Hammersmith Hospital (1966 to 1976) showed that all neonatal deaths in infants weighing more than 3000 g at birth associated with intracranial birth trauma: 2 out of 3 had occipital osteodiastasis which seems to be more common than is generally recognized and is only found with careful autopsy technique.

Currently osteoarticular tuberculosis [5, 8, 10] remains the most frequently observed extrapulmonary form of tuberculosis [10]. The spine is involved in 50 to 60% of the cases of osteoarticular tuberculosis, most commonly of the dorsolumbar level [2, 3]. Cervical Pott’s disease is an uncommon localization (1–10% of the cases with spinal involvement) and its appearance in the suboccipital region is even rarer (0–4.8%), although its consequences are much more serious [1, 4, 6, 12].

The theoretical risk of injuring the vertebral artery or anomalous vessels at lateral cervical puncture is assessed. In just less than 30% of vertebral arteries the vessel overlies the lateral aspect of the spinal canal between the first and second cervical vertebrae, usually the antero-inferior quadrant. Directing the spinal needle to the posterior third of the canal virtually eliminates the possibility of injuring this and most anomalous arteries traversing the region. The likelihood of inducing subarachnoid haemorrhage by injuring these vessels would appear to be considerably less in lateral cervical than in cisternal puncture.

To the Editor.— This case report describes the possible association of positional nystagmus of the benign paroxysmal type (PN-BPT) with posterior fossa medulloblastoma. Report of a Case.— A 35-year-old man complained of an eight-month, nonprogressive history of headache and dizziness. The headache occurred almost daily and began immediately when he sat up in bed in the morning and lasted about an hour. Sometimes it would occur later in the day with a sudden change in head position, but it would be milder and shorter in duration. The morning head pain occurred in the left occipital region, was severe, and was aggravated by straining at stool, bending over, or turning the head from side to side. It was accompanied by dizziness that lasted from seconds to a minute or two without nausea. Physical examination showed a good range of neck movement but severe muscular tenderness in the suboccipital region. A striking

The authors have designed various implants made of alumina ceramic for neurosurgical use. They were used for reconstruction of the sellar floor and orbital wall and for cranioplasty to repair bone defects in both the convexity and the suboccipital region. Burr hole and sphenoid buttons were made to prevent postoperative dents in the skin. A ceramic-silicon sponge was developed as a marker prosthesis for neurovascular decompression. There were no untoward side effects such as infection or rejection by recipient tissue in humans or dogs. The advantages and disadvantages of the material are discussed.

This case is reported because of its rarity and because of the fact that a cure of the patient was effected. A white baby, aged 5 months, was brought to the office by its mother, March 17, 1932, who gave the following clinical history: She had noticed a lump in the suboccipital region of the infant when it was only a few days old. This lump had gradually increased in size until it had become as large as the child's head. During the preceding two weeks the child had vomited after each feeding, and it had lost weight. She had taken the child to several doctors, who had given her no hopes for cure. The baby was poorly nourished and markedly dehydrated. It weighed 9 pounds (4 Kg.). There was a huge suboccipital meningocele about the size of the child's head. The coverings of the meningocele were sufficiently thin to

Flexion of the head with obliteration of the folds usually found in the occipital and cervical regions is essential in order to obtain the best exposure in either suboccipital craniotomy or cervical laminectomy. We have sometimes found that sufficient flexion is not produced by the head rest, and traction by an assistant has been necessary. If a retractor is used it is usually applied in the region of the external occipital protuberance where only a scant purchase is possible, and if the retractor slips the tissues are likely to be stripped from the cranium or torn. Such traumatism where the corners of the incision come together is unfortunate, since it is the weakest part of the wound and, unless the tissues at this point are brought together accurately, leakage of cerebrospinal fluid may be favored. In order to obtain flexion and better exposure of the suboccipital region without additional traction

To the Editor:— I am offering a suggestion for fastening the Levin nasal tube in place, which I consider simple and practical. After the tube is passed the desired distance and wiped free of lubricant, a 2 foot length of 1 or 2 inch gauze roller bandage is placed parallel to the tube, with its midpoint just beneath the nostril. The bandage is fastened to this point on the tube by a few turns of 1/2 inch adhesive tape. The bandage is then knotted over the tape, and the free ends are brought across the face over the ears and tied in the suboccipital region, as in tying the strings of a surgical mask. This method is comfortable and avoids slipping of adhesive tape which has been loosened by perspiration.