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Classically, fractures of the labyrinth are commonly divided into longitudinal, transverse, and oblique fractures. (a) Longitudinal fractures are parallel to the petrous axis, and are the result of traumata of the temporo-parietal region. The line of fracture comes down from the temporo-parietal region, passes at the level, or in front, of the external acoustic meatus, and ends at the foramen lacerum, or at the foramen spinosum, after running along the grooves of the petrosal nerves. The petrous bone is thus divided into two parts: an external one containing the anterior part of the tympanic cavity proper and a posterior one containing the Fallopian canal, the internal acoustic meatus, the internal ear, and part of the antrum. The tympanum is torn, hence otorrhagia, the internal ear is intact and, generally, the facial nerve is also free from injury. As a rule, this line of fracture is fairly wide. (b) Transverse fractures are the result of a trauma of either the occipital or the occipitomastoid regions; ...

The intracranial dura mater is supplied mainly by the middle meningeal artery, a branch of the external carotid artery which enters the cranial cavity through the foramen spinosum. Other more or less constant branches of the external carotid artery augment the supply. These small vessels arise from the superficial temporal artery, the occipital artery, the ascending pharyngeal artery and from other branches of the external carotid artery and enter the intracranial cavity through the foramina in the base of the skull, through the parietal and condyloid foramina and directly through the calvarium via other small channels. Further small and more constant supply vessels are the accessory meningeal artery, a branch of the maxillary artery, which enters the cranial cavity through the foramen ovale and the posterior meningeal artery which arises from the ascending pharyngeal artery and enters the cranial cavity through the jugular foramen. These supply small areas of the dura near the site of entry and freely anastomose with branches of the middle meningeal artery and other meningeal vessels. Familiarity with these small meningeal arteries is important because an intracranial tumour supplied by the external carotid artery is almost certainly a meningioma. The best method Based on a paper read at the Meeting of the Swedish Society for Medical Radiology in 1959. Submitted for publication 31 October 1960.

HE most radical and effective treatment of carotid-cavernous fistula consists of isolation of the cavernous portion of the internal carotid artery by ligation in the neck after intracranial clipping of its terminal portion. Because of its hazards, however, this procedure is often avoided, and the results are correspondingly poor. This report describes the successful intraluminal occlusion of the terminal internal carotid artery by embolization with a porcelain bead, thus eliminating the need for craniotomy. Case Report A 42-year-old man had been brutally beaten about the head. He was admitted in deep shock in a stuporous condition with severe facial and scalp lacerations, multiple linear fractures, and a severe right parietal depressed fracture. After treatment for shock, the depressed fragment was removed, a large epidural hematoma was evacuated, and the middle meningeal artery occluded close to the foramen spinosum. The dura had not been damaged. The patient made an uneventful recovery. Two months after discharge the patient became aware of a pulsatile bruit over the left eye; in the course of the next 2 weeks this eye protruded severely. There was chemosis and engorgement of conjunctival vessels in both eyes, more marked in the left. The optic discs were normal but the retinal veins were slightly engorged. There was no visual impairment. Intraocular pressure was elevated to 22 mm Hg in the right eye and 24 mm Hg in the left eye. All over the cranium a blowing bruit could be heard, louder over the left eye, and synchronous with the pulse and abolished by carotid compression. Left carotid angiography (Fig. 1 left) dem

THE greater (superficial) petrosal nerve and the geniculate ganglion are major anatomic landmarks in the surgical approach to the internal auditory canal through the middle cranial fossa. 1 The dura is elevated from the superior surface of the temporal bone through a craniectomy just above the root of the zygomatic process. The middle meningeal artery may be divided at the foramen spinosum to facilitate reflection of the dura. The greater petrosal nerve is then exposed a few millimeters posterior to the foramen spinosum. This part of the operation is similar to that used by neurosurgeons in their approach through the middle fossa to the gasserian ganglion in operative procedures for relief of trigeminal neuralgia. The otologist needs to remove a portion of the petrous bone over the internal auditory canal, and to locate this area he follows the greater petrosal nerve to the geniculate ganglion. The geniculate ganglion and proximal

A young man with conductive hearing loss, pulsatile tinnitus, and a mass behind the tympanic membrane was found to have a persistent stapedial artery and an aberrant internal carotid within the middle ear cavity. The stapedial artery is a continuation of the primitive hyoid branch of the internal carotid artery which terminates as the middle meningeal artery, but normally regresses in the 24-mm embryo. Radiographic findings of the persistent stapedial artery include absence of the foramen spinosum, a special opening for the stapedial artery in the temporal bone best seen on tomograms, and demonstration of the characteristic course of the artery on carotid angiograms.

To the Editor:— InThe Journal, Sept. 26, page 405, in the article "Emergency Care of Extradural Hematoma," Drs. Craig and Hunt describe a procedure which they recommend for the general surgeon who may have to treat this surgical emergency in the absence of neurosurgical help. After the temporal fossa has been opened and the clot evacuated, bleeding may not be controllable except by packing the foramen spinosum. This maneuver may not be possible for the surgeon untrained in neurosurgery, but the general surgeon can readily find and ligate the external carotid artery in the neck, which serves the same purpose.

The injection of the ganglion of Gasser through the foramen ovale for the relief of trigeminal neuralgia has passed beyond the experimental stage and will eventually supersede surgical extirpation of the ganglion, division of the sensory root, peripheral and nerve trunk injection, and other more or less unsatisfactory procedures. The operation is, of course, a very delicate one and requires, in addition to thorough knowledge of the topography of the parts, some surgical skill and dexterity; the needle will necessarily pass very near to important blood vessels, principally the internal maxillary artery, which lies in close proximity to the inferior maxillary nerve in the sphenomaxillary fossa and sends a small meningeal branch through the foramen ovale. If improperly directed, the needle may enter the foramen spinosum, the jugular foramen, or an anomalous foramen transmitting an emissary vein known as the foramen Civinini, occasionally found