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Ojiambo is diagnosed to have an arteriovenous fistula within cavernous

sinus as a result of fracture of the skull base.
a. Using your anatomy knowledge, list the clinical features seen in this
Patients may present with the following ocular complaints:
 Red eye
 Diplopia
 Bruit (buzzing or swishing sounds)
 Decreased vision
 Bulging eye
 Facial pain in the distribution of the first (and rarely the second) division of the
trigeminal nerve

b. State the anatomical basis of the development of this fistula

 Carotid-cavernous sinus fistulae occur because of traumatic or spontaneous

rents in the walls of the intracavernous internal carotid artery or its branches.
This results in short-circuiting of the arterial blood into the venous system of
the cavernous sinuses. [1]
 Direct carotid-cavernous sinus fistulae, which represent 70-90% of all carotid-
cavernous sinus fistulae in most series, are characterized by a direct
connection between the intracavernous segment of the internal carotid artery
and the cavernous sinus. These fistulae usually have high rates of arterial
blood flow and most commonly are caused by a single traumatic tear in the
arterial wall.
 Dural carotid-cavernous sinus fistulae are characterized by a communication
between the cavernous sinus and one or more meningeal branches of the
internal carotid artery, external carotid artery, or both. These fistulae usually
have low rates of arterial blood flow and almost always produce symptoms
and signs spontaneously, without any antecedent trauma or manipulation.

152. Describe the surgical anatomy of the cerebellopontine angle under the
a. Boundaries, relations and contents

 superior: tentorium cerebelli
 posterior: anterior surface of cerebellum
 inferior: lower cranial nerves
 anterior: prepontine cistern
 anterolateral: posterior surface of petrous temporal bone, including internal
acoustic meatus
 medial: pons
 CN V lies superior to this space
 CN IX, CN X, and CN XI lie inferior
 the middle cerebellar peduncle is inferior

 flocculus of the cerebellum
 foramen Luschka of the 4th ventricle
 anterior inferior cerebellar artery (AICA)

Related pathology
 cerebellopontine angle masses
o acoustic schwannomas (nearly 80% of all CP angle tumours)
o meningiomas
o epidermoid cysts
o dermoid tumours
o arachnoid cysts
o lipomas
o metastatic tumours
o vascular tumours

b. Anatomical basis gradenigo syndrome

This is a complication of otitis media and mastoiditis involving the apex of the
petrous temporal bone.

Gradenigo syndrome consists of the triad of:

 petrous apicitis
 abducens nerve palsy, secondary to involvement of the nerve as it passes
through Dorello canal
 retro-orbital pain, or pain in the cutaneous distribution of the frontal and maxillary
divisions of the trigeminal nerve, due to extension of inflammation into Meckel
 Common pathogens are Pseudomonas and Enterococcus spp.

c. Surgical approaches to CP angle tumors

Translabyrinthine Approach
The microsurgical translabyrinthine approach was described by House in 1964. It
exposes the posterior fossa dura in the retromeatal trigone (Trautmann's triangle)
formed by the sigmoid sinus, the jugular bulb and the superior petrosal sinus. This
approach is usually reserved for patients with moderate-size tumors (1.0 to 2.5 cm in

Translabyrinthine-transtentorial Approach

The combined translabyrinthine-transtentorial approach has been used for the

removal of lesions of the cerebellopontine angle. The surgery is performed through a
small lateral scalp flap centered on the ear with a posterior limb extending down over
the mastoid process.

Middle Fossa Approach

The middle fossa approach involves an extradural subtemporal approach with

microneurosurgical unroofing of the internal auditory canal. This approach is limited
to the excision of small intracanalicular tumors that have not escaped the confines of
the internal auditory canal. It is usually performed in patients in whom hearing
remains at a functional level, providing a chance of hearing preservation

Subtemporal-Transtentorial Approach

The subtemporal-transtentorial approach uses a craniotomy centered low over the

petrous ridge, extending anteriorly over the middle cranial fossa, superiorly to the
parietal boss and posteriorly to a point midway between the mastoid process and the
inion. A U-shaped dural flap based on the transverse sinus is made. The temporal
lobe is retracted anteriorly and the occipital lobe is retracted posteriorly.