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Large lesions extending from the posterior to the middle fossa symptoms kidney bimatoprost 3 ml free shipping, typically petroclival meningiomas symptoms 2016 flu buy cheap bimatoprost 3 ml on-line, can be removed using a combined presigmoid approach and temporal craniotomy with transection of the tentorium (presigmoid transtento rial approach) (Gross et al 2012). The implementation of many of the skull base approaches detailed here has evolved in recent decades, facilitated by the introduction of modern technology (surgical microscope, microinstrumentation, high speed drill) and the pioneer efforts of surgical innovators. The latest of all innovations in skull base surgery has been the introduction of the endoscopic endonasal approach, which uses the nostrils as natural cor ridors to access the ventral aspect of the skull base. The transsphenoidal route, described more than a century ago to access the sella turcica, can now be greatly expanded thanks to the development of endoscopic visualization and specifically designed instrumentation. Accessing the skull base from the endonasal route is ideal for lesions located in the midline skull base because it facilitates a direct approach to the target without any external incision, craniotomy or manipulation of the brain (Kassam et al 2005a, Kassam et al 2005b). The endoscopic endonasal approach has become an excellent alternative choice for tumours such as large pituitary adenomas (Paluzzi et al 2014, Koutourousiou et al 2013a), craniopharyngiomas (Koutourousiou et al 2013b, Fernandez Miranda et al 2012), midline anterior and posterior skull base menin giomas (Koutourousiou et al 2014, FernandezMiranda et al 2014a), chordomas and chondrosarcomas (FernandezMiranda et al 2014b, Koutourousiou et al 2012), given their favourable anatomical location. The main disadvantage of the endonasal approach in comparison to the open approaches is the more difficult skull base reconstruction, currently solved largely with the use of pedicled vascularized flaps har vested locally from the nasal septum. As a result, contemporary skull base surgery selectively uses and occasionally combines transcranial and endonasal approaches to the anterior, middle and posterior skull base for effective treatment. There are two main transcranial approaches to this region: anterior (or bifrontal transbasal) and anterolateral (or frontola teral). The bifrontal transbasal approach consists of a bifrontal crani otomy and provides direct access to the cribriform plate region and planum sphenoidale bilaterally; the approach can be augmented with orbital osteotomies that provide a more basal trajectory and hence minimize brain retraction, and it can also include nasal bone and medial orbital wall osteotomies to enhance access the sinonasal cavity, sphenoid sinus and clival region (FeizErfan et al 2008). The frontolateral approach entails an ipsilateral craniotomy that provides access to the anterior skull base, anterior clinoid process, optic canal and basal cisterns from a lateral to medial trajectory. It can be augmented with an orbital osteotomy to facilitate a more inferior to superior trajectory for lesions that expand in the vertical axis (Jane et al 1982, Delashaw et al 1993). Lesions that are exclusively located in this fossa can be accessed with a temporal craniotomy, which can be supplemented with zygomatic osteotomies to improve the inferior to superior working cor ridor or to facilitate access to the infratemporal fossa by further mobi lization of the temporalis muscle. Lesions, however, often occupy anterior and middle cranial fossas, for which a frontotemporal or pte rional craniotomy with optional orbitozygomatic osteotomies is typi cally required. Kawase T, Toya S, Shiobara R et al 1985 Transpetrosal approach for aneur ysms of the lower basilar artery. Even a minor visual difference can result in a reduced level of perceived attractiveness in general society and is associated with several negative factors concerning appearance, symmetry and facial expression. This, in turn, adversely affects the quality of life of a person and has been shown to trouble patients with cleft lip and palate ­ the most common craniofacial deformity, which is present in 1 in 700 live births (Mossey et al 2009). This can cause emotional distress in childhood and adolescence due to teasing from peers, and subsequent unhappiness with facial appearance into adulthood, despite optimal surgical correction (Marcusson 2001). Embryologically, all tissues of the head and face of vertebrates are derived from the three primary germ layers (endoderm, mesoderm, ectoderm) and a fourth layer, the neural crest. Through migration and proliferation of neural crest cells in the branchial arches at the fourth week of gestation, five facial primordia develop around the primitive mouth or stomatodeum. They include: a single frontonasal prominence (forming forehead, middle of the nose, philtrum and primary palate) and paired mandibular and maxillary prominences (lower jaw, middle and lower face, lateral border of lips and secondary palate) (Baynam et al 2013). The proportions and position of various facial features continue to develop slowly from week eight until birth, with the rapidly enlarging brain causing the ears to rise, the eyes to move medially and the forehead to become more apparent. While human facial anatomy can be thought of as largely similar, with features such as eyes, nose and mouth approximately in the same location, there are enough minor differences in proportions, size and position both between and within different ethnicities to make us all unique individuals. When considering more local features such as inner and outer canthi, columella or philtrum, there can be considerable differences in addition to the effects of congenital malformations or acquired deformities due to trauma and surgical repair. The human face is a complex three-dimensional (3D) structure and capturing an image in its entirety with true-to-life precision is likely to be challenging for both human and machine. A systematic review of methods of facial aesthetic assessment in a specific patient population and a rating system for outcome comparison have been described previously (Sharma et al 2012). Traditionally, direct facial measurements have been taken using manual anthropometry utilizing rulers, tape measures and callipers, as pioneered by Leslie Farkas, the father of modern craniofacial anthropometry (Farkas 1994). Although low-cost and straightforward, this method requires a high degree of cooperation from the subject and is very labour-intensive if used to assess hundreds of individuals to obtain representative normative data. Digital photography, by contrast, provides a rapid and permanent image that can be rapidly processed and archived on to computer databases. Drawbacks of using a twodimensional (2D) modality to derive accurate facial measurements include differential positioning of subjects despite a standardization protocol and perspective projection distortion, where a 3D object is unavoidably misrepresented by an attempted projection on to a 2D plane. Capturing a face in three dimensions is mainly achieved by laser scanning or stereo photogrammetric devices that can capture many thousands of points in an instant. Three-dimensional photogrammetry is a software-driven approach utilizing multiple digital cameras set at different angles to acquire the facial image rapidly, in little over a millisecond. Time-of-flight technology, which measures the time taken for emitted light from an illumination unit to reach an object and travel back to a detector, has been used by a range of scanners to make very precise measurements of distance. This technology uses either optical shutter technology or modulated light of various wavelengths to create a 3D image of the actual face and head (Zhang and Lu 2013). It allows human faces to be recognized and tracked in real time in a manner that is both rapid and efficient from a computational standpoint. Furthermore, it is not affected by differences in facial orientation, illumination or features that might obscure part of the face (Meers and Ward 2009). The nasal tip is the optimal facial landmark to use, as it is easily detected by an observer, has a central position on the face and is not usually obscured by hair or spectacles (Gorodnichy 2002). However, there are currently no clinical validation studies for facial assessment using time-of-flight 3D cameras. Gross anatomical landmarks on the face are captured by a series of relatively simple measurements. Delineation of finer features that will allow a detailed surface-based analysis of facial shape, however, requires a significantly larger number of densely arranged surface points corresponding to quasi-landmarks. Tens of thousands of these points can be derived from as few as 22 facial landmarks.

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The posterior auricular artery ascends between the parotid gland and the styloid process to the groove between the auricular cartilage and mastoid process medications made from plasma discount bimatoprost 3 ml fast delivery. The superior auricular artery has a constant course and connects the superior temporal artery and the posterior auricular arterial network; this branch can provide a reliable vascular pedicle for retro-auricular flaps (Moschella et al 2003) symptoms 24 hours before death buy 3 ml bimatoprost with amex. The auricle is also supplied by anterior auricular branches of the superficial temporal artery, which are distributed to its lateral surface, and by a branch from the occipital artery. Arteriovenous anastomoses are numerous in the skin of the auricle and are thought to be important in the regulation of core temperature. Lymphatic drainage the posterior aspect of the pinna drains to nodes at the mastoid tip. The tragus and upper part of the pinna drain Relations of the meatus the condylar process of the mandible lies anterior to the meatus and is partially separated from the cartilaginous part by a small portion of the parotid gland. The middle cranial fossa lies above the osseous meatus and the mastoid air cells are posterior to it, separated from the meatus only by a thin layer of bone. This is perhaps because the external ear represents an area where skin originally derived from a branchial region meets skin originally derived from a postbranchial region. The sensory nerves involved are the great auricular nerve, which supplies most of the cranial surface and the posterior part of the lateral surface (helix, antihelix, lobule); the lesser occipital nerve, which supplies the upper part of the cranial surface; the auricular branch of the vagus, which supplies the concavity of the concha and posterior part of the eminentia; the auriculotemporal nerve, which supplies the tragus, crus of the helix and the adjacent part of the helix; and the facial nerve, which, together with the auricular branch of the vagus, probably supplies small areas on both aspects of the auricle, in the depression of the concha and over its eminence. The details of the cutaneous innervation derived from the facial nerve require further clarification. It is possible that, as the auricular branch of the vagus traverses the temporal bone and crosses the facial canal, approximately 4 mm above the stylomastoid foramen, it contributes an ascending branch to the facial nerve and that, in this way, fibres of the vagus are carried via the facial nerve to the pinna. B, A more detailed view of the relationships of structures in the middle and inner ear. Associated veins drain into the external jugular and maxillary veins and the pterygoid plexus. Provided the external acoustic meatus is wide enough, the tympanic membrane can be elevated by incising the skin of the bony meatus circumferentially, leaving a vascular pedicle superiorly. The canal skin is then elevated from the underlying bone until the fibrous anulus of the tympanic membrane is visualized. This can then be elevated from the tympanic groove and the middle ear mucosa can be incised to allow the tympanic membrane to be reflected forwards and upwards. The periosteum is incised and elevated to expose the bony external acoustic meatus from behind. The skin over the junction of the bony and cartilaginous meatus is incised to allow the cartilage of the auricle and meatus to be swung forwards on its blood supply and so expose the bony meatus and mastoid process. Access can then be gained by drilling and elevating a tympanomeatal skin flap, as described for the endaural approach. Temporalis fascia is the most popular tissue used as a free graft for repair of the tympanic membrane because it is easily obtainable. In recent years, tragal perichondrium has become a popular alternative; it has the additional advantage that the cartilage can also be harvested and used to reinforce the repair. More extensive resections of the temporal bone are undertaken using extended pre- or postauricular incisions into the temporal region and neck. The blood supply of the pinna is sufficient to maintain viability despite significant elevation and undermining. If the external acoustic meatus is too narrow to allow adequate visualization of the middle ear, or if access is required to the mastoid aditus and antrum, it is necessary to displace the superficial soft tissues. There are two main external approaches to the middle ear: the endaural approach and the postauricular approach. The endaural approach involves making an incision in the notch between the tragus and the helix. This is carried down to expose the lower margin of temporalis muscle and the bone of the external acoustic meatus. The cartilaginous meatus is separated from the bony meatus and reflected laterally as a conchomeatal flap. This gives more space to manipulate the delicate structures of the middle ear, as well as improving subsequent visualization of the tympanic membrane when the incision has healed. The middle ear contains three small bones ­ the malleus, incus and stapes, collectively called the auditory ossicles ­ which form an articulated chain connecting the lateral and medial walls of the cavity, and which transmit the vibrations of the tympanic membrane across the cavity to the cochlea. The essential function of the middle ear is to transfer energy efficiently from relatively weak vibrations in the elastic, compressible air in the external acoustic meatus to the incompressible fluid around the delicate receptors in the cochlea. The tympanic cavity and mastoid antrum, auditory ossicles and structures of the internal ear are all almost fully developed at birth and subsequently alter little; almost all of the volume changes are due to expansion of the epitympanic space (Osborn et al 2011). In the fetus, the cavity contains a gelatinous tissue that has practically disappeared by birth, when it is filled by a fluid that is absorbed when air enters via the pharyngotympanic tube. It is prolonged posteriorly as the roof of the mastoid antrum and anteriorly it covers the canal for tensor tympani. In youth, the unossified petrosquamosal suture may allow the spread of infection from the tympanic cavity to the meninges. In adults, veins from the tympanic cavity traverse this suture to reach the superior petrosal or petrosquamous sinus and thus may also transmit infection to these structures through a process of thrombophlebitis. Longitudinal fractures of the middle cranial fossa almost always involve the tympanic roof, accompanied by dislocation of the ossicular chain, rupture of the tympanic membrane, or a fractured roof of the osseous external acoustic meatus, which can be seen as a notch on otoscopy. Floor the floor of the tympanic cavity is a narrow, thin, convex plate of bone that separates the cavity from the superior bulb of the internal jugular vein.

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The sympathetic trunks descend in contact with bone medications not covered by medicaid discount bimatoprost 3 ml buy, medial to the foramina treatment yeast diaper rash order bimatoprost 3 ml overnight delivery, as do the median sacral vessels in the midline. Ventral surfaces of the first, second and part of the third sacral bodies are covered by parietal peritoneum and crossed obliquely, left of the midline, by the attachment of the sigmoid mesocolon. The rectum is in contact with the pelvic surfaces of the third to fifth sacral vertebrae and with the bifurcation of the superior rectal artery between the rectum and third sacral vertebra. Key: 1, upper border of body of S1 (sacral promontory); 2, superior articular process of S1; 3, attachment of iliacus; 4, attachment of piriformis; 5, attachment of coccygeus; 6, coccyx; 7, ala; 8, incompletely fused S1­2 intervertebral joint; 9, first pelvic sacral foramen. Key: 1, body of S1; 2, posterosuperior ala (transverse process element); 3, superior articular process; 4, sacral canal; 5, spinous process of S1; 6, anterosuperior ala (costal element); 7, lamina. Key: 1, superior articular facet of S1; 2, ala; 3, first dorsal sacral foramen; 4, attachments of interosseous sacroiliac ligaments; 5, lateral crest and transverse tubercles; 6, median crest and spinous processes; 7, attachment of gluteus maximus; 8, sacral hiatus; 9, cornua; 10, intermediate crest and articular tubercle (inferior articular process); 11, posterior surface of body of S1 forming anterior wall of sacral canal; 12, area of attachment of multifidus (bounded by thin line); 13, attachment of erector spinae aponeurosis (thick line). Bones Below the fourth (or third) tubercle there is an arched sacral hiatus in the posterior wall of the sacral canal. This hiatus is produced by the failure of the laminae of the fifth sacral vertebra to meet in the median plane, and as a result the posterior surface of the body of that vertebra is exposed on the dorsal surface of the sacrum. Flanking the median crest, the posterior surface is formed by fused laminae, and lateral to this are four pairs of dorsal sacral foramina. Like the pelvic foramina, they lead into the sacral canal through intervertebral foramina, and each transmits the dorsal ramus of a sacral spinal nerve. Medial to the foramina, and vertically below each articular process of the first sacral vertebra, is a row of four small tubercles, which collectively constitute the intermediate sacral crest. These are sometimes termed articular tubercles, and represent fused contiguous articular processes. The inferior articular processes of the fifth sacral vertebra are free and project downwards at the sides of the sacral hiatus as sacral cornua, connected to coccygeal cornua by intercornual ligaments. The interrupted roughened crest to the lateral side of the dorsal sacral foramina is the lateral sacral crest, which is formed by fused transverse processes, whose apices appear as a row of transverse tubercles. The upper three sacral spinal dorsal rami pierce multifidus as they emerge via dorsal foramina. Thereafter, the upper and lower surfaces of each sacral body are covered by an epiphysial plate of hyaline cartilage, which is separated from its neighbour by the fibrocartilaginous precursor of an intervertebral disc. Laterally, successive conjoined vertebral arches and costal elements are separated by hyaline cartilage; a cartilaginous epiphysis, sometimes divided into upper and lower parts, develops on each auricular and adjacent lateral surface. Soon after puberty, the fused vertebral arches and costal elements of adjacent vertebrae begin to coalesce from below upwards. At the same time, individual epiphysial centres develop for the upper and lower surfaces of bodies, spinous tubercles, transverse tubercles and costal elements. The costal epiphysial centres appear at the lateral extremities of the hyaline cartilages between adjacent costal elements; two anterior and two posterior centres appear in each of the intervals between the first, second and third sacral vertebrae. One costal epiphysial centre, placed anteriorly, occurs in each remaining interval and from them ossification spreads to the epiphysial plate covering the lower part of the lateral surface of the sacrum. Sacral bodies unite at their adjacent margins after the twentieth year, but the central and greater part of each intervertebral disc remains unossified up to or beyond middle life. The broad upper part bears an auricular surface for articulation with the ilium, and the area posterior to this is rough and deeply pitted by the attachment of ligaments. The shorter, cranial limb is restricted to the first sacral vertebra; the caudal limb descends to the middle of the third. Caudally, it curves medially to the body of the fifth sacral vertebra at the inferior lateral angle, beyond which the surface becomes a thin lateral border. A variable accessory sacral articular facet sometimes occurs, posterior to the auricular surface. The auricular surface is covered by hyaline cartilage, and formed entirely by costal elements. It shows cranial and caudal elevations and an intermediate depression, behind which a third elevation is visible in the elderly. The rough area behind the auricular surface shows two or three marked depressions for the attachment of strong interosseous sacroiliac ligaments. Below the auricular surface the sacrotuberous and sacrospinous ligaments are attached between gluteus maximus dorsally and coccygeus ventrally. VariantsThe sacrum may contain six vertebrae, by development of an additional sacral element or by incorporation of the fifth lumbar or first coccygeal vertebra. Inclusion of the fifth lumbar vertebra (sacralization) is usually incomplete and limited to one side. In the most minor degree of the abnormality, a fifth lumbar transverse process is large and articulates, sometimes by a synovial joint, with the sacrum at the posterolateral angle of its base. Reduction of sacral constituents is less common but lumbarization of the first sacral vertebra does occur; it remains partially or completely separate. The bodies of the first two sacral vertebrae may remain unfused when the lateral masses are fused. The dorsal wall of the sacral canal may be variably deficient, due to imperfect development of laminae and spines. Orientation of the superior sacral articular facets displays wide variation, as does the sagittal curvature of the sacrum. Asymmetry (facet tropism) of the superior facets alters the relation between the planes of the two lumbosacral facet joints. Apex the apex is the inferior aspect of the fifth sacral vertebral body, and bears an oval facet for articulation with the coccyx. The inclination of the sacrum means that it is directed cranially in the standing position. Each lateral wall presents four intervertebral foramina, through which the canal is continuous with pelvic and dorsal sacral foramina. The canal contains the cauda equina and the filum terminale, and the spinal meninges.

Syndromes

• Anxiety
• Painful urination
• Depression
• Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are used most often.
• Gastroschisis
• Infection (a slight risk any time the skin is broken)
• Spread of the tumor into surrounding areas  
• Decreased amount of urine
• Osteomalacia
• Pain in the lower belly or pelvic area

The upper eyelid is larger and more mobile than the lower eyelid and contains an elevator muscle medications that cause weight loss 3 ml bimatoprost order overnight delivery, levator palpebrae superioris (see above) medications for adhd buy bimatoprost 3 ml low price. A transverse opening, the palpebral fissure, lies between the free margins of the lids, which join at their extremities (termed the medial and lateral canthus). The medial canthus is approximately 2 mm lower than the lateral canthus; this distance is increased in some Asiatic groups. It is separated from the eyeball by a small triangular space, the lacrimal lake (lacus lacrimalis), in which a small, reddish body called the lacrimal caruncle is situated. The caruncle represents an area of modified skin containing some fine hairs and is mounted on the plica semilunaris, a fold of conjunctiva that is believed by some to be a vestige of the nictitating membrane of other animals. A small elevation, the lacrimal papilla, is located on each palpebral margin approximately one-sixth of the way along from the medial canthus of the eye. There is a small aperture, the punctum lacrimale, in the centre of the papilla that forms the opening to the lacrimal drainage system. The skin is extremely thin and is continuous at the palpebral margins with the conjunctiva. The subcutaneous connective tissue is very delicate, seldom contains any adipose tissue, and lacks elastic fibres. The palpebral part of orbicularis oculi is subdivided anatomically into ciliary, pretarsal and preseptal parts. The palpebral fibre bundles are thin and pale, and lie parallel with the palpebral margins. Deep to them is the submuscular connective tissue, a loose fibrous layer that is continuous in the upper lid with the subaponeurotic layer of the scalp; effusions of blood or pus at this level can therefore pass down from the scalp into the upper eyelid. The main nerves lie in the submuscular layer, which means that local anaesthetics should be injected deep to orbicularis oculi. Each is convex and conforms to the configuration of the anterior surface of the eye. The superior tarsus, the larger of the two, is semi-oval, approximately 10 mm in height centrally. The smaller inferior tarsus is narrower and approximately 4 mm in vertical height. Key: 1, pupil; 2, plica semilunaris; 3, lacrimal caruncle; 4, medial canthus; 5, conjunctiva; 6, upper eyelid; 7, eyelashes; 8, lateral canthus; 9, lid margin; 10, iris; 11, lower eyelid. At birth, the upper eyelid is at its lowest position and the margin of the lower eyelid is close to the centre of the pupil. Between the ages of 3 and 6 months, the upper eyelid reaches its maximum height and then declines in a linear fashion. The distance between the centre of the pupil and the margin of the lower eyelid increases linearly until the age of 18 months, when it stabilizes in position. The most common pattern of the lower eyelid crease is a single crease at birth and a double crease by the age of about 3 years. Ageing mainly affects the size of the horizontal eyelid fissure, which lengthens by about 10% between the ages of 12 and 25, and shortens by almost the same amount between middle age and old age. The peak level of growth in the horizontal dimension of the palpebral fissure is reached between the ages of 17 and 19 years, in the vertical dimension between 10 and 13 years, and in the intercanthal distance between 14 and 16 years in Asian children (Park et al 2008). It splits at its insertion into the tarsal plates to surround the lacrimal canaliculi, and lies in front of the nasolacrimal sac and the orbital septum. It passes from the lateral ends of the tarsal plates to a small tubercle on the zygomatic bone within the orbital margin and is more deeply situated than the medial palpebral ligament. It lies beneath the orbital septum and the lateral palpebral raphe of orbicularis oculi. The deepest fibres of the aponeurosis of levator palpebrae superioris are attached to the anterior surface of the superior tarsus. The superior and inferior tarsal plates are also associated with a thin lamina of smooth muscle forming the superior and inferior tarsal muscles, respectively. The muscle is innervated by the sympathetic nervous system and, on contraction, elevates the eyelid. Although it may be regarded as supplementing the action of the levator muscle, its full role is not clear. A corresponding but less prominent inferior tarsal muscle in the lower eyelid unites the inferior border, and possibly also the anterior surface, of the inferior tarsus to the capsulopalpebral fascia, which is the anterior expansion of the fused fascial sheath of inferior rectus and inferior oblique. Contraction of inferior rectus during downward gaze therefore also pulls the lower lid downwards. The lower lid is capable of depressing by 4­5 mm, although it is not equipped with a striated muscle counterpart to the levator of the upper lid. Palpebral glands Tarsal (Meibomian) glands are modified sebaceous glands embedded in the tarsi. They are yellow and arranged in approximately 25 parallel rows perpendicular to the eyelid margin in the upper lid, and slightly fewer in the lower lid. They occupy the full tarsal height and are therefore longer centrally where the tarsi are higher. Each gland consists of a straight tube with many lateral secretory diverticula, and opens by a minute orifice on the free palpebral margin. It is enclosed by a basement membrane, and is lined at its orifice by stratified epithelium and elsewhere by a single layer of polyhedral cells. The sebaceous secretion of the tarsal glands spreads over the margins of the eyelids, and so an oily layer is drawn over the tear film as the palpebral fissure opens after a blink, reducing evaporation and contributing to tear film stability. The presence of the oily, hydrophobic secretions of tarsal glands along the margins of the eyelids also inhibits the spillage of tears on to the face. Obstruction of the tarsal gland ducts by lipid and cellular debris may result in lipogranulomatous inflammation and the clinical manifestations of an internal hordeolum or chalazion. Their branches course laterally along the tarsal edges to form superior and inferior arcades (two in the upper eyelid and one in the lower).

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It is predominantly acellular medicine upset stomach purchase bimatoprost 3 ml free shipping, and consists mainly of densely packed fascicles of collagen fibres arranged in laminae medications zovirax cheap 3 ml bimatoprost mastercard. The fascicles run in different directions in adjacent laminae, producing a lattice-like appearance that is particularly obvious in the tentorium cerebelli and around the defects or perforations that sometimes occur in the anterior portion of the falx cerebri. The cranial dura, which lines the cranial cavity, differs from the spinal dura mainly in its relationship to the surrounding bones. As a the falx cerebelli is a small midline fold of dura mater that lies below the tentorium cerebelli and projects forwards into the posterior cerebellar notch between the cerebellar hemispheres. Its base is directed upwards and is attached to the posterior part of the inferior surface of the tentorium cerebelli in the midline. Its posterior margin contains the occipital sinus and is attached to the internal occipital crest. The lower apex of the falx cerebelli frequently divides into two small folds, which disappear at the sides of the foramen magnum. Diaphragma sellae 432 the diaphragma sellae is a small, circular, horizontal sheet of dura mater. The infundibulum (also known as pituitary stalk) passes into the pituitary fossa through a central opening in the diaphragma. A trans-sphenoidal approach is currently the preferred option for accessing pituitary tumours, irrespective of whether there is suprasellar extension beyond the diaphragma sellae. It lies between the cerebellum and the occipital lobes of the cerebral hemispheres, and divides the cranial cavity into supratentorial and infratentorial compartments, which contain the forebrain and hindbrain, respectively. Its concave anterior edge is free and separated from the dorsum sellae of the sphenoid bone by a large curved hiatus, the tentorial incisure or notch, which is filled by the midbrain and the anterior part of the superior aspect of the cerebellar vermis. The convex outer limit of the tentorium is attached posteriorly to the lips of the transverse sulci of the occipital bone and to the posterior inferior angles of the parietal bones, where it encloses the transverse sinuses. Laterally, it is attached to the superior borders of the petrous parts of the temporal bones, where it contains the superior petrosal sinuses. The cave is entered by the posterior root of the trigeminal nerve and contains cerebrospinal fluid and the trigeminal ganglion; the evaginated meningeal layer fuses in front with the anterior part of the ganglion. The arrangement of the dura mater in the central part of the middle cranial fossa is complex. On both sides, the rim of the tentorial incisure is attached to the apex of the petrous temporal bone and continues forwards as a ridge of dura, known as the anterior petroclinoidal ligament, to attach to the anterior clinoid process. This ligament marks the junction of the roof and the lateral wall of the cavernous sinus. The periphery of the tentorium cerebelli (attached to the superior border of the petrous temporal bone), crosses under the free border of the tentorial incisure at the apex of the petrous temporal bone, and continues forwards to the posterior clinoid process as a rounded ridge of the dura mater known as the posterior petroclinoidal ligament. The dural extension between the anterior and posterior petroclinoidal ligaments forms the roof of the cavernous sinus. On either side, it is pierced superiorly by the oculomotor nerve and behind by the trochlear nerve, which proceed anteroinferiorly into the lateral wall of the cavernous sinus. In the anteromedial part of the middle cranial fossa, the dura ascends as the lateral wall of the cavernous sinus, reaches the ridge produced by the anterior petroclinoidal ligament, and runs medially as the roof of the cavernous sinus, where it is pierced by the internal carotid artery. The interclinoidal ligament, between the anterior and posterior clinoid processes, forms the medial limit of the roof of the cavernous sinus and continues medially with the diaphragma sellae. At, or just below, the opening in the diaphragma for the pituitary stalk, the dura of the diaphragma and the suprasellar arachnoid blend with each other and with the capsule of the pituitary gland; the subarachnoid space does not extend into the sella turcica. However, when there is focal brain swelling or a focal space-occupying lesion within the brain or cranial cavity, mass effect and raised intracranial pressure may cause the brain to herniate under the falx cerebri or, more significantly, through the tentorial incisure. In this case, the medial temporal lobe, and particularly the uncus, will compress the oculomotor nerve, midbrain and the posterior cerebral arteries. This life-threatening event and neurosurgical emergency, occurring in patients with supratentorial space-occupying lesions, is known as transtentorial uncal herniation. Less wellestablished meningeal branches have been described arising from the vagus and hypoglossal nerves, and possibly from the facial and glossopharyngeal nerves. In the anterior cranial fossa, the dura is innervated by meningeal branches of the anterior and posterior ethmoidal nerves and anterior filaments of the meningeal rami of the maxillary (nervus meningeus medius) and mandibular (nervus spinosus) divisions of the trigeminal nerve. Nervi meningeus medius and spinosus are, however, largely distributed to the dura of the middle cranial fossa, which also receives filaments from the trigeminal ganglion. The nervus spinosus re-enters the cranium through the foramen spinosum with the middle meningeal artery, and divides into anterior and posterior branches that accompany the main divisions of the artery and supply the dura mater in the middle cranial fossa and, to a lesser extent, the anterior fossa and calvarium. The nervus spinosus contains sympathetic postganglionic fibres from the middle meningeal plexus. The nervus tentorii, a recurrent branch of the intracranial portion of the ophthalmic division of the trigeminal, supplies the supratentorial falx cerebri and the tentorium cerebelli. Intraoperative mechanical stimulation of the falx may trigger the trigeminocardiac reflex (Bauer et al 2005). The dura in the posterior cranial fossa is innervated by ascending meningeal branches of the upper cervical nerves, which enter through the anterior part of the foramen magnum (second and third cervical nerves) and through the hypoglossal canal and jugular foramen (first and second cervical nerves). Meningeal branches from the vagus apparently start from the superior vagal ganglion and are distributed to the dura mater in the posterior cranial fossa. Those from the hypoglossal leave the nerve in its canal and supply the diploë of the occipital bone, the dural walls of the occipital and inferior petrosal sinuses, and much of the floor and anterior wall of the posterior cranial fossa. These meningeal rami may not contain vagal or hypoglossal fibres but ascending, mixed sensory and sympathetic fibres from the upper cervical nerves and superior cervical sympathetic ganglion. All meningeal nerves contain a postganglionic sympathetic component, either from the superior cervical sympathetic ganglion or by communication with its perivascular intracranial extensions. Sensory nerve endings are restricted to the dura mater and cerebral blood vessels, and are not found in either the brain itself, or in the arachnoid or pia mater. Stimulation of these nerve endings causes pain, as evidenced during awake craniotomy procedures, and is the basis of certain forms of headache. The density of dural innervation, particularly around the dural venous sinuses, increases during the later part of ges- tation, peaking at term and subsequently decreasing during the first year of postnatal life (Davidson et al 2012).

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