An anatomical-angiographic classification for carotid-cavernous sinus fistulas is introduced and a series of 14 patients with spontaneous carotid-cavernous sinus fistulas is reviewed to illustrate the usefulness of such a classification for patient evaluation and treatment. Fistulas are divided into four types: Type A are direct high-flow shunts between the internal carotid artery and the cavernous sinus; Type B are dural shunts between meningeal branches of the internal carotid artery and the cavernous sinus; Type C are dural shunts between meningeal branches of the external carotid artery and the cavernous sinus; and Type D are dural shunts between meningeal branches of both the internal and external carotid arteries and the cavernous sinus. The anatomy, clinical manifestations, angiographic evaluation, indications for therapy, and therapeutic options for spontaneous carotid-cavernous sinus fistulas are discussed.

Intracranial aneurysms are an unusual complication of sickle-cell anemia; only 15 patients have been described in the world literature. An additional 15 patients with sickle-cell anemia and subarachnoid hemorrhage (SAH) from ruptured intracranial aneurysms are presented. There was a high incidence of multiple aneurysms (60%); some of which were in unusual locations. The clinical and pathological features of this series of patients have provided a paradigm for acquired aneurysm formation that may be applicable to other intracranial aneurysms. Thirteen patients underwent craniotomy and clip ligation; the perioperative management of these patients is discussed. Of these 13, eight had a good recovery, three were left with moderate disability, one patient died of surgical complications, and one died of complications related to sickle-cell anemia. Two of the 15 patients died of SAH. The authors propose that endothelial injury from the abnormal adherence of sickle erythrocytes to the endothelium is the initiating event in arterial wall injury. Subsequently, there is fragmentation of the internal elastic lamina and degeneration of the smooth-muscle layer. Hemodynamic stress at these loci of arterial wall damage results in aneurysm formation. This hypothesis also explains other cerebrovascular manifestations of sickle-cell anemia, namely vaso-occlusive disease and hemorrhage without aneurysm formation. Pathological material from this series and data from the literature are presented to support this hypothesis.

Transcranial stab wounds are uncommon. Three such cases are presented. The severity of the wounds may vary from innocuous to devastating. Skull films are useful in delineating the depth of penetration. The presence of the knife blade in situ may make the computed tomographic scan impossible to perform or difficult to interpret. Cerebral angiography may be indicated if injury to a major cerebral vessel is suspected or if the patient suffers a delayed subarachnoid or intracerebral hemorrhage. Provided that the patient's clinical status indicates a positive prognosis, transcranial stab wounds should be explored surgically. The weapon should be removed in the operating room immediately before or at the time of operation.

A case of diffuse idiopathic skeletal hyperostosis presenting as acute thoracic myelopathy is reported. Diffuse idiopathic skeletal hyperostosis has long been regarded as a radiological entity with an innocuous clinical course. The manifestations of this disease are reviewed. There is mounting evidence that it is neither a clinically infrequent nor, as this case report illustrates, an exclusively benign condition.