Historical epidemiology of hepatitis C virus in select countries-volume 4.

Due to the introduction of newer, more efficacious treatment options, there is a pressing need for policy makers and public health officials to develop or adapt national hepatitis C virus (HCV) control strategies to the changing epidemiological landscape. To do so, detailed, country-specific data are needed to characterize the burden of chronic HCV infection. In this study of 17 countries, a literature review of published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates was conducted, and inputs were validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Hong Kong to 2.4% in Taiwan, while the largest viraemic populations were in Nigeria (2 597 000 cases) and Taiwan (569 000 cases). Diagnosis, treatment and liver transplant rates varied widely across the countries included in this analysis, as did the availability of reliable data. Addressing data gaps will be critical for the development of future strategies to manage and minimize the disease burden of hepatitis C.

Strategies to manage hepatitis C virus infection disease burden-Volume 4.

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 17 countries in Africa, Asia, Europe, Latin America and the Middle East, and interventions for achieving the Global Health Sector Strategy on viral hepatitis targets-"WHO Targets" (65% reduction in HCV-related deaths, 90% reduction in new infections and 90% of infections diagnosed by 2030) were considered. Scaling up treatment and diagnosis rates over time would be required to achieve these targets in all but one country, even with the introduction of high SVR therapies. The scenarios developed to achieve the WHO Targets in all countries studied assumed the implementation of national policies to prevent new infections and to diagnose current infections through screening.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm: Volume 4.

Factors influencing the morbidity and mortality associated with viremic hepatitis C virus (HCV) infection change over time and place, making it difficult to compare reported estimates. Models were developed for 17 countries (Bahrain, Bulgaria, Cameroon, Colombia, Croatia, Dominican Republic, Ethiopia, Ghana, Hong Kong, Jordan, Kazakhstan, Malaysia, Morocco, Nigeria, Qatar and Taiwan) to quantify and characterize the viremic population as well as forecast the changes in the infected population and the corresponding disease burden from 2015 to 2030. Model inputs were agreed upon through expert consensus, and a standardized methodology was followed to allow for comparison across countries. The viremic prevalence is expected to remain constant or decline in all but four countries (Ethiopia, Ghana, Jordan and Oman); however, HCV-related morbidity and mortality will increase in all countries except Qatar and Taiwan. In Qatar, the high-treatment rate will contribute to a reduction in total cases and HCV-related morbidity by 2030. In the remaining countries, however, the current treatment paradigm will be insufficient to achieve large reductions in HCV-related morbidity and mortality.

Fibulin Levels in Autosomal Dominant Polycystic Kidney Disease and Its Relationship to Arterial Stiffness.

BACKGROUND: The objective of the present study was to evaluate fibulin 1 levels in different stages of patients with autosomal dominant polycystic kidney disease (ADPKD) and investigate possible connections between fibulin-1 and arterial stiffness. METHODS: For this cross-sectional study, we included 74 patients with ADPKD (mean age, 50.92 ± 15.70 years) and 32 healthy controls (mean age, 49.53 ± 7.32 years). Patients with ADPKD were classified based on CKD epidemiology collaboration (CKD-EPI) equation assessments of estimated glomerular filtration rate (eGFR). Blood levels of fibulin 1 and creatinine levels were analyzed. We measured brachial artery PWV (baPWV), augmentation index (AIx), and pulse pressure (PP) for the assessment of arterial stiffness and systolic and diastolic blood pressures (SBP and DBP, respectively). RESULTS: Fibulin 1 was significantly higher in the patient group (p < 0.001). SBP, DBP, MAP, PP, and baPWV levels were also significantly higher in the patient group. A statistically significant positive correlation was found between fibulin 1 and creatinine (r = 0.377, p = 0.001). No significant correlation was found between the fibulin 1 levels and age, SBP, DBP, MAP, baPWV, and AIx. CONCLUSIONS: Plasma concentrations of fibulin 1 increased in patients with ADPKD. Arterial stiffness measured by baPWV increased in patients with ADPKD, but it was not related to fibulin 1 levels.

A case report of metastasis of malignant mesothelioma to the retromolar trigone.

BACKGROUND: Malignant mesothelioma is a rare and aggressive tumor with a poor prognosis. Distant metastases are very rare, and the oral cavity metastases are exceedingly rare. Only a few cases with metastasis to oral gingiva are reported. To our knowledge, this is the first case report of pleural mesothelioma metastasized to the retromolar trigone. CASE PRESENTATION: A 59-year-old male was referred with a painless growth at retromolar trigone area. It had been present for 2 months and had increased in size during this period of time. Past medical history revealed a malignant mesothelioma. Intraoral examination showed a soft, haemorrhagic, ulcerated lesion at the right retromolar trigone area. There was no destruction of the bony architecture. An incisional biopsy was performed under local anaesthesia. Based on the histopathological and immunohistochemical findings, a final diagnosis of metastatic mesothelioma was made. The patient was informed about the possibility of multiple metastases within the body, but he succumbed after 45 days following deterioration of his medical condition. CONCLUSIONS: Biopsy, history of the patient and clinical picture were provided to the clinicians to make an efficient differential diagnosis. Differential diagnosis must be performed with other oral cancers, because the management is totally different.

Volume and landmark analysis: comparison of MRI measurements obtained with an endorectal coil and with a phased-array coil.

AIM: To compare prostate volumes and distances between anatomical landmarks on MRI images obtained with a phased-array coil (PAC) only and with a PAC and an endorectal coil (ERC). MATERIALS AND METHODS: Informed consent was waived for this Health Insurance Portability and Accountability Act-compliant study. Fifty-nine men underwent PAC-MRI and ERC-MRI at 1.5 (n = 3) or 3 T (n = 56). On MRI images, two radiologists independently measured prostate volume and distances between the anterior rectal wall (ARW) and symphysis pubis at the level of the verumontanum; ARW and symphysis pubis at the level of the mid-symphysis pubis; and bladder neck and mid-symphysis pubis. Differences between measurements from PAC-MRI and ERC-MRI were assessed with the Wilcoxon RANK SUM test. Inter-reader agreement was assessed using the concordance correlation coefficient (CCC). RESULTS: Differences in prostate volume between PAC-MRI and ERC-MRI [median: -0.75 mm(3) (p = 0.10) and median: -0.84 mm(3) (p = 0.06) for readers 1 and 2, respectively] were not significant. For readers 1 and 2, median differences between distances were as follows: -10.20 and -12.75 mm, respectively, ARW to symphysis pubis at the level of the verumontanum; -6.60 and -6.08 mm, respectively, ARW to symphysis pubis at the level of the mid-symphysis pubis; -3 and -3 mm respectively, bladder neck to mid-symphysis pubis. All differences in distance were significant for both readers (p ≤ 0.0005). Distances were larger on PAC-MRI (p ≤ 0.0005). Inter-reader agreement regarding prostate volume was almost perfect on PAC-MRI (CCC: 0.99; 95% CI: 0.98-1.00) and ERC-MRI (CCC: 0.99; 95% CI: 0.99-1.00); inter-reader agreement for distance measurements varied (CCCs: 0.54-0.86). CONCLUSION: Measurements of distances between anatomical landmarks differed significantly between ERC-MRI and PAC-MRI, although prostate volume measurements did not.

The feasibility of epidemiological research on prostate cancer in African men in Ibadan, Nigeria.

BACKGROUND: Men of African descent have the highest incidence and mortality rates of prostate cancer (PrCa) worldwide. Notably, PrCa is increasing in Africa with Nigerian men being mostly affected. Thus, it is important to understand risk factors for PrCa in Nigeria and build capacity for cancer research. The goals of this study were to determine the feasibility of conducting an epidemiological study of PrCa and to obtain preliminary data on risk factors for PrCa in Nigeria. METHODS: A case-control study (50 cases/50 controls) was conducted at the University College Hospital (UCH) in Ibadan, Nigeria, between October 2011 and December 2012. Men aged 40 to 80 years were approached for the study and asked to provide informed consent and complete the research protocol. Logistic regression models were used to examine associations between demographic, social and lifestyle characteristics and risk of PrCa. RESULTS: The participation rate among cases and controls was 98% and 93%, respectively. All participants completed a questionnaire and 99% (50 cases/49 controls) provided blood samples. Cases had a median serum diagnostic PSA of 73 ng/ml, and 38% had a Gleason score 8-10 tumor. Family history of PrCa was associated with a 4.9-fold increased risk of PrCa (95% CI 1.0 - 24.8). There were statistically significant inverse associations between PrCa and height, weight and waist circumference, but there was no association with body mass index (kg/m(2)). There were no associations between other socio-demographic and lifestyle characteristics and PrCa risk. CONCLUSION: This feasibility study demonstrated the ability to ascertain and recruit participants at UCH and collect epidemiological, clinical and biospecimen data. Our results highlighted the advanced clinical characteristics of PrCa in Nigerian men, and that family history of PrCa and some anthropometric factors were associated with PrCa risk in this population. However, larger studies are needed to better understand the epidemiological risk factors of PrCa in Nigeria.

Dynamic contrast enhanced-MRI for the detection of pathological complete response to neoadjuvant chemotherapy for locally advanced rectal cancer.

OBJECTIVE: To determine the ability of dynamic contrast enhanced (DCE-MRI) to predict pathological complete response (pCR) after preoperative chemotherapy for rectal cancer. METHODS: In a prospective clinical trial, 23/34 enrolled patients underwent pre- and post-treatment DCE-MRI performed at 1.5T. Gadolinium 0.1 mmol/kg was injected at a rate of 2 mL/s. Using a two-compartmental model of vascular space and extravascular extracellular space, K(trans), k(ep), v(e), AUC90, and AUC180 were calculated. Surgical specimens were the gold standard. Baseline, post-treatment and changes in these quantities were compared with clinico-pathological outcomes. For quantitative variable comparison, Spearman's Rank correlation was used. For categorical variable comparison, the Kruskal-Wallis test was used. P ≤ 0.05 was considered significant. RESULTS: Percentage of histological tumour response ranged from 10 to 100%. Six patients showed pCR. Post chemotherapy K(trans) (mean 0.5 min(-1) vs. 0.2 min(-1), P = 0.04) differed significantly between non-pCR and pCR outcomes, respectively and also correlated with percent tumour response and pathological size. Post-treatment residual abnormal soft tissue noted in some cases of pCR prevented an MR impression of complete response based on morphology alone. CONCLUSION: After neoadjuvant chemotherapy in rectal cancer, MR perfusional characteristics have been identified that can aid in the distinction between incomplete response and pCR. KEY POINTS: Dynamic contrast enhanced (DCE) MRI provides perfusion characteristics of tumours. These objective quantitative measures may be more helpful than subjective imaging alone Some parameters differed markedly between completely responding and incompletely responding rectal cancers. Thus DCE-MRI can potentially offer treatment-altering imaging biomarkers.

"Stripping" to prevent prolonged air leak; is there a future in the past?

BACKGROUND: A number of technical precautions and many synthetic or biological materials have been suggested to reduce the frequency of prolonged air leak (PAL) following lung resection. Preserving the three-dimensional properties of the remaining lung parenchyma may prevent this complication to some extent. This study presents our experience with an old technique called "stripping" for the division of incomplete fissures to preserve the original shape of the remaining lung with the hope that this will minimize PAL-related problems. METHODS: 262 consecutive patients with incomplete fissures underwent lobectomy or bilobectomy. Stripping was employed for the division of incomplete fissures in Group S (Study arm; n = 148) and a cut-and-sew technique or staplers were used in Group C (Control arm; n = 114). To evaluate a possible learning curve effect with this technique, Group S was further divided into two subgroups, designated the initial experience (Group S (IE)) and the late experience group (Group S (LE)) and consisting of the first 1/3 (n = 50) and remaining 2/3 (n = 98) of patients, respectively. The frequency of PAL and other related morbidities were investigated. RESULTS: Morbidity and mortality rates were comparable between Group S and C (10 % vs. 8.7 % and 2 % vs. 2.6 %; P = 0.83 and P = 0.96), as was the frequency of PAL, which occurred in 12 (8.1 %) and 13 (11.4 %) patients ( P = 0.40), respectively. When each of the subgroups was compared with Group C, PAL occurred in 9 (18 %) patients in Group S(IE) ( P = n. s.) but only in 3 (3 %) patients in Group S(LE) ( P = 0.03). There was also more postoperative persistent air space in Group C, without this difference reaching statistical significance. CONCLUSION: This study suggests that preservation of the original shape of the remaining lung might decrease the incidence of PAL in patients with relatively healthy lung tissue. An actual favorable effect of stripping over other techniques emerges only when the technique is precisely applied, which is only possible with experience.

Serum heavy metal and antioxidant element levels of children with recurrent wheezing.

STUDY OBJECTIVES: The aim of the study is to investigate the levels of toxic heavy metals related with environmental pollution and trace elements involved in antioxidant system in children suffering from recurrent wheezing. STUDY DESIGN: One hundred children with recurrent wheezing (at least three recurrences) between the ages from 1 to 6 years took part in the study, and also 116 age- and sex- matched healthy children were involved in the study as a control group. Venous blood samples were collected and serum mercury, lead, aluminium, zinc, selenium, and copper levels were studied using ICP-MS. RESULTS: Serum lead (0.76±0.15 vs. 0.27±0.01, p:0.001) and mercury levels (1.31±0.15 vs 0.71±0.05, p<0.001) were higher in wheezy group than those acquired from the control group. Serum zinc (69.4±1.65 vs. 78.9±2.78, p:0.005) and selenium (115.6±1.87 vs. 125.4±2.94, p:0.008) levels were lower in wheezy group than those acquired from the control group. Serum zinc levels were found to be correlated with number of ARTIs (r(p):-0.332, p:0.001) and the number of wheezy attacks (r(p):-0.776, p<0.001) during the previous year in the wheezy group. CONCLUSION: Elevated levels of serum lead and mercury and low levels of zinc and selenium may suggest some disturbances in the antioxidant system in children with recurrent wheezing. This means that children with recurrent wheezing are much more susceptible to environmental pollutants and respiratory tract infections than healthy children and this heavy metal-antioxidant relationship may play a role as a contributing factor in the pathogenesis of recurrent wheezing in children.

Evolutionary trends of the COVID-19 epidemic and effectiveness of government interventions in Nigeria: A data-driven analysis.

Background: Nigeria became the first sub Saharan African country to record a case of COVID-19 after an imported case from Italy was confirmed on February 27, 2020. Moving averages and the Epidemic Evaluation Indices (EEI) are two important but complementary methods useful in monitoring epidemic trends, they can also serve as a useful guide for policy makers and inform the timing of decisions on preventive measures. The objectives of this paper are to graphically depict the trends of new COVID-19 cases nationally and in two key States (Lagos and Kano) and the Federal Capital Territory (FCT) using the moving averages and the EEI. In addition, we examined the effects of government's public health interventions on the spread of COVID-19 and appraise the progress made so far in addressing the challenges of COVID-19 in Nigeria. Methods: We used data on new cases of COVID-19 from public sources released by the Nigeria Center for Disease Control (NCDC) from the 27th February 2020, when the first case was recorded, to 11th May, 2020, one week after the lockdowns in Lagos and the FCT were lifted. We computed moving averages of various orders, the log transformations of the moving averages and then the EEIs of new COVID-19 cases for Nigeria as a whole, and then for two of the most affected states i.e. Lagos and Kano, as well as the Federal Capital Territory (FCT). Then, we plotted graphs to depict these indices and show the epidemic trends for COVID-19 in each scenario. Results: Nationally, the number of new cases of COVID-19 showed an initial gradual rise from the first reported case on the 27th February 2020. However, by the second week in April, these numbers began to show a relatively sharper increase and this trend has continued till date. Similar trends were observed in Lagos state and the FCT. The rate of growth of the logarithm-transformed moving average in the period leading to, and including the lockdowns reduced by a factor of 0.65. This suggests that the policies put in place by the government including the lockdown measures in Lagos and the FCT may have had a positive effect on the development of new cases of COVID-19 in Nigeria. Nationally and in Lagos, the EEIs of the COVID-19 cases started off on very high notes, however, the effects of the lockdown gradually became evident by the end of April and early May 2020, as the EEIs headed closer to 1.0. In all case scenarios, the EEIs are still above 1.0. Conclusions and recommendations: The number of new cases of COVID-19 has been on a steady rise since the first reported case. In Nigeria especially across the two states and the FCT, public health interventions including the lockdown measures appear to have played a role in reducing the rate of increase of new infections. The EEIs are still above 1.0, suggesting that despite the progress that appears to have been made, the epidemic is still evolving and Nigeria has not yet reached her peak for COVID-19 cases. We recommend that aggressive public health interventions and restrictions against mass gatherings should be sustained.

The role of positron emission tomography/computed tomography in the diagnosis of pleural diseases.

BACKGROUND: The aim of the study was to assess the role of F-18 fluoro-2-D-deoxyglucose positron emission tomography ( (18)FDG-PET)/computed tomography (CT) in patients with undiagnosed pleural diseases and to compare the findings with those of invasive diagnostic procedures. METHODS: The study included 83 patients with pleural lesions (63 with pleural effusion; 20 with pleural thickening) on CT scan performed between November 2005 and December 2007. The study group consisted of 63 males and 20 females; their median age was 47 years. PET-CT scan was performed for all patients before surgery. A maximum standard uptake value greater than 3.0 was accepted as positive for malignancy. For histopathological diagnosis, video-assisted thoracoscopic surgery was performed in 76 patients and a mini-thoracotomy was performed for the remaining 7 patients. RESULTS: Postoperative histopathological examination revealed malignancy in 44 cases, 25 of which were malignant mesothelioma; the remaining 39 cases were benign. There were no false negative results, but two false positive results (tuberculosis). PET-CT scanning had 100 % sensitivity, 94.8 % specificity and 97.5 % accuracy. CONCLUSION: Our study suggests that PET-CT may be an effective tool for the differentiation of benign and malignant pleural diseases. We believe that PET/CT may prevent redundant surgical procedures in young patients who are SUVmax negative.

Effects of Cholerella sp. microalgae extract on colonic anastomosis in rats with protein-energy malnutrition.

OBJECTIVE: Algae, which are used as supplementary nutrients in various countries, are products rich in protein, vitamins and minerals. The aim of this study was to investigate the effects of algae extracts on the healing of colonic anastomosis in malnourished rats. METHOD: Seventy-two rats were randomized to three groups. Group 1 was fed with standard diet for 15 days, before and after the colonic anastomosis. Groups 2 and 3 were fed with a malnutrition diet for 15 days prior to colonic anastomosis and then with the basic diet for 15 days there after. Group 3 also received an extract of algae derived from Cholerella sp. via oral gavage postoperatively, in addition to the basic diet. Rats were killed on the 3rd, 7th and 15th postoperative day. Blood samples were collected to evaluate prealbumin, transferring and albumin levels. Anastomotic bursting pressures (BPs), histopathology and tissue hydroxyproline levels were evaluated after killing. RESULTS: In group 3, the prealbumin level on the 3rd postoperative day and transferrin and albumin levels on the 7th and 15th postoperative days were significantly increased compared with the other groups (P < 0.05). Tissue hydroxyproline levels and anastomotic BPs of group 3 were significantly higher than in group 2 on the 3rd, 7th and 15th postoperative days (P < 0.05). Histopathological examination of the anastomosis revealed significantly better healing patterns for group 3 than for groups 1 and 2 (P < 0.05). CONCLUSION: Extract derived from Cholerella sp. microalgae has favourable effects on healing of experimental colon anastomoses.

Prostate cancer imaging.

As prostate cancer is a biologically heterogeneous disease for which a variety of treatment options are available, the major objective of prostate cancer imaging is to achieve more precise disease characterization. Magnetic resonance imaging (MRI) may enhance the staging of prostate cancer compared with clinical evaluation, transrectal ultrasound, or computed tomography (CT), and allows concurrent evaluation of prostatic, periprostatic, and pelvic anatomy. In clinical practice, the fusion of MRI or dynamic contrast-enhanced MRI (DCE-MRI) with MR spectroscopic imaging (MRSI) is improving the evaluation of cancer location, size, and extent, while providing an indication of tumor aggressiveness. Pretreatment knowledge of these prognostic variables is essential for achieving minimally invasive, patient-specific therapy.

Serum leptin and ghrelin concentrations of maternal serum, arterial and venous cord blood in healthy and preeclamptic pregnant women.

Preeclampsia, a common complication of pregnancy, is associated with alteration in the concentration of leptin in maternal blood. The action of leptin is antagonistic to that of ghrelin. Here, we compared the levels of leptin and ghrelin in maternal serum and in arterial and venous cord blood between healthy pregnant women and those suffering from mild and severe preeclampsia. The levels of leptin in maternal and newborn's blood were elevated in both mild and severe preeclamptic patients (p < 0.05). Moreover, serum ghrelin levels were negatively correlated with blood pressure and leptin/ghrelin ratio was decreased in preeclampsia (p < 0.05). We concluded that increased production of ghrelin may represent a compensatory hypotensive mechanism in preeclamptic women.

Ghrelin immunohistochemistry of gastric adenocarcinoma and mucoepidermoid carcinoma of salivary gland.

Ghrelin (G-HH) synthesized in several tissues including salivary and stomach glands stimulates appetite in humans by modulating neuropeptide Y neurons in the hypothalamic arcuate nucleus. Loss of appetite is one of the most important symptoms of stomach cancer. We conducted a study using immunohistochemistry to determine whether salivary glands and stomach cancer tissues produce ghrelin. We determined that negative ghrelin immunohistochemistry discriminates tumors from normal tissues and may therefore further our understanding of the clinically important problem of reduced food intake and anorexia in cancer patients. Radioimmunoassay analyses confirmed that cancer cells do not produce a G-HH peptide, whereas normal cells yield this peptide.

Neonatal hyperthermia and thermal stress in low- and middle-income countries: a hidden cause of death in extremely low-birthweight neonates.

BACKGROUND: Over 70% of neonatal deaths in Nigeria occur within the first 7 days of life and, despite the millennium development goals, there has been no significant reduction of this figure. OBJECTIVE: To investigate how rapid changes of temperature outside the physiologically allowable range in extremely low-birthweight infants are associated with increased mortality. METHODS: Ninety-eight neonatal cases in three Nigerian tertiary-care hospitals were retrospectively recruited; on the basis of birthweight < 1500 g, this number was reduced to 41 for a two-stage analysis. In the first stage, 34 cases recruited over 24 months were analysed. In the second stage, seven cases recruited over 6 months were analysed; these were neonates managed with a new temperature control technique (the 'handy approach') to enable comparison of outcomes. The mean (SD) birthweight of the infants analysed was 991 g (251), and 28 of them were of extremely low-birthweight (ELBW) [mean (SD) 846 g (128)]. A lifetime temperature plot with a clearly visible reference zone was developed, from which all thermal stresses and their duration associated with mortality were identified and defined on the basis of their characteristics. Methods of quantifying the magnitude and duration of these thermal stresses were devised to enable definition of critical values. This was then applied to calculate a measure of the various thermal stresses which may have contributed to neonatal death. RESULTS: Hypothermic events were very common in all the infants in the study period, but were not significantly associated with mortality. However, hyperthermic events occurred in 35% of the infants and were more likely to be associated with mortality. Most neonates with prolonged hypothermia culminating in rapid hyperthermia survived. However, all ELBW neonates who experienced prolonged hyperthermia culminating in rapid hypothermia died within 8 hours of the event. There was greater ELBW survival (6/6) in the second stage using the 'handy approach' than in the first stage (2/22). CONCLUSION: Hyperthermia is a high-risk event in ELBW infants and methods of cooling a high and prolonged temperature must be reviewed.

Anatomical study of the cavernous sinus emphasizing operative approaches and related vascular and neural reconstruction.

The efficacy of three operative approaches to the cavernous sinus (CS) and the possibilities of vascular and cranial nerve reconstruction in and around the CS were studied in 50 cadaver specimens (25 heads). The lateral operative approach was through the lateral wall, between Cranial Nerves V1 and IV, or between Cranial Nerves V1 and V2. The superior approach was through the superior wall of the CS after removing the anterior clinoid process and unroofing the optic canal. The inferior approach followed the petrous internal carotid artery (ICA) into the CS after an extradural subtemporal exposure or after a combined subtemporal and infratemporal fossa exposure. The different exposures of the spaces of the CS and of the intracavernous structures provided by the superior and the lateral approaches were complementary. The exposure provided by the inferior approach was minimal; however, the junction of the petrous and cavernous ICA was best exposed by this route. The combined subtemporal and infratemporal fossa approach exposed the petrous ICA (for proximal control or for reconstruction) with the greatest ease and with the least temporal lobe retraction. The combination of the superior and lateral approaches and the complete mobilization of the intracavernous ICA facilitated its repair after experimental lacerations. Lacerations of either the inferior and the inferomedial aspects of any portion of the cavernous ICA or of the anterior surface of the posterior vertical segment of the artery were the most difficult to repair. End-to-end anastomosis was more difficult with the posterior third of the artery than with the anterior two-thirds. A vein graft with an average length of 3.5 cm could be sutured from the petrous to the supraclinoid ICA to bypass the cavernous ICA, with an average occlusion time of 45 minutes. End-to-end technique was judged better for the proximal anastomosis, but end (graft)-to-side anastomosis was easier to perform at the distal end because of the location of the ophthalmic artery. Resuture of Cranial Nerves III and VI could not be performed in fresh cadavers if the gap exceeded 0.3 cm. In 3 specimens, the exposure of Cranial Nerve VI in the posterior fossa through the petrous apex and in the orbital apex was followed by graft placement (bypassing the CS). The complex anatomy of the cranial nerves at the apex of the CS was also defined in 10 specimens. Surgeons who perform operations in and around the CS for neoplastic and vascular lesions will find these studies useful.