The patient start to notice slight exophthalmus of the left eye for 2 years with elevation of the left temporal region for 6 months and temporal anopia left eye for 3 months. The patient has arterial hypertension for 15 years, diabetes mellitus for 3 years and using glasses for 10 years for reading. She had clinical manifestations of PLD L4-5 with right sciatica 6 years ago.

MRI of the brain with contrast done 06-November-2012 showing huge meningioma occupying the left middle fossa floor , pushing the sylvian cistern up, abutting the left optic nerve and the ICA, but not involving it intracranially. The mass has hyperostosis of the great wing reaching the pterional area  with soft component extending to the lateral wall of the left orbit reaching the optic nerve in the intraocular segment. The mass also has extracranial component pushing the temporal muscle and reaching the left sphenoid fossa. 

On examination: the patient has slight exophthalmus left eye with slight edema of the eyelids. The visual acuity is normal with glasses of both eyes and the fundi are normal. There is considerable scatoma of the temporal field left eye. The weakness of dorsiflexion right foot 4/5 is due to the old PLD L4-5. Otherwise the patient is neurologically free.

Left pterional approach was done with removal of the bone flap which was invaded by the meningioma. It was sent for boiling for 15 min to kill the tumor cells within the bone. The meningioma part invading the temporalis muscle was resected. The left zygomatic arch was bisected and reflected down. Drilling of the pterion which was actually the intraossal part of the meningioma was drilled out down to the subtemporal fossa. The affected lateral and superior wall of the left orbit were drilled out. Most of the lesser wing was also drilled out. Opening of the dura parallel to wide matrix which was reaching the foramen spinosum and the superior orbital fissure and anterior 5 mm lateral to the optic nerve. The meningioma with its wide carpet was removed and sent to biopsy which confirmed the meningioma pathology. The annulus of Zinn was inspected after exposure of the left optic nerve inside its canal. The pathological involvement was removed. The periorbital fascia was inspected and opened to so as not to miss any mass under the ocular muscles. The periorbital fascia was closed and using large piece of lyodura and wide dural defect was closed water-tightly with stitches running from the foramen spinosum to the superior orbital fissure and the dura covering the lesser wing then all around. The zygoma then was returned back and stitched and bone flap returned back.

Routine closure of the wound. Smooth postoperative recovery.

The patient has wide based pterional meningioma with intraossal, intracranial, extracranial and extension to the left orbit. Practical radical removal was achieved.

Such a meningioma with massive intraossal and invasion even the overlying muscle must have aggressive behavior  and radiotherapy is recommended even with such radical excision.

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