The patient came to the clinic 12-August-2008 complaining of left sided headache for 20 days with repetitive sensory-motor Jacksonian attacks in the right side of the body taking place several times daily. The patient came from a hospital were they were treating him for encephalitis.

CT-scan of the brain done 11-August-2008 showed left fronto-temporal mass. MRI done 12-August-2008 confirming the presence of wide-spread mass infiltrating the left fronto-temporal lobes with shifting of the midline structures and pending conning. High-grade astrocytoma was in the top of the diagnosis and glioblastoma multiforme could be the second in the list.

On examination: Romberg was stable with no signs of cerebellar dysfunction, except for fine tremor of the right hand. There was no meningism and he had mild paresis of the right limbs more in the distal muscles with flattened right naso-labial fold. The patient is left handed, but using the right hand.

The patient was advised to repeat MRI of the brain with contrast with MRA and MRV of the brain to be performed after 3 days. It was done and the mass still the same.

It was advised that performing surgery without using gliadel wafers. could yield relatively bad prognosis. The relatives agreed and 16 wafers were ordered.

Left temporal approach was performed and the bone flap was reflected to the left ear. Despite the use of aggressive dehydration and hyperventilation and all measures to decrease the intracranial pressure, the dura was stony tense. It was decided to make a mini-incision over the lower temporal gyrus. Suction of the tumor was performed from this incision with the use of bipolar, because the tumor was rich in vascularity with abnormal vessels running inside it. Frozen sections revealed the presence of high grade astrocytoma.

After the dura became relatively lax, the dura was opened more wide and not reaching the sylvian cistern and not reaching the junction of the vein of Labbe.

The resection was limited 10 mm away from the sylvian cistern, so as to avoid any mechanical irritation of the left MCA branches and 10 mm away from the edge of the tentorium in the plan so as to avoid any contact with the brainstem. The upper temporal gyrus was preserved so as not to cause any damage to the Broca and Wernike-Mann areas. Taking these areas into consideration and the use of Inomed IOM intraoperative navigation, it was possible to remove a plenty part of the tumor with a cavity inside the temporal lobe. After achieving heamostasis, the 16 Gliadel wafers were implanted in the cavity of the tumor bed and over the tumorous cortex of upper temporal gyrus. Tachyseal was covered over the the wafers and the dura was stitched . Over the dura another layer of Tachyseal was used.

Routine closure of the wound and smooth postoperative recovery with smooth postoperative recovery.

The patient has very aggressive tumor. Surgery alone is not a sufficient option. Using Gliadel wafers could improve the long-term outcome.

Usually radiotherapy will be planned after 4-5 weeks after surgery.

In case that the dura is very tense before opening, if the conservative measures fail to decrease the pressure, it is advisable to perform small dural incision and perform decompression, after what the dura can be widened to prevent brain from bulging and secondary brain damage due to shift and vein cutting at the edge of the dura.