The patient came to the clinic 09-November-2019 complaining inability to walk the last 3 months with epi attacks. MRI of the brain bad quality, not complete study performed 27-September-2019 showing lesion left parieto-frontal and less in the right.

On examination: there is weak grip right hand 4/5, extensors right hand and right biceps 3/5. Weak dorsi and planterflexion right foot 3/5, abduction right knee 4/5, right quadriceps femoris and right iliopsoas muscles 2/5.

The patient was sent for investigations  with complete protocol of MRI with clinical applications, including fMRI, which were done 12-November-2019 showing huge meningioma occupying both parietal areas more the left with involvement of the falx cerebri  and tumor was extending inside the mid third of the SSS with draining veins anterior and posterior to the involved SSS. The motor area was located posterior to the lesion. The patient was sent for cardio evaluation.

In semi-setting position with vertex is at its superior position, trying to decrease the pressure of the SSS, extended wide craniotomy of both fronto-parietal area with reflexion of the flap to the left, trying during that the avoid traction injury to the SSS. The tumorous bone flap sent for sterilization to kill the inside growing tumor. The dura was opened lateral to the left meningioma margin and followed to the edge of the SS anterior and posterior. The tumor was rubbery in consistency and highly vascular. Using SONOCA 300 with different handles the tumor was resected step-wise. Part of it was sent for histologic investigations. The resection was carried down until the falx cerebri was seen. Opening the right side confirmed that there is no apparent tumor and the presence of huge draining veins and Pacchoinian granulation, restricted the full exposure of the area to explore the other side of the right wall of the SSS, which in fact was full of tumor. The dura in the right side was closed and the patient was sent for intraoperative MRI investigation with contrast and MRV. The defect of the SSS still the same and the tumor is inside and around the SSS. After consulting all the team members, it was decided to satisfy this degree of resection and to be followed by radiation 8-10 months after surgery. The sterilized bone was returned back.  Routine closure of the wound.

Smooth postoperative recovery with right severe spastic paraparesis. She was sent to the ICU.

The patient 4 hours after surgery in the ICU is alert responding to verbal stimuli talking and the paresis regressed dramatically.

The final histologic result was that of meningioma, transitional type (mixed meningothelial and fibrous); WHO Grade I. (Prof. Yahia F. Dajani 07-12-2019).

The patient came three times to the clinic with dramatic improvement of her neurologic status to evacuate fluid collection over the bone flap.

This case is challenging with its involvement of the SSS. Without violating it the patient progressed immediate postoperative deep right sided spastic paraparesis.

What if the SSS was violated? Death could be one of the options which is not desirable in account.