The patient a Libyan citizen, came to the clinic 21-July-2024 complaining of weak right lower limb after performed surgery to recurrent meningioma in Turkey 2012 and Gamma-knife treatment. She was initially operated by me for giant meningioma in the left parieto-occipital region 03-November-2003. She is still in Tegretol CR 200 once a day and Epanutin 100 mg three times a day. She still suffering from epi attacks 4-5 times a day. MRI of the brain done 15-June-2024 showing recurrence of meningioma mid-posterior third of the falx cerebri, more to the left side.

On examination: the patient is limping. dragging her right lower limb. SLRS was 70 degrees with pain in the left and 90 degrees left side without pain. There is weak dorsiflexion right foot -4/5.

The patient was sent for new MRI and performed 22-July-2024 showing recurrent meningioma of the same location with bilateral extension, more to the left. SWI showing veins abutting the posterior border of the tumor. Spectroscopy showing elevated choline at the center of the mass, mandating aggressive character of the tumor. The tumor in saggital plane was 41.1 mm in it's maximum dimension.

In semi setting position and the head elevated above the heart level, biparietal approach was done the bone flap kept.  The scar over the left parietal region was full of scar and the dura was adherent to the bone. Right side parietal approach was achieved and the tumor was resected by piece-meal fashion. The edge of the dura was identified left to the SSS and left sided parietal approach was achieved. The tumor was resected. There is no falx cerebri in the area and the dura was bleeding from the calcified parts lateral to the SSS. Strict hemostasis. Using Lyodura, the dural defect was used to cover the left parietal area. After completion, the dural cover was tense, denoting accumulation of subdural hematoma. The lyodura was opened and the hematoma was evacuated and strict hemostasis was achieved with application of Surgicele in the tumor bed. Routine closure of the wound. Intraoperative MRI done confirming removal of the tumor and telling that the brain has the edema of the left parietal lobe regressing in comparison to the preoperative one. Smooth postoperative recovery. The patient was sent to the ICU.

Too early now.

There is still an estimated postoperative recurrence because the flax cerebri having running veins behind the tumor scarifying them will cause neurological deficit.