The patient a Libyan citizen was operated by me 2 day ago 27-July-2024 for falx meningioma and after closure of the dural defect using Lyodura, hematoma was suspected for what the Lyodura was opened and evacuation of the hematoma was achieved. Intraoperative MRI did not show remnants of the tumor but it was interpreted as Surgicele. The next day another MRI was done showing 2 remnants of the tumor in the right side and enlargement of the hematoma with slippage to the third and left anterior horn.

Using the same setting as during first surgery, the wound was refreshed. The bone flap was pushed up due to compression. The lyodura was opened parallel to the SSS in the left parietal lobe. The hematoma was evacuated and the Surgicele was removed with the 2 pieces of the remained tumor. At the bed of the evacuated hematoma from the defect of the corpus callosum the CSF start to come out. Strict hemostasis with brain lax transmitting the cardio-pulmonary pulsation. One hour was waited to ensure that no active bleeding have place. SNoW Surgicele was applied to the wall of the cavity. It is crystal clean. The Lyodura was stitched and routine closure of the wound. The patient was sent to MRI suite. There is no residual of the tumor nor hematoma. The patient was extubated and smooth postoperative recovery, better that during the first surgery. The patient was sent to the ICU.

The patient awake, but she progressed total tetraplegia with inability to hold the head. 2 days later she could elevate the head and the right upper limb improve to normal. The patient was transferred to the ward after 10 days. Physiotherapy was started 10-August-2024. The patient feeling the four limbs and mild improvement of the left upper limb started and to less degree both lower limbs better the right. Daily evacuation of serous fluid from under the scalp was done with the amount of 100-140 ml.
MRI of the brain done 17-August-2024 showing regression of the edema and tiny tear of the corpus callosum. There is no hematoma and the debris of the Surgicele is noted in the cavity of the removed tumor.

The subgalial collection disappeared 05-September-2024 and the power of the left hand regained full power, but the proximal muscles of the left upper limb, still weak with inability to control them and needs long-term physiotherapy. The family was advised to transfer the patient to local hospital in Libya, where she is living and to continue physiotherapy for 10-18 months until maximal recovery take place.
The patient can be transported by airline, with consideration that she needs extra space for the lying position. She must be transferred to the airport by ambulance and received in Libya by ambulance and to have organized hospital ready to accept her.
Comment: Epanutin, which she was using for long time was the trigger of such coagulation disturbance and stopping it and using Keppra could stop the coagulation disturbance and stop the epiactivity.

The report is given upon the request of the family 14-September-2024. The patient now have no epiattacks. The patient is fit to be transferred by airlines with a stretcher accompanied by her family.
 

During the first surgery. T2W coronal, saggital and SWI did not catch the 2 pieces. In the next day the T1W protocol could catch the tumor residuals.