The patient was operated 20 days ago in Beirut, Lebanon through posterior approach and biopsy was performed, which revealed in 2 separate histologic verifications that it it was G III glioma with neuronal differentiation, strong expression to S-100, GFAP, synaptophysine positive, Pankeratine and EMA negative. The patient before this surgery was complaining of headache and ataxia for 2 months, which improved slightly after this biopsy and decompression. MRI of the brain performed 25-March-2017 the tumor occupying the vermis, reaching the tentorium in the left side and invading both cerebellar hemispheres more the right. It is the same as before the surgery as seen by MRI performed 02-March-2017. The patient has congenital deformity of the left foot with burn below the left knee since childhood.

On examination, the patient is limping with ataxic gait, which he tells that it is better than before the first surgery. He is walking with wide based steppage. Romberg relatively acceptable. There is no nystagmus and otherwise neurologically free. The incision in back of the neck is not midline and shifting to the right side in the upper part.

he patient was sent for investigations and MRI of the brain with contrast, MRA of the brain and carotids, MRV brain, posterior fossa protocol, SWI, spectroscopy of the tumor and fibertraking were requested and performed the same day, which revealed the tumor borders and the malignant nature of the tumor with high choline levels, ruling out the hematoma inside the 4th ventricle. There is collection of fluid around the bony flap which is pushed slight backward. The left transverse sinus is not seen in MRV. 

In setting position, the wound was opened and the skin flap slightly extended up to the left. The bone flap was hanging free and it was removed and kept. The dural incision was refreshed and reflected up to see the infratentorial space and extended down to see below the tonsils. The tumor was attacked from above and several pieces sent for permanent histologic studies. Step wise resection of the tumor until the floor of the 4th ventricle was seen from the calamis scriptorius below and the aqueduct of Sylvius above. Practical resection of the vermis was achieved with preservation of the linqula and central lobule above and the tonsils and tela choroidea below . The patient was sent for MRI and the resection showed remnants of the edematous adjacent part of the right cerebellar hemisphere. MRI spectroscopy ruled out presence of any active parts of the resected tumor. That part at the right brachium pontis was removed and strict hemostasis was achieved. Routine closure of the wound.

Smooth postoperative recovery. The patient responding to verbal command and moving four limbs. Sent to ICU for 24 hour observation.

The final histologic result was high grade astrocytoma. The patient walking without aid 07-April-2017, without nystagmus, nor neurologic deficit.

The patient came 19-January-2020 for follow up and MRI performed 05-December-2019 showing complete resolution of the tumor.

The patient has high grade glioma and radical resection must be attempted as far as possible to give the patient a longer period for other treatment modalities .

Anatomical landmarks must guide the surgeon about the limits of resection, aided with intraoperative MRI with spectroscopy to confirm the degree of resection.

So as to avoid catastrophic postoperative events, the surgeon must respect the brain stem and the medulla and in this case the angle between the right brachium pontis and the right upper corner of the 4th ventricle.