The trilateral approach has several advantages to visually control all aspects of the tumor with different angles, making practical resection of such huge tumor feasible.

Such surgery must have difficult postoperative course, which must be considered with great caution.

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The patient  came to the clinic 17-April-2002 from Egypt complaining of bilateral sciatica, more the right. She had fracture med third right tibia with subsequent plate fixation 12 years ago. Exacerbation of LBP the last 3 years with ataxic gait for 2 months. She had diabetes mellitus for 1 year in diamicron and glucophage. Arterial hypertension for 6 years in hypoten 50 mg once daily. She had also hypercholesterolemia.

On examination, she had unstable Romberg swaying to all directions. Mild bilateral lagophthalm was noted. SLRS was 90 degrees both sides with Babinski positive left side. Hypalgesia with numbness both feet  with weak muscles both feet more the left.

Considering these data, the patient was sent to perform MRI of the brain with MRA of the brain and carotids  with MRI of the lumbar spine.

The patient showed postoperative medullary signs with left sided hemiparesis which persisted for several days, with complete resolution of the signs over 10-14 days.

The patient  came back to the clinic 23-April-2002 with MRI of the brain, showing giant tentorial edge meningioma with mild spondylolisthesis L5-S1. The patient was advised to undergo surgery for the meningioma, and she was surprised, that she was claiming of LBP and why, she must be operated for her brain tumor. It was explained for her, that most of her complains were due to the tumor.

In setting position, a long vertical incision of the skin was created over the posterior mid parietal and occipital region. The wide bone flap was created and reflected down to the lower corner of the wound, so that to confluence sinuum was at the center of the bone defect. A V-shaped incision of the dura was created  over the cerebellar hemispheres and reflected up. Subtentorial approach to the tumor was proceeded and the meningioma was seen and piece-meal resection of the visible tumor was achieved. Dural incision over the right occipital lobe parallel to the superior edge of the transverse sinus and posterior third of the SSS and the seen parts of the supratentorial part of the tumor was resected. Then infratentorial approach was used to continue the tumor removal. All efforts were taken to preserve the deep cerebral vein and its divisions. The left occipital approach in this case was not needed. Hemostasis and routine closure of the wound.

Smooth postoperative recovery. The patient was sent to the ICU for observation. She progressed dense left sided plegia and deep paresis of the right with aphonia and swallowing difficulty and was semicomatose, but started to recover over one week in the ICU. In the ward she continued to recover and she could walk the 10th postoperative day with help and all neurological deficits regressed dramatically.

The patient came to the clinic 25-May-2002 with ataxic gait. She was in glucophage twice daily, Amaryl 2 mg once daily and hypoten 50 mg once daily. She received trental, tapering doses of Epanutin, Gincosan and L-thyroxin 100 microgram once daily.
She was sent for follow-up MRI and lab investigations and came 30-June-2002. MRI done 30-June-2002 showing residual of the mass 2x2 mm at the sinus recti junction. Thyroid functions were within normal limits. She was advised to decrease the L-thyroxin and to be followed by endocrinologist and come back after one year.
The patient came back 27-December-2003 with the recurrence 3x3 mm. Romberg was stable the walking improved considerably. She had hypalgesia of the index left hand, weak dorsiflexion big toe right foot with hypalgesia of right L5 territory. She improved dramatically and no lagophthalm and she was advised in case of considerable enlargement of the tumor, to undergo radiotherapy.