The patient came to the clinic 12-July-2015 complaining of epi attacks for 4 years and was in Tegretol 400 CR twice a week. MRI of the brain done 01-June-2014 showing cystic lesion anterior to the left inferior horn.

On examination: The patient is alert with slight right hemiparesis,

The patient was sent for new investigations and MRI of the brain performed 22-July-2015 showing the mass considerably enlarged in diameter 28.3x18.4 mm anterior to the left inferior horn. Spectroscopy showed high choline levels with glioma nature of the mass.

Lazy S-shape incision to the left temporal region. A bony flap was created over the projection of the tumor. The dura was opened in t-shaped fashion. Transcortical approach to the tumor. The tumor was violate friable, and multiple consistency. The tumor was resected and the inferior horn was exposed as landmark confirming the radical resection of the mass, which was sent for histologic investigations. Hemostasis and before closing the wound, MRI was done, which confirmed the radical resection of the mass but showing a separate seeder in the left border of the anterior commeasure abutting the posterior border of the left MCA, reaching the left Internal capsule. It was decided not to violate them, because they are deeply seated and the mortality and permanent postoperative plegia is at best outcome.  Routine closure of the wound.

Smooth postoperative recovery. The patient showed dense right sided plegia which was improving over hours after surgery. She was sent to the ward.

The patient showed mutism after surgery with denial to move the right side of the body. She could move with painful stimulation and produce sounds. She could write and understand the verbal commands. Largatil 25 mg was started 20-September-2015.

The final histologic result was astrocytoma grade II.

The data from which the plan was configured was from 22-July-2015. It seems due to malignant nature of the tumor, many changes took place. during 45 days. The next time MRI must be fresh not less than 1-4 days before surgery.

The spectroscopy raise alert about the non-benign nature of the tumor, but I personally gave admission to the patient at the first visit. The family delay due to financial reasons, pushed to me to ignore asking for new MRI.