The patient was seen at the ICU 10-October-2011 2 days after performed ENT intervention to the left ear. The patient was lethargic  with right sided paresis and plegia of the right upper limb and dilated pupil left eye and paralysis of the left oculomotor nerve and a massive CSF leak coming from the external meatus.

On examination: the patient has full dilated left pupil with complete paralysis of the left oculomotor nerve. Broca area is preserved, but she has dense plegia of the upper limb and deep paresis of the right side of the face and less of the lower limb.

MRI brain and CT-scan of the brain with DICOM were requested and the investigations showed massive ICH and infarction of the brainstem left side and the crus cerebri with laceration of the left temporal lobe with IVH of the left lateral ventricle. Using ORSVisual  the character of the bone defect and the dural defect were identified.

Left temporal approach was performed and the dural defect was circumferentially identified over the bone defect. The internal temporal artery was coagulated and cut, for further exposure of the torn dura. Lacerotomy of the temporal lobe was done until the normal brain matter was seen.  Using 30x20 mm lyodura, the dural defect was water-tightly closed and another layer of lyodura was used with glue over this layer to aid more security to prevent possible CSF leak. A piece of muscle was used to cover the inner ear cavity, over what several pieces of bone were used to cover the bone defect aided with glue.

Routine closure of the wound.  Smooth postoperative recovery  with disappearance of the dilated pupil and improvement of the power of the right side of the body.

The patient has huge dural and bone defect. Conservative treatment is not considered in this case.

Lacerotomy is a powerful measure to reduce arterial spasm and improve the neurological outcome.