The patient was operated by me 11-Noveber-2007. The patient as previously mentioned, was in ventilator waiting for the Gliadel wafer, which we received at the morning today directly from USA.
The patient was taken to the operating room and tracheostomy was performed.
The flail bone flap was reflected to the ear. It was noticeable, that the tumor growth was rapid and a lot of necrotic material was filling all the cavities. All the necrotic material was removed and further removal of the tumorous temporal lobe and the frontal lobe was performed and decompression was achieved maximally 10 mm anterior to the optic nerves.
After achieving good decompression and hemostasis, Gliadel Wafer (polifeprosan 20 with carmustine implant, Guilford Pharmaceuticals, Baltimore, MD 21224 NDC 61379-0100-1) 16 pieces were implanted in the two cavities.
Water-tight closure of the dura using lyodura. The previous implanted lyodura was stuck to the bone flap and it was used to further cover the area.
The bone flap was rigidly fixed to the bone defect and the wound closed.
The patient was weaned immediately after surgery and his clinical status is still the same: deep paresis of the left side and obeying verbal command with difficulty and moving the right side of the body.
The patient asked for small incision. It means, that during flavotomy it is necessary to use the loupes with magnification to see exactly what is going on and to perform the usual tasks.
The neurosurgeon must be a good MRI reader so as not to miss the separated piece. Foraminotomy was extended more than usual so as not to escape such far migrating piece.

The patient in next postoperative day 09-December-2007 doing well and control CT-scan done showing the resection limits and the Gliadel wafers in the cavities.

The patient underwent radiotherapy, and MRI done 17-Maech-2008 showed no signs of recurrence, still bedridden and can eat well and some times talking and responding to verbal stimuli.

MRI repeated 18-August-2008  showing of the other left hemisphere and involvement of the brain stem in the right side. with deterioration of his condition.

MRI done 04-December-2008 showing enlargement of the right sylvian mass location and down to the vermis. He is completely bedridden and to my knowledge he died 3-4 months later.

The family of the patient is insisting to provide to the patient the at most care and chances. Gliadel is an expensive drug and the 16 pieces cost is around 40.000 USD and needs urgent production and delivery in -250 C. Thanks for the cooperation H.E. Minister of Health in Jordan and Dr. Janet Merza Deputy Minster of Health, and Simona Ulisse, who made this feasible.

Gliadel was the only choice in this case to suggest, because the very aggressive behavior of the tumor could not provide a room for manipulating with the patient treatment and we were stuck with the ventilator and every day we evacuated 80-100 ml of tumorous fluid subgalialy, for what he was also in the ICU. After the second surgery the fluid stopped and we could discharge the patient from the ICU and send him later home,

As mentioned the Gliadel has less systemic toxic effects and such patient in the ICU with these parameters cannot tolerate BCNU I/V infusion.

We hope that could yield some benefit to the patient.