The patient came to the clinic 06-November-2007 with headache and neck pain from the right for 1 month with progressive course, with weak left lower limb. MRI done 05-November-2007 showing glioblastoma right temporo-parietal lobes. The MRI was of bad quality.

On examination, the patient is right handed with left hemihypalgesia and paresis more the distal muscles both left upper and lower limbs. The patient was sent for another MRI, which confirmed the diagnosis and MRA showed the involvement of the right MCA and its tributaries inside the mass with massive edema and midline shift of the brain to the left. The son was asked separately to gather the family and detailed discussion about the situation was performed. They were asked not to hurry with their decision and to discuss the matter with all the members of the family. They decided to let the patient undergo surgical resection of the tumor with maximal possible resection. The patient is a known hypertensive in concor 5 mg a day. He was admitted 10-November-2007 and operated the next day.

A wide fronto-temporo-parietal craniotomy with reflection of the bony flap to the right ear was performed. The dura was stony tight and 100 gm Mannitol and 80 mg Lasix was administered with 16 mg Decadron. A slight decrease of the dural tension was noted. The ISIS Inomed highline ion was used and PRESP was used and epidural mapping was performed, which showed were the pre and postcentral sulci are. The dura was opened over the temporal lobe and partial decompression of the tumor was was achieved. More relaxation was noted. While extending the dura incision, the brain became more edematous and mapping was performed to see exactly where the central and postcentral gyri are located. They were pushed anteriorly.
Temporal lobectomy was performed and the uppermost part of the tumor was seen with the MCA branches which were pushed upward and the tumor through them was removed with preservation of their continuity. The inferior horn of the right temporal lobe was violated and seen with CSF coming from there. The Sylvian cistern was dissected of the tumor and the branches of the right MCA were hanging free in the tumor cavity.
The tentorial edge was seen to be occupied by the tumor and using the arachnoid, the cleavage was used to remove the tumor parts pushing the brainstem. Part of the frontal lobe anterior to the motor area was violated to regain more ample to the edematous brain, but colleagues and the general thinking was that performing frontal lobectomy was not that good option. The MCA and its branches were irrigated with Papaverine and the PRESP was repeated and confirmed that the pre and postcentral gyri still functioning with the amplitude of the motor area N20 is low as at the start of the operation, but still present. Hemostasis with water-tight closure of the dura and the wound. Ready-Vac drain left under the skin.

The patient extubated after surgery with deep left sided hemiplegia, which started to resolve partially within the next hours.

The patient obeyed commands after 90 min of extubation and CT-scan was performed 2 hours later, which showed the tumor cavity with air and fluid (Saline and hematoma inside the tumor bed), with hematoma in the frontal area and the midline shifting is decreased in relation to the preoperative data.

The patient in next postoperative day was doing well until he progressed PGE attack. Serial CT-scan of the brain performed immediately after surgery and 2 hours before the attack and immediately after the attack were the same with residual blood at the bed of the resected tumor. It is worthy to note, that in these serial CT-scans the edema of the right occipital lobe is regaining more intense and wide-spread character. The patient was given Tegretol over the previously prescribed Epanutin.

At 10.00 p.m. 12-November-2007, the patient progressed decerebrating attacks, for what he was urgently taken to the operating room and the bony flap was reflected. The dura was stony tense and the dura was opened first at the temporal region, through which the lacerated temporal lobe came out through the small incision. Another small incision over the most anterior part of the frontal lobe was performed. through which the blood clot came out. Lacerotomy of the temporal lobe and the anterior part of the right frontal pole was undertaken. Both incisions were extended to be parallel to the inferior edge of the bone defect. The clot above the MCA candelabra was removed with preservation of the tiny feeders. The previously mapped cortical areas were in good shape and appearance and started to give cardio-pulmonary pulsation and the CSF started to flow from the posterior horn and the sylvian cistern. Strict hemostasis with application of Surgicele in the surgical field. External drain was inserted to the temporal cavity and other to the frontal area.
The idea of removing the bone flap was abandoned, since the brain regained relaxed appearance. The bone was reflected back to its original place, after covering the dural incision by lyodura.

The patient was put in ventilator and the morning of 13-November-2007 another CT-scan was performed and the hematomas disappeared and the shift decreased.

The patient was put in Inomed Highline ISIS monitor, using ICU-AEP-SEP protocol for 24 hours and the parameters were stable.

The patient was kept in ventilator until 17-November-2007 and weaning was successful. The patient showed dense left side hemiparesis. The patient the next day 18-November-2007 obeying commands and moving right side of the body and moving the left upon pain stimulation. The external drains were removed. 

22-November-2007: The patient is clinically improving and he is still in NGT feeding with the Chaine-Stokes breathing pattern decreasing and he is for three days in air room and serial CT-scan of the brain showed decrease in the midline shift with appearance of the sulci in the right parietal region. Slight movement of the left limbs upon painful stimulation and communicating well with the surrounding. The amount of aspirated fluid from the subgalial area is decreasing. Physiotherapy started three days ago and he can tolerate setting position for 2-3 hours twice a day.

25-November-2007: the patient started to deteriorate with difficult breathing and he was put in ventilator with dormicum 10 mg/h to control the epileptic activity and it was noticeable, that he got sensory aphasia.

The patient dressing showed huge amount of tumorous fluid coming out under the skin flap with around 100-200 ml daily.
04-December-2007: the patient still in ventilator with stable vital signs with the same neurologic condition and the tumorous collection still aspirated and waiting for Gliadel to insert it to tumor bed in hope to stop the rapid tumor activity. Tracheostomy is planned during that.

The patient has the most malignant tumor of the brain with giant size. Controversy still have place in what to do exactly and this is governed by several factors, among them are paramedical ones.

Subtotal resection can help in temporal resolution of the problem, but the chances for long survival still remain minimal.

Removal of the insular part of the tumor was the most difficult and hazardous, because the tumor was highly vascular and it was difficult to distinguish the right MCA candelabra from the feeders and SEP was of no help to decide exactly the degree of the motor function and application of Papaverine did not help. This is clearly mentioned in chapter 15 of Deletis V. in Neurophysiological Monitoring 2002 edition.

SEP was recorded from both sides and it was acceptable, despite the fact that, the patient had dense paresis in the left side of the body.
PRESP can help mapping the brain, but it cannot predict the outcome of the surgery. MEP is more informative.
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