The patient an Iraqi citizen came to the clinic 21-March-2004 complaining of diabetes insipidus since 1998 in Minirin daily for the last year, 2003 got right sided paresis with dysphonia and right facial paresis with difficult swallowing with ataxic gait. Blurring vision left eye for 1 month. Headache the last 3 weeks.

On examination: the patient is walking with help. Romberg was unable to evaluate. Horizontal nystagmus both side. Right side paresis with right facial nerve paresis. Sensation not affected. Dysphonia with hypotrophy of the right side of the tongue.

The patient was sent for thorough investigations and MRI done 22-March-2004 of the brain showed masses in the IV ventricle and the left lesser wing meningioma involving the left cavernous sinus, extending subtentorially, pushing the brain stem to the right, right acoustic schwannoma with intracanalicular extension pushing the brain stem to the left with scattered small foci in the brainstem and cerebellar hemispheres. The patient has manifestations of neurofibromatosis.

In setting position with midline occipital approach with osteoplastic craniotomy with reflection of the bone flap to the lower field of the incision. the dura was opened in Y-shaped fashion. Transvermian approach with the opex and the IV ventricle were seen. The mass in this ventricle was totally removed and fresh frozen section confirmed that it is low grade glioma. The aqueduct of Sylvii and the cavity of the III ventricle were seen. Strict hemostasis. Routine closure of the wound. Smooth postoperative recovery. The patient was sent to the ICU for 3 days observation.

The patient came to the clinic 01-April-2004 with slight oozing from the wound and showed improved power four limbs, but same ataxia.

The patient then came 15-June-2004 with clean wound and still cannot walk by himself with right hemiparesis with decreased hearing right ear.

The patient has long way with his tumors. They need several approaches and the mortality rate for these lesions is high.