The patient a boy 9 years age started to complain of headache with repeated vomiting for 6 months with progressive clinical picture, for what MRI done showing a huge suprasellar mass, which could be a craniopharyngioma or optic chiasm glioma. It has major extension to the third ventricle and retrosellar involvement. The mass was pushing the ACAa anteriorly.

The patient was sent for further examination and the visual fields were constricted both eyes. visual acuity right eye 6/9, left 6/24 accordingly. with no swelling of the optic nerves. No signs of diabetes incipidus or hormonal disturbances.

Bifrontal monoflap osteoplastic craniotomy was done with reflection of the bony flap to the right ear. The anterior lower edge of the bony defect was flush with the base of the anterior fossa. Mobilization of both olfactory tracts was performed and the brain was slightly retracted. The optic nerves were of prefix variant and they were enlarged, as ballooning by a mass. Inspection of both carotids, revealed, that the enlarged chiasm occupying the whole suprasellar area. The suprachiasmatic cistern was opened by sharp dissection and after 25 mm behind the anterior edge of the chiasm, the optic chiasm glioma start to be visible, from where FFB was done, which confirmed a high-grade astrocytoma. The tumor was violet-bluish in color and it was easily resectable. Subtotal resection of the tumor was done, after what it was possible to see the floor of the third ventricle and the optic nerves regained more or less normal appearance. The perichiasmatic cisterns got relaxed position and the ICAa hanging free.

Uneventful postoperative recovery. No deterioration of the visual and olfactory functions.

This is an example about subfrontal approach with preservation of the olfactory tracts after their mobilization from the mediobasl frontal lobes. You can notice that, they are not making obstacle to the surgical manipulations, even after dissection of the suprachiasmatic cistern and working in the third ventricle.

It is early to tell now, but almost radical resection of the glioma can be achieved if the boundaries and consistency can make the surgeon able to do that. This can help in improving the postoperative results