The patient an Iraqi citizen came to the clinic 28-June-2022 complaining of hallucination for 6 years. The condition deteriorated 15-March-2022 with condition of disorientation with headache and sleepiness. MRI of the brain done 16-March-2022 showed a huge mass in the right temporo-parietal lobes with intratumoral hemorrhage. The patient is using Topamax 50 mg once daily, but still complaining of fainting attacks. The patient is a known hypertensive for 12 years in Lofral 5 mg and Covarsyl 10/12.5 daily. 

On examination, the patient complaining of headache right side, weak right upper limb, hypalgesia left leg below the knee, loss of urination control, tremor right hand with deep reflexes increased at the right side.

The patient was sent for thorough MRI investigation, lab investigations and cardio evaluation. MRI done 30-June-2022 under G.A. showing the mass in the right temporal lobe reaching and violating the right posterior horn with residual of hematoma inside the tumor cavity and the floor of the right posterior horn. The tumor dimensions is around 5.6x3x3.3 cm in dimensions with minimal peritumoral edema. The tumor is attached to the tentorium. Spectroscopy suggesting high grade malignant mass. There is right uncal herniation shifting the right cerebral peduncle. There is widening of the ventricular system with blood seen at the bottom of the intratumoral cystic cavity and the right posterior horn.

In semi lateral, with the right ear up, curved incision done with the bone flap reflected to the ear. The bone window was extend3ed down to abut the floor of the middle fossa. The dura was opened parallel to the inferior edge of the bone window. The tumor was attacked from the inferior part with massive vascularity with massive venous loops. There was hyperostosis of the floor of the middle fossa, which was coagulated and waxed. The tumor was followed up and resection was proceeded until that part violating the posterior horn of the right lateral ventricle. Several parts were sent for biopsy. After strict hemostasis, the wound was closed and the patient was sent for check MRI. There is still a part of the tumor at the upper most part of the resected tumor located anteriorly. The wound was opened and that part was removed. So as to avoid possible postoperative bleeding a Surgicele was applied to the resected tumor bed. Inspection of the surround was uneventful and the pterion was possible to see and running huge normal veins were preserved at the edge of the tentorium. It was impossible to see the vein of Labbe fro the created dural flap. Routine closure. Attempt to re-check MRI failed because the docking table of the MRI machine was troubleshooting and the Siemens engineer was fixing it. Smooth postoperative recovery and the patent was sent to the ICU.

The patient showed slow improvement  and the final histologic result was of small cell glioblastoma. The patient was advised to undergo radiotherapy.

Spectroscopy confirming the malignant nature of the tumor. The mass was full of abnormal huge veins  and the was a bony matrix to the tumor with rich feeders from the bone of the floor of the right middle fossa.