The patient came to Al-Shmaisani hospital 01-July-2007 with a history of drowsiness for a month and left sided hemiparesis for one week.

MRI performed the same day showed a pilocytic astrocytoma right cerebral hemisphere under the sensorimotor strip extending down to the right lateral ventricle and pushing the brainstem down and the third ventricle to the other side. It had small cystic component located anteriorly.

In supine position with the head rotated to the left, a wide osteoplastic frontal craniotomy was performed and transcortical approach was achieved most anteriorly to avoid the possible shifting of the sensory motor strip. The cystic component was evacuated and the solid component was removed by piece-meal resection. It was pinkish in color and variable consistency. It had arterial feeders and pathologic veins, which were coagulated. A proper cleavage was found and followed. The anterior horn was pushed laterally and the the head of the caudate nucleus was pushed anteriorly. It was possible to see the flax cerebri and the running inferiorly the anterior cerebral artery. A small hole was seen at the location of the III ventricle. The posterior horn was inspected and all the remnants of the tumor were removed. After the removal of the tumor the supposed to be far from the motor strip incision became closer to this area indicating, that it was pushed anteriorly.

Routine closure of the wound with smooth postoperative recovery.

The tumor was located under the motor and sensory strip and interhemispheric approach will cause permanent damage to them, for what anterior transcortical approach was planned to avoid this important area and at the time to gain direct visual access to the extending down to the posterior horn part of the tumor and the part which was transgessering the subfalcine region.

For more details about pilocytic astrocytomas, please click here!
The final histologic result was that of ependymoma of intermediate grade with sites of cystic and necrotic degeneration. There was occasional mitotic activity and the proliferation index (ki-67 approaches 15% in areas). GFAP was positive For more details about ependymomas please refer to ependymomas.com.