The patient was seen by me the morning of 22-May-2008. She was admitted to Al-Shmaisani hospital under supervision of other neurosurgeon.

The clinical course of the patient was protracted over 18 months, with ataxic gait visual disturbances.

MRI performed 5 days ago showed a giant cystic mass in the sellar region pushing the floor of the third ventricle , causing dramatic ventricular dilatation and pushing the brainstem posteriorly with the basilar artery and spreading down over the clivus.

 On examination, the patient is aphonic and cannot protrude her tongue with motor aphasia. She was almost quadriplegic with slight movement of her left hand. She had hiccup, but the breathing pattern was acceptable.

During 5 hours of observation with 9 time reevaluation, the patient was deteriorating with conning pending. The breathing pattern start to deteriorate, for what she was taken urgently to the operating theater.

 Bifrontal craniotomy was performed and right subfrontal approach was performed initially, to see the right optic nerve and mobilizing during that the right olfactory tract.

The cystic mass was attacked lateral to the right optic nerve. Around 70 ml of yellowish milky fluid was evacuated. The walls of a craniopharyngioma was removed from the medial side of the right optic nerve, which was pushed anteriorly. All the material was sent for histologic studies.

So as to assure that there is no remnant of the tumor the other optic nerve was seen running under the lesion. Part of the left olfactory tract was mobilized to prevent traction avulsion. Both ICAs and the basilar artery were inspected without touching them to avoid the possible progression of vasospasm. After dissecting all the necessary neural and vascular structures with anatomical preservation, it was sure that total resection of the craniopharyngioma was achieved.

Routine closure of the wound and smooth postoperative recovery.

The patient start to talk and moving all limbs and all neurological deficits regressed immediately after the operation. She was sent to the ICU for observation.

The giant dimension of the tumor made it impossible to see the origin of its growth. Mostly it was arising from the pituitary stalk with minimal solid component. Her neurologic manifestations were due to hypertensive-diencephalic syndrome, which resolved dramatically after the operation.

Bifrontal craniotomy give 160 degrees angle of vision. The lower edge of the bone defect must be flush with the anterior fossa floor, even violating the frontal sinuses, as in this case.

Mobilizing the olfactory tracts make it possible to preserve them anatomically and in 85% functionally.

By this method, the surgeon have almost an absolute visual control about what he is doing in the sellar region.

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