The patient came to the clinic 03-February-2014 complaining of left sided headache for 28 years and considered as having migraine with exacerbation the last month. MRI of the brain of bad quality done at Al-Bashir hospital 12-October-2011 reported to be normal, but there was a lesion in the left CPA. The last month has ataxic gait. Numbness of the left side of the face and the the tongue. The patient is left handed. Sialorrhea from the left side.

On examination; the patient is alert is responding to all verbal responses. She has hypalgesia of the left side of the face. Romberg stable. The hearing decreased in the left side with tinnitus left ear for 4-5 months. There is weak right upper and lower limbs right side 4/5. Hoffmann was positive in the right. Babinski and clonus of the right foot ?.

The patient sent for new MRI of the brain with contrast and spectroscopy. All data were in favor of huge left CPA meningioma 33x32x30 mm dimension. MRA showed compression of the basilar artery with the corresponding PICA by the tumor mass. Spectroscopy was typical of meningioma.

Setting position. Craniotomy done to expose the left cerebellar hemisphere and the left transverse sinus and abutting the left sigmoid sinus. The dura was opened to reach the subtentorial area. The meningioma was seen at the most anterior parts. The tentorium was not involved by the matrix of the tumor, nor the superior petrosal sinus. The tumor was rubbery in consistency with good cleavage. Piece meal resection was started and the tumor was dissected off the brain stem, cerebellar hemisphere. After total resection of the tumor, the trigeminal nerve was pushed upward flattened and stuck with the brainstem. The facial and vestibulo-cochlear nerves were pushed down and posterior. The left AICA and its branches were preserved. The tumor matrix was superior to the meatus acousticus internus. Some feeders were coagulated to achieve Hemostasis. Further hemostasis was achieved by applying surgicele. The patient was sent to MRI to confirm the total resection of the tumor. There is no any residual mass, except the surgicele. The patient now in supine position and routine closure of the wound.

Smooth postoperative recovery. The facial and all the nerves of the area are functioning properly. Sent to the ICU.

The patient complained of double vision when looking to the left. It could be explained by the reaction of the quadrigeminal structures after tumor removal.

The final histologic result was fibroblastic meningioma.

The patient underwent intraoperative MRI to confirm the radical resection of the tumor. The good shape of the brainstem, gave the decision, that the patient can be extubated immediately after surgery and this was achieved.

The essential purpose of intraoperative MRI control is to catch any complication during surgery and to know exactly what happened and to respond accordingly.

The patient was operated in setting position during tumor removal, but the surgery was continued after MRI control in supine position. A massive bleeding took place from the intraoseous veins from the bone defect. The conclusion is that it is mandatory to wax all the bone edges for 2 reasons. First the prevent the progression of air embolism, second: to prevent postoperative extradural bleeding.