The patient was operated by me 9 months ago for very aggressive glioblastoma multiforme left fronto-temporo-parietal lobes with involvement of the left insula and internal capsule. Gliadel 16 wafers were inserted at that time, that could slow down the aggressive progression and binging it to halt for 8 months.

Serial MRIs were performed every 2 months and confirmed the stabilization of the process.

The last month, the patient started to show deterioration with swallowing difficulty and the verbal response and talking became poor.

MRI of the brain performed 18-August-2008 confirmed the presence of wide-spread recurrence of the tumor over the cerebral hemispheres mainly locally and in the contralateral Sylvian cistern.

Considering that the patient underwent radiotherapy with maximum permitted dose, the option of boostering dose is omitted. Taking into consideration that the patient showed good response to the previously inserted Gliadel wafers, the family agreed to give him another chance.

Through mini-subtemporal approach from the left side, small craniotomy was performed. That part which was occupying the left temporal fossa was removed and the left PCA and brain-stem were visible and the CSF came out freely from the interpedincular cistern. The choroid plexus of the left inferior horn was seen and the inferior horn was inspected. The CSF pathways were intentionally created to make doors for gliadel to reach the contralateral hemisphere.

Some parts of the tumor were sent to histological studies and some wafers, which were inserted at the first surgery were still present at their site. They were removed and sent for histological studies.

16 Gliadel wafers were inserted near the brain stem and at the left inferior horn and the tumor bed and posteriorly under the temporo-occipital lobes with special attention to the vein of Labbe.

Routine closure of the wound and smooth postoperative recovery.

The patient had very aggressive glioblastoma multiforme 9 months ago and Gliadel could bring to halt the aggressive nature of the lesion.

It is early to predict the behavior of the tumor with next Gliadel implantation. Time will tell.

The microscopic examination revealed a glial tumor showing extensive necrosis, edema and fibrin thrombosis of blood vessels and mixed inflammatory cell infiltrate. Areas showing palisading of tumor cells with moderate degree of anaplasia with focal place reveal increased mitotic figures more than 16 per 10HPF. The membranous fragments noted grossly reveal mostly fibrin in addition to a minor ropy and delicate component and patchy chronic inflammatory cell infiltrate.