The brother of the patient is a doctor came 13-February-2010 telling that the patient start to complain of signs of frontal lobe syndrome, for more than a year for what he lost his job and he was treated by psychiatrists.

MRI of the brain done the same day showing huge olfactory groove meningioma, occupying the entire anterior fossa more the left with involvement of the optic nerves and both carotids inside the tumor with possible involvement of both cavernous sinuses.

Repeat MRI of the brain with contrast and MRA was requested and done the next day.

On examination the day before surgery: the patient is alert , but with signs of frontal lobe syndrome with anosmia and visual disturbances of the left eye. He has weak both upper limbs both sides more the right.

Bifrontal osteoplastic craniotomy with reflection of the flap to the right ear. The dura was opened parallel to the inferior edge of bony defect, which was violating the frontal sinuses, which were managed accordingly. The anterior border of the tumor bed was attacked from the left  and the matrix of the tumor was involving the left olfactory groove and the planum sphenoidale. Piece-meal resection of the tumor was started and it was rubbery in consistency and bony hard spheroid masses about 12X12 mm were found inside the tumor.  Inspection for the left olfactory tract revealed negative results. It was absent and completely replaced by the tumor. After completion the resection of the antechiasmal part, dissection of the tumor off the Aa and the optic chiasm and nerves was succeeded. That part which was occupying the suprasellar region was removed and both optic nerves were free of the tumor and it was possible to see the pituitary stalk. The tumor parts which were invading the Sylvain cisterns and engulfing the supraclinoid both ICAa  were removed and it was possible to see the ICAa and the bifurcation to A1 and M1 both sides. The cavernous sinuses were not involved with the tumor. Total resection was achieved. The right olfactory bulb and tract were preserved anatomically.

Routine closure of the wound.

Smooth postoperative recovery, and the patient was sent to the ICU.

Before the surgery in such a case, when the tumor reach a giant size, it is difficult to know exactly which structures are involved in the tumor matrix. In this case the cavernous sinuses were suspected to be involved with the tumor process, which was negative during the surgery.

The total resection is not the main aim of surgery, but when it is feasible, it is a welcome result.

The olfactory function was lost before surgery for unknown period, and preservation of the right olfactory tract will not bring olfaction. Preserving this anatomical structure, means from one side that the surgeon was delicately reacting with the neural tissues, which means minimal surgical trauma, and from the another hand, olfaction could return, which is highly unexpected.

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