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The patient came to the
clinic 21-November-2007 complaining of
decreased hearing of the right ear with diplopea
for 45 days duration. |
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On examination: the patient
had left sided weakness and paresis of the right
abducens nerve. |
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MRI performed 2005 showing
dermoid of the posterior fossa and she was
advised to wait and see. |
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It was explained to the
patient, that the sooner the better it is to
perform surgery, since every loss in her neural
functions, it will be hard to regain after
surgery. |
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The patient was admitted
24-November-2007 to Shmaisani hospital and new
MRI was performed, which showed increase in the
dimensions of the tumor. Most of the tumor was
located in the left side, but the patient was
complaining from the right abducens nerve and
had left sided hemiparesis. |
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With the setting position and
TIVA and using Inomed Highline ISIS IOM with HSG
KHBW scenario, posterior osteoplastic midline
craniotomy with the flap attached to the C1
lamina, was performed and the flap reflected
down near C2 spinous process. |
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The dura was opened in
V-shaped fashion and the upper edge was stitched
to the upper border of the bony defect. |
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The arachnoid of the cisterna
magna was opened and the cistern, which was full
of epidermoid was evacuated and that part, which
was reaching the C2 level was decompressed and
removed completely. The medulla was shifted to
the left and the callamus screptorius was
distorted and exposed to the field. It was
possible to see the lower half of the floor of
the fourth ventricle. |
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Further removal of the tumor
was achieved around the left PICA and left
vertebral artery and the atrophied hypoglossal
and accessory rootlets and the vagus. They were
preserved, even with their tiny feeders. |
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The removal was continued
forward until the petrous bone came to view and
the vein of Dandy was preserved with the shifted
acoustico-vestibular and facial nerves with the
ability to remove the expanding part
supratentorially in the left side. The
trigeminal nerve was preserved.
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The Hollow traction system
was applied only for the left cerebellar lobe,
and no constant traction was applied to the
brainstem to avoid possible traction injury. |
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The left vertebral artery and
the basilar arteries were stuck to the distorted
brainstem. This was advantageous, since the
clinically manifesting part was separate from
the rest of the mass. That part was opened and
the epidermoid material was evacuated
separately, decompressing the right clival
region from the left lower angle of the field.
The clivus was inspected and it became free of
any remnants, except for 0.5 mm thickness of a
carpet which was thought that it could be
attached to tiny major atrophied neural
structures. Another small fragment at the
projection of the left cochlear nuclei 0.2 X 0.3
mm was left attached to a running vein, which
could lead to venous problems. |
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No any bleeding or problems
happened during the surgery and her husband Dr.
Ayed Haddad a general surgeon, was present in
most of the stages of the operation. |
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All the data of the iom were
steady and without any changes from the start of
the surgery until the end. It was possible to
communicate with the patient in certain stages
of the operation. |
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Water-tight closure of the
dura and Lyodura was used to obtain this tight
closure. |
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The bony flap was reflected
to place and the bony dust harvested during
craniotomy was gathered and used to fill the
prominent bur holes. |
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Routine closure of the wound
and immediate smooth postoperative recovery of
the patient with no neurologic deficit. |