Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
The patient came to the hospital with history of
longstanding ataxia, headache with decreased
hearing left ear and left ophthalmalgia and
blurring vision left eye. Neurologically the
patient was intact. except for nystagmus and
decreased hearing left ear and mild facial
paresis left side.
The patient performed MRI, which showed massive
left posterior fossa mass, resembling
meningioma. Considering its giant dimensions
with extension down to the caudal group of
nerves left side, it was difficult to establish
the histologic diagnosis. But the patient claim,
that she has remnant hearing with this giant
mass and the absence of intracanalicular growth
of the mass, made the diagnosis more favorable
In the setting position with head tilted to look
to the left with moderated extension, a wide
osteoplastic craniotomy was performed over the
left cerebellar hemisphere, exposing during that
the left transverse sinus and the sigmoid sinus.
The tumor was attacked subtentorially. The
matrix of the meningioma could be seen starting
from the level of the left petrosal vein.
Intracapsular resection started and piecemeal
resection followed with coagulation of the
matrix of the tumor which was reaching the
tentorial edge. After debulking of the tumor
without applying any traction, with preservation
of the Dandy vein to control the level traction
of the left cerebellum by gravity. The tumor was
stuck to the vestibular nerve, but by sharp
dissection it was anatomically preserved to the
end of the operation. The major portion of the
tumor attached to left SCA was removed, except a
tiny remnant engulfing it at the level of the
tentorial edge , which was left intentionally to
avoid catastrophic sequelae. The trochlear nerve
was dissected and preserved.
The caudal part of the mass was dissected off
the vertebral artery and one of branches of the
accessory nerve. No attempt was made to violate
the facial nerve, so as not to expose it to
surgical trauma. It was hidden under the
petrosal and the preserved vestibular nerve.
The matrix of the tumor was stony hard and it
was decided to remove it. When this action was
started, it became clear, that the bone is under
the tentorium and it was removed by
Smith-Kerrison rongeur. That part of the bone
parallel to the superior petrosal sinus was left
in place to avoid possible fracture of the bone
with possible bleeding from the superior
petrosal sinus, which could be uncontrollable to
stop due bony involvement.
All the neural and vascular structures were
preserved and routine closure of the wound. The
bone reflected back to place and the patient was
extubated immediately after the operation, which
took 14 hours. The nystagmus increased after
surgery and there was noticeable left facial
The next day 16-January-2006, the patient is
fully conscious, ambulating with mild paresis of
the left facial nerve with with preserved
hearing and subsiding nystagmus. The left side
of the face is numb with hypalgesia.
CT-scan done showing complete resection of the
tumor with part of the hyperostosis left in
place at the anterior third of the left pyramid.
The patient after several days had deepening of
the facial paresis to paralysis and she was
followed for this over a year without
improvement for what she was operated
The patient has meningioma with involvement of
most of nearby neural structures. Careful
dissection can preserve their functional
Even with anatomical preservation of the facial
nerve, it happens that it continue to function
for several days, then the paresis gradually
progress over several days to complete paralysis
with inability to recover.
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Preoperative CT-scan showing the mass with hyperostosis of the left
petrous anterior third and calcified tentorium with preoperative MRI T1 W with contrast showing the tentorial edge
Immediate postoperative CT-scan demonstrating practical radical
resection of the tumor
Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .