The patient came to the clinic 24-April-2013 complaining of headache for 1 year with fainting attacks. The patient suffered partial seizures with secondary generalization 5 times during the last 2 months. The headache increasing during night with nausea and right upper limb numbness. CT-scan of the brain done 12-March-2013 showing a huge arachnoid cyst left sylvian cistern. He was operated for this cyst 15 years ago. The patient has lazy right eye. He is blind at this eye and has panophthalmoplegia right eye.

The patient was sent for investigations and given Tegretol 400 CR twice a day, but he came back 12-May-2014 with new MRI done 20-April-2014 showing a huge arachnoid cyst left sylvian cistern. The patient telling that he got 2 convulsions during the last 45 days. EEG done 13-April-2014 confirming epi activity over the left temporal region. The patient was not using medications and it was explained to him the importance of that.

The patient then came 22-May-2014 telling that his condition is deteriorating and he got 2 attacks and the headache is increasing. Kotral 500 mg twice a day was added, but the patient then came 24-May-2014 to the Emergency of Shmaisani hospital with fainting attacks and headache. He was admitted to the hospital and continuous EEG recording was done over 12 hours confirming the presence epi activity with in the left cerebral hemisphere.

The old incision in the left pterional region refreshed and the bone flap reflected to the ear. The dura was opened and the arachnoid sac followed down until the left ICA and left optic nerve and dissection of the arachnoidal layers was performed meticulously. The left M1 and its branches are running along the field. It was preserved and mechanically untouched to avoid possible spasm. Resection of the left temporal pole and left hippocampectomy was done. A thin layer of cortex was left near the course of the left M1 to avoid possible spasm. Strict hemostasis with routine closure of the wound.

Smooth postoperative recovery. The patient was sent to the ward. There is no further neurologic deficit.

The patient has 2 problems, need to be resolved: The mass effect of the growing arachnoid cyst and the epi activity. Both goal were achieved during surgery.