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
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18-SEPTEMBER-2014 HIBA HAMED THAMER 30 YEARS
POSTERIOR THIRD OF THE III VENTRICLE TUMOR WITH SECONDARY HYDROCEPHALUS.
The patient came to clinic 13-September-2014
complaining of headache for 2 months,
bifronto-occipital localization without
asymmetry associated with blurred vision and
attacks of blindness, vomiting and episodes of
nausea with attacks of de ja vu with fainting
attacks. The condition is deteriorating. MRI of
the brain done 07-September-2014 showing upper
stem mass of bad quality, mostly posterior third
of the III ventricle.
On examination; the patient is swaying in
Romberg position. There is left hemihypalgesia
with weak four limbs more the left side. The
deep reflexes are more brisk in the left side.
SLRS was 80 degrees in the left because of
weakness. The left quadriceps is -3/5 and
the right is 3/5. The mother noting that the
patient is hallucinating some times.
MRI of the brain with contrast and MRA, MRV of
the brain with spectroscopy and DTI were
performed the same day, showing the tumor inside
the posterior third of the III ventricle,
pushing upward the deep cerebral veins. The
tumor is multi in consistency, but not invading
the surrounding structures and pushing the
mesencephalon down and the basal ganglii
Midline incision over the parietal and occipital
area with craniotomy to include both sides of
the postero-parietal and antero-occipital area.
The dura was opened parallel to the sagittal
sinus from the right and reflected to left.
Interhemispheric approach without scarifying any
running vein. Transcallosal approach was
achieved and the deep cerebral veins identified.
The tumor was highly vascular and
multiconsistency and was sent to frozen section
which gave the result of highly malignant
astrocytoma. The tumor was attacked until the
bed of the mesencephalon was seen and the right
lateral ventricle was under vision. It was felt
that total resection was achieved. The patient
was sent for MRI, which confirmed the presence
of almost 2/3 of the tumor still persisting in
the left side. The patient was brought back and
the left part of the tumor was removed. Both
lateral ventricles and the third ventricle and
the preserved deep cerebral veins were seen.
Inspection of the tumor cavity was inspected.
All the surrounding wall are normal brain
tissue. An external drain was left to the left
lateral ventricle and routine closure of the
wound was achieved.
Smooth postoperative recovery.
The patient was extubated immediately after
surgery and she is moving all limbs with good
communication, but with episodes name
The patient was doing well. When we started to
taper the Decadron, she got mutism and with
difficulty got verbal response, for what we
elevated the Decadron to 8 mg three times a day,
after what some improvement took place.
The final histologic result was anaplastic
The patient without intraoperative MRI
could be left with 2/3 of the tumor left behind. Do not ever
trust your sense. Always check when you are in doubt, even
when you are confident.
The patient will not need VPS since there
is communication through the callosotomy site.
Skyra MRI with all clinical applications in the run since 28-Novemeber-2013.
The World's first and the only Headmounted Microscope.
Freedom combined with Outstanding Vision, but very bad video recording and
After long years TRUMPF TruSystem 7500 is running with in the neurosuite at
Shmaisani hospital starting from 23-March-2014
Inomed MER system
Axial T1 with contrast.
Frontal T1 with contrast
Sagittal T1 with contrast.
Choline distribution showing a small nidus of possible malignant
Short Echo spectroscopy in favor of pinealoblastoma.
DTI showing no fibers inside the tumor mass.
Normal anatomy of the pineal gland
Same anatomy with reflected callosum.
The next intraoperative MRI showing total resection of the mass and
floating venous structures with deformed choroidal veins.
Sagittal and coronal vies showing the external drain and
a clot over the mesencephalon.
Postsurgical callosotomy due to transcallosal approach. Fibertraking
DTI showing the transcallosal approach in the posterior third. Done
Choline elevation confirming still persisting active sites
intermingled with the hematoma in the right side.
Choline/NAA ratio confirming the presence of active lesion at the
The hematoma in the bed of resected tumor.
Strict midline sagittal section showing the transcallosal approach
and abundant of venous structures and the hematoma.
Spectroscopy short TE showing low choline ratio? with high lipids
1.3 and 0.9.
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 .