A 45-year-old female presented with a 1-year history of headaches and recent onset of vision loss, smell loss, and urinary incontinence. Examination found visual impairment, anosmia, and papilledema in one eye with optic atrophy in the other. Imaging revealed a likely anterior skull base tumor involving the frontal lobe, with differential diagnoses including meningioma, pituitary adenoma, or fungal infection. The patient underwent a bifrontal craniotomy for tumor excision. Postoperative complications can include issues like CSF leak, hemorrhage, or deficits in motor function or vision. Long-term outcomes depend on factors like the tumor grade, extent of resection, and use of radiation therapy

1. DR.MUMTAZ ALI
DEPARTMENT OFNEUROSURGERY
JPMC KARACHI

2. History
45 years old female Miss Noor Khatoon, married ,
housewife ,left handed , resident of karachi with NKCM
admitted via OPD with c/o :
 Headache for 1 year
 Decreased vision in both eyes for 2 months
 Loss of smell 2month
 Urinary incontinence 2month
 No history of weakness, seizures , speech difficulty
,dec hearing

3.  According to pt she was alright 1 year back then
she developed headache gradual in onset ,diffuse
in nature involve whole head , moderate intensity
,continous , progressive ,usually occuring in
morning time aggravated by bending farward ,
coughing straining , micturition and defecation
and relieved by vomitting and painkillers.It is
associated with vomitting and dec vision

4.  She has dec vision in both eyes since 2 months which
is gradual , in all fields ,near complete ,progressive .she
can see only light .she has no orbital pain , visual
hallucination.
 She has loss of smell since 2 months which is on both
sides.it is gradual and progressive.No hx of trauma ,
allergic rhinitis ,DNS.
 She has urinary incontinence for 2 months which is
gradual and progressive.she cann’t hold urine.it also
occurs on coughing.

5.  She has changed behaviour ,anxious , aggressive .she has
lost intrest and will in domestic issues and work
 No hx of memory loss ,combing , buttoning , calculation.
 No hx of fever , night sweats ,weight loss, TB contact ,
trauma.
 No hx of fascial numbness ,weakness , change in voice and
difficulty in swallowing ,climbing stairs,drop attack.
 Cerebellar symptoms ,endocrine symptoms ,respiratory ,
cvs , abdominal , genitourinary, MSK are absent.
 No significant past medical and surgical hx , personal hx ,
family hx , socioeconomic hx , drug hx, allergic hx and
menstrual hx.

6. LEVEL and D/D
 LEVEL : anterior skull base involving frontal lobe
 D/D :
 Olfactory groove meningioma
 Pitiutary adenoma
 Planum sphenoidal meningioma
 Tuberculum sella meningioma
 Fungal infection

7. Examination
 A middle age pt , well dressed ,ill looking ,anxious ,
depressed mood ,not oriented with time ,place and
person with normal built and height with canula in
right hand with following vitals and non vitals
 Pulse : 78 bpm , BP : 120/80 mm hg , RR : 16
breaths/min , T: A/F
 Pallorness , clubbing , koilynchia dehydration , cynosis
, jaundice , lymphadenopathy , edema not present.
 No buldge on scalp palpation scar mark of Vp shunt
present on head
 No thydroid swelling is palpated on deglutition

8.  MME 25/30
 Primitive reflexes absent
 Pronator drift absent
 Judgement and abstract thought affected
 Calculation , reading , writing , memory unaffected
 Anosmia present bilaterally
 She percieve only light
 Fundoscopy : right : papilledema , left : optic atrophy
 Plantars upgoing bilaterally
 Other cranial nerve,cerebellar examination unremarkable

9.  Motor examination : unremarkable
 Sensory examination : unremarkable
 Systemic examination : unremarkable
 LEVEL : anterior skull base involving frontal lobe
 D/D :
 Olfactory groove meningioma
 Pitiutary adenoma
 Planum sphenoidal meningioma
 Tuberculum sella meningioma
 Fungal infection

10. Investigations
 Specific :
 CT scan brain
 MRI brain with contrast
 CT angiogram
 Relevant :
 Visual perimetry
 Routine :
 CBC ,suce , PT/APTT/INR , Hep b and c , CXR

22. Management
 Admission
 Counsellin g
 Optimization
 Preop care
 Surgery : Bifrontal craniotomy and excision
 Postop care
 Followp
 Rehabilitation
 Outcome

23. Bifrontal craniotomy
 Shifting : shifted to ot counselling and consent
 Position : Supine , head is extended to 15 degree , pressure points padded ,
thorax elevated.head us fixed with mayfield head holder
 Equipment : Microscope , cusa , bipolar ,dropler u/s
 Incision : Bicoronal
 Craniotomy : Bifrontal
 Bilateral orbital osteotomy :
 Durotomy : low lying
 Microscopic dissection :
 Interupption of blood supply
 Intracapsular disection
 Extracapsular discetion
 Hemostasis
 Dural repir
 Wound closure

24. Complication
 Intraoperative :
 Injury to ACA
 Injury to SSI
 Injury to frontal sinus
 Injury to speech area
 Injury to optic nerve , ICA
 Postoperative complication :
 Frontal sinusitis , mucocele
 CSf leak
 Hematoma
 Motor Speech deficit
 Complete visual loss
 Craniotomy complications

25. Outcome
 Vision will not improve
 5 year survival = 91%
 Recurrence rate = 37 – 85%
 According to extent of resection :
 Total resection = 4%
 Subtotal resection with radiotherapy = 32%
 Subtotal resection without radiotherapy = 64%
 According to WHO grade , MIB- index , KI-67 index :
 Who grade 1 , MIB-index / KI-67 index : 0.7% = 9%
 Who grdae 2 , MIB-index / KI-67 index : 2.1% = 29%
 Who grdae 3 , MIB-index / KI-67 index : 11% = 50%
 According to simpson grdaing :
 Grade 1 : 9%
 Grade 2: 19%
 Grdae 3 : 29%
 Grade 4 : 39%
 Grade 5 : 100%

26. Thank you