the median survival rate reported for surgically treated patients with brain metastases from melanoma ranges from 5 to 22 months . the most significant factor influencing the survival of patients with brain metastases is the number of their cerebral metastases . surgical treatment of multiple brain metastases is only considered a palliative solution for improving the quality of life . however , recently the performance of multiple resections of brain metastases from melanoma has led to a reconsideration of the surgery s benefits . we report one case of multiple brain metastases from malignant melanoma with two large lesions located in the right frontal and left parietal lobes . this is a case report of simultaneous one - stage resections of distant lesions with two approaches for multiple metastatic malignant melanoma lesions . a 41-year - old woman had a mole in her right ear that grew noticeably , and swelling was detected in her right neck lymph nodes . aspiration biopsy cytology of the neck lymph node was performed , and malignant melanoma was diagnosed . she underwent an operative resection of the ear lesion , right neck lymph nodes and parotid gland with subsequent chemotherapy and radiotherapy . her level of consciousness had deteriorated , and she was transferred to our hospital 6 months after being diagnosed with malignant melanoma . on admission , her glasgow coma scale score was 11 ( e2v3m6 ) , and she had a right hemiparesis . additionally , symptoms of gerstmann syndrome such as finger agnosias , right - left disorientation , acalculia and agraphia were noted . computed tomography showed two large lesions in the right frontal lobe and left parietal lobe surrounded with severe brain edema ( fig . magnetic resonance ( mr ) images revealed that the two lesions were strongly enhanced with cystic change ( fig . 1b , c , f , g ) , and a small round lesion was present in the left head of the caudate nucleus ( fig . 1i ) . the subarachnoid space surrounding the left parietal lesion was also enhanced ( fig . ( 18f ) fluoro-2-deoxyglucose positron emission tomography ( ( 18f ) fdg pet ) exhibited high levels of accumulation in the two large lesions ( fig . 1d , h ) , but revealed no signs of metastatic lesions except in the brain . a , e : computed tomography images reveal right frontal and left parietal mass lesions . b , c , f , g : magnetic resonance ( mr ) images show right frontal and left parietal mass lesions as strongly enhanced on t1-weighted image with gadolinium ( b , f ) , and peripheral edema on the t2-weighted image ( c , g ) . d , h : ( 18f ) fluoro-2-deoxyglucose positron emission tomography images show high accumulations in right frontal and left parietal lesions . i , j : axial ( i ) and sagittal ( j ) of t1-weighted images with gadolinium revealed an enhanced , small mass lesion in the left head of the caudate nucleus ( i ) , and enhanced subarachnoid space surrounding the left parietal lesion ( j ) . first , the patient was placed in a prone position . a left parietal craniotomy and a parietal lesion resection were performed . the patient was then turned to a supine position under general anesthesia , after which a right frontal craniotomy and a frontal lesion resection were performed . both frontal and parietal lesions consisted of soft and fragile black tissues . both lesions were resected , but the malignant melanoma tissues in the subarachnoid space were residual ( fig . histological examinations showed typical numerous pleomorphic and hyperchromatic cells , which confirmed the diagnosis of metastatic malignant melanoma . a , b , c : intraoperative microscopic views show the black malignant melanoma tissues spread in subarachnoid space ( a ) , the border with normal brain was not clear ( b ) , and tumor tissues of subarachnoid space were residual ( c ) . her consciousness disturbance , right hemiparesis and symptoms of gerstmann syndrome could no longer be seen . she was discharged to her home 10 days after the operation , almost completely free of neurological deficits . following surgery , the patient received a course of whole brain radiation therapy consisting of 30 gy in 10 fractions , and chemotherapy at another hospital . then she presented with pain in her extremities , but there were no signs of bone metastases detected by fdg - pet and bone scintigraphy . mr images showed a mild enlargement of the left head of the caudate nucleus lesion , but no signs of problems around previous surgical resections ( fig . spinal mr images revealed a small mass lesion attached to the spinal dura mater at the atlas level ( fig . the patient presented with a generalized seizure and was again admitted to a nearby hospital . eventually , she was able to spend time with her family for 3 months at home . a - c : mr t1-weighted images with gadolinium show mild enlargement of the left head of the caudate nucleus lesion 3 months after the operation ( a ) , but not presenting recurrence as mass lesions at left frontal and right parietal lesions ( b , c ) . d - f : spinal mr t1-weighted images with gadolinium revealed a small mass lesion attached to spinal dura mater at the atlas level with no signs of spinal cord compression 3 months after operation . melanomas are the third most common source of intracranial metastases after breast and lung carcinomas . the incidence of central nervous system ( cns ) metastases in patients with melanomas ranges from 10% to 40% in clinical studies . cns metastasis is the most worrisome feature of malignant melanoma , leading directly to death in the majority of patients . the prognosis for patients with malignant melanoma brain metastasis is poor , with a median survival time ranging between 2 to 10 months . it is noteworthy that only 10% of patients survive more than 1 year after diagnosis . an important factor strongly influencing the therapeutic response of patients is the number of metastases . age , sex , and the time interval from the primary malignant melanoma manifestation to the cerebral metastasis seem not to affect the clinical outcome . prospective randomized trials have demonstrated the benefit of surgery for the treatment of a single metastasis in the brain . surgical therapy is ordinarily used for the majority of patients with a single metastatic lesion , but only a few selected patients with multiple metastases in the brain are treated surgically . recently , konstadoulakis et al . reported that the median survival time of surgical resection for multiple brain metastases was 8 months . they concluded that performing multiple resections of brain metastases from melanoma is considered a radical approach , especially in young patients with well - controlled systemic disease . the main aim of a simultaneous one - stage resection for multiple metastatic lesions is limited improvement in the quality of the patient s limited remaining life , so the indications are extremely limited . the two preconditions are that the patients are young and have well - controlled systemic disease , and that dramatic improvements of neurological symptoms may be expected following the resections . the surgical options for managing two intracranial lesions are influenced by the presence of another intracranial tumor . when two lesions are contiguous , they may usually be removed using a single approach , but when they are distant from each other , the surgical approach depends upon the type of lesions . when one tumor is malignant and the other is benign , the malignant tumor must be removed first . a second craniotomy may be performed at least 10 to 12 months later , when the benign tumor is large enough and/or symptomatic , or shows a tendency to grow . when the two lesions are malignant , large , or symptomatic tumors , both lesions may require early resection . in such cases , there is no consensus as to the best surgical management . in the present case , therefore , we selected simultaneous one - stage tumor resection with a left parietal craniotomy and a right frontal craniotomy , and found no adverse events associated with the simultaneous one - stage operation . the patient s surgical position must be changed under general anesthesia , and the operation time is longer , and more invasive . nevertheless , the significant reduction of intracranial pressure obtained by surgery may produce immediate and dramatic improvements of the patient s neurological symptoms . the superiority surgical treatment has over radiotherapy for managing multiple metastatic brain tumors is an immediate reduction in intracranial pressure . while our patient s survival period was not extended , her symptomatic improvements enabled her to return home and spend time with her family . because it improves the quality of the patient s limited remaining life , simultaneous one - stage tumor resection using two approaches is a viable option for the surgical management of multiple metastatic brain tumors , especially in young patients with well - controlled systemic disease .