Borislav Kitov

Idiopathic septic arthritis of a lumbar facet joint associated with paraspinal abscess

A 48-year-old woman presented with a 1-month history of severe lower back pain on a background of 24 h of mild fever and general tiredness with an associated right-sided foot drop. Five weeks after the onset and with no improvement in symptoms in spite of analgesia and physiotherapy, the patient had a lumbar spine MRI which demonstrated a collection extending from the facet joints of L5 and L6 to the iliacus muscle on the right. A CT-guided aspiration was performed with a lengthy hospital stay for intravenous antibiotic treatment. The culture and sensitivity study of the aspirate isolated Streptococcus pneumoniae.

Postnatally Diagnosed Agenesis of Corpus Callosum in Fetuses

Objectives: To examine and characterize the agenesis of the corpus calosum (ACC) in an epidemiological study of fetal autopsies, as well as, to analyze the associated anomalies and to emphasize the importance of the clinical examination of ACC. Methods: The subjects of observation are 20 fetuses from a total of 2238 autopsies carried out during a period of three years (2006–2009) in Tunis. Results: The associated abnormalities are hydrocephalus, cerebellar hypoplasia, agenesis of vermis cerebelli, polymicrogyria and lissencephaly. Sixteen of the cases (80%) are syndromic: Trisomy 13,18,21 (5,1,2 fetuses respectively) and Thanatophoric dysplasia, Fetal akinesia syndrome, Dandy-Walker Malformation and the Association VACTERL are represented by two cases each. Conclusion: The prenatal diagnosis of ACC must be the result of a multidisciplinary approach. The phenotype of the XLAG syndrome creates an interest to study asymptomatic patients with ACC, especially when the anomaly is detected prenatally.

Neurocognitive impairments in brain tumor patients.

Abstract There is an increased scientific interest in cognitive impairments caused by brain tumors during the last decade. It has lead to the introduction and routine clinical usage of neuropsychological test batteries in brain tumor patients, thus making them an important clinical measure for the assessment of the efficacy of the different treatment regimens such as surgery, radiotherapy and chemotherapy. The effect of cognitive deficit on patients’ quality of life and survival has been unequivocally proven. These are among the most common neurological symptoms associated with brain tumors. The improvement in cognitive function and delay in neurocognitive decline are acceptable endpoints in clinical trials. Cognition has been demonstrated to be an independent predictor of survival in patients with cerebral neoplasms. РЕЗЮМЕ За последнее десятилетие наблюдается нарастаю- щий научный интерес к нарушениям познавательной способности, вызванным мозговыми опухолями. Это привело к введению и рутинному клиническому при- менению нейропсихологических тестовых методик у пациентов с этим заболеванием, при чем они превратились в клиническое средство оценки эффек- тивности примененных лечебных методов (оператив- ное лечение, лучетерапия, химиотерапия). Доказана значимость когнитивных нарушений, их влияние на качество жизни и их прогностическая стоимость для выживаемости пациентов. Они самые часто встречаемые неврологические осложнения, вызванные мозговыми опухолями. Улучшение когнитивной функ- ции и замедление когнитивного ухудшения рассмат- риваются как приемлемая цель при лечении этих пациентов. Наряду с этим когниция представляет и прогностический фактор выживаемости у паци- ентов с опухолями центральной нервной системы.

Spontaneous Spondylodiscitis - Epidemiology, Clinical Features, Diagnosis and Treatment

Abstract Spontaneous spondylodiscitis is a rare but serious infectious disease which is a combination of an inflammatory process, involving one or more adjacent vertebral bodies (spondylitis), the intervertebral discs (discitis) and finally - the neighboring neural structures. In most cases the condition is due to a hematogenous infection and can affect all regions of the spinal cord, but it is usually localized in the lumbar area. The most common clinical symptom is a pronounced, constant and increasing nocturnal paravertebral pain, while consequently different degrees of residual neurological symptoms from nerve roots and/or spinal cord may appear. The disease course is chronic and the lack of specific symptoms often prolongs the time between its debut and the diagnosis. This delay in diagnosis determines its potentially high morbidity and mortality. Treatment is conservative in cases with no residual neurological symptoms and consists of antibiotic therapy and immobilization. Surgical treatment is necessary in patients with neurological deficit, spinal instability or drug resistance.

Delayed Posttraumatic Unilateral Occipital Epidural Hygroma in Early Childhood

Delayed Posttraumatic Unilateral Occipital Epidural Hygroma in Early Childhood An extremely rare case of posttraumatic epidural hygroma in the left occipital supratentorial and infratentorial region is reported. A year and five months old child was admitted to the Clinic of Neurosurgery with sustained occipital head injury. She presented with drowsiness and vomiting due to intracranial hypertension. Initial computed tomography scan revealed left-sided fracture of the squamous part of the occipital bone without associated traumatic changes to the brain. A second spiral computed tomography scan was obtained two days later because of persisting symptoms of increased intracranial pressure. It demonstrated a newly formed left-sided epidural hygroma adjacent to the skull fracture in the left supratentorial and infratentorial occipital region. The case is discussed with emphasis on the mechanism of formation of epidural hygroma and an attempt has been made to outline the major predisposing factors leading to the development of this traumatic disease. Necessity for computed tomography follow-up is pointed out in order to diagnose delayed posttraumatic hygromas. The recommended surgical approach should include craniotomy centered at the site of the epidural hygroma and obligatory dural elevation by means of traction sutures to eliminate the posttraumatic epidural cavity. Травматическая односторонняя окципитальная гидрома замедлен-ного развития в раннем детском возрасте Представлен исключительно редкий случай трав-матической эпидуралъной гидромы в левой ок-ципиталъной, супратенториалъной и инфра-тенториалъной областях. Ребенок в возрасте 1 г. 5 мес. поступает в клинику нейрохирургии после травмы головы в затылочной области с симптомами повышенного внутричерепного давления, проявляющимися сонливостью и рвотой. Данные сканирования указывают на левостороннюю фрактуру сквамозной части окципиталъной кос-ти (другие очаговые повреждения мозговой па-ренхимы не наблюдаются). Два дня спустя из-за персистирования симптомов повышенного внутричерепного давления проведена контрольная спиральная компьютерная томография, указы-вающая на наличие данных о сформированной левосторонней эпидуралъной гидроме окципиталъной, супратенториалъной и инфратенториалъной ло-кализаций. Обращается внимание на механизм возникновения эпидуралъной гидромы и указывается на основные предрасполагающие факторы ее образования. Авторы указывают также и на необходимость в сканировании при подобных случаях. Рекомендуется оперативный метод лечения, включающий краниотомию в области эпидуралъной гидромы с обязательной поставкой дуропериостальных ниток в целях элиминации посттравматически сформированной полости.

Spontaneous chronic subdural hematoma in elderly people – Arterial hypertension and other risk factors

Background: The risk factors implicated in the genesis of chronic subdural hematomas include old age, alcoholism, diabetes mellitus, arachnoid cysts, coagulopathy, anticoagulant (ACTh) and antiplatelet drugs. However, no study has reported an association between arterial hypertension (HTA) and chronic subdural hematomas. Therefore, the aim of this study was to investigate whether HTA is a risk factor for spontaneous chronic subdural hematomas (SCSDHs). Methods: This multicenter study included patients aged over 60 years and was conducted from January 2009 to the end of 2015. One hundred and twenty‐two patients with SCSDHs and 111 controls treated for other reasons with no evidence of intracranial hemorrhages on brain computed tomography were enrolled. The patients were separated into three age subgroups to provide a better insight into the role of risk factors with age. Results: The average age in the SCSDH group was 74.45 ± 8.16 years, compared to 71.28 ± 6.69 years in the control group. The SCSDH group was significantly older than the control group (p = 0.0014). The patients in the 60–69 years age group diagnosed with SCSDHs had significantly higher rates of HTA (p = 0.0519), ACTh treatment (p = 0.0292) and alcoholism (p = 0.0300) than the control group. The patients in the 70–79 years age group diagnosed with SCSDHs had significantly higher rates of HTA (p = 0.0071) and ACTh treatment (p = 0.0158) than the control group. In the subgroup of patients older than 80 years, there were no statistical differences. Conclusion: The incidence of HTA had borderline significance in the patients aged 60–69 years with SCSDHs and statistical significance in the patients aged 70–79 years with SCSDHs. Anticoagulant therapy was the most significant risk factor. Among the patients with SCSDHs aged 60–69 years, the percentage of heavy drinkers was significantly higher than in the control group.

Mucocele of the Paranasal Sinuses – Retrospective Analysis of a Series of Seven Cases

Abstract Aim: The present study aimed at identifying the risk factors, typical clinical symptoms and applied treatment in seven cases with mucocele of the paranasal sinuses. Materials and methods: Seven patients suffering from mucocele of the paranasal sinuses were admitted to the Clinic of Neurosurgery and the Clinic of Ear, Nose and Throat Diseases between 2014 and 2016. There were 4 females and 3 males aged between 22 and 78 (95% CI [31.44, 70.23]). Initial symptoms, their duration, clinical presentation upon admission, localization of the mucocele, type of surgical intervention and outcome have all been studied. Results: The localization of the mucocele was frontal (2 cases), fronto-ethmoidal (2 cases), ethmoidal (1 case) and spheno-ethmoidal (2 cases). Risk factors were identified in 4 cases. Endoscopic marsupialization of the mucocele was performed in 5 cases. One patient with intracranial extension of frontal mucocele was treated via right frontobasal craniotomy. One of the patients refused surgery. Conclusion: Endoscopic marsupialization should be considered as a method of choice in cases with mucoceles without extensive intracranial invasion. This approach offers adequate drainage, balloon dilatation of the natural sinus openings that prevents future recurrence.

Spontaneous Direct Carotid-Cavernous Fistula in an Elderly Patient

Abstract We describe the case of an 83-year-old woman with left-sided ophthalmoplegia. She had no family history of connective tissue disease. The computed tomography study found a dilated left cavernous sinus. The conventional cerebral panangiography confirmed the diagnosis - a direct carotid-cavernous fistula (CCF), with no evidence of ruptured aneurysm. The woman underwent endovascular treatment with coiling of the cavernous sinus in combination with application of the Onyx embolic agent in the fistula. During the first 48 hours after the embolization the local pain, exophthalmos and conjunctival injection of the left eye were significantly ameliorated. The pulsatile tinnitus on the left disappeared and the ptosis of the left eyelid partially recovered. Selective angiography is the best method for the diagnosis and classification of CCF. Currently, treatment is possible with low mortality and morbidity rates. The endovascular intervention is able to completely occlude the fistula and maintain adequate blood fl ow through the carotid artery.

Mucocele of the Sphenoid Sinus

Abstract Mucocele of the paranasal sinuses is a rare disease with slow evolution. It is a benign, encapsulated and destructive formation filled with mucous fluid and tapistrated with respiratory epithelium. Of all the paranasal sinuses, the sphenoid sinus is affected in only 1-7% of the cases. We present two cases of mucocele of the sphenoid sinus involving the posterior ethmoidal cells. We consider here their clinical presentation, use of neuroimaging in the diagnosis, surgical care and postoperative results. Both patients presented with a history of persistent headache and in addition, one of them had a paresis of the right oculomotor and abducens nerves. A transnasal endoscopic sphenoidectomy was performed in both patients, in one - with an evacuation of the mucocele and marsupialization, and in the other - with a balloon dilatation of the natural foramen of the sinus. Postoperatively, a complete reversal of the symptoms was observed in both patients. Mucocele of the paranasal sinuses should be considered as a diagnosis in cases of persistent headache with a primarily retrobulbar location and eye symptoms. Computed tomography and magnetic resonance imaging can be used to successfully diagnose the disease. The transnasal endoscopic sphenoidectomy is the therapeutic method of choice which allows evacuation of the mucocele, while the marsupialization allows good drainage and prevents recurrence.

Initial Experience with O-Arm Navigated Spinal Surgery - Report on Two Cases.

Abstract Image-guided spinal surgery is becoming increasingly popular because it allows surgeons to achieve minimal invasiveness and maximum precision in the performed procedures. We present our initial experience with two cases operated on using O-arm-based spinal navigation at the Clinic of Neurosurgery in St George University Hospital, Plovdiv, Bulgaria. In the first case, we performed removal of extradural spinal tumor of the sixth thoracic vertebra and O-arm-navigated pedicle screw fixation. In the second case, we performed O-arm-navigated corpectomy of the fifth cervical vertebra and anterior spinal reconstruction and fusion with titanium expandable mesh and cervical plate in connection with degenerative narrowing of the cervical spinal canal that lead to clinically manifested myelopathy. The initial experience allows us to conclude that O-arm-based image-guided spinal surgery can lead to considerably higher precision of spinal instrumented procedures. At the same time, it reduces the irradiation dose of the patient and surgical team.