Ivo Kehayov

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.

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.

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.

Thoracic Meningioma In Combination With Severe Lumbar Spinal Stenosis Presenting With Atypical Neurological Deficit.

Abstract We report on a case of a 47-year-old female patient with a long history of low back pain irradiating bilaterally to the legs. Twenty days before admission to our clinic, she had developed progressive weakness in the legs, more pronounced on the left side. The initial neurological examination revealed signs of damage to both the cauda equina and the spinal cord. The neuroimaging studies (computed tomography, myelography and magnetic-resonance tomography) found spinal stenosis most severe at L4-L5 level, and right lateral thoracic intradural-extramedullary tumor at T9-T10 level. The patient underwent two neurosurgical procedures. The first stage included microsurgical resection of the thoracic lesion and the second stage aimed at decompressing the lumbar spinal stenosis. To avoid missing a diagnosis of thoracic lesions, it is necessary to perform a thorough neurological examination of the spinal cord motor and sensory functions. In addition, further MRI examination of upper spinal segment is needed if the neuroimaging studies of the lumbar spine fail to provide reasonable explanation for the existing neurological symptoms.

Surgical management of metastatic tumors of the cervical spine

ABSTRACT OBJECTIVE: To present the results from the clinical presentation, the imaging diagnostics, surgery and postoperative status of 17 patients with cervical spine metastases, to analyse all data and make the respective conclusions and compare them with the available data in the literature. PATIENTS AND METHODS: The study analysed data obtained by patients with metastatic cervical tumours treated in St George University Hospital over a period of seven years. All patients underwent diagnostic imaging tests which included, separately or in combination, cervical x-rays, computed tomography scan and magnetic-resonance imaging. Severity of neurological damage and its pre- and postoperative state was graded according to the Frankel Scale. For staging and operating performance we used the Tomita scale and Harrington classification. RESULTS: Seven patients had only one affected vertebra, 4 patients - two vertebrae, one patient - three vertebrae, 2 patients - four vertebrae, and in the other 3 patients more than one segment was affected. Surgery was performed in 12 patients. One level anterior corpectomy was performed in 6 patients, three patients had two-level surgery, and one patient - three-level corpectomy; in the remaining 2 cases we used posterior approach in surgery. Complete corpectomy was performed in 4 patients, subtotal corpectomy was used in 6 patients and partial - in 2 patients. Anterior stabilization system ADD plus® (Ulrich GmbH & Co. KG, Ulm, Germany) was implanted in 2 patients; in 8 patients anterior titanium plate and bone graft were used, and in 1 patient - posterior cervical stabilization system. CONCLUSIONS: Because of the pronounced pain syndrome and frequent neurological lesions as a result of the cervical spine metastases use of surgery is justified. The main purpose is to maximize tumor resection, achieve optimal spinal cord and nerve root decompression and stabilize the affected segment. РЕЗЮМЕ ЦЕЛЬ: Представить результаты клинической кар- тины, образной диагностики, проведенного лечения и постоперативных результатов у 17 пациентов с метастатическими опухолями на шейном участке позвоночника, анализировать материал и сделать соответствующие выводы, которые сопоставляются с литературными данными. ПАЦИЕНТЫ И МЕТОДЫ: Анализированы данные лече- ния в клинике нейрохирургии, УМБАЛ им. «Святого Георгия», пациентов с метастатическими шейными опухолями в течение 7 лет. Во всех случаях проведена образная диагностика, включающая самостоятельно или в сочетании шейные спондилографии, компью- терную томографию и магнитную резонансную то- мографию. Тяжесть нейрологического повреждения и его динамику до и постоперативно определяли по классификации Frankel. В целях определения стадии заболевания и оперативного поведения использовали шкалу Tomita и классификацию Harrington. РЕЗУЛЬТАТЫ: У 7 пациентов поражен один позво- нок, у 4 - два соседних, у 1 - три, у 2 - четыре, а у остальных трех пациентов затронуто более одного сегмента. Оперативная интервенция проведена на 12 пациентах; корпорэктомия на одном уровне - на 6 пациентах; на двух уровнях - на трех пациентах; на трех уровнях - на одном больном; в остальных двух случаях применен задний оперативный доступ. Тотальное устранение достигнуто у 4 больных; суб- тотальное - у 6; парциальное - у 2. Стабилизация затронутых сегментов в двух случаях достигнута посредством системы ADD+ (Ulrich GmbH & Co. KG, Ulm, Germany); у 8 больных использованы тита- ниевая пластинка и аутотрансплантат, а у одного пациента - задняя шейна стабилизация. ВЫВОДЫ: Выраженный болевой синдром и частое поражение невральных структур метастазами в области шейного участка позвоночного столба оправ- дывают их оперативное лечение, при чем основной целью является максимальная резекция опухолевой массы, декомпрессия позвоночного мозга и корешков, а также и стабилизация пораженного сегмента.