A combination of pathologies - facet joint synovial cyst, epidural lipomatosis and conjoined nerve root anomaly in the lumbar spine of a 45-year-old patient. A case report

Facet joint synovial cysts are abnormal fluid-filled cystic formations that develop from a degenerative process of the facet joints. Spinal epidural lipomatosis is a process of excessive accumulation of fat in the epidural space. Conjoined nerve root (CNR) anomaly refers to an anatomical variation in which two adjacent nerve roots share a common dural sleeve. The aforementioned three rare pathologies cause the same pathological process of stenosis, therefore compressing the nervous structures. A 45-year-old female patient was admitted to the Department of Neurosurgery with severe low back and radicular pain, and numbness along her left leg. Antalgic posture, painful paravertebral muscle tenderness, L4 radiculopathy, and L5 and S1 dermatome hypoesthesia on the left as well as positive straight leg raising sign (Laseque) were present upon examination. CT and MRI scanning showed stenosis on L4-L5 level caused by bilateral synovial cyst formation. Microsurgical decompression by foraminotomy at L4-L5 level on the left with dissection of the synovial cyst and epidural lipomatosis was performed. In the course of the operation CNR anomaly was discovered. The complete decompression alleviated the symptoms and after 3 uneventful postoperative days the patient was discharged. Spinal stenosis causing compression upon nervous structures is a process that could be caused by a number of conditions. The incidence of rare pathologies and anomalies or even the more rarely occurring combination of them must be considered on daily basis in the clinical practice in order to make the correct diagnosis and plan the best possible treatment for the patient

Sialoendoscopic treatment of parotid gland diseases

In the present survey, the emergence of parotid gland endoscopy or sialoendoscopy as well as the most recent achievements of this minimally invasive technique for safe and effective treatment of salivary gland diseases are discussed. The results from some meta-analyses in this interdisciplinary field are briefly presented. The clinical applications of interventional sialoendoscopy in patients with chronic parotitis, in adults and children as well as with salivary gland stones are briefly presented

Brain Abscess in a Child. Case Report

Brain abscesses in children are rare, but can lead to severe complications, especially if they are not recognized and treated promptly.We present the clinical case of a four-year-old girl who was admitted in the Second pediatric clinic at St. Marina University hospital in Varna because of attacks of severe frontal headache, sometimes accompanied by vomiting. The child was first hospitalized at the Infectious disease clinic for a bacterial intestinal infection, but during the hospital stay the attacks became more frequent. After the child was discharged, the parents noticed that the movements of the left limbs were severely impaired, with the left leg being swayed during walking. At the Second pediatric clinic, the child was conscious, afebrile, with normal general exam, but with pronounced syndrome of meningeal irritation and with left hemiparesis. Blood tests showed evidence of bacterial infection. Computed tomography was performed, where a large cystic formation (70/50 mm) was visualized in the right cerebral hemisphere, corresponding to an abscess with severe dislocation, requiring surgery to be performed urgently. The child had a smooth post-operative period, with no evidence of infection and no seizures. The focal neurological signs regressed over the following few days. A repeat CT scan of the head showed complete evacuation of the abscess and reduction of the edema. The girl was discharged on the fifteenth day, in good overall condition, with no headaches, and with fully restored motor activity. We discuss the diagnosis, differential diagnosis, the role of timely imaging and the treatment applied for the good prognosis of the patient

Stereotactic neuronavigation-assisted evacuation of intracranial abscess localized in the thalamus. A case report

Introduction: A brain abscess is a localized focal area of intracerebral infection that develops into a collection of pus surrounded by a well vascularized capsule. It has a rare incidence of 2% of all space occupying lesions and the deep-seated thalamus as a location is reported in 1.3 to 6% of all brain abscesses. The use of stereotactic neuronavigation-guided surgical evacuation is a minimally invasive option for achieving good treatment results.Materials and Methods: A 67-year-old female with constant headache, vertigo, staggering and muscle weakness for the right leg developed memory problems and confusion few days prior to admission in the Department of Neurosurgery. Upon examination, raised intracranial pressure, right-sided spastic hemiparesis, and memory and cognitive disturbance were present. The laboratory results showed leukocytosis, elevated glucose, cholesterol and C-reactive protein levels. A computed tomography (CT) scan showed a circular ring-like lesion localized in the region of the left thalamus that enhanced its peripheral hyperdensity after contrast application. Neuronavigation-assisted surgical evacuation was executed. A biopsy needle was inserted in the left thalamic region and the evacuated sample was sent for pathological and microbiological examinations.Results: The lesion was verified as an abscess and antibiotic therapy was prescribed for 20 days based upon the isolated bacterium and its sensitivity.Conclusion: An abscess localized in the deep-seated region of the brain is a diagnostic and therapeutic challenge. Frameless neuronavigation-guided surgical procedure is an elegant option for minimally invasive approach that allows evacuation and additional examination for correct diagnosis and effective treatment

PET-CT visualization of intracranial lipomas

Intracranial lipomas are rare lesions, infrequently indicated for neurosurgical treatment due to their benign course and significant surgery-related complications rate. The aim of this study was to collect, describe and analyze the patients with intracranial lipomas verified by PET-CT and reported in the literature up to date. The literature search was performed through Pub Med using the combination of the terms intracranial lipomas, CT, MRI and PET-CT. The thorough review of the relevant papers did not find even one case with PET-CT images of intracranial lipomas. The first two personal illustrative cases were demonstrated by our report. The value of PET-CT in the primary and differential diagnosis of intracranial lipomas was analyzed, in comparison with CT, MRI and PET-MRI

Eosinophilic granuloma of the skull bone: a case report Langenharns cell granulomatosis

Eosinophilic granuloma is a rare benign tumor which is a variety of histiocytosis-X with unknown etiology. Eosinophilic granuloma occurs as single or multiple lesions of bone destruction. The eosinophilic granuloma of the skull can be asymptomatic or presented with pain and swelling. We present a clinical case of 20-years-old female patient who has entered the Neurosurgery clinic of “St. Marina” University Hospital with clinical manifestation of growing and painful tumor formation in the left frontal area for several weeks. MRI scan discovered evidence of a tumor formation on the left frontal side of the skull, suspicious for an eosinophilic granuloma. Under general anesthesia, an operative treatment was performed. Total extirpation of the tumor mass was achieved and cranioplasty with titanium mesh of the bone defect was performed. Posteratively, the patient had a good cosmetic effect, she was mobilized on the first day after the intervention and discharged from the hospital on the 5th day. Surgery-related complications were not observed. In the postoperative period the patient was followed-up by a hematologist. It is important and recommended for clinicians to include eosinophilic granuloma in the differential diganosis of bone lesions in patients because of the possible expansion of the disease if untreated. A follow-up of a year is necessary for possible recurrence

Cortical laminar necrosis after subarachnoid hemorrhage

Кортикалната ламинарна некроза е рядко наблюдавана при пациент след емболизиране на мозъчна аневризма. Съобщаваме случай на 51-годишна пациентка, която след емболизация на мозъчната аневризма на дясната средна мозъчна артерия остава в коматозно състояние.От извършения ядрено-магнитен резонанс имаше висок интензитет на сигнала в темпоралния лоб на мозъка на T2- изображенията, и линеарен хиперинтензитет по протежение на мозъчните кората на T1-изображенията с дифузно усилване на мозъчната кора.Cortical laminar necrosis has rarely been observed in a patient after coil embolization. We report a 51-year-old female patient who became comatose after the embolization of an aneurysm in the right middle cerebral artery. There were high signal intensities in the temporal brain on T2-weighted MRI images and linear hyperintensities along the cerebral cortices on T1-weighted images with a diffuse gyriform enhancement

Multiple proliferating trichilemmal cysts of the skalp: a case report. Multiple proliferating pilar tumors of the scalp

Proliferating trichilemmal cyst, also known as proliferating pilar scalp tumor, is a rare benign tumor of the hair follicle. While trichilemmal cysts are common intradermal or subcutaneous cysts, occuring in 5–10% of the population, only 2% will develop into proliferative trichilemmal cyst. The differential diagnosis should include lesions such as malignant proliferating trichilemmal tumor and squamous cell carcinoma. Surgical treatment is the only effective method for treating these rare cysts. We present a case report of a 78-years-old female patient who hasentered the Neurosurgery clinic of “St. Marina” University Hospital with clinical manifestation of rapidly growing from several months subcutaneous formation on the head and the presence of two smaller ones. MRI scan discovered three subcutaneous tumor formations suspicious for trichilem cysts, one of which was gigantic in size. After clinical discussion, under general anesthesia an operative treatment was performed with total extirpation of the cysts. Postoperatively, surgery-related complications were not observed. The patient was mobilized and verticalized on the day after intervention and discharged on the 5th day. As a result, a good cosmetic effect was obtained. Proliferating trichilemmal cyst is an uncommon neoplasm, and reporting of these lesions are important due to the good clinical evolution compared to the malignant macroscopic and microscopic feature of these tumor formations

Preventable Errors and Complications in Neurosurgery /// Предотвратими грешки и усложнения в неврохирургията

[EN] Based on a thorough literature review of the preventable errors and complications in neurosurgery, the purpose of this thesis is to develop and introduce into routine clinical practice a universal neurosurgical safety checklist. The checklist is designated for prevention of all types of wrong-site surgery in neurosurgery, for elimination of complications due to incorrect positioning of patients for neurosurgical intervention and of the complicating consequences of a failure of the devices required for every single neurosurgical procedure. Along with the above, the checklist aims to evaluate its own long-term results for patients’ safety in neurosurgery by comparing them with the results preceding the checklist introduction. Based on the performance analysis, we aim to accomplish eventual beneficial modifications of the universal neurosurgical safety checklist, and to submit the checklist for adjustment and application in the concerned neurosurgical centres. The study has been performed at the Neurosurgery Clinic at St. Marina University Hospital - Varna and rests on two research periods. The first one covers a period from March, 2011 to November 2012 (20 months), i.e. the time stretch from the opening of the Neurosurgery Clinic at St. Marina University Hospital – Varna, up to the introduction of the author’s unique for the world Universal neurosurgical checklist, and includes 396 operations. The second period is defined by the checklist being put into practice (November 2012), and expands till February 2015 (27 months). The second period is branded with 1089 surgical procedures based on the checklist.[BG] Настоящият дисертационен труд си поставя за цел, въз основа на обстоен анализ на литературата свързана с предотвратимите грешки и усложнения в неврохирургията, да разработи и да въведе рутинно в клиничната практика универсален неврохирургичен чеклист за предотвратяване на всички форми на хирургия на грешно място в неврохирургията, за елиминиране на усложненията дължащи се на некоректно позициониране на болните за неврохирургична интервенция, и на усложненията последица на неизправност на необходимите за специфичната неврохирургична интервенция устройства, да оцени неговите дългосрочни резултати за безопасността на пациентите в неврохирургията, както и да ги сравни с тези преди въвеждането на чеклиста. На базата на осъществения анализ да се реализират евентуални подобряващи модификации на универсалния неврохирургичен чеклист и той да се предостави за адаптиране и въвеждане на заинтересованите неврохирургични центрове. Проучването е проведено в Клиниката по неврохирургия на УМБАЛ „Св. Марина”, гр. Варна и включва два периода. Първият период, обхваща интервала от основаването на Клиниката по неврохирургия на УМБАЛ „Св. Марина“ през месец Март 2011 г. до въвеждането на авторския и уникален за света Универсален неврохирургичен чеклист през месец Ноември 2012 г. (20 месеца) и включва 396 операции. Вторият период, е от въвеждането на Универсалния неврохирургичен чеклист през месец Ноември 2012 г. до месец Февруари 2015 г. (27 месеца) и включва 1089 оперативни интервенции