Yavor Enchev’s research while affiliated with Medical University of Varna and other places

Background: Decompressive Hemicraniectomy (DHC) is a potentially life-saving operation with controversial indications. Complications related to this procedure include bleeding, brain herniation and in the post-operative period include damage to the unprotected parenchyma of the brain and infections. A few techniques exist with all of them agreeing that opening the dura is essential. Methods: A clinical series comprising of 16 patients with stroke who underwent surgical treatment for the period from 2012 to 2023 due to malignant brain edema (MBE). In all a DHC was performed in the first 48 hours after the MBE was confirmed with computed tomography (CT). Glasgow Coma Scale (GCS) on admission and Glasgow Outcome Scale (GOS) postoperatively were assessed. Results: Average surgical duration was two and a half hours. DHC was performed in ten of the cases on the right part of the cranial vault, six on the left part of the cranial vault. Ten patients had middle cerebral artery infarction. Five patients had thrombolysis and thrombectomy prior. All the patients had VII and XII cranial nerve paresis and contralateral hemiparesis. Only four patients had GCS between 12 and 15 points and the other had GCS lower than 9 points. Nine patients had a GOS=1, three had GOS=3, two GOS=4 and two had GOS=5 Conclusions: DHC outcomes depend on preoperative GCS and on time between first clinical signs and operative treatment. Postoperative intensive care and rehabilitation is vital.

Objective: The aim of this study was to examine the effects of bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) on motor symptoms and quality of life (QoL) in patients with advanced Parkinson Disease (PD) receiving treatment at the University Hospital "St. Marina" in Varna, Bulgaria. Background: Bilateral STN-DBS surgery may be highly beneficial for patients with advanced Parkinson's Disease (PD) who have refractory tremor, dyskinesia, or motor fluctuations. While DBS significantly improves motor symptoms, the overall effect on QoL is more difficult to predict and is influenced by multiple factors, such as non-motor symptoms and comorbidities. Methods: Twenty-four individuals (17men and 7women) with a mean age of 61.7±7.5 and a mean time from first symptoms of 10.2±3.9 years were included in the study. The participants' quality of life (QoL) was assessed using the Parkinson Disease Questionnaire (PDQ-39) and the Unified Parkinson's Disease Rating Scale (UPDRS) at 3, 6, 12, and 24 months following the DBS surgery. Evaluations of the post-surgical UPDRS were conducted with stimulation turned on. Results: Compared to the pre-DBS state, the motor and overall UPDRS scores in the DBS-ON state showed a significant (p<0.001) improvement throughout the course of the two-year follow-up period (Table 1). Upon examining each patient individually, we discovered significant variations in the motor and total UPDRS score dynamics, which can be explained by individual features of the patients, and neurostimulation constraints (Figure 1). With the exception of one patient who experienced severe non-motor symptoms, all patients' overall QoL dramatically improved throughout the first year of follow-up (p<0.001) (Figure 2). Up to 18 months after surgery, we observed a steady improvement in both motor functioning and QoL, with a slight trend for QoL deterioration beyond this time (p=0.034). In spite of this, the average PDQ-39 score was still higher than it was prior to the DBS. There was a positive correlation between the changes in the motor UPDRS and thePDQ-39 score (Figure 3). Conclusion: Bilateral STN-DBS is a highly effective treatment for advanced PD patients leading to significant improvement of their motor activities and QoL up to 2 years post-surgery. There was evidence of a positive correlation between the motor UPDRS and the overall QOL measured by PDQ-39.

The neural tube abnormality known as split cord malformation (SCM) is characterized by longitudinally separated functional hemicords. SCM is the result of a single basic ontogenetic error and may be associated with other anomalies. One such anomaly is Klippel-Feil syndrome (KFS), which is characterized by abnormal fusion of two or more cervical vertebrae. We present the case of a 15-year-old boy with a history of mandibular deformity, neck pain, and stiffness. Diagnostic imaging revealed type II cervical SCM, KFS, C1 vertebral arch anomaly, thoracic syringomyelia, and S1 paraspinous cleft. He was treated symptomatically with ultrasound-guided intramuscular injection of botulinum toxin (BT). Follow-ups showed that the treatment had a good effect on pain and stiffness, and an improvement in head posture was also achieved. Seven months after the first injection, a second injection was performed because the effect of BT diminished. In this report, we present the first case of cervical SCM type II associated with KFS treated symptomatically with BT injection. This is also the first reported case in a male patient; only 10 cases with both anomalies have been published in PubMed, and all of these cases are in females.

ntroduction: Vertebroplasty is a minimally invasive neurosurgical procedure for the treatment of osteoporotic vertebral compression fractures. Implementing multilevel systems is still a subject of debate. Aim: To examine the effectiveness and safety of vertebroplasty at 4 or more levels by analyzing clinical outcomes. Materials and Methods: The study was carried out at the Neurosurgery Clinic, UMBAL "St. Marina", Varna, Bulgaria for a period of 3 years (2020-2023). The clinical material included 39 patients (7m/32y) with osteoporotic vertebral compression fractures and ASIA scale E treated by vertebroplasty (167 vertebrae in total). VAS was applied to evaluate clinical outcomes, as well as CT scan and X-ray to evaluate vertebral height correction and kyphotic deformities. All patients were followed for a period of 2 months and examined for the presence of new fractures, morbidity or mortality Results: The reported, re-operative values of 6.62 t and post-operaverage operating time is approximately 55 minutes. Excelwith plent clinical results according to VAS were ative values of 2.14 t. The average value for restoring vertebrae height and correcting kyphotic deformity is about 4-5 degrees. Cement leakage into the spinal canal, large vessels, or intervertebral disc spaces is a common occurrence in approximately 50% of cases. In the series, there were no cases that underwent open revision and tmorbidity. In here were no documented cases of disease-related 7 patients, a new fracture caused a repeat vertebroplasty. The mortality rate was 5.1% (2 patients) and it occurred in one case due to Covid-19 and PE two weeks after surgery, and in the other due to an acute heart problem 30 days after discharge Conclusion: In patients with osteoporotic compression fractures, vertebroplasty of the fourth or more levels can be a safe and effective solution to reduce the pain syndrome and return to a normal lifestyle. Unfortunately, it is associated with minimal restoration of vertebral height and correction of kyphotic deformity. The high percentage of cement leakage during multisegmental vertebroplasty is not clinically significant and does not lead to a new surgical intervention.

Intraorbital foreign body (IOFB) is a vision-threatening condition that requires careful management. IOFB can manifest clinically from asymptomatic up to severe inflammation and blindness. Diagnosis and treatment are determined by the nature of the IOFB. The type, location, and complications related to the IOFB are taken into consideration when planning the surgery. Here, we report the case of a male in his 20s who was admitted to our clinic with a computed tomography (CT) scan which verified the presence of an IOFB. The patient underwent surgery and the IOFB was removed. Using a surgical navigation system (SNS), it was difficult to pinpoint the IOFB precisely during surgery. We took radiographs with a C-arm to improve our orientation and locate the IOFB. The patient recovered uneventfully, and no issues were noticed one month following surgery. This case report highlights the selection of treatment methods and demonstrates when radiographs can be more helpful than an SNS in the removal of the IOFB.

Introduction: Multiple myeloma (MM) is a cancer of the bone marrow's plasma cells that often affects the vertebrae and can lead to pathological fractures, instability and neurological deficit. Percutaneous vertebroplasty (PV) is a minimally invasive procedure in which medical cement is injected into fractured vertebrae, stabilizing the spine, and thus alleviating pain. Materials and Methods: A clinical series comprising of 15 patients (6m and 9f) undergoing surgical treatment for the period from 2018 to 2024. In all patients preoperative CT scans were performed. Ten of these patients have not been diagnosed with MM prior to their admission in the clinic. Patients were followed up neurologically and evaluated by VAS scale before and after surgical intervention. Results: The average operative time was 50 minutes. In 7 patients cement leakage occurred with no clinical significance. The most operated vertebrae were in thoracolumbar region (58% of every operated vertebrae). The average preoperative VAS score was 6.6p. and the postoperative was 2.1p (68% decrease in VAS score). Discussion: In patients with multiple vertebral fractures MM should be considered as a differential diagnosis. In order for this to happen additional blood and urine samples should be processed. In patients with multileveled PV with MM the risk of cement leakage is higher. In patients with MM pain is only partially alleviated due to the involvment of other bones. Conclusions: Multileveled PV is an effective way to treat pain from pathological vertebral fractures but even after this surgical treatment patients require hematological follow-up exams and treatment.

Background Bertolotti syndrome (BS) is defined as a congenital anomaly of the spine that includes sacralization of the lowest lumbar vertebra or lumbarization of the first sacral vertebra (i.e., lumbosacral transitional vertebra- LSTV) and the pain associated with this condition. The incidence of BS in adolescence is rare; we found only three such case reports of patients under the age of 18 in the literature, here will add a fourth. Case Description A 17-year-old female presented with a 2-month history of low back pain exacerbated by physical activity. Her neurological examination was normal, except for pain elicited when applying pressure over the sacroiliac joints bilaterally, and over the spinous process of the L5 vertebra. The computed tomography scan documented BS: (i.e., LSTV – Castellvi classification: Type IIa on the left side). She was successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs) alone. Conclusion Here, we report a 17-year-old female who was symptomatic from BS and was successfully treated with NSAIDs.

Introduction: Vestibular schwannomas are benign tumors arising from the 8th cranial nerve with a varying natural history. Cystic vestibular schwannomas (VS) form are a rare benign subgroup that diffeers the solid variant clinically and radiologically. Certain unique features of the cystic VS are larger size, clinical presentation with atypical symptoms such as dysgeusia, vertigo, facial pain and etc. The symptoms can have a rapid progression and a short duration. Case Presentation: We present a clinical case of a 67-year-old male patient who has entered the Neurosurgery clinic of University Hospital „Saint Marina '' with clinical manifestation of progressive facial numbness, faltering, instability, change in taste and ataxy from several months. MRI has discovered a tumor formation in the right pontocerebellar angle suspicious for schwannoma. Under general anesthesia, a right suboccipital craniectomy with retrosigmoid approach was performed. Through microsurgical technique, a yellowish-white cystic tumor formation was found with a clear outline of the surrounding parenchyma, moderately bleeding. Subtotal extirpation of the tumor formation by microsurgical technique under neuronavigation was followed. Postoperatively, the patient was verticalized on the day after intervention. Surgery-related complications were not observed. The patient was without an added neurological deficit. He had relief of his symptoms and he was discharged on the 5th day Discussion: The differential diagnosis for cystic VS includes squamous cell cyst, arachnoid cyst, neurenteric cyst, dermoid cyst and lipoma. In their study Nair S. et. al found that cystic VS have poor surgical outcomes with a higher incidence of subtotal tumor excision. Subtotal resection has been achieved in our patient due to displacement of the facial nerve. VS can be treated through observation, surgical removal, or radiosurgery. Benech et. al recommend sharp dissection techniques in order to separate the peritumoral adherences in order to avoid injury to the facial nerve. In our case, we also used the sharp dissection technique, which correlated with Benech et. al Conclusion: Cystic VS are a rare subgroup of VS presenting with short duration and rapid progression of symptoms with frequent facial nerve involvement due to the expansion of the cystic elements. The resection of cystic VS is complicated due to peritumoral adhesions of the capsule to the 8th cranial nerve and the large size of the tumor. Our recommendations are subtotal resection, especially in type B- anterior and medial placed cysts, in order to preserve facial nerve integrity.

Gliosarcoma(GS) is a rare high-end malignant tumor that is highly aggressive and is accompanied by a poor prognosis in most instances. It is an unusual subtype of glioblastoma multiforme(GB). In most cases it is hardly distinguishable from a GB therefore a histological analysis is mandatory for an accurate diagnosis. GS has unusual features such as: biphasic configuration, constituting a define, separate glial and sarcomatous differentiation. There are a lot of conflicting reports regarding the aggressiveness of GS. Here, we present a case of a 71 year old male who presents to the clinic of “Saint Marina” University Hospital with a severe headache that has been going on for a few weeks accompanied by moments of dizziness and disorientation. Through an MRI of the brain a tumor formation was imaged. Under general anesthesia a craniotomy was performed and through a microsurgical technique with neuronavigation a total extirpation of the tumor mass was achieved. Postoperatively the patient had neurological improvements. Started moving the first day after the intervention and discharged on the 7th day. Keywords: case report, gliosarcoma, MRI, glioblastoma multiforme