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Frič R, Ringstad G, Eide PK. Low versus High Intracranial Compliance in Adult Patients with Chiari Malformation Type 1-Comparison of Long-Term Outcome After Tailored Treatment. World Neurosurg 2023; 173:e699-e707. [PMID: 36889634 DOI: 10.1016/j.wneu.2023.02.134] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/27/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND In patients with Chiari malformation type 1 (CMI) presenting with low intracranial compliance (ICC), foramen magnum decompression (FMD) often fails and the complication rate may be higher. We therefore routinely perform a preoperative assessment of ICC from intracranial pressure measurement. Patients with low ICC are treated with ventriculoperitoneal shunt (VPS) before FMD. In this study, we assess the outcome of patients with low ICC, compared with patients with high ICC treated with FMD alone. METHODS We reviewed the clinical and radiologic data of all consecutive patients with CMI treated between April 2008 and June 2021. ICC was assessed by overnight measurement of the pulsatile intracranial pressure: mean wave amplitude (MWA) above a previously defined threshold for abnormality was considered a surrogate marker for low ICC. The outcome was scored by Chicago Chiari Outcome Scale. RESULTS Of 73 patients, 23 with low ICC (average MWA 6.8 ± 1.2 mm Hg) received VPS before FMD, whereas 50 with high ICC (average MWA 4.4 ± 1.0 mm Hg) received only FMD. After a mean follow-up of 78.7 ± 41.4 months, 96% of all patients subjectively improved. The mean Chicago Chiari Outcome Scale score was 13.1 ± 2.2. Enlargement of cerebrospinal fluid space in the foramen magnum was achieved in 95% and regression of syringomyelia in 74% of cases. We found no significant difference in outcome between the patients with low and high ICC. CONCLUSIONS By identifying patients with CMI associated with low ICC and tailoring their treatment by VPS before FMD, we achieved favorable clinical and radiologic outcomes comparable to those with high ICC.
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Affiliation(s)
- Radek Frič
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.
| | - Geir Ringstad
- Department of Radiology, Oslo University Hospital-Rikshospitalet, Oslo, Norway; Department of Geriatrics and Internal Medicine, Sørlandet Hospital Arendal, Arendal, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
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2
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Alshamrani J, Qasim H, Alsuwaine H, Alotaibi F. Craniospinal subdural hygroma postdecompression for Chiari malformation: the slit valve mechanism. BMJ Case Rep 2021; 14:e244587. [PMID: 34380689 PMCID: PMC8359452 DOI: 10.1136/bcr-2021-244587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Jude Alshamrani
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
| | - Hiba Qasim
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
| | - Haifa Alsuwaine
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
| | - Faisal Alotaibi
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
- Neuroscience Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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3
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Han IB, Choi UY, Shin DE, Ropper AE, Choi DS, Ahn TK. Symptomatic posterior fossa and supratentorial subdural hygromas as a rare complication following transarticular screw fixation with posterior wiring for atlantoaxial instability: A case report. Medicine (Baltimore) 2019; 98:e14847. [PMID: 31305388 PMCID: PMC6641781 DOI: 10.1097/md.0000000000014847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Atlantoaxial transarticular screw fixation has been an effective and appealing method for inducing fusion of the C1-C2 complex. This technique is usually performed with Gallie fusion. In performing Gallie fusion using sublaminar wiring, a major concern is the risk of dural tear associated with passing sublaminar wires through the epidural space. We present the first report on symptomatic symptomatic subdural hygroma (SDH) due to transarticular screw fixation with posterior wiring. PATIENTS CONCERNS A 50-year-old man had sustained dens fracture 20 years ago and presented with severe neck pain following a recent traffic accident. The images showed atlantoaxial instability due to nonunion of the dens fracture and the patient underwent transarticular screw fixation with posterior sublaminar wiring using Gallie technique. When the U-shaped wire was passed under the arch of C1 from inferior to superior, a dural tear and cerebrospinal fluid (CSF) leak occurred. The site of dural tear was repaired by direct application of sutures. The patient was discharged in good condition. Fifteen day after surgery, the patient was readmitted with a history of a progressive headache associated with vomiting and vertigo. DIAGNONSIS Brain CT and MRI showed bilateral posterior fossa and a right-sided supratentorial SDH. INTERVENTIONS The patient underwent right occipital burr hole and evacuation of posterior fossa SDH due to deteriorating neurological status. OUTCOMES The patient's condition gradually improved after the operation and became asymptomatic at 3-year follow-up. LESSONS Posterior fossa and supratentorial SDH could occur resulting from any intraoperative dural tear and CSF leakage during posterior cervical spinal surgery. Symptomatic SDH after posterior cervical spinal surgery should be cautiously assessed and treated. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- In-Bo Han
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center
| | - Un Yong Choi
- Department of Neurosurgery, CHA University School of Medicine, CHA Bundang Medical Center
| | - Dong-Eun Shin
- Department of Orthopedic Surgery, CHA University School of Medicine, CHA Bundang Medical Center, South Korea
| | | | - Dae-Sung Choi
- Department of Orthopedic Surgery, CHA University School of Medicine, CHA Bundang Medical Center, South Korea
| | - Tae-Keun Ahn
- Department of Neurosurgery, Baylor College of Medicine, TX
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4
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Vivas AC, Shimony N, Jackson EM, Xu R, Jallo GI, Rodriguez L, Tuite GF, Carey CM. Management of hydrocephalus and subdural hygromas in pediatric patients after decompression of Chiari malformation type I: case series and review of the literature. J Neurosurg Pediatr 2018; 22:426-438. [PMID: 30028271 DOI: 10.3171/2018.4.peds17622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Hydrocephalus associated with subdural hygromas is a rare complication after decompression of Chiari malformation type I (CM-I). There is no consensus for management of this complication. The authors present a series of 5 pediatric patients who underwent CM-I decompression with placement of a dural graft complicated by posterior fossa hygromas and hydrocephalus that were successfully managed nonoperatively. METHODS A retrospective review over the last 5 years of patients who presented with hydrocephalus and subdural hygromas following foramen magnum decompression with placement of a dural graft for CM-I was conducted at 2 pediatric institutions. Their preoperative presentation, perioperative hospital course, and postoperative re-presentation are discussed with attention to their treatment regimen and ultimate outcome. In addition to reporting these cases, the authors discuss all similar cases found in their literature review. RESULTS Over the last 5 years, the authors have encountered 194 pediatric cases of CM-I decompression with duraplasty equally distributed at the 2 institutions. Of those cases, 5 pediatric patients with a delayed postoperative complication involving hydrocephalus and subdural hygromas were identified. The 5 patients were managed nonoperatively with acetazolamide and high-dose dexamethasone; dosages of both drugs were adjusted to the age and weight of each patient. All patients were symptom free at follow-up and exhibited resolution of their pathology on imaging. Thirteen similar pediatric cases and 17 adult cases were identified in the literature review. Most reported cases were treated with CSF diversion or reoperation. There were a total of 4 cases previously reported with successful nonoperative management. Of these cases, only 1 case was reported in the pediatric population. CONCLUSIONS De novo hydrocephalus, in association with subdural hygromas following CM-I decompression, is rare. This presentation suggests that these complications after posterior fossa decompression with duraplasty can be treated with nonoperative medical management, therefore obviating the need for CSF diversion or reoperation.
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Affiliation(s)
- Andrew C Vivas
- 2Department of Neurosurgery, University of South Florida, Tampa, Florida; and
| | - Nir Shimony
- 1Department of Neurosurgery, Johns Hopkins All Children's Institute for Brain Protection Sciences, St. Petersburg
| | - Eric M Jackson
- 3Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Risheng Xu
- 3Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - George I Jallo
- 1Department of Neurosurgery, Johns Hopkins All Children's Institute for Brain Protection Sciences, St. Petersburg.,3Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Luis Rodriguez
- 1Department of Neurosurgery, Johns Hopkins All Children's Institute for Brain Protection Sciences, St. Petersburg
| | - Gerald F Tuite
- 1Department of Neurosurgery, Johns Hopkins All Children's Institute for Brain Protection Sciences, St. Petersburg
| | - Carolyn M Carey
- 1Department of Neurosurgery, Johns Hopkins All Children's Institute for Brain Protection Sciences, St. Petersburg
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5
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Subdural Fluid Collection and Hydrocephalus After Foramen Magnum Decompression for Chiari Malformation Type I: Management Algorithm of a Rare Complication. World Neurosurg 2017; 106:1057.e9-1057.e15. [DOI: 10.1016/j.wneu.2017.07.112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 11/24/2022]
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6
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Prasad GL, Menon GR. Coexistent Supratentorial and Infratentorial Subdural Hygromas with Hydrocephalus After Chiari Decompression Surgery: Review of Literature. World Neurosurg 2016; 93:208-14. [DOI: 10.1016/j.wneu.2016.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 06/07/2016] [Accepted: 06/08/2016] [Indexed: 12/27/2022]
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7
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Benedetto N, Cagnazzo F, Gambacciani C, Perrini P. Subdural fluid collection and hydrocephalus following cervical schwannoma resection: hydrocephalus resolution after spinal pseudomeningocele repair: case report. J Neurosurg Spine 2016; 25:762-765. [PMID: 27391399 DOI: 10.3171/2016.5.spine16153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The authors report the case of a 31-year-old man who developed neck pain and headache 2 months after the uncomplicated resection of a cervical schwannoma. MR imaging revealed infratentorial subdural fluid collections and obstructive hydrocephalus associated with cervical pseudomeningocele. The clinical symptoms, subdural fluid collections, and ventricular dilation resolved after surgical correction of the pseudomeningocele. This report emphasizes that hydrocephalus may be related to disorders of cerebrospinal fluid flow dynamics induced by cervical pseudomeningocele. In these rare cases, both the hydrocephalus and the symptoms are resolved by the simple correction of the pseudomeningocele.
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Affiliation(s)
- Nicola Benedetto
- Neurosurgical Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Federico Cagnazzo
- Neurosurgical Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Carlo Gambacciani
- Neurosurgical Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Paolo Perrini
- Neurosurgical Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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8
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Ohya J, Chikuda H, Nakatomi H, Sakamoto R, Saito N, Tanaka S. Acute obstructive hydrocephalus complicating decompression surgery of the craniovertebral junction. Asian J Neurosurg 2016; 11:311-2. [PMID: 27366268 PMCID: PMC4849310 DOI: 10.4103/1793-5482.179643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Obstructive hydrocephalus has been described as a rare complication following foramen magnum decompression for Chiari malformation. However, there are few reports of obstructive hydrocephalus after spinal surgery for other pathologies of the craniovertebral junction (CVJ). The authors herein report a 52-year-old female with achondroplasia presenting with an 8-month history of myelopathy due to spinal cord compression at CVJ. She underwent resection of the C1 posterior arch and part of the edge of the occipital bone. A computed tomography (CT) scan obtained 1-week after the surgery revealed bilateral infratentorial fluid collection. The patient was first managed conservatively; however, on the 17th day, her consciousness level showed sudden deterioration. Emergency CT demonstrated marked hydrocephalus due to obstruction of the cerebral aqueduct. Acute obstructive hydrocephalus can occur late after decompression surgery at the CVJ, and thus should be included in the differential diagnosis of a deteriorating mental status.
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Affiliation(s)
- Junichi Ohya
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Ryuji Sakamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
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9
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Frič R, Eide PK. Perioperative monitoring of pulsatile and static intracranial pressure in patients with Chiari malformation type 1 undergoing foramen magnum decompression. Acta Neurochir (Wien) 2016; 158:341-7; discussion 346-7. [PMID: 26711284 DOI: 10.1007/s00701-015-2669-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with Chiari malformation type 1 (CMI) often present with elevated pulsatile and static intracranial pressure (ICP). The preferred treatment of CMI, foramen magnum decompression (FMD), is assumed to normalise ICP and craniospinal pressure dissociation. In order to further explore the mechanisms behind FMD, the present study investigated whether or not pulsatile and static ICP normalises immediately after FMD. METHOD The study included CMI patients undergoing FMD with perioperative ICP monitoring as a part of clinical management. The pulsatile and static ICP scores were retrieved from the department's ICP database, and the clinical and radiological data from the patient records. RESULTS Eleven patients were included in the study. During the first 3 days following FMD, mixed model analysis revealed no significant time-dependent differences of preoperatively elevated either pulsatile (mean wave amplitude, MWA; p = 0.85) and/or static (mean ICP, p = 0.90) ICP. Percentage of mean ICP >15 mmHg increased during days 2 and 3 after FMD. Two patients from the present series had to receive ventriculoperitoneal shunt after FMD in the early postoperative period. CONCLUSIONS The present observations suggest that anatomical restoration of cerebrospinal fluid pathways by FMD does not lead to immediate normalisation of preoperatively altered pulsatile and static ICP in patients with CMI. This finding may explain persistent symptoms during the early period after FMD.
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Affiliation(s)
- Radek Frič
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O.Box 4950, Nydalen, 0424, Oslo, Norway.
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O.Box 4950, Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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THAKAR S, DADLANI R, TAWARI M, HEGDE AS. Atypical Cerebellar Slump Syndrome and External Hydrocephalus following Craniocervical Decompression for Chiari I Malformation: Case Report. Neurol Med Chir (Tokyo) 2014; 54:567-71. [DOI: 10.2176/nmc.cr2013-0066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sumit THAKAR
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences
| | - Ravi DADLANI
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences
| | - Manish TAWARI
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences
| | - Alangar S HEGDE
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences
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Killeen T, Tromop-VAN-Dalen C, Alexander H, Wickremesekera A. Bilateral retrocerebellar arachnoid cysts exerting mass effect and associated with cerebellar tonsillar ectopia in an otherwise healthy adult. Neurol Med Chir (Tokyo) 2013; 53:266-9. [PMID: 23615422 DOI: 10.2176/nmc.53.266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rarely, midline or unilateral posterior fossa arachnoid cysts (ACs) exert local mass effect resulting in the symptoms and signs of cerebellar and brainstem dysfunction. These cysts are sometimes seen in conjunction with cerebellar tonsillar ectopia (TE), although the relationship between these two entities is unclear. Bilateral ACs in the posterior fossa are virtually unprecedented. We describe the case of a 33-year-old man with a history of multiple minor head injuries observed to harbour asymptomatic, bilateral cerebrospinal fluid-density collections over the cerebellar hemispheres. Six years later, he presented with headaches, limb paraesthesias, and drop attacks. Computed tomography, magnetic resonance imaging, and operative findings during burrhole drainage of the lesions showed bilateral posterior fossa ACs, with associated cerebellar TE of 11 mm. The cysts partially recurred, necessitating reopening of the burrholes, after which the patient's symptoms resolved entirely. We then discuss the challenges in diagnosing this unusual case, the relationship between AC and TE, and the role of minor head injury in the symptomatic progression of AC.
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Affiliation(s)
- Tim Killeen
- Department of Neurosurgery, Wellington Regional Hospital, Wellington, New Zealand.
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Klekamp J. Surgical Treatment of Chiari I Malformation—Analysis of Intraoperative Findings, Complications, and Outcome for 371 Foramen Magnum Decompressions. Neurosurgery 2012; 71:365-80; discussion 380. [DOI: 10.1227/neu.0b013e31825c3426] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Abstract
BACKGROUND:
Foramen magnum decompression is widely accepted as the treatment of choice for Chiari I malformation. However, important surgical details of the procedure are controversial.
OBJECTIVE:
This study analyzes 371 decompressions focusing on intraoperative findings, analysis of complications, and long-term outcomes.
METHODS:
Among 644 patients between 1985 and 2010, 359 patients underwent 371 decompressions. Surgery for symptomatic patients consisted of suboccipital craniectomy, C1 laminectomy, arachnoid dissection, and duraplasty. Short-term results were determined after 3 months; long-term outcomes were evaluated with Kaplan-Meier statistics.
RESULTS:
The mean age was 40 ± 16 years; mean follow-up was 49 ± 56 months; 75.8% demonstrated syringomyelia. The complication rate was 21.8% with permanent surgical morbidity of 3.2% and surgical mortality of 1.3%. Of the patients, 73.6% reported improvement after 3 months; 21% were unchanged. Overall, 14.3% demonstrated a neurological deterioration within 5 years and 15.4% within 10 years. The severity of neurological symptoms correlated with the grade of arachnoid pathology. Outcome data correlated with the number of previous decompressions, severity of arachnoid pathology, handling of the arachnoid, type of duraplasty, and surgical experience. First-time decompressions with arachnoid dissection and an alloplastic duraplasty resulted in surgical morbidity for 2.0%, a 0.9% mortality rate, postoperative improvement after 3 months for 82%, and neurological recurrence rates of 7% after 5 years and 8.7% after 10 years.
CONCLUSION:
Arachnoid pathology in Chiari I malformation has an impact on clinical symptoms and postoperative results. Decompressions with arachnoid dissection and an alloplastic duraplasty performed by surgeons experienced with this pathology offer a favorable long-term prognosis.
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Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Christliches Krankenhaus, Quakenbrück, Germany
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