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Heiss JD. Cerebrospinal Fluid Hydrodynamics in Chiari I Malformation and Syringomyelia: Modeling Pathophysiology. Neurosurg Clin N Am 2023; 34:81-90. [PMID: 36424067 PMCID: PMC9708110 DOI: 10.1016/j.nec.2022.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Anatomic MRI, MRI flow studies, and intraoperative ultrasonography demonstrate that the Chiari I malformation obstructs CSF pathways at the foramen magnum and prevents normal CSF movement through the foramen magnum. Impaired CSF displacement across the foramen magnum during the cardiac cycle increases pulsatile hindbrain motion, pressure transmission to the spinal subarachnoid space, and the amplitude of CSF subarachnoid pressure waves driving CSF into the spinal cord. Central canal septations in adults prevent syrinx formation by CSF directly transmitting its pressure wave from the fourth ventricle to the central canal.
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Affiliation(s)
- John D Heiss
- Clinical Unit, Surgical Neurology Branch, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Drive, Room 3D20, MSC-1414, Bethesda, MD 20892, USA.
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Kilgore MD, Mathkour M, Dunn RH, Scullen T, Gouveia EE, Shapiro SZ, Glynn R, Tubbs RS, Bui CJ. Spontaneous resolution of syringomyelia following pregnancy and parturition in a patient with type I chiari malformation: A case and systematic review. Clin Neurol Neurosurg 2022; 222:107413. [PMID: 36049402 DOI: 10.1016/j.clineuro.2022.107413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 07/30/2022] [Accepted: 08/11/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Spontaneous resolution of syringomyelia has rarely been reported in the literature. Rarer still are cases wherein this process is associated with pregnancy and parturition. We review theories on syringomyelia development and spontaneous resolution to better understand the role pregnancy and parturition may play in both processes. METHODS We present a 30-year-old female with MRI-confirmed spontaneous syrinx regression following caesarean delivery of a full-term pregnancy. We additionally review the literature to identify previously reported cases of spontaneous syrinx regression both independent of and associated with pregnancy. RESULTS Including the present case, 39 cases describing spontaneous regression of syringomyelia have been reported in the literature, of which only four are associated with pregnancy and parturition. 75% of all reported cases were associated with type I Chiari malformation, though several disorders of the craniocervical junction and spinal canal were implicated. Complete syrinx regression was achieved in 33.3% of cases and 5% of cases described recurrence of syringomyelia following the spontaneous resolution. CONCLUSION Syringomyelia likely develops due to disturbance of the physiologic flow of cerebrospinal fluid around the craniocervical junction and the obex. Several mechanisms including fissuring of the spinal cord parenchyma and reduction of subarachnoid scarring are likely involved in this process. In the setting of pregnancy, additional mechanisms surrounding the increased intraabdominal forces imparted by a growing fetus, Valsalva-like strain experienced during labor, and hemodynamic changes that occur to accommodate gestation are likely implicated. Nevertheless, patients should continue to be monitored periodically for syrinx recurrence.
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Affiliation(s)
- Mitchell D Kilgore
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Mansour Mathkour
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA; Department of Neurosurgery, Ochsner Neuroscience Institute, New Orleans, LA, USA.
| | - Rachel H Dunn
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Tyler Scullen
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA; Department of Neurosurgery, Ochsner Neuroscience Institute, New Orleans, LA, USA.
| | - Edna E Gouveia
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Stephen Z Shapiro
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA; Department of Neurosurgery, Ochsner Neuroscience Institute, New Orleans, LA, USA.
| | - Ryan Glynn
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA; Department of Neurosurgery, Ochsner Neuroscience Institute, New Orleans, LA, USA.
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA; Department of Neurosurgery, Ochsner Neuroscience Institute, New Orleans, LA, USA.
| | - Cuong J Bui
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA; Department of Neurosurgery, Ochsner Neuroscience Institute, New Orleans, LA, USA.
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Van Der Veken J, Harding M, Hatami S, Agzarian M, Vrodos N. Syringomyelia intermittens: highlighting the complex pathophysiology of syringomyelia. Illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21341. [PMID: 35855301 PMCID: PMC9265193 DOI: 10.3171/case21341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chiari Type I malformation (CM1) is a disorder recognized by caudal displacement of the cerebellar tonsils through the foramen magnum and into the cervical canal. Syringomyelia is frequently found in patients with CM1, but the pathophysiology of syringomyelia remains an enigma. As a general consensus, symptomatic patients should be treated and asymptomatic patients without a syrinx should not be treated. Mildly symptomatic patients or asymptomatic patients with a syrinx, on the other hand, pose a more challenging dilemma, as the natural evolution is uncertain. For many surgeons, the presence of a syrinx is an indication to offer surgery even if the patient is asymptomatic or mildly symptomatic. OBSERVATIONS The authors describe an illustrative case of a 31-year-old female with an incidental finding of a CM1 malformation and cervical syrinx in 2013. Conservative management was advocated as the patient was asymptomatic. Monitoring of the syrinx over a course of 8 years showed resolution, followed by reappearance and finally a complete resolution in 2021. A review of the literature and the possible pathophysiology is discussed. LESSONS The unusual course of this patient highlights the importance of guiding treatment by clinical symptoms, not radiological findings. Furthermore it reflects the complexity of the pathophysiology and the uncertain natural history of syringomyelia.
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Affiliation(s)
| | | | - Saba Hatami
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, South Australia, Australia; and
- College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Marc Agzarian
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, South Australia, Australia; and
- College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
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Gallo E, Rahmathulla G, Rao D, Tavanaiepour K, Tavanaiepour D. Spontaneous syrinx resolution in patient with Chiari I malformation: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE21236. [PMID: 35854904 PMCID: PMC9245757 DOI: 10.3171/case21236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUIND Chiari malformations include a spectrum of congenital hindbrain herniation syndromes. In patients with the most common subtype, Chiari malformation Type I, 50% to 75% develop a syrinx. The pathogenesis of syringomyelia is not well understood, with multiple theories outlined in the literature. Although the presence of a syrinx in a patient with Chiari malformation is generally accepted as an indication for surgical intervention, there are documented cases of spontaneous resolution that support a more conservative approach to management. OBSERVATIONS The authors reported a case of spontaneous resolution of a cervical syrinx in an adult with an unchanged Chiari malformation. LESSONS Given the possibility of spontaneous resolution over time, the authors believe a more conservative approach of observation with periodic surveillance, magnetic resonance imaging, and neurological examination should be considered in the management of a patient with a Chiari malformation and associated syringomyelia.
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Affiliation(s)
| | | | - Dinesh Rao
- Division of Neuroradiology, University of Florida, College of Medicine, Jacksonville, Florida
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Wong CE, Tsai YS, Chen JS, Chen YN, Lee JS. Resolution of type I Chiari malformation and associated syringomyelia following intrathecal chemotherapy: case report. J Neurosurg Pediatr 2021; 27:145-150. [PMID: 33276330 DOI: 10.3171/2020.7.peds20411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/13/2020] [Indexed: 11/06/2022]
Abstract
Type I Chiari malformation (CM-I) consists of downward herniation of the cerebellar tonsils below the foramen magnum and often requires surgical decompression if symptomatic. Spontaneous resolution of CM-I is rare. We present a case of resolved CM-I without surgery in a 6-year-old boy with B-cell lymphoma who was diagnosed with CM-I during lymphoma staging. Cerebrospinal fluid cytology and brain MRI revealed negative CNS involvement but showed CM-I with tonsillar ectopia 19 mm below the foramen magnum. The patient underwent induction chemotherapy including 5 doses of intrathecal chemotherapy. Follow-up MRI demonstrated marked regression of CM-I to less than 6 mm in 3 months, and complete resolution of CM-I was observed in 2 years. To the best of our knowledge, this is the first case of resolved CM-I and syringomyelia following chemotherapy. In this case report, the authors summarize all of the clinical characteristics, the radiological appearance, and the potential causes of resolution based on a review of the literature and propose the mechanisms through which intrathecal chemotherapy contributed to the CM-I and syringomyelia resolution in the present case.
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Affiliation(s)
| | | | - Jiann-Shiuh Chen
- 3Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Yu-Ning Chen
- 4Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City; and
| | - Jung-Shun Lee
- 1Section of Neurosurgery
- 5Department of Cell Biology and Anatomy and
- 6Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Spontaneous Resolution of Syringomyelia with a 16-Year Serial Magnetic Resonance Imaging Follow-Up: A Case Report and Literature Review. World Neurosurg 2019; 130:432-438. [DOI: 10.1016/j.wneu.2019.07.138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 11/18/2022]
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Spontaneous regression of post-traumatic syringomyelia: A case report and literature review. J Clin Neurosci 2017; 44:249-253. [DOI: 10.1016/j.jocn.2017.06.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/21/2017] [Indexed: 11/22/2022]
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Cell Therapy as a New Approach to the Treatment of Posttraumatic Syringomyelia. World Neurosurg 2017; 107:1047.e5-1047.e8. [PMID: 28804041 DOI: 10.1016/j.wneu.2017.08.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/30/2017] [Accepted: 08/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cell transplantation with autologous bone marrow-derived mesenchymal stromal cells (MSCs) seems to be a therapeutic promise for patients with established spinal cord injury, achieving improvement in their quality of life, but there is no experience with the application of this type of cell therapy in patients suffering posttraumatic syringomyelia. OBJECTIVE To study the possible utility of cell therapy with autologous MSCs in posttraumatic syringomyelia. METHODS A 40-year-old man with complete paraplegia since 1991 as a consequence of a Th4 vertebral fracture showed a great posttraumatic syringomyelia that extended up to C2 vertebral level, without signs of recent worsening. Autologous MSCs (150 × 106) were injected into the syrinx, without drainage or aspiration. RESULTS One year after cell therapy, syrinx was reduced without collapse of cervical spinal cord. During the course of follow-up, clear clinical improvement was observed, mainly in sphincter dysfunction. CONCLUSIONS Injection of MSCs in the syrinx of posttraumatic syringomyelia is safe and is associated with clinical and neuroimaging improvement. The possibility of cell therapy as a new approach to posttraumatic syringomyelia, or even for idiopathic syringomyelia, is an open door that requires further study.
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Khanna AR, Coumans JV. Spontaneous Improvement of Chiari I Malformation and Syringomyelia in a Patient With Cystic Fibrosis. Neurosurgery 2015; 78:E305-8. [DOI: 10.1227/neu.0000000000000980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
ABSTRACT
BACKGROUND AND IMPORTANCE:
Syringomyelia is highly associated with Chiari I malformation, but the pathophysiologic mechanism of syrinx formation and its relation to downward cerebellar tonsillar displacement remains elusive. Cough, Valsalva maneuver, and other physiological strains transiently exacerbate the clinical symptoms of these conditions, exert profound effects on the flow dynamics across the craniospinal junction, and are thought to play an important role in the pathogenesis of syringomyelia.
CLINICAL PRESENTATION:
We report the case of a patient with cystic fibrosis who presented during an exacerbation of bronchiectasis and was found to have a Chiari I malformation with associated syringomyelia. Eight months later, when the patient had returned to baseline pulmonary status, repeat imaging showed interval improvement in both the size of the syrinx and descent of cerebellar tonsils.
CONCLUSION:
This rare case of spontaneous improvement of syringomyelia and Chiari I malformation attributable to relief from chronic cough offers interesting insight into the mechanism of these disorders.
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Affiliation(s)
- Arjun R. Khanna
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jean-Valery Coumans
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
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Tortora F, Napoli M, Caranci F, Cirillo M, Pepe D, Cirillo S, Briganti F. Spontaneous regression of syringomyelia in a young patient with Chiari type I malformation. Neuroradiol J 2013; 25:593-7. [PMID: 24029095 DOI: 10.1177/197140091202500513] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 09/14/2012] [Indexed: 11/16/2022] Open
Abstract
Syringomyelia is a disorder in which a cyst or cavity forms within the spinal cord. This cyst, called syrinx, can expand and elongate over time, destroying the spinal cord. We describe the case of a young patient with partial spontaneous regression of syringomyelia in Chiari I malformation, confirmed by magnetic resonance imaging three years after the diagnosis. During this period the patient did not experience any clinical symptoms. Although described in literature, spontaneous regression is an unusual event and very few cases have been reported. This case report supports the belief that conservative management together with both clinical and imaging periodic controls should be preferred in stable mild-symptomatic patients.
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Affiliation(s)
- F Tortora
- Department of Neurological Sciences, Neuroradiology Division, Second University of Naples; Naples, Italy -
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Plessas IN, Rusbridge C, Driver CJ, Chandler KE, Craig A, McGonnell IM, Brodbelt DC, Volk HA. Long-term outcome of Cavalier King Charles spaniel dogs with clinical signs associated with Chiari-like malformation and syringomyelia. Vet Rec 2012; 171:501. [DOI: 10.1136/vr.100449] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- I. N. Plessas
- Department of Veterinary Clinical Sciences; Royal Veterinary College; Hatfield UK
| | - C. Rusbridge
- Goddard Veterinary Group; Stone Lion Veterinary Hospital; London UK
| | - C. J. Driver
- Department of Veterinary Clinical Sciences; Royal Veterinary College; Hatfield UK
| | - K. E. Chandler
- Department of Veterinary Clinical Sciences; Royal Veterinary College; Hatfield UK
| | - A. Craig
- Department of Small Animal Medicine; Faculty of Veterinary Science; University of Sydney; Australia
| | - I. M. McGonnell
- Department of Veterinary Basic Sciences; Royal Veterinary College; Hatfield UK
| | - D. C. Brodbelt
- Department of Veterinary Clinical Sciences; Royal Veterinary College; Hatfield UK
| | - H. A. Volk
- Department of Veterinary Clinical Sciences; Royal Veterinary College; Hatfield UK
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