Clinical and electrophysiologic recovery in Arnold-Chiari malformation

The Role of Neurophysiology in Managing Patients with Chiari Malformations

Chiari malformation type 1 (CM1) includes various congenital anomalies that share ectopia of the cerebellar tonsils lower than the foramen magnum, in some cases associated with syringomyelia or hydrocephalus. CM1 can cause dysfunction of the brainstem, spinal cord, and cranial nerves. This functional alteration of the nervous system can be detected by various modalities of neurophysiological tests, such as brainstem auditory evoked potentials, somatosensory evoked potentials, motor evoked potentials, electromyography and nerve conduction studies of the cranial nerves and spinal roots, as well as brainstem reflexes. The main goal of this study is to review the findings of multimodal neurophysiological examinations in published studies of patients with CM1 and their indication in the diagnosis, treatment, and follow-up of these patients, as well as their utility in intraoperative monitoring.

Prognostic value of newborn hearing screening in patients with myelomeningocele

OBJECT

Brainstem dysfunction occurs in a minority of patients with myelomeningocele (MMC), most of whom have Chiari Type II malformation. Some surgeons advocate early identification of these patients for craniocervical decompression to avoid significant mortality. The auditory brainstem response has been found to be abnormal in most children with MMC. The present study examines whether failure of routine newborn hearing screening (NHS) predicts brainstem dysfunction in MMC patients.

METHODS

The charts of 40 newborns with MMC and 50 newborns without MMC who stayed in the neonatal intensive care unit were reviewed. Results of NHS, brainstem symptoms, birth demographics, and surgical history were retrospectively examined. Differences in the presence and onset of brainstem symptoms by NHS result were assessed.

RESULTS

Failure of NHS was more common among newborns with MMC who developed brainstem symptoms (31%, 4 of 13 patients) than among newborns without MMC (0%, 0 of 50 patients; p = 0.001). Among the 40 newborns with MMC, brainstem symptoms were more common in those who failed NHS (80%, 4 of 5 patients) than in those who passed (26%, 9 of 35 patients; p = 0.031). Respiratory symptom onset occurred later in patients who failed NHS (median 16 months) than among those who passed (median 0 months; p = 0.022). The positive and negative predictive values of NHS for brainstem dysfunction in MMC were 0.80 and 0.74, respectively.

CONCLUSIONS

Results of NHS may help predict future brainstem dysfunction in patients with MMC and may be useful to incorporate into prognostic assessment and surgical decision making.

Improvement in brainstem auditory evoked potentials after suboccipital decompression in patients with chiari I malformations

OBJECT

The optimal treatment for patients with symptoms related to Chiari I malformation remains controversial. Although a suboccipital decompression with duraplasty is most commonly performed, there may be a subset of patients who improve in response to bone decompression alone. In an initial attempt to identify such patients, we performed a continuous study of intraoperative brainstem auditory evoked potentials (BAEPs) in patients undergoing a standard decompression with duraplasty and compared conduction times at three different time points: 1) baseline while the patient is supine (before positioning); 2) immediately after opening of the bone and release of the atlantooccipital membrane (that is, the dural band); and 3) after opening of the dura mater.

METHODS

Eleven children and young adults (mean age 9.8 years) with symptoms related to Chiari I malformation underwent suboccipital decompression and duraplasty with intraoperative monitoring of BAEPs and somatosensory evoked potentials (SSEPs). Six patients (55%) had associated syringomyelia. At baseline, the I to V interpeak latency (IPL) for both sides (total 21 BAEPs) was 4.19 +/- 0.22 msec (mean +/- standard deviation). After complete bone decompression and before the dura mater was opened, the I to V IPL decreased to 4.03 +/- 0.25 msec (p = 0.0005). When the dura was opened, however, no further decrease in the I to V IPL was detected (4.03 +/- 0.25 msec; p = 0.6). The SSEPs remained stable throughout the procedure.

CONCLUSIONS

In children and young adults undergoing suboccipital decompression with duraplasty for Chiari I malformation, the vast majority of improvement in conduction through the brainstem occurs after bone decompressionand division of the atlantooccipital membrane, rather than after opening of the dura. Additional studies are needed to establish whether the improvement seen with BAEP monitoring during bone decompression will predict long-term clinical improvement in these patients.

[Correlations between clinical deficits, motor and sensory evoked potentials and radiologic aspects of MRI in malformative syringomyelia. 27 Cases]

Twenty-seven patients (15 males, 12 females, age range: 16-66 years) were admitted for malformative syringomyelia diagnosed on MRI with measures of syrinx extending and transverse diameter. Posterior tibial somatosensory evoked potentials (PT SEP), median (M SEP), trigeminal (V3 SEP), brain stem auditory evoked potentials (BEAP), cortical and cervical motor evoked potentials (MEP) were correlated with clinical and radiological findings. SEP abnormalities were not correlated with the duration of symptoms. PT SEP proved to be more sensitive than M SEP. MEP abnormalities were very frequent (87% of the cases), even without clinical motor deficits. Trigeminal SEP were more sensitive than BEAP which were not related to the presence of associated cranio-vertebral abnormalities. We found no significative relationship between clinical and radiological results. Moreover, there was a positive relationship between electrophysiological and radiological results: abnormal trigeminal SEP were detected in 85% of the patients with high cervical syringomyelia. In all cases, trigeminal SEP and MEP should be done in association with M and PT SEP as both of them detect subclinical evidence of spinal cord dysfunction in syringomyelia.

Audio-vestibular manifestations of Chiari malformation and outcome of surgical decompression: a case report

Sensorineural hearing loss, tinnitus, dizziness and ataxia are recognised symptoms associated with Chiari malformations but they are rarely the presenting complaints. Patients with such symptoms are frequently referred to otolaryngologists and audiological physicians. We report a case of a 13-year-old girl who presented complaining of tinnitus and impaired hearing, and was subsequently diagnosed as having a type I Chiari malformation. Pure tone audiogram showed a mild hearing impairment on the left side and the speech audiogram was normal. Auditory brain stem responses and the electronystagmography were abnormal. The patient underwent posterior fossa decompression following which her tinnitus disappeared, the hearing problem recovered and some of the abnormal electrophysiological parameters were corrected.

Somatosensory evoked potentials to median nerve stimulation in meningomyelocele: what is occurring in the hindbrain and its connections during growth?

Twenty patients with meningomyelocele (MMC) and shunted hydrocephalus, ranging in age from 3 to 23 years old, underwent serial recording of short-latency somatosensory evoked potentials (SEPs) to median nerve stimulation, on the basis of which to assess the evolution of dysfunction in the brainstem and its connections (cervical spinal cord, cervical nerve roots, lower cranial nerves). Eighteen patients had Chiari type II malformations, none of which was symptomatic. In all 20 patients, serial SEP recordings were obtained repeatedly after periods ranging from 2 to 7 years. The results were as follows: (1) the ratio of EP-N13 interpeak latencies (IPLs) to body height (BH) tended to lengthen gradually after starting in the normal range with growth. (2) In contrast, the ratio N13-N20 IPLs/BH decreased continuously to the normal range with growth, after initial prolongation. These findings and our earlier studies of brainstem auditory evoked potentials suggest that compression and traction result in strangulation of the cervical spinal cord and kinked medulla as well as stretching of the cervical nerve roots and lower cranial nerves. However, primary intrinsic functional disorders of the brainstem appeared to improve gradually during growth. The natural history of Chiari type II malformations involves these opposing dynamic phenomena in the hindbrain and its connections.

Blink reflex in meningomyelocele, with special reference to its usefulness in the evaluation of brainstem dysfunction

The electrically elicited blink reflex (BR) was studied in 30 patients with meningomyelocele (MMC), including 21 with Chiari type II malformation. The relationship between the BR and brainstem auditory evoked potentials (BAEPs) is discussed with regard to its usefulness in the evaluation of MMC's brainstem dysfunction. The following results were obtained: (1) The R2 component was abnormal in 90% of these patients. The BR disclosed subclinical lesions in the medulla oblongata which were not detected by BAEPs alone. (2) In all patients in whom the BAEPs suggested the presence of stretched cochlear nerves, the BR indicated the existence of some dysfunction of the medulla oblongata. (3) No close relationship was found between the dysfunction detected by the BR and the degree of hindbrain anomaly on the neuroimaging. (4) Combining results from assessment of the measurement of the BR and BAEPs permits evaluation of the function of the fifth, seventh, and eighth cranial nerves, as well as the brainstem including the medulla oblongata, which is more comprehensive than evaluation by neuroimaging alone.

BAEPs in infants with myelomeningocele and later development of Chiari II malformation-related brainstem dysfunction

Thirty-seven infants with myelomeningocele received brainstem auditory evoked potentials (BAEPs) at a median age of eight days. No infant had brainstem dysfunction at the time of testing. Median follow-up was at 30 months. Of 12 infants who subsequently developed brainstem dysfunction at a median age of three months, 11 had had abnormal neonatal BAEPs. In contrast, only 10 of 25 infants who did not develop brainstem dysfunction had abnormal BAEPs. The mean average I-V interpeak latencies was greater among those who developed symptoms than among those who did not. Neonatal BAEPs can identify a group of asymptomatic infants with myelomeningocele who need close follow-up for the subsequent development of brainstem dysfunction.

Evoked potentials in infant brainstem syndrome associated with Arnold-Chiari malformation

This study evaluated the contribution of brainstem auditory evoked potentials (BAEPs) and median nerve somatosensory evoked potentials (SEPs) to the assessment of brainstem dysfunction in infants with myelomeningocele and Arnold-Chiari malformation. 16 infants under one year of age were studied. Six had infant brainstem syndrome (IBS). 11 had abnormally prolonged I-V interwave latency (brainstem transmission time, BSTT); BSTT did not differentiate those patients with and without IBS. The cortical 'N20' component of the median-nerve SEPs was absent or had low amplitude and prolonged latency in all six patients with clinical signs of brainstem dysfunction and in four without. Median-nerve SEPs were normal in the patients without IBS. There was a significant difference between patients with and without IBS. Median-nerve SEPs may be a helpful measure of brainstem function in infants with Arnold-Chiari malformation.

Brain stem auditory-evoked potentials in meningomyelocele. Natural history of Chiari II malformations

Brain stem auditory-evoked potentials (BAEPs) were recorded in 30 patients with meningomyelocele and shunted hydrocephalus ranging in age from birth to 33 years. Twenty-two of them had Chiari II malformation, one of which was symptomatic. In 22 cases, including 15 with Chiari II malformation, BAEPs were recorded repeatedly after periods ranging from 18 months to 7 years. The results were as follows: (1) III-V interpeak latency (IPL) decreased progressively from prolonged to the normal range with growth until 25 years of age; (2) I-III IPL tended to prolong gradually from the normal range; (3) these findings may indicate that the natural history of Chiari II malformation is delayed maturation of the brain stem and intensification in the elongation and stretching of the hindbrain and lower cranial nerves.

Brainstem auditory evoked potentials in Chiari-II malformation

Brainstem function in patients with Chiari-II malformation was evaluated by brainstem auditory-evoked potentials (BAEPs). All cases had associated hydrocephalus, some of which were shunted. The effect of the shunting operation on the wave forms was examined as well as the age-wave relationships. Although the shunting operation resulted in shortened brainstem conduction time, the overall postshunt responses were still far from normal. Another significant finding was that whereas there were remarkable abnormalities in recorded waveforms in cases younger than 8 years, normal or almost normal responses were obtained in all cases older than 8. BAEP abnormalities could not be correlated with the severity of meningomyelocele, nor was the predictive value of response in assessing potential risk of symptomatic Chiari malformation established.

Chiari malformation in adults: a review of 40 cases

Forty adult patients (average age 40 years), with the clinical and radiological features of the Chiari malformations, were seen at the Toronto Western Hospital between 1967 and 1984. Surgical confirmation of the diagnosis was obtained in 32 cases; of these, 23 were classified as Chiari I malformation while 9 fulfilled the anatomic criteria of Chiari II. The patient population consisted of 22 males and 18 females. Common presenting symptoms included head and neck pain (60%), sensory complaints (60%), upper extremity weakness (42%), and gait disturbance (40%). Neurological findings included signs of central cord dysfunction (73%), long-tract motor and/or sensory findings (58%), brainstem signs (38%), cerebellar dysfunction (18%), and increased intracranial pressure (15%). The majority of patients underwent myelography with or without computed tomography of the cervical-medullary junction. Two recent patients had 0.15T MRI scans which helped demonstrate an intramedullary syrinx. Thirty-three patients underwent 47 operative procedures (discounting spinal fusion and CSF shunt revisions). Open surgical management was performed in 32 patients, with CSF shunting along in one patient. Five patients (15%) incurred surgical complications within a six week postoperative period. Follow-up to date, ranges from one month to 11 years. In the 33 surgically treated patients, 18 are improved (55%), 10 are neurologically stable (30%), and five have worsened clinically (15%), including one death. Based on this study it appears that the Chiari II malformation may be more common in adults than previously recognized. Surgical intervention has a favourable outcome in the majority of patients but a significant proportion continue to deteriorate.

Large intramedullary lipoma of the cervical cord and posterior fossa. Case report

A large intramedullary lipoma of the cervical cord extending into the posterior fossa is reported in a 7-year-old boy. Magnetic resonance imaging was very useful for delineation of the anatomy of the lipoma as an aid in planning the operation.