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Mekbib KY, Muñoz W, Allington G, McGee S, Mehta NH, Shofi JP, Fortes C, Le HT, Nelson-Williams C, Nanda P, Dennis E, Kundishora AJ, Khanna A, Smith H, Ocken J, Greenberg ABW, Wu R, Moreno-De-Luca A, DeSpenza T, Zhao S, Marlier A, Jin SC, Alper SL, Butler WE, Kahle KT. Human genetics and molecular genomics of Chiari malformation type 1. Trends Mol Med 2023; 29:1059-1075. [PMID: 37802664 DOI: 10.1016/j.molmed.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 10/08/2023]
Abstract
Chiari malformation type 1 (CM1) is the most common structural brain disorder involving the craniocervical junction, characterized by caudal displacement of the cerebellar tonsils below the foramen magnum into the spinal canal. Despite the heterogeneity of CM1, its poorly understood patho-etiology has led to a 'one-size-fits-all' surgical approach, with predictably high rates of morbidity and treatment failure. In this review we present multiplex CM1 families, associated Mendelian syndromes, and candidate genes from recent whole exome sequencing (WES) and other genetic studies that suggest a significant genetic contribution from inherited and de novo germline variants impacting transcription regulation, craniovertebral osteogenesis, and embryonic developmental signaling. We suggest that more extensive WES may identify clinically relevant, genetically defined CM1 subtypes distinguished by unique neuroradiographic and neurophysiological endophenotypes.
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Affiliation(s)
- Kedous Y Mekbib
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA; Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Center for Hydrocephalus and Neurodevelopmental Disorders, Massachusetts General Hospital, Boston, MA, USA
| | - William Muñoz
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Center for Hydrocephalus and Neurodevelopmental Disorders, Massachusetts General Hospital, Boston, MA, USA
| | - Garrett Allington
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Neel H Mehta
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - John P Shofi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Carla Fortes
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hao Thi Le
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Pranav Nanda
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Evan Dennis
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Arjun Khanna
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hannah Smith
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jack Ocken
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ana B W Greenberg
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Rui Wu
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Andres Moreno-De-Luca
- Department of Radiology, Autism and Developmental Medicine Institute, Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Tyrone DeSpenza
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Shujuan Zhao
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Sheng Chih Jin
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Seth L Alper
- Division of Nephrology and Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - William E Butler
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA; Harvard Center for Hydrocephalus and Neurodevelopmental Disorders, Massachusetts General Hospital, Boston, MA, USA; Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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Cough syncope and hyperventilation-induced convulsion in Chiari 1.5 malformation. Neurol Sci 2021; 42:2069-2073. [PMID: 33389244 DOI: 10.1007/s10072-020-05017-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022]
Abstract
Chiari malformation type I (CM1) is defined as cerebellar tonsillar herniation below the level of the foramen magnum. Syncope, especially cough syncope, is a rare but important symptom of CM1 patients. Here, we report a CM1 patient, in combination with brainstem herniation (CM1.5), presenting with repetitive syncope who was successfully treated by decompressive surgery. A 43-year-old right-handed male, with 5-year history of repeated episodes of loss of consciousness in association with cough, was investigated. Neurological examination revealed slight muscle weakness, clumsiness, and sensory disturbance in the left upper limb. There was no sign of orthostatic hypotension or orthostatic intolerance. Cranial and spinal magnetic resonance imaging revealed a herniation of the cerebellar tonsils and a syringomyelia. Forced hyperventilation during electroencephalogram (EEG) induced brief generalized symmetric clonic convulsions with preserved consciousness, but no overt EEG seizure patterns or slow activities were found. Based on the diagnosis of CM1.5 with recurrent episodes of loss of consciousness, he underwent foramen magnum decompression. He has no recurrence of the episode after the surgery on 1 year follow-up. Decompressive surgery was an effective procedure for cough syncope and other symptoms of the current patient with CM1.5. Dissociation of cerebrospinal fluid pressure between the cranial and spinal compartments which leads further herniation of the cerebellar tonsils and subsequent compression on the cerebellum and the brainstem is considered to be the major mechanism of his cough syncope. Analysis of EEG can be useful not only to diagnose epileptic seizures but also to elucidate mechanisms of syncope and concurrent involuntary movements.
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122. [DOI: 10.1161/cir.0000000000000499] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G. Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I. Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E. Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P. Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H. Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D. Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R. Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C. Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W. Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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Langridge B, Phillips E, Choi D. Chiari Malformation Type 1: A Systematic Review of Natural History and Conservative Management. World Neurosurg 2017; 104:213-219. [PMID: 28435116 DOI: 10.1016/j.wneu.2017.04.082] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Chiari malformation type 1 (CM-1) is a variation of hindbrain development that can sometimes occur in asymptomatic individuals. Conventional treatment is surgical decompression, but little is known about the natural history of patients who do not undergo surgical management. This information is critical to determine how these patients should be managed. We conducted a systematic literature review to determine the natural history of CM-1, particularly in patients who did not undergo surgery and in asymptomatic individuals, to help patients and physicians determine when surgery is likely to be beneficial. METHODS The literature search was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the electronic databases PubMed, Scopus, Cochrane Library, and Web of Science. Inclusion and exclusion criteria were predefined. RESULTS In symptomatic patients who did not undergo surgery, headaches and nausea often improved, whereas ataxia and sensory disturbance tended not to improve spontaneously. Of patients, 27%-47% had an improvement in symptoms after 15 months, and 37%-40% with cough headache and 89% with nausea who were managed nonoperatively improved at follow-up. Most asymptomatic individuals with CM-1 remained asymptomatic (93.3%) even in the presence of syringomyelia. CONCLUSIONS The natural history of mild symptomatic and asymptomatic CM-1 in adults is relatively benign and nonprogressive; the decision to perform surgical decompression should be based on severity and duration of a patient's symptoms at presentation. It is reasonable to observe a patient with mild or asymptomatic symptoms even in the presence of significant tonsillar descent or syringomyelia.
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Affiliation(s)
- Benjamin Langridge
- University College London Medical School, Bloomsbury, London, United Kingdom.
| | - Edward Phillips
- University College London Medical School, Bloomsbury, London, United Kingdom
| | - David Choi
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Shin HS, Kim JA, Kim DS, Lee JS. Type I Chiari malformation presenting orthostatic syncope who treated with decompressive surgery. KOREAN JOURNAL OF PEDIATRICS 2016; 59:S149-S151. [PMID: 28018469 PMCID: PMC5177700 DOI: 10.3345/kjp.2016.59.11.s149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/06/2014] [Accepted: 10/20/2014] [Indexed: 11/27/2022]
Abstract
Chiari malformations are a congenital anomaly of the hindbrain. The most common, Chiari malformation type I (CM-I), is characterized by herniation of the cerebellar tonsils extending at least 3 mm below the plane of the foramen magnum. Consequently, CM-I is associated with hydrocephalus and symptoms involving compression of the cervicomedullary junction by ectopic tonsils. Several studies have reported the clinical symptoms associated with CM-I, including suboccipital headache, weakness in the upper extremities, facial numbness, loss of temperature sensation, ataxia, diplopia, dysarthria, dysphagia, vomiting, vertigo, nystagmus, and tinnitus. Syncope is one of the rarest presentations in patients with CM-I. There are many hypotheses regarding the causes of syncope in patients with CM-I; however, the mechanisms are not clearly understood. Although surgical decompression for CM-I in patients with syncope has yielded good clinical results in some studies, such cases are rarely reported. We report a case of orthostatic syncope in a patient with CM-I who was treated with surgical intervention.
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Affiliation(s)
- Hyun-Seung Shin
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong A Kim
- Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Seok Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Soo Lee
- Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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