1
|
Krasnow MD, McGuirk L, Alexandrov A, Naparst M, Patale T, Mehta S, Noto R. Growth hormone therapy does not impact the development of intracranial hypertension in children with Chiari malformation. J Pediatr Endocrinol Metab 2024; 0:jpem-2024-0064. [PMID: 38776636 DOI: 10.1515/jpem-2024-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Patients with Chiari malformation (CM) are prone to a variety of neurological sequelae, including benign intracranial hypertension (BIH). In these patients, BIH is attributed to impaired cerebrospinal fluid (CSF) flow due to anatomical abnormalities of the posterior fossa. Occasionally, patients with CM may require growth hormone therapy (GHT), which can increase the production of CSF. It is thought that patients with CM who undergo GHT are at high risk of BIH-associated symptoms (BIHAS). We describe the incidence of neurological symptoms in 34 patients with CM before and during GHT. METHODS The database of a pediatric endocrinology center was queried for patients with CM who received GHT from 2010-22. Records were reviewed for adverse events. Demographic and radiological data were collected and analyzed. Patients with neoplastic disease, active inflammation, or acute trauma were excluded. CM diagnoses were independently assigned by a neuroradiology department. Patients were grouped based on the presence and nature of symptoms before and during GHT. Relationships between starting dose/BMI and occurrence of BIHAS/all GHT-associated symptoms were evaluated. RESULTS GHT was not associated with new-onset or worsening of preexisting BIHAS in 33 out of 34 patients with CM. Five complex patients continued to have preexisting BIHAS, which did not worsen. Of the four patients who developed new-onset BIHAS during GHT, three patients' symptoms were attributed to other medical conditions. No patient permanently discontinued GHT due to BIHAS. CONCLUSIONS Growth hormone therapy is likely a safe treatment in patients with Chiari malformation and is unlikely to cause BIHAS.
Collapse
Affiliation(s)
- Matthew D Krasnow
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - Liam McGuirk
- 228379 Donald and Barbara Zucker School of Medicine at Hofstra/Northwell , Hempstead, NY, USA
| | - Alice Alexandrov
- Department of Pediatrics, New York Medical College, Tarrytown, NY, USA
| | - Monica Naparst
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - Tara Patale
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - Shilpa Mehta
- Diabetes and Endocrine Center for Children and Young Adults, Hawthorne, NY, USA
| | - Richard Noto
- New York Medical College, Sleepy Hollow, NY, USA
| |
Collapse
|
2
|
Tomai XH, Nguyen HT, Nguyen Thi TT, Nguyen TA, Nguyen TV. Prenatal diagnosis of non-typical Chiari malformation type I associated with de novo Nuclear Factor I A gene mutation: a case report. J Med Case Rep 2024; 18:90. [PMID: 38347602 PMCID: PMC10863238 DOI: 10.1186/s13256-024-04361-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/03/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Chiari malformation is one of the most common Central nervous system (CNS) abnormalities that can be detected in routine fetal scanning. Chiari malformation type I (CMI) is a congenital defect characterized by a displacement of the cerebellar tonsils through the foramen magnum. The etiology of CMI has not been well established and suggested having multifactorial contributions, especially genetic deletion. Clinical characteristics of this anomaly may express in different symptoms from neurological dysfunction and/or skeletal abnormalities in the later age, but it is rarely reported in pregnancy. CASE PRESENTATION We present a case in which the Chiari malformation type I was diagnosed with comorbidities of facial anomalies (flatting forehead and micrognathia) and muscular-skeletal dysmorphologies (clenched hands and clubfeet) at the 24+6 weeks of gestation in a 29-year-old Vietnamese pregnant woman. The couple refused an amniocentesis, and the pregnancy was followed up every 4 weeks until a spontaneous delivery occurred at 38 weeks. The newborn had a severe asphyxia and seizures at birth required to have an emergency resuscitation at delivery. He is currently being treated in the intensive neonatal care unit. He carries the novel heterozygous NFIA gene mutation confirmed after birth. No further postnatal malformation detected. CONCLUSION CMI may only represent with facial abnormalities and muscle-skeletal malformations at the early stage of pregnancy, which may also alert an adverse outcome. A novel heterozygous NFIA gene mutation identified after birth helps to confirm prenatal diagnosis of CMI and to provide an appropriate consultation.
Collapse
Affiliation(s)
- Xuan-Hong Tomai
- University of Alberta, Alberta, Canada
- University of Nam Can Tho, Can Tho, Vietnam
| | - Huu-Trung Nguyen
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam. *
- University Medical Center, Branch 2, Ho Chi Minh City, Vietnam. *
| | | | - Tuan-Anh Nguyen
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
- University Medical Center, Branch 2, Ho Chi Minh City, Vietnam
| | | |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Bauer DF, Niazi T, Qaiser R, Infinger LK, Vachhrajani S, Ackerman LL, Jackson EM, Jernigan S, Maher CO, Pattisapu JV, Quinsey C, Raskin JS, Rocque BG, Silberstein H. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Diagnosis. Neurosurgery 2023; 93:723-726. [PMID: 37646512 DOI: 10.1227/neu.0000000000002633] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/28/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Chiari I malformation (CIM) is characterized by descent of the cerebellar tonsils through the foramen magnum, potentially causing symptoms from compression or obstruction of the flow of cerebrospinal fluid. Diagnosis and treatment of CIM is varied, and guidelines produced through systematic review may be helpful for clinicians. OBJECTIVE To perform a systematic review of the medical literature to answer specific questions on the diagnosis and treatment of CIM. METHODS PubMed and Embase were queried between 1946 and January 23, 2021, using the search strategies provided in Appendix I of the full guidelines. RESULTS The literature search yielded 567 abstracts, of which 151 were selected for full-text review, 109 were then rejected for not meeting the inclusion criteria or for being off-topic, and 42 were included in this systematic review. CONCLUSION Three Grade C recommendations were made based on Level III evidence. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/1-imaging .
Collapse
Affiliation(s)
- David F Bauer
- Department of Neurosurgery, Baylor College of Medicine, Houston , Texas , USA
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston , Texas , USA
| | - Toba Niazi
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami , Florida , USA
| | - Rabia Qaiser
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Libby Kosnik Infinger
- Department of Neurosurgery, Medical University of South Carolina (MUSC), Charleston , South Carolina , USA
| | - Shobhan Vachhrajani
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton , Ohio , USA
| | - Laurie L Ackerman
- Department of Neurological Surgery, Indiana University Health, Indianapolis , Indiana , USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Sarah Jernigan
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
| | - Cormac O Maher
- Department of Neurosurgery, Stanford Medicine, Palo Alto , California , USA
| | - Jogi V Pattisapu
- Pediatric Neurosurgery, University of Central Florida College of Medicine, Orlando , Florida , USA
| | - Carolyn Quinsey
- Department of Neurosurgery, University of North Carolina Chapel Hill, Chapel Hill , North Carolina , USA
| | - Jeffrey S Raskin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago , Illinois , USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham , Alabama , USA
| | - Howard Silberstein
- Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester , New York , USA
| |
Collapse
|
5
|
Sivakumaran P, Ashwood N, Kamal M, Jayakumar N. The Pathogenesis of Chiari Malformation and Syringomyelia: A Case Report and Systematic Review of Current Theories. Cureus 2023; 15:e47301. [PMID: 38022024 PMCID: PMC10656570 DOI: 10.7759/cureus.47301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
We report a case of a 42-year-old female presenting with left axillary pain radiating down the arm and weakness in the ipsilateral hand. Specialist examinations of neurological and musculoskeletal systems were insignificant. Magnetic resonance imaging (MRI) of the whole spine and brain revealed cerebellar tonsillar herniation of 9-10mm indicating a Chiari type 1 malformation and a large tubular T2 high-intensity lesion in the cervical cord, extending from the C2/3-disc level down to C6/C7 as well as a similar but smaller lesion behind the bodies of C7 and T1. Both lesions were consistent with syringomyelia. Surgical intervention was deemed inappropriate, and she was treated with three months of physiotherapy. Regular follow-up for two years showed gradual symptom resolution, syrinx shrinkage, and no further complications arising secondary to Chiari type 1 malformation. Chiari malformation is an anatomical anomaly of the cranio-cervical junction. It is often incidentally found on MRI, but although asymptomatic in the population, complications associated with the condition such as syringomyelia are a common initial presentation. The relationship between Chiari malformation, particularly Chiari type 1 malformation, and syringomyelia is close with the majority of patients often presenting with idiopathic syringomyelia also found to have a Chiari type 1 malformation. Considerable discussion about the pathogenic mechanisms for syringomyelia development in Chiari malformation is recognized and advancing continually.
Collapse
Affiliation(s)
- Priya Sivakumaran
- Geriatrics, Kingston Hospital National Health Service (NHS) Foundation Trust, London, GBR
| | - Neil Ashwood
- Trauma and Orthopaedics, University Hospitals of Derby and Burton National Health Service Foundation Trust, Derby, GBR
| | - Muhammad Kamal
- Neurology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, GBR
| | - Nithish Jayakumar
- Neurosurgery, The James Cook University Hospital, Middlesbrough, GBR
| |
Collapse
|
6
|
Matsuura N. Hoquet dû à une malformation de Chiari de type I. CMAJ 2023; 195:E1018-E1019. [PMID: 37553151 PMCID: PMC10446151 DOI: 10.1503/cmaj.221870-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Affiliation(s)
- Naoki Matsuura
- Département de médecine interne, Hôpital général de Koga, Miyazaki, Japon
| |
Collapse
|
7
|
Bin Wan Hassan WMN, Mistretta F, Molinaro S, Russo R, Bosco G, Gambino A, Bergui M. Overview of Spontaneous Intracranial Hypotension and Differential Diagnosis with Chiari I Malformation. J Clin Med 2023; 12:jcm12093287. [PMID: 37176727 PMCID: PMC10179697 DOI: 10.3390/jcm12093287] [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: 02/15/2023] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Spontaneous intracranial hypotension (SIH) occurs due to a leakage of the cerebrospinal fluid (CSF) lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. As a result of less support provided by CSF pressure, intracranial structures are stretched downward, leading to a constellation of more or less typical MRI findings, including venous congestion, subdural effusions, brainstem sagging and low-lying cerebellar tonsils. Clinic examination and an MRI are usually enough to allow for the diagnosis; however, finding the location of the dural tear is challenging. SIH shares some MRI features with Chiari malformation type I (CM1), especially low-lying cerebellar tonsils. Since SIH is likely underdiagnosed, these findings could be interpreted as signs of CM1, leading to a misdiagnosis and an incorrect treatment pathway. Medical treatment, including steroids, bed rest, hydration caffeine, and a blind epidural blood patch, have been used in this condition with variable success rates. For some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic pathway have been proposed. The current literature on SIH with a focus on diagnosis, treatment, and differential diagnosis with CM1, is reviewed and discussed.
Collapse
Affiliation(s)
| | - Francesco Mistretta
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Stefano Molinaro
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Riccardo Russo
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Giovanni Bosco
- Department of Neuroscience, Stroke Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Andrea Gambino
- Department of Surgical Sciences, Radiology Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| | - Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, 10126 Turin, Italy
| |
Collapse
|
8
|
Akyuz ME, Karadag MK, Sahin MH. Effect of modified clivoaxial angle on surgical decision making and treatment outcomes in patients with Chiari malformation type 1. Front Surg 2023; 10:1143086. [PMID: 37215352 PMCID: PMC10196391 DOI: 10.3389/fsurg.2023.1143086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Chiari malformation type 1 (CM1), a complex pathological developmental disorder of the craniovertebral junction, is typically characterized by herniation of the cerebellar tonsils from the foramen magnum. Treatment using posterior fossa decompression alone without taking the ventral cervico-medullary compression into consideration may lead to unsatisfactory treatment outcomes. The current study evaluated the utility of the modified clivoaxial angle (MCAA) in assessing ventral compression and also examined its effect on treatment outcomes. Method This retrospective study included 215 adult patients who underwent surgical treatment for CM1 at one medical center over a 10-year period. The following surgical techniques were used to decompress the posterior fossa: (a) PFD: bone removal only; (b) PFDwD: bone removal with duraplasty; and (c) CTR: cerebellar tonsil resection. The morphometric measurements of the craniovertebral junction (including MCAA) were recorded using preoperative images, and the postoperative clinical status was evaluated using the Chicago Chiari outcome scale (CCOS). Results MCAA was positively correlated with the CCOS score and also independently predicted treatment outcome. To enable Receiver operating characteristic (ROC) curve analysis of CCOS scores, the patients were divided into three groups based on the MCAA cut-off values, as follows: (a) severe (n = 43): MCAA ≤ 126; (b) moderate (n = 86): 126 < MCAA ≤ 138; and (c) mild (n = 86): MCAA > 138. Group a exhibited severe ventral cervico-medullary compression (VCMC), and their CCOS scores for the PFD, PFDwD, and CTR groups were 11.01 ± 1.2, 11.24 ± 1.3, and 13.01 ± 1.2, respectively (p < 0.05). The CCOS scores increased with widening of the MCAA angle in all surgical groups (p < 0.05). Furthermore, patients with mild MCAA (>138°) exhibited 78% regression of syringomyelia, and this was significantly greater than that observed in the other groups. Discussion MCAA can be used in the selection of appropriate surgical techniques and prediction of treatment outcomes, highlighting the importance of preoperative evaluation of ventral clivoaxial compression in patients with CM1.
Collapse
|
9
|
Barpujari A, Kiley A, Ross JA, Veznedaroglu E. A Systematic Review of Non-Opioid Pain Management in Chiari Malformation (Type 1) Patients: Current Evidence and Novel Therapeutic Opportunities. J Clin Med 2023; 12:jcm12093064. [PMID: 37176505 PMCID: PMC10179593 DOI: 10.3390/jcm12093064] [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: 03/21/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Chiari Malformation Type I (CM) includes a range of cranial abnormalities at the junction of the skull with the spine, with common symptoms including pain and headaches. Currently, CM pain is managed medically through anti-inflammatory drugs, muscle relaxants, and opioids, while surgical management includes posterior fossa decompression. Given the adverse effects of opioid use, and an ongoing opioid epidemic, there is a need for safe, non-opioid alternatives for clinical pain management. This systematic review was performed to provide an update on the current literature pertaining to the treatment of CM pain with non-opioid alternatives. A literature search was performed in June 2022 utilizing the PubMed and Google Scholar databases, and articles were identified that included information regarding non-opioid pain management in CM patients. A total of 90 articles were obtained from this search, including 10 relevant, drug-specific studies. Two independent reviewers selected and included all relevant articles based on the chosen search criteria to minimize bias risk. Currently available treatments for neurosurgical pain management include anticonvulsants, corticosteroids, NSAIDs, anti-inflammatory drugs, NMDA receptor antagonists, local anesthetics, nerve blocks, scalp blocks, and neuromuscular blocks. While more information is needed on the use of non-opioid pain management, the present literature provides potential evidence of its efficacy amongst the CM patient population, on account of the success that non-opioid pain management has demonstrated within other neurological pain syndromes. Further research into non-pharmacological pain management would also benefit the CM population and could be generalized to related conditions.
Collapse
Affiliation(s)
| | - Alina Kiley
- Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | | | | |
Collapse
|
10
|
Al-Zamil M, Shnayder NA, Davydova TK, Nasyrova RF, Trefilova VV, Narodova EA, Petrova MM, Romanova IV, Chumakova GA. Amyotrophic Lateral Sclerosis Mimic Syndrome in a 24-Year-Old Man with Chiari 1 Malformation and Syringomyelia: A Clinical Case. J Clin Med 2023; 12:jcm12082932. [PMID: 37109269 PMCID: PMC10143794 DOI: 10.3390/jcm12082932] [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: 02/24/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Chiari 1 Malformation (CM1) is classically defined as a caudal displacement of the cerebellar tonsils through the foramen magnum into the spinal cord. Modern imaging techniques and experimental studies disclose a different etiology for the development of CM1, but the main etiology factor is a structural defect in the skull as a deformity or partial reduction, which push down the lower part of the brain and cause the cerebellum to compress into the spinal canal. CM1 is classified as a rare disease. CM1 can present with a wide variety of symptoms, also non-specific, with consequent controversies on diagnosis and surgical decision-making, particularly in asymptomatic or minimally symptomatic. Other disorders, such as syringomyelia (Syr), hydrocephalus, and craniocervical instability can be associated at the time of the diagnosis or appear secondarily. Therefore, CM1-related Syr is defined as a single or multiple fluid-filled cavities within the spinal cord and/or the bulb. A rare CM1-related disorder is syndrome of lateral amyotrophic sclerosis (ALS mimic syndrome). We present a unique clinical case of ALS mimic syndrome in a young man with CM1 and a huge singular syringomyelic cyst with a length from segment C2 to Th12. At the same time, the clinical picture showed upper hypotonic-atrophic paraparesis in the absence of motor disorders in the lower extremities. Interestingly, this patient did not have a disorder of superficial and deep types of sensitivity. This made it difficult to diagnose CM1. For a long time, the patient's symptoms were regarded as a manifestation of ALS, as an independent neurological disease, and not as a related disorder of CM1. Surgical treatment for CM1 was not effective, but it allowed to stabilize the course of CM1-related ALS mimic syndrome over the next two years.
Collapse
Affiliation(s)
- Mustafa Al-Zamil
- Department of Physiotherapy, Faculty of Continuing Medical Education, Peoples' Friendship University of Russia, 117198 Moscow, Russia
| | - Natalia A Shnayder
- Institute of Personalized Psychiatry and Neurology, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
- Shared Core Facilities "Molecular and Cell Technologies", V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Tatiana K Davydova
- Department of Neurogenerative Disorders, Yakut Science Centre of Complex Medical Problems, 677000 Yakutsk, Russia
| | - Regina F Nasyrova
- Institute of Personalized Psychiatry and Neurology, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
| | | | - Ekaterina A Narodova
- Shared Core Facilities "Molecular and Cell Technologies", V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Marina M Petrova
- Shared Core Facilities "Molecular and Cell Technologies", V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Irina V Romanova
- Shared Core Facilities "Molecular and Cell Technologies", V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Galina A Chumakova
- Department of Therapy and General Medical Practice with a Course of Postgraduate Professional Education, Altai State Medical University, 656038 Barnaul, Russia
| |
Collapse
|
11
|
Clarke JE, Reyes JM, Luther E, Govindarajan V, Leuchter JD, Niazi T, Ragheb J, Wang S. Chiari I malformation management in patients with heritable connective tissue disorders. World Neurosurg X 2023; 18:100173. [PMID: 36969375 PMCID: PMC10031113 DOI: 10.1016/j.wnsx.2023.100173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/08/2023] Open
Abstract
Background Chiari malformation type I (CMI) is relatively common neurosurgical condition typically treated with posterior fossa decompression. However, the management of CMI in patients with heritable connective tissue disorders (CTDs), such as Ehlers-Danlos Syndrome, Marfan Syndrome, or Osteogenesis Imperfecta, involves a unique set of perioperative challenges. Objective This study aims to define the demographic information, comorbidities, and perioperative course of patients with concomitant CMI and CTD. Methods Patients with CMI admitted for surgical decompression from 2008 to 2015 were captured using the National Inpatient Sample (NIS). Information was collected based on ICD-9 codes. Descriptive and regression analyses were performed in SPSS (version 26). Results 38,169 CMI patients, 353 of whom had CTD (0.92%), were identified. CMI patients with CTD were more likely to be female (p < 0.001) and present during teenage (p = 0.033) or young adult years (p < 0.001). They had more chronic issues (p < 0.001): systemic comorbidities include postural orthostatic tachycardia syndrome, cardiac dysrhythmias, and gastroparesis (all p < 0.001). CNS comorbidities include migraine, tethered spinal cord, and epilepsy (all p < 0.001). They have increased joint instability (both p < 0.001), as well as craniocervical instability (CCI). More posterior cervical fusion surgeries and application of cervical halo devices were seen during the same inpatient stay (both p < 0.001). Conclusions Patients with concurrent CTD and CMI were more likely to present with complex Chiari and associated CCI. They were also younger, more often female, and had more systemic, CNS, and joint abnormalities. As such, preoperative recognition of an underlying CTD is imperative to achieve optimal outcomes in this patient population.
Collapse
|
12
|
Dolas I, Yorukoglu AG, Sencer A, Unal TC, Gulsever CI, Aydoseli A, Aras Y, Sabanci PA, Ruetten S. Full-endoscopic technique for posterior fossa decompression in Chiari malformation type I: An anatomical feasibility study in human cadavers. Clin Anat 2023; 36:660-668. [PMID: 36786563 DOI: 10.1002/ca.24024] [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: 11/05/2022] [Revised: 01/30/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023]
Abstract
Although endoscope-assisted techniques have been described, a full-endoscopic approach is yet to be performed for posterior fossa decompression (PFD) in Chiari malformation type I (CM-I). This study aims to describe the full-endoscopic PFD technique and evaluate its feasibility. Five fresh-frozen anonymized adult human cadavers were operated on using an endoscope with an oval shaft cross-section with a diameter of 9.3 mm, a working length of 177 mm, and a viewing angle of 20°. It also had an eccentric working channel with a diameter of 5.6 mm, a light guide, a sheath for continuous irrigation, and a rod lens system. The instruments were introduced from the working channel. Posterior craniocervical structures were dissected, and PFD was achieved. The planned steps were performed in all five cadavers. The endoscope was introduced to the posterior craniocervical region, dissecting the structures to easily expose the suboccipital bone and C1 posterior arch. Important structures, such as the C1 posterior tubercle, rectus capitis posterior minor muscles, and posterior atlantooccipital membrane, were used as landmarks. PFD was feasible even with the dural opening. Using the full-endoscopic approach, posterior craniocervical structures can be reached, and PFD can be performed successfully. The instruments used are well-defined for spinal usage; thus, this full-endoscopic technique can be widely used in the surgical treatment of patients with CM-I.
Collapse
Affiliation(s)
- I Dolas
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A G Yorukoglu
- Department of Neurosurgery, Istanbul Scoliosis and Spine Center, Florence Nightingale Hospital, Istanbul, Turkey
| | - A Sencer
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tugrul Cem Unal
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - C I Gulsever
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A Aydoseli
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Y Aras
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - P A Sabanci
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - S Ruetten
- Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology of the St. Elisabeth Group-Catholic Hospitals Rhein-Ruhr, St. Anna Hospital Herne/Marien Hospital Herne University Hospital/Marien Hospital Witten, Herne, Germany
| |
Collapse
|
13
|
Karadag MK, Akyuz ME, Sahin MH. The role of ONSD in the assessment of headache associated with Chiari malformation type 1. Front Neurol 2023; 14:1127279. [PMID: 36824423 PMCID: PMC9941673 DOI: 10.3389/fneur.2023.1127279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Abstract
Background Cough associated headache is the most common symptom in Chiari malformation type 1 (CM1). However, its pathophysiology and treatment are not clear. The aim of this study was to investigate the relationship between optic nerve sheath diameter (ONSD), an indicator of intracranial pressure, and headache and to investigate its predictive value on postoperative outcome. Methods In symptomatic CM1 patients, craniovertebral junction morphometric measurements and ONSD measurements were made from preoperative MR images, and headache intensities and characteristics were evaluated. After different surgical procedures, the clinical characteristics of the patients were evaluated according to the Chicago Chiari Outcome Scale, the change in headache intensity was assessed and the relationship with ONSD was evaluated. Results Preoperative headache intensity was significantly correlated with ONSD measurement (p < 0.01). Modified clivoaxial angle and ONSD were independent predictors of postoperative clinical outcome (p < 0.01). The procedure that achieved the greatest surgical enlargement of the foramen Magnum stenosis provided the best clinical outcome. Postoperative reduction in headache intensity and ONS diameter were correlated (p < 0.01). Conclusion The fact that ONSD is found to be wide in the preoperative period in CM1 patients indicates that the intracranial pressure is permanently high. This diameter increase is correlated with headache and is a valuable guide in the selection of the appropriate treatment method.
Collapse
|
14
|
Giannakaki V, Wildman J, Thejasvin K, Pexas G, Nissen J, Ross N, Mitchell P. Foramen Magnum Decompression for Chiari Malformation Type 1: Is There a Superior Surgical Technique? World Neurosurg 2023; 170:e784-e790. [PMID: 36455845 DOI: 10.1016/j.wneu.2022.11.119] [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: 07/27/2022] [Revised: 11/25/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Foramen magnum decompression is a common operation used to treat Chiari malformation. There are different surgical techniques; however, some are anecdotally more effective than others. Our aim was to determine whether there is a superior technique in relation to revision rates, presence of persistent postoperative headache and nausea, and syrinx reduction. METHODS This was a retrospective analysis of foramen magnum decompressions performed between 2012 and 2017 for Chiari 1 in a single institution. Three types of operations were performed: 1) bony decompression alone; 2) bony decompression with durotomy and dura left open; 3) bony decompression with opening of dura and duraplasty. We compared postoperative symptoms and revision rates between these 3 operations. RESULTS In 168 patients, 185 foramen magnum decompressions were performed. Among the 168 primary operations, in 66 the dura was not opened, in 86 the dura was opened without a duraplasty, and in 16 a duraplasty was performed. Of 185 operations, 17 were revision surgery. For primary procedures, the revision rates were 12 (18%) where the dura was not opened, 4 (5%) where the dura was left open, and 1 (6%) when duraplasty was performed. Severe postoperative headache and nausea occurred in 2 (3%) patients where the dura was not opened, 4 (25%) patients after primary duraplasty, and 64 (74%) patients after primary durotomy. CONCLUSIONS In this study, rate of revision surgery was highest in patients who had bony decompression without dural opening. Rate of postoperative headache and nausea was highest in the durotomy group. Overall duraplasty had the best results.
Collapse
Affiliation(s)
- Venetia Giannakaki
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom.
| | - Jack Wildman
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - K Thejasvin
- Newcastle University Medical School, Newcastle upon Tyne, United Kingdom
| | - Georgios Pexas
- School of Biological Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - Justin Nissen
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Nicholas Ross
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Patrick Mitchell
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
15
|
Krishnan N, McMullan P, Yang Q, Buscarello AN, Germain-Lee EL. Prevalence of Chiari malformation type 1 is increased in pseudohypoparathyroidism type 1A and associated with aberrant bone development. PLoS One 2023; 18:e0280463. [PMID: 36662765 PMCID: PMC9858345 DOI: 10.1371/journal.pone.0280463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Albright hereditary osteodystrophy (AHO) is caused by heterozygous inactivating mutations in GNAS. Patients with maternally-inherited mutations develop pseudohypoparathyroidism type 1A (PHP1A) with multi-hormone resistance and aberrant craniofacial and skeletal development among other abnormalities. Chiari malformation type 1 (CM1), a condition in which brain tissue extends into the spinal canal when the skull is too small, has been reported in isolated cases of PHP1A. It has been hypothesized to be associated with growth hormone (GH) deficiency. Given the adverse clinical sequelae that can occur if CM1 goes unrecognized, we investigated the previously undetermined prevalence of CM1, as well as any potential correlations with GH status, given the known increased prevalence of GH deficiency in PHP1A. We also investigated these metrics for low lying cerebellar tonsils (LLCT), defined as tonsillar descent less than 5 mm below the foramen magnum. In addition, we investigated possible correlations of CM1/LLCT with advanced hand/wrist bone ages and craniofacial abnormalities known to occur in PHP1A to determine whether premature chondrocyte differentiation and/or aberrant craniofacial development could be potential etiologies of CM1/LLCT through both human studies and investigations of our AHO mouse model. METHODS We examined patients with PHP1A in our clinic and noticed CM1 more frequently than expected. Therefore, we set out to determine the true prevalence of CM1 and LLCT in a cohort of 54 mutation-confirmed PHP1A participants who had clinically-indicated brain imaging. We examined potential correlations with GH status, clinical features, biological sex, genotype, and hand/wrist bone age determinations. In addition, we investigated the craniofacial development in our mouse model of AHO (Gnas E1+/-m) by histologic analyses, dynamic histomorphometry, and micro-computerized tomographic imaging (MCT) in order to determine potential etiologies of CM1/LLCT in PHP1A. RESULTS In our cohort of PHP1A, the prevalence of CM1 is 10.8%, which is at least 10-fold higher than in the general population. If LLCT is included, the prevalence increases to 21.7%. We found no correlation with GH status, biological sex, genotype, or hand/wrist bone age. Through investigations of our Gnas E1+/-m mice, the correlate to PHP1A, we identified a smaller cranial vault and increased cranial dome angle with evidence of hyperostosis due to increased osteogenesis. We also demonstrated that there was premature closure of the spheno-occipital synchondrosis (SOS), a cartilaginous structure essential to the development of the cranial base. These findings lead to craniofacial abnormalities and could contribute to CM1 and LLCT development in PHP1A. CONCLUSION The prevalence of CM1 is at least 10-fold higher in PHP1A compared to the general population and 20-fold higher when including LLCT. This is independent of the GH deficiency that is found in approximately two-thirds of patients with PHP1A. In light of potential serious consequences of CM1, clinicians should have a low threshold for brain imaging. Investigations of our AHO mouse model revealed aberrant cranial formation including a smaller cranium, increased cranial dome angle, hyperostosis, and premature SOS closure rates, providing a potential etiology for the increased prevalence of CM1 and LLCT in PHP1A.
Collapse
Affiliation(s)
- Neetu Krishnan
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Albright Center, Division of Pediatric Endocrinology & Diabetes, Connecticut Children’s, Farmington, Connecticut, United States of America
| | - Patrick McMullan
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, Connecticut, United States of America
| | - Qingfen Yang
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, Connecticut, United States of America
| | - Alexzandrea N. Buscarello
- Albright Center, Division of Pediatric Endocrinology & Diabetes, Connecticut Children’s, Farmington, Connecticut, United States of America
| | - Emily L. Germain-Lee
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Albright Center, Division of Pediatric Endocrinology & Diabetes, Connecticut Children’s, Farmington, Connecticut, United States of America
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, Connecticut, United States of America
| |
Collapse
|
16
|
Makoshi Z, Leonard JR. Clinical Manifestations of Chiari I Malformation. Neurosurg Clin N Am 2023; 34:25-34. [DOI: 10.1016/j.nec.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
17
|
Elucidating the Genetic Basis of Chiari I Malformation. Neurosurg Clin N Am 2023; 34:55-60. [DOI: 10.1016/j.nec.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
18
|
Ellington M, Francomano CA. Chiari I Malformations and the Heritable Disorders of Connective Tissue. Neurosurg Clin N Am 2023; 34:61-65. [DOI: 10.1016/j.nec.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
19
|
Zisakis A, Sun R, Pepper J, Tsermoulas G. Chiari Malformation Type 1 in Adults. Adv Tech Stand Neurosurg 2023; 46:149-173. [PMID: 37318574 DOI: 10.1007/978-3-031-28202-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The term Chiari malformation refers to a heterogeneous group of anatomical abnormalities at the craniovertebral junction. Chiari malformation type 1 (CM1) refers to the abnormal protrusion of cerebellar tonsils through the foramen magnum and is by far the commonest type. Its prevalence is estimated approximately 1%; it is more common in women and is associated with syringomyelia in 25-70% of cases. The prevalent pathophysiological theory proposes a morphological mismatch between a small posterior cranial fossa and a normally developed hindbrain that results in ectopia of the tonsils.In most people, CM1 is asymptomatic and diagnosed incidentally. In symptomatic cases, headache is the cardinal symptom. The typical headache is induced by Valsalva-like maneuvers. Many of the other symptoms are nonspecific, and in the absence of syringomyelia, the natural history is benign. Syringomyelia manifests with spinal cord dysfunction of varying severity. The approach to patients with CM1 should be multidisciplinary, and the first step in the management is phenotyping the symptoms, because they may be due to other pathologies, like a primary headache syndrome. Magnetic resonance imaging, which shows cerebellar tonsillar decent 5 mm or more below the foramen magnum, is the gold standard investigative modality. The diagnostic workup may include dynamic imaging of the craniocervical junction and intracranial pressure monitoring.The management of CM1 is variable and sometimes controversial. Surgery is usually reserved for patients with disabling headaches or neurological deficits from the syrinx. Surgical decompression of the craniocervical junction is the most widely used procedure. Several surgical techniques have been proposed, but there is no consensus on the best treatment strategy, mainly due to lack of high-quality evidence. The management of the condition during pregnancy, restriction to lifestyle related to athletic activities, and the coexistence of hypermobility require special considerations.
Collapse
Affiliation(s)
- Athanasios Zisakis
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Rosa Sun
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Joshua Pepper
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
| |
Collapse
|
20
|
Lo A, LaRocca MC, Whalen D, Gonzalez-Castillo Z. Progressive Flaccid Paraplegia in a Toddler due to Chiari Type I Malformation Complicated with Hydrocephalus and Syringomyelia. A Case Report. Child Neurol Open 2023; 10:2329048X231169510. [PMID: 37122875 PMCID: PMC10141243 DOI: 10.1177/2329048x231169510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/07/2023] [Accepted: 03/20/2023] [Indexed: 05/02/2023] Open
Abstract
Chiari malformation is a clinico-radiological entity defined by herniation of rhombencephalic structures through the foramen magnum. The most common type, Chiari I, involves herniation of the cerebellar tonsils specifically. We present the case of a 2-year-old with three weeks of progressive bilateral leg weakness, absent reflexes, and the inability to walk. The patient was found to have Chiari I with hydrocephalus and syringomyelia. This is the youngest patient reported in the literature presenting with a clinical picture of spinal shock. Early recognition of this entity allows for proper treatment and improved outcomes.
Collapse
Affiliation(s)
- Angelina Lo
- School of Medicine, University of California, Irvine, Irvine, CA, USA
- Angelina Lo, School of Medicine, University of
California, Irvine, 1001 Health Sciences Rd, Irvine, CA, 92617, USA.
| | - Megan C. LaRocca
- School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Danielle Whalen
- Department of Child Neurology, Children's Hospital Orange County, Orange, CA, USA
| | | |
Collapse
|
21
|
Use of deep learning in the MRI diagnosis of Chiari malformation type I. Neuroradiology 2022; 64:1585-1592. [PMID: 35199210 PMCID: PMC9271110 DOI: 10.1007/s00234-022-02921-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/16/2022] [Indexed: 11/10/2022]
Abstract
Purpose To train deep learning convolutional neural network (CNN) models for classification of clinically significant Chiari malformation type I (CM1) on MRI to assist clinicians in diagnosis and decision making. Methods A retrospective MRI dataset of patients diagnosed with CM1 and healthy individuals with normal brain MRIs from the period January 2010 to May 2020 was used to train ResNet50 and VGG19 CNN models to automatically classify images as CM1 or normal. A total of 101 patients diagnosed with CM1 requiring surgery and 111 patients with normal brain MRIs were included (median age 30 with an interquartile range of 23–43; 81 women with CM1). Isotropic volume transformation, image cropping, skull stripping, and data augmentation were employed to optimize model accuracy. K-fold cross validation was used to calculate sensitivity, specificity, and the area under receiver operating characteristic curve (AUC) for model evaluation. Results The VGG19 model with data augmentation achieved a sensitivity of 97.1% and a specificity of 97.4% with an AUC of 0.99. The ResNet50 model achieved a sensitivity of 94.0% and a specificity of 94.4% with an AUC of 0.98. Conclusions VGG19 and ResNet50 CNN models can be trained to automatically detect clinically significant CM1 on MRI with a high sensitivity and specificity. These models have the potential to be developed into clinical support tools in diagnosing CM1. Supplementary Information The online version contains supplementary material available at 10.1007/s00234-022-02921-0.
Collapse
|
22
|
Goel A. Letter to the Editor. Chiari and scoliosis. J Neurosurg Pediatr 2021; 29:235-236. [PMID: 34678782 DOI: 10.3171/2021.8.peds21398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Atul Goel
- 1Lilavati Hospital and Research Center, Bandra, Mumbai, India
| |
Collapse
|
23
|
Imaging and health metrics in incidental cerebellar tonsillar ectopia: findings from the Adolescent Brain Cognitive Development Study (ABCD). Neuroradiology 2021; 63:1913-1924. [PMID: 34247260 DOI: 10.1007/s00234-021-02759-y] [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: 05/04/2021] [Accepted: 06/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Incidental cerebellar tonsillar ectopia (ICTE) that meets the radiographic criterion for Chiari malformation type I (CMI) is an increasingly common finding in the clinical setting, but its significance is unclear. The present study examined posterior cranial fossa (PCF) morphometrics and a broad range of health instruments of pediatric ICTE cases and matched controls extracted from the Adolescent Brain Cognitive Development (ABCD) dataset. METHODS One-hundred-six subjects with ICTE and 106 matched controls without ICTE were identified from 11,411 anatomical MRI of healthy screened pediatric subjects from the ABCD project. Subjects were matched by sex, age, body mass index, race, and ethnicity. Twenty-two brain morphometrics and 22 health instruments were compared between the two groups to identify unrecognized CMI symptoms and assess the general health impact of ICTE. RESULTS Twelve and 15 measures were significantly different between the ICTE and control groups for females and males, respectively. Notably, for females, the anterior CSF space was significantly smaller (p = 0.00005) for the ICTE group than controls. For males, the clivus bone length was significantly shorter (p = 0.0002) for the ICTE group compared to controls. No significant differences were found among the 22 health instruments between the two groups. CONCLUSION This study demonstrated that pediatric ICTE subjects have similar PCF morphometrics to adult CMI. ICTE alone did not appear to cause any unrecognized CMI symptoms and had no impact on the subjects' current mental, physical, or behavioral health. Still, given their cranial and brain morphology, these cases may be at risk for adult-onset symptomatic CMI.
Collapse
|
24
|
Sadler B, Wilborn J, Antunes L, Kuensting T, Hale AT, Gannon SR, McCall K, Cruchaga C, Harms M, Voisin N, Reymond A, Cappuccio G, Brunetti-Pierri N, Tartaglia M, Niceta M, Leoni C, Zampino G, Ashley-Koch A, Urbizu A, Garrett ME, Soldano K, Macaya A, Conrad D, Strahle J, Dobbs MB, Turner TN, Shannon CN, Brockmeyer D, Limbrick DD, Gurnett CA, Haller G. Rare and de novo coding variants in chromodomain genes in Chiari I malformation. Am J Hum Genet 2021; 108:100-114. [PMID: 33352116 DOI: 10.1016/j.ajhg.2020.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/24/2020] [Indexed: 12/16/2022] Open
Abstract
Chiari I malformation (CM1), the displacement of the cerebellum through the foramen magnum into the spinal canal, is one of the most common pediatric neurological conditions. Individuals with CM1 can present with neurological symptoms, including severe headaches and sensory or motor deficits, often as a consequence of brainstem compression or syringomyelia (SM). We conducted whole-exome sequencing (WES) on 668 CM1 probands and 232 family members and performed gene-burden and de novo enrichment analyses. A significant enrichment of rare and de novo non-synonymous variants in chromodomain (CHD) genes was observed among individuals with CM1 (combined p = 2.4 × 10-10), including 3 de novo loss-of-function variants in CHD8 (LOF enrichment p = 1.9 × 10-10) and a significant burden of rare transmitted variants in CHD3 (p = 1.8 × 10-6). Overall, individuals with CM1 were found to have significantly increased head circumference (p = 2.6 × 10-9), with many harboring CHD rare variants having macrocephaly. Finally, haploinsufficiency for chd8 in zebrafish led to macrocephaly and posterior hindbrain displacement reminiscent of CM1. These results implicate chromodomain genes and excessive brain growth in CM1 pathogenesis.
Collapse
|
25
|
Brener A, Kozyrev DA, Shiran SI, Azoulay E, Pratt LT, Precel R, Ben-Sira L, Eyal O, Constantini S, Roth J, Lebenthal Y. Incidental Findings on Brain Magnetic Resonance Imaging (MRI) in Pediatric Endocrine Patients. Endocr Pract 2020; 26:1105-1114. [PMID: 33471712 DOI: 10.4158/ep-2020-0208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/10/2020] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To explore incidental findings on brain magnetic resonance imaging (MRI) studies of pediatric patients referred due to endocrine disorders. METHODS A retrospective, observational study conducted in a tertiary referral center. The neuroimaging database of 17,445 brain MRI studies of 11,011 pediatric patients were searched for cases with endocrine referrals and without medical history of malignancy, genetic syndromes, and/or neurologic comorbidities. This database was linked to the pediatric neurosurgical database. Clinical data were retrieved from medical files. RESULTS In total, 524 patients (50.2% males, mean age 8.5±3.5 years) were referred to brain MRI due to growth disturbances (n = 313), pubertal disorders (n = 183), prolactin hypersecretion (n = 18), central diabetes insipidus (n = 8), and obesity (n = 1). Incidental findings were found in 128 (24.4%) cases. Chiari type 1 malformation was more prevalent in patients with growth disturbances (P<.001). Small pituitary cysts were observed in 20 (3.8%) patients, and pineal cysts in 25 (4.8%) patients, mostly girls (68%, P<.001). White matter lesions were diagnosed in 30 (5.7%) patients, none with clinical evidence of neurologic disease. Brain asymmetry without clinical significance and developmental venous anomalies were observed in 14 (2.7%) and 8 (1.5%) patients, respectively. Twelve patients were diagnosed with intracranial tumors, and 5 required surgical intervention for a histopathologic diagnosis of juvenile pilocytic astrocytoma (n = 3), choroid plexus papilloma (n = 1), or inconclusive (n = 1). The rest were managed conservatively. CONCLUSION Incidental findings on brain MRIs of pediatric patients referred by endocrinologists are common and raise dilemmas. The spectrum ranges from structural disruptions to tumors. Decision-making is individualized and patient-centered.
Collapse
Affiliation(s)
- Avivit Brener
- From the Pediatric Endocrinology and Diabetes Unit, Tel-Aviv, Israel.
| | | | - Shelly I Shiran
- the Pediatric Radiology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Erez Azoulay
- From the Pediatric Endocrinology and Diabetes Unit, Tel-Aviv, Israel
| | - Li-Tal Pratt
- the Pediatric Radiology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ronit Precel
- the Pediatric Radiology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Liat Ben-Sira
- the Pediatric Radiology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ori Eyal
- From the Pediatric Endocrinology and Diabetes Unit, Tel-Aviv, Israel
| | | | - Jonathan Roth
- the Department of Pediatric Neurosurgery, Tel-Aviv, Israel
| | - Yael Lebenthal
- From the Pediatric Endocrinology and Diabetes Unit, Tel-Aviv, Israel
| |
Collapse
|