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Jha R, Chalif JI, Lu Y. Evaluating the Need for Durotomy and Duraplasty in Adults Undergoing Suboccipital Craniectomy for Chiari Decompression: A Case Series Analysis of Radiographic and Clinical Outcomes. Cureus 2024; 16:e60694. [PMID: 38899249 PMCID: PMC11186607 DOI: 10.7759/cureus.60694] [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: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
Background Suboccipital craniectomy (SOC) in conjunction with dura opening and duraplasty for posterior fossa decompression is an effective treatment for symptomatic Chiari 1 malformations (CM1), primarily carried out in the pediatric population. However, dural opening and reconstruction are associated with an increased risk of complications, and their necessity in the adult population has not yet been robustly demonstrated. Given differences in clinical presentation and disease severity between the pediatric and adult patients, we aimed to identify if SOC alone with intraoperative ultrasound confirmation of adequate restoration of pulsatile motion of cerebellar tonsil is sufficient to treat symptomatic CM1 while mitigating surgical risks. Methods We identified a retrospective, institutional cohort of adult patients who underwent SOC for Chiari decompression between 2014 and 2023. Demographic, clinical, and radiographic features were extracted for each patient. Clinical outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) and Motor-Sensory-Sphincter signs score (Clinical Sign Score (CSS)). Radiographic outcomes assessed cerebellar ectopia and associated syrinx characteristics. Results A total of 15 patients were identified, with an average follow-up period of three years. Eight patients underwent SOC with duraplasty, whereas seven patients underwent SOC only without duraplasty. Both groups of patients were of similar age at surgery and had similar nature and duration of symptoms prior to surgery. On pre-operative radiographic evaluation, both groups of patients had similar lengths of cerebellar ectopia (9.9±11.0 mm to 11.1±5.7 mm, p=0.591), and associated syrinxes (75% vs. 42.9%, p=0.205). Intraoperatively, both groups had similar estimated blood losses, though the length of surgery was significantly shorter when durotomy was spared (202±58.3 minutes to 116.3±47.8 minutes, p=0.011). The length of ICU stay was also significantly longer in the durotomy group (1.1±0.6 days to 0.0 days, p<0.001). Neither group reported any post-operative complications. On follow-up, both groups demonstrated similar reductions in cerebellar ectopia and syrinx characteristics. Clinically, the CCOS and CSS scores were similar between the two cohorts at follow-up, with no repeat surgery required in either group. Conclusion Our cohort suggests that for adult CM1 patients, SOC decompression alone without dural reconstruction might lead to comparable clinical and radiographic outcomes to SOC decompression with durotomy/duraplasty, especially if intraoperative ultrasound confirms good cerebrospinal fluid (CSF) flow after SOC. Notably, sparing durotomy and duraplasty is also associated with decreased operative time and decreased ICU stay.
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Affiliation(s)
- Rohan Jha
- Neurosurgery, Harvard Medical School, Boston, USA
| | | | - Yi Lu
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
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2
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Abenza-Abildúa MJ, Pérez-López C, Giner-García J. [Effectiveness of surgery on headache attributed to Chiari malformation type 1]. Med Clin (Barc) 2024; 162:398-399. [PMID: 38151365 DOI: 10.1016/j.medcli.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/11/2023] [Accepted: 11/15/2023] [Indexed: 12/29/2023]
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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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Acharya A, Panigrahi S, Deo RC, Senapati SB, Mahapatra AK, Samal RL. Pedunculated Chiari 3 malformation with proatlas defect. Childs Nerv Syst 2023; 39:3613-3616. [PMID: 37368065 DOI: 10.1007/s00381-023-06044-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/17/2023] [Indexed: 06/28/2023]
Abstract
Chiari III malformation is considered to be a rare congenital abnormality in human with very high mortality rates. Seventy percent of Chiari III is found to be associated with C1 arch defect as reported by Cakirer (Clin Imaging 27:1-4, 2003). The herniation of posterior fossa elements or dysplastic neural tissue is a must to stamp it as Chiari 3 malformation. The malformation is a result of the abnormal development of craniovertebral junction (CVJ). The CVJ developed from the occipital somites and the first spinal sclerotome. The major role in the development of the CVJ is played by the fourth occipital somite, which is otherwise known as "proatlas." The Chiari III anomalies are due to a result of proatlas defect, which results from failures of segmentation, failures of fusion of different components of each bone, or hypoplasia and ankylosis. We are presenting a case of a 1-year 4-month-old female child who presented with pedunculated swelling at the suboccipital region. The swelling was cystic and with pulsation. On evaluation, we found Chiari III anomaly with C1 posterior arch deficiency (proatlas defect). He was surgically managed. The outcome of the patient was good. Despite literature concluding Chiari 3 malformation with an unfavorable outcome, however, meticulous management and good pre- and postoperative care, physical therapy, and follow-up are necessary for good outcome.
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Affiliation(s)
- Abhijit Acharya
- Department of Neurosurgery, IMS and SUM Hospital, SOA University, Kalinga Nagar, Bhubaneswar, India.
| | - Souvagya Panigrahi
- Department of Neurosurgery, IMS and SUM Hospital, SOA University, Kalinga Nagar, Bhubaneswar, India
| | - Rama Chandra Deo
- Department of Neurosurgery, IMS and SUM Hospital, SOA University, Kalinga Nagar, Bhubaneswar, India
| | - Satya Bhusan Senapati
- Department of Neurosurgery, IMS and SUM Hospital, SOA University, Kalinga Nagar, Bhubaneswar, India
| | - Ashok Kumar Mahapatra
- Department of Neurosurgery, IMS and SUM Hospital, SOA University, Kalinga Nagar, Bhubaneswar, India
| | - Rajiba Lochan Samal
- Department of Anesthesia, IMS and SUM Hospital, SOA University, Kalinga Nagar, Bhubaneswar, India
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Hu Y, Zhang M, Duan C, Song D, Wei M, Guo F. A long-term follow-up study of adults with Chiari malformation type I combined with syringomyelia. Front Neurol 2023; 14:1274971. [PMID: 38107634 PMCID: PMC10722987 DOI: 10.3389/fneur.2023.1274971] [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: 08/10/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023] Open
Abstract
Background There is a considerable amount of controversy regarding the treatment and prognosis of adult patients with Chiari malformation type I (CM-I) at home and abroad; furthermore, no large-sample, long-term, follow-up studies have examined CM-I patients with syringomyelia (SM) comparing posterior fossa decompression with resection of tonsils (PFDRT) vs. posterior fossa decompression with duraplasty (PFDD). Objective This study retrospectively analyzed the factors affecting the treatment and long-term prognosis of adults with CM-I combined with SM. Methods We retrospectively analyzed data from 158 adult CM-I patients combined with SM who underwent PFDRT or PFDD, including 68 patients in group PFDRT and 90 patients in group PFDD. We examined the clinical manifestations, imaging features, and follow-up data of patients. Clinical outcomes were assessed using the Chicago Chiari Outcomes Scale (CCOS), and radiographic outcomes were indicated by the syrinx remission rate. Multivariate logistic regression analysis and multiple linear regression analysis were used to explore the relevant factors affecting the long-term prognosis of patients. Results This study showed that compared with preoperative patients in the PFDRT group and PFDD group, the sensory impairment, cough-related headache, and movement disorder were significantly improved (p < 0.01); meanwhile, the diameter of the syrinx and the volume of the syrinx decreased significantly (p < 0.001). Additionally, the study found that there were significant differences in the syrinx remission rate (p = 0.032) and the clinical cure rates (p = 0.003) between the two groups. Multivariate logistic regression analysis showed that age (p = 0.021), cerebellar-related symptoms (p = 0.044), preoperative cisterna magna volume (p = 0.043), and peak systolic velocity (p = 0.036) were independent factors for clinical outcomes. Multiple linear regression analysis showed that different surgical procedures were positively correlated with the syrinx remission rate (p = 0.014), while preoperative syrinx diameter (p = 0.018) and age (p = 0.002) were negatively correlated with the syrinx remission rate. Conclusion In conclusion, this study suggested that, in a long-term follow-up, although both surgical procedures are effective in treating patients with CM-I and SM, PFDRT is better than PFDD; age and cerebellar-related signs independently affect the patient's prognosis. Additionally, an effective prognosis evaluation index can be developed for patients, which is based on imaging characteristics, such as preoperative cisterna magna volume, preoperative syrinx diameter, and preoperative cerebrospinal fluid (CSF) hydrodynamic parameters to guide clinical work.
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Affiliation(s)
- Yan Hu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Mingchu Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Chengcheng Duan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Dengpan Song
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Mingkun Wei
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
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Toader C, Ples H, Covache-Busuioc RA, Costin HP, Bratu BG, Dumitrascu DI, Glavan LA, Ciurea AV. Decoding Chiari Malformation and Syringomyelia: From Epidemiology and Genetics to Advanced Diagnosis and Management Strategies. Brain Sci 2023; 13:1658. [PMID: 38137106 PMCID: PMC10741770 DOI: 10.3390/brainsci13121658] [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: 11/06/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023] Open
Abstract
Chiari Malformation and Syringomyelia are neurosurgical entities that have been the subject of extensive research and clinical interest. Globally prevalent, these disorders vary demographically and have witnessed evolving temporal trends. Chiari Malformation impacts the normal cerebrospinal fluid flow, consequently affecting overall health. Key observations from canine studies offer pivotal insights into the pathogenesis of Syringomyelia and its extrapolation to human manifestations. Genetics plays a pivotal role; contemporary knowledge identifies specific genes, illuminating avenues for future exploration. Clinically, these disorders present distinct phenotypes. Diagnostically, while traditional methods have stood the test of time, innovative neurophysiological techniques are revolutionizing early detection and management. Neuroradiology, a cornerstone in diagnosis, follows defined criteria. Advanced imaging techniques are amplifying diagnostic precision. In therapeutic realms, surgery remains primary. For Chiari 1 Malformation, surgical outcomes vary based on the presence of Syringomyelia. Isolated Syringomyelia demands a unique surgical approach, the effectiveness of which is continually being optimized. Post-operative long-term prognosis and quality of life measures are crucial in assessing intervention success. In conclusion, this review amalgamates existing knowledge, paving the way for future research and enhanced clinical strategies in the management of Chiari Malformation and Syringomyelia.
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Affiliation(s)
- Corneliu Toader
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania
| | - Horia Ples
- Department of Neurosurgery, Centre for Cognitive Research in Neuropsychiatric Pathology 6 (NeuroPsy-Cog), 300736 Timișoara, Romania
- Department of Neurosurgery, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Razvan-Adrian Covache-Busuioc
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Horia Petre Costin
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Bogdan-Gabriel Bratu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - David-Ioan Dumitrascu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Luca Andrei Glavan
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Alexandru Vlad Ciurea
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
- Neurosurgery Department, Sanador Clinical Hospital, 010991 Bucharest, Romania
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García M, Amayra I, Pérez M, Salgueiro M, Martínez O, López-Paz JF, Allen PA. Cognition in Chiari Malformation Type I: an Update of a Systematic Review. Neuropsychol Rev 2023:10.1007/s11065-023-09622-2. [PMID: 37798373 DOI: 10.1007/s11065-023-09622-2] [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: 03/31/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Abstract
Chiari malformation has been classified as a group of posterior cranial fossa disorders characterized by hindbrain herniation. Chiari malformation type I (CM-I) is the most common subtype, ranging from asymptomatic patients to those with severe disorders. Research about clinical manifestations or medical treatments is still growing, but cognitive functioning has been less explored. The aim of this systematic review is to update the literature search about cognitive deficits in CM-I patients. A literature search was performed through the following electronic databases: MEDLINE, PsychINFO, Pubmed, Cochrane Library, Scopus, and Web of Science. The date last searched was February 1, 2023. The inclusion criteria were as follows: (a) include pediatric or adult participants with a CM-I diagnosis, (b) include cognitive or neuropsychological assessment with standardized tests, (c) be published in English or Spanish, and (d) be empirical studies. Articles that did not report empirical data, textbooks and conference abstracts were excluded. After the screening, twenty-eight articles were included in this systematic review. From those, twenty-one articles were focused on adult samples and seven included pediatric patients. There is a great heterogeneity in the recruited samples, followed methodology and administered neurocognitive protocols. Cognitive functioning appears to be affected in CM-I patients, at least some aspects of attention, executive functions, visuospatial abilities, episodic memory, or processing speed. However, these results require careful interpretation due to the methodological limitations of the studies. Although it is difficult to draw a clear profile of cognitive deficits related to CM-I, the literature suggests that cognitive dysfunction may be a symptom of CM-I. This suggest that clinicians should include cognitive assessment in their diagnostic procedures used for CM-I. In summary, further research is needed to determine a well-defined cognitive profile related to CM-I, favoring a multidisciplinary approach of this disorder.
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Affiliation(s)
- Maitane García
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain.
| | - Imanol Amayra
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain
| | - Manuel Pérez
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain
- Faculty of Health Sciences, Isabel I University, Burgos, Spain
| | - Monika Salgueiro
- Department of Clinical and Health Psychology, and Research Methodology, Faculty of Psychology, University of the Basque Country, Donostia, Spain
| | - Oscar Martínez
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain
| | - Juan Francisco López-Paz
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain
| | - Philip A Allen
- Conquer Chiari Research Center, Department of Psychology, University of Akron, Akron, OH, USA
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Onafowokan OO, Das A, Mir JM, Alas H, Williamson TK, Mcfarland K, Varghese J, Naessig S, Imbo B, Passfall L, Krol O, Tretiakov P, Joujon-Roche R, Dave P, Moattari K, Owusu-Sarpong S, Lebovic J, Vira S, Diebo B, Lafage V, Passias PG. Predictors of reoperation for spinal disorders in Chiari malformation patients with prior surgical decompression. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:336-340. [PMID: 38268684 PMCID: PMC10805163 DOI: 10.4103/jcvjs.jcvjs_140_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/10/2023] [Indexed: 01/26/2024] Open
Abstract
Background Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning. Materials and Methods This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004-2011. Chiari malformation Types 1-4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded. Results One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40-50 years had the most reoperations (11); however, patients aged 15-20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026). Conclusions Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes.
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Affiliation(s)
- Oluwatobi O. Onafowokan
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Ankita Das
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Jamshaid M. Mir
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Haddy Alas
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Tyler K. Williamson
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Kimberly Mcfarland
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | | | - Sara Naessig
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Bailey Imbo
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Lara Passfall
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Oscar Krol
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Peter Tretiakov
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Rachel Joujon-Roche
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Pooja Dave
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Kevin Moattari
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Stephane Owusu-Sarpong
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Jordan Lebovic
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
| | - Shaleen Vira
- Department of Orthopedic Surgery, Banner Health, Phoenix, AZ, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, RI, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, USA
| | - Peter Gust Passias
- Department of Orthopedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York, USA
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Wieland CM, Holste KG, Selzer B, Garton HJL, Muraszko KM, Maher CO. Sports Participation and Neurological Injuries in Pediatric Patients With Chiari I Malformation. Neurosurgery 2023; 93:646-653. [PMID: 36961215 DOI: 10.1227/neu.0000000000002468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/30/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Currently, there is no consensus recommendation regarding the safety of sports participation for pediatric patients with Chiari I malformation (CM-I). OBJECTIVE To prospectively survey the treated and untreated patients with CM-I to define the risk of sports-associated neurological injury. METHODS A prospective survey was administered to 744 pediatric patients at one neurosurgery clinic between 2010 and 2021. Data were recorded on demographic information, imaging characteristics, treatment, sports participation, and presence of sports-related neurological injury. Patients with incomplete data were called. Two hundred seven patients completed at least 1 subsequent survey and were prospectively followed (mean 1.6 years). RESULTS Of 744 patients with completed surveys, 462 participated in sports. Sports participants were more likely to be older at presentation ( P < .001) and have rounded cerebellar tonsil morphology ( P < .001). Seasons of sports played before and after CM-I decompression (CMD) totaled 5918.7 and 936, respectively. There were 84 sports-related concussions among 55 patients; 79 in untreated patients and 5 after CMD. For all sports participants, the concussion rate was 12.3/1000 seasons of all sports, 9.2/1000 seasons of limited-contact sports, and 13.8/1000 of contact sports. The concussion rate after CMD was 5.3/1000 seasons of all sports, 9.2/1000 seasons of limited-contact sports, and 7.1/1000 seasons of contact sports. There were no reports of long-lasting neurological issues postconcussion or of permanent spinal cord injury. CONCLUSION No permanent or catastrophic sports-associated neurological injuries were reported. The concussion rates in treated and untreated patients with CM-I were low. Therefore, sports participation in this population should be permitted in most cases.
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Affiliation(s)
- Clare M Wieland
- School of Medicine, University of Michigan, Ann Arbor , Michigan , USA
| | - Katherine G Holste
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Bela Selzer
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Karin M Muraszko
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
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Li YF, Wei RX, Yang KQ, Hack GD, Chi YY, Tang W, Sui XJ, Zhang ML, Sui HJ, Yu SB. A valuable subarachnoid space named the occipito-atlantal cistern. Sci Rep 2023; 13:12096. [PMID: 37495633 PMCID: PMC10372020 DOI: 10.1038/s41598-023-38825-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 07/15/2023] [Indexed: 07/28/2023] Open
Abstract
The cisterna magna has been defined as the space between the inferior margin of the cerebellar vermis to the level of the foramen magnum, while an enlarged dorsal subarachnoid space at the occipito-cervical junction extending from the foramen magnum to the upper border of the axis (C2) is still ignored. Recently, the myodural bridge complex is proved to drive the cerebral spinal fluid flowing via this region, we therefore introduce the "occipito-atlantal cistern (OAC)" to better describe the subarachnoid space and provide a detailed rationale. The present study utilized several methods, including MRI, gross anatomical dissection, P45 sheet plastination, and three-dimensional visualization. OAC was observed to be an enlarge subarachnoid space, extending from the foramen magnum to the level of the C2. In the median sagittal plane, OAC was a funnel shape and its anteroposterior dimensions were 15.92 ± 4.20 mm at the level of the C0, 4.49 ± 1.25 mm at the level of the posterior arch of the C1, and 2.88 ± 0.77 mm at the level of the arch of the C2, respectively. In the median sagittal plane, the spino-dural angle of the OAC was calculated to be 35.10 ± 6.91°, and the area of OAC was calculated to be 232.28 ± 71.02 mm2. The present study provides OAC is a subarachnoid space independent from the cisterna magna. Because of its distinctive anatomy, as well as theoretical and clinical significance, OAC deserves its own name.
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Affiliation(s)
- Yun-Fei Li
- Department of Anatomy, College of Zhongshan, Dalian Medical University, Dalian, 116085, China
| | - Rui-Xue Wei
- Second Affiliated Hospital, Dalian Medical University, Dalian, 116052, China
| | - Kai-Qi Yang
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China
| | - Gary D Hack
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD, 21201, USA
| | - Yan-Yan Chi
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China
| | - Wei Tang
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China
| | - Xue-Jun Sui
- Dalian Hoffen Preservation Technique Institution, Dalian, 116052, China
| | - Meng-Liang Zhang
- Department of Molecular Medicine, University of Southern Denmark, 5000, Odense C, Denmark
| | - Hong-Jin Sui
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China.
- Dalian Hoffen Preservation Technique Institution, Dalian, 116052, China.
| | - Sheng-Bo Yu
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China.
- China Denmark Joint Research Center for Biological Plastination Technique, Dalian Medical University, Dalian, 116044, China.
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11
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Rezigh AC, Rezigh AB. Catching the diagnosis: A peculiar presentation of Chiari malformation type I. Arch Clin Cases 2023; 10:86-88. [PMID: 37293687 PMCID: PMC10246598 DOI: 10.22551/2023.39.1002.10247] [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] [Indexed: 06/10/2023] Open
Abstract
Chiari I malformation is a congenital anatomic anomaly of the cerebellar tonsils resulting in their downward displacement through the foramen magnum. While often incidentally discovered on imaging with no attributable symptoms, the most common symptomatic presentation is non-specific headache. Herein, we describe a case of symptomatic Chiari I malformation in a woman with psychiatric comorbidities manifesting as a sensation of brain catching. While a peculiar description easily misconstrued by her mental health history, clinicians should consider this diagnosis in those describing symptoms compatible with headaches or occiput pain related to meningeal irritation.
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Affiliation(s)
- Austin C. Rezigh
- Department of Medicine, University of Texas Health Science Center San Antonio, TX, USA
| | - Alec B. Rezigh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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12
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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.
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13
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Guan J, Yuan C, Yao Q, Du Y, Fang Z, Zhang L, Jia S, Zhang C, Liu Z, Wang K, Duan W, Wang Z, Wang X, Wu H, Chen Z, Jian F. A novel scoring system for assessing adult syringomyelia associated with CM I treatment outcomes. Acta Neurol Belg 2023:10.1007/s13760-023-02264-4. [PMID: 37046133 DOI: 10.1007/s13760-023-02264-4] [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: 01/23/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND A specific scoring system for syringomyelia is lacking. Our objective was to investigate the value of a novel scoring system (Syringomyelia Outcome Scale of Xuanwu hospital, SOS-XW) in assessing surgical outcomes in the treatment of syringomyelia (SM) associated with Chiari malformation type I (CM I). METHODS A quantitative evaluation system (SOS-XW) of SM includes 4 parameters: pain (P), sensation (S), movement (M), and syringomyelia tension index (STI). The clinical data of 88 patients with CM I-related syringomyelia treated by foramen magnum and Magendie dredging (FMMD) from January 2018 to January 2019 were retrospectively analysed with a mean follow-up of 14.3 months, and the SOS-XW score was used to assess the efficacy. RESULTS The higher the SOS-XW score, the more severe was the SM and related symptoms. The mean preoperative score was 5.97, and the postoperative score was 2.66. The symptom improvement rates were 77.78% for P, 69.01% for S, 31.82% for M, and 95.06% for the syringomyelia tension index (STI). The symptom improvement rate of the PSM score was weakly correlated with the improvement rate of STI, R2 = 0.0016. The percentage of PSM (P + S + M) improvement was lower in patients with an STI of 0. The postoperative SOS-XW score was positively correlated with the postoperative JOA score, R2 = 0.8314. The positive detection rate of SOS-XW was higher than that of the JOA score. CONCLUSIONS To evaluate the surgical procedure efficacy in the treatment of syringomyelia, the SOS-XW score can provide a more objective, detailed, and comprehensive analysis, especially STI. A reduction in STI is the practical standard for assessing the effectiveness of surgery.
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Affiliation(s)
- Jian Guan
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Chenghua Yuan
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Qingyu Yao
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Yueqi Du
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Zeyu Fang
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Lei Zhang
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Shanhang Jia
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Can Zhang
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Zhenlei Liu
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Kai Wang
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Wanru Duan
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Zuowei Wang
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Xingwen Wang
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Hao Wu
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Zan Chen
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Fengzeng Jian
- Department of Neurosurgery, China-INI, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China.
- Spine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China.
- Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
- National Center for Neurological Disorders, Beijing, China.
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Famili HP, Zalewski CK, Ibrahimy A, Mack J, Cantor F, Heiss JD, Brewer CC. Audiovestibular Findings in a Cohort of Patients with Chiari Malformation Type I and Dizziness. J Clin Med 2023; 12:jcm12082767. [PMID: 37109107 PMCID: PMC10142081 DOI: 10.3390/jcm12082767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Chiari Malformation Type I (CM1) is a neurological condition in which the cerebellar tonsils extend past the foramen magnum. While many studies have reported dizziness symptoms in patients with CM1, the prevalence of peripheral labyrinthine lesions is largely unknown. This study aimed to comprehensively describe the audiovestibular phenotype in a cohort of patients with CM1 expressly referred for dizziness. Twenty-four patients with CM1 and a complaint of dizziness/vertigo were evaluated. Hearing and auditory brainstem tract function were essentially normal. While vestibular abnormalities were most prevalent during rotational testing (33%), abnormal functional balance was the most common finding (40%). Patients with CM1 had a greater likelihood of exhibiting an abnormal sensory organization test (SOT) postural stability score for fixed platform conditions, and for the somatosensory analysis score. While no significant associations were identified between tonsillar ectopia extent and any vestibular/balance outcome measure, a significant negative association was identified between neck pain and the somatosensory sensory analysis score. Abnormal functional balance in the somatosensory domain was remarkable, with poorer scores associated with neck pain. An isolated peripheral vestibulopathy was present in only 8% of patients. Despite the low prevalence of vestibulopathy, vestibular/balance assessment is warranted to identify patients who may benefit from referral to specialized medical disciplines.
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Affiliation(s)
- Hannah P Famili
- Audiology Unit, NIDCD, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | | | - Alaaddin Ibrahimy
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jessica Mack
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Fredric Cantor
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - John D Heiss
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Carmen C Brewer
- Audiology Unit, NIDCD, National Institutes of Health, Bethesda, MD 20892, USA
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15
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Türkmen C, Köse N, Bal E, Bilgin S, Çetin H, Zengin HY, Gümeler E, Mut M. Effects of Two Exercise Regimes on Patients with Chiari Malformation Type 1: a Randomized Controlled Trial. CEREBELLUM (LONDON, ENGLAND) 2023; 22:305-315. [PMID: 35325392 DOI: 10.1007/s12311-022-01397-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/25/2022]
Abstract
This study aims to measure the effects of two different exercise programs on neck pain, proprioception, balance, coordination, posture, and quality of life in patients with Chiari malformation (CM) type 1. Sixteen patients were randomized to two different exercise programs: a tailored exercise protocol for CM (TEP-CM) and cervical spinal stabilization exercises (CSSE). Both exercise programs were implemented by a physiotherapist 3 days a week for 6 weeks. The primary outcome was Neck Disability Index. Secondary outcomes were visual analogue scale for pain, joint position sense error measurement, Berg Balance Scale, Time Up and Go Test, International Coordination Ataxia Rating Scale, PostureScreen Mobile, and Short Form-36. Assessments were done immediately before and after the intervention programs. Both groups showed significant improvement in Neck Disability Index, and some secondary outcome measures (P < 0.05). However, there were no statistical differences in post-intervention changes between the groups (P > 0.05). This is the first study to examine the effects of different exercise programs on symptoms in patients with CM type 1. Our preliminary findings indicate that exercise programs can improve pain, balance, proprioception, posture, coordination, and quality of life in CM type 1. Therefore, exercise should be considered safe, beneficial, and low-cost treatment option for CM type 1 patients without surgical indications.
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Affiliation(s)
- Ceyhun Türkmen
- Faculty of Health Sciences, Çankırı Karatekin University, 18200 Sıhhiye St., Çankırı, Turkey.
| | - Nezire Köse
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Ercan Bal
- Department of Neurosurgery, Ankara Yıldırım Beyazıt University, Ankara, 06100, Turkey
| | - Sevil Bilgin
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Hatice Çetin
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Hatice Yağmur Zengin
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Ekim Gümeler
- Department of Radiology, Faculty of Medicine, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
| | - Melike Mut
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Samanpazari, Ankara, 06100, Turkey
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Hwang JK, Park EK, Shim KW, Kim DS. Effectiveness of C1 Laminectomy for Chiari Malformation Type 1: Posterior Fossa Volume Expansion and Syrinx-Volume Decrease Rate. Yonsei Med J 2023; 64:191-196. [PMID: 36825345 PMCID: PMC9971440 DOI: 10.3349/ymj.2022.0506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE This study aimed to analyze the effect of foramen magnum decompression with C1 laminectomy (C1L) for Chiari malformation type 1 (CM-1) in terms of improving clinical symptoms, expanding posterior fossa volume, and decreasing syrinx volume. MATERIALS AND METHODS Between January 2007 and June 2019, 107 patients with CM-1 were included. The median patient age was 13±13 years (range: 9 months-60 years), female-to-male ratio was 1:1, and average length of tonsil herniation was 13±5 mm (range: 5-24 mm). Surgical techniques were divided into four groups based on duraplasty or C1L usage. Among the study subjects, 38 patients underwent duraplasty and had their syrinx volumes measured separately on serial magnetic resonance imaging. A three-dimensional visualization software was used to evaluate the syrinx-volume decrease rate. RESULTS Bony decompression exhibited a mere 20% volume expansion of the lower-half posterior fossa. C1L offered a 3% additional volume expansion, which rose to 5% when duraplasty was added (p=0.029). There were no significant differences in complication rate when C1L was combined with duraplasty (p=0.526). Syrinx volumes were analyzed in 38 patients who had undergone duraplasty. Among them, 28 patients who had undergone duraplasty without C1L demonstrated a 5.9% monthly decrease in syrinx volume, which was 7.5% in the remaining 10 patients with C1L (p=0.040). CONCLUSION C1L was effective in increasing posterior fossa volume expansion, both with and without duraplasty. A more rapid decrease in syrinx volume occurred when C1L was combined with duraplasty.
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Affiliation(s)
- Jun Kyu Hwang
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Eun Kyung Park
- Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Won Shim
- Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Seok Kim
- Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Abdallah A, Çınar İ, Gündağ Papaker M, Güler Abdallah B, Emel E. Management of Adult Chiari I Patients Based on CSF Flow Magnetic Resonance Imaging: Experience of Two Neurosurgical Centers. J Neurol Surg A Cent Eur Neurosurg 2023; 84:128-143. [PMID: 35830872 DOI: 10.1055/s-0042-1745845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND STUDY AIMS Chiari malformation type 1 (CM1) is one of the most discussed neurosurgical disorders. No consensus exists how to manage adult CM1 patients. We aimed to evaluate all adult CM1 patients consecutively managed at our institutions and discuss our approach based on the phase-contrast (PC) magnetic resonance imaging (MRI). PATIENTS AND METHODS The medical charts of adult patients diagnosed with CM1 at two referral neurosurgical centers between 2010 and 2017 were reviewed. The patients were either managed conservatively or surgically. We evaluated the patients clinically with the Chicago Chiari Outcome Scale (CCOS). The radiologic diagnosis was based on both craniocervical and PC-MRI. RESULTS Ninety adult CM1 patients were managed conservatively. Conservative treatment failed in 5 of these 90 patients. Seventy-two patients (including those 5 patients who did not benefit from conservative treatment) underwent posterior fossa decompression with duraplasty. Eighty-five patients (94.4%) from the conservative group and 61 patients (84.7%) from the surgical group were treated successfully. An aqueductal stroke volume (ASV) value of 12 µL was found as the cutoff value for surgical candidates. A strong positive correlation between the increase in ASV values and clinical improvement was observed. CONCLUSIONS PC-MRI can help in the management and follow-up of adult CM1 patients. Conservative management is possible in selected symptomatic CM1 patients with a high ASV (ASV > 15 µL). Surgery should be considered in patients with an ASV ≤ 12 µL. CM1 patients with ASV ≤12 to >15 μL require close follow-up. Long-standing symptoms, severe sleep apnea, symptoms influencing functionality, and syrinx are factors that affected outcomes negatively.
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Affiliation(s)
- Anas Abdallah
- Department of Neurosurgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - İrfan Çınar
- Department of Neurosurgery, Aile Hospital, Istanbul, Turkey
| | | | - Betül Güler Abdallah
- Department of Psychiatry - AMATEM Unit, University of Health Sciences, Bakırköy Research and Training Hospital for Neurology Neurosurgery, and Psychiatry, Istanbul, Turkey
| | - Erhan Emel
- Department of Neurosurgery, University of Health Sciences, Bakırköy Research and Training Hospital for Neurology Neurosurgery, and Psychiatry, Istanbul, Turkey
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Tabesh H, Riazi A, Mahmoodkhani M, Sharafi M, Sourani A, Mahdkhah A, Foroughi M. Surgical outcomes of calvaria reconstruction in cranial pansynostosis associated with Arnold-Chiari type 1.5 malformation, a case report. Clin Case Rep 2023; 11:e6981. [PMID: 36891239 PMCID: PMC9986723 DOI: 10.1002/ccr3.6981] [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: 04/29/2022] [Revised: 01/02/2023] [Accepted: 02/06/2023] [Indexed: 03/08/2023] Open
Abstract
A 6-year-old girl with persistent headaches and the visual problem was diagnosed as a delayed onset cranial pansynostosis with concurrent type 1.5 Arnold-Chiari malformation. She underwent multi-sutural reconstructive surgery and followed. The headache was greatly decreased and tonsillar-brain stem herniation and syrinx were resolved.
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Affiliation(s)
- Homayoun Tabesh
- Department of Neurosurgery School of Medicine, Isfahan University of Medical Sciences Isfahan Iran
| | - Ali Riazi
- Department of Neurosurgery School of Medicine, Isfahan University of Medical Sciences Isfahan Iran
| | - Mehdi Mahmoodkhani
- Department of Neurosurgery School of Medicine, Isfahan University of Medical Sciences Isfahan Iran
| | - Mohammad Sharafi
- Department of Neurosurgery School of Medicine, Isfahan University of Medical Sciences Isfahan Iran
| | - Arman Sourani
- Department of Neurosurgery School of Medicine, Isfahan University of Medical Sciences Isfahan Iran
| | - Ata Mahdkhah
- Department of Neurosurgery Urmia University of Medical Sciences Urmia Iran
| | - Mina Foroughi
- Isfahan Medical Students' Research Committee (IMSRC) Isfahan University of Medical Sciences Isfahan Iran
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Secondary cough headache: Independent course of headache and response to a COX-2 inhibitor. Clin Neurol Neurosurg 2023; 227:107646. [PMID: 36893522 DOI: 10.1016/j.clineuro.2023.107646] [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: 01/03/2023] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023]
Abstract
We report on two patients with secondary cough headache who responded to the cyclo-oxygenase-2 (COX-2) inhibitor etoricoxib and showed an independent temporal course. This case report shows that secondary cough headache can also respond to medical treatment and can respond to a COX-2 inhibitor, not previously reported. As is seen in primary cough headache, the headache disorder can go into natural remission (case 1) while the secondary pathology progresses and conversely, persist once the secondary pathology has resolved (case 2). The course of the headache and that of the secondary pathology do not necessarily correlate. It is, therefore, proposed that any treatment of the secondary pathology is independent to that of the headache. In NSAID-intolerant cases a COX-2 inhibitor can be trialled first line.
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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.
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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] [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.
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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.
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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
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Idiopathic Intracranial Hypertension and Vascular Anomalies in Chiari I Malformation. Neurosurg Clin N Am 2023; 34:175-183. [DOI: 10.1016/j.nec.2022.09.008] [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]
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24
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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]
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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.
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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.
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Prenatal screening for neural tube defects: from maternal serum alpha-fetoprotein to ultrasonography. Obstet Gynecol Sci 2023; 66:1-10. [PMID: 36575050 PMCID: PMC9849725 DOI: 10.5468/ogs.22263] [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: 09/29/2022] [Accepted: 11/02/2022] [Indexed: 12/29/2022] Open
Abstract
The two main screening tests during pregnancy are those for chromosomal abnormalities and neural tube defects (NTDs). In particular, for NTDs, measurement of maternal serum alpha-fetoprotein (MSAFP) levels early in the second trimester (15-18 weeks of gestation) has been considered the gold standard screening test for the past 4 decades. However, with remarkable technological advancements and the widespread use of ultrasound during those periods, mid-trimester ultrasonography has gradually replaced the role of measuring MSAFP levels as a screening method for NTDs. This change was initiated more about 10 years ago in some countries, which have issued national guidelines to use mid-trimester ultrasonography instead of measuring MSAFP levels as a prenatal screening method for NTDs. However, no significant changes have occurred in Korea, where second-trimester ultrasonography is routinely performed with high-quality equipment. We aimed to provide information regarding the importance of changing the screening method for NTDs from MSAFP measurement to ultrasonography, and to detail methods of implementing mid-trimester ultrasonography for screening purposes. We also share our experience of operating a prenatal diagnostic program for NTDs without using MSAFP for more than 15 years.
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Ng C, Vazquez S, Auerbach-Tash R, Naftchi AF, Dominguez JF, Singh AR, Overby P, Muh CR. Use of Intraoperative Neuromonitoring in Surgical Treatment of Acute Presentation of Chiari I Malformation: A Case Report. J Neurol Surg Rep 2023; 84:e26-e30. [PMID: 36923100 PMCID: PMC10010903 DOI: 10.1055/a-2028-6419] [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: 07/04/2022] [Accepted: 01/26/2023] [Indexed: 02/07/2023] Open
Abstract
Intraoperative neuromonitoring (IONM) has been used in neurosurgical procedures to assess patient safety and minimize risk of neurological deficit. However, its use in decompressive surgeries of Chiari malformation type I (CM-I) remains a topic of debate. Here we present the case of a 5-year-old girl who presented with acute right lower extremity monoplegia after accidental self-induced hyperflexion of the neck while playing. Imaging revealed 15 mm of tonsillar ectopia with cervical and upper thoracic spinal cord edema. She was taken to surgery for a suboccipital decompression with expansile duraplasty. IONM demonstrated improvement in motor evoked potentials during the decompression. Postoperatively, she had full recovery of strength and mobility. This is a case of acute weakness after mild trauma in the setting of previously asymptomatic CM-I that showed close correlation with IONM, clinical findings, and imaging. IONM during decompressive surgery for CM-I may be useful in patients who present acutely with cervical cord edema.
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Affiliation(s)
- Christina Ng
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Rose Auerbach-Tash
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, United States
| | | | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, United States
| | - Aalok R Singh
- Division of Pediatric Critical Care, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, United States
| | - Philip Overby
- Division of Pediatric Neurology, Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, New York, United States
| | - Carrie R Muh
- Division of Pediatric Neurosurgery, Westchester Medical Center, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York, United States
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Giannakaki V, Nissen J. Foramen magnum decompression for Chiari malformation type I - UK surgical practice. Br J Neurosurg 2022; 36:737-742. [PMID: 35946115 DOI: 10.1080/02688697.2022.2107177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: Symptomatic Chiari 1 malformation (CM1) is a common condition in Neurosurgery. Surgery involves hindbrain decompression and restoration of CSF flow through different surgical approaches. No Class 1 evidence exists to suggest the superiority of any of the surgical techniques.Aims: To investigate current surgical practice for symptomatic CM1 patients in the United Kingdom (UK) and determine the willingness to participate in a randomised controlled trial (RCT) comparing different surgical techniques.Methods: An electronic survey was sent to consultant members of the Society of British Neurological Surgeons and the British Chiari-Syringomyelia Group. The questions covered pre-operative and intra-operative management, presence of equipoise/uncertainty in optimal technique and willingness to participate in an RCT.Results: 98 responses were received. 67% operate on adults. 30% on adult and paediatric patients. There is variation in routine pre-operative use of: ICP monitoring (18%), flexion/extension x-rays (16%), venography (20%) and ophthalmology assessment (26%). 18% of neurosurgeons would not offer foramen magnum decompression when the presenting symptom is only refractory cough/sneeze headache. 15% routinely perform bony decompression alone in adults vs 8% in children. In 68% of adult cases, durotomy is performed routinely (46% of them leave the dura open, 54% perform a type of duroplasty) and 16% routinely resect the cerebellar tonsils. Only 17% leave the dura open in children. The most common indicators for durotomy are syringomyelia and intra-operative ultrasound findings. 61% believe there is equipoise/uncertainty in the optimal strategy for decompression and would be willing to participate in an RCT. Comments also mention the heterogeneity of CM1 and that treatment should be tailored to each patient.Conclusion: There is wide variation in pre- and intra-operative management of CM1 patients in the UK and the majority of neurosurgeons would be willing to participate in an RCT comparing bony decompression alone vs dural opening with/without duroplasty.
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Affiliation(s)
- Venetia Giannakaki
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Justin Nissen
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
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A Clinical Study on the Treatment of Recurrent Chiari (Type I) Malformation with Syringomyelia Based on the Dynamics of Cerebrospinal Fluid. BIOMED RESEARCH INTERNATIONAL 2022; 2022:9770323. [DOI: 10.1155/2022/9770323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022]
Abstract
Objective. Combining the dynamics of cerebrospinal fluid, our study investigates the clinical effects of syringomyelia after the combination of fourth ventricle-subarachnoid shunt (FVSS) for recurrent Chiari (type I) malformations after cranial fossa decompression (foramen magnum decompression (FMD)). Methods. From December 2018 to December 2020, 15 patients with recurrent syringomyelia following posterior fossa decompression had FVSS surgery. Before and after the procedure, the clinical and imaging data of these individuals were retrospectively examined. Results. Following FVSS, none of the 15 patients experienced infection, nerve injury, shunt loss, or obstruction. 13 patients improved dramatically after surgery, while 2 patients improved significantly in the early postoperative period, but the primary symptoms returned 2 months later. The Japanese Orthopedic Association (JOA) score was
, which was considerably better than preoperatively (
,
0.001). The MRI results revealed that the cavities in 13 patients were reduced by at least 50% compared to the cavities measured preoperatively. The shrinkage rate of syringomyelia was 86.67% (13/15). One patient’s cavities nearly vanished following syringomyelia. The size of the cavity in the patient remain unchanged, and the cavity’s maximal diameter was significantly smaller than the size measured preoperatively (
) PC-MRI results indicated that the peak flow rate of cerebrospinal fluid at the central segment of the midbrain aqueduct and the foramen magnum in patients during systole and diastole were significantly reduced after surgery (
). Conclusion. After posterior fossa decompression, FVSS can effectively restore the smooth circulation of cerebrospinal fluid and alleviate clinical symptoms in patients with recurrent Chiari (type I) malformation and syringomyelia. It is a highly effective way of treatment.
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Yılmaz Y, Karademir M, Caygın T, Yağcıoğlu OK, Özüm Ü, Kuğu N. Executive Functions, Intellectual Capacity, and Psychiatric Disorders in Adults with Type 1 Chiari Malformation. World Neurosurg 2022; 168:e607-e612. [DOI: 10.1016/j.wneu.2022.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/17/2022] [Indexed: 11/08/2022]
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Yuksel U, Burulday V, Akkaya S, Baser S, Ogden M, Alhan A, Bakar B. Possible predictive clinical and radiological markers in decision making for surgical intervention in patients with Chiari Malformation type 1. Neurol Res 2022; 44:975-988. [PMID: 35758154 DOI: 10.1080/01616412.2022.2089402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The first aim of this study was to compare the clinical data and posterior fossa morphometry obtained during the admission to the hospital between control group individuals (who had not Chiari Malformation (CM) type 1) and CM type 1 patients treated surgically or not. The second aim was to create a valid and reliable scale that can predict the decision-making for surgical intervention simply and easily in these patients. MATERIALS Medical data and radiological images of 70 CM type 1 patients during their admission to the hospital were compared with the data of 69 control group individuals. RESULTS Conservative treatment and/or follow-up was applied to 58 (82.9%) patients, and 12 (17.1%) patients underwent surgery. ROC analysis showed that the presence of myelopathy, tonsillar herniation >8 mm, Chamberlain line >84 mm, McRae line >44.50 mm, and odontoid process-McRae line angle <10.50 degrees could be used as predictive markers in decision-making for surgical intervention (p < 0.05). Logistic Regression analysis revealed that symptoms severity, and McRae line value would be the 'best parameters' in decision-making for surgical intervention (p < 0.05). A scale named the CHIASURG scale developed using this study's parameters showed that the parameters of 'depth of tonsillar herniation', 'Chamberlain line', and 'McRae line' could predict the surgical intervention risk. CONCLUSION It was found that symptoms severity and McRae line value could be used as predictive markers in decision-making for surgical intervention. Additionally, it was concluded that a new scale called CHIASURG could predict surgical intervention risk validly and reliably.
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Affiliation(s)
- Ulaş Yuksel
- Kirikkale University Faculty of Medicine, Department of Neurosurgery, Kirikkale, Turkey
| | - Veysel Burulday
- Inonu University Faculty of Medicine, Department of Radiology, Kirikkale, Turkey
| | - Suleyman Akkaya
- Kirikkale University Faculty of Medicine, Department of Neurosurgery, Kirikkale, Turkey
| | - Selcuk Baser
- Kirikkale University Faculty of Medicine, Department of Radiology, Kirikkale, Turkey
| | - Mustafa Ogden
- Kirikkale University Faculty of Medicine, Department of Neurosurgery, Kirikkale, Turkey
| | - Aslihan Alhan
- Ufuk University Faculty of Medicine, Department of Biostatistics, Ankara, Turkey
| | - Bulent Bakar
- Kirikkale University Faculty of Medicine, Department of Neurosurgery, Kirikkale, Turkey
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Case Report: Downbeat Nystagmus Due to Epidural Puncture during Labor with Undiagnosed Arnold Chiari Malformation. Optom Vis Sci 2022; 99:721-724. [PMID: 35678639 DOI: 10.1097/opx.0000000000001916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Epidural anesthesia is a safe procedure used in pregnant patients during labor. However, caution should be exercised in those patients that have concurrent Arnold Chiari malformation. PURPOSE To report a rare and atypical presentation of downbeat nystagmus, in a pregnant patient with Arnold Chiari malformation type 1 (ACM1), secondary to accidental dural puncture. CASE REPORT A 31-year-old African American female presented with a chief complaint of decreased vision and oscillopsia that occurred after giving birth, six months earlier. Her medical history prior to presentation was unremarkable. Her delivery was typical; however, the patient did receive epidural anesthesia which resulted in a dural puncture. The patient noted her symptoms a few days after delivery. Upon examination, persistent down beat nystagmus was noted in both eyes. Magnetic resonance imaging revealed a 2.5 cm inferior displacement of the cerebellar tonsils below the foramen magnum consistent with ACM1. The patient was referred to neurosurgery for posterior fossa decompression. However, surgery was deferred until appropriate weight reduction could be achieved. Follow-up examination six months later revealed no change in her clinical findings. CONCLUSIONS This case report highlights an atypical presentation of downbeat nystagmus secondary to an accidental dural puncture in a pregnant patient with undiagnosed ACM1. Clinicians should consider the importance of considering ocular complications that can occur in pregnant patients with ACM1. Questioning of women who have recently given birth about epidural anesthesia should be considered with an acute presentation of downbeat-nystagmus.
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Stella I, Remen T, Petel A, Joud A, Klein O, Perrin P. Postural control in Chiari I malformation: protocol for a paediatric prospective, observational cohort - potential role of posturography for surgical indication. BMJ Open 2022; 12:e056647. [PMID: 35551083 PMCID: PMC9109102 DOI: 10.1136/bmjopen-2021-056647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Chiari I malformation (CM1) is an anatomical abnormality characterised by the cerebellar tonsils descending at least 5 mm below the foramen magnum. CM1 causes obstruction of cerebrospinal fluid (CSF) circulation as well as direct compression on the brainstem, thus causing typical consequences (syringomyelia), and typical clinical features (characteristic headaches and neurological impairment). Surgery is the only available treatment, indicated when symptomatology is present. However, sometimes patients have atypical complaints, which are often suggestive of otolaryngological (ears, nose and throat, ENT) involvement. This may be difficult for a neurosurgeon to explain. Our study aims to investigate the relationship between one of these atypical symptoms, for example, postural instability, in a paediatric population using a Computerised Dynamic Posturography (Equitest, NeuroCom, Clackamas, OR). To our knowledge, there are no previously published studies carried out on children with CM1, using dynamic posturography. METHODS AND ANALYSIS Forty-five children aged 6-18 years old presenting with radiologically confirmed CM1 and presenting ENT clinical complaints will be included in the study for a duration of 3 years. As primary endpoint, posturographic results will be described in the population study. Second, posturographic results will be compared between patients with and without indication for surgery. Finally, preoperative and postoperative posturographic results, as well as CSF circulation quality at foramen magnum level, syringomyelia, sleep apnoea syndrome, scoliosis and behaviour will be compared in the operated patient group. ETHICS AND DISSEMINATION This protocol received ethical approval from the Clinical Research Delegation of Nancy University Hospital, in accordance with the National Commission on Informatics and Liberties (Commission Nationale de l'Informatique et des Libertés) (protocol number 2019PI256-107). Our data treatment was in accordance with the Methodology of reference Methodology Reference-004 specification for data policy. The study findings will be disseminated via peer-reviewed publications and conference presentations, especially to the Neurosphynx's rare disease healthcare network. TRIAL REGISTRATION NUMBER NCT04679792; Pre-results.
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Affiliation(s)
- Irene Stella
- EA 3450 DevAH - Development, Adaptation and Handicap, Faculty of Medicine, University of Lorraine, Nancy, France
- Paediatric Neurosurgery, CHRU de Nancy, Nancy, France
- Laboratory for the Analysis of Posture, Equilibrium and Motor Function (LAPEM), CHRU de Nancy, Nancy, France
| | - Thomas Remen
- Methodologic, Data-Management and Statistics Unit, CHRU de Nancy, Nancy, France
| | - Arthur Petel
- EA 3450 DevAH - Development, Adaptation and Handicap, Faculty of Medicine, University of Lorraine, Nancy, France
- Laboratory for the Analysis of Posture, Equilibrium and Motor Function (LAPEM), CHRU de Nancy, Nancy, France
| | - Anthony Joud
- Paediatric Neurosurgery, CHRU de Nancy, Nancy, France
| | - Olivier Klein
- EA 3450 DevAH - Development, Adaptation and Handicap, Faculty of Medicine, University of Lorraine, Nancy, France
- Paediatric Neurosurgery, CHRU de Nancy, Nancy, France
- Laboratory for the Analysis of Posture, Equilibrium and Motor Function (LAPEM), CHRU de Nancy, Nancy, France
| | - Philippe Perrin
- EA 3450 DevAH - Development, Adaptation and Handicap, Faculty of Medicine, University of Lorraine, Nancy, France
- Laboratory for the Analysis of Posture, Equilibrium and Motor Function (LAPEM), CHRU de Nancy, Nancy, France
- Paediatric Oto-Rhyno-laryngology, CHRU de Nancy, Na, Nancy, France
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Conservative Treatment of Chiari Malformation Type I Based on the Phase-Contrast MRI: A Retrospective Study. World Neurosurg 2022; 163:e323-e334. [PMID: 35367644 DOI: 10.1016/j.wneu.2022.03.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The phase-contrast magnetic resonance image (PC-MRI) use is interestingly increased in diagnosis and follow-up patients with Chiari Type I Malformation (CM1). The current study aimed to elaborate the benefits of conservative treatment by evaluating consecutively treated adult patients with CM1 who were selected on basis of the PC-MRIs. METHODS Medical records of patients diagnosed with CM1 were retrospectively reviewed at two neurosurgical centers spanning eight years (2010-2017). Adult patients with CM1, who were treated conservatively and met study criteria, were selected to be the core sample for this study. Between-groups (benefited vs non-benefited) comparisons were performed to understand the factors that may affect the outcomes. RESULTS Ninety (68 females and 22 males) adult patients received conservative treatment for CM1. The mean age was 40.6. Headaches and pinprick loss were the most commonly recorded symptoms and clinical findings which were recorded in 58 (64.4%) and 31 (34.4%) patients, respectively. Eleven patients were presented with a syrinx. The mean aqueductal stroke volume (ASV) was 16.5 μl. The conservative treatment failed in treating five (5.6%) patients who underwent surgical intervention. The means of ASV in the benefited and non-benefited groups were 16.7 and 13.2 μl, respectively (p=0.004). CONCLUSION Conservative approaches (prescriptive medications, physical therapy, Pilates, and swimming) can improve the life quality of non-surgical candidate adult patients with CM1. Conservative treatment can be useful in selected patients with variably CM1 (ASV=16.7 μl). The presence of heavy sleep apnea or/and functional symptoms were prognostic factors that were affected the conservative treatment negatively.
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Abdallah A, Çınar İ, Gündağ Papaker M, Güler Abdallah B, Sofuoğlu ÖE, Emel E. The factors affecting the outcomes of conservative and surgical treatment of chiari i adult patients: a comparative retrospective study. Neurol Res 2022; 44:165-176. [PMID: 35109779 DOI: 10.1080/01616412.2021.1967681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The prognosis of the Chiari malformation type 1 (CM1) demonstrates a variant spectrum that varies from full recovery to complicated worse neurological disability. OBJECTIVE To investigate the factors affecting the outcomes of conservative and surgical treatment for CM1 by evaluating adult patients consecutively managed at our institutions. MATERIALS AND METHODS We retrospectively reviewed the medical records of patients diagnosed with CM1 at two reference neurosurgical centers for eight years (2010-2017). We selected all CM1 adult patients who managed conservatively or surgically as the core sample for this study. For clinical evaluation, we used a Chicago Chiari Outcome Scale (CCOS). For radiological assessment, we adopted both craniocervical and contrast-phase MRIs. We investigate factors such as age, sex, pretreatment symptoms, symptoms duration, and radiological findings in both groups. RESULTS Ninety patients were treated conservatively. After a progression, five of them were treated surgically later and included in a total of 72 patients who underwent decompressive surgery. We successfully managed 85 patients (94.4%) of the conservative group and 64 patients (88.9%) of the surgical group. We found that patients with aqueductal stroke volume (ASV) of 12 µl are surgical candidates. We observed a strong positive correlation between clinical improvement and the increase in ASV values. CONCLUSIONS ASV≤12 µl is a significant predictor for surgical intervention. The presence of heavy sleep apnea or/and functional symptoms, tonsillar herniation >13.4 mm on coronal images, low ASV, long symptom durations, and a syrinx are the independent prognostic factors that affected outcomes negatively.
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Affiliation(s)
- Anas Abdallah
- Department Of Neurosurgery, Private Aile Hospital, Istanbul, Turkey
| | - İrfan Çınar
- Department Of Neurosurgery, Private Aile Hospital, Istanbul, Turkey
| | - Meliha Gündağ Papaker
- Department Of Neurosurgery, Bezmialem Vakif University, Istanbul, Fatih - Istanbul; Turkey
| | - Betül Güler Abdallah
- Department Of Psychiatry - Amatem Unit, University Of Health Sciences, Bakırköy Research And Training Hospital For Neurology Neurosurgery, And Psychiatry, Bakırköy -Istanbul; Turkey
| | - Özden Erhan Sofuoğlu
- Department Of Neurosurgery, University Of Health Sciences, Bakırköy Research And Training Hospital For Neurology Neurosurgery, And Psychiatry, Istanbul, Bakırköy - Istanbul; Turkey
| | - Erhan Emel
- Department Of Neurosurgery, University Of Health Sciences, Bakırköy Research And Training Hospital For Neurology Neurosurgery, And Psychiatry, Istanbul, Bakırköy - Istanbul; Turkey
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Turk ML, Schmidt K, McGrath ML. Diagnosis, Management, and Return to Sport of a 16-Year-Old Patient With a Chiari I Malformation: A Case Report and Literature Review. J Athl Train 2022; 57:177-183. [PMID: 34185839 PMCID: PMC8876886 DOI: 10.4085/1062-6050-0001.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This case report discusses a 16-year-old female volleyball, basketball, and track and field athlete who was diagnosed with a Chiari I malformation after a concussion. Surgical decompression was recommended and performed 3 months after her initial diagnosis. This patient presented unique challenges due to her age, desire to return to sport, and lack of access to medical care due to living in a rural area. Few evidence-based best-practice recommendations are available for the management and return to sport of patients with Chiari I malformation, particularly for those who have undergone surgical decompression. In this case study, we address the treatment and return-to-sport process for the patient and provide a comprehensive review of the published literature on patients attempting to return to sport after a diagnosis of Chiari I malformation. In addition, we explore the value of an athletic trainer in reconciling various barriers in management and return to sport evident in this case and the reviewed literature.
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Affiliation(s)
| | - Kelly Schmidt
- Pediatric Neurosurgery, Logan Health Children's, Kalispell, MT
| | - Melanie L. McGrath
- School of Integrative Physiology and Athletic Training, University of Montana, Missoula
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Diagnosis and treatment of Chiari malformation and syringomyelia in adults: international consensus document. Neurol Sci 2022; 43:1327-1342. [PMID: 34129128 DOI: 10.1007/s10072-021-05347-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Syringomyelia and Chiari malformation are classified as rare diseases on Orphanet, but international guidelines on diagnostic criteria and case definition are missing. AIM OF THE STUDY to reach a consensus among international experts on controversial issues in diagnosis and treatment of Chiari 1 malformation and syringomyelia in adults. METHODS A multidisciplinary panel of the Chiari and Syringomyelia Consortium (4 neurosurgeons, 2 neurologists, 1 neuroradiologist, 1 pediatric neurologist) appointed an international Jury of experts to elaborate a consensus document. After an evidence-based review and further discussions, 63 draft statements grouped in 4 domains (definition and classification/planning/surgery/isolated syringomyelia) were formulated. A Jury of 32 experts in the field of diagnosis and treatment of Chiari and syringomyelia and patient representatives were invited to take part in a three-round Delphi process. The Jury received a structured questionnaire containing the 63 statements, each to be voted on a 4-point Likert-type scale and commented. Statements with agreement <75% were revised and entered round 2. Round 3 was face-to-face, during the Chiari Consensus Conference (Milan, November 2019). RESULTS Thirty-one out of 32 Jury members (6 neurologists, 4 neuroradiologists, 19 neurosurgeons, and 2 patient association representatives) participated in the consensus. After round 2, a consensus was reached on 57/63 statements (90.5%). The six difficult statements were revised and voted in round 3, and the whole set of statements was further discussed and approved. CONCLUSIONS The consensus document consists of 63 statements which benefited from expert discussion and fine-tuning, serving clinicians and researchers following adults with Chiari and syringomyelia.
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Arslan A, Olguner SK, Acik V, İstemen İ, Arslan B, Ökten Aİ, Gezercan Y. Surgical Outcomes of C1-2 Posterior Stabilization in Patients With Chiari Malformation Type 1. Global Spine J 2022; 12:37-44. [PMID: 32787628 PMCID: PMC8965300 DOI: 10.1177/2192568220945293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
STUDY DESIGN Retrospective chart review. OBJECTIVES Chiari malformation (CM) is characterized by a downward displacement of the cerebellar tonsils through the foramen magnum. This tonsillar herniation may sometimes be accompanied by syringomyelia and/or basilar invagination (BI). In this study, we examined the surgical outcomes of patients by underwent C1-2 reduction + fixation (C1-2RF), which is a new method defined by Goel, in the literature. METHODS Between 2015 and 2018, 21 patients (mean age and duration of follow-up: 39 years and 20 months, respectively) with CM were treated with atlantoaxial fixation. We found syringomyelia in all patients and BI in 9 of them. In all cases, radiography, computed tomography, and magnetic resonance imaging were performed radiologically. C1-2RF was performed in all patients. Preoperative and postoperative clinical Japanese Orthopaedic Association scores were obtained. Syrinx size and cerebrospinal fluid flow rate were compared radiologically. RESULTS All patients were treated with C1-2RF. None of the patients underwent foramen magnum decompression or intervention for the syrinx. Occipital bone and subaxial spinal structures were not included in the fixation. In addition to significant clinical improvement, significant improvement in syringomyelia and cerebrospinal fluid flow rate was seen on the radiographs of all patients. CONCLUSIONS Although posterior fossa decompression and/or duraplasty is a common treatment modality in CM, we propose that the C1-2RF method described by Goel is a radiologically and clinically effective treatment method, whether or not BI and/or syringomyelia in CM are present. This article is the first article of central and axial atlantoaxial dislocation, except for Goel's writings in the literature.
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Affiliation(s)
- Ali Arslan
- Adana City Training and Research Hospital, Adana, Turkey,Ali Arslan, Department of Neurosurgery, Adana City Training and Research Hospital, Dr. Mithat Özsan Bulvarı Kışla Mah. 4522 Sok. No:1 Yüreğir, Adana, Turkey.
| | | | - Vedat Acik
- Adana City Training and Research Hospital, Adana, Turkey
| | - İsmail İstemen
- Adana City Training and Research Hospital, Adana, Turkey
| | - Barış Arslan
- Adana City Training and Research Hospital, Adana, Turkey
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Thakar S, Kanneganti V, Talla Nwotchouang BS, Salem SJ, Eppelheimer M, Loth F, Allen PA, Aryan S, Hegde AS. Are Two-Dimensional Morphometric Measures Reflective of Disease Severity in Adult Chiari I Malformation? World Neurosurg 2022; 157:e497-e505. [PMID: 34710575 PMCID: PMC8692430 DOI: 10.1016/j.wneu.2021.10.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Two-dimensional (2D) morphometric measures have been previously used to diagnose Chiari I malformation (CMI) and distinguish patients from healthy subjects. There is, however, a paucity of literature regarding whether morphometric differences exist across the range of CMI disease severity. We evaluated whether 2D morphometrics demonstrate significant changes across standardized grades of CMI severity in adults. METHODS This retrospective observational study comprised 76 patients with symptomatic CMI with or without syringomyelia. Patients matched for age, sex, and body mass index were selected from each of the 3 severity grades of the Chiari Severity Index (CSI). The study used 17 2D craniocervical and posterior fossa morphometric variables that were previously found to differentiate patients with CMI from healthy subjects. The measurements were performed on midsagittal T1-weighted magnetic resonance imaging sequences using 2 custom in-house software tools, MorphPro and CerePro, and compared across CSI grades. RESULTS Analysis of variance showed that none of the 17 morphometric variables were significantly different across the 3 CSI grades (P > 0.003). Bayes factor 10 scores ranged from 0.11 to 0.82. Of variables, 9 had Bayes factor 10 scores between 0.10 and 0.30, while 8 had scores between 0.30 and 1. None of the Bayes factor 10 scores provided support for the alternative hypothesis that the morphometric measures differed across the CSI grades. CONCLUSIONS Our study indicated that 2D morphometrics are not reflective of CMI disease severity as indicated by the CSI grading system. The findings of our study support the need for further investigation into whether non-2D morphometric variables can be used as markers of disease severity.
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Affiliation(s)
- Sumit Thakar
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Vidyasagar Kanneganti
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | | | - Sara J. Salem
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, Ohio, United States
| | - Maggie Eppelheimer
- Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, Ohio, United States
| | - Francis Loth
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, Ohio, United States,Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, Ohio, United States
| | - Philip A. Allen
- Conquer Chiari Research Center, Department of Psychology, The University of Akron, Akron, Ohio, United States
| | - Saritha Aryan
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Alangar S Hegde
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
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Occipitocervical fusion as treatment of instability in Chiari malformation. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh220203041z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction. Occipitocervical (OC) fusion is a method for fixation of the OC
junction when there is instability of that segment. Arnold Chiari
malformation is a congenital disorder where cerebellar tonsils descend
through the foramen magnum, which can lead to cervicomedular compression and
formation of syrinx. While treating this condition, for the purpose of
decompression, the foramen magnum is expanded which can potentially harm the
stability of the OC junction. Case outline. We are presenting the case of a
16 year old female who was surgically treated (suboccipital craniectomy and
decompression) because of Arnold Chiari malformation type I. One-year
post-op multislice computed tomography verified a slight enlargement of
basion-axial and basion-dens intervals, with signs of spinal cord
compression. Surgery was performed - occipitocervical fusion, canal
decompression on C1 and C2 levels with a plate on occipital bone and screws
placed in the third, fourth, and fifth cervical vertebra. Conclusion.
Occipitocervical fusion is a complex surgical procedure (vital neurovascular
structures), but it is a reliable method for treatment of instability of the
OC junction.
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Malformations of the craniocervical junction: Casamassima-morton-nance syndrome and type I Chiari malformation. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Chakraborty AR, Pelargos PE, Milton CK, Martin MD, Bauer AM, Dunn IF. Occipital condyle screw fixation after posterior decompression for Chiari malformation: Technical report and application. Surg Neurol Int 2021; 12:543. [PMID: 34877029 PMCID: PMC8645510 DOI: 10.25259/sni_26_2021] [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: 01/11/2021] [Accepted: 09/15/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical techniques for stabilization of the occipital cervical junction have traditionally consisted of screw-based techniques applied in conjunction with occipital plating and rods connected to subaxial instrumentation in the form of pars, pedicle, or lateral mass screws. In patients with type 1 Chiari malformation (CM-1) and evidence of occipital cervical junction instability who have undergone posterior decompression, the occipital condyle (OC) represents a potential alternative cranial fixation point. To date, this technique has only been described in pediatric case reports and morphometric cadaver studies. METHODS Patients underwent posterior fossa decompression for treatment of CM. Subsequently, patients received occipital cervical stabilization using OC screws. RESULTS Patients were successfully treated with no post-operative morbidity. Patient 2 was found to have pseudoarthrosis and underwent revision. Both patients continue to do well at 1-year follow-up. CONCLUSION Placement of the OC screw offers advantages over traditional plate-based occipital fixation in that bone removal for suboccipital decompression is not compromised by the need for hardware placement, screws are hidden underneath ample soft tissue in patients with thin skin which prevents erosion, and the OC consists of primarily cortical bone which provides for robust tricortical fixation. These cases demonstrate the novel application of the OC screw fixation technique to the treatment of occipital cervical junction instability in adult patients undergoing simultaneous posterior fossa decompression.
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Affiliation(s)
| | | | | | | | | | - Ian F. Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
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Philip JT, Conway NB, Tailor DR. Unique presentation and management of Gowers intrasyringal hemorrhage. J Spinal Cord Med 2021; 44:1011-1014. [PMID: 31603391 PMCID: PMC8725733 DOI: 10.1080/10790268.2019.1674056] [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] [Indexed: 10/25/2022] Open
Abstract
Context: Intrasyringal hemorrhage was first described in literature in the renowned Lectures on Diseases of the Nervous System by Sir William Richard Gowers [Gowers W. A lecture on syringal haemorrhage into the spinal cord. Lancet [Internet]; 162(4180):993-997. [cited 2019 August 19]. Available from https://www.sciencedirect.com/science/article/pii/S0140673601362785]. The pathophysiology of this disease is a hemorrhage within a preexisting intramedullary fluid-filled cavity or hydrosyringomyelia in the spinal cord. Most common symptoms of this disease are numbness, weakness, paresthesia in the extremities and gait disturbances. Since first noted in 1903, there have been just fourteen confirmed cases of this disease reported in literature, making it extremely rare and difficult to study.Findings: Here we discuss a unique presentation of Gowers intrasyringal hemorrhage. The patient is a male in his late teens with no prior established neurological history. He presented at our institution four days post suspected injury with persistent mild left upper extremity numbness and weakness. The patient was admitted and underwent an MRI of the cervical spine without intravenous contrast. The imaging findings confirm subacute on chronic Gowers intrasyringal hemorrhage in the setting of a Chiari 1 malformation. This patient underwent neurosurgical intervention four months post initial presentation and had complete postoperative resolution of his interval non-progressive but persistent symptoms.Clinical relevance: This unique case suggests immediate surgical intervention may not always be necessary for treating Gowers intrasyringal hemorrhage.
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Affiliation(s)
- Justin T. Philip
- AdventHealth Medical Group Radiology, Orlando, Florida, USA,Correspondence to: Justin T. Philip, AdventHealth Medical Group Radiology, 601 E. Rollins St., Orlando, FL32803, USA.
| | - Nicholas B. Conway
- Department of Radiology, AdventHealth Medical Group Radiology, Orlando, Florida, USA
| | - Dharmesh R. Tailor
- Department of Radiology, AdventHealth Medical Group Radiology, Orlando, Florida, USA
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Van Der Veken J, Harding M, Hatami S, Agzarian M, Vrodos N. Syringomyelia intermittens: highlighting the complex pathophysiology of syringomyelia. Illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21341. [PMID: 35855301 PMCID: PMC9265193 DOI: 10.3171/case21341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chiari Type I malformation (CM1) is a disorder recognized by caudal displacement of the cerebellar tonsils through the foramen magnum and into the cervical canal. Syringomyelia is frequently found in patients with CM1, but the pathophysiology of syringomyelia remains an enigma. As a general consensus, symptomatic patients should be treated and asymptomatic patients without a syrinx should not be treated. Mildly symptomatic patients or asymptomatic patients with a syrinx, on the other hand, pose a more challenging dilemma, as the natural evolution is uncertain. For many surgeons, the presence of a syrinx is an indication to offer surgery even if the patient is asymptomatic or mildly symptomatic. OBSERVATIONS The authors describe an illustrative case of a 31-year-old female with an incidental finding of a CM1 malformation and cervical syrinx in 2013. Conservative management was advocated as the patient was asymptomatic. Monitoring of the syrinx over a course of 8 years showed resolution, followed by reappearance and finally a complete resolution in 2021. A review of the literature and the possible pathophysiology is discussed. LESSONS The unusual course of this patient highlights the importance of guiding treatment by clinical symptoms, not radiological findings. Furthermore it reflects the complexity of the pathophysiology and the uncertain natural history of syringomyelia.
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Affiliation(s)
| | | | - Saba Hatami
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, South Australia, Australia; and
- College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Marc Agzarian
- South Australia Medical Imaging, Flinders Medical Centre, Bedford Park, South Australia, Australia; and
- College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
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Rodriguez VV, Tello CA, Piantoni L, Wilson IAF, Galareto E, Remondino RG, Bersusky SE, Davies R, Noel MA. Chiari 1: Is decompression always necessary previous to scoliosis surgery? Spine Deform 2021; 9:1253-1258. [PMID: 33792837 DOI: 10.1007/s43390-021-00336-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
The association between Chiari 1 malformation and scoliosis is well known in the literature. Prevalence has increased after the advent of magnetic resonance imaging. In children with this association, prophylactic suboccipital decompression prior to scoliosis correction is a common surgical procedure although the rationale for this surgical management and whether not performing it may lead to spinal cord injury has not been clearly elucidated. We conducted a systematic review of the literature with the aim to obtain strong data to support the hypothesis that it is safe to proceed with scoliosis correction without prior prophylactic suboccipital decompression for Chiari 1 in an asymptomatic population. Using the Prisma methodology, we analyzed 3250 studies published between 1972 and 2018. Only four studies met the inclusion criteria. None of the studies had a level of evidence high enough to recommend prophylactic decompression previous to correction of the spinal deformity.
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Affiliation(s)
- V Vazquez Rodriguez
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - C A Tello
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - L Piantoni
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina.
| | - I A Francheri Wilson
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - E Galareto
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - R G Remondino
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - S E Bersusky
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - R Davies
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
| | - M A Noel
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Combate de Los Pozos 1881CABA, C1245AAM, Buenos Aires, Argentina
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46
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Technical Report: Durable efficacy of an endoscope-assisted syringo-panventriculoatrial shunt for concurrent hydrocephalus and syrinx. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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47
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Still M, Miller P, Dodd W, Moor R, Lucke-Wold B, Porche K, Foote K. Chiari I malformation and Noonan's syndrome: Shared manifestations of RASopathy. JOURNAL OF CLINICAL IMAGES AND MEDICAL CASE REPORTS 2021; 2:1334. [PMID: 34661197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Neurologic sequalae of Noonan syndrome have been postulated in the literature. A topic of significance is the role of RASopathy in the shared pathophysiology of Noonan Syndrome and Chiari I malformation. In this unique case report, we present a patient with concomitant Noonan Syndrome and Chiari I with 4th ventricular outflow obstruction. The case highlights the importance of close clinical suspicion in this patient population. We utilize the case to delve into intricacies of the known pathophysiology and encourage ongoing investigation.
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Affiliation(s)
- Megan Still
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | - Patricia Miller
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | - William Dodd
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | - Rachel Moor
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | | | - Ken Porche
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | - Kelly Foote
- Department of Neurosurgery, University of Florida, Gainesville, USA
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48
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Muthiah N, McDowell MM, Zenonos G, Agarwal N, Snyderman CH, Friedlander RM, Gardner PA. Endoscopic Endonasal Resection of Cranio-Cervical Junction Chordoma and Ventral Chiari Decompression: A Case Report. Oper Neurosurg (Hagerstown) 2021; 21:E421-E426. [PMID: 34392369 DOI: 10.1093/ons/opab285] [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: 02/08/2021] [Accepted: 06/28/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chiari I malformations secondary to other causes represent a small subset of presenting symptomatic cases. Typically, the primary cause of the malformation is addressed first and results in resolution of the malformation and symptoms. However, in some cases, a patient may present with both a primary Chiari I malformation and another unrelated neurosurgical lesions. OBJECTIVE To present a unique case in which resection of a ventral tumor allowed for spontaneous resolution of a simultaneously noted dorsal Chiari I malformation. METHODS Pertinent data, including presenting symptoms, hospital course, surgical notes, preoperative images, and postoperative images, were collected using the electronic medical record. RESULTS We present a case of a 46-yr-old man with a Chiari I malformation in conjunction with a ventral cranio-cervical junction chordoma. Endoscopic endonasal resection of the chordoma and ventral foramen magnum decompression resulted in radiographic resolution of the Chiari malformation and resolution of his symptoms. Our report represents a rare case of ventral foramen magnum decompression as a treatment for Chiari I malformation. CONCLUSION It is felt that the chordoma mass effect was not the source of the Chiari I malformation. Thus, both ventral and dorsal decompressions of the posterior fossa may be considered for Chiari I decompression in select circumstances.
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Affiliation(s)
- Nallammai Muthiah
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Georgios Zenonos
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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49
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Kotaki Y, Hattori G, Uchikado H, Komaki S, Takeshige N, Miyahara T, Hasegawa Y, Morioka M. "Motion-specific Headache": A Predictor for Diagnosis and Favorable Prognosis after Surgery in Young Patients with Chiari Malformation Type 1. Neurol Med Chir (Tokyo) 2021; 61:577-582. [PMID: 34321386 PMCID: PMC8531875 DOI: 10.2176/nmc.oa.2020-0427] [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] [Indexed: 11/25/2022] Open
Abstract
As headache is known as one of the most common symptoms in the patients with Chiari malformation type 1 (CM1), it is difficult to find out CM1-related headache among the symptoms because headache itself is commonly seen. Herein, we retrospectively review the cases of six CM1 patients complaining only of headache by which they complained of deterioration in daily life activities. The symptom of headache worsened during anteflexion (n = 2; 33%), retroflexion (n = 1; 17%), jumping (n = 3; 50%), going up the stairs (n = 1; 17%), and running (n = 1; 17%). Mean age at the onset was 15.7 years old (ranging 11–18) and four out of six were female. These inductive factors were clearly different from “Valsalva-like maneuvers,” although the mechanism might originate from dynamic tonsil changes. We named these headaches as “motion-specific.” These headaches radiated to the posterior side. MRI revealed that the extent of tonsillar ectopia was 11.3 mm, while syringomyelia was observed in three out of six patients (50%). All patients underwent surgical treatment, with the “motion-specific headache” completely disappearing 12.5 days thereafter. Although headaches are common, “motion-specific headache” may be a good candidate symptom to distinguish CM1 patients, especially among teenagers with headaches, and a good predictor for favorable outcomes after surgical treatment.
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Affiliation(s)
- Yoshikuni Kotaki
- Department of Neurosurgery, Kurume University School of Medicine
| | - Gohsuke Hattori
- Department of Neurosurgery, Kurume University School of Medicine
| | - Hisaaki Uchikado
- Department of Neurosurgery, Kurume University School of Medicine
| | - Satoru Komaki
- Department of Neurosurgery, Kurume University School of Medicine
| | | | | | - Yu Hasegawa
- Department of Neurosurgery, Kurume University School of Medicine.,Department of Pharmaceutical Sciences, School of Pharmacy at Fukuoka, International University of Health and Welfare
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine
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50
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Jussila MP, Nissilä J, Vakkuri M, Olsén P, Niinimäki J, Leinonen V, Serlo W, Salokorpi N, Suo-Palosaari M. Preoperative measurements on MRI in Chiari 1 patients fail to predict outcome after decompressive surgery. Acta Neurochir (Wien) 2021; 163:2005-2014. [PMID: 33977335 PMCID: PMC8195958 DOI: 10.1007/s00701-021-04842-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/30/2021] [Indexed: 11/27/2022]
Abstract
Background The purpose of our study was to research the parameters of magnetic resonance imaging (MRI) that would predict the outcome of surgery in patients with Chiari 1 malformation (CM1) and to evaluate changes in MRI parameters after surgery. Methods Fifty-one patients (19 children, 13 adolescents, and 19 adults) operated on due to CM1 in Oulu University Hospital between 2004 and 2018 were evaluated. Seventeen parameters were measured from the preoperative MRI and 11 from the postoperative MRI. The correlations between the MRI parameters and the clinical variables before and after surgery were analyzed. Results The majority (88.2%) of the patients had favorable surgical outcomes. Postoperatively, subjective symptoms improved in 88.6% of the patients and syringomyelia in 81.8%. The location of the cerebellar tonsils, when measured in relation to the C2 synchondrosis or the end plate, postoperatively moved cranially in 51.0% (n = 26), did not change in 27.4% (n = 14), and moved caudally in 21.6% (n = 11) of the patients. However, neither the location of the tonsils nor any other parameters measured from pre- or postoperative MRI correlated with the patients’ symptoms or surgical outcomes. Conclusions No specific parameters on preoperative MRI evaluation were predictive of the outcome of surgery, emphasizing clinical examination in surgical decision-making. Furthermore, the postoperative MRI parameters did not correlate with the surgical outcomes. Thus, routine postoperative imaging is suggested only for patients with preoperatively diagnosed syringomyelia or worsening of symptoms.
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Affiliation(s)
- Miro-Pekka Jussila
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu and Research Unit of Medical Imaging, Physics, and Technology, Oulu University Hospital and University of Oulu, Kajaanintie 50, OYS, P.O. Box 50, 90029, Oulu, Finland
| | - Juho Nissilä
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu and Research Unit of Medical Imaging, Physics, and Technology, Oulu University Hospital and University of Oulu, Kajaanintie 50, OYS, P.O. Box 50, 90029, Oulu, Finland
| | - Minna Vakkuri
- Department of Neurosurgery, Oulu University Hospital, Oulu and Research Unit of Clinical Neuroscience, Medical Research Center Oulu (MRC Oulu), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Päivi Olsén
- Department of Children and Adolescents, Oulu University Hospital, Oulu and PEDEGO Research Unit, University of Oulu and Medical Research Center Oulu (MRC Oulu), Oulu, Finland
| | - Jaakko Niinimäki
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu and Research Unit of Medical Imaging, Physics, and Technology, Oulu University Hospital and University of Oulu, Kajaanintie 50, OYS, P.O. Box 50, 90029, Oulu, Finland
| | - Ville Leinonen
- Department of Neurosurgery, Kuopio University Hospital, Kuopio and Institute of Clinical Medicine-Neurosurgery, University of Eastern Finland, Kuopio, Finland
| | - Willy Serlo
- Department of Children and Adolescents, Oulu University Hospital, Oulu and PEDEGO Research Unit, University of Oulu and Medical Research Center Oulu (MRC Oulu), Oulu, Finland
| | - Niina Salokorpi
- Department of Neurosurgery, Oulu University Hospital, Oulu and Research Unit of Clinical Neuroscience, Medical Research Center Oulu (MRC Oulu), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Maria Suo-Palosaari
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu and Research Unit of Medical Imaging, Physics, and Technology, Oulu University Hospital and University of Oulu, Kajaanintie 50, OYS, P.O. Box 50, 90029, Oulu, Finland.
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