1
|
Montgomery EY, Caruso JP, Price AV, Whittemore BA, Weprin BE, Swift DM, Braga BP. Predictors of syrinx presentation and outcomes in pediatric Chiari malformation type I: a single institution experience of 218 consecutive syrinx patients. Childs Nerv Syst 2024; 40:2527-2534. [PMID: 38777910 DOI: 10.1007/s00381-024-06403-x] [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: 04/23/2023] [Accepted: 04/12/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Chiari I malformation (CM-I) in pediatric patients can impose substantial neurologic and functional impairment. Additionally, the presence of syrinx is often a harbinger of clinical compromise, but little attention has been devoted to identifying features associated with syrinx development and the clinical impact of syrinx resolution. Therefore, this study aims to identify clinical and radiographic variables associated with preoperative syrinx presence and postoperative syrinx reduction in pediatric patients with CM-I and determine the relationship between postoperative syrinx reduction and clinical symptom improvement. METHODS The authors performed a retrospective analysis of 435 consecutive pediatric patients who underwent surgical treatment of CM-I from 2001 to 2021 at a single tertiary pediatric medical center. All patients underwent pre- and postoperative MRI, and clinical and radiographic variables were recorded and subject to inferential analysis. RESULTS Syrinx at presentation was independently associated with symptoms of spinal cord dysfunction at presentation (OR 2.17 (95% CI 1.05-4.48); p = 0.036), scoliosis (OR 5.33 (2.34-10.86); p = 0.001), and greater pB-C2 (posterior basion to C2 distance) measurement length (OR 1.14 (95% CI 1.01-1.30); p = 0.040). Syrinx at presentation was inversely associated with tussive headaches at presentation (OR 0.27 (95% CI 0.16-0.47); p = 0.001) and cranial nerve deficits at presentation (OR 0.49 (95% CI 0.26-0.92); p = 0.025). Postoperatively, patients with radiographic evidence of syrinx improvement had greater rates of symptom improvement (93.1% vs 82.1%; p = 0.049), better CCOS scores (15.4 vs 14.2; p = 0.001), and decreased rates of readmission (6.0% vs 25.0%, p = 0.002) and reoperation (0.5% vs 35.7%; p = 0.001). The difference in syrinx resolution was similar but not statistically significant (10.3% vs 16.7%; p = 0.251). AO joint anomaly (OR 0.20, 95% CI 0.04-0.95; p = 0.026) and foramen magnum diameter (OR 1.12, 95% CI 1.00-1.25; p = 0.049) were the only independent predictors of syrinx improvement, and surgical technique was the only predictor for syrinx resolution (OR 2.44, 95% CI 1.08-5.50; p = 0.031). Patients that underwent tonsil reduction surgery whose syrinx improved had a wider foramen magnum diameter than those whose did not improve (34.3 vs 31.7; p = 0.028). CONCLUSIONS Radiographic syrinx improvement is associated with greater rates of symptom improvement and less readmissions and reoperations for CM-I. AO joint anomalies and narrower foramen magnums were independent risk factors for the lack of syrinx improvement. These novel insights will help guide preoperative patient counseling, pre- and intraoperative surgical decision-making, and postoperative clinical prognostication in the treatment of pediatric CM-I.
Collapse
Affiliation(s)
- Eric Y Montgomery
- Department of Neurological Surgery - UT Southwestern Medical Center, Dallas, TX, USA
| | - James P Caruso
- Department of Neurological Surgery - UT Southwestern Medical Center, Dallas, TX, USA
| | - Angela V Price
- Department of Neurological Surgery - UT Southwestern Medical Center, Dallas, TX, USA
- Children's Medical Center, Dallas, TX, USA
| | - Brett A Whittemore
- Department of Neurological Surgery - UT Southwestern Medical Center, Dallas, TX, USA
- Children's Medical Center, Dallas, TX, USA
| | - Bradley E Weprin
- Department of Neurological Surgery - UT Southwestern Medical Center, Dallas, TX, USA
- Children's Medical Center, Dallas, TX, USA
| | - Dale M Swift
- Department of Neurological Surgery - UT Southwestern Medical Center, Dallas, TX, USA
- Children's Medical Center, Dallas, TX, USA
| | - Bruno P Braga
- Department of Neurological Surgery - UT Southwestern Medical Center, Dallas, TX, USA.
- Children's Medical Center, Dallas, TX, USA.
| |
Collapse
|
2
|
Henderson FC, Schubart JR, Narayanan MV, Tuchman K, Mills SE, Poppe DJ, Koby MB, Rowe PC, Francomano CA. Craniocervical instability in patients with Ehlers-Danlos syndromes: outcomes analysis following occipito-cervical fusion. Neurosurg Rev 2024; 47:27. [PMID: 38163828 PMCID: PMC10758368 DOI: 10.1007/s10143-023-02249-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/30/2023] [Accepted: 12/09/2023] [Indexed: 01/03/2024]
Abstract
Craniocervical instability (CCI) is increasingly recognized in hereditary disorders of connective tissue and in some patients following suboccipital decompression for Chiari malformation (CMI) or low-lying cerebellar tonsils (LLCT). CCI is characterized by severe headache and neck pain, cervical medullary syndrome, lower cranial nerve deficits, myelopathy, and radiological metrics, for which occipital cervical fusion (OCF) has been advocated. We conducted a retrospective analysis of patients with CCI and Ehlers-Danlos syndrome (EDS) to determine whether the surgical outcomes supported the criteria by which patients were selected for OCF. Fifty-three consecutive subjects diagnosed with EDS, who presented with severe head and neck pain, lower cranial nerve deficits, cervical medullary syndrome, myelopathy, and radiologic findings of CCI, underwent open reduction, stabilization, and OCF. Thirty-two of these patients underwent suboccipital decompression for obstruction of cerebral spinal fluid flow. Questionnaire data and clinical findings were abstracted by a research nurse. Follow-up questionnaires were administered at 5-28 months (mean 15.1). The study group demonstrated significant improvement in headache and neck pain (p < 0.001), decreased use of pain medication (p < 0.0001), and improved Karnofsky Performance Status score (p < 0.001). Statistically significant improvement was also demonstrated for nausea, syncope (p < 0.001), speech difficulties, concentration, vertigo, dizziness, numbness, arm weakness, and fatigue (p = 0.001). The mental fatigue score and orthostatic grading score were improved (p < 0.01). There was no difference in pain improvement between patients with CMI/LLCT and those without. This outcomes analysis of patients with disabling CCI in the setting of EDS demonstrated significant benefits of OCF. The results support the reasonableness of the selection criteria for OCF. We advocate for a multi-center, prospective clinical trial of OCF in this population.
Collapse
Affiliation(s)
- Fraser C Henderson
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA.
| | - Jane R Schubart
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Malini V Narayanan
- Division of Neurosurgery, University of Maryland Capital Region Medical Center, Largo, Maryland, USA
| | - Kelly Tuchman
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
| | - Susan E Mills
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Dorothy J Poppe
- Bobby Jones Chiari & Syringomyelia Foundation, Staten Island, New York, USA
| | - Myles B Koby
- Luminis Health, Doctors Community Medical Center, Lanham, Maryland, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
3
|
Lu C, Ma L, Guan J, Liu Z, Wang K, Duan W, Chen Z, Wu H, Jian F. Relationship Between Syrinx Resolution and Cervical Sagittal Realignment Following Decompression Surgery for Chiari I Malformation Related Syringomyelia Based on Configuration Phenotypes. Neurospine 2022; 19:1057-1070. [PMID: 36597642 PMCID: PMC9816586 DOI: 10.14245/ns.2244530.265] [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] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/26/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Combined with different configuration types of syringomyelia, to analyze the correlation between syrinx resolution and changes in cervical sagittal alignment following Foramen magnum and Magendie dredging (FMMD) for syringomyelia associated with Chiari I malformation (CM-I), and to further explore the respective relationship with clinical outcome. METHODS A consecutive series of 127 patients with CM-I and syringomyelia who underwent FMMD in our center met the inclusion criteria of this study. Their clinical records and radiologic data were retrospectively reviewed. The Japanese Orthopedic Association (JOA) scoring system and the Chicago Chiari Outcome Scale (CCOS) were used to evaluate the surgical efficacy. The phenotypes of syringomyelia and the clinical characteristics of the patients were analyzed according to grouping by cervical curvature at baseline. RESULTS The preoperative straight or kyphotic cervical alignment is more common in the moniliform syrinx. After surgery, the syrinx resolution and cervical sagittal realignment in the moniliform group are more obvious, and the corresponding prognosis is relatively better. Spearman correlation analysis showed that the ΔS/C ratio (the change ratio of syrinx/cord) was positively correlated with the CCOS (p = 0.001, r = 0.897) and ΔC2-7A (the change of lower cervical angle) (p = 0.002, r = 0.560). There was also a correlation between the ΔJOA score (the change rate of the JOA score) and ΔC2-7A (p = 0.012, r = 0.467). CONCLUSION After decompression surgery, syrinx resolution may coexist with the changes in the subaxial lordosis angle, especially for syrinx in moniliform type, and the relationship between syrinx resolution and cervical sagittal realignment might be valuable for evaluating the surgical outcome.
Collapse
Affiliation(s)
- Chunli Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,Neurospine 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
| | - Longbing Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,Neurospine 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
| | - Jian Guan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,Neurospine 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, Xuanwu Hospital, Capital Medical University, Beijing, China,Neurospine 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, Xuanwu Hospital, Capital Medical University, Beijing, China,Neurospine 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, Xuanwu Hospital, Capital Medical University, Beijing, China,Neurospine 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, Xuanwu Hospital, Capital Medical University, Beijing, China,Neurospine 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, Xuanwu Hospital, Capital Medical University, Beijing, China,Neurospine 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, Xuanwu Hospital, Capital Medical University, Beijing, China,Neurospine 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,Corresponding Author Fengzeng Jian China International Neuroscience Institute (CHINA-INI), Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing 100053, China
| |
Collapse
|
4
|
Rosenblum JS, Pomeraniec IJ, Heiss JD. Chiari Malformation (Update on Diagnosis and Treatment). Neurol Clin 2022; 40:297-307. [PMID: 35465876 PMCID: PMC9043468 DOI: 10.1016/j.ncl.2021.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chiari Malformation Type I (CMI) is a congenital malformation diagnosed by MRI findings of at least 5 mm of cerebellar ectopy below the foramen magnum. CM1 is frequently associated with syringomyelia. Herein, we discuss the history of CMI and syringomyelia, including early pathological and surgical studies. We also describe recent investigations into the pathogenesis and pathophysiology of CMI and their practical implications on management and surgical intervention. We also highlight the recent development of the Common Data Elements for CMI, providing a framework for ongoing investigations. Finally, we discuss current controversies of surgical management in CMI.
Collapse
|
5
|
Marianayagam NJ, Chae JK, Hussain I, Cruz A, Baaj AA, Härtl R, Greenfield JP. Increase in clivo-axial angle is associated with clinical improvement in children undergoing occipitocervical fusion for complex Chiari malformation: patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21433. [PMID: 36061080 PMCID: PMC9435577 DOI: 10.3171/case21433] [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: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The authors analyzed the pre- and postoperative morphometric properties of pediatric patients with complex Chiari malformation undergoing occipitocervical fusion (OCF) to assess clinical outcomes and morphometric properties that might influence postoperative outcomes. OBSERVATIONS The authors retrospectively reviewed 35 patients younger than 22 years with Chiari malformation who underwent posterior fossa decompression and OCF with or without endoscopic endonasal odontoidectomy at their institution (13 with and 22 without odontoidectomy). Clivo-axial angle (CXA), pB-C2, atlantodental interval, basion-dens interval, basion-axial interval, and canal diameter at the level of C1 were measured on preoperative and approximately 3-month postoperative computed tomography or magnetic resonance imaging. The authors further stratified the patient cohort into three age groups and compared the three cohorts. The most common presenting symptoms were headache, neck/shoulder pain, and dysphagia; 80% of the cohort had improved clinical outcomes. CXA increased significantly after surgery. When stratified into those who showed postoperative improvement and those who did not, only the former showed a significant increase in CXA. After age stratification, the significant changes in CXA were observed in the 7- to 13-year-old and 14- to 21-year-old cohorts. LESSONS CXA may be the most important morphometric predictor of clinical outcomes after OCF in pediatric patients with complex Chiari malformation.
Collapse
Affiliation(s)
- Neelan J. Marianayagam
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - John K. Chae
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - Amanda Cruz
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - Ali A. Baaj
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - Jeffrey P. Greenfield
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| |
Collapse
|
6
|
Alford EN, Atchley TJ, Leon TJ, Laskay NMB, Arynchyna AA, Smith BP, Aban I, Johnston JM, Blount JP, Rozzelle CJ, Oakes WJ, Rocque BG. Imaging characteristics associated with surgery in Chiari malformation type I. J Neurosurg Pediatr 2021; 27:620-628. [PMID: 33892468 DOI: 10.3171/2020.9.peds20347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In Chiari malformation type I (CM-I), a variety of imaging findings have been purported to be important; however, results have been inconclusive, inconsistent, or not replicated in independent studies. The purpose of this study was to report imaging characteristics for a large cohort of patients with CM-I and identify the imaging findings associated with surgical decompression. METHODS Patients were identified using ICD-9 codes for CM-I for the period from 1996 to 2017. After review of the medical records, patients were excluded if they 1) did not have a diagnosis of CM-I, 2) were not evaluated by a neurosurgeon, or 3) did not have available preoperative MRI. Retrospective chart review was performed to collect demographic and clinical data. Imaging parameters were measured according to the Chiari I Malformation Common Data Elements. RESULTS A total of 731 patients were included for analysis, having a mean follow-up duration of 25.5 months. The mean age at presentation was 8.5 years. The mean tonsil position was 11.4 mm below the foramen magnum, and 62.8% of patients had a pegged tonsil shape. Two hundred patients (27.4%) underwent surgery for life-dominating tussive headache, lower cranial nerve dysfunction, syrinx, and/or brainstem dysfunction. Surgical treatment was associated with a syrinx (OR 20.4, 95% CI 12.3-33.3, p < 0.0001), CM-1.5 (OR 1.797, 95% CI 1.08-2.98, p = 0.023), lower tonsil position (OR 1.130, 95% CI 1.08-1.18, p < 0.0001), and congenital fusion of cervical vertebrae (OR 5.473, 95% CI 1.08-27.8, p = 0.040). Among patients with benign CM-I, tonsil position was statistically significantly associated with future surgery. CONCLUSIONS Comprehensive imaging characteristics for a large cohort of patients with CM-I are reported. Analysis showed that a lower tonsillar position, a syrinx, and CM-1.5 were associated with undergoing posterior fossa decompression. This study demonstrates the importance of considering imaging findings in the context of patient symptomatology.
Collapse
Affiliation(s)
| | - Travis J Atchley
- 1Division of Pediatric Neurosurgery, Department of Neurosurgery; and
| | | | | | | | | | | | - James M Johnston
- 1Division of Pediatric Neurosurgery, Department of Neurosurgery; and
| | - Jeffrey P Blount
- 1Division of Pediatric Neurosurgery, Department of Neurosurgery; and
| | - Curtis J Rozzelle
- 1Division of Pediatric Neurosurgery, Department of Neurosurgery; and
| | - W Jerry Oakes
- 1Division of Pediatric Neurosurgery, Department of Neurosurgery; and
| | - Brandon G Rocque
- 1Division of Pediatric Neurosurgery, Department of Neurosurgery; and
| |
Collapse
|
7
|
Feghali J, Xie Y, Chen Y, Li S, Huang J. External validation of current prediction systems of improvement after decompression surgery in Chiari malformation type I patients: can we do better? J Neurosurg 2021; 134:1466-1471. [PMID: 32357331 DOI: 10.3171/2020.2.jns20181] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Chiari Severity Index (CSI) and points-based algorithm of Thakar et al. are two prognostic tools that have been developed to predict the likelihood of improvement after suboccipital decompression in adult patients with Chiari malformation type I (CM-I). This study aimed to externally validate and critically evaluate these algorithms in the interest of guiding the development of improved prediction systems. METHODS A consecutive cohort of CM-I patients undergoing suboccipital decompression between September 2006 and September 2018 were included. The CSI and Thakar point score were computed for all patients, and associations with improvement were analyzed. The ability of both prediction systems to predict improvement as measured by different Chicago Chiari Outcome Scale (CCOS) cutoffs was assessed using receiver operating curve analysis. Post hoc correlations between the algorithms and different CCOS subcomponents were also assessed. RESULTS The surgical cohort was composed of 149 adult CM-I patients, of whom 39 (26%) had a syrinx. Most patients experienced improvement after surgery (80% CCOS ≥ 13; 96% CCOS ≥ 11). The proportion of patients improving decreased with increasing CSI, but the results were not statistically significant (p = 0.246). No statistically significant difference in the mean Thakar point score was identified between improved and nonimproved patients using both CCOS cutoffs (p = 0.246 for a cutoff of 13 and p = 0.480 for a cutoff of 11). The CSI had a poor ability in identifying improved patients at a CCOS cutoff of 13 (area under the curve [AUC] 0.582) and 11 (AUC 0.646). The Thakar point score similarly had poor discrimination at a cutoff of 13 (AUC 0.467) and 11 (AUC 0.646). Neither algorithm had significant correlation with any of the CCOS subcomponents except for CSI and nonpain symptom improvement (coefficient = -0.273, p = 0.001). CONCLUSIONS Previously published algorithms failed to provide prediction value with regard to clinically meaningful improvement following suboccipital decompression in adult CM-I patients. Future models and practical scoring systems are still required to improve the decision-making process.
Collapse
Affiliation(s)
- James Feghali
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Yangyiran Xie
- 2Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland; and
| | - Yuxi Chen
- 2Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland; and
| | - Sean Li
- 3Pratt School of Engineering, Duke University, Durham, North Carolina
| | - Judy Huang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine
| |
Collapse
|
8
|
Williams G, Thyagaraj S, Fu A, Oshinski J, Giese D, Bunck AC, Fornari E, Santini F, Luciano M, Loth F, Martin BA. In vitro evaluation of cerebrospinal fluid velocity measurement in type I Chiari malformation: repeatability, reproducibility, and agreement using 2D phase contrast and 4D flow MRI. Fluids Barriers CNS 2021; 18:12. [PMID: 33736664 PMCID: PMC7977612 DOI: 10.1186/s12987-021-00246-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/03/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Phase contrast magnetic resonance imaging, PC MRI, is a valuable tool allowing for non-invasive quantification of CSF dynamics, but has lacked adoption in clinical practice for Chiari malformation diagnostics. To improve these diagnostic practices, a better understanding of PC MRI based measurement agreement, repeatability, and reproducibility of CSF dynamics is needed. METHODS An anatomically realistic in vitro subject specific model of a Chiari malformation patient was scanned three times at five different scanning centers using 2D PC MRI and 4D Flow techniques to quantify intra-scanner repeatability, inter-scanner reproducibility, and agreement between imaging modalities. Peak systolic CSF velocities were measured at nine axial planes using 2D PC MRI, which were then compared to 4D Flow peak systolic velocity measurements extracted at those exact axial positions along the model. RESULTS Comparison of measurement results showed good overall agreement of CSF velocity detection between 2D PC MRI and 4D Flow (p = 0.86), fair intra-scanner repeatability (confidence intervals ± 1.5 cm/s), and poor inter-scanner reproducibility. On average, 4D Flow measurements had a larger variability than 2D PC MRI measurements (standard deviations 1.83 and 1.04 cm/s, respectively). CONCLUSION Agreement, repeatability, and reproducibility of 2D PC MRI and 4D Flow detection of peak CSF velocities was quantified using a patient-specific in vitro model of Chiari malformation. In combination, the greatest factor leading to measurement inconsistency was determined to be a lack of reproducibility between different MRI centers. Overall, these findings may help lead to better understanding for application of 2D PC MRI and 4D Flow techniques as diagnostic tools for CSF dynamics quantification in Chiari malformation and related diseases.
Collapse
Affiliation(s)
- Gwendolyn Williams
- Department of Chemical and Biological Engineering, University of Idaho, 875 Perimeter Dr. MC1122, Moscow, ID, 83844, USA
| | - Suraj Thyagaraj
- Department of Mechanical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, 44325, USA
| | - Audrey Fu
- Department of Mathematics and Statistical Science, University of Idaho, Moscow, ID, 83844, USA
| | - John Oshinski
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, 30322, USA
| | - Daniel Giese
- Department of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Alexander C Bunck
- Department of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Eleonora Fornari
- CIBM, Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Francesco Santini
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Mark Luciano
- Department of Neurosurgery, John Hopkins University, Baltimore, MD, USA
| | - Francis Loth
- Department of Mechanical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, 44325, USA
| | - Bryn A Martin
- Department of Chemical and Biological Engineering, University of Idaho, 875 Perimeter Dr. MC1122, Moscow, ID, 83844, USA.
- Alcyone Therapeutics Inc, Lowell, MA, USA.
| |
Collapse
|
9
|
Gholampour S, Gholampour H. Correlation of a new hydrodynamic index with other effective indexes in Chiari I malformation patients with different associations. Sci Rep 2020; 10:15907. [PMID: 32985602 PMCID: PMC7523005 DOI: 10.1038/s41598-020-72961-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 09/09/2020] [Indexed: 12/13/2022] Open
Abstract
This study aimed to find a new CSF hydrodynamic index to assess Chiari type I malformation (CM-I) patients’ conditions and examine the relationship of this new index with morphometric and volumetric changes in these patients and their clinical symptoms. To this end, 58 CM-I patients in four groups and 20 healthy subjects underwent PC-MRI. Ten morphometric and three volumetric parameters were calculated. The CSF hydrodynamic parameters were also analyzed through computational fluid dynamic (CFD) simulation. The maximum CSF pressure was identified as a new hydrodynamic parameter to assess the CM-I patients’ conditions. This parameter was similar in patients with the same symptoms regardless of the group to which they belonged. The result showed a weak correlation between the maximum CSF pressure and the morphometric parameters in the patients. Among the volumetric parameters, PCF volume had the highest correlation with the maximum CSF pressure, which its value being higher in patients with CM-I/SM/scoliosis (R2 = 65.6%, P = 0.0022) than in the other patients. PCF volume was the more relevant volumetric parameter to assess the patients’ symptoms. The values of PCF volume were greater in patients that headache symptom was more obvious than other symptoms, as compared to the other patients.
Collapse
Affiliation(s)
- Seifollah Gholampour
- Department of Biomedical Engineering, North Tehran Branch, Islamic Azad University, Tehran, Iran.
| | - Hanie Gholampour
- Department of Electrical and Computer Engineering, Science and Research Branch, Islamic Azad University, Tehran, Iran
| |
Collapse
|
10
|
Emergency Department Visits Following Suboccipital Decompression for Adult Chiari Malformation Type I. World Neurosurg 2020; 144:e789-e796. [PMID: 32956886 PMCID: PMC7500401 DOI: 10.1016/j.wneu.2020.09.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Postoperative emergency department (ED) visits following suboccipital decompression in Chiari malformation type I (CM-1) patients are not well described. We sought to evaluate the magnitude, etiology, and significance of postoperative ED service utilization in adult CM-1 patients at a tertiary referral center. METHODS A prospectively maintained database of CM-1 patients seen at our institution between January 1, 2006 and December 31, 2019 was used. ED visits occurring within 30 days after surgery were tracked for postoperative patients, while comparing clinical, imaging, and operative characteristics between patients with and without an ED visit. Clinical improvement at last follow-up was also compared between both groups of patients in a univariable and multivariable analysis using the Chicago Chiari Outcome Scale (CCOS). RESULTS In 175 surgically treated patients, 44 (25%) visited an ED in the 1-month period after surgery. The most common reason for seeking care was isolated headache (41%), and concentration disturbance at presentation was the only factor significantly associated with a postoperative ED visit (P = 0.023). The occurrence of a postoperative ED visit was independently associated with a lower chance of clinical improvement at last follow-up (adjusted odds ratio of CCOS ≥13 = 0.35, P = 0.021; adjusted odds ratio of CCOS ≥14 = 0.38, P = 0.016). CONCLUSIONS Adult CM-1 patients undergoing surgery at a tertiary referral center have an elevated rate of postoperative ED visits, which are mostly due to pain-related complaints. Such visits are hard to predict but are associated with worse long-term clinical outcome. Interventions that decrease the magnitude of postoperative ED service utilization are warranted.
Collapse
|
11
|
Feghali J, Chen Y, Xie Y, Chen C, Huang J. The impact of depression on surgical outcome in Chiari malformation type I: an assessment based on the Chicago Chiari Outcome Scale. J Neurosurg Spine 2020; 33:273-280. [PMID: 32330896 DOI: 10.3171/2020.2.spine2069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The effect of depression on outcomes in Chiari malformation type I (CM-1) is unclear. The authors sought to determine whether depression affects outcome in a surgical cohort of CM-1 patients by using a validated outcome assessment tool, the Chicago Chiari Outcome Scale (CCOS). METHODS The authors performed a retrospective analysis of a prospectively maintained database of 149 adult CM-1 patients undergoing suboccipital decompression with duraplasty and cranioplasty. Baseline presentation characteristics and composite as well as subcomponent CCOS scores at last follow-up were compared between depressed and nondepressed patients. Outcome comparisons included both a univariable analysis and a logistic regression model adjusting for several covariates. RESULTS The prevalence of depression in the study cohort was 28% (41/149). Baseline demographic and imaging characteristics were similar between the 2 patient groups. Dizziness (p = 0.019) and imbalance (p = 0.015) were significantly more common among depressed patients, but clinical symptoms and severity were otherwise comparable. On univariable analysis, depressed patients were significantly less likely to experience improvement in pain symptoms (OR 0.14, 95% CI 0.03-0.61, p = 0.003) and functionality (OR 0.17, 95% CI 0.03-0.99, p = 0.049). No significant difference was identified in complications, nonpain symptom improvement, or overall composite CCOS improvement. Similar results were obtained on multivariable analysis controlling for several covariates. CONCLUSIONS Depression is independently associated with poor surgical outcome in adult CM-1 patients, namely when evaluating improvement in pain symptoms and functionality. Optimizing the management of depression preoperatively and ensuring follow-up for psychiatric comorbidity in the postoperative period may possibly lead to improved outcomes.
Collapse
Affiliation(s)
- James Feghali
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Yuxi Chen
- 2Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore; and
| | - Yangyiran Xie
- 2Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore; and
| | - Christopher Chen
- 3Robert H. Smith School of Business, University of Maryland, College Park, Maryland
| | - Judy Huang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| |
Collapse
|
12
|
Feghali J, Marinaro E, Xie Y, Chen Y, Li S, Huang J. Family History in Chiari Malformation Type I: Presentation and Outcome. World Neurosurg 2020; 142:e350-e356. [PMID: 32653513 DOI: 10.1016/j.wneu.2020.06.238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/28/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Some patients with Chiari malformation type I (CM-1) present with a positive family history of CM-1, the significance of which remains unknown. We aimed to study whether family history affects the clinical presentation characteristics and surgical outcome of adult patients with CM-1. METHODS A database of adult patients with CM-1 presenting between January 1, 2006 and December 31, 2018 was used. Presenting characteristics were compared between patients with and without a family history (first, second, or third degree) of CM-1. Among surgically treated patients, perioperative and long-term outcomes, with favorable outcome defined as a Chiari Outcome Scale score ≥14, were compared between patients with and without CM-1 family history. All patients completed at least 6 months of postoperative follow-up. RESULTS The database consisted of 233 adult patients with CM-1, 14 of whom (6%) had a positive family history. Presenting characteristics were comparable between patients with and without a positive family history. A total of 150 patients underwent suboccipital decompression, 12 of whom (8%) had a positive family history. After a mean follow-up of 1.9 years, patients with a family history of CM-1 were significantly less likely to achieve a favorable outcome (odds ratio, 0.22; 95% confidence interval, 0.06-0.78; P = 0.019) while controlling for several covariates. Post hoc analysis showed that the difference was most significant when looking at pain symptoms. CONCLUSIONS Presentation characteristics are comparable between patients with and without a family history of CM-1. Patients with a positive family history may be less likely to respond favorably to suboccipital decompression.
Collapse
Affiliation(s)
- James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Marinaro
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yangyiran Xie
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yuxi Chen
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sean Li
- Pratt School of Engineering, Duke University, Durham, North Carolina, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| |
Collapse
|
13
|
Feghali J, Xie Y, Chen Y, Li S, Huang J. The SHORE Score: A Novel Predictive Tool for Improvement After Decompression Surgery in Adult Chiari Malformation Type I. World Neurosurg 2020; 142:e195-e202. [PMID: 32599206 DOI: 10.1016/j.wneu.2020.06.175] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND A practical scoring system predicting significant improvement after surgical decompression in adult Chiari malformation type I (CM-1) based on validated outcome measures is lacking. We aimed to develop a simple score and improvement calculator to facilitate the decision making process in symptomatic CM-1 patients. METHODS We evaluated adult CM-1 patients who presented to our institution between September 2006 and September 2018 and underwent surgical decompression. Previously treated patients were excluded. Univariable analysis and multivariable logistic regression were conducted to derive an optimal model predictive of improvement on last follow-up as measured by the Chicago Chiari Outcome Scale. A score was derived using the beta coefficients of the model, and predictive performance was assessed using receiver operating curves with bootstrap validation. Finally, a web-based improvement calculator was deployed. RESULTS The surgical cohort consisted of 149 adult CM-1 patients, of which 100 (67%) experienced significant clinical improvement (Chicago Chiari Outcome Scale ≥14) after a mean follow-up of 1.9 years. The final model predictive of significant clinical improvement consisted of headache with Valsalva (odds ratio [OR] = 2.39; P = 0.030), nonwhite race (OR = 2.57; P = 0.041), absence of visual symptoms (OR = 2.59; P = 0.015), syrinx absence (OR = 1.59; P = 0.315), and increased odontoid retroflexion (OR = 2.82; P = 0.009). The score was termed SHORE, which summarizes the model's predictive factors, each assigned 1 point. The model had an area under the curve of 0.754 with an optimism-correct value of 0.721. A calculator was deployed under: https://jhuspine2.shinyapps.io/SHORE_score/. CONCLUSIONS The score and calculator can serve as supplements to clinical decision making by providing realistic and personalized expectations of postoperative outcome.
Collapse
Affiliation(s)
- James Feghali
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yangyiran Xie
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yuxi Chen
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sean Li
- Pratt School of Engineering, Duke University, Durham, North Carolina, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA.
| |
Collapse
|
14
|
Outcomes of dura-splitting technique compared to conventional duraplasty technique in the treatment of adult Chiari I malformation: a systematic review and meta-analysis. Neurosurg Rev 2020; 44:1313-1329. [PMID: 32567026 DOI: 10.1007/s10143-020-01334-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/14/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
Chiari malformation type I is a developmental abnormality with an array of surgical techniques introduced for the management of it. The most common technique is foramen magnum decompression with duraplasty. Dura-splitting technique as one of the non-dura-opening techniques is a less known procedure that spares the internal layer of the dura and can theoretically result in fewer complications compared to duraplasty. So, we performed a review of literature and meta-analysis on different clinical and radiological aspects of this technique and compared its outcomes to duraplasty. MOOSE guidelines were followed. A systematic search of three databases based on predefined search strategy and inclusion/exclusion criteria was performed. After quality assessment and data extraction by two authors, summarized data were presented in form of tables, and meta-analysis results were illustrated in forest plots. A review of 10 included studies consisting of 370 patients revealed significantly shorter operation duration and less intraoperative blood loss in the dura-splitting technique compared to duraplasty. Interestingly, there was no significant difference between these two techniques in terms of clinical and radiological outcomes. Overall complication rate and incidence of CSF-related complications or infections were significantly in favor of the dura-splitting technique. Dura-splitting technique can be considered as a safe and effective surgical procedure for Chiari I malformation with comparable outcomes and fewer complications compared to duraplasty, although this interpretation is derived from retrospective observational studies and lack of a prospective clinical trial is evident.
Collapse
|
15
|
Atchley TJ, Alford EN, Rocque BG. Systematic review and meta-analysis of imaging characteristics in Chiari I malformation: does anything really matter? Childs Nerv Syst 2020; 36:525-534. [PMID: 31701278 DOI: 10.1007/s00381-019-04398-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/26/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Previous studies have attempted to evaluate the utility of preoperative magnetic resonance imaging (MRI) parameters in predicting outcomes in Chiari I malformation. We performed a systematic review and meta-analysis to determine what preoperative imaging features (if any) predict (1) presence of preoperative symptoms or associated findings, (2) need for surgical decompression, or (3) improvement after surgical decompression. METHODS All publications through June 2018 on PubMed, Embase, and Cochrane Library databases were searched using the keywords "Chiari I malformation" AND "decompression" OR "imaging." One thousand two hundred ten publications were identified, and 20 were included for our systematic review; nine were included in the meta-analysis. RESULTS Tonsil position, clivus gradient, and scoliotic curve of > 20° were all associated with the presence of preoperative syrinx. Degree of scoliotic curve was associated with length of syrinx. Pre-operative findings of central syrinx morphology, shorter syrinx, and scoliotic curve < 20° were associated with post-operative stability/improvement. Post-operative symptomatic improvement was associated with preoperative pB-C2 line ≥ 3 mm, absence of scoliosis, and presence of syrinx. By meta-analysis, there was no significant difference in post-operative improvement between patients with and without syrinx (OR = 0.89; 95% CI 0.58-1.37). Meta-analysis showed no significant difference in post-operative improvement between patients with and without basilar invagination (OR = 1.31; 95% CI 0.72-2.36). CONCLUSIONS Multiple studies have attempted to identify preoperative imaging parameters to predict post-operative improvement, but no consistently reliable criteria have been defined. This review and meta-analysis highlight the importance of considering each patient's clinical history and physical exam within the context of associated radiographic abnormalities.
Collapse
Affiliation(s)
- Travis J Atchley
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth N Alford
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Children's of Alabama-University of Alabama at Birmingham, Lowder Bldg., Suite 400, 1600 7th Ave. S, Birmingham, AL, 35233, USA.
| |
Collapse
|