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Zarrin D, Goel K, Kim WJ, Holly LT, Batzdorf U. Chiari Type I Revision Decompressive Surgery Indications and Operative Technique: Experience in a Large Adult Cohort. World Neurosurg 2024; 185:e1074-e1085. [PMID: 38490446 DOI: 10.1016/j.wneu.2024.03.026] [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: 11/21/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Chiari malformation is characterized by inferior displacement of the cerebellar tonsils through the foramen magnum, frequently resulting in strain related headaches, and motor/sensory dysfunction. Chiari decompression technique varies significantly, possibly contributing to frequent revisions. We reviewed revision Chiari decompressions at our institution to determine the primary indications for revision and outcomes after revision. METHODS We retrospectively reviewed patients who underwent revision of Chiari decompression at our institution from 2005 to 2020. Demographics, indications for revision surgery, operative techniques, imaging findings, and preoperative/postoperative symptoms were collected. χ2 test was performed to determine statistical significance using a P < 0.05. Independent predictors of operative outcomes were identified. RESULTS A total of 46 patients (91% females, mean age 38.8 years) were included for analysis. The median time to revision surgery was 69.1 months (range 0-364 months) with headache (n = 37, 80%) being the most commonly recurring symptom. Large craniectomy (n = 28, 61%) was the most frequent indication for revision surgery. Thirty-two (70%) patients underwent cranioplasty, 20 (43%) required duraplasty, 15 (33%) required arachnoid dissection, and 15 (33%) required tonsillar reduction during revision surgery. Postrevision follow-up (at 8.9 ± 5.2 months average, range 1-18 months), revealed an average reduction in all Chiari-related symptoms relative to symptoms before the revision. CONCLUSIONS The most common indication for revision Chiari decompression was a large craniectomy resulting in cerebellar ptosis. We found that tonsillar reduction paired with modest craniectomy achieved near-complete resolution of symptoms with minimal complications. For patients with recurrent or persistent sequelae of Chiari malformation after decompression, revision may reduce symptom severity.
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Affiliation(s)
- David Zarrin
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Wi Jin Kim
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Langston T Holly
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Ulrich Batzdorf
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA.
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Perrini P, Lorenzini D, Vercelli A, Perrone A, Di Carlo DT. Post-Operative Complications after Foramen Magnum Decompression with Duraplasty Using Different Graft Materials in Adults Patients with Chiari I Malformation: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12103382. [PMID: 37240488 DOI: 10.3390/jcm12103382] [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: 03/07/2023] [Revised: 04/28/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Despite extensive investigations, the choice of graft material for reconstructive duraplasty after foramen magnum decompression for Chiari type I malformation (CMI) is still a topic of discussion. The authors performed a systematic review and meta-analysis of the literature examining the post-operative complications in adult patients with CMI after foramen magnum decompression and duraplasty (FMDD) using different graft materials. Our systematic review included 23 studies with a total of 1563 patients with CMI who underwent FMDD with different dural substitutes. The most common complications were pseudomeningocele (2.7%, 95% CI 1.5-3.9%, p < 0.01, I2 = 69%) and CSF leak (2%, 95% CI 1-2.9%, p < 0,01, I2 = 43%). The revision surgery rate was 3% (95% CI 1.8-4.2%, p < 0.01, I2 = 54%). A lower rate of pseudomeningocele was observed with autologous duraplasty when compared with synthetic duraplasty (0.7% [95% CI 0-1.3%] vs. 5.3% [95% CI 2.1-8.4%] p < 0.01). The rate of CSF leak and revision surgery was lower after autologous duraplasty than after non-autologous dural graft (1.8% [95% CI 0.5-3.1%] vs. 5.3% [95% CI 1.6-9%], p < 0.01 and 0.8% [95% CI 0.1-1.6%] vs. 4.9% [95% CI 2.6-7.2%] p < 0.01, respectively). Autologous duraplasty is associated with a lower rate of post-operative pseudomeningocele and reoperation. This information should be considered when planning duraplasty after foramen magnum decompression in patients with CMI.
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Affiliation(s)
- Paolo Perrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Daniele Lorenzini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
| | - Alberto Vercelli
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
| | - Alessandra Perrone
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
| | - Davide Tiziano Di Carlo
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
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Batzdorf U. Short-Term and Long-Term Complications Associated with Posterior Fossa Decompression for Chiari Malformation. Neurosurg Clin N Am 2023; 34:113-117. [DOI: 10.1016/j.nec.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Balasa A, Kunert P, Bielecki M, Kujawski S, Marchel A. Significance of Pseudomeningocele After Decompressive Surgery for Chiari I Malformation. Front Surg 2022; 9:895444. [PMID: 36034387 PMCID: PMC9406808 DOI: 10.3389/fsurg.2022.895444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPseudomeningoceles (PMCs) as abnormal collections of cerebrospinal fluid are quite common findings on follow-up MRI after Chiari decompression surgery (CDS). However, the importance of their identification has not been truly determined, especially when PMCs are described occasionally in the process of radiological follow-up. We retrospectively analyzed surgical outcomes and imaging findings after CDS depending upon the occurrence and thickness of PMCs.MethodsA total of 76 adult patients who underwent CDS were analyzed. The clinical and radiological outcomes of patients with a pseudomeningocele (wPMC) were evaluated and compared to those of patients without a pseudomeningocele (w/oPMC). Radiological morphometric measurements were performed and compared between groups. Comparisons of the maximal PMC thickness were made within the wPMC group.ResultsPMCs were recognized in 27 (35.5%) patients, of whom 3 (11.1%) required reoperation. Differences in satisfactory result rates regarding gestalt assessment and Chicago Chiari Outcome Scale were statistically insignificant between the w/oPMC and wPMC groups (p = 1 and p = 0.56, respectively). The postoperative syringomyelia decrease and cerebellar tonsil elevation were similar between the groups (p = 1 and p = 0.74, respectively) in the long-term follow-up. Additionally, the clinical or radiological outcomes with radiological details were not related to PMC thickness in the long-term follow-up. However, radiological details showed the cooccurrence of PMCs with a postsurgical of cerebello-tentorial distance increase (p < 0.05), basion-pontomedullary sulcus distance decrease (p < 0.05) and tonsillo-graft distance decrease (p < 0.05).ConclusionsWe found no significant relationships between PMC presence or thickness and clinical or radiological outcomes. However, postoperative changes within the posterior fossa associated with PMCs resemble brain sagging, which occurs in intracranial hypotension. Therefore, extradural cerebrospinal fluid escape may also be responsible for symptoms in some patients with PMCs after CDS.
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Affiliation(s)
- Artur Balasa
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
- Correspondence: Przemysław Kunert
| | - Mateusz Bielecki
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Sławomir Kujawski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Torun´, Bydgoszcz, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Perrini P. Commentary: Comparison of Pericranial Autograft and AlloDerm for Duraplasty in Patients With Type I Chiari Malformation: Retrospective Cohort Analysis. Oper Neurosurg (Hagerstown) 2021; 21:E467-E468. [PMID: 34634818 DOI: 10.1093/ons/opab350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/31/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Paolo Perrini
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy.,Department of Translational Research and New Technologies in Medicine and Surgery, Pisa University Hospital, Pisa, Italy
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Yuan C, Guan J, Du Y, Zhang C, Ma L, Yao Q, Cheng L, Liu Z, Wang K, Duan W, Wang X, Wu H, Chen Z, Jian F. Repeat Craniocervical Decompression in Patients with a Persistent or Worsening Syrinx: A Preliminary Report and Early Results. World Neurosurg 2020; 138:e95-e105. [DOI: 10.1016/j.wneu.2020.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 11/25/2022]
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Holly LT, Batzdorf U. Chiari malformation and syringomyelia. J Neurosurg Spine 2019; 31:619-628. [PMID: 31675698 DOI: 10.3171/2019.7.spine181139] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 07/25/2019] [Indexed: 11/06/2022]
Abstract
Chiari malformation was first described over a century ago, and consists of posterior fossa anomalies that generally share the feature of cerebellar tonsillar descent through the foramen magnum. Our understanding of this disorder was initially based on autopsy studies, and has been greatly enhanced by the advent of MRI. The surgical management of Chiari anomalies has also evolved in a parallel fashion. Although the exact surgical technique varies among individual surgeons, the goals of surgery remain constant and consist of relieving brainstem compression and cranial nerve distortion, restoring the normal flow of CSF across the foramen magnum, and reducing the size of any associated syrinx cavity. Syrinx cavities are most commonly associated with Chiari anomalies, yet primary spinal syringomyelia (PSS) can be caused by traumatic, infectious, degenerative, and other etiologies that cause at least a partial CSF flow obstruction in the spinal subarachnoid space. As with syringomyelia associated with Chiari anomalies, the main goal of PSS surgery is to reestablish CSF flow across the area of obstruction. In addition to MRI, myelography with CT can be very helpful in the evaluation and management of these patients by identifying focal regions of CSF obstruction that may be amenable to surgical intervention. Future directions for the treatment of Chiari anomalies and syringomyelia include the application of advanced imaging techniques, more widespread use of genetic evaluation, large-scale outcome studies, and the further refinement of surgical technique.
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Treatment failure of syringomyelia associated with Chiari I malformation following foramen magnum decompression: how should we proceed? Neurosurg Rev 2018; 42:705-714. [DOI: 10.1007/s10143-018-01066-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/21/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022]
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Azzam D, Romiyo P, Nguyen T, Sheppard JP, Alkhalid Y, Lagman C, Prashant GN, Yang I. Dural Repair in Cranial Surgery Is Associated with Moderate Rates of Complications with Both Autologous and Nonautologous Dural Substitutes. World Neurosurg 2018; 113:244-248. [PMID: 29374609 DOI: 10.1016/j.wneu.2018.01.115] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Duraplasty, a common neurosurgical intervention, involves synthetic or biological graft placement to ensure dural closure. The objective of this study is to advance our understanding of the use of dural substitutes in cranial surgery. METHODS The PubMed database was systematically searched to identify studies published over the past decade (2007-2017) that described duraplasty procedures. Clinical data were disaggregated and analyzed for the comparisons of biological versus synthetic grafts. RESULTS A total of 462 cases were included in the quantitative synthesis. Overall, the most common indication for duraplasty was tumor resection (53%). Allografts were more frequently used in decompression for Chiari malformations compared with xenografts and synthetic grafts (P < 0.001). Xenografts were more frequently used in decompressive hemicraniectomy procedures for evacuation of acute subdural hematomas over allografts and synthetics (P < 0.001). Synthetic grafts were more frequently used in tumor cases than biological grafts (P = 0.002). The cumulative complication rate for dural substitutes of all types was 11%. There were no significant differences in complication rates among the 3 types of dural substitutes. CONCLUSIONS Dural substitutes are commonly used to ensure dural closure in a variety of cranial procedures. This study provides greater insight into duraplasty practices and highlights the moderate complication rate associated with the procedure. Future studies are needed to determine the safety and efficacy of such procedures in larger prospective cohorts.
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Affiliation(s)
- Daniel Azzam
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Prasanth Romiyo
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - John P Sheppard
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Yasmine Alkhalid
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Carlito Lagman
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA
| | - Isaac Yang
- Department of Neurosurgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; Department of Radiation Oncology, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; Department of Head and Neck Surgery, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; UCLA Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center of the University of California, Los Angeles, USA; Department of Neurosurgery, Harbor-UCLA Medical Center, Torrance, California, USA; Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA.
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Complicated Pseudomeningocele Repair After Chiari Decompression: Case Report and Review of the Literature. World Neurosurg 2015; 88:688.e1-688.e7. [PMID: 26704196 DOI: 10.1016/j.wneu.2015.11.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/11/2015] [Accepted: 11/14/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Pseudomeningocele is a recognised complication after posterior fossa decompression for Chiari malformation. Its management can be challenging and treatment options vary in literature. CASE DESCRIPTION A difficult-to-treat case of a pseudomeningocele after posterior fossa decompression for a Chiari I malformation is presented. A 34-year-old woman underwent an initial decompression followed by multiple revision surgeries after the development of a symptomatic pseudomeningocele and a low-grade infection. Complications associated with standard treatment modalities, including lumbar drainage and dural repair, are discussed. A review of the existing literature is presented. CONCLUSIONS The reported case ultimately required complete removal of all dural repair materials to eliminate the patient's low-grade infection, a muscular flap, and placement of a ventricular-peritoneal shunt for definitive treatment after a trial of a lumbar drain led to herniation and development of a syrinx.
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Assina R, Meleis AM, Cohen MA, Iqbal MO, Liu JK. Titanium mesh-assisted dural tenting for an expansile suboccipital cranioplasty in the treatment of Chiari 1 malformation. J Clin Neurosci 2014; 21:1641-6. [DOI: 10.1016/j.jocn.2014.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 03/09/2014] [Indexed: 11/30/2022]
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Posterior Fossa Reconstruction Using Titanium Plate for the Treatment of Cerebellar Ptosis After Decompression for Chiari Malformation. World Neurosurg 2014; 81:836-41. [DOI: 10.1016/j.wneu.2013.01.081] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/07/2012] [Accepted: 01/15/2013] [Indexed: 11/19/2022]
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Chotai S, Kshettry VR, Lamki T, Ammirati M. Surgical outcomes using wide suboccipital decompression for adult Chiari I malformation with and without syringomyelia. Clin Neurol Neurosurg 2014; 120:129-35. [DOI: 10.1016/j.clineuro.2014.02.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 02/16/2014] [Indexed: 02/02/2023]
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McVige JW, Leonardo J. Imaging of Chiari Type I Malformation and Syringohydromyelia. Neurol Clin 2014; 32:95-126. [DOI: 10.1016/j.ncl.2013.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Oró JJ, Mueller DM. Posterior fossa decompression and reconstruction in adolescents and adults with the Chiari I malformation. Neurol Res 2013; 33:261-71. [DOI: 10.1179/016164111x12962202723841] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Naftel RP, Tubbs RS, Menendez JY, Wellons JC, Pollack IF, Oakes WJ. Worsening or development of syringomyelia following Chiari I decompression: case report. J Neurosurg Pediatr 2013; 12:351-6. [PMID: 23931767 DOI: 10.3171/2013.7.peds12522] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The effects of posterior fossa decompression on Chiari malformation Type I-induced syringomyelia have been well described. However, treatment of worsening syringomyelia after Chiari decompression remains enigmatic. This paper defines patient and clinical characteristics as well as treatment and postoperative radiological and clinical outcomes in patients experiencing this complication. METHODS The authors performed a retrospective review of patients at the Children's Hospital of Pittsburgh and Children's of Alabama who developed worsening syringomyelia after Chiari decompression was performed. RESULTS Fourteen children (age range 8 months to 15 years), 7 of whom had preoperative syringomyelia, underwent posterior fossa decompression. Aseptic meningitis (n = 3) and bacterial meningitis (n = 2) complicated 5 cases (4 of these patients were originally treated at outside hospitals). Worsening syringomyelia presented a median of 1.4 years (range 0.2-10.3 years) after the primary decompression. Ten children presented with new, recurrent, or persistent symptoms, and 4 were asymptomatic. Secondary Chiari decompression was performed in 11 of the 14 children. The other 3 children were advised to undergo secondary decompression. A structural cause for each failed primary Chiari decompression (for example, extensive scarring, suture in the obex, arachnoid web, residual posterior arch of C-1, and no duraplasty) was identified at the secondary operation. After secondary decompression, 8 patients' symptoms completely resolved, 1 patient's condition stabilized, and 2 patients remained asymptomatic. Radiologically, 10 of the 11 children had a decrease in the size of their syringes, and 1 child experienced no change (but improved clinically). The median follow-up from initial Chiari decompression was 3.1 years (range 0.8-14.1 years) and from secondary decompression, 1.3 years (range 0.3-4.5 years). No patient underwent syringopleural shunting or other nonposterior fossa treatment for syringomyelia. CONCLUSIONS Based on the authors' experience, children with worsening syringomyelia after decompression for Chiari malformation Type I generally have a surgically remediable structural etiology, and secondary exploration and decompression should be considered.
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Affiliation(s)
- Robert P Naftel
- Department of Neurosurgery, Children's Hospital of Pittsburgh, Pennsylvania
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Klekamp J. Neurological deterioration after foramen magnum decompression for Chiari malformation type I: old or new pathology? J Neurosurg Pediatr 2012; 10:538-47. [PMID: 23039841 DOI: 10.3171/2012.9.peds12110] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Decompression of the foramen magnum is widely accepted as the procedure of choice for patients with Chiari malformation Type I (CM-I). This study was undertaken to determine the mechanisms responsible for neurological deterioration after foramen magnum decompression and the results of secondary interventions. METHODS Between 1987 and 2010, 559 patients with CM-I presented, 107 of whom had already undergone a foramen magnum decompression, which included a syrinx shunt in 27 patients. Forty patients who were neurologically stable did not undergo another operation. Sixty-seven patients with progressive symptoms received a recommendation for surgery, which was refused by 16 patients, while 51 patients underwent a total of 61 secondary operations. Hospital and outpatient records, radiographic studies, and intraoperative images were analyzed. Additional follow-up information was obtained by telephone calls and questionnaires. Short-term results were determined after 3 and 12 months, and long-term outcomes were evaluated using Kaplan-Meier statistics. RESULTS Sixty-one secondary operations were performed after a foramen magnum decompression. Of these 61 operations, 15 involved spinal pathologies not related to the foramen magnum (spinal group), while 46 operations were required for a foramen magnum issue (foramen magnum group). Except for occipital pain and swallowing disturbances, the clinical course was comparable in both groups. In the spinal group, 5 syrinx shunt catheters were removed because of nerve root irritations or spinal cord tethering. Eight patients underwent a total of 10 operations on their cervical spine for radiculopathies or a myelopathy. No permanent surgical morbidity occurred in this group. In the foramen magnum group, 1 patient required a ventriculoperitoneal shunt for hydrocephalus 7 months after decompression. The remaining 45 secondary interventions were foramen magnum revisions, of which 10 were combined with craniocervical fusion. Intraoperatively, arachnoid scarring with obstruction of the foramen of Magendie was the most common finding. Complication rates for foramen magnum revisions were similar to first decompressions, whereas permanent surgical morbidity was higher at 8.9%. Postoperative clinical improvements were marginal in both surgical groups. With the exception of 1 patient who underwent syrinx catheter removal and had a history of postoperative meningitis, all patients in the spinal group were able to be stabilized neurologically. Long-term results in the foramen magnum group revealed clinical stabilizations in 66% for at least 5 years. CONCLUSIONS Neurological deterioration in patients after a foramen magnum decompression for CM-I may be related to new spinal pathologies, craniocervical instability, or recurrent CSF flow obstruction at the foramen magnum. Whereas surgery for spinal pathologies is regularly followed by clinical stabilization, the rate of long-term success for foramen magnum revisions was limited to 66% for 5 years due to severe arachnoid scarring in a significant proportion of these patients. Therefore, foramen magnum revisions should be restricted to patients with progressive symptoms.
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Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Christliches Krankenhaus, Danziger Strausse 2, Quakenbrück, Germany.
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Klekamp J. Surgical Treatment of Chiari I Malformation—Analysis of Intraoperative Findings, Complications, and Outcome for 371 Foramen Magnum Decompressions. Neurosurgery 2012; 71:365-80; discussion 380. [DOI: 10.1227/neu.0b013e31825c3426] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Abstract
BACKGROUND:
Foramen magnum decompression is widely accepted as the treatment of choice for Chiari I malformation. However, important surgical details of the procedure are controversial.
OBJECTIVE:
This study analyzes 371 decompressions focusing on intraoperative findings, analysis of complications, and long-term outcomes.
METHODS:
Among 644 patients between 1985 and 2010, 359 patients underwent 371 decompressions. Surgery for symptomatic patients consisted of suboccipital craniectomy, C1 laminectomy, arachnoid dissection, and duraplasty. Short-term results were determined after 3 months; long-term outcomes were evaluated with Kaplan-Meier statistics.
RESULTS:
The mean age was 40 ± 16 years; mean follow-up was 49 ± 56 months; 75.8% demonstrated syringomyelia. The complication rate was 21.8% with permanent surgical morbidity of 3.2% and surgical mortality of 1.3%. Of the patients, 73.6% reported improvement after 3 months; 21% were unchanged. Overall, 14.3% demonstrated a neurological deterioration within 5 years and 15.4% within 10 years. The severity of neurological symptoms correlated with the grade of arachnoid pathology. Outcome data correlated with the number of previous decompressions, severity of arachnoid pathology, handling of the arachnoid, type of duraplasty, and surgical experience. First-time decompressions with arachnoid dissection and an alloplastic duraplasty resulted in surgical morbidity for 2.0%, a 0.9% mortality rate, postoperative improvement after 3 months for 82%, and neurological recurrence rates of 7% after 5 years and 8.7% after 10 years.
CONCLUSION:
Arachnoid pathology in Chiari I malformation has an impact on clinical symptoms and postoperative results. Decompressions with arachnoid dissection and an alloplastic duraplasty performed by surgeons experienced with this pathology offer a favorable long-term prognosis.
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Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Christliches Krankenhaus, Quakenbrück, Germany
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Perrini P, Di Lorenzo N. Letter to the Editor: Subdural fluid collections after decompression for Chiari malformation. J Neurosurg 2011; 114:1488-9; author reply 1489-90. [DOI: 10.3171/2010.11.jns101850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Noudel R, Gomis P, Sotoares G, Bazin A, Pierot L, Pruvo JP, Bordet R, Roche PH. Posterior fossa volume increase after surgery for Chiari malformation Type I: a quantitative assessment using magnetic resonance imaging and correlations with the treatment response. J Neurosurg 2011; 115:647-58. [PMID: 21294619 DOI: 10.3171/2010.11.jns102148] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECT The aim of this paper was to measure the posterior fossa (PF) volume increase resulting from a given-sized occipital craniectomy in Chiari malformation Type I surgery and to analyze its correlations with the PF size and the treatment response, with the perspective of tailoring the amount of bone removal to the patient-specific PF dimensions. METHODS Between January 2005 and June 2006, 11 adult patients with symptomatic Chiari malformation Type I underwent a standardized PF decompression. A prospective evaluation with clinical examination, functional grading, and MR imaging measurement protocols was performed pre- and postoperatively. A method is reported for the measurement of PF volume (PFV) after surgery. The degree of PFV increase was compared with the preoperative size of the PF and with the clinical outcome. RESULTS All 11 patients improved postoperatively, with complete and partial recovery in 4 and 7 patients, respectively. No postoperative complication occurred after a mean follow-up period of 45 months. The mean relative increase in PFV accounted for 10% (range 1.5%-19.7%) of the initial PFV; the increase was greater in cases in which the PF was small (r = -0.52, p = 0.09) and the basiocciput was short (r = -0.37, p = 0.2). A statistically significant positive correlation was found between the degree of PFV increase and the treatment response (p = 0.014); complete recovery was observed with a PFV increase of 15% and partial recovery with an increase of 7%. CONCLUSIONS The treatment response is significantly influenced by the degree of PFV increase, which is dependent on the size of the PF and the extent of the craniectomy, suggesting that the optimal patient-specific PFV increase could be predicted on the basis of preoperative MR imaging and enhancing the perspective that the craniectomy size could be tailored to the individual PFV.
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Affiliation(s)
- Rémy Noudel
- Department of Neurosurgery, Maison Blanche Hospital, University of Reims, France.
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Furtado SV, Thakar S, Hegde AS. Correlation of Functional Outcome and Natural History With Clinicoradiological Factors in Surgically Managed Pediatric Chiari I Malformation. Neurosurgery 2011; 68:319-27; discussion 328. [DOI: 10.1227/neu.0b013e31820206e5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Chiari I malformation occurs because of an underdeveloped posterior fossa with reduced volume that cannot accommodate the normally developed hindbrain.
OBJECTIVE:
To study the clinical presentation and surgical outcome of pediatric Chiari I malformation and to correlate outcome with demographic and clinical factors and radiological changes in the syrinx, spinal cord, and preoperative intracranial, posterior fossa, and foramen magnum dimensions.
METHODS:
This retrospective study spanning 9 years included 20 symptomatic patients who underwent foramen magnum decompression, shrinkage of tonsils, and duraplasty. Improvement at follow-up was assessed with a modified Asgari scoring system. Mean differences in the dimensions of the syrinx and cord, foramen magnum morphometry, and intracranial and posterior fossa for 2 groups (with or without improvement) were analyzed with the independent-sample Student t test. Correlation of outcome in relation to change in radiological factors and influence of variables such as age, type and duration of symptoms, and presence of syrinx were evaluated with the Pearson χ2 test.
RESULTS:
Sixty percent of patients showed functional improvement at follow-up. Of various demographic and radiological factors assessed, there was significant difference in mean values of change in cord diameter for the entire cohort (P = .05) and for the subgroup with preoperative syringes (P = .03). There was no correlation between change in any of these factors and functional improvement (χ2 range, 0-4.673; P > .05).
CONCLUSION:
More than half the pediatric patients with Chiari I malformation improve after surgery. The age at presentation, duration and type of symptoms, cranial and foramen magnum morphometry, and syrinx-related changes have no bearing on outcome at short-term follow-up. The spinal cord diameter differs significantly in patients with and without functional improvement.
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Affiliation(s)
- Sunil V. Furtado
- Departments of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Sumit Thakar
- Departments of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Alangar S. Hegde
- Departments of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
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Complicaciones postquirúrgicas de la malformación de Chiari tipo I: duroplastia y fístula de líquido cefalorraquídeo. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70003-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Heiss JD, Suffredini G, Smith R, DeVroom HL, Patronas NJ, Butman JA, Thomas F, Oldfield EH. Pathophysiology of persistent syringomyelia after decompressive craniocervical surgery. Clinical article. J Neurosurg Spine 2010; 13:729-42. [PMID: 21121751 PMCID: PMC3822767 DOI: 10.3171/2010.6.spine10200] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECT Craniocervical decompression for Chiari malformation Type I (CM-I) and syringomyelia has been reported to fail in 10%-40% of patients. The present prospective clinical study was designed to test the hypothesis that in cases in which syringomyelia persists after surgery, craniocervical decompression relieves neither the physiological block at the foramen magnum nor the mechanism of syringomyelia progression. METHODS The authors prospectively evaluated and treated 16 patients with CM-I who had persistent syringomyelia despite previous craniocervical decompression. Testing before surgery included the following: 1) clinical examination; 2) evaluation of the anatomy using T1-weighted MR imaging; 3) assessment of the syrinx and CSF velocity and flow using cine phase-contrast MR imaging; and 4) appraisal of the lumbar and cervical subarachnoid pressures at rest, during a Valsalva maneuver, during jugular compression, and following the removal of CSF (CSF compliance measurement). During surgery, ultrasonography was performed to observe the motion of the cerebellar tonsils and syrinx walls; pressure measurements were obtained from the intracranial and lumbar intrathecal spaces. The surgical procedure involved enlarging the previous craniectomy and performing an expansile duraplasty with autologous pericranium. Three to 6 months after surgery, clinical examination, MR imaging, and CSF pressure recordings were repeated. Clinical examination and MR imaging studies were then repeated annually. RESULTS Before reexploration, patients had a decreased size of the CSF pathways and a partial blockage in CSF transmission at the foramen magnum. Cervical subarachnoid pressure and pulse pressure were abnormally elevated. During surgery, ultrasonographic imaging demonstrated active pulsation of the cerebellar tonsils, with the tonsils descending during cardiac systole and concomitant narrowing of the upper pole of the syrinx. Three months after reoperation, patency of the CSF pathways was restored and pressure transmission was improved. The flow of syrinx fluid and the diameter of the syrinx decreased after surgery in 15 of 16 patients. CONCLUSIONS Persistent blockage of the CSF pathways at the foramen magnum resulted in increased pulsation of the cerebellar tonsils, which acted on a partially enclosed cervical subarachnoid space to create elevated cervical CSF pressure waves, which in turn affected the external surface of the spinal cord to force CSF into the spinal cord through the Virchow-Robin spaces and to propel the syrinx fluid caudally, leading to syrinx progression. A surgical procedure that reestablished the CSF pathways at the foramen magnum reversed this pathophysiological mechanism and resolved syringomyelia. Elucidating the pathophysiology of persistent syringomyelia has implications for its primary and secondary treatment.
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Affiliation(s)
- John D Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892-1414, USA.
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Perrini P, Di Lorenzo N. The fate of syringomyelia after surgical treatment of syringomyelia-Chiari I complex. Neurol Sci 2010; 32:529-30. [PMID: 21116670 DOI: 10.1007/s10072-010-0450-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 11/02/2010] [Indexed: 10/18/2022]
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Nurboja B, Choi D. Extensive spinal cord oedema and early syrinx formation due to tension pseudomeningocele after foramen magnum decompression. Br J Neurosurg 2009; 23:443-5. [PMID: 19637019 DOI: 10.1080/02688690802716137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pseudomeningoceles can cause syringomyelia. However, this is the first case report to show an unusually acute complication of a post-operative pseudomeningocele: spinal cord oedema and early syrinx, treated favourably with an early surgical intervention.
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Affiliation(s)
- B Nurboja
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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26
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Belen D, Er U, Gurses L, Yigitkanli K. Delayed pseudomyelomeningocele: a rare complication after foramen magnum decompression for Chiari malformation. ACTA ACUST UNITED AC 2009; 71:357-61, discussion 361. [DOI: 10.1016/j.surneu.2007.08.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Accepted: 08/09/2007] [Indexed: 11/27/2022]
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Di X, Luciano MG, Benzel EC. Acute respiratory arrest following partial suboccipital cranioplasty for cerebellar ptosis from Chiari malformation decompression. Neurosurg Focus 2008; 25:E12. [DOI: 10.3171/foc.2008.25.12.e12] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cerebellar ptosis is a rare complication following Chiari malformation decompression, and generally is the result of a very large suboccipital craniectomy. This can lead to the descent of the cerebellum through the craniectomy defect, which in turn may result in cerebellar herniation through the surgical defect as well as the reestablishment of contact between the cerebellar tonsils and the brainstem. In addition, dorsal adherence of the herniated cerebellum to the dura mater or dural patch and an associated obstruction of cerebrospinal fluid flow at the cervicomedullary junction may ensue. Such a result is not desirable, in that it reproduces or mimics the pathoanatomical relationships that existed prior to the surgical decompression.
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Affiliation(s)
- Xiao Di
- 1Section of Pediatric and Congenital Neurosurgery, and
| | | | - Edward C. Benzel
- 2Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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28
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Acute external hydrocephalus complicating craniocervical decompression for syringomyelia–Chiari I complex. Neurosurg Rev 2008; 31:331-5. [DOI: 10.1007/s10143-008-0129-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Revised: 11/20/2007] [Accepted: 01/02/2008] [Indexed: 10/22/2022]
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29
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Oberer DM, Aaronson OS, Cheng JS. Quadriparesis due to the delayed formation of a compressive epidural cerebrospinal fluid collection following suboccipital craniectomy with duraplasty for Chiari malformation Type I. Case report. J Neurosurg Spine 2007; 7:450-3. [PMID: 17933322 DOI: 10.3171/spi-07/10/450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe a previously undocumented complication of suboccipital craniectomy combined with duraplasty for the treatment of Chiari malformation Type I and propose techniques to prevent its occurrence. Although there have been reports of epidural pseudomeningoceles in the setting of spontaneous intracranial hypotension and intracranial hygromas following suboccipital craniectomy with duraplasty, the authors believe this case to be the first instance of quadriparesis caused by the delayed formation of a compressive epidural cerebrospinal fluid collection after suboccipital craniectomy with duraplasty. This complication is significant and must be recognized given the potential severity of neurological insult and the number of these procedures performed yearly in both the pediatric and adult populations.
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Affiliation(s)
- Daniel M Oberer
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina 28204, USA.
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30
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Abstract
BACKGROUND/OBJECTIVE Syringomyelia is characterized by a fluid-filled cavity within the spinal cord. While its pathogenesis is currently debated, the relationship of syringomyelia with other conditions, such as Chiari I malformation and cord/column trauma, is well accepted. Despite these common associations, a nidus for syrinx formation has not been identified in a subset of patients. We report 2 patients with idiopathic cervicothoracic syringomyelia who presented with progressive neurologic dysfunction. Diagnostic and treatment algorithms used in the care of these patients are presented. METHODS Retrospective review, including preoperative and postoperative studies, intraoperative findings, and the patients' surgical outcomes. RESULTS Patients underwent laminectomy, lysis of adhesions, untethering of spinal cord, fenestration of syrinx, and duraplasty after preoperative studies demonstrated evidence of focal cerebrospinal fluid flow block at the level of the syrinx. One patient's neurologic condition improved after surgery, whereas the other's remained unchanged without further deterioration; both showed radiographic decrease in the syrinx on immediate postoperative magnetic resonance imaging. CONCLUSIONS These 2 cases illustrate patients who develop a cervicothoracic syrinx in the absence of any trauma, infection, previous manipulation of the neuraxis, or malformations known to be associated with a syringomyelia. Whereas there is no consensus on the optimal management of these patients, the patients reported here experienced arrest in deterioration or improvement of their neurologic examination, making the identification of this condition important as a potentially reversible cause of neurologic deficits. Long-term follow-up is required to determine the efficacy, durability, and lifestyle impact of the procedure.
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Affiliation(s)
- Paul Porensky
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, 675 N. Clair Street, Suite 20-250, Chicago, IL 60611, USA.
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Sgouros S, Kountouri M, Natarajan K. Posterior fossa volume in children with Chiari malformation Type I. J Neurosurg 2006; 105:101-6. [PMID: 16922070 DOI: 10.3171/ped.2006.105.2.101] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECT The authors sought to establish whether the volume of the posterior fossa in children suffering from Chiari malformation Type I (CM-I) is smaller than normal, as has been suggested previously. They also investigated the role of syringomyelia in posterior fossa development. METHODS Both posterior fossa volume (PFV) and intracranial volume (ICV) were measured using segmentation techniques on preoperative magnetic resonance images obtained in 42 children who underwent surgery for CM-I (mean age 127 months, range 36-204 months); 25 (59%) of the patients had syringomyelia. The PFV/ICV ratio was calculated to eliminate differential supratentorial growth. Patients who had deformities potentially interfering with skull growth or who had undergone a shunt insertion procedure prior to craniovertebral decompression were excluded. The results were compared with measurements of 51 healthy children using one-way analysis of variance. In patients with CM-I only, the mean PFV and PFV/ICV ratios were not statistically different than those for healthy children. In patients with both CM-I and syringomyelia (CM-S), the mean PFV and PFV/ICV ratios were statistically smaller than those for healthy children. The ICV was 1383 cm3 in the healthy group, 1459 cm3 in the CM-I only group, and 1400 cm3 in the CM-S group (p = 0.363); the PFV was 186 cm3 in the healthy group, 196 cm3 in the CM-I only group, and 171 cm3 in the CM-S group (p = 0.036); the PFV/ICV ratio was 0.135 in the healthy group, 0.134 in the CM-I only group, and 0.122 in the CM-S group (p = 0.004). These differences were more prominent in the first 10 years of life. CONCLUSIONS Children with isolated CM-I do not have a PFV smaller than normal, whereas children with both CM-I and syringomyelia have a PFV significantly smaller than normal. This result indicates that the two subgroups may represent different phenotypic expression or even a different pathogenesis.
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Affiliation(s)
- Spyros Sgouros
- Department of Neurosurgery and Neuroscience Informatics Laboratory of the Institute of Child Health, Birmingham Children's Hospital, Birmingham, England.
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Doughty KE, Tubbs RS, Webb D, Oakes WJ. Delayed Resolution of Chiari I-associated Hydromyelia after Posterior Fossa Decompression: Case Report and Review of the Literature. Neurosurgery 2004; 55:711. [PMID: 16933383 DOI: 10.1227/01.neu.0000134548.16165.9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE:
The expected time interval for resolution of hydromyelia after Chiari I decompression is lacking in the literature. This case report highlights one instance of delayed resolution of Chiari-induced hydromyelia.
CLINICAL PRESENTATION:
We report an adolescent girl with a Chiari I malformation and hydromyelia.
INTERVENTION:
A suboccipital craniectomy and C1 laminectomy with intradural exploration and duraplasty were performed. Serial imaging at 1 and 2 years after posterior cranial fossa decompression with duraplasty demonstrated no change in the size of the hydromyelia. At 3 years after surgery and before reoperation for continued hydromyelia, repeat magnetic resonance imaging demonstrated significant diminution of the fluid cavity. If this hydromyelia did resolve as a result of surgery, the interval for radiological observation clearly needs to be reconsidered.
CONCLUSION:
Unfortunately, this is an area in which the literature is lacking. With this case as a nidus, studies are now necessary to determine the range of time necessary for Chiari I malformation-related hydromyelia to resolve.
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Affiliation(s)
- Kyle E Doughty
- Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Abstract
ETV using contemporary instrumentation has been used for more than 50 years, but its use has become widespread only in the last 10 to 15 years. Randomized prospective trials comparing ETV with shunts are needed before definitive statements can be made about the role of the former in managing the many forms of hydrocephalus. The absolute and relative contraindications for the use of ETV in the management of hydrocephalus are shown in the Box 1 on this page. It is important not to presume that a specific radiographic or clinical feature would prevent a patient from responding to this rather new procedure without testing the hypothesis. Patients should be given as much information as possible regarding the risks and benefits of ETV so they can participate in the decision-making process. When should the role of ETV in the management of hydrocephalus be discussed with a patient? At the initial diagnosis of hydrocephalus, the patient or family should be informed of this potential alternative to shunting for the management of hydrocephalus. I also believe that patients with working shunts who are being followed chronically should be informed about ETV as a potential treatment option when their shunt fails. Every shunt failure or infection should be viewed as an opportunity to explore the possibility that the patient could become shunt independent.
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Affiliation(s)
- Harold L Rekate
- Pediatric Neurosurgery, Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ 85013, USA.
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Abstract
Chiari malformations comprise four different hindbrain anomalies originally described by Hans Chiari, a professor of pathology at the German University in Prague. There are four basic Chiari malformations. The reasons for revision of Chiari malformation decompression may be for conservative or inadequate initial decompression or the development of postoperative complications. Another reason involves cases of both hindbrain herniation and syringomyelia in patients who have undergone adequate posterior fossa decompression without resolution of symptoms, signs, or radiological appearance of their syrinx cavity. Additionally, symptom recurrence has been reported in association with various types of dural grafts. Reoperation or revision surgery for patients with Chiari malformations is common and may not be due to technical error or inadequate decompression. The types of revision surgeries, their indications, and initial presentations will be reviewed.
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Affiliation(s)
- Catherine A Mazzola
- Department of Neurosurgery, Pediatric Neurosciences Institute, Hackensack University Medica Center, Hackensack, New Jersey 07601, USA.
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Holly LT, Batzdorf U. Management of cerebellar ptosis following craniovertebral decompression for Chiari I malformation. J Neurosurg 2001; 94:21-6. [PMID: 11147893 DOI: 10.3171/jns.2001.94.1.0021] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this report the authors review their experience in the treatment of seven patients with symptomatic cerebellar ptosis following craniovertebral decompression (CVD) for Chiari I malformation. METHODS The mean age of the patients was 37 years and the average amount of time between the initial suboccipital craniectomy and evaluation for cerebellar ptosis was 6.8 years. Five patients presented primarily with intractable headache and the remaining two patients with neurological deficits caused by recurrent syringomyelia. Three different surgical modalities were used to treat these patients: ventriculoperitoneal shunt placement (one patient), syringoperitoneal shunt placement (two patients), and partial suboccipital cranioplasty with or without intradural exploration (four patients). The mean follow-up period was 51 months. The three patients who underwent shunt placement procedures experienced poor results, with no evidence of symptom relief and continued neurological deterioration. In contrast, all four patients who underwent cranioplasty experienced good or excellent clinical outcomes. Postoperative magnetic resonance imaging studies revealed a reduction in the size of the syrinx cavity in patients who simultaneously underwent intradural exploration. CONCLUSIONS The emergence of symptomatic cerebellar ptosis following CVD for Chiari I malformation is primarily caused when the suboccipital craniectomy is too large for the specific patient. The cerebellar ptosis usually presents with severe headache and/or neurological deficit due to persistent or recurrent syringomyelia. Partial suboccipital cranioplasty, with or without intradural exploration, is effective in treating this condition.
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Affiliation(s)
- L T Holly
- Division of Neurosurgery, University of California Los Angeles Medical Center, 90095-6901, USA
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Young WF, Tuma R, O'Grady T. Intraoperative measurement of spinal cord blood flow in syringomyelia. Clin Neurol Neurosurg 2000; 102:119-23. [PMID: 10996707 DOI: 10.1016/s0303-8467(00)00082-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The role of spinal cord ischemia in the pathophysiology of syringomyelia remains undetermined. Previous reports in the literature suggest that shunting of syringes can improve spinal cord blood flow. In order to determine the effects of syrinx decompression on spinal cord blood flow in patients with syringomyelia, we prospectively measured regional spinal cord blood flow (RSCBF) intraoperatively pre and post shunting in patients with symptomatic syringomyelia using laser doppler flowmetry. Six patients with MRI documented syringomyelia were studied (three with Arnold Chiari I malformation and associated syrinx and three with post-traumatic syringomyelia). Surgery was performed on all patients with either a syringopleural or syringoperitoneal shunt. Laser doppler blood flow and somatosensory evoked potentials were monitored prior to myelotomy and after shunt insertion. Results indicate that there was a significant increase in RSCBF after decompression of the syrinx. This study supports the hypothesis that spinal cord ischemia is important in the pathophysiology of syringomyelia and confirms previous reports in the literature regarding RSCBF in syringomyelia.
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Affiliation(s)
- W F Young
- Department of Neurosurgery, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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