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Hernández-Hernández A, Uribe-Pacheco R, Guinto-Nishimura GY, Álvarez-Castro A, Castro-Soto F, Villanueva-Castro E, Del Pino-Camposeco J, Rodríguez-Hernández LA, Gómez JAP, Arriada-Mendicoa N. Predictors of poor functional outcomes in adults with type I Chiari Malformation: Clinical and surgical factors assessed with the Chicago Chiari Outcome Scale over long-term follow-up. Clin Neurol Neurosurg 2024; 243:108392. [PMID: 38945118 DOI: 10.1016/j.clineuro.2024.108392] [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: 05/08/2024] [Revised: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE This study aimed to identify clinical and surgical features associated with poor long-term postoperative outcomes in patients diagnosed with Type I Chiari Malformation (CMI) treated with posterior fossa decompression with duroplasty (PFDD), with or without tonsillar coagulation. METHODS This retrospective, single-center study included 107 adult patients with CMI surgically treated between 2010 and 2021. The surgical technique involved a midline suboccipital craniectomy, C1 laminectomy, durotomy, arachnoid dissection, duroplasty, and tonsillar coagulation until 2014, after which tonsillar coagulation was discontinued. Postoperative outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) at a median follow-up of 35 months. Clinical, surgical, and neuroimaging data were analyzed using the Wilcoxon signed-rank test, Cox regression analysis, and Kaplan-Meier survival curves to identify predictors of poor functional outcomes. RESULTS Of the 107 patients (mean age 43.9 years, SD 13), 81 (75.5 %) showed functional improvement, 25 (23.4 %) remained unchanged, and 1 (0.9 %) experienced worsened outcomes. Cephalalgia, bilateral motor weakness, and bilateral paresthesia were the most frequent initial symptoms. Tonsillar coagulation was performed in 31 cases (28.9 %) but was clinically associated with higher rates of unfavorable outcomes. The Wilcoxon signed-rank test indicated that long-term follow-up CCOS was significantly higher than postoperative CCOS (Z = -7.678, p < 0.000). Multivariate Cox analysis identified preoperative bilateral motor weakness (HR 6.1, 95 % CI 1.9-18.9; p = 0.002), hydrocephalus (HR 3.01, 95 % CI 1.3-6.9; p = 0.008), and unilateral motor weakness (HR 2.99, 95 % CI 1.1-8.2; p = 0.033) as significant predictors of poor outcomes on a long-term follow-up. CONCLUSION This study highlights the high rate of functional improvement in CMI patients following PFDD. Preoperative motor weakness and hydrocephalus were significant predictors of poor long-term outcomes. Tonsillar coagulation did not demonstrate a clear clinical benefit and may be associated with worse outcomes. Our findings suggest that careful preoperative assessment and selection of surgical techniques are crucial for optimizing patient outcomes.
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Affiliation(s)
- Alan Hernández-Hernández
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Rodrigo Uribe-Pacheco
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
| | | | - Alfonso Álvarez-Castro
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
| | - Fernando Castro-Soto
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Eliezer Villanueva-Castro
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
| | - Jorge Del Pino-Camposeco
- Spine Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | - Juan Antonio Ponce Gómez
- Spine Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
| | - Nicasio Arriada-Mendicoa
- Spine Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
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Marcelli V, Giannoni B, Volpe G, Faralli M, Fetoni AR, Pettorossi VE. Downbeat nystagmus: a clinical and pathophysiological review. Front Neurol 2024; 15:1394859. [PMID: 38854962 PMCID: PMC11157062 DOI: 10.3389/fneur.2024.1394859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/29/2024] [Indexed: 06/11/2024] Open
Abstract
Downbeat nystagmus (DBN) is a neuro-otological finding frequently encountered by clinicians dealing with patients with vertigo. Since DBN is a finding that should be understood because of central vestibular dysfunction, it is necessary to know how to frame it promptly to suggest the correct diagnostic-therapeutic pathway to the patient. As knowledge of its pathophysiology has progressed, the importance of this clinical sign has been increasingly understood. At the same time, clinical diagnostic knowledge has increased, and it has been recognized that this sign may occur sporadically or in association with others within defined clinical syndromes. Thus, in many cases, different therapeutic solutions have become possible. In our work, we have attempted to systematize current knowledge about the origin of this finding, the clinical presentation and current treatment options, to provide an overview that can be used at different levels, from the general practitioner to the specialist neurologist or neurotologist.
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Affiliation(s)
- Vincenzo Marcelli
- Audiology and Vestibology Unit, Department of ENT, Ospedale del Mare, ASL Napoli 1 Centro, Napoli, Italy
- Department of Neuroscience, Reproductive Science and Dentistry, Section of Audiology, University of Naples ‘’Federico II’’, Napoli, Italy
| | - Beatrice Giannoni
- Department of Neuroscience, Psychology, Drug’s Area and Child’s Health, University of Florence, Florence, Italy
| | - Giampiero Volpe
- Department of Neurology, Ospedale San Luca di Vallo della Lucania, ASL Salerno, Salerno, Italy
| | - Mario Faralli
- Department of ENT, University of Perugia, Perugia, Italy
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Anna Rita Fetoni
- Department of Neuroscience, Reproductive Science and Dentistry, Section of Audiology, University of Naples ‘’Federico II’’, Napoli, Italy
| | - Vito E. Pettorossi
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Rachapudi SS, Laylani NA, Davila-Siliezar PA, Lee AG. Neuro-ophthalmic manifestations of Ehlers-Danlos syndrome. Curr Opin Ophthalmol 2023; 34:476-480. [PMID: 37729660 DOI: 10.1097/icu.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
PURPOSE OF REVIEW To review the neuro-ophthalmic manifestations of Ehlers-Danlos syndrome (EDS). RECENT FINDINGS Ehlers-Danlos syndrome (EDS) is a rare genetic disorder with an estimated prevalence of 1 in 5000 individuals, but its true prevalence may be underestimated because of variable clinical presentations and limited awareness among healthcare professionals. The neuro-ophthalmic features of EDS may be difficult to recognize in context but new molecular genetic testing is now available for identification of specific subtypes of EDS. SUMMARY Ophthalmic manifestations of EDS include loss of vision and double vision (strabismus), high myopia, retinal detachment, and blue sclera. The vascular subtype of EDS can present as a carotid-cavernous fistula, intracranial aneurysm, or arterial dissection.
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Affiliation(s)
| | - Noor A Laylani
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas
| | | | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York
- Department of Ophthalmology, University of Texas Medical Branch, Galveston
- University of Texas MD Anderson Cancer Center, Houston
- Texas A and M College of Medicine, Bryan, Texas
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Famili HP, Zalewski CK, Ibrahimy A, Mack J, Cantor F, Heiss JD, Brewer CC. Audiovestibular Findings in a Cohort of Patients with Chiari Malformation Type I and Dizziness. J Clin Med 2023; 12:jcm12082767. [PMID: 37109107 PMCID: PMC10142081 DOI: 10.3390/jcm12082767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Chiari Malformation Type I (CM1) is a neurological condition in which the cerebellar tonsils extend past the foramen magnum. While many studies have reported dizziness symptoms in patients with CM1, the prevalence of peripheral labyrinthine lesions is largely unknown. This study aimed to comprehensively describe the audiovestibular phenotype in a cohort of patients with CM1 expressly referred for dizziness. Twenty-four patients with CM1 and a complaint of dizziness/vertigo were evaluated. Hearing and auditory brainstem tract function were essentially normal. While vestibular abnormalities were most prevalent during rotational testing (33%), abnormal functional balance was the most common finding (40%). Patients with CM1 had a greater likelihood of exhibiting an abnormal sensory organization test (SOT) postural stability score for fixed platform conditions, and for the somatosensory analysis score. While no significant associations were identified between tonsillar ectopia extent and any vestibular/balance outcome measure, a significant negative association was identified between neck pain and the somatosensory sensory analysis score. Abnormal functional balance in the somatosensory domain was remarkable, with poorer scores associated with neck pain. An isolated peripheral vestibulopathy was present in only 8% of patients. Despite the low prevalence of vestibulopathy, vestibular/balance assessment is warranted to identify patients who may benefit from referral to specialized medical disciplines.
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Affiliation(s)
- Hannah P Famili
- Audiology Unit, NIDCD, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | | | - Alaaddin Ibrahimy
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jessica Mack
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Fredric Cantor
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - John D Heiss
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Carmen C Brewer
- Audiology Unit, NIDCD, National Institutes of Health, Bethesda, MD 20892, USA
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Makoshi Z, Leonard JR. Clinical Manifestations of Chiari I Malformation. Neurosurg Clin N Am 2023; 34:25-34. [DOI: 10.1016/j.nec.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Zisakis A, Sun R, Pepper J, Tsermoulas G. Chiari Malformation Type 1 in Adults. Adv Tech Stand Neurosurg 2023; 46:149-173. [PMID: 37318574 DOI: 10.1007/978-3-031-28202-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The term Chiari malformation refers to a heterogeneous group of anatomical abnormalities at the craniovertebral junction. Chiari malformation type 1 (CM1) refers to the abnormal protrusion of cerebellar tonsils through the foramen magnum and is by far the commonest type. Its prevalence is estimated approximately 1%; it is more common in women and is associated with syringomyelia in 25-70% of cases. The prevalent pathophysiological theory proposes a morphological mismatch between a small posterior cranial fossa and a normally developed hindbrain that results in ectopia of the tonsils.In most people, CM1 is asymptomatic and diagnosed incidentally. In symptomatic cases, headache is the cardinal symptom. The typical headache is induced by Valsalva-like maneuvers. Many of the other symptoms are nonspecific, and in the absence of syringomyelia, the natural history is benign. Syringomyelia manifests with spinal cord dysfunction of varying severity. The approach to patients with CM1 should be multidisciplinary, and the first step in the management is phenotyping the symptoms, because they may be due to other pathologies, like a primary headache syndrome. Magnetic resonance imaging, which shows cerebellar tonsillar decent 5 mm or more below the foramen magnum, is the gold standard investigative modality. The diagnostic workup may include dynamic imaging of the craniocervical junction and intracranial pressure monitoring.The management of CM1 is variable and sometimes controversial. Surgery is usually reserved for patients with disabling headaches or neurological deficits from the syrinx. Surgical decompression of the craniocervical junction is the most widely used procedure. Several surgical techniques have been proposed, but there is no consensus on the best treatment strategy, mainly due to lack of high-quality evidence. The management of the condition during pregnancy, restriction to lifestyle related to athletic activities, and the coexistence of hypermobility require special considerations.
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Affiliation(s)
- Athanasios Zisakis
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Rosa Sun
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Joshua Pepper
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Case Report: Downbeat Nystagmus Due to Epidural Puncture during Labor with Undiagnosed Arnold Chiari Malformation. Optom Vis Sci 2022; 99:721-724. [PMID: 35678639 DOI: 10.1097/opx.0000000000001916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Epidural anesthesia is a safe procedure used in pregnant patients during labor. However, caution should be exercised in those patients that have concurrent Arnold Chiari malformation. PURPOSE To report a rare and atypical presentation of downbeat nystagmus, in a pregnant patient with Arnold Chiari malformation type 1 (ACM1), secondary to accidental dural puncture. CASE REPORT A 31-year-old African American female presented with a chief complaint of decreased vision and oscillopsia that occurred after giving birth, six months earlier. Her medical history prior to presentation was unremarkable. Her delivery was typical; however, the patient did receive epidural anesthesia which resulted in a dural puncture. The patient noted her symptoms a few days after delivery. Upon examination, persistent down beat nystagmus was noted in both eyes. Magnetic resonance imaging revealed a 2.5 cm inferior displacement of the cerebellar tonsils below the foramen magnum consistent with ACM1. The patient was referred to neurosurgery for posterior fossa decompression. However, surgery was deferred until appropriate weight reduction could be achieved. Follow-up examination six months later revealed no change in her clinical findings. CONCLUSIONS This case report highlights an atypical presentation of downbeat nystagmus secondary to an accidental dural puncture in a pregnant patient with undiagnosed ACM1. Clinicians should consider the importance of considering ocular complications that can occur in pregnant patients with ACM1. Questioning of women who have recently given birth about epidural anesthesia should be considered with an acute presentation of downbeat-nystagmus.
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Tran TM, Lee MS, McClelland CM. Downbeat nystagmus: a clinical review of diagnosis and management. Curr Opin Ophthalmol 2021; 32:504-514. [PMID: 34456290 DOI: 10.1097/icu.0000000000000802] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW This review will extensively cover the clinical manifestations, causes, diagnostic evaluation, and management strategies of downbeat nystagmus (DBN). RECENT FINDINGS Historically, MRI to assess for structural lesions at the cervicomedullary junction has been the primary diagnostic test in the evaluation of DBN since the 1980s. In recent years, there is increasing awareness of nonstructural causes of DBN including gluten ataxia, nutritional deficiencies, and paraneoplastic syndromes, among others. Medical management with aminopyridines has become first-line therapy in addition to disease-specific therapies. SUMMARY DBN is a common form of acquired nystagmus and the differential diagnosis remains broad, including both benign and potentially fatal causes. For practical purposes, the causes can be categorized as structural vs. nonstructural with MRI as the ideal, initial diagnostic study to differentiate the two. General therapeutic options include pharmacotherapy to enhance Purkinje cell function, strabismus surgery or prisms to shift null points, and behavioural changes. Disease-specific treatment is necessarily broad, though a significant proportion of patients will be idiopathic.
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Affiliation(s)
- Tu M Tran
- Department of Ophthalmology and Visual Neurosciences
| | - Michael S Lee
- Department of Ophthalmology and Visual Neurosciences
- Department of Neurology
- Department of Neurosurgery, University of Minnesota, Minneapolis, USA
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Imaging and health metrics in incidental cerebellar tonsillar ectopia: findings from the Adolescent Brain Cognitive Development Study (ABCD). Neuroradiology 2021; 63:1913-1924. [PMID: 34247260 DOI: 10.1007/s00234-021-02759-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Incidental cerebellar tonsillar ectopia (ICTE) that meets the radiographic criterion for Chiari malformation type I (CMI) is an increasingly common finding in the clinical setting, but its significance is unclear. The present study examined posterior cranial fossa (PCF) morphometrics and a broad range of health instruments of pediatric ICTE cases and matched controls extracted from the Adolescent Brain Cognitive Development (ABCD) dataset. METHODS One-hundred-six subjects with ICTE and 106 matched controls without ICTE were identified from 11,411 anatomical MRI of healthy screened pediatric subjects from the ABCD project. Subjects were matched by sex, age, body mass index, race, and ethnicity. Twenty-two brain morphometrics and 22 health instruments were compared between the two groups to identify unrecognized CMI symptoms and assess the general health impact of ICTE. RESULTS Twelve and 15 measures were significantly different between the ICTE and control groups for females and males, respectively. Notably, for females, the anterior CSF space was significantly smaller (p = 0.00005) for the ICTE group than controls. For males, the clivus bone length was significantly shorter (p = 0.0002) for the ICTE group compared to controls. No significant differences were found among the 22 health instruments between the two groups. CONCLUSION This study demonstrated that pediatric ICTE subjects have similar PCF morphometrics to adult CMI. ICTE alone did not appear to cause any unrecognized CMI symptoms and had no impact on the subjects' current mental, physical, or behavioral health. Still, given their cranial and brain morphology, these cases may be at risk for adult-onset symptomatic CMI.
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Florou C, Andreanos K, Georgakoulias N, Espinosa E, Papakonstantinou E, Georgalas I, Rotsos T. Acute Visual Loss Secondary to Arnold Chiari Type I Malformation Completely Resolving After Decompressive Posterior Fossa Surgery. Int Med Case Rep J 2020; 13:657-661. [PMID: 33239924 PMCID: PMC7680680 DOI: 10.2147/imcrj.s253883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/22/2020] [Indexed: 11/23/2022] Open
Abstract
We describe the case of a 22-year-old woman of southeast-Asian origin, presenting with unilateral sudden visual loss after a self-healing hearing loss a week before. Ophthalmological examination showed visual acuity of light perception in the left eye, mild RAPD, normal ocular motility and an elevated optic disc with indistinct margins. Neurological examination showed no acute pathology and brain CT-MRI imaging revealed a small-almost subclinical-herniation of the cerebellar tonsils. As investigation eliminated every other infectious or inflammatory cause of papillitis, neurosurgical intervention was proposed. The patient underwent an uncomplicated occipital craniotomy with posterior fossa decompression and had a favorable revolution with regression of papilledema and a fully recovering visual acuity that reached 20/20. Chiari malformation type I refers to an abnormality of the posterior fossa that has a smaller volume than normal, leading to the herniation of cerebellar tonsils, at least 5 mm below the foramen magnum. The occurrence of papilledema associated with Chiari malformation type 1 is rare. Chiari malformation has, until today, mainly been studied among children populations, usually with a poor visual acuity recovery. The originality of our case report consists in the description of an adult patient case showing unilateral, unusual ophthalmological findings and complete recovery after surgical treatment.
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Affiliation(s)
- Chrysoula Florou
- Department of Ophthalmology, University of Athens, G Gennimatas General Hospital, Athens, Greece
| | - Konstantinos Andreanos
- Department of Ophthalmology, University of Athens, G Gennimatas General Hospital, Athens, Greece
| | | | - Edroulfo Espinosa
- Neurosurgery Department, G Gennimatas General Hospital, Athens, Greece
| | | | - Ilias Georgalas
- Department of Ophthalmology, University of Athens, G Gennimatas General Hospital, Athens, Greece
| | - Tryfon Rotsos
- Department of Ophthalmology, University of Athens, G Gennimatas General Hospital, Athens, Greece
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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.
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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.
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Clivus length distinguishes between asymptomatic healthy controls and symptomatic adult women with Chiari malformation type I. Neuroradiology 2020; 62:1389-1400. [PMID: 32418026 DOI: 10.1007/s00234-020-02453-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/29/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE While the presence of cerebellar tonsillar descent in radiological images has been used as evidence of Chiari malformation type I (CMI), tonsillar ectopia alone is insufficient to identify individuals with symptomatic CMI. This study sought to identify differences in brain morphology between symptomatic CMI and healthy controls in adult females. METHODS Two hundred and ten adult females with symptomatic CMI and 90 age- and body mass index-matched asymptomatic female controls were compared using seven brain morphometric measures visible on magnetic resonance images. The CMI and control groups were divided into four subgroups based on the tonsillar position (TP) relative to the foramen magnum: group 1 was made up of healthy controls with normal TP (TP < 0 mm); group 2 was comprised of control individuals with low-lying TP (1-5 mm); group 3 was comprised of symptomatic CMI patients with low-lying TP (1-5 mm); group 4 contained symptomatic CMI patients with severe tonsillar descent (6-13 mm). RESULTS All morphometrics for symptomatic CMI with severe tonsillar descent were significantly different than those for both control groups. The CMI group with low-lying TP was significantly different for four measures when compared to controls with normal TP. However, only clivus length was statistically different between the CMI and healthy control groups with low-lying TP. CONCLUSION This study demonstrates that clivus length distinguishes adult female healthy individuals with low-lying tonsils from those with symptomatic CMI. Further investigation is required to understand the importance of a shorter clivus length on CMI symptomatology and pathophysiology.
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Bronstein R, Capowski EE, Mehrotra S, Jansen AD, Navarro-Gomez D, Maher M, Place E, Sangermano R, Bujakowska KM, Gamm DM, Pierce EA. A combined RNA-seq and whole genome sequencing approach for identification of non-coding pathogenic variants in single families. Hum Mol Genet 2020; 29:967-979. [PMID: 32011687 PMCID: PMC7158377 DOI: 10.1093/hmg/ddaa016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/23/2019] [Accepted: 01/21/2020] [Indexed: 12/13/2022] Open
Abstract
Inherited retinal degenerations (IRDs) are at the focus of current genetic therapeutic advancements. For a genetic treatment such as gene therapy to be successful, an accurate genetic diagnostic is required. Genetic diagnostics relies on the assessment of the probability that a given DNA variant is pathogenic. Non-coding variants present a unique challenge for such assessments as compared to coding variants. For one, non-coding variants are present at much higher number in the genome than coding variants. In addition, our understanding of the rules that govern the non-coding regions of the genome is less complete than our understanding of the coding regions. Methods that allow for both the identification of candidate non-coding pathogenic variants and their functional validation may help overcome these caveats allowing for a greater number of patients to benefit from advancements in genetic therapeutics. We present here an unbiased approach combining whole genome sequencing (WGS) with patient-induced pluripotent stem cell (iPSC)-derived retinal organoids (ROs) transcriptome analysis. With this approach, we identified and functionally validated a novel pathogenic non-coding variant in a small family with a previously unresolved genetic diagnosis.
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Affiliation(s)
- Revital Bronstein
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Ocular Genomics Institute, Boston, MA 02114, USA
| | - Elizabeth E Capowski
- Waisman Center Stem Cell Research Program, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Sudeep Mehrotra
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Ocular Genomics Institute, Boston, MA 02114, USA
| | - Alex D Jansen
- Waisman Center Stem Cell Research Program, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Daniel Navarro-Gomez
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Ocular Genomics Institute, Boston, MA 02114, USA
| | - Mathew Maher
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Ocular Genomics Institute, Boston, MA 02114, USA
| | - Emily Place
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Ocular Genomics Institute, Boston, MA 02114, USA
| | - Riccardo Sangermano
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Ocular Genomics Institute, Boston, MA 02114, USA
| | - Kinga M Bujakowska
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Ocular Genomics Institute, Boston, MA 02114, USA
| | - David M Gamm
- Department of Ophthalmology and Visual Sciences, Waisman Center Stem Cell Research Program, McPherson Eye Research Institute, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Eric A Pierce
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Ocular Genomics Institute, Boston, MA 02114, USA
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Lind T, Atkinson S, Marsh JD. Diagnosis of Accommodative Spasm Aided by Handheld Photoscreener. J Binocul Vis Ocul Motil 2020; 70:37-39. [PMID: 31967529 DOI: 10.1080/2576117x.2020.1712184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We report a case of accommodative spasm in an 8-year-old girl discovered by handheld photoscreener. The patient was found to have a Chiari I malformation, and managed with atropine drops and reading glasses, ultimately with improvement in her symptoms. We believe this to be the first case of accommodative spasm diagnosis aided by the use of a handheld photoscreener.
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Affiliation(s)
- Taylor Lind
- School of Medicine, UMKC SOM, Kansas City, Missouri
| | - Scott Atkinson
- Ophthalmology Department, Children's Mercy Hospital, Kansas City, Missouri
| | - Justin D Marsh
- Ophthalmology Department, Children's Mercy Hospital, Kansas City, Missouri
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Nwotchouang BST, Eppelheimer MS, Bishop P, Biswas D, Andronowski JM, Bapuraj JR, Frim D, Labuda R, Amini R, Loth F. Three-Dimensional CT Morphometric Image Analysis of the Clivus and Sphenoid Sinus in Chiari Malformation Type I. Ann Biomed Eng 2019; 47:2284-2295. [PMID: 31187348 DOI: 10.1007/s10439-019-02301-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023]
Abstract
This study evaluated three-dimensional (3D) volumetric image reconstructions to identify morphological differences of the clivus and sphenoid sinus on computed tomography (CT) scans of Chiari malformation type I (CMI) and control subjects. Axial CT images of adult females for 30 CMI subjects and 30 age and body mass index (BMI) matched controls were used for this retrospective study. 3D volumetric reconstructions were created from the bone windows of axial data following image registration for position and orientation correction of the head. The volume, surface area, linear dimensions and spatial position in the x, y, and z-axes were computed separately for the clivus and the sphenoid sinus for each subject. Eleven parameters were found to be significantly different between CMI subjects compared to controls. Most notably, clivus volume was reduced by 31% on average in CMI subjects. In contrast, we found that the sphenoid sinus volume was 38% greater on average in CMI subjects. Moreover, clivus length, height, width, and thickness were 3.7, 2.8, 3.0 and 9.4 mm reduced, respectively, in CMI subjects. This is the first study to demonstrate cephalometric differences in the 3D morphology of the clivus and sphenoid sinus between CMI subjects and controls.
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Affiliation(s)
| | - Maggie S Eppelheimer
- Department of Biomedical Engineering, University of Akron, Akron, OH, 44325-3903, USA
| | - Paul Bishop
- Department of Biomedical Engineering, University of Akron, Akron, OH, 44325-3903, USA
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Dipankar Biswas
- Department of Mechanical Engineering, University of Akron, Akron, OH, USA
| | | | - Jayapalli R Bapuraj
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - David Frim
- Department of Neurosurgery, University of Chicago, Chicago, IL, USA
| | | | - Rouzbeh Amini
- Department of Biomedical Engineering, University of Akron, Akron, OH, 44325-3903, USA
| | - Francis Loth
- Department of Biomedical Engineering, University of Akron, Akron, OH, 44325-3903, USA
- Department of Mechanical Engineering, University of Akron, Akron, OH, USA
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Low SYY, Ng LP, Tan AJL, Low DCY, Seow WT. The Seow Operative Score (SOS) as a decision-making adjunct for paediatric Chiari I malformation: a preliminary study. Childs Nerv Syst 2019; 35:1777-1783. [PMID: 31175390 DOI: 10.1007/s00381-019-04226-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 05/23/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE The natural history of Chiari I malformation (C1M) in the paediatric population is poorly understood. There are conflicting reports with regards to surgical indications, operative techniques and peri-operative prognostic indicators. In this paper, we report our institutional experience in the management of paediatric C1M. METHODS The workflow process which includes preferred imaging modalities, surgical techniques and indications for intervention is discussed. In particular, we describe one of our current projects-an in-house designed Seow Operative Score (SOS) as a feasibility scoring system for neurosurgical intervention in our local cohort of paediatric C1M patients. RESULTS In our series, we have 2 groups: 10 non-operated patients versus 19 operated patients. In the non-operated group, the majority of patients had a SOS of 0 to 1. One patient had a score of 2.5 and was kept under close surveillance. Follow-up imaging demonstrated resolution of the cerebellar herniation and intraspinal syrinx. In the operated group, 17 patients had a SOS of 3 or more. Two patients had a SOS of 2. For these 2, 1 developed progressive symptoms, and the other had an extensive cervico-thoracic syrinx. Decision was made for surgery after a period of surveillance. CONCLUSIONS In this paper, we report our institutional experience in managing paediatric C1M and, at the same time, highlight salient points of our practices. Meanwhile, we advocate collective global efforts and in-depth research for better disease understanding of this challenging condition.
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Affiliation(s)
- Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore. .,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Audrey J L Tan
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - David C Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
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Clinical diagnosis-part II: what is attributed to Chiari I. Childs Nerv Syst 2019; 35:1681-1693. [PMID: 31093732 DOI: 10.1007/s00381-019-04192-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Chiari malformation type I is identified as radiological appearance of cerebellar tonsil herniation below the foramen magnum. The wide spectrum of clinical manifestations variably associated sometimes encompasses signs and symptoms whose correlation with the malformation remains debatable. However, a correct clinical framework is relevant in tailoring the strategy of management, and in particular, establishing the appropriate surgical intervention. METHODS An analysis of relevant articles on this issue was performed, involving both single case reports and case series. The papers were obtained from electronic databases including PubMed/MEDLINE and Google Scholar, as well as direct contact with some authors. RESULTS This review focuses on those unusual clinical pictures attributed to Chiari malformation type I (CMI), investigating their actual relationship with the morphological condition. Supposed physiopathogenetic mechanisms and clinical relevance are discussed along with an analysis on the surgical indications and results. CONCLUSION There is no clear explanation on why some patients may exhibit uncommon symptoms, often in association with the most frequent ones, but even reported as single initial clinical occurrence. Their actual incidence may have been roughly underestimated in the literature so far, because of wide heterogeneity of selection and analysis among different studies. Most of the authors appear sharing the impression that CMI surgical decompression plays a significant role in controlling the majority of these unusual symptoms, stressing their actual occurrence in relation with the malformation. A routinely multidisciplinary clinical approach has become advisable to encompass the diversity of conditions potentially associated with CMI and improve the care of CMI patients.
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Shaikh AG, Zee DS. Eye Movement Research in the Twenty-First Century-a Window to the Brain, Mind, and More. THE CEREBELLUM 2019; 17:252-258. [PMID: 29260439 DOI: 10.1007/s12311-017-0910-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The study of eye movements not only addresses debilitating neuro-ophthalmological problems but has become an essential tool of basic neuroscience research. Eye movements are a classic way to evaluate brain function-traditionally in disorders affecting the brainstem and cerebellum. Abnormalities of eye movements have localizing value and help narrow the differential diagnosis of complex neurological problems. More recently, using sophisticated behavioral paradigms, measurement of eye movements has also been applied to disorders of the thalamus, basal ganglia, and cerebral cortex. Moreover, in contemporary neuroscience, eye movements play a key role in understanding cognition, behavior, and disorders of the mind. Examples include applications to higher-level decision-making processes as in neuroeconomics and psychiatric and cognitive disorders such as schizophrenia and autism. Eye movements have become valued as objective biomarkers to monitor the natural progression of disease and the effects of therapies. As specific genetic defects are identified for many neurological disorders, ocular motor function often becomes the cornerstone of phenotypic classification and differential diagnosis. Here, we introduce other important applications of eye movement research, including understanding movement disorders affecting the head and limbs. We also emphasize the need to develop standardized test batteries for eye movements of all types including the vestibulo-ocular responses. The evaluation and treatment of patients with cerebellar ataxia are particularly amenable to such an approach.
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Affiliation(s)
- Aasef G Shaikh
- Neurological Institute, University Hospitals Health System, Cleveland, OH, USA. .,Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA. .,Department of Neurology, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44110, USA.
| | - David S Zee
- Department of Neuroscience, The Johns Hopkins University, Baltimore, MD, USA.,Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA.,Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University, Baltimore, MD, USA.,Department of Ophthalmology, The Johns Hopkins University, Baltimore, MD, USA
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Paraneoplastic seesaw nystagmus and opsoclonus provides evidence for hyperexcitable reciprocally innervating mesencephalic network. J Neurol Sci 2018; 390:239-245. [DOI: 10.1016/j.jns.2018.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/28/2018] [Accepted: 05/01/2018] [Indexed: 11/18/2022]
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