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Vagianou F, Khirani S, de Saint Denis T, Beccaria K, Amaddeo A, Breton S, James S, Paternoster G, Arnaud E, Zerah M, Fauroux B. The utility of poly(somno)graphy in evaluating children with Chiari malformation type II before and after surgical intervention: a case series. Br J Neurosurg 2024; 38:125-127. [PMID: 34747686 DOI: 10.1080/02688697.2021.1999392] [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: 07/28/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Children with Chiari Malformation type II (CM-II) have an increased risk of sleep apnoea. The aim of the study was to describe the management of patients with CM-II in relation to sleep apnoea syndrome, clinical symptoms and magnetic resonance imaging (MRI) findings. CASE SERIES PRESENTATION The paper reports 8 consecutive patients with CM-II followed between September 2013 and April 2017. The prevalence of sleep apnoea syndrome was high with 6 out of 8 patients having mild-to-severe sleep apnoea. Patients with severe sleep apnoea syndrome (3 patients) were treated with upper airway surgery and/or noninvasive ventilation. CONCLUSION Our findings highlight the importance of respiratory polygraphy in the management of patients with CM-ΙΙ. Poly(somno)graphy is recommended in the follow-up care of children with CM-II.
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Affiliation(s)
- Foteini Vagianou
- Paediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Sonia Khirani
- Paediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- ASV Santé, Gennevilliers, France
| | - Timothée de Saint Denis
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Kevin Beccaria
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Alessandro Amaddeo
- Paediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- Université de Paris, VIFASOM, Paris, France
| | - Sylvain Breton
- Paediatric radiology department, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Syril James
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- Clinique Marcel Sembat, Ramsay Générale de Santé, Boulogne Billancourt, France
| | - Giovanna Paternoster
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Eric Arnaud
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- Clinique Marcel Sembat, Ramsay Générale de Santé, Boulogne Billancourt, France
| | - Michel Zerah
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Brigitte Fauroux
- Paediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- Université de Paris, VIFASOM, Paris, France
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Atallah O, Wireko AA, Chaurasia B. Respiratory arrest after posterior fossa decompression in patients with Chiari malformations: An overview. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:217-220. [PMID: 37860018 PMCID: PMC10583799 DOI: 10.4103/jcvjs.jcvjs_70_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 10/21/2023] Open
Abstract
Background Chiari malformation type 1 (CM1) is a structural abnormality in the skull and cerebellum, causing cerebellar tonsils to shift downward. Decompression of the posterior fossa is a common surgical method to relieve symptoms and prevent neurological deterioration. After posterior fossa decompression (PFD), individuals with CM1 were more likely to have respiratory arrest. Here, we present, for the first time, a comprehensive overview of the potential risk factors and causes of respiratory arrest following PFD. Methods A review of the literature highlighting the risk factors for postoperative respiratory arrest in CM1 patients was conducted in the databases of PubMed, Medline, and Google Scholar. Results Patients with syringomyelia and CM1 are at increased risk for respiratory arrest due to a number of factors, including impaired respiratory mechanics, central respiratory center dysfunction from edema or ischemia, intraoperative brain stem ischemia, and delayed gastric emptying from autonomic dysfunction. Occipitalization of the first cervical vertebra, basilar impression, and fusion of C2-C3 are all risk factors for respiratory arrest. Conclusion Implications for CM1 patient care and prospects for further investigation of postoperative respiratory arrest's causes and risk factors were discussed.
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Affiliation(s)
- Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
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Voutsas G, St-Laurent A, Hutchinson C, Amin R, Drake J, Narang I. The efficacy of neurosurgical intervention on sleep-disordered breathing in pediatric patients with Chiari malformation type I. J Neurosurg Pediatr 2021; 27:611-619. [PMID: 33892471 DOI: 10.3171/2020.11.peds20574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chiari malformation type I (CM-I) involves the herniation of the cerebellar tonsils through the foramen magnum. CM-I is associated with both obstructive sleep apnea (OSA) and central sleep apnea (CSA) in children. The primary management of symptomatic CM-I remains surgical decompression. There is, however, a paucity of data evaluating the efficacy of decompression surgery on outcomes related to sleep-disordered breathing (SDB). The objective of this study was to evaluate SDB outcomes, specifically the need for respiratory support following decompression in pediatric patients with CM-I. METHODS This was a retrospective chart review of all children diagnosed with CM-I when younger than 18 years of age who had polysomnography (PSG) studies pre- and postsurgery, between January 2008 and October 2018 at the Hospital for Sick Children in Toronto. Patient demographics, symptoms, PSG data, ongoing respiratory support, and surgical notes were recorded. Differences in PSG studies obtained pre- and postsurgery were compared using the Wilcoxon test for paired samples. RESULTS A total of 15 children with 15 interventions met inclusion criteria with pre- and postsurgery PSG studies and were considered for statistical analysis. Of the 15 subjects included for analysis, preoperative OSA was present in 2 (13.3%), CSA in 5 (33.3%), mixed SDB (both OSA and CSA) in 4 (26.7%), and no significant SDB in 4 (26.7%). Postoperatively, OSA was present in 3 (20.0%), CSA in 4 (26.7%), mixed SDB in 0 (0%), and no significant SDB in 8 (53.3%). The presence of severe OSA decreased from 4/15 (26.7%) to 2/15 (13.3%) postoperatively, and severe CSA decreased from 5/15 (33.3%) to 2/15 (13.3%) postoperatively. Following decompression surgery, 7/15 subjects (46.7%) required positive airway pressure for management of their SDB. Overall, significant improvements were observed in a number of respiratory parameters following decompression including the following: the total apnea-hypopnea index (AHI) (17.5 ± 48.2 vs 6.1 ± 32.7 events/hour; p = 0.001), obstructive AHI (2.1 ± 16.1 vs 1.0 ± 6.6 events/hour; p = 0.005), central AHI (6.3 ± 48.9 vs 2.7 ± 33.0 events/hour; p = 0.005), and the desaturation index (16.7 ± 49.6 vs 3.8 ± 25.3; p = 0.001). CONCLUSIONS Although decompression surgery led to a significant reduction in obstructive and central events, many children continued to have persistent SDB and required additional positive airway pressure therapy. This information is important and relevant for anticipatory guidance around decompression surgery and the necessity for respiratory support for the management of SDB in pediatric patients with CM-I.
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Affiliation(s)
- Giorge Voutsas
- 1Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Ontario
- 2University of Toronto, Ontario
| | | | - Crystal Hutchinson
- 1Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Ontario
| | - Reshma Amin
- 2University of Toronto, Ontario
- 4Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario; and
| | - James Drake
- 2University of Toronto, Ontario
- 5Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Indra Narang
- 1Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Ontario
- 2University of Toronto, Ontario
- 4Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario; and
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Zhang X, Wang J, Liu Y, Li Z, Han B. A rare case of difficult airway management in a Klippel-Feil syndrome pediatric patient with osseous torticollis undergone orthopedic surgery : Difficult airway in pediatric patient with torticollis. BMC Anesthesiol 2021; 21:121. [PMID: 33874892 PMCID: PMC8054383 DOI: 10.1186/s12871-021-01341-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Orthopedic surgery for cervical torticollis poses potential threat to airway management both in tracheal intubation and extubation. Klippel-Feil syndrome (KFS) is a complex syndrome of osseous and visceral anomalies. The anatomical characteristics of KFS might have significant implications for airway management. Case presentation This is a rare case of an 8-year-old boy presenting with osseous torticollis, congenital occipito-atlantal deformity, congenital basilar invagination and KFS undergone elective torticollis correction surgery. Though with difficulty, tracheal intubation was successfully performed. Extubation failed twice on postoperative day 2 and 10, and required tracheostomy. Based on radiological findings, we speculated that prolonged airway edema accounted for the main reason of the failed extubation, the hypertrophic tonsil and occipito-cervical fusion resulted in reduced oropharyngeal space and limited cervical range of motion. Moreover, the Chiari malformation and KFS complicated the airway condition and lead to prolonged airway obstruction. The tracheostomy casing was removed 1 month later. Conclusions Cautions should be taken in extubation of pediatric patients undergone major osseous torticollis surgery. Reintubation should be prepared in case of failed extubation. Severe post-operative airway edema, complicated with hypertrophic tonsil, the structural abnormalities in the oropharyngeal cavity, and occipito-cervical deformities constituted the decreased oropharyngeal space and resulted in failed extubation. For severe airway compromise and prolonged intubation, tracheostomy should be considered.
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Affiliation(s)
- Xiaoqing Zhang
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China
| | - Jun Wang
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China
| | - Yajie Liu
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China
| | - Bin Han
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China.
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Herkenrath S, Randerath W. Zentrale Schlafapnoe bei Chiari-Malformation Typ I. SOMNOLOGIE 2020. [DOI: 10.1007/s11818-020-00236-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Alford EN, Hopson BD, Safyanov F, Arynchyna A, Bollo RJ, Hankinson TC, Rocque BG, Blount JP. Care management and contemporary challenges in spina bifida: a practice preference survey of the American Society of Pediatric Neurosurgeons. J Neurosurg Pediatr 2019; 24:539-548. [PMID: 31470398 DOI: 10.3171/2019.5.peds18738] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neurosurgical management preferences related to myelomeningocele (MMC) care demonstrate significant variability. The authors sought to evaluate variability in practice patterns across a group of senior pediatric neurosurgeons. The purpose of this study was to identify the extent of variability and of consensus with regard to neurosurgical management of MMC and associated hydrocephalus, Chiari II malformation, and tethered spinal cord. METHODS A 43-question survey was distributed electronically to the members of the American Society of Pediatric Neurosurgeons (ASPN). The survey covered domains such as clinic case volume, newborn management, hydrocephalus management, transition to adulthood, clinical indications for shunt revision, Chiari II malformation decompression (C2MD), and tethered cord release (TCR). Ninety responses were received from 200 active ASPN members, for an overall response rate of 45%. RESULTS The majority (58%) of respondents closed 5-15 new cases of open MMC per year. Nearly all (98%) respondents perform back closure within 48 hours of birth, with the majority imbricating the placode and striving for a 3- to 4-layer closure. The most consistent indications for surgical intervention in early hydrocephalus were CSF leak from the back (92%), progressive ventricular enlargement (89%), and brainstem symptoms, including apnea/bradycardia (81%), stridor (81%), and dysphagia (81%). Eighty percent of respondents indicated that spina bifida care is delivered through multidisciplinary clinics, with neurosurgery, orthopedic surgery, urology, physical therapy, and social work as the most common disciplines included. One-third of clinics see both pediatric and adult patients, one-third offer a formal transition program to adult care, and one-third have no transition program. The vast majority of respondents offer prenatal counseling (95%), referral for in utero closure (66%), and endoscopic third ventriculostomy/choroid plexus cauterization (72%). Respondents were more willing to perform shunt revision for symptoms alone than for image changes alone. An asymptomatic broken shunt without ventricular enlargement produced responses evenly divided between observation, intervention, and further investigation. Operative shunt exploration was always performed before C2MD by 56% of respondents and performed sometimes by 40% of respondents. Symptoms of brainstem dysfunction were the strongest clinical triggers reported for C2MD, while declines in urinary continence, leg strength or sensation, or ambulation were the most consistent thresholds for TCR. CONCLUSIONS Significant disparities exist surrounding key areas of decision making regarding treatment for patients with MMC, though there are central areas of agreement among ASPN members. Additionally, there is significant variation in the clinical management of chronic hydrocephalus, C2MD, and TCR, underscoring the need for further research into these specific areas.
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Affiliation(s)
- Elizabeth N Alford
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
| | - Betsy D Hopson
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
| | | | - Anastasia Arynchyna
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
| | - Robert J Bollo
- 4Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City
- 5Primary Children's Hospital, Salt Lake City, Utah; and
| | - Todd C Hankinson
- 6Pediatric Neurosurgery, Children's Hospital Colorado, and
- 7Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brandon G Rocque
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
| | - Jeffrey P Blount
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 2Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham
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Role of sleep study in children with Chiari malformation and sleep disordered breathing. Childs Nerv Syst 2019; 35:1763-1768. [PMID: 31372737 DOI: 10.1007/s00381-019-04302-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 07/07/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Chiari malformation incorporate numerous forms of congenital or acquired cerebellar herniation through the foramen magnum. This may lead to brain stem, high spinal cord and cranial nerve compression resulting in obstructive and central apneas. This review highlights he high prevalence of sleep-disordered breathing in this population and the importance of refering these patients for sleep studies as part of their workup. METHODS A review of the literature was performed through a PubMed and EMBASE search of original articles and reviews using the key words "chiari" "chiari malformation" "hindbrain herniation" "sleep disordered breathing" "obstructive sleep apnea" "central sleep apnea" "sleep study" and "foramen magnum decompression". DISCUSSION We highlight the pathophysiology of sleep disordered breathing in patients with Chiari malformation, how it can be diagnosed and what the treatment options are. CONCLUSIONS Sleep-disordered breathing is highly prevalent in patients with CM1. Clinicians caring for these patients should be aware of this and prioritise sleep diagnostic testing to allow for early diagnosis and management particularly in the presence of neurological symptoms and specific brain MRI pointers.
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Ferré Á, Poca MA, de la Calzada MD, Moncho D, Romero O, Sampol G, Sahuquillo J. Sleep-Related Breathing Disorders in Chiari Malformation Type 1: A Prospective Study of 90 Patients. Sleep 2017; 40:3766874. [DOI: 10.1093/sleep/zsx069] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Picciotti PM, Battista M, Pandolfini M, Paludetti G, Ausili E, Romagnoli C, Rendeli C. Audiological evaluation in children affected by myelomeningocele. Childs Nerv Syst 2015; 31:2321-4. [PMID: 26351072 DOI: 10.1007/s00381-015-2898-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 09/01/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of the present study is to evaluate the auditory system in children affected by myelomeningocele and comparing the results with clinical neurological conditions. MATERIALS AND METHODS Forty-three children, aged between 7 and 26 years, affected by myelomeningocele were investigated by means of subjective tonal audiometry and objective impedance audiometry (tympanometry and acoustic stapedial reflex). RESULTS Audiological evaluation showed an alteration in 32 patients (74%%). Nine patients presented a mild hearing loss: bilateral in six cases (three sensorineural, one mixed, and two conductive) and unilateral in three cases (two mixed and one conductive). One patient had moderate unilateral conductive deafness and, finally another one severe unilateral sensorineural. Almost all patients with deafness were affected by myelomeningocele and Chiari II. Stapedial-cochlear reflex investigation showed an alteration in 30 patients (70%): 9 of these also showed deafness while the remaining 21 was normal hearing. In these 30 patients, we demonstrated the presence of myelomeningocele, hydrocephalus, and Chiari II malformation in 21 subjects (70%). CONCLUSION Otoneurological evaluation is important in myelomeningocele not only at the birth but also in the follow-up. It could have an important prognostic role for neurological impairment.
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Affiliation(s)
- Pasqualina Maria Picciotti
- Department of Otolaryngology Head and Neck Surgery and Paediatrics, Rome, Italy. .,Department of Otolaryngology, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - M Battista
- Department of Otolaryngology Head and Neck Surgery and Paediatrics, Rome, Italy
| | - M Pandolfini
- Department of Otolaryngology Head and Neck Surgery and Paediatrics, Rome, Italy
| | - G Paludetti
- Department of Otolaryngology Head and Neck Surgery and Paediatrics, Rome, Italy
| | - E Ausili
- Catholic University of Sacred Heart, Rome, Italy
| | - C Romagnoli
- Catholic University of Sacred Heart, Rome, Italy
| | - C Rendeli
- Catholic University of Sacred Heart, Rome, Italy
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Imaging the course of a hypoplastic cerebellum in a spina bifida newborn. Childs Nerv Syst 2013; 29:2131-5. [PMID: 23686389 DOI: 10.1007/s00381-013-2156-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 05/08/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION We report about a spina bifida patient with myelomeningocele at the lumbar level L5, extensive Chiari malformation type II with vermal herniation reaching to C6 with downward pontine shift, and a severe hypoplastic cerebellum. Chromosomal diagnostic tests showed no abnormalities. CASE REPORT The infant experienced severe central apneas successfully treated with oxygen therapy and caffeine medication; functional motor level was established at L5 with sparse anal sphincter function. DISCUSSION After surgical intervention (myelomeningocele repair and ventriculoperitoneal shunt placement), these abnormalities significantly improved on radiological imaging; the preoperative hypoplastic, almost undetectable, cerebellum developed to a fair sized cerebellum. Apneas disappeared over time and the patient showed further developmental improvement. Herein, we illustrate and discuss the changes of the cerebellar volume before and after neurosurgical intervention.
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Li D, Hao SY, Lou XH, Tang J, Xiao XR, Wu Z, Zhang LW, Zhang JT. Apnea as an uncommon preoperative manifestation of medulla cavernous malformation: surgical treatment and literature review. Br J Neurosurg 2013; 28:335-9. [PMID: 24073756 DOI: 10.3109/02688697.2013.841849] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Apnea is not a common preoperative manifestation of medulla cavernous malformations (CMs). The role of surgical resection in patients suffering from apnea secondary to hemorrhage from medulla CMs requires further definition. METHODS Medical records and radiographs were reviewed retrospectively for four patients treated surgically for medulla CMs in our institution between 2008 and 2011. Recent outcomes for these patients were also evaluated. The modified Rankin Scale (mRS) was used to evaluate neurological function. RESULTS All four patients (3 male, 1 female; mean age: 41.3 years) suffered two or three hemorrhages with a preoperative mRS of five and, due to the loss of autonomous respiration and consciousness, underwent a preoperative tracheotomy for mechanical ventilation, which lasted an average of 4.5 days. Prior to surgery, all patients had recovered to the point of maintaining spontaneous breath and normal blood gas values with oxygen supplementation. Lesions were totally resected in all patients via the posterior suboccipital approach. Postoperative ventilation was continued in one patient for 1 day. The mean postoperative mRS score at discharge was 3.5, and all patients had improved from their previous scores. The tracheostomy was closed in three patients at 15, 16, and 35 days after surgery. After a mean follow-up of 34.7 months, the most recent mRS scores were 3, 2, 2, and 2; no recurrent hemorrhage was noted, and three patients lived independently. CONCLUSION In carefully selected patients with hemorrhage due to medulla CMs, favorable outcomes can be achieved even if apnea was a part of the preoperative clinical presentation. Surgery should be considered in these patients, particularly in those with repeated hemorrhages, and apnea should not be considered an absolute contraindication to surgery.
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Affiliation(s)
- Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University , Beijing , P. R. China
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Messing-Jünger M, Röhrig A. Primary and secondary management of the Chiari II malformation in children with myelomeningocele. Childs Nerv Syst 2013; 29:1553-62. [PMID: 24013325 DOI: 10.1007/s00381-013-2134-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 04/26/2013] [Indexed: 12/13/2022]
Abstract
OBJECT Chiari malformation type II is almost exclusively found in patients with open spinal dysraphism. Etiology and pathophysiology are not yet completely understood, and management guidelines regarding the best follow-up and treatment of this pathological entity do not exist. In order to assess essential management aspects, literature and a series of secondary neurosurgical interventions in Chiari II patients have been reviewed. METHODS A literature review regarding etiology, diagnostics, pathophysiology, and management of Chiari malformation type II (CMII) and a retrospective evaluation of a series (2009-2012) of secondary interventions in Chiari II patients have been performed. Inclusion criteria were ICD for myelomeningocele with or without hydrocephalus and ICD for Chiari malformation and neurosurgical OR procedure. Evaluated parameters were: patient demographics, primary management, secondary neurosurgical operations (cranio-cervical decompression, shunt revision, myelolysis) as well as specific findings pre- and postoperatively. Essential results from literature review and patients' series are compiled in order to define management recommendations. RESULTS Fifty patients (28 f, 22 m; mean age, 7.1 years (range, 0.5-26 years)) with myelomeningocele-associated Chiari malformation type II were operated on between 2009 and 2012. Twenty-four patients had syringomyelia and scoliosis each, and 12 suffered from both. Orthopedic surgery for scoliosis or kyphosis had been performed in 13 cases. Shunt revision was performed in 38 cases, myelolysis in 17, and decompression of the foramen magnum in 14 (28 %). After a mean follow-up of 1.9 years, syringomyelia decreased from 24 to 16 cases. There was a postoperative reduction of neck pain (one third), sensorimotor (two fifths), and cranial nerve deficits (one half). CSF flow at the foramen magnum did not change visibly after surgery. Ventricular size improved in about half of the patients. Slit-like ventricles were found in nine (6 pre-surgical) and enlarged ventricles in nine (23 pre-surgical). Complication rate was 6 % (3/50) per cases, and no patient died or deteriorated neurologically after surgery. CONCLUSION CMII-related management guidelines are not well defined, since clinical constellations and presentations are varying. Often associated findings are syringomyelia, hydrocephalus, and scoliosis, and symptomatic CMII may be triggered by more than one underlying condition. According to literature and clinical experience, management recommendations can be defined. The most important finding is that hydrocephalus is often involved in symptomatic CMII and must always be considered first in any symptomatic patient. Intrinsic brain stem dysfunctions cannot be treated surgically, and monitoring of vital functions is sometimes the only clinical means that can be offered to the patient. Knowledge of the complex background has led to improved follow-up programs for the affected children and thus also improved longtime survival.
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Affiliation(s)
- Martina Messing-Jünger
- Neurosurgical Department, Asklepios Children's Hospital, Arnold-Janssen Strasse 29, 53757, Sankt Augustin, Germany.
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Navarro Patiño N, Rodríguez Cimadevilla JL, Peraita-Adrados R, Salcedo Posadas A. [Obstructive sleep apnea-hypopnea syndrome associated with type II Arnold-Chiari malformation. Benefits of neurosurgical intervention]. An Pediatr (Barc) 2012; 78:195-8. [PMID: 22898178 DOI: 10.1016/j.anpedi.2012.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 06/06/2012] [Accepted: 06/07/2012] [Indexed: 10/28/2022] Open
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Vidmer S, Sergio C, Veronica S, Flavia T, Silvia E, Sara B, Valentini LG, Daria R, Solero CL. The neurophysiological balance in Chiari type 1 malformation (CM1), tethered cord and related syndromes. Neurol Sci 2012; 32 Suppl 3:S311-6. [PMID: 22012627 DOI: 10.1007/s10072-011-0692-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The Chiari malformation (CM) is a syndrome embodied in heterogeneous groups of malformations, spanning from the more benign and known, the CM1, to more complex syndromes such as the rare association with the tethered cord, as spinal lipomas, and the CM2, associated to open spina bifida. The clinical picture may be well expressed and detected at birth or even during intrauterine life, as for CM2, but in the other cases they may run a rather subtle clinical course. The diagnosis of these syndromes is driven by clinical examination and MRI, and it usually requires a multidisciplinary approach in order to plan the therapeutic strategies, such as surgery. Among the diagnostic investigations, the imaging techniques represent the most useful, for their capabilities to detect subclinical lesions, such as syringomyielia and lipoma; the urological investigation is useful to evaluate the urogenital dysfunctions. The neurophysiological investigations represent a non invasive diagnostic procedure to investigate the peripheral nerve, the spinal cord, the brainstem functionalities and more higher brain functions; the nerve conduction studies and the cranial reflexes, the brainstem (BAEP) and the somatosensory (SEPs) evoked potentials (EPs), alone or in combination, can be used for the diagnosis, follow-up and intraoperative monitoring. The most useful diagnostic tools in CM1 are likely represented by the brainstem auditory evoked potentials (BAEPs) and the blink-reflex (BR), while the usefulness of SEPs is still doubtful and debated; in CM2 and tethered cord the neurophysiological techniques can be combined in different ways in order to make a functional balance and to answer specific questions. BAEPs and BR can be useful to investigate the brain stem functionality and SEP to evaluate whether the ascending sensory pathway to the cortex can be hampered at some level; the visual EPs are particularly useful to evaluate the integrity of posterior visual pathway and visual cortex in the case of associated hydrocephalus. In the tethered cord, both nerve conduction study and somatosensory evoked potentials (SEPs) are useful to evaluate motor and sensory dysfunction of the lombosacral roots and nerves and spinal cord for their capability to detect subclinical impairment of conduction along the sensory and motor pathway. Finally, last but not the least, the neurophysiological techniques are remarkably useful during surgery; the intraoperative monitoring (IOM) by means of electromyography and direct nerve stimulation and recordings are able to detect early nerve damage, minimize nerve lesions and optimise the surgical techniques. In the operated children with incomplete removal of lipoma and/or persistent tethering, the recordings of SEP and BAEP are useful to demonstrate a conduction deterioration along the ascending sensory pathway due to increasing tethering of the spinal cord due to somatic growth.
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Affiliation(s)
- Scaioli Vidmer
- Fondazione IRCCS Istituto Nazionale Neurologico C.Besta, Via Celoria 11, 20133, Milan, Italy.
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