1
|
Huisman TAGM. Invited Commentary: Chiari 1 Deformity: Not a Malformation. Radiographics 2024; 44:e240100. [PMID: 39115995 DOI: 10.1148/rg.240100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Affiliation(s)
- Thierry A G M Huisman
- From the Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, 6701 Fannin St, Ste 470, Houston, TX 77030
| |
Collapse
|
2
|
Lu VM, Shimony N, Jallo GI, Niazi TN. Infant Hydrocephalus. Pediatr Rev 2024; 45:450-460. [PMID: 39085190 DOI: 10.1542/pir.2023-006318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/06/2024] [Accepted: 03/15/2024] [Indexed: 08/02/2024]
Abstract
Hydrocephalus is a neurosurgical condition that is highly prevalent in pediatric medicine. In the infant population, there is a distinct set of features that all primary pediatricians would benefit from understanding. Infant hydrocephalus can present prenatally on imaging and postnatally with symptomatic enlargement of the head and associated skull features and raised intracranial pressures. The 2 major pathophysiology models of infant hydrocephalus are the bulk flow and the intracranial pulsatility models. The most common acquired forms of hydrocephalus include posthemorrhagic hydrocephalus, postinfectious hydrocephalus, and brain tumor. The most common congenital forms of hydrocephalus include those due to myelomeningocele, aqueductal stenosis, and posterior fossa malformations. There are various evaluation and treatment algorithms for these different types of hydrocephalus, including cerebrospinal fluid shunting and endoscopic third ventriculostomy. The aim of this review was to elaborate on those features of hydrocephalus to best equip primary pediatricians to diagnose and manage hydrocephalus in infants.
Collapse
Affiliation(s)
- Victor M Lu
- Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL
| | - Nir Shimony
- Department of Surgery, St Jude Children's Research Hospital, Le Bonheur Neuroscience Institute, University of Tennessee, Memphis, TN
| | - George I Jallo
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Toba N Niazi
- Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL
| |
Collapse
|
3
|
Bianchi F, Montedoro B, Frassanito P, Massimi L, Tamburrini G. Chiari I malformation: management evolution and technical innovation. Childs Nerv Syst 2023; 39:2757-2769. [PMID: 37368069 DOI: 10.1007/s00381-023-06051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND DEFINITION In recent years thanks to the growing use of radiological assessment, Chiari I malformation became one of the major diseases for a neurosurgeon to deal with. CIM can be classified according to the extent of cerebellar tonsil tip into the foramen magnum being a protrusion over five mm considered pathological. Such a disease is a heterogeneous condition with a multifactorial pathogenetic mechanism that can subdivided into a primary and secondary form. Regardless of the form, it seems that CIM is the result of an imbalance between the volume of the braincase and its content. Acquired CIMs are secondary to conditions causing intracranial hypertension or hypotension while the pathogenesis of primary forms is still controversial. PATHOGENESIS AND TREATMENT There are several theories in the literature but the most accepted one implies an overcrowding due to a small posterior cranial fossa. While asymptomatic CIM do not need treatment, symptomatic ones prompt for surgical management. Several techniques are proposed being the dilemma centered in the need for dural opening procedures and bony decompression ones. CONCLUSION Alongside the paper, the authors will address the novelty presented in the literature on management, diagnosis and pathogenesis in order to offer a better understanding of such a heterogeneous pathology.
Collapse
Affiliation(s)
- Federico Bianchi
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy.
| | | | - Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Luca Massimi
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Tamburrini
- Pediatric Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
4
|
Sahuquillo J, Moncho D, Ferré A, López-Bermeo D, Sahuquillo-Muxi A, Poca MA. A Critical Update of the Classification of Chiari and Chiari-like Malformations. J Clin Med 2023; 12:4626. [PMID: 37510741 PMCID: PMC10380265 DOI: 10.3390/jcm12144626] [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: 06/03/2023] [Revised: 06/27/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Chiari malformations are a group of craniovertebral junction anomalies characterized by the herniation of cerebellar tonsils below the foramen magnum, often accompanied by brainstem descent. The existing classification systems for Chiari malformations have expanded from the original four categories to nine, leading to debates about the need for a more descriptive and etiopathogenic terminology. This review aims to examine the various classification approaches employed and proposes a simplified scheme to differentiate between different types of tonsillar herniations. Furthermore, it explores the most appropriate terminology for acquired herniation of cerebellar tonsils and other secondary Chiari-like malformations. Recent advances in magnetic resonance imaging (MRI) have revealed a higher prevalence and incidence of Chiari malformation Type 1 (CM1) and identified similar cerebellar herniations in individuals unrelated to the classic phenotypes described by Chiari. As we reassess the existing classifications, it becomes crucial to establish a terminology that accurately reflects the diverse presentations and underlying causes of these conditions. This paper contributes to the ongoing discussion by offering insights into the evolving understanding of Chiari malformations and proposing a simplified classification and terminology system to enhance diagnosis and management.
Collapse
Affiliation(s)
- Juan Sahuquillo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - Dulce Moncho
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Clinical Neurophysiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Alex Ferré
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Sleep Unit, Pneumology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Diego López-Bermeo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Aasma Sahuquillo-Muxi
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Maria A Poca
- Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
| |
Collapse
|
5
|
Mascioli I, Iapadre G, Ingrosso D, Donato GD, Giannini C, Salpietro V, Chiarelli F, Farello G. Brain and eye involvement in McCune-Albright Syndrome: clinical and translational insights. Front Endocrinol (Lausanne) 2023; 14:1092252. [PMID: 37274327 PMCID: PMC10235602 DOI: 10.3389/fendo.2023.1092252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/10/2023] [Indexed: 06/06/2023] Open
Abstract
McCune-Albright Syndrome (MAS) is a rare mosaic (post-zygotic) genetic disorder presenting with a broad continuum clinical spectrum. MAS arises from somatic, activating mutations in the GNAS gene, which induces a dysregulated Gsα-protein signaling in several tissues and an increased production of intracellular cyclic adenosine monophosphate (cAMP). Overall, MAS is a rare disorder affecting less than 1/100,000 children and, for this reason, data establishing genotype-phenotype correlations remain limited. Affected individuals clinically present with a variable combination of fibrous dysplasia of bone (FD), extra-skeletal manifestations (including cafeí-au-lait spots) and precocious puberty which might also be associated to broad hyperfunctioning endocrinopathies, and also gastrointestinal and cardiological involvement. Central nervous system (CNS) and eye involvement in MAS are among the less frequently described complications and remain largely uncharacterized. These rare complications mainly include neurodevelopmental abnormalities (e.g., delayed motor development, cognitive and language impairment), CNS anomalies (e.g., Chiari malformation type I) and a wide array of ophthalmological abnormalities often associated with vision loss. The pathophysiological mechanisms underlying abnormal neurological development have not been yet fully elucidated. The proposed mechanisms include a deleterious impact of chronically dysregulated Gsα-protein signaling on neurological function, or a secondary (damaging) effect of (antenatal and/or early postnatal) hypercortisolism on early pre- and post-natal CNS development. In this Review, we summarize the main neurological and ophthalmological features eventually associated with the MAS spectrum, also providing a detailed overview of the potential pathophysiological mechanisms underlying these clinical complications.
Collapse
Affiliation(s)
- Ilaria Mascioli
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Giulia Iapadre
- Department of Pediatrics, University of L’Aquila, L’Aquila, Italy
| | | | - Giulio Di Donato
- Department of Pediatrics, University of L’Aquila, L’Aquila, Italy
| | - Cosimo Giannini
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | | | - Giovanni Farello
- Department of Pediatrics, University of L’Aquila, L’Aquila, Italy
| |
Collapse
|
6
|
Krishnan N, McMullan P, Yang Q, Buscarello AN, Germain-Lee EL. Prevalence of Chiari malformation type 1 is increased in pseudohypoparathyroidism type 1A and associated with aberrant bone development. PLoS One 2023; 18:e0280463. [PMID: 36662765 PMCID: PMC9858345 DOI: 10.1371/journal.pone.0280463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Albright hereditary osteodystrophy (AHO) is caused by heterozygous inactivating mutations in GNAS. Patients with maternally-inherited mutations develop pseudohypoparathyroidism type 1A (PHP1A) with multi-hormone resistance and aberrant craniofacial and skeletal development among other abnormalities. Chiari malformation type 1 (CM1), a condition in which brain tissue extends into the spinal canal when the skull is too small, has been reported in isolated cases of PHP1A. It has been hypothesized to be associated with growth hormone (GH) deficiency. Given the adverse clinical sequelae that can occur if CM1 goes unrecognized, we investigated the previously undetermined prevalence of CM1, as well as any potential correlations with GH status, given the known increased prevalence of GH deficiency in PHP1A. We also investigated these metrics for low lying cerebellar tonsils (LLCT), defined as tonsillar descent less than 5 mm below the foramen magnum. In addition, we investigated possible correlations of CM1/LLCT with advanced hand/wrist bone ages and craniofacial abnormalities known to occur in PHP1A to determine whether premature chondrocyte differentiation and/or aberrant craniofacial development could be potential etiologies of CM1/LLCT through both human studies and investigations of our AHO mouse model. METHODS We examined patients with PHP1A in our clinic and noticed CM1 more frequently than expected. Therefore, we set out to determine the true prevalence of CM1 and LLCT in a cohort of 54 mutation-confirmed PHP1A participants who had clinically-indicated brain imaging. We examined potential correlations with GH status, clinical features, biological sex, genotype, and hand/wrist bone age determinations. In addition, we investigated the craniofacial development in our mouse model of AHO (Gnas E1+/-m) by histologic analyses, dynamic histomorphometry, and micro-computerized tomographic imaging (MCT) in order to determine potential etiologies of CM1/LLCT in PHP1A. RESULTS In our cohort of PHP1A, the prevalence of CM1 is 10.8%, which is at least 10-fold higher than in the general population. If LLCT is included, the prevalence increases to 21.7%. We found no correlation with GH status, biological sex, genotype, or hand/wrist bone age. Through investigations of our Gnas E1+/-m mice, the correlate to PHP1A, we identified a smaller cranial vault and increased cranial dome angle with evidence of hyperostosis due to increased osteogenesis. We also demonstrated that there was premature closure of the spheno-occipital synchondrosis (SOS), a cartilaginous structure essential to the development of the cranial base. These findings lead to craniofacial abnormalities and could contribute to CM1 and LLCT development in PHP1A. CONCLUSION The prevalence of CM1 is at least 10-fold higher in PHP1A compared to the general population and 20-fold higher when including LLCT. This is independent of the GH deficiency that is found in approximately two-thirds of patients with PHP1A. In light of potential serious consequences of CM1, clinicians should have a low threshold for brain imaging. Investigations of our AHO mouse model revealed aberrant cranial formation including a smaller cranium, increased cranial dome angle, hyperostosis, and premature SOS closure rates, providing a potential etiology for the increased prevalence of CM1 and LLCT in PHP1A.
Collapse
Affiliation(s)
- Neetu Krishnan
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Albright Center, Division of Pediatric Endocrinology & Diabetes, Connecticut Children’s, Farmington, Connecticut, United States of America
| | - Patrick McMullan
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, Connecticut, United States of America
| | - Qingfen Yang
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, Connecticut, United States of America
| | - Alexzandrea N. Buscarello
- Albright Center, Division of Pediatric Endocrinology & Diabetes, Connecticut Children’s, Farmington, Connecticut, United States of America
| | - Emily L. Germain-Lee
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Albright Center, Division of Pediatric Endocrinology & Diabetes, Connecticut Children’s, Farmington, Connecticut, United States of America
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, Connecticut, United States of America
| |
Collapse
|
7
|
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]
|
8
|
Elucidating the Genetic Basis of Chiari I Malformation. Neurosurg Clin N Am 2023; 34:55-60. [DOI: 10.1016/j.nec.2022.07.001] [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]
|
9
|
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.
Collapse
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.
| |
Collapse
|
10
|
Huguenard *AL, Johnson GW, Desai RR, Osbun JW, Dacey RG, Braverman AC. Relationship between phenotypic features in Loeys-Dietz syndrome and the presence of intracranial aneurysms. J Neurosurg 2022; 138:1385-1392. [PMID: 36308480 DOI: 10.3171/2022.9.jns221373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Loeys-Dietz syndrome (LDS) is a rare autosomal dominant condition characterized by aneurysms of the aorta, aortic branches, and intracranial arteries; skeletal and cutaneous abnormalities; and craniofacial malformations. Previous authors have reported that higher craniofacial severity index (CFI) scores, which indicate more severe craniofacial abnormalities, correlate with the severity of aortic aneurysm pathology. However, the association between syndromic features and the formation of intracranial aneurysms in LDS patients has yet to be determined. In this study, the authors evaluate the incidence of phenotypic abnormalities, craniofacial features, and Chiari malformation type I (CM-I) in a large LDS cohort and explore possible risk factors for the development of intracranial aneurysms.
METHODS
This was a retrospective cohort study of all patients with LDS who had been seen at the Marfan Syndrome and Aortopathy Center at Washington University School of Medicine in St. Louis in 2010–2022. Medical records were reviewed to obtain demographic, clinical, and radiographic data. The prevalence of craniofacial, skeletal, and cutaneous pathologies was determined. Bivariate logistic regression was performed to identify possible risk factors for the formation of an intracranial aneurysm.
RESULTS
Eighty-one patients with complete medical records and intracranial vascular imaging were included in the analysis, and 18 patients (22.2%) had at least 1 intracranial aneurysm. Patients frequently demonstrated the thin or translucent skin, doughy skin texture, hypertelorism, uvular abnormalities, and joint hypermobility typical of LDS. CM-I was common, occurring in 7.4% of the patients. Importantly, the patients with intracranial aneurysms were more likely to have CM-I (22.2%) than those without intracranial aneurysms (3.2%). The mean CFI score in the cohort with available data was 1.81, with higher means in the patients with the TGFBR1 or TGFBR2 disease-causing variants (2.05 and 3.30, respectively) and lower in the patients with the SMAD3, TGFB2, or TGFB3 pathogenic variants (CFI < 1). No significant CFI difference was observed in patients with or without intracranial aneurysms (2.06 vs 1.74, p = 0.61).
CONCLUSIONS
CM-I, and not the CFI, is significantly associated with the presence of intracranial aneurysms in patients with LDS. Surveillance for intracranial aneurysms is essential in all patients with LDS and should not be limited to those with severe phenotypes. Long-term monitoring studies will be necessary to determine whether a correlation between craniofacial abnormalities and adverse outcomes from intracranial aneurysms (growth, intervention, or rupture) exists.
Collapse
Affiliation(s)
| | | | - Rupen R. Desai
- Department of Neurosurgery, Washington University in St. Louis; and
| | - Joshua W. Osbun
- Department of Neurosurgery, Washington University in St. Louis; and
| | - Ralph G. Dacey
- Department of Neurosurgery, Washington University in St. Louis; and
| | - Alan C. Braverman
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, Missouri
| |
Collapse
|
11
|
Stagi S, Ferrari V, Ferrari M, Priolo M, Tartaglia M. Inside the Noonan "universe": Literature review on growth, GH/IGF axis and rhGH treatment: Facts and concerns. Front Endocrinol (Lausanne) 2022; 13:951331. [PMID: 36060964 PMCID: PMC9434367 DOI: 10.3389/fendo.2022.951331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/18/2022] [Indexed: 12/21/2022] Open
Abstract
Noonan syndrome (NS) is a disorder characterized by a typical facial gestalt, congenital heart defects, variable cognitive deficits, skeletal defects, and short stature. NS is caused by germline pathogenic variants in genes coding proteins with a role in the RAS/mitogen-activated protein kinase signaling pathway, and it is typically associated with substantial genetic and clinical complexity and variability. Short stature is a cardinal feature in NS, with evidence indicating that growth hormone (GH) deficiency, partial GH insensitivity, and altered response to insulin-like growth factor I (IGF-1) are contributing events for growth failure in these patients. Decreased IGF-I, together with low/normal responses to GH pharmacological provocation tests, indicating a variable presence of GH deficiency/resistance, in particular in subjects with pathogenic PTPN11 variants, are frequently reported. Nonetheless, short- and long-term studies have demonstrated a consistent and significant increase in height velocity (HV) in NS children and adolescents treated with recombinant human GH (rhGH). While the overall experience with rhGH treatment in NS patients with short stature is reassuring, it is difficult to systematically compare published data due to heterogeneous protocols, potential enrolment bias, the small size of cohorts in many studies, different cohort selection criteria and varying durations of therapy. Furthermore, in most studies, the genetic information is lacking. NS is associated with a higher risk of benign and malignant proliferative disorders and hypertrophic cardiomyopathy, and rhGH treatment may further increase risk in these patients, especially as dosages vary widely. Herein we provide an updated review of aspects related to growth, altered function of the GH/IGF axis and cell response to GH/IGF stimulation, rhGH treatment and its possible adverse events. Given the clinical variability and genetic heterogeneity of NS, treatment with rhGH should be personalized and a conservative approach with judicious surveillance is recommended. Depending on the genotype, an individualized follow-up and close monitoring during rhGH treatments, also focusing on screening for neoplasms, should be considered.
Collapse
Affiliation(s)
- Stefano Stagi
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
| | - Vittorio Ferrari
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
| | - Marta Ferrari
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
| | - Manuela Priolo
- Medical Genetics Unit, Grande Ospedale Metropolitano “Bianchi-Melacrino-Morelli”, Reggio Calabria, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| |
Collapse
|
12
|
The Course and Interaction of Ventriculomegaly and Cerebellar Tonsillar Herniation in Crouzon Syndrome over Time. PLASTIC AND RECONSTRUCTIVE SURGERY - GLOBAL OPEN 2022; 10:e3979. [PMID: 35083101 PMCID: PMC8785943 DOI: 10.1097/gox.0000000000003979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022]
Abstract
Children with Crouzon syndrome have a higher incidence of cerebellar tonsillar herniation (TH) and ventriculomegaly than the general population, or children with other craniosynostosis syndromes.
Collapse
|
13
|
Botelho RV, Botelho PB, Hernandez B, Sales MB, Rotta JM. Association between Brachycephaly, Chiari Malformation, and Basilar Invagination. J Neurol Surg A Cent Eur Neurosurg 2021; 84:329-333. [PMID: 34929749 DOI: 10.1055/s-0041-1739503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is evidence that Chiari malformation (CM) and basilar invagination (BI) are largely due to disproportion between the content and volume of the posterior fossa. A recent study identified an increased association between brachycephaly and BI. In several types of craniosynostosis, the posterior fossa volume is smaller than normal, and this is more pronounced in coronal synostosis. The aim of this study is to evaluate the association between CM and BI. METHODS The cephalic index (CI) measured on magnetic resonance imaging (MRI) from a sample of patients with craniocervical malformation was compared with that of normal subjects. RESULTS The average CI in the craniovertebral junction malformation (CVJM) group was significantly higher in BI patients than in normal subjects. The BI patients also had the highest CI among the whole sample of patients (p = 0.009). CONCLUSIONS In this study, BI patients had the highest CI among patients with CVJM and a significantly higher CI than those in the control group. Our data confirm the association between BI and brachycephaly.
Collapse
Affiliation(s)
- Ricardo Vieira Botelho
- Department of Neurosurgery, Inst Assistencia Med Ao Serv Publ Estadual Sao Pa, São Paulo, Brazil
| | | | | | - Mauricio Bezerra Sales
- Department of Neurosurgery, Inst Assistencia Med Ao Serv Publ Estadual Sao Pa, São Paulo, Brazil
| | - José Marcus Rotta
- Department of Neurosurgery, Inst Assistencia Med Ao Serv Publ Estadual Sao Pa, São Paulo, Brazil
| |
Collapse
|
14
|
Abstract
Importance Craniosynostosis is a fetal condition caused by premature closure of the cranial sutures. Through provider awareness, we can raise suspicion in high-risk individuals, increase prenatal detection, optimize genetic testing, perform appropriate antenatal surveillance and delivery planning, and allow for a comprehensive, multidisciplinary approach to treatment. Objective The aim of this study was to review what is currently known regarding the genetics, pathophysiology, diagnosis, and treatment of craniosynostosis for the obstetric care provider. Evidence Acquisition A comprehensive literature review was performed using the PubMed database with the search term "craniosynostosis." The search was limited to the English language. Results A total of 220 articles were identified, and a total of 53 were used in completion of this article. The results highlight the multiple factors involved with abnormal suture formation, including various genetic factors. Although rare at this time, prenatal detection can allow families to prepare and practitioners to provide appropriate clinical treatment. Both 3-dimensional sonography and magnetic resonance imaging have been identified as modalities to aid in detection for high-risk individuals. Early referral allows for less-invasive surgical outcomes with lower complication rates. Results Familiarity with craniosynostosis among obstetric providers can improve patient counseling, prenatal detection rates, and appropriate antepartum, intrapartum, and postpartum counseling.
Collapse
|
15
|
Sadler B, Wilborn J, Antunes L, Kuensting T, Hale AT, Gannon SR, McCall K, Cruchaga C, Harms M, Voisin N, Reymond A, Cappuccio G, Brunetti-Pierri N, Tartaglia M, Niceta M, Leoni C, Zampino G, Ashley-Koch A, Urbizu A, Garrett ME, Soldano K, Macaya A, Conrad D, Strahle J, Dobbs MB, Turner TN, Shannon CN, Brockmeyer D, Limbrick DD, Gurnett CA, Haller G. Rare and de novo coding variants in chromodomain genes in Chiari I malformation. Am J Hum Genet 2021; 108:100-114. [PMID: 33352116 PMCID: PMC7820723 DOI: 10.1016/j.ajhg.2020.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/24/2020] [Indexed: 12/16/2022] Open
Abstract
Chiari I malformation (CM1), the displacement of the cerebellum through the foramen magnum into the spinal canal, is one of the most common pediatric neurological conditions. Individuals with CM1 can present with neurological symptoms, including severe headaches and sensory or motor deficits, often as a consequence of brainstem compression or syringomyelia (SM). We conducted whole-exome sequencing (WES) on 668 CM1 probands and 232 family members and performed gene-burden and de novo enrichment analyses. A significant enrichment of rare and de novo non-synonymous variants in chromodomain (CHD) genes was observed among individuals with CM1 (combined p = 2.4 × 10-10), including 3 de novo loss-of-function variants in CHD8 (LOF enrichment p = 1.9 × 10-10) and a significant burden of rare transmitted variants in CHD3 (p = 1.8 × 10-6). Overall, individuals with CM1 were found to have significantly increased head circumference (p = 2.6 × 10-9), with many harboring CHD rare variants having macrocephaly. Finally, haploinsufficiency for chd8 in zebrafish led to macrocephaly and posterior hindbrain displacement reminiscent of CM1. These results implicate chromodomain genes and excessive brain growth in CM1 pathogenesis.
Collapse
Affiliation(s)
- Brooke Sadler
- Department of Pediatrics, Washington University, St. Louis, MO 63110, USA
| | - Jackson Wilborn
- Department of Neurosurgery, Washington University, St. Louis, MO 63110, USA
| | - Lilian Antunes
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110, USA
| | - Timothy Kuensting
- Department of Neurosurgery, Washington University, St. Louis, MO 63110, USA
| | - Andrew T Hale
- Division of Genetic Medicine, Vanderbilt University Medical Center & Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Stephen R Gannon
- Division of Pediatric Neurosurgery and Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN 37232, USA
| | - Kevin McCall
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110, USA
| | - Carlos Cruchaga
- Department of Psychiatry, Washington University, St. Louis, MO 63110, USA
| | - Matthew Harms
- Department of Neurology, Columbia University, New York, NY 10027, USA
| | - Norine Voisin
- Center for Integrative Genomics (CIG), University of Lausanne, Lausanne 1015, Switzerland
| | - Alexandre Reymond
- Center for Integrative Genomics (CIG), University of Lausanne, Lausanne 1015, Switzerland
| | - Gerarda Cappuccio
- Department of Translational Medicine, Section of Pediatrics, Federico II University, Naples 80138, Italy; Telethon Institute of Genetics and Medicine (TIGEM), Pozzuoli 80078, Italy
| | - Nicola Brunetti-Pierri
- Department of Translational Medicine, Section of Pediatrics, Federico II University, Naples 80138, Italy; Telethon Institute of Genetics and Medicine (TIGEM), Pozzuoli 80078, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome 00165, Italy
| | - Marcello Niceta
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome 00165, Italy
| | - Chiara Leoni
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione-Policlinico-Universitario-A. Gemelli-IRCCS, Rome 00168, Italy
| | - Giuseppe Zampino
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione-Policlinico-Universitario-A. Gemelli-IRCCS, Rome 00168, Italy
| | - Allison Ashley-Koch
- Duke Molecular Physiology Institute, Department of Medicine, Duke University, Durham, NC 27708, USA
| | - Aintzane Urbizu
- Duke Molecular Physiology Institute, Department of Medicine, Duke University, Durham, NC 27708, USA
| | - Melanie E Garrett
- Duke Molecular Physiology Institute, Department of Medicine, Duke University, Durham, NC 27708, USA
| | - Karen Soldano
- Duke Molecular Physiology Institute, Department of Medicine, Duke University, Durham, NC 27708, USA
| | - Alfons Macaya
- Pediatric Neurology Research group, University Hospital Vall d'Hebron, Barcelona 08035, Spain
| | - Donald Conrad
- Oregon National Primate Research Center, Oregon Health and Science University, Beaverton, OR 97006, USA
| | - Jennifer Strahle
- Department of Neurosurgery, Washington University, St. Louis, MO 63110, USA
| | - Matthew B Dobbs
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110, USA; Shriners Hospital for Children, St. Louis, MO 63110, USA
| | - Tychele N Turner
- Department of Genetics, Washington University, St. Louis, MO 63110, USA
| | - Chevis N Shannon
- Division of Genetic Medicine, Vanderbilt University Medical Center & Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Douglas Brockmeyer
- Department of Neurological Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT 84113, USA
| | - David D Limbrick
- Department of Neurosurgery, Washington University, St. Louis, MO 63110, USA
| | - Christina A Gurnett
- Department of Pediatrics, Washington University, St. Louis, MO 63110, USA; Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63110, USA; Department of Neurology, Washington University, St. Louis, MO 63110, USA
| | - Gabe Haller
- Department of Neurosurgery, Washington University, St. Louis, MO 63110, USA; Department of Neurology, Washington University, St. Louis, MO 63110, USA; Department of Genetics, Washington University, St. Louis, MO 63110, USA.
| |
Collapse
|
16
|
Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis. Acta Neurochir (Wien) 2020; 162:1553-1563. [PMID: 32504118 PMCID: PMC7295832 DOI: 10.1007/s00701-020-04429-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/22/2020] [Indexed: 12/27/2022]
Abstract
Introduction Recently, a novel hypothesis has been proposed concerning the origin of craniovertebral junction (CVJ) abnormalities. Commonly found in patients with these entities, atlantoaxial instability has been suspected to cause both Chiari malformation type I and basilar invagination, which renders the tried and tested surgical decompression strategy ineffective. In turn, C1-2 fusion is proposed as a single solution for all CVJ abnormalities, and a revised definition of atlantoaxial instability sees patients both with and without radiographic evidence of instability undergo fusion, instead relying on the intraoperative assessment of the atlantoaxial joints to confirm instability. Methods The authors conducted a comprehensive narrative review of literature and evidence covering this recently emerged hypothesis. The proposed pathomechanisms are discussed and contextualized with published literature. Conclusion The existing evidence is evaluated for supporting or opposing sole posterior C1-2 fusion in patients with CVJ abnormalities and compared with reported outcomes for conventional surgical strategies such as posterior fossa decompression, occipitocervical fusion, and anterior decompression. At present, there is insufficient evidence supporting the hypothesis of atlantoaxial instability being the common progenitor for CVJ abnormalities. Abolishing tried and tested surgical procedures in favor of a single universal approach would thus be unwarranted.
Collapse
|
17
|
Prevalence and Impact of Underlying Diagnosis and Comorbidities on Chiari 1 Malformation. Pediatr Neurol 2020; 106:32-37. [PMID: 32113729 PMCID: PMC7156318 DOI: 10.1016/j.pediatrneurol.2019.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/09/2019] [Accepted: 12/12/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Chiari malformation type 1 affects approximately one in 1,000 people symptomatically, although one in 100 meet radiological criteria, making it a common neurological disorder. The diagnosis of underlying conditions has become more sophisticated, and new radiological markers of disease have been described. We sought to determine the prevalence and impact of additional comorbidities and underlying diagnoses in patients with Chiari malformation type 1 on symptomatology and surgical treatment. METHODS A retrospective review of 612 pediatric patients with a Chiari malformation type 1 diagnosis and imaging data evaluated between 2008 and 2018 was performed. Because of extensive clinical heterogeneity, patients were separated into four categories based on their primary comorbidities (nonsyndromic, central nervous system, skeletal, and multiple congenital anomalies) to identify associations with age of onset, radiographic measurements, syringomyelia, and surgical treatment. RESULTS The largest group had nonsyndromic Chiari malformation type 1 (70%) and the latest age at diagnosis of any group. In the syndromic group, 6% were diagnosed with a known genetic abnormality, with overgrowth syndromes being the most common. Patients with multiple congenital anomalies had the earliest Chiari malformation type 1 onset, the most severe tonsillar ectopia and obex position, and were overrepresented among surgical cases. Although there were no statistically significant differences between groups and rates of syrinx, we observed differences in individual diagnoses. CONCLUSION The underlying diagnoses and presence of comorbidities in patients with Chiari malformation type 1 impacts rates of syringomyelia and surgery. Although most Chiari malformation type 1 cases are nonsyndromic, clinical evaluation of growth parameters, scoliosis, and joint hypermobility should be routine for all patients as they are useful to determine syringomyelia risk and may impact treatment.
Collapse
|
18
|
Mathkour M, Keen JR, Huang B, Werner C, Scullen T, Garces J, Skovgard M, Iwanaga J, Tubbs RS, Dumont A, Biro E, Bui CJ. “Two-Birds-One-Stone” Approach for Treating an Infant with Chiari I Malformation and Hydrocephalus: Is Cerebrospinal Fluid Diversion as Sole Treatment Enough? World Neurosurg 2020; 137:174-177. [DOI: 10.1016/j.wneu.2020.01.188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
|
19
|
Bordes S, Jenkins S, Tubbs RS. Defining, diagnosing, clarifying, and classifying the Chiari I malformations. Childs Nerv Syst 2019; 35:1785-1792. [PMID: 31049667 DOI: 10.1007/s00381-019-04172-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/21/2019] [Indexed: 01/03/2023]
Abstract
PURPOSE Chiari malformations (CM) have been traditionally classified into four categories: I, II, III, and IV. In light of more recent understandings, variations of the CM have required a modification of this classification. METHODS This article discusses the presentation, diagnostics, and treatment of the newer forms of hindbrain herniation associated with the CM type I. RESULTS The CM 1 is a spectrum that includes some patients who do not fall into the exact category of this entity. CONCLUSIONS While CM have been categorically recognized as discrete and individual conditions, newer classifications such as CM 0 and CM 1.5 exhibit some degree of continuity with CM 1; however, they require distinct and separate classification as symptoms and treatments can vary among these clinical subtypes.
Collapse
Affiliation(s)
- Stephen Bordes
- Seattle Science Foundation, Seattle, WA, USA.,Department of Anatomical Sciences, St. George's University, Saint George's, Grenada
| | - Skyler Jenkins
- Seattle Science Foundation, Seattle, WA, USA.,Department of Anatomical Sciences, St. George's University, Saint George's, Grenada
| | | |
Collapse
|
20
|
Chiari I malformation in defined genetic syndromes in children: are there common pathways? Childs Nerv Syst 2019; 35:1727-1739. [PMID: 31363831 DOI: 10.1007/s00381-019-04319-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/18/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Chiari malformation type I (CMI) is a common pediatric neurologic anomaly that can be associated with a variety of genetic disorders; however, it is not always clear whether the observed associations are real or random. The knowledge of the real associations could provide useful guidance to clinicians. Furthermore, it could be of help to better understand the still unknown genetic etiology of CMI. METHODS With the aim of implementing such insights, we retrospectively reviewed clinical, neuroradiological, and genetic data of patients harboring CMI evaluated at the Child Neurology Unit of our institution between January 2008 and December 2018. RESULTS The cohort consists of 205 patients (111 males and 94 females), with a mean age at diagnosis of 6.3 years (range 0-18 years). 188 patients completed an average follow-up period of 5.2 years (range one month-18 years). Mean age at last assessment was 11.4 years (range nine months-23 years). 127 (62%) children have been classified as syndromic due to the presence of neurodevelopmental disorders, phenotypic anomalies, or malformations. Among syndromic CMI children, a molecular diagnosis was identified in 35/127 (27.6%) (20 males and 15 females). The most common diagnoses were syndromic craniosynostosis in 8/35 children (22.9%), among which sevenare FGFR-related and one ERF-related craniosynostosis; disorders of the RAS/MAPK pathway, termed RASopathies or RAS/MAPK syndromes in 9/35 (25.7%); disorders of the PTEN-PI3K/AKT signal transduction cascade, termed PTENopathies in 3/35 children (8.6%); and chromosomal rearrangements in 6/35 patients (17.1%), two of whom with del16p11.2. CONCLUSIONS We polarized our attention on the defined genetic diagnoses focusing not only on the phenotypic hallmarks but also on the phenotypic overlapping features. In addition, we discussed the pathophysiological mechanisms leading to progressive cerebellar ectopia and the involved molecular pathways. Along with the recent literature evidence, we suppose that interactions between FGFR and RAS/MAPK pathway and between RAS/MAPK and PTEN-PI3K/AKT pathways could explain some phenotypic overlapping features and could have a significant role in the pathogenesis of CMI.
Collapse
|
21
|
Massimi L, Pennisi G, Frassanito P, Tamburrini G, Di Rocco C, Caldarelli M. Chiari type I and hydrocephalus. Childs Nerv Syst 2019; 35:1701-1709. [PMID: 31227858 DOI: 10.1007/s00381-019-04245-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 05/30/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The association between Chiari type I malformation (CIM) and hydrocephalus raises a great interest because of the still unclear pathogenesis and the management implications. The goal of this paper is to review the theories on the cause-effect mechanisms of such a relationship and to analyze the results of the management of this condition. METHODS A review of the literature has been performed, focusing on the articles specifically addressing the problem of CIM and hydrocephalus and on the series reporting about its treatment. Also, the personal authors' experience is briefly discussed. RESULTS As far as the pathogenesis is concerned, it seems clear that raised intracranial pressure due to hydrocephalus can cause a transient and reversible tonsillar caudal ectopia ("pressure from above" hypothesis), which is something different from CIM. A "complex" hypothesis, on the other hand, can explain the occurrence of hydrocephalus and CIM because of the venous engorgement resulting from the hypoplasia of the posterior cranial fossa (PCF) and the occlusion of the jugular foramina, leading to cerebellar edema (CIM) and CSF hypo-resorption (hydrocephalus). Nevertheless, such a mechanism can be advocated only in a minority of cases (syndromic craniosynostosis). In non-syndromic CIM subjects, the presence of hydrocephalus could be explained by an occlusion of the basal CSF pathways, which would occur completely in a minority of cases (only 7-10% of CIM patients show hydrocephalus) while it would be partial in the remaining cases (no hydrocephalus). This hypothesis still needs to be demonstrated. As far as the management is concerned, the strategy to treat the hydrocephalus first is commonly accepted. Because of the "obstructive" origin of CIM-related hydrocephalus, the use of endoscopic third ventriculostomy (ETV) is straightforward. Actually, the analysis of the literature, concerning 63 cases reported so far, reveals very high success rates of ETV in treating hydrocephalus (90.5%), CIM (78.5%), and syringomyelia symptoms (76%) as well as in giving a radiological improvement of both CIM (74%) and syringomyelia (89%). The failures of ETV were not attributable to CIM or syringomyelia. Only 11% of cases required PCF decompression after ETV. CONCLUSIONS The association between CIM and hydrocephalus probably results from different, multifactorial, and not yet completely understood mechanisms, which place the affected patients in a peculiar subgroup among those constituting the heterogeneous CIM population. ETV is confirmed as the best first approach for this subset of patients.
Collapse
Affiliation(s)
- Luca Massimi
- Fondazione Policlinico Gemelli IRCCS, Neurochirurgia Infantile, Roma, Italy.
- Istituto di Neurochirurgia, Università Cattolica del Sacro Cuore, Roma, Italy.
- International Neuroscience Institute, Hannover, Germany.
| | - Giovanni Pennisi
- Istituto di Neurochirurgia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Paolo Frassanito
- Istituto di Neurochirurgia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Gianpiero Tamburrini
- Fondazione Policlinico Gemelli IRCCS, Neurochirurgia Infantile, Roma, Italy
- Istituto di Neurochirurgia, Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Massimo Caldarelli
- Fondazione Policlinico Gemelli IRCCS, Neurochirurgia Infantile, Roma, Italy
- Istituto di Neurochirurgia, Università Cattolica del Sacro Cuore, Roma, Italy
| |
Collapse
|
22
|
Lou Y, Yang J, Wang L, Chen X, Xin X, Liu Y. The clinical efficacy study of treatment to Chiari malformation type I with syringomyelia under the minimally invasive surgery of resection of Submeningeal cerebellar Tonsillar Herniation and reconstruction of Cisterna magna. Saudi J Biol Sci 2019; 26:1927-1931. [PMID: 31885484 PMCID: PMC6921303 DOI: 10.1016/j.sjbs.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/16/2019] [Accepted: 07/24/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose Discuss the clinical efficacy of treatment to Chiari malformation type I with syringomyelia under the minimally invasive surgery of resection of Submeningeal Cerebellar Tonsillar Herniation and reconstruction of Cisterna magna. Methods 130 Chiari malformation type I with syringomyelia patients, divided into treatment group, literature group and control group, were collected to be treated under the monitoring of ultrasound in the surgery. Results 6 months after operation, the lesions were decreased or disappeared, the symptoms were relieved obviously. According to MRI and Mimics 17.0 software, the volumes of Cisterna magna increased distinctly (P < 0.001), the proportions of brain in foramen magnum region were decreased (P < 0.001). Assessed by CCOS scale and Tator methods, the improvement rates of treatment group were 97.7% and 94.6%, the literature group and control group were 82.2% and 77.8%, respectively. Conclusion The efficacy of Chiari malformation type I with syringomyelia under the minimally invasive surgery of resection of Submeningeal Cerebellar Tonsillar Herniation and reconstruction of Cisterna magna is remarkable, and the complications are fewer. This surgery emphasizes recovery of tonsil of cerebellum and reconstruction of Cisterna magna and the circulation path of cerebrospinal fluid, which is a safe and efficient treatment.
Collapse
Affiliation(s)
- Yongli Lou
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Jichao Yang
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Liuxiang Wang
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Xi Chen
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Xin Xin
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Yong Liu
- Department of Neurospinal Surgery, Yuquan Hospital of Tsinghua University, Beijing 10000, China
| |
Collapse
|
23
|
The Incidence of Chiari Malformations in Patients with Isolated Sagittal Synostosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2090. [PMID: 30881832 PMCID: PMC6416108 DOI: 10.1097/gox.0000000000002090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/06/2018] [Indexed: 11/26/2022]
Abstract
Background: We report the incidence of Chiari malformation I (CMI) in a cohort of 377 patients with isolated sagittal synostosis (ISS), which is to the best of our knowledge the largest such series reported to date. Methods: A retrospective review of patients seen at a single institution from 2007 to 2017 was completed. ISS, Chiari malformations (CMI and CMII) and hydrocephalus were diagnosed by a senior neuroradiologist (G.Z.). Patients who met the inclusion criteria were divided into early (group A) and late (group B) presenting groups, as well as operated (group I) and unoperated (group II) groups. The patients were further subdivided into group AI (early operated), group AII (early unoperated), group BI (late operated), and group BII (late unoperated). Once identified, patient notes were examined for the following data sets: date of birth, age of presentation, age at last follow-up, other systemic conditions as well as molecular testing results. Surgical interventions, ophthalmological, and other relevant data were recorded. Statistical analysis was run in the form of a chi-square test to identify a significant difference between each subgroup. A literature review of the incidence of Chiari malformations in patients with ISS was conducted. Results: Three hundred seventy-seven patients constitute the study’s total cohort (272 were males and 105 females). This cohort was divided into patients who underwent surgical repair of ISS (group 1: n = 200), and patients who did not (group 2: n = 177). The entire cohort was also divided into early (group A: n = 161) and late (group B: n = 216) presenting craniosynostosis. In the total cohort, 22/377 (5.8%) patients with CMI were identified. CMI was found in 14/200 (7.0%) patients in group I, and 8/177 (4.5%) patients in group II. CMI was found in 2/161 (1%) patients in group A, and 20/216 (9.2%) patients in group B. The incidence of CMI in group AI (early operated) was 2/151 (1.3%), in group AII (early unoperated) was 0/10, in group BI (late operated) was 11/49 (21%), and in group BII (late unoperated) was 9/167 (5.4%). Chi-square analysis revealed a significant difference between the incidence of CMI in the early-presenting (group A) and late-presenting (group B) groups (P = 0.001) and between the late-presenting operated (BI) and late-presenting unoperated (BII) groups (P = 0.001). The incidence of hydrocephalus was 1.6% (6/377) in the total cohort. However, all patients diagnosed with hydrocephalus came from group II (no surgical ISS correction). The incidence of hydrocephalus in group II was 3.3% (6/177). The incidence of hydrocephalus in group BII (late unoperated ISS) was 3.0% (5/167). The incidence of hydrocephalus in group AII (early unoperated ISS) was 9.0% (1/11). Conclusions: We noted the highest incidence of CMI—21%—in group BI (late-presenting operated). We noted hydrocephalus in group II (nonoperated), with the highest incidence of hydrocephalus found in the group BII (late-presenting unoperated) subgroup. We therefore recommend patients with ISS receive funduscopic examination to screen for raised intracranial pressure (ICP) associated with CMI and hydrocephalus, especially patients with late-presenting ISS.
Collapse
|
24
|
Pan KS, Heiss JD, Brown SM, Collins MT, Boyce AM. Chiari I Malformation and Basilar Invagination in Fibrous Dysplasia: Prevalence, Mechanisms, and Clinical Implications. J Bone Miner Res 2018; 33:1990-1998. [PMID: 29924878 PMCID: PMC6218312 DOI: 10.1002/jbmr.3531] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 06/08/2018] [Accepted: 06/17/2018] [Indexed: 01/22/2023]
Abstract
Fibrous dysplasia (FD) is a mosaic disorder of benign fibro-osseous lesions, which may be associated with extraskeletal features as part of McCune-Albright syndrome (MAS). Cranial base abnormalities, including Chiari I malformation (CM1), in which the cerebellum extends below the foramen magnum, and secondary basilar invagination (BI), in which the odontoid prolapses into the posterior cranial fossa, are potentially serious complications of metabolic bone disorders. The purpose of this study was to determine the prevalence, natural history, and risk factors for CM1 and BI in patients with FD/MAS, and to determine mechanisms of cranial base deformities. Clinical and radiographic data from subjects in an FD/MAS natural history study were evaluated and compared to normal controls. In 158 patients with craniofacial FD, 10 (6.3%) cases of CM1 and 12 (7.6%) cases of BI were diagnosed. No cranial base abnormalities were identified in 10 control subjects. Craniomorphometric and volumetric analyses identified cranial constriction and cranial settling as the primary mechanisms of cranial base abnormalities, whereas intracranial hypertension was a contributing factor in a minority of subjects. Longitudinal analyses found progression of odontoid position with age, but no progression of tonsillar position. No endocrinopathies were associated with CM1. MAS endocrinopathies associated with BI included hyperthyroidism (odds ratio [OR] 12.0; 95% confidence interval [CI], 2.9 to 55.6; p < 0.01), precocious puberty (OR 5.6; 95% CI, 1.2 to 26.0; p < 0.05), and hypophosphatemia (OR 7.7; 95% CI, 1.9 to 27.0; p < 0.01). Scoliosis was associated with both CM1 (OR 4.8; 95% CI, 1.1 to 22.8; p < 0.05) and BI (OR = infinity; 95% CI, 4.7 to infinity; p < 0.01). This study successfully characterized cranial base abnormalities in FD/MAS and the pathophysiological connection between them. These findings support routine screening for cranial base abnormalities in patients with craniofacial FD, as well as aggressive management of contributory risk factors. © 2018 American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Kristen S Pan
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - John D Heiss
- Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Sydney M Brown
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
25
|
Abstract
Chiari malformations (CMs) are variant structural setup of cerebellum and brain stem at the craniovertebral junction. Normally the cerebellum and parts of the brain stem lie above the foramen magnum. When the part of the cerebellum and/or brainstem protrudes into the upper spinal canal through foramen magnum, it is defined as CM. Chiari malformations may develop when part of the skull is smaller than normal or misshapen, due to which the cerebellum herniates into spinal canal through foramen magnum. This compresses the cerebellum and brainstem affecting functions controlled by these parts and blocks the flow of cerebrospinal fluid that surrounds and cushions the brain and spinal cord. Chiari malformation may cause sensory loss, ataxia, weakness, nystagmus, spastic limbs to name a few. Thus, various morbid and mortal neurologic disorders result from CM. Therefore, sound and thorough knowledge of CM and its variant anatomy are essential for diagnosis and management of neurologic disorders. Therefore, review study has been carried out for updating and consolidating the knowledge of all the variations of CMs. Literature search was carried out using databases, SciELO, ScopeMed, MEDLINE, PubMed, and Wiley Online Library. Papers containing original data were selected and secondary references retrieved from bibliographies. Various terms related to CMs were used for net surfing. The knowledge will be of immense importance to neurologists and neurosurgeons to diagnose and treat the CMs and decrease the mortality associated with CM and to radiologists for correctly interpreting the magnetic resonance imaging.
Collapse
|
26
|
Azahraa Haddad F, Qaisi I, Joudeh N, Dajani H, Jumah F, Elmashala A, Adeeb N, Chern JJ, Tubbs RS. The newer classifications of the chiari malformations with clarifications: An anatomical review. Clin Anat 2018; 31:314-322. [PMID: 29344999 DOI: 10.1002/ca.23051] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 01/15/2018] [Indexed: 11/07/2022]
Abstract
In 1891, Hans Chiari described a group of congenital hindbrain anomalies, which were eventually named after him. He classified these malformations into three types (Chiari malformations I, II, and III), and four years later added the Chiari IV malformation. However, numerous reports across the literature do not seem to fit Chiari's original descriptions of these malformations, so researchers have been encouraged to propose new classifications to encompass these variants (e.g., Chiari 0, Chiari1.5, and Chiari 3.5 malformations). Moreover, there is a continued misunderstanding and misuse of the term "Chiari IV malformation." Therefore, the current review intended to describe anatomical, pathophysiological, and clinical aspects of the newer classifications with clarifications of the Chiari malformations. We reviewed available literature about Chiari malformations and their variants using "PubMed" and "Google Scholar." We also looked into the term Chiari IV, clarifying its original description and citing examples where the term has been used erroneously. References in the reviewed articles were searched manually. Variants of the originally described Chiari malformations are termed Chiari 0, Chiari 1.5, and Chiari 3.5. Each has distinct anatomical characteristics and some of these are extremely rare and incompatible with life (e.g. Chiari 3.5). Chiari IV malformation has been further clarified. Some physicians might be unfamiliar with the newer classifications of Chiari malformations because these conditions are rare or even unique. Furthermore, care is needed in using the term "Chiari IV malformation", which must be consistent with Chiari's original description, i.e. an occipital encephalocele containing supratentorial contents. Clin. Anat. 31:314-322, 2018. © 2018 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
| | - Ibraheem Qaisi
- School of Medicine, An-Najah National University, Nablus, Palestine
| | - Nagham Joudeh
- School of Medicine, An-Najah National University, Nablus, Palestine
| | - Hamada Dajani
- School of Medicine, An-Najah National University, Nablus, Palestine
| | - Fareed Jumah
- School of Medicine, An-Najah National University, Nablus, Palestine
| | | | - Nimer Adeeb
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Los Angeles
| | - Joshua J Chern
- Pediatric Neurosurgical Associates, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, Grenada
- Seattle Science Foundation, Seattle, Washington
| |
Collapse
|
27
|
Mori T, Nishino E, Jitsukawa T, Hoshino E, Hirakawa S, Kuroiwa Y, Fuse S, Yoto Y, Tsutsumi H. Chiari type 1 malformation associated with central sleep apnea after high dose growth hormone (GH) therapy in a 12-year-old boy: A case report. Clin Pediatr Endocrinol 2018; 27:45-51. [PMID: 29403156 PMCID: PMC5792821 DOI: 10.1297/cpe.27.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 09/12/2017] [Indexed: 11/30/2022] Open
Abstract
We describe the case of a short-statured 12-yr-old boy who developed a Chiari type 1
malformation associated with central sleep apnea after administration of high-dose GH
therapy, which he had been receiving since the age of 10 yr and 4 mo. He responded well to
GH therapy, and his height increased by 18.8 cm in 2 yr. At 12 yr and 4 mo of age, his
mother reported that he had developed sleep apnea during the previous year and it had
worsened over a month prior to presentation at our hospital. Otolaryngological examination
did not reveal tonsillar or adenoidal hypertrophy. Polysomnography demonstrated severe
central sleep apnea with an apnea-hypopnea index of 46.5/h. Sagittal T1-weighted magnetic
resonance imaging (MRI) demonstrated herniation of the cerebellar tonsils 15 mm below the
foramen magnum into the cervical spinal cord. Continuous positive airway pressure therapy
initiated prior to performing neurosurgery was ineffective. Following uncomplicated
foramen magnum decompression, his breathing pattern during sleep returned to normal.
Sagittal MRI examination should be considered in patients who develop sleep apnea
during/following administration of GH therapy.
Collapse
Affiliation(s)
- Toshihiko Mori
- Department of Pediatrics, NTT East Sapporo Hospital, Hokkaido, Japan
| | - Eri Nishino
- Department of Pediatrics, NTT East Sapporo Hospital, Hokkaido, Japan
| | - Tomomi Jitsukawa
- Department of Pediatrics, NTT East Sapporo Hospital, Hokkaido, Japan
| | - Emiko Hoshino
- Department of Pediatrics, NTT East Sapporo Hospital, Hokkaido, Japan
| | - Satoshi Hirakawa
- Department of Pediatrics, NTT East Sapporo Hospital, Hokkaido, Japan
| | - Yuki Kuroiwa
- Department of Pediatrics, NTT East Sapporo Hospital, Hokkaido, Japan
| | - Shigeto Fuse
- Department of Pediatrics, NTT East Sapporo Hospital, Hokkaido, Japan
| | - Yuko Yoto
- Department of Pediatrics, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Hiroyuki Tsutsumi
- Department of Pediatrics, Sapporo Medical University School of Medicine, Hokkaido, Japan
| |
Collapse
|
28
|
Chiari I malformation in a child with PTEN hamartoma tumor syndrome: Association or coincidence? Eur J Med Genet 2017; 60:261-264. [DOI: 10.1016/j.ejmg.2017.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/04/2017] [Indexed: 11/16/2022]
|
29
|
Pozetti M, Belsuzarri TAB, Belsuzarri NCB, Seixas NB, Araujo JFM. Neurofibromatosis type 1 and Chiari type 1 malformation: A case report and literature review of a rare association. Surg Neurol Int 2016; 7:S469-72. [PMID: 27500008 PMCID: PMC4960925 DOI: 10.4103/2152-7806.185778] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 04/26/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The association between neurofibromatosis type 1 (NF-I) and Chiari I malformation (CMI) is rare, and not many studies are reported in the literature. Performing magnetic resonance imaging (MRI) in patients with NF-1 is essential because several cases of Chiari type I are completely asymptomatic. We emphasize the need for inclusion of Chiari I as diagnosis in association with NF-1. CASE DESCRIPTION The patient was a 51-year-old black man who presented with complaints of pain and decreased motion and sensibility of his hands, wrists, and forearms, along with progressive dysarthria. Even though the computed tomography (CT) scan of the skull did not show changes, the MRI showed hydro/syringomyelia in the cervical spine area. Midline suboccipital craniectomy with total laminectomy of c1 and partial laminectomy of c2 was performed; tonsillectomy was also performed for cistern expansion because of intense thickening and obliteration of the obex by the cerebellar tonsils. Following treatment, the patient showed remission of symptoms. CONCLUSION NF-1 in association with CMI is rare, and early diagnosis and surgical treatment are essential to slow down the myelopathy; although they prevent neurological damages, patients with NF-1 must remain under doctor's attention in case of association with CMI. Our literature review showed that symptoms can vary and include headache, gait disturbance, and sensory/motor diminution, until asymptomatic patients. Moreover, the incidence of NF-1 is considerably higher in CMI patients in comparison to the global incidence (8.6-11.8% and 0.775%, respectively). The surgical technique must be evaluated case by case according to the degree of cerebrospinal fluid obstruction.
Collapse
Affiliation(s)
- Marianne Pozetti
- Faculty of Medicine, Pontifical Catholic University of Campinas, Campinas, São Paulo, Brazil
| | - Telmo Augusto Barba Belsuzarri
- Department of Neurosurgery of Hospital e Maternidade Celso Pierro, Pontifical Catholic University of Campinas, Campinas, São Paulo, Brazil
| | | | - Naira B. Seixas
- Faculty of Medicine, Pontifical Catholic University of Campinas, Campinas, São Paulo, Brazil
| | - João F. M. Araujo
- Department of Neurosurgery of Hospital e Maternidade Celso Pierro, Pontifical Catholic University of Campinas, Campinas, São Paulo, Brazil
| |
Collapse
|
30
|
Tijssen MP, Poretti A, Huisman TA. Chiari type 1 malformation, corpus callosum agenesis and patent craniopharyngeal canal in an 11-year-old boy. Neuroradiol J 2016; 29:307-9. [PMID: 27329972 DOI: 10.1177/1971400916656487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We describe the neuroimaging findings of an 11-year-old boy who presented with mild occipital headache and precocious puberty. This child was found to have a combination of various midline anomalies including a Chiari type 1 malformation, corpus callosum agenesis and patent craniopharyngeal canal with adjacent intracranial dermoid cyst.
Collapse
Affiliation(s)
- Maud Pm Tijssen
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, USA Department of Radiology, Maastricht University Medical Center, The Netherlands
| | - Andrea Poretti
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, USA
| | - Thierry Agm Huisman
- Section of Pediatric Neuroradiology, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, USA
| |
Collapse
|
31
|
Poretti A, Boltshauser E, Huisman TA. Chiari Malformations and Syringohydromyelia in Children. Semin Ultrasound CT MR 2016; 37:129-42. [DOI: 10.1053/j.sult.2015.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
32
|
Calandrelli R, D'Apolito G, Panfili M, Massimi L, Caldarelli M, Colosimo C. Role of "major" and "minor" lambdoid arch sutures in posterior cranial fossa changes: mechanism of cerebellar tonsillar herniation in infants with multisutural craniosynostosis. Childs Nerv Syst 2016; 32:451-9. [PMID: 26572514 DOI: 10.1007/s00381-015-2956-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 11/05/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aimed to explain the functional role of lambdoid arch sutures in the development of cerebellar tonsillar herniation. Posterior cranial fossa (PCF) changes were investigated in infants with premature synostosis of the major and minor sutures of the lambdoid arch without premature synostosis of the PCF synchondroses. METHODS Morphometric and volumetric PCF measurements were performed on preoperative high-resolution CT studies in 12 infants with multisutural craniosynostosis involving the lambdoid arch and compared with those of 12 age-matched healthy subjects. RESULTS All 12 patients had hypoplasia of PCF bone structures and normal volumes of the PCF and neural structures. PCF hypoplasia was related to exocciput length in infants with isolated involvement of major sutures, while it was related to posterior skull base hemifossae in infants with isolated involvement of minor lambdoid arch sutures. Foramen magnum AP diameter was reduced in babies with major suture involvement and tonsillar herniation, while foramen magnum AP and LL diameters were reduced in babies with minor suture involvement without tonsillar herniation. Right and left jugular foramen (JF) areas differed in all infants; however, the area of the smaller JF was significantly reduced only in infants with involvement of minor lambdoid arch sutures. CONCLUSION Hypoplasia of PCF bone structures due to sutural synostosis of the lambdoid arch is a required predisposing but not sufficient factor for the development of cerebellar tonsillar herniation through the foramen magnum. Normal PCF volume and foramen magnum anatomy may partly explain the development of cerebellar tonsil herniation in infants with lambdoid arch synostosis.
Collapse
Affiliation(s)
- Rosalinda Calandrelli
- Institute of Radiology, Università Cattolica Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy.
| | - Gabriella D'Apolito
- Institute of Radiology, Università Cattolica Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Marco Panfili
- Institute of Radiology, Università Cattolica Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Luca Massimi
- Institute of Neurosurgery, Università Cattolica Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Massimo Caldarelli
- Institute of Neurosurgery, Università Cattolica Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Cesare Colosimo
- Institute of Radiology, Università Cattolica Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| |
Collapse
|
33
|
Holdsworth SJ, Rahimi MS, Ni WW, Zaharchuk G, Moseley ME. Amplified magnetic resonance imaging (aMRI). Magn Reson Med 2016; 75:2245-54. [PMID: 26888418 DOI: 10.1002/mrm.26142] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/31/2015] [Accepted: 12/31/2015] [Indexed: 01/03/2023]
Abstract
PURPOSE This work describes a new method called amplified MRI (aMRI), which uses Eulerian video magnification to amplify the subtle spatial variations in cardiac-gated brain MRI scans and enables better visualization of brain motion. METHODS The aMRI method takes retrospective cardiac-gated cine MRI data as input, applies a spatial decomposition, followed by temporal filtering and frequency-selective amplification of the MRI cardiac-gated frames before synthesizing a motion-amplified cine data set. RESULTS This approach reveals deformations of the brain parenchyma and displacements of arteries due to cardiac pulsatility, especially in the brainstem, cerebellum, and spinal cord. CONCLUSION aMRI has the potential for widespread neuro- and non-neuro clinical use because it can amplify and characterize small, often barely perceptible motion and can visualize the biomechanical response of tissues using the heartbeat as an endogenous mechanical driver. Magn Reson Med 75:2245-2254, 2016. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Samantha J Holdsworth
- Lucas Center for Imaging, Department of Radiology, Stanford University Stanford, California, USA
| | - Mahdi Salmani Rahimi
- Lucas Center for Imaging, Department of Radiology, Stanford University Stanford, California, USA
| | - Wendy W Ni
- Lucas Center for Imaging, Department of Radiology, Stanford University Stanford, California, USA
| | - Greg Zaharchuk
- Lucas Center for Imaging, Department of Radiology, Stanford University Stanford, California, USA
| | - Michael E Moseley
- Lucas Center for Imaging, Department of Radiology, Stanford University Stanford, California, USA
| |
Collapse
|
34
|
Udayakumaran S, Onyia CU. Beckwith-Wiedemann syndrome and Chiari I malformation--a case-based review of central nervous system involvement in hemihypertrophy syndromes. Childs Nerv Syst 2015; 31:637-41. [PMID: 25686896 DOI: 10.1007/s00381-015-2642-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/03/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Beckwith-Wiedemann syndrome (BWS) is an unusual complex of abnormalities that includes mainly omphalocele, macroglossia, gigantism, visceromegaly, and neonatal hypoglycemia. Type I Chiari malformation, on the other hand, is defined as ectopia of the cerebellar tonsils below the plane of the foramen magnum. Only one case of association of BWS with Chiari I malformation has been previously reported in the literature. DISCUSSION Several conditions involving congenital hemihypertrophy have been previously reported in association with Type I Chiari malformation. The pathophysiological mechanism for most of these associations is thought to be quite complex and still remains unclear. However, the presence of tonsillar herniation in BWS has been explained by Tubbs and Oakes in the only one existing case report of BWS with Type I Chiari malformation in the literature, to be due to associated hemihypertrophy of the skull base. We additionally suggest that cerebellar hypertrophy may also contribute to the tonsillar herniation and fourth ventricular outlet obstruction. ILLUSTRATIVE CASE We now report our recent experience on this association following a review of the literature on association of other hemihypertrophy syndromes with the central nervous system anomalies. CONCLUSION We believe that a common pathogenesis of Type I Chiari malformation occurs in conditions of hemihypertrophy including BWS, probably secondary to dysmorphology involving the posterior cranial fossa, and is not just an associated finding.
Collapse
Affiliation(s)
- Suhas Udayakumaran
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, 682 041, India,
| | | |
Collapse
|
35
|
Abstract
OBJECTIVE To estimate the risk of athletes with Chiari malformations sustaining a catastrophic injury. DESIGN Retrospective, descriptive cohort study. PARTICIPANTS All patients diagnosed with Chiari malformation at our institution between June 2008 and November 2011. ASSESSMENT OF RISK FACTORS Participants were mailed a questionnaire regarding the number of seasons they participated in organized athletics. Magnetic resonance images were reviewed to describe the characteristics of respondent's Chiari malformations. MAIN OUTCOME MEASURES Whether or not the patient had sustained an injury resulting in death, coma, or paralysis. RESULTS We had a 53% (N = 147) response rate. Respondents were of a mean age of 15 years (SD, 2 years) at the time of diagnosis. The mean length of protrusion of the cerebellar tonsils below the foramen magnum was 11.2 mm (SD, 5.7 mm). Most of the respondents had pointed cerebellar tonsils and some degree of crowding within the foramen magnum. During a total of 1627 athletic seasons played by patients with Chiari malformation, 0 respondents [95% confidence interval (CI), 0.0000-0.0023] sustained an injury resulting in death, coma, or paralysis. Likewise, during 191 collision sport athletic seasons, 0 (95% CI, 0.0000-0.0191) respondents sustained an injury resulting in death, coma, or paralysis. CONCLUSIONS The risk of athletes with Chiari malformations suffering catastrophic injuries during sports participation is low. This estimate of risk should be considered when making return-to-play decisions. Given the variability of anatomical consideration for patients with Chiari malformations, however, each return-to-play decision must continue to be made on a case-by-case basis, considering all of the available information. CLINICAL RELEVANCE The low risk of athletes with Chiari malformations suffering catastrophic injuries in sports should be considered when making return-to-play decisions.
Collapse
|
36
|
Winston KR, Stence NV, Boylan AJ, Beauchamp KM. Upward Translation of Cerebellar Tonsils following Surgical Expansion of Supratentorial Cranial Vault: A Unified Biomechanical Explanation of Chiari Type I. Pediatr Neurosurg 2015; 50:243-9. [PMID: 26367858 DOI: 10.1159/000437146] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/23/2015] [Indexed: 11/19/2022]
Abstract
Cerebellar tonsils moved significantly upward in 3 patients with Chiari type I who underwent supratentorial cranial vault expansion to alleviate intracranial pressure related to multisutural craniosynostosis. The Chiari type I deformities in these patients were the biomechanical consequence of posterior fossa-cerebellar disproportion caused by supratentorial craniocerebral disproportion secondary to multisutural craniosynostosis. The authors postulate that all cases of Chiari type I deformity share the sine qua non feature of posterior fossa-cerebellar disproportion.
Collapse
|
37
|
Knickmeyer RC, Meltzer-Brody S, Woolson S, Hamer RM, Smith JK, Lury K, Gilmore JH. Rate of Chiari I malformation in children of mothers with depression with and without prenatal SSRI exposure. Neuropsychopharmacology 2014; 39:2611-21. [PMID: 24837031 PMCID: PMC4207341 DOI: 10.1038/npp.2014.114] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 04/16/2014] [Accepted: 04/24/2014] [Indexed: 02/04/2023]
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are frequently prescribed to pregnant women. Therefore, research on in utero exposure to SSRIs can be helpful in informing patients and clinicians. The aim of this retrospective two-cohort study was to determine whether there is a statistically significant increase in Chiari I malformations (CIM) in children exposed to SSRIs during pregnancy. A total of 33 children whose mothers received a diagnosis of depression and took SSRIs during pregnancy (SSRI-exposed cohort) were matched to 66 children with no history of maternal depression and no SSRI exposure. In addition, 30 children whose mothers received a diagnosis of depression, but did not receive antidepressants during pregnancy (history of maternal depression cohort), were matched to 60 children with no history of maternal depression and no SSRI exposure. Main outcome was presence/absence of CIM on MRI scans at 1 and/or 2 years of age. Scans were reviewed by two independent neuroradiologists who were blind to exposure status. The SSRI-exposed children were significantly more likely to be classified as CIM than comparison children with no history of maternal depression and no SSRI exposure (18% vs 2%, p=0.003, OR estimate 10.32, 95% Wald confidence limits 2.04-102.46). Duration of SSRI exposure, SSRI exposure at conception, and family history of depression increased the risk. The history of maternal depression cohort did not differ from comparison children with no history of maternal depression and no SSRI exposure in occurrence of CIM (7% vs 5%, p=0.75, OR estimate 1.44, 95% Wald confidence limits 0.23-7.85). Replication is needed, as is additional research to clarify whether SSRIs directly impact risk for CIM or whether this relationship is mediated by severity of depressive symptoms during pregnancy. We would discourage clinicians from altering their prescribing practices until such research is available.
Collapse
Affiliation(s)
- Rebecca C Knickmeyer
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samantha Meltzer-Brody
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sandra Woolson
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert M Hamer
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Keith Smith
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kenneth Lury
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - John H Gilmore
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
38
|
Eshetu T, Meoded A, Jallo GI, Carson BS, Huisman TA, Poretti A. Diffusion tensor imaging in pediatric Chiari type I malformation. Dev Med Child Neurol 2014; 56:742-8. [PMID: 24825432 DOI: 10.1111/dmcn.12494] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2014] [Indexed: 11/29/2022]
Abstract
AIM Chiari type I malformation (C1M) may be symptomatic or asymptomatic as an incidental finding. In this retrospective study, we applied diffusion tensor imaging (DTI) to study the brainstem and cerebellar white matter tracts in C1M. METHOD Diffusion tensor imaging (DTI) data were acquired on a 1.5T MR-scanner using balanced pairs of diffusion gradients along 20 non-collinear directions. Measurements from regions of interest in each pontine corticospinal tract, medial leminscus, and middle cerebellar peduncle (MCP) and in the lower brainstem were obtained for fractional anisotropy and mean, axial, and radial diffusivity. Values in symptomatic and asymptomatic children, and children with and without hydromyelia were compared using analysis of variance. RESULTS Fifteen children with C1M (10 males, five females; six symptomatic [four with hydromyelia] and nine asymptomatic) were included. Median age was 6 years 5 months (range 2y 10mo-15y 4mo). No significant differences in DTI scalars were found in the lower brainstem. In both MCPs, axial diffusivity values were lower in symptomatic than in asymptomatic children (p=0.049 and p=0.035 respectively) and higher in children with hydromyelia versus without hydromyelia (p=0.018 and p=0.006 respectively). In the left MCP, mean diffusivity values were lower in symptomatic than in asymptomatic children (p=0.047). INTERPRETATION Our results show that microstructural tissue alterations may be present in C1M. Additionally, our study suggests a specific role for the MCPs in C1M. Further large-scale studies are warranted.
Collapse
Affiliation(s)
- Tadesse Eshetu
- Division of Neuroradiology, The Russell H Morgan Department of Radiology and Radiological Science, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | | | | | | |
Collapse
|
39
|
Lee S, Wang KC, Cheon JE, Phi JH, Lee JY, Cho BK, Kim SK. Surgical outcome of Chiari I malformation in children: clinico-radiological factors and technical aspects. Childs Nerv Syst 2014; 30:613-23. [PMID: 24604349 DOI: 10.1007/s00381-013-2263-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The optimal treatment for Chiari I malformation in children is still under debate. The aim of this study was to evaluate the surgical outcome of the pediatric Chiari I malformation,focusing on clinico-radiological factors and technical aspects. METHODS Fifty-six patients with Chiari I malformation who received surgery at Seoul National University Children’s Hospital were included. The mean age was 7.9 years. The patients were divided into three groups: group I (n =8) with hydrocephalus, group II (n =11) without syrinx, and group III (n =37) with syrinx. Group I received shunting operation initially,and others received foramen magnum decompression (FMD). Group III was further subdivided: group IIIa (n =9), minimal intradural manipulation, and group IIIb (n =27), active intradural manipulation. The outcomes were compared between the groups. The mean follow-up period was 75.9 months. RESULTS In group I, symptoms were resolved or had improved in most patients, with only one patient received additional FMD. Symptoms resolved or improved in 10 (91 %) and 25 cases (84 %) in groups II and III, respectively. Syrinx was markedly decreased in 31 cases (86 %) in group III. FMD was less effective for scoliosis (improved or stabilized in 57 %).The persistence of syrinx was related with an aggravation of scoliosis. The outcomes between group IIIa and IIIb showed no significant difference. CONCLUSIONS In most pediatric Chiari I patients with hydrocephalus,a shunting operation was sufficient. FMD showed high efficacy in treating patients without hydrocephalus. The extent of the intradural procedure did not have a significant effect on the clinical outcome.
Collapse
|
40
|
Association between Noonan syndrome and Chiari I malformation: a case-based update. Childs Nerv Syst 2013; 29:749-52. [PMID: 23239255 DOI: 10.1007/s00381-012-2000-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 12/03/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Chiari I malformations (CM-I) have been associated with a variety of developmental abnormalities in the literature. A few cases of CM-I in patients with Noonan syndrome (NS) have been reported; however, opinion remains divided as to whether the observed association is coincidental. DISCUSSION Six previous cases of CM-I in patients with NS have been described in the literature. Many of these had other neurological abnormalities; however, neurological problems are not a prominent part of earlier descriptions of NS. A statistically significant association between NS and CM-I is difficult to obtain at present due to availability and logistical issues with scanning many asymptomatic patients. Although we believe a link exists between CM-I and NS, there is little understanding on how NS may cause CM-I. The most logical cause would be posterior fossa abnormality; however, the most common genetic mutation in NS tends to cause frontal and facial abnormalities, and the posterior fossa tends to be relatively spared. Other genetic mutations may also affect the posterior cranium and thus create the appropriate conditions for a CM-I to develop. ILLUSTRATIVE CASE We report a case of CM-I in a 9-year-old patient with Noonan syndrome, severe scoliosis and syringomyelia. CONCLUSION We believe that CM-I is a part of Noonan syndrome; however, statistical validation of this opinion is necessary.
Collapse
|