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Loftus JR, Wassef C, Ellika S. Chiari I Deformity: Beyond 5 mm below the Foramen Magnum. Radiographics 2024; 44:e230227. [PMID: 39115997 DOI: 10.1148/rg.230227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Although originally described as a consecutive series of pathologic changes, Chiari syndrome represents a spectrum of disease divided into two subsets: development deformities of the paraxial mesoderm manifesting after birth (types 0-1.5) and true congenital malformations due to failure of neural tube closure present in utero (types 2-5). Heterogeneity among patients with a Chiari deformity and incomplete understanding of its pathophysiologic characteristics have led to inconsistency in radiologic reporting and difficulty in defining appropriate management strategies tailored to an individual patient's condition. The radiologist is tasked with going beyond the criteria for cerebellar tonsillar herniation to define an individual patient's disease state, determine candidacy for surgery, and assist in selecting the proper surgical approach. In addition, the radiologist must be able to identify conditions that result in cerebellar tonsillar herniation that are not related to Chiari deformity to avoid inappropriate surgery. Last, the radiologist must be able to interpret postoperative imaging examinations to assess for adequacy of treatment and complications. The authors summarize recent literature regarding the pathophysiologic basis of Chiari 1 and related deformities and detail the ideal morphologic and physiologic imaging assessment, focusing on Chiari 1 and related deformities (Chiari 0, 0.5, and 1.5). Also discussed are surgical techniques and "pearls" of postsurgical imaging, including complications that must be recognized. This review provides clarity to a commonly encountered but less understood condition to optimize outcomes for patients with Chiari 1 and related deformities. ©RSNA, 2024 Supplemental material is available for this article. See the invited commentary by Huisman in this issue.
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Affiliation(s)
- James Ryan Loftus
- From the Department of Imaging Sciences, New York University Langone Health, 550 1st Ave, New York, NY 10016 (J.R.L.); and Departments of Neurosurgery (C.W.) and Imaging Sciences (S.E.), University of Rochester Medical Center, Rochester, NY
| | - Catherine Wassef
- From the Department of Imaging Sciences, New York University Langone Health, 550 1st Ave, New York, NY 10016 (J.R.L.); and Departments of Neurosurgery (C.W.) and Imaging Sciences (S.E.), University of Rochester Medical Center, Rochester, NY
| | - Shehanaz Ellika
- From the Department of Imaging Sciences, New York University Langone Health, 550 1st Ave, New York, NY 10016 (J.R.L.); and Departments of Neurosurgery (C.W.) and Imaging Sciences (S.E.), University of Rochester Medical Center, Rochester, NY
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Kirjavainen T, Miraftabi P, Martelius L, Karppinen A. Type one chiari malformation as a cause of central sleep apnea and hypoventilation in children. Sleep Med 2024; 116:32-40. [PMID: 38417306 DOI: 10.1016/j.sleep.2024.02.019] [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: 05/22/2023] [Revised: 12/31/2023] [Accepted: 02/07/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVES Chiari type 1 malformation (CM1) may occasionally lead to central sleep apnea (CSA). We studied, in a large clinical cohort of pediatric CM1 patients, the effect of CM1 on breathing during sleep. METHODS This is a retrospective single pediatric pulmonology center study with a systematic evaluation of pediatric CM1 patients under age 18 with polysomnography (PSG) during 2008-2020. Children with syndromes were excluded. All patients had undergone head and spine magnetic resonance imaging. RESULTS We included 104 children with CM1 with a median age of 7 (interquartile range (IQR) 5-13) years. The median extent of tonsillar descent (TD) was 13 (IQR 10-18) mm. Syringomyelia was present in 19 children (18%). Of all children, 53 (51%) had normal PSG, 35 (34%) showed periodic breathing or central apnea and hypopnea index ≥5 h-1, and 16 (15%) displayed features of compensated central hypoventilation and end-tidal or transcutaneous carbon dioxide 99th percentile level above 50 mmHg. TD had the best predictive value for central breathing disorders. In a linear model, both age (61%) and TD (39%) predicted median breathing frequency (R = 0.33, p < 0.001). CONCLUSIONS Although severe CSA is a rare complication of brainstem compression in pediatric patients with CM1, short arousal-triggered episodes of periodic breathing and mild compensated central hypoventilation are common. TD shows the best but still poor prediction of the presence of a central breathing disorder. This highlights the use of PSG in patient evaluation. Posterior fossa decompression surgery effectively treats central breathing disorders.
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Affiliation(s)
- Turkka Kirjavainen
- Department of Pediatrics, New Children's Hospital, Helsinki, Finland; Department of Clinical Neurophysiology and Neurological Sciences, New Children's Hospital, Helsinki, Finland.
| | - Päriä Miraftabi
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Martelius
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Atte Karppinen
- Department of Neurosurgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Finland
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Shekhawat D, Gupta T, Singh P, Sahni D, Tubbs RS, Gupta SK. Surgical anatomy of the cerebellar tonsils: A cadaveric study. Clin Anat 2024; 37:25-32. [PMID: 37248820 DOI: 10.1002/ca.24075] [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: 05/02/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Knowledge of the normal anatomy of the cerebellar tonsils is a prerequisite in various surgeries of the posterior cranial fossa Clinical conditions, as the Chiari I malformations (CIM) alter the normal position of the cerebellar tonsils. OBJECTIVE Therefore, we aim to better elucidate the surgical anatomy of and around the cerebellar tonsils in regard to the CIM. METHODS Fifty formalin-fixed adult cadavers injected with colored latex through vertebral arteries underwent craniotomy and durotomy to expose the cerebellar tonsils and related structures. The tonsils and their surrounding anatomy were then studied. RESULTS Forty cerebellar tonsils were at or above the foramen magnum. Five specimens presented with CIM with the tonsils below (3-5 mm) the FM with a mean tonsillar decent of 7.9 ± 2.3 mm. Of the cadavers without CIM, in forty-two cases, the thickness of the dura mater was within ±3SD ranges. In three cases, the dura mater was thinner at the CVJ and one case; the dura adhered tightly to the inner aspect of the occipital squama. In five CIM cadavers, the dura mater was markedly thicker at the CVJ. The PICA caudal loop was 5.9 ± 1.6 mm long. In CIM cases, the PICA loop was longer, nearer the dura, 1 mm below the superior border of the C1 posterior arch. The distances from the PICA loop were markedly reduced by 3 mm from the spinal accessory nerve and 2 mm from the first spinal nerve. The DN was significantly closer to the tonsillar peduncle in CIM cases. CONCLUSION These data are important for better understanding the intrinsic and extrinsic anatomy of the cerebellar tonsils in patients with and without CIM. Importantly, tonsillectomy/tonsillar coagulation must consider the close relationship of the dentate nucleus to the base of the cerebellar tonsil to avoid iatrogenic injury.
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Affiliation(s)
- Devendra Shekhawat
- Department of Anatomy, Post graduate Institute of Medical Education & Research, Chandigarh, India
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tulika Gupta
- Department of Anatomy, Post graduate Institute of Medical Education & Research, Chandigarh, India
| | - Paramajeet Singh
- Department of Radiodiagnosis, Post graduate Institute of Medical Education & Research, Chandigarh, India
| | - Daisy Sahni
- Department of Anatomy, Post graduate Institute of Medical Education & Research, Chandigarh, India
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA
- Brisbane Clinical Neuroscience Centre, University of Queensland, Brisbane, Australia
| | - S K Gupta
- Department of Neurosurgery, Post graduate Institute of Medical Education & Research, Chandigarh, India
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Bogdanov EI, Heiss JD. Evaluation and Treatment of Patients with Small Posterior Cranial Fossa and Chiari Malformation, Types 0 and 1. Adv Tech Stand Neurosurg 2024; 50:307-334. [PMID: 38592536 DOI: 10.1007/978-3-031-53578-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
The diagnosis of Chiari I malformation is straightforward in patients with typical signs and symptoms of Chiari I malformation and magnetic resonance imaging (MRI) confirming ≥5 mm of cerebellar tonsillar ectopia, with or without a syrinx. However, in many cases, Chiari I malformation is discovered incidentally on MRI to evaluate global headache, cervical radiculopathy, or other conditions. In those cases, the clinician must consider if cerebellar tonsillar ectopia is related to the presenting symptoms. Surgical decompression of the cerebellar tonsils and foramen magnum in patients with symptomatic Chiari I malformation effectively relieves suboccipital headache, reduces syrinx distension, and arrests syringomyelia progression. Neurosurgeons must avoid operative treatments decompressing incidental tonsillar ectopia, not causing symptoms. Such procedures unnecessarily place patients at risk of operative complications and tissue injuries related to surgical exploration. This chapter reviews the typical signs and symptoms of Chiari I malformation and its variant, Chiari 0 malformation, which has <5 mm of cerebellar tonsillar ectopia and is often associated with syringomyelia. Chiari I and Chiari 0 malformations are associated with incomplete occipital bone development, reduced volume and height of the posterior fossa, tonsillar ectopia, and compression of the neural elements and cerebrospinal fluid (CSF) pathways at the foramen magnum. Linear, angular, cross-sectional area, and volume measurements of the posterior fossa, craniocervical junction, and upper cervical spine identify morphometric abnormalities in Chiari I and Chiari 0 malformation patients. Chiari 0 patients respond like Chiari I patients to foramen magnum decompression and should not be excluded from surgical treatment because their tonsillar ectopia is <5 mm. The authors recommend the adoption of diagnostic criteria for Chiari 0 malformation without syringomyelia. This chapter provides updated information and guidance to the physicians managing Chiari I and Chiari 0 malformation patients and neuroscientists interested in Chiari malformations.
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Affiliation(s)
- Enver I Bogdanov
- Department of Neurology and Rehabilitation, Kazan State Medical University, Kazan, Russia
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - John D Heiss
- Department of Neurology and Rehabilitation, Kazan State Medical University, Kazan, Russia.
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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Chugh A, Punia P, Gotecha S, Gaud JA, Reddy R, Aziz RA. Immediate postoperative resolution of syrinx post-C1/C2 fixation in an operated case of foramen magnum decompression for Chiari malformation: Is Goel's procedure a rescue surgery or a gold standard? JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:105-109. [PMID: 38644925 PMCID: PMC11029114 DOI: 10.4103/jcvjs.jcvjs_182_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 04/23/2024] Open
Abstract
Chiari malformation (CM) is a common neurological disorder with foramen magnum decompression (FMD) as a commonly accepted treatment. The authors present a case of CM-1 wherein there was no radiological instability preoperatively and FMD was done as a treatment, after which the patient improved transiently only to deteriorate further. Atlantoaxial fixation was done as a second-stage procedure, after which the patient improved clinically and radiologically. The knowledge of this case and surgical entity should be borne in mind before the formulation of a treatment plan. It is important that the solution is to identify and treat the underlying pathology rather than to decompress and directly manipulate the tonsils.
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Affiliation(s)
- Ashish Chugh
- Department of Neurosurgery, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra, India
| | - Prashant Punia
- Department of Neurosurgery, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra, India
| | - Sarang Gotecha
- Department of Neurosurgery, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra, India
| | - Jayant Arun Gaud
- Department of Neurosurgery, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra, India
| | - Rajeev Reddy
- Department of Neurosurgery, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra, India
| | - Ramis Abdul Aziz
- Department of Neurosurgery, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra, India
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Hu Y, Zhang M, Duan C, Song D, Wei M, Guo F. A long-term follow-up study of adults with Chiari malformation type I combined with syringomyelia. Front Neurol 2023; 14:1274971. [PMID: 38107634 PMCID: PMC10722987 DOI: 10.3389/fneur.2023.1274971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023] Open
Abstract
Background There is a considerable amount of controversy regarding the treatment and prognosis of adult patients with Chiari malformation type I (CM-I) at home and abroad; furthermore, no large-sample, long-term, follow-up studies have examined CM-I patients with syringomyelia (SM) comparing posterior fossa decompression with resection of tonsils (PFDRT) vs. posterior fossa decompression with duraplasty (PFDD). Objective This study retrospectively analyzed the factors affecting the treatment and long-term prognosis of adults with CM-I combined with SM. Methods We retrospectively analyzed data from 158 adult CM-I patients combined with SM who underwent PFDRT or PFDD, including 68 patients in group PFDRT and 90 patients in group PFDD. We examined the clinical manifestations, imaging features, and follow-up data of patients. Clinical outcomes were assessed using the Chicago Chiari Outcomes Scale (CCOS), and radiographic outcomes were indicated by the syrinx remission rate. Multivariate logistic regression analysis and multiple linear regression analysis were used to explore the relevant factors affecting the long-term prognosis of patients. Results This study showed that compared with preoperative patients in the PFDRT group and PFDD group, the sensory impairment, cough-related headache, and movement disorder were significantly improved (p < 0.01); meanwhile, the diameter of the syrinx and the volume of the syrinx decreased significantly (p < 0.001). Additionally, the study found that there were significant differences in the syrinx remission rate (p = 0.032) and the clinical cure rates (p = 0.003) between the two groups. Multivariate logistic regression analysis showed that age (p = 0.021), cerebellar-related symptoms (p = 0.044), preoperative cisterna magna volume (p = 0.043), and peak systolic velocity (p = 0.036) were independent factors for clinical outcomes. Multiple linear regression analysis showed that different surgical procedures were positively correlated with the syrinx remission rate (p = 0.014), while preoperative syrinx diameter (p = 0.018) and age (p = 0.002) were negatively correlated with the syrinx remission rate. Conclusion In conclusion, this study suggested that, in a long-term follow-up, although both surgical procedures are effective in treating patients with CM-I and SM, PFDRT is better than PFDD; age and cerebellar-related signs independently affect the patient's prognosis. Additionally, an effective prognosis evaluation index can be developed for patients, which is based on imaging characteristics, such as preoperative cisterna magna volume, preoperative syrinx diameter, and preoperative cerebrospinal fluid (CSF) hydrodynamic parameters to guide clinical work.
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Affiliation(s)
- Yan Hu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Mingchu Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Chengcheng Duan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Dengpan Song
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Mingkun Wei
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
| | - Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- International Joint Laboratory of Nervous System Malformations of Henan Province, Zhengzhou, Henan, China
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Toader C, Ples H, Covache-Busuioc RA, Costin HP, Bratu BG, Dumitrascu DI, Glavan LA, Ciurea AV. Decoding Chiari Malformation and Syringomyelia: From Epidemiology and Genetics to Advanced Diagnosis and Management Strategies. Brain Sci 2023; 13:1658. [PMID: 38137106 PMCID: PMC10741770 DOI: 10.3390/brainsci13121658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023] Open
Abstract
Chiari Malformation and Syringomyelia are neurosurgical entities that have been the subject of extensive research and clinical interest. Globally prevalent, these disorders vary demographically and have witnessed evolving temporal trends. Chiari Malformation impacts the normal cerebrospinal fluid flow, consequently affecting overall health. Key observations from canine studies offer pivotal insights into the pathogenesis of Syringomyelia and its extrapolation to human manifestations. Genetics plays a pivotal role; contemporary knowledge identifies specific genes, illuminating avenues for future exploration. Clinically, these disorders present distinct phenotypes. Diagnostically, while traditional methods have stood the test of time, innovative neurophysiological techniques are revolutionizing early detection and management. Neuroradiology, a cornerstone in diagnosis, follows defined criteria. Advanced imaging techniques are amplifying diagnostic precision. In therapeutic realms, surgery remains primary. For Chiari 1 Malformation, surgical outcomes vary based on the presence of Syringomyelia. Isolated Syringomyelia demands a unique surgical approach, the effectiveness of which is continually being optimized. Post-operative long-term prognosis and quality of life measures are crucial in assessing intervention success. In conclusion, this review amalgamates existing knowledge, paving the way for future research and enhanced clinical strategies in the management of Chiari Malformation and Syringomyelia.
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Affiliation(s)
- Corneliu Toader
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania
| | - Horia Ples
- Department of Neurosurgery, Centre for Cognitive Research in Neuropsychiatric Pathology 6 (NeuroPsy-Cog), 300736 Timișoara, Romania
- Department of Neurosurgery, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Razvan-Adrian Covache-Busuioc
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Horia Petre Costin
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Bogdan-Gabriel Bratu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - David-Ioan Dumitrascu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Luca Andrei Glavan
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Alexandru Vlad Ciurea
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
- Neurosurgery Department, Sanador Clinical Hospital, 010991 Bucharest, Romania
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García M, Amayra I, Pérez M, Salgueiro M, Martínez O, López-Paz JF, Allen PA. Cognition in Chiari Malformation Type I: an Update of a Systematic Review. Neuropsychol Rev 2023:10.1007/s11065-023-09622-2. [PMID: 37798373 DOI: 10.1007/s11065-023-09622-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Abstract
Chiari malformation has been classified as a group of posterior cranial fossa disorders characterized by hindbrain herniation. Chiari malformation type I (CM-I) is the most common subtype, ranging from asymptomatic patients to those with severe disorders. Research about clinical manifestations or medical treatments is still growing, but cognitive functioning has been less explored. The aim of this systematic review is to update the literature search about cognitive deficits in CM-I patients. A literature search was performed through the following electronic databases: MEDLINE, PsychINFO, Pubmed, Cochrane Library, Scopus, and Web of Science. The date last searched was February 1, 2023. The inclusion criteria were as follows: (a) include pediatric or adult participants with a CM-I diagnosis, (b) include cognitive or neuropsychological assessment with standardized tests, (c) be published in English or Spanish, and (d) be empirical studies. Articles that did not report empirical data, textbooks and conference abstracts were excluded. After the screening, twenty-eight articles were included in this systematic review. From those, twenty-one articles were focused on adult samples and seven included pediatric patients. There is a great heterogeneity in the recruited samples, followed methodology and administered neurocognitive protocols. Cognitive functioning appears to be affected in CM-I patients, at least some aspects of attention, executive functions, visuospatial abilities, episodic memory, or processing speed. However, these results require careful interpretation due to the methodological limitations of the studies. Although it is difficult to draw a clear profile of cognitive deficits related to CM-I, the literature suggests that cognitive dysfunction may be a symptom of CM-I. This suggest that clinicians should include cognitive assessment in their diagnostic procedures used for CM-I. In summary, further research is needed to determine a well-defined cognitive profile related to CM-I, favoring a multidisciplinary approach of this disorder.
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Affiliation(s)
- Maitane García
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain.
| | - Imanol Amayra
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain
| | - Manuel Pérez
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain
- Faculty of Health Sciences, Isabel I University, Burgos, Spain
| | - Monika Salgueiro
- Department of Clinical and Health Psychology, and Research Methodology, Faculty of Psychology, University of the Basque Country, Donostia, Spain
| | - Oscar Martínez
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain
| | - Juan Francisco López-Paz
- Department of Psychology, Faculty of Health Sciences, Neuro-E-Motion Research Team, University of Deusto, Bilbao, Spain
| | - Philip A Allen
- Conquer Chiari Research Center, Department of Psychology, University of Akron, Akron, OH, USA
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Tokar DM, Kaut KP, Allen PA. Revisiting the factor structure of the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2): Evidence for a bifactor model in individuals with Chiari malformation. PLoS One 2023; 18:e0287208. [PMID: 37797067 PMCID: PMC10553824 DOI: 10.1371/journal.pone.0287208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 06/01/2023] [Indexed: 10/07/2023] Open
Abstract
The Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2; Dworkin et al., 2009) is intended to measure the multidimensional qualities of pain (i.e., continuous, intermittent, neuropathic, and affective) as well as total pain. Using structural equation modeling, we evaluated the fit of four competing measurement models of the SF-MPQ-2-an oblique 4-factor model, a 1-factor model, a higher-order model, and a bifactor model-in 552 adults diagnosed with Chiari malformation, a chronic health condition whose primary symptoms include head and neck pain. Results revealed the strongest support for the bifactor model, suggesting that SF-MPQ-2 item responses are due to both a general pain factor and a specific pain factor that is orthogonal to the general pain factor. Additional bifactor analyses of the SF-MPQ-2's model-based reliability and dimensionality revealed that most of the SF-MPQ-2's reliable variance is explained by a general pain factor, and that the instrument can be modeled unidimensionally and scored as a general pain measure. Results also indicated that the general and affective pain factors in the bifactor model uniquely predicted pain-related external criteria (e.g., depression, anxiety, and stress); however, the continuous, intermittent, and neuropathic factors did not.
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Affiliation(s)
- David M. Tokar
- Department of Social and Behavioral Sciences, Central State University, Wilberforce, OH, United States of America
| | - Kevin P. Kaut
- Department of Psychology, University of Akron, Akron, OH, United States of America
| | - Philip A. Allen
- Department of Psychology, University of Akron, Akron, OH, United States of America
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10
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Wieland CM, Holste KG, Selzer B, Garton HJL, Muraszko KM, Maher CO. Sports Participation and Neurological Injuries in Pediatric Patients With Chiari I Malformation. Neurosurgery 2023; 93:646-653. [PMID: 36961215 DOI: 10.1227/neu.0000000000002468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/30/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Currently, there is no consensus recommendation regarding the safety of sports participation for pediatric patients with Chiari I malformation (CM-I). OBJECTIVE To prospectively survey the treated and untreated patients with CM-I to define the risk of sports-associated neurological injury. METHODS A prospective survey was administered to 744 pediatric patients at one neurosurgery clinic between 2010 and 2021. Data were recorded on demographic information, imaging characteristics, treatment, sports participation, and presence of sports-related neurological injury. Patients with incomplete data were called. Two hundred seven patients completed at least 1 subsequent survey and were prospectively followed (mean 1.6 years). RESULTS Of 744 patients with completed surveys, 462 participated in sports. Sports participants were more likely to be older at presentation ( P < .001) and have rounded cerebellar tonsil morphology ( P < .001). Seasons of sports played before and after CM-I decompression (CMD) totaled 5918.7 and 936, respectively. There were 84 sports-related concussions among 55 patients; 79 in untreated patients and 5 after CMD. For all sports participants, the concussion rate was 12.3/1000 seasons of all sports, 9.2/1000 seasons of limited-contact sports, and 13.8/1000 of contact sports. The concussion rate after CMD was 5.3/1000 seasons of all sports, 9.2/1000 seasons of limited-contact sports, and 7.1/1000 seasons of contact sports. There were no reports of long-lasting neurological issues postconcussion or of permanent spinal cord injury. CONCLUSION No permanent or catastrophic sports-associated neurological injuries were reported. The concussion rates in treated and untreated patients with CM-I were low. Therefore, sports participation in this population should be permitted in most cases.
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Affiliation(s)
- Clare M Wieland
- School of Medicine, University of Michigan, Ann Arbor , Michigan , USA
| | - Katherine G Holste
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Bela Selzer
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Karin M Muraszko
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor , Michigan , USA
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11
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Zhang M, Hu Y, Song D, Duan C, Wei M, Zhang L, Lei S, Guo F. Exploring the prognostic differences in patients of Chiari malformation type I with syringomyelia undergoing different surgical methods. Front Neurol 2023; 13:1062239. [PMID: 36686516 PMCID: PMC9846178 DOI: 10.3389/fneur.2022.1062239] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/12/2022] [Indexed: 01/05/2023] Open
Abstract
Background The best surgical treatment of Chiari malformation patients with syringomyelia remains controversial, and whether cerebellar tonsillectomy should be performed has not been decided. Objective To evaluate the efficacy of posterior fossa decompression with duraplasty (PFDD) and Posterior fossa decompression with resection of tonsils (PFDRT) in patients of Chiari malformation type I (CM-I) with syringomyelia and explore relevant factors affecting prognosis. Patients and methods We retrospectively analyzed 182 adult patients of CM-I with syringomyelia who underwent PFDD or PFDRT over a 6-year period, and analyzed their clinical manifestations, imaging features, and follow-up data. Clinical outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS), and imaging outcomes were assessed using the syrinx remission rate. Difference comparisons were performed to compare the differences between different surgical groups. Influencing factors associated with outcome were investigated using bivariate analysis and multiple linear regression analysis. Results There were statistically significant differences in CCOS score (p = 0.034) and syrinx remission rates (p = 0.046) between the PFDRT group and the PFDD group after surgery. Regression analysis showed that preoperative motor dysfunction, cerebellar-related symptoms and different surgical methods may have influenced the CCOS score and that brainstem-related symptoms and age may have influenced the syrinx remission rates in the total patient group (p < 0.05). Regression analysis showed that the duration of symptoms, cerebellar-related symptoms and preoperative syrinx diameter may have influenced the CCOS score and that the preoperative cerebellar tonsillar hernia distance may have influenced the postoperative syrinx remission rate in the PFDRT group (p < 0.05). Age and length of hospital stay may have influenced the CCOS score, and brainstem-related symptoms and age may have influenced the syrinx remission rates in the PFDD group (p < 0.05). Conclusion This study showed that the CCOS score in the PFDRT group was better than that in the PFDD group. Preoperative motor dysfunction, cerebellar-related symptoms, and different surgical methods in patients of CM-I with syringomyelia affected postoperative CCOS score. Both the duration of symptoms and the age of the patients should be actively considered as factors influencing prognosis. Symptomatic CM-I patients with syringomyelia should undergo surgical treatment as early as possible.
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Affiliation(s)
- Mingchu Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Yan Hu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Dengpan Song
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Chengcheng Duan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Mingkun Wei
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Longxiao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Shixiong Lei
- Department of Neurosurgery, Beijing Hospital, Beijing, China
| | - Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China,*Correspondence: Fuyou Guo ✉
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12
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Zisakis A, Sun R, Pepper J, Tsermoulas G. Chiari Malformation Type 1 in Adults. Adv Tech Stand Neurosurg 2023; 46:149-173. [PMID: 37318574 DOI: 10.1007/978-3-031-28202-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The term Chiari malformation refers to a heterogeneous group of anatomical abnormalities at the craniovertebral junction. Chiari malformation type 1 (CM1) refers to the abnormal protrusion of cerebellar tonsils through the foramen magnum and is by far the commonest type. Its prevalence is estimated approximately 1%; it is more common in women and is associated with syringomyelia in 25-70% of cases. The prevalent pathophysiological theory proposes a morphological mismatch between a small posterior cranial fossa and a normally developed hindbrain that results in ectopia of the tonsils.In most people, CM1 is asymptomatic and diagnosed incidentally. In symptomatic cases, headache is the cardinal symptom. The typical headache is induced by Valsalva-like maneuvers. Many of the other symptoms are nonspecific, and in the absence of syringomyelia, the natural history is benign. Syringomyelia manifests with spinal cord dysfunction of varying severity. The approach to patients with CM1 should be multidisciplinary, and the first step in the management is phenotyping the symptoms, because they may be due to other pathologies, like a primary headache syndrome. Magnetic resonance imaging, which shows cerebellar tonsillar decent 5 mm or more below the foramen magnum, is the gold standard investigative modality. The diagnostic workup may include dynamic imaging of the craniocervical junction and intracranial pressure monitoring.The management of CM1 is variable and sometimes controversial. Surgery is usually reserved for patients with disabling headaches or neurological deficits from the syrinx. Surgical decompression of the craniocervical junction is the most widely used procedure. Several surgical techniques have been proposed, but there is no consensus on the best treatment strategy, mainly due to lack of high-quality evidence. The management of the condition during pregnancy, restriction to lifestyle related to athletic activities, and the coexistence of hypermobility require special considerations.
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Affiliation(s)
- Athanasios Zisakis
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Rosa Sun
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Joshua Pepper
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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13
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The Small Posterior Cranial Fossa Syndrome and Chiari Malformation Type 0. J Clin Med 2022; 11:jcm11185472. [PMID: 36143119 PMCID: PMC9503629 DOI: 10.3390/jcm11185472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Patients showing typical Chiari malformation type 1 (CM1) signs and symptoms frequently undergo cranial and cervical MRI. In some patients, MRI documents >5 mm of cerebellar tonsillar herniation (TH) and the diagnosis of CM1. Patients with 3−5 mm TH have “borderline” CM1. Patients with less than 3 mm of TH and an associated cervical syrinx are diagnosed with Chiari “zero” malformation (CM0). However, patients reporting CM1 symptoms are usually not diagnosed with CM if MRI shows less than 3−5 mm of TH and no syrinx. Recent MRI morphometric analysis of the posterior fossa and upper cervical spine detected anatomical abnormalities in and around the foramen magnum (FM) that explain these patients’ symptoms. The abnormalities include a reduced size of the posterior fossa, FM, and upper cervical spinal canal and extension of the cerebellar tonsils around the medulla rather than inferior to the foramen magnum, as in CM1. These morphometric findings lead some neurologists and neurosurgeons to diagnose CM0 in patients with typical CM1 signs and symptoms, with or without cervical syringes. This article reviews recent findings and controversies about CM0 diagnosis and updates current thinking about the clinical and radiological relationship between CM0, borderline CM1, and CM1.
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14
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Mazerand E, Benichi S, Taverne M, Paternoster G, Rolland A, Antherieu P, Todeschi J, Kamdem Noumoye L, Gilard V, Bretonnier M, Fournier LL, Jecko V, Gimbert E, Proust F, Boetto S, Roujeau T, James S, Khonsari RH, Riffaud L, Delion M, Zerah M, Scavarda D. Chiari malformation type I surgery in children: French multicenter 10-year cohort. J Neurosurg Pediatr 2022; 30:210-216. [PMID: 35916100 DOI: 10.3171/2022.4.peds21410] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 04/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chiari malformation type I (CM-I) is frequent in children and remains a surgical challenge. Several techniques have been described for posterior fossa decompression. No decision algorithm has been validated, and strategies are highly variable between institutions. The goal of this study was to define therapeutic guidelines that take into consideration patient specificities. METHODS The authors retrospectively collected data from patients who were < 18 years of age, were diagnosed with CM-I, and were treated surgically between 2008 and 2018 in 8 French pediatric neurosurgical centers. Data on clinical features, morphological parameters, and surgical techniques were collected. Clinical outcomes at 3 and 12 months after surgery were assessed by the Chicago Chiari Outcome Scale. The authors used a hierarchical clustering method to define clusters of patients by considering their anatomical similarities, and then compared outcomes between surgical strategies in each of these clusters. RESULTS Data from 255 patients were collected. The mean age at surgery was 9.6 ± 5.0 years, syringomyelia was reported in 60.2% of patients, the dura mater was opened in 65.0% of patients, and 17.3% of patients underwent a redo surgery for additional treatment. The mean Chicago Chiari Outcome Scale score was 14.4 ± 1.5 at 3 months (n = 211) and 14.6 ± 1.9 at 12 months (n = 157). The hierarchical clustering method identified three subgroups with potentially distinct mechanisms underlying tonsillar herniation: bony compression, basilar invagination, and foramen magnum obstruction. Each cluster matched with specific outcomes. CONCLUSIONS This French multicenter retrospective cohort study enabled the identification of three subgroups among pediatric patients who underwent surgery for CM-I, each of which was associated with specific outcomes. This morphological classification of patients might help in understanding the underlying mechanisms and providing personalized treatment.
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Affiliation(s)
| | - Sandro Benichi
- 2Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris
| | - Maxime Taverne
- 3Craniofacial Growth and Form, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris
| | - Giovanna Paternoster
- 2Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris.,12Department of Pediatric Neurosurgery, CHU Timone Enfant, Marseille, France
| | - Alice Rolland
- 4Department of Pediatric Neurosurgery, Montpellier University Hospital, Montpellier
| | - Pierre Antherieu
- 5Department of Neurosurgery, Toulouse University Hospital, Toulouse
| | - Julien Todeschi
- 6Department of Neurosurgery, Strasbourg University Hospital, Strasbourg
| | | | - Vianney Gilard
- 8Department of Neurosurgery, Rouen University Hospital, Rouen
| | | | - Luc Le Fournier
- 1Department of Neurosurgery, Angers University Hospital, Angers
| | - Vincent Jecko
- 7Department of Pediatric Neurosurgery, Bordeaux University Hospital, Bordeaux
| | - Edouard Gimbert
- 7Department of Pediatric Neurosurgery, Bordeaux University Hospital, Bordeaux
| | - François Proust
- 6Department of Neurosurgery, Strasbourg University Hospital, Strasbourg
| | - Sergio Boetto
- 5Department of Neurosurgery, Toulouse University Hospital, Toulouse
| | - Thomas Roujeau
- 4Department of Pediatric Neurosurgery, Montpellier University Hospital, Montpellier
| | - Syril James
- 2Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris.,10Department of Neurosurgery, French Reference Center for Chiari and Rare Vertebral and Medullary Malformations (C-MAVEM), Montpellier University Hospital, Montpellier
| | - Roman H Khonsari
- 3Craniofacial Growth and Form, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris.,11Department of Pediatric Maxillofacial and Plastic Surgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris; and
| | - Laurent Riffaud
- 9Department of Neurosurgery, Rennes University Hospital, Rennes
| | - Matthieu Delion
- 1Department of Neurosurgery, Angers University Hospital, Angers
| | - Michel Zerah
- 2Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris.,10Department of Neurosurgery, French Reference Center for Chiari and Rare Vertebral and Medullary Malformations (C-MAVEM), Montpellier University Hospital, Montpellier
| | - Didier Scavarda
- 12Department of Pediatric Neurosurgery, CHU Timone Enfant, Marseille, France
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15
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Yilmaz TF, Toprak H, Sari L, Oz II, Kitis S, Kaya A, Alkan A. Chiari Type 1 malformation: CSF flow dynamics and morphology in the posterior fossa and craniocervical junction and correlation of these findings with syrinx formation. Neurochirurgie 2022; 68:595-600. [PMID: 35752467 DOI: 10.1016/j.neuchi.2022.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Chiari type 1 malformation (CMI) is a disorder in which cerebellar tonsils descend below the foramen magnum. Although syringomyelia associated with CMI thought to be caused by hypoplastic posterior fossa and stenosis at the craniocervical junction; it has characteristic neurological and radiological features and the exact mechanism of syringomyelia remains unknown. PURPOSE The purposes of this study were to gain insight into morphological changes in posterior fossa and to find whether there is a difference in aqueductal stroke volume (ASV) between CMI with syrinx and without syrinx which may be an underlying mechanism of syrinx development. MATERIALS AND METHODS We consecutively evaluated 85 patients with Chiari malformation between January 2017 and December 2019 who had undergone phase-contrast MRI examination for CSF flow and between 18-60-years-old. We divided patients into two groups as subjects with syrinx (n=19) and without syrinx (n=66). After evaluating morphological changes, peak and average velocity (cm/s), forward and reverse flow volume (μl), net forward flow volume (μl), ASV (aqueductal stroke volume) (μl), aqueductus Sylvi (AS) area (mm2), and prepontine cistern diameter to AS diameter ratio (PPC/AS) were calculated. Distribution of variables from two groups was evaluated by using Shapiro-Wilk normality test. Independent t test was used for groups comparison. RESULTS The forward and reverse volumes were statistically significantly higher in patients with syrinx (P=0.021, P=0.005 respectively). ASV was significantly increased in patients with syringomyelia (P=0.014). The PPC/AS was significantly lower in patients with syrinx compared to those without (P <0.001). AS area was significantly larger in those with syrinx. (P=0.022). The diameter of foramen magnum was significantly lower in patients with syrinx than those without (P <0.0001). The diameter of the herniated tonsilla at the foramen magnum level was found to be significantly lower in those with syrinx (P=0.011). CONCLUSION Foramen magnum diameter, ASV, diameter of herniated tonsil, and PPC/AS ratio are important factors in syrinx development.
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Affiliation(s)
- T F Yilmaz
- Departments of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - H Toprak
- Departments of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - L Sari
- Departments of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey.
| | - I I Oz
- Departments of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - S Kitis
- Department of Neurosurgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - A Kaya
- Departments of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - A Alkan
- Departments of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
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Labuda R, Nwotchouang BST, Ibrahimy A, Allen PA, Oshinski JN, Klinge P, Loth F. A new hypothesis for the pathophysiology of symptomatic adult Chiari malformation Type I. Med Hypotheses 2022; 158. [PMID: 34992329 PMCID: PMC8730378 DOI: 10.1016/j.mehy.2021.110740] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chiari malformation Type I (CMI) is characterized by herniation of the cerebellar tonsils through the foramen magnum. The pathophysiology of CMI is not well elucidated; however, the prevailing theory focuses on the underdevelopment of the posterior cranial fossa which results in tonsillar herniation. Symptoms are believed to be due to the herniation causing resistance to the natural flow of cerebrospinal fluid (CSF) and exerting a mass effect on nearby neural tissue. However, asymptomatic cases vastly outnumber symptomatic ones and it is not known why some people become symptomatic. Recently, it has been proposed that CMI symptoms are primarily due to instability of either the atlanto-axial (AA) or the atlanto-occipital (AO) joint and the cerebellar tonsils herniate to prevent mechanical pinching. However, only a small percentage of patients exhibit clinical instability and these theories do not account for asymptomatic herniations. We propose that the pathophysiology of adult CMI involves a combination of craniocervical abnormalities which leads to tonsillar herniation and reduced compliance of the cervical spinal canal. Specifically, abnormal AO and/or AA joint morphology leads to chronic cervical instability, often subclinical, in a large portion of CMI patients. This in turn causes overwork of the suboccipital muscles as they try to compensate for the instability. Over time, the repeated, involuntary activation of these muscles leads to mechanical overload of the myodural bridge complex, altering the mechanical properties of the dura it merges with. As a result, the dura becomes stiffer, reducing the overall compliance of the cervical region. This lower compliance, combined with CSF resistance at the same level, leads to intracranial pressure peaks during the cardiac cycle (pulse pressure) that are amplified during activities such as coughing, sneezing, and physical exertion. This increase in pulse pressure reduces the compliance of the cervical subarachnoid space which increases the CSF wave speed in the spinal canal, and further increases pulse pressure in a feedback loop. Finally, the abnormal pressure environment induces greater neural tissue motion and strain, causing microstructural damage to the cerebellum, brainstem, and cervical spinal cord, and leading to symptoms. This hypothesis explains how the combination of craniocervical bony abnormalities, anatomic CSF restriction, and reduced compliance leads to symptoms in adult CMI.
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Affiliation(s)
- Rick Labuda
- Conquer Chiari, 320 Osprey Ct., Wexford, PA 15090, United States
| | - Blaise Simplice Talla Nwotchouang
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, 264 Wolf Ledges Pkwy Rm 211b, Akron, OH 44325, United States
| | - Alaaddin Ibrahimy
- Department of Biomedical Engineering, Yale University, 17 Hillhouse Avenue, New Haven, CT 06520, United States
| | - Philip A Allen
- Conquer Chiari Research Center, Department of Psychology, The University of Akron, 302 Buchtel Hall, Akron, OH 44325, United States
| | - John N Oshinski
- Department of Radiology & Imaging Sciences, Emory University School of Medcinece, Atlanta, GA 30322, United States
| | - Petra Klinge
- The Warren Alpert Medical School of Brown University, United States
| | - Francis Loth
- Department of Mechanical & Industrial Engineering, Department of Bioengineering, Northeastern University, 334 Snell Engineering, 360 Huntington Ave, Boston, MA 02115, United States
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Influence of Pain on Cognitive Dysfunction and Emotion Dysregulation in Chiari Malformation Type I. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1378:155-178. [DOI: 10.1007/978-3-030-99550-8_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bogdanov E. Dislocations of the cerebellar tonsils in the large occipital foramen and the spectrum of Chiari malformations Type 1. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:7-15. [DOI: 10.17116/jnevro20221220417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tam SKP, Chia J, Brodbelt A, Foroughi M. Assessment of patients with a Chiari malformation type I. BRAIN AND SPINE 2022; 2:100850. [PMID: 36248113 PMCID: PMC9560699 DOI: 10.1016/j.bas.2021.100850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 11/30/2022]
Abstract
Introduction The prevalence of Chiari malformation type I (CM-I) has been estimated as up to 1% of the general population. The majority of patients are asymptomatic and usually do not need treatment. Symptomatic patients, and some asymptomatic patients with associated conditions, may benefit from further assessment and treatment. Research question The aim of this review was to describe the clinical and radiological assessment of patients presenting with a CM-I. Material and methods A literature search was performed using the PubMed and Embase databases focused on clinical assessment and imaging techniques used to diagnose CM-I. Results Following a complete clinical evaluation in patients with symptomatic CM-I and/or radiologically significant CM-I (tonsillar impaction, resulting tonsillar asymmetry and loss of CSF spaces), MRI of the brain and whole spine enables an assessment of the CM-I and potential associated or causative conditions. These include hydrocephalus, syringomyelia, spinal dysraphism, and tethered cord. Flow and Cine MRI can provide information on CSF dynamics at the craniocervical junction, and help in surgical decision-making. Hypermobility or instability at the upper cervical and craniocervical junction is less common and can be measured with CT imaging and flexion/extension or upright MRI. Discussion and conclusion The majority of CM-I detected are incidental findings on MRI imaging of brain or spine, and do not require intervention. Once a radiological diagnosis and concern has been raised, clinical assessment by an appropriate specialist is required. A MRI brain and cervical spine is indicated in all radiologically labelled CM-I. In symptomatic patients or cases of radiologically significant CM-I, MRI of the brain and entire spine is indicated. Further investigations should be tailored to individuals’ needs. A CM-I assessment should include a history and examination and a referral to a specialist. MRI of the brain and spine enables an assessment of the CM-I and potential associated conditions. Flow and Cine MRI can help in surgical decision-making.
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Affiliation(s)
- Sharon Ka Po Tam
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
- Corresponding author.
| | - Jonathan Chia
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
| | | | - Mansoor Foroughi
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
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20
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Bogdanov EI. [Clinical significance of subthreshold cerebellar tonsil ectopia into foramen magnum and Chiari malformation type 0]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:92-98. [PMID: 35758084 DOI: 10.17116/neiro20228603192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Cerebellar tonsil dislocation into foramen magnum exceeding 5 mm is traditionally considered as Chiari malformation type 1. This disease requires surgical treatment in case of severe clinical manifestations. In patients with hypoplasia of posterior cranial fossa (PCF), subthreshold tonsil dislocations or tonsil position inside the foramen magnum can result clinical signs identical to Chiari malformation type 1. These disorders are presumably referred to phenotypic variant of Chiari malformation type 1 (Chiari malformation type 0). The authors discuss the data on the prevalence and mechanisms of cerebellar tonsil ectopia into foramen magnum, the role of hereditary and environmental factors in development of PCF hypoplasia and its role in Chiari malformation type 1 and 0. Significance of MR-based morphometry of PCF in identifying the primary forms (Chiari malformation type 1 and 0), clinical and radiological signs of malformation type 0, as well as data on surgical treatment of Chiari malformation type 0 combined and non-combined with syringomyelia are analyzed. Literature data confirm validity of the concept of Chiari malformation type 0. We emphasize the need for further analysis of this problem to identify sensitive and specific diagnostic signs of Chiari malformation type 0 and determine optimal treatment strategy.
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Chotai S, Nadel JL, Holste KG, Mossner JM, Smith BW, Kapurch JR, Muraszko KM, Garton HJL, Maher CO, Strahle JM. Longitudinal scoliosis behavior in Chiari malformation with and without syringomyelia. J Neurosurg Pediatr 2021; 28:585-591. [PMID: 34479199 DOI: 10.3171/2021.5.peds20915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 05/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to understand the natural history of scoliosis in patients with Chiari malformation type I (CM-I) with and without syringomyelia. METHODS A retrospective review of data was conducted. Patients with CM-I were identified from a cohort of 14,118 individuals age 18 years or younger who had undergone MRI over an 11-year period at the University of Michigan. Patients eligible for study inclusion had a coronal curve ≥ 10° on radiography, associated CM-I with or without syringomyelia, and at least 1 year of clinical follow-up prior to any surgery. Curve magnitude at initial diagnosis, prior to posterior fossa decompression (PFD; if applicable), and at the last follow-up (prior to any surgical correction of scoliosis) was recorded, and clinical and radiographic characteristics were noted. The change in curve magnitude by 10° was defined as curve progression (increase by 10°) or regression (decrease by 10°). RESULTS Forty-three patients met the study inclusion criteria and were analyzed. About one-third (35%) of the patients presented with symptoms attributed to their CM-I. The mean degree of scoliosis at presentation was 32.6° ± 17.7°. Twenty-one patients (49%) had an associated syrinx. The mean tonsil position below the level of the foramen magnum was 9.8 ± 5.8 mm. Patients with a syrinx were more likely to have a curve > 20° (86% vs 41%, p = 0.002). Curve magnitude remained stable (≤ ±10°) in 77% of patients (33/43), progressed in 16% (7/43), and regressed in 7% (3/43). Mean age was higher (14.8 ± 0.59 years) among patients with regressed curves (p = 0.026). All regressed curves initially measured ≤ 20° (mean 14° ± 5.3°), and none of the patients with regressed curves had a syrinx. The change in curve magnitude was statistically similar in patients with (7.32° ± 17.7°) and without (5.32° ± 15.8°) a syrinx (p = 0.67). After a mean follow-up of 3.13 ± 2.04 years prior to surgery, 27 patients (63%) ultimately underwent posterior fossa or scoliosis correction surgery. For those who eventually underwent PFD only, the rate of change in curve magnitude prior to surgery was 0.054° ± 0.79°. The rate of change in curve magnitude was statistically similar before (0.054° ± 0.79°) and after (0.042° ± 0.33°) surgery (p = 0.45) for patients who underwent PFD surgery only. CONCLUSIONS The natural history of scoliosis in the presence of CM-I is variable, though most curves remained stable. All curves that regressed were ≤ 20° at initial diagnosis, and most patients in such cases were older at scoliosis diagnosis. Patients who underwent no surgery or PFD only had similar profiles for the change in curve magnitude, which remained relatively stable overall, as compared to patients who underwent PFD and subsequent fusion, who demonstrated curve progression. Among the patients with a syrinx, no curves regressed, most remained stable, and some progressed. Understanding this variability is a first step toward building a prediction model for outcomes for these patients.
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Affiliation(s)
- Silky Chotai
- 1Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey L Nadel
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Katherine G Holste
- 3Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - James M Mossner
- 3Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Brandon W Smith
- 3Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Joseph R Kapurch
- 4Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; and
| | - Karin M Muraszko
- 3Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Hugh J L Garton
- 3Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cormac O Maher
- 3Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Bogdanov EI, Faizutdinova AT, Heiss JD. Posterior cranial fossa and cervical spine morphometric abnormalities in symptomatic Chiari type 0 and Chiari type 1 malformation patients with and without syringomyelia. Acta Neurochir (Wien) 2021; 163:3051-3064. [PMID: 34448046 DOI: 10.1007/s00701-021-04941-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND To better understand how anatomical features of Chiari malformation type 0 (CM0) result in the manifestation of Chiari malformation type 1 (CM1) signs and symptoms, we conducted a morphometric study of the posterior cranial fossa (PCF) and cervical canal in patients with CM1 and CM0. METHODS This retrospective study had a STROBE design and included 120 adult patients with MRI evidence of a small PCF (SPCF), typical clinical symptoms of CM1, and a diagnosis of CM1, CM0, or SPCF-TH0-only (SPCF with cerebellar ectopia less than 2 mm and without syringomyelia). Patients were divided by MRI findings into 4 groups: SPCF-TH0-only, SPCF-TH0-syr (CM0 with SPCF and syringomyelia), SPCF-CM1-only (SPCF with cerebellar ectopia 5 mm or more without syringomyelia), and SPCF-CM1-syr (CM1 with syringomyelia). Neurological examination data and MRI parameters were analyzed. RESULTS All patient cohorts had morphometric evidence of a small, flattened, and overcrowded PCF. The PCF phenotype of the SPCF-TH0-only group differed from that of other CM cohorts in that the length of clivus and supraocciput and the height of the PF were longer, the upper CSF spaces of PCF were taller, and the area of the foramen magnum was smaller. The SPCF-TH0 groups had a more significant narrowing of the superior cervical canal and a smaller decrease in PCF height than the SPCF-CM1 groups. CONCLUSIONS Patients with SPCF-TH0 with and without syringomyelia developed Chiari 1 symptoms and signs. Patients with SPCF-TH0-syr (Chiari 0) had more constriction of their CSF pathways in and around the foramen magnum than patients with SPCF-TH0-only.
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23
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Houk JL, Amrhein TJ, Gray L, Malinzak MD, Kranz PG. Differentiation of Chiari malformation type 1 and spontaneous intracranial hypotension using objective measurements of midbrain sagging. J Neurosurg 2021:1-8. [PMID: 34715671 DOI: 10.3171/2021.6.jns211010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chiari malformation type 1 (CM-1) and spontaneous intracranial hypotension (SIH) are causes of headache in which cerebellar tonsillar ectopia (TE) may be present. An accurate method for differentiating these conditions on imaging is needed to avoid diagnostic confusion. Here, the authors sought to determine whether objective measurements of midbrain morphology could distinguish CM-1 from SIH on brain MRI. METHODS This is a retrospective case-control series comparing neuroimaging in consecutive adult subjects with CM-1 and SIH. Measurements obtained from brain MRI included previously reported measures of brain sagging: TE, slope of the third ventricular floor (3VF), pontomesencephalic angle (PMA), mamillopontine distance, lateral ventricular angle, internal cerebral vein-vein of Galen angle, and displacement of iter (DOI). Clivus length (CL), an indicator of posterior fossa size, was also measured. Measurements for the CM-1 group were compared to those for the entire SIH population (SIHall) as well as a subgroup of SIH patients with > 5 mm of TE (SIHTE subgroup). RESULTS Highly significant differences were observed between SIHall and CM-1 groups in the following measures: TE (mean ± standard deviation, 3.1 ± 5.7 vs 9.3 ± 3.5 mm), 3VF (-16.8° ± 11.2° vs -2.1° ± 4.6°), PMA (44.8° ± 13.1° vs 62.7° ± 9.8°), DOI (0.2 ± 4.1 vs 3.8 ± 1.6 mm), and CL (38.3 ± 4.5 vs 44.0 ± 3.3 mm; all p < 0.0001). Eight (16%) of 50 SIH subjects had TE > 5 mm; in this subgroup (SIHTE), a cutoff value of < -15° for 3VF and < 45° for PMA perfectly discriminated SIH from CM-1 (sensitivity and specificity = 1.0). DOI showed perfect specificity (1.0) in detecting SIH among both groups. No subjects with SIH had isolated TE without other concurrent findings of midbrain sagging. CONCLUSIONS Measures of midbrain sagging, including cutoff values for 3VF and PMA, discriminate CM-1 from SIH and may help to prevent misdiagnosis and unnecessary surgery.
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Affiliation(s)
- Jessica L Houk
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
| | - Timothy J Amrhein
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
| | - Linda Gray
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
| | - Michael D Malinzak
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
| | - Peter G Kranz
- 1Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina
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24
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den Ottelander BK, Dremmen MHG, de Planque CA, van der Oest MJW, Mathijssen IMJ, van Veelen MLC. Does the association between abnormal anatomy of the skull base and cerebellar tonsillar position also exist in syndromic craniosynostosis? J Plast Reconstr Aesthet Surg 2021; 75:797-805. [PMID: 34799294 DOI: 10.1016/j.bjps.2021.09.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 06/28/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Cerebellar tonsillar herniation (TH) occurs frequently in syndromic craniosynostosis; however, the exact pathogenesis is unknown. This study evaluates the association between skull base deformities and TH in syndromic craniosynostosis. METHODS Retrospective study MRI study comparing syndromic craniosynostosis to controls. Measured parameters included clivus length, skull base angle, Boogard's angle, foramen magnum area, and cerebellar tonsillar position (TP). The association between skull base parameters and TP was evaluated with linear mixed models, correcting for age and risk factors for TH in craniosynostosis (hydrocephalus, intracranial hypertension, craniocerebral disproportion, and lambdoid synostosis). RESULTS Two hundred and eighty-two scans in 145 patients were included, and 146 scans in 146 controls. The clivus was smaller at birth, and its growth was retarded in all syndromes. The skull base angle was smaller at birth in Apert and Crouzon syndromes, and the evolution through time was normal. Boogard's angle was smaller at birth in Apert syndrome, and its evolution was disturbed in Apert and Saethre-Chotzen syndromes. The foramen magnum was smaller at birth in Crouzon and Saethre-Chotzen syndromes, and its growth was disturbed in Apert, Crouzon, and Saethre-Chotzen syndromes. TP was higher at birth in Apert syndrome, but lowered faster. In Crouzon syndrome, TP was lower at birth and throughout life. A smaller clivus and larger foramen magnum were associated with a lower TP in controls (p<0.001, p=0.007), and in Crouzon syndrome, this applied to only foramen magnum size (p=0.004). CONCLUSION The skull base and its growth are significantly different in syndromic craniosynostosis compared to controls. However, only foramen magnum area is associated with TP in Crouzon syndrome.
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Affiliation(s)
- Bianca K den Ottelander
- Erasmus MC, University Medical Center Rotterdam, Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Room EE-1591, Postbus 2040, 3000 CA, Rotterdam, the Netherlands.
| | - Marjolein H G Dremmen
- Erasmus MC, University Medical Center Rotterdam, Dutch Craniofacial Center, Department of Radiology, Postbus 2040, 3000 CA, Rotterdam, the Netherlands
| | - Catherine A de Planque
- Erasmus MC, University Medical Center Rotterdam, Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Room EE-1591, Postbus 2040, 3000 CA, Rotterdam, the Netherlands
| | - Mark J W van der Oest
- Erasmus MC, University Medical Center Rotterdam, Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Room EE-1591, Postbus 2040, 3000 CA, Rotterdam, the Netherlands
| | - Irene M J Mathijssen
- Erasmus MC, University Medical Center Rotterdam, Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Room EE-1591, Postbus 2040, 3000 CA, Rotterdam, the Netherlands
| | - Marie-Lise C van Veelen
- Erasmus MC, University Medical Center Rotterdam, Dutch Craniofacial Center, Department of Neurosurgery, Room SK-1204, Postbus 2040, 3000 CA, Rotterdam, the Netherlands
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25
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杨 胜, 唐 超, 李 海, 钟 德. [Effects of age and gender on posterior cranial fossa linear volume and cerebellar tonsil position in normal populations]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1167-1171. [PMID: 34523283 PMCID: PMC8444132 DOI: 10.7507/1002-1892.202103158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/19/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the effects of gender and age on the posterior cranial fossa linear volume and cerebellar tonsil position in normal populations. METHODS A total of 180 normal adults who underwent cervical MRI examination at the physical examination center were selected, including 90 males and 90 females; the age ranged from 20 to 79 years, with an average of 50.4 years. The posterior cranial fossa linear volume and cerebellar tonsil position were measured by two spine surgeons on the mid-sagittal plane of the cervical MRI T2-weighted image. The posterior cranial fossa linear volume included the length of clivus (AB), anteroposterior diameter of foramen magnum (BC), length of supraocciput (CD), anteroposterior diameter of posterior fossa (DA), posterior fossa height (BE), and clivus angle (∠α). The index of the cerebellar tonsil position was the distance from the lower edge of the cerebellar tonsil to the baseline (MN). The differences of each indicators between males and females were compared, and the correlations between age and each indicators were analyzed. RESULTS The posterior fossa cranial linear volume AB, BC, CD, BE, and ∠α in males were significantly larger than those in females ( P<0.05); DA in males was larger than that in females, but showing no significant difference ( t=1.978, P=0.050). The cerebellar tonsil position (MN) in females was higher than that in males, but showing no significant difference ( t=0.526, P=0.600). Correlation analysis showed that age was negatively correlated with AB, BC, CD, DA, BE, ∠α, and MN ( r=-0.375, P=0.001; r=-0.417, P=0.001; r=-0.046, P=0.001; r=-0.244, P=0.001; r=-0.326, P=0.001; r=-0.320, P=0.001; r=-0.334, P=0.001). CONCLUSION The posterior cranial fossa linear volume of normal adults is significantly larger in males than in females; the posterior cranial fossa linear volume and the cerebellar tonsil position may have a decreasing process of age-related degeneration.
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Affiliation(s)
- 胜 杨
- 成都市双流区第一人民医院骨科(成都 610000)Department of Orthopedics, the First People’s Hospital of Shuangliu District, Chengdu Sichuan, 610000, P.R.China
| | - 超 唐
- 成都市双流区第一人民医院骨科(成都 610000)Department of Orthopedics, the First People’s Hospital of Shuangliu District, Chengdu Sichuan, 610000, P.R.China
| | - 海波 李
- 成都市双流区第一人民医院骨科(成都 610000)Department of Orthopedics, the First People’s Hospital of Shuangliu District, Chengdu Sichuan, 610000, P.R.China
| | - 德君 钟
- 成都市双流区第一人民医院骨科(成都 610000)Department of Orthopedics, the First People’s Hospital of Shuangliu District, Chengdu Sichuan, 610000, P.R.China
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26
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Ebrahimzadeh SA, Loth F, Ibrahimy A, Nwotchouang BST, Bhadelia RA. Diagnostic utility of parasagittal measurements of tonsillar herniation in Chiari I malformation. Neuroradiol J 2021; 35:233-239. [PMID: 34428087 DOI: 10.1177/19714009211041524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Although the cerebellar tonsils are parasagittal structures, the extent of tonsillar herniation (ETH) in Chiari I malformation (CMI) is currently measured in the midsagittal plane. We measured the ETH of each cerebellar tonsil in the parasagittal plane and assessed their diagnostic utility by comparing them to the midsagittal ETH measurements in predicting cough-associated headache (CAH), an indicator of clinically significant disease in CMI. METHODS Eighty-five CMI patients with 3D-MPRAGE images were included. Neurosurgeons determined the presence of CAH. Sagittal images were used to measure ETH in the midsagittal (MS_ETH) and parasagittal planes (by locating tonsillar tips on each side on reformatted coronal images). Given the parasagittal ETH (PS_ETH) asymmetry in the majority of cases, they were considered Smaller_PS_ETH or Larger_PS_ETH. The accuracy of ETH measurements was assessed by the receiver operating characteristic (ROC) curve. RESULTS Of 85 patients, 46 reported CAH. ROC analysis showed an area under the curve (AUC) of 0.78 for Smaller_PS_ETH significantly better than 0.65 for MS-ETH in predicting CAH (p = 0.001). An AUC of 0.68 for Larger_PS_ETH was not significantly different from MS_ETH. The sensitivity and specificity of predicting CAH were 87% and 28% for MS_ETH >6 mm versus 90% and 46% for Smaller_PS_ETH >6 mm, and 52% and 67% for MS_ETH >9 mm versus 48% and 87% for Smaller_PS_ETH >9 mm. At ETH >15 mm, no differences were seen between the measurements. CONCLUSIONS Diagnostic utility of ETH measurements in detecting clinically significant CMI can be improved by parasagittal measurements of the cerebellar tonsillar herniation.
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Affiliation(s)
| | - Francis Loth
- Department of Mechanical Engineering, Conquer Chiari Research Center, The University of Akron, USA
| | - Alaaddin Ibrahimy
- Department of Mechanical Engineering, Conquer Chiari Research Center, The University of Akron, USA
| | | | - Rafeeque A Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, USA
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27
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Kotaki Y, Hattori G, Uchikado H, Komaki S, Takeshige N, Miyahara T, Hasegawa Y, Morioka M. "Motion-specific Headache": A Predictor for Diagnosis and Favorable Prognosis after Surgery in Young Patients with Chiari Malformation Type 1. Neurol Med Chir (Tokyo) 2021; 61:577-582. [PMID: 34321386 PMCID: PMC8531875 DOI: 10.2176/nmc.oa.2020-0427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
As headache is known as one of the most common symptoms in the patients with Chiari malformation type 1 (CM1), it is difficult to find out CM1-related headache among the symptoms because headache itself is commonly seen. Herein, we retrospectively review the cases of six CM1 patients complaining only of headache by which they complained of deterioration in daily life activities. The symptom of headache worsened during anteflexion (n = 2; 33%), retroflexion (n = 1; 17%), jumping (n = 3; 50%), going up the stairs (n = 1; 17%), and running (n = 1; 17%). Mean age at the onset was 15.7 years old (ranging 11–18) and four out of six were female. These inductive factors were clearly different from “Valsalva-like maneuvers,” although the mechanism might originate from dynamic tonsil changes. We named these headaches as “motion-specific.” These headaches radiated to the posterior side. MRI revealed that the extent of tonsillar ectopia was 11.3 mm, while syringomyelia was observed in three out of six patients (50%). All patients underwent surgical treatment, with the “motion-specific headache” completely disappearing 12.5 days thereafter. Although headaches are common, “motion-specific headache” may be a good candidate symptom to distinguish CM1 patients, especially among teenagers with headaches, and a good predictor for favorable outcomes after surgical treatment.
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Affiliation(s)
- Yoshikuni Kotaki
- Department of Neurosurgery, Kurume University School of Medicine
| | - Gohsuke Hattori
- Department of Neurosurgery, Kurume University School of Medicine
| | - Hisaaki Uchikado
- Department of Neurosurgery, Kurume University School of Medicine
| | - Satoru Komaki
- Department of Neurosurgery, Kurume University School of Medicine
| | | | | | - Yu Hasegawa
- Department of Neurosurgery, Kurume University School of Medicine.,Department of Pharmaceutical Sciences, School of Pharmacy at Fukuoka, International University of Health and Welfare
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine
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Imaging and health metrics in incidental cerebellar tonsillar ectopia: findings from the Adolescent Brain Cognitive Development Study (ABCD). Neuroradiology 2021; 63:1913-1924. [PMID: 34247260 DOI: 10.1007/s00234-021-02759-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Incidental cerebellar tonsillar ectopia (ICTE) that meets the radiographic criterion for Chiari malformation type I (CMI) is an increasingly common finding in the clinical setting, but its significance is unclear. The present study examined posterior cranial fossa (PCF) morphometrics and a broad range of health instruments of pediatric ICTE cases and matched controls extracted from the Adolescent Brain Cognitive Development (ABCD) dataset. METHODS One-hundred-six subjects with ICTE and 106 matched controls without ICTE were identified from 11,411 anatomical MRI of healthy screened pediatric subjects from the ABCD project. Subjects were matched by sex, age, body mass index, race, and ethnicity. Twenty-two brain morphometrics and 22 health instruments were compared between the two groups to identify unrecognized CMI symptoms and assess the general health impact of ICTE. RESULTS Twelve and 15 measures were significantly different between the ICTE and control groups for females and males, respectively. Notably, for females, the anterior CSF space was significantly smaller (p = 0.00005) for the ICTE group than controls. For males, the clivus bone length was significantly shorter (p = 0.0002) for the ICTE group compared to controls. No significant differences were found among the 22 health instruments between the two groups. CONCLUSION This study demonstrated that pediatric ICTE subjects have similar PCF morphometrics to adult CMI. ICTE alone did not appear to cause any unrecognized CMI symptoms and had no impact on the subjects' current mental, physical, or behavioral health. Still, given their cranial and brain morphology, these cases may be at risk for adult-onset symptomatic CMI.
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O'Neill NP, Miller PE, Hresko MT, Emans JB, Karlin LI, Hedequist DJ, Snyder BD, Smith ER, Proctor MR, Glotzbecker MP. Scoliosis with Chiari I malformation without associated syringomyelia. Spine Deform 2021; 9:1105-1113. [PMID: 33471302 DOI: 10.1007/s43390-021-00286-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 01/02/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Many patients with presumed idiopathic scoliosis are found to have Chiari I malformation (CM-I) on MRI. The objective of this study is to report on scoliosis progression in CM-I with no syringomyelia. METHODS A retrospective review of patients with scoliosis and CM-I was conducted from 1997 to 2015. Patients with syringomyelia and/or non-idiopathic scoliosis were excluded. Clinical and radiographic characteristics were recorded at presentation and latest follow-up. CM-I was defined as the cerebellar tonsil extending 5 mm or more below the foramen magnum on MRI. RESULTS Thirty-two patients (72% female) with a mean age of 11 years (range 1-16) at scoliosis diagnosis were included. The average initial curve was 30.3° ± SD 16.3. The mean initial Chiari size was 9.6 mm SD ± 4.0. Fifteen (46.9%) experienced Chiari-related symptoms, and three (9%) patients underwent Posterior Fossa Decompression (PFD) to treat these symptoms. 10 (31%) patients went on to fusion, progressing on average 13.6° (95% CI 1.6-25.6°). No association was detected between decompression and either curve progression or fusion (p = 0.46, 0.60). For those who did not undergo fusion, curve magnitude progressed on average 1.0° (95% CI - 4.0 to 5.9°). There was no association between age, Chiari size, presence of symptoms, initial curve shape, or bracing treatment and fusion. CONCLUSION Patients with CM-I and scoliosis may not require surgical treatment, including PFD and fusion. Scoliosis curvature stabilized in the non-surgical population at an average progression of 1.0°. These results suggest that CM-I with no syringomyelia has minimal effect on scoliosis progression.
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Affiliation(s)
- Nora P O'Neill
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Patricia E Miller
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Michael T Hresko
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - John B Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Lawrence I Karlin
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Daniel J Hedequist
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brian D Snyder
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mark R Proctor
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Pediatric Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
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García M, Eppelheimer MS, Houston JR, Houston ML, Nwotchouang BST, Kaut KP, Labuda R, Bapuraj JR, Maleki J, Klinge PM, Vorster S, Luciano MG, Loth F, Allen PA. Adult Age Differences in Self-Reported Pain and Anterior CSF Space in Chiari Malformation. THE CEREBELLUM 2021; 21:194-207. [PMID: 34106419 DOI: 10.1007/s12311-021-01289-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 11/30/2022]
Abstract
Chiari malformation type I (CMI) is a neural disorder with sensory, cognitive, and motor defects, as well as headaches. Radiologically, the cerebellar tonsils extend below the foramen magnum. To date, the relationships among adult age, brain morphometry, surgical status, and symptom severity in CMI are unknown. The objective of this study was to better understand the relationships among these variables using causal modeling techniques. Adult CMI patients (80% female) who either had (n = 150) or had not (n = 151) undergone posterior fossa decompression surgery were assessed using morphometric measures derived from magnetic resonance images (MRI). MRI-based morphometry showed that the area of the CSF pocket anterior to the cervico-medullary junction (anterior CSF space) correlated with age at the time of MRI (r = - .21). Also, self-reported pain increased with age (r = .11) and decreased with anterior CSF space (r = - .18). Age differences in self-reported pain were mediated by anterior CSF space in the cervical spine area-and this effect was particularly salient for non-decompressed CMI patients. As CMI patients age, the anterior CSF space decreases, and this is associated with increased pain-especially for non-decompressed CMI patients. It is recommended that further consideration of age-related decreases in anterior CSF space in CMI patients be given in future research.
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Affiliation(s)
- Maitane García
- Faculty of Psychology and Education, University of Deusto, Bilbao, Spain
| | - Maggie S Eppelheimer
- Department of Biomedical Engineering, College of Engineering, The University of Akron, Akron, OH, USA
| | - James R Houston
- Department of Psychology, Middle Tennessee State University, Murfreesboro, TN, USA
| | - Michelle L Houston
- Department of Psychology, The University of Akron, Akron, OH, 44325-4301, USA
| | | | - Kevin P Kaut
- Department of Psychology, The University of Akron, Akron, OH, 44325-4301, USA
| | | | - J Rajiv Bapuraj
- Department of Radiology, Division of Neuroradiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jahangir Maleki
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Petra M Klinge
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School Brown University, Providence, RI, USA
| | - Sarel Vorster
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark G Luciano
- Department of Neurosurgery, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Francis Loth
- Department of Biomedical Engineering, College of Engineering, The University of Akron, Akron, OH, USA.,Department of Mechanical Engineering, College of Engineering, The University of Akron, Akron, OH, USA
| | - Philip A Allen
- Department of Psychology, The University of Akron, Akron, OH, 44325-4301, USA.
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Nwotchouang BST, Eppelheimer MS, Pahlavian SH, Barrow JW, Barrow DL, Qiu D, Allen PA, Oshinski JN, Amini R, Loth F. Regional Brain Tissue Displacement and Strain is Elevated in Subjects with Chiari Malformation Type I Compared to Healthy Controls: A Study Using DENSE MRI. Ann Biomed Eng 2021; 49:1462-1476. [PMID: 33398617 PMCID: PMC8482962 DOI: 10.1007/s10439-020-02695-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022]
Abstract
While the degree of cerebellar tonsillar descent is considered the primary radiologic marker of Chiari malformation type I (CMI), biomechanical forces acting on the brain tissue in CMI subjects are less studied and poorly understood. In this study, regional brain tissue displacement and principal strains in 43 CMI subjects and 25 controls were quantified using a magnetic resonance imaging (MRI) methodology known as displacement encoding with stimulated echoes (DENSE). Measurements from MRI were obtained for seven different brain regions-the brainstem, cerebellum, cingulate gyrus, corpus callosum, frontal lobe, occipital lobe, and parietal lobe. Mean displacements in the cerebellum and brainstem were found to be 106 and 64% higher, respectively, for CMI subjects than controls (p < .001). Mean compression and extension strains in the cerebellum were 52 and 50% higher, respectively, in CMI subjects (p < .001). Brainstem mean extension strain was 41% higher in CMI subjects (p < .001), but no significant difference in compression strain was observed. The other brain structures revealed no significant differences between CMI and controls. These findings demonstrate that brain tissue displacement and strain in the cerebellum and brainstem might represent two new biomarkers to distinguish between CMI subjects and controls.
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Affiliation(s)
| | - Maggie S Eppelheimer
- Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, OH, 44325-3903, USA
| | | | - Jack W Barrow
- Department of Radiology, University of Tennessee, Knoxville, TN, USA
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Deqiang Qiu
- Radiology & Imaging Sciences and Biomedical Engineering, Emory University School of Medicine, Atlanta, USA
| | - Philip A Allen
- Conquer Chiari Research Center, Department of Psychology, The University of Akron, Akron, OH, USA
| | - John N Oshinski
- Radiology & Imaging Sciences and Biomedical Engineering, Emory University School of Medicine, Atlanta, USA
| | - Rouzbeh Amini
- Department of Mechanical and Industrial Engineering, Department of Bioengineering, Northeastern University, Boston, MA, USA
| | - Francis Loth
- Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, OH, 44325-3903, USA
- Department of Mechanical Engineering, The University of Akron, Akron, OH, USA
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Ciaramitaro P, Rota E, Ferraris M, Stura I, Migliaretti G, Cocito D. Migraine in Chiari 1 Malformation: a cross-sectional, single centre study. Acta Neurol Belg 2021; 122:947-954. [PMID: 34047952 DOI: 10.1007/s13760-021-01716-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022]
Abstract
In Chiari 1 Malformation (CM1) the most frequent symptom is exertional headache, but other headache types have been reported, such as migraine. This cross-sectional study is aimed to examine the prevalence of migraine in a group of CM1 headache patients and to compare clinical-demographic characteristics between migraine and non-migraine patients. 427 adults were enrolled at the multidisciplinary Chiari Center in Torino. 230 headache patients were classified, based on radiological criteria. Frequencies (absolute/percentage values) were calculated in the whole sample for: migraine presence (with and without aura), gender, age, radiologic phenotypes and headache clinical characteristics. The association between CM1 diagnosis and headache characteristics (independent variables) and migraine diagnosis (dependent variable) was estimated by logistic regression models. Seventy-eight patients (67 females) out of 230 presenting headache had a migraine (34%), 44/78 (56%) with aura; in 58/78 (74%) migraine was comorbid with secondary headache attributable to CM1. Migraine prevalence in patients with isolated CM1 (52/120, 43.3%) was higher (p = 0.0016) than in all the other patients (26/110, 23.6%). Although migraine was prevalent in females (86%; 6:1 female:male ratio), age classes and gender were not risk factors for migraine at multivariate analysis, while migraine was associated with isolated CM1 phenotype (OR = 2.6). This study shows a high prevalence of migraine in CM1 patients and a significant association between migraine and isolated CM1. In patients with radiological evidence of CM1, particularly in the absence of neurological signs, a careful headache clinical characterization, according to the International Headache Society criteria, may be advised.
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Affiliation(s)
- Palma Ciaramitaro
- Centro Regionale Esperto Siringomielia e Sindrome di Chiari (CRESSC), Department of Neuroscience, AOU Città della Salute e della Scienza di Torino, Presidio CTO, Via Zuretti, 29, 10126, Turin, Italy.
| | - Eugenia Rota
- Neurology Unit, San Giacomo Hospital, Novi Ligure, ASL Alessandria, Novi Ligure, Italy
| | - Marilena Ferraris
- Diagnostic Imaging Department, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Ilaria Stura
- Department of Public Health and Paediatric Sciences, University of Torino, Torino, Italy
| | - Giuseppe Migliaretti
- Department of Public Health and Paediatric Sciences, University of Torino, Torino, Italy
| | - Dario Cocito
- Centro Regionale Esperto Siringomielia e Sindrome di Chiari (CRESSC), Department of Neuroscience, AOU Città della Salute e della Scienza di Torino, Presidio CTO, Via Zuretti, 29, 10126, Turin, Italy
- Istituti Clinici Scientifici Maugeri, Pavia, Italy
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Ibrahimy A, Huang CWC, Bezuidenhout AF, Allen PA, Bhadelia RA, Loth F. Association Between Resistance to Cerebrospinal Fluid Flow Near the Foramen Magnum and Cough-Associated Headache in Adult Chiari Malformation Type I. J Biomech Eng 2021; 143:051003. [PMID: 33454731 PMCID: PMC8086178 DOI: 10.1115/1.4049788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/18/2020] [Indexed: 01/03/2023]
Abstract
Cough-associated headaches (CAHs) are thought to be distinctive for Chiari malformation type I (CMI) patients and have been shown to be related to the motion of cerebrospinal fluid (CSF) near the foramen magnum (FM). We used computational fluid dynamics (CFD) to compute patient-specific resistance to CSF motion in the spinal canal for CMI patients to determine its accuracy in predicting CAH. Fifty-one symptomatic CMI patients with cerebellar tonsillar position (CTP) ≥ 5 mm were included in this study. The patients were divided into two groups based on their symptoms (CAH and non-CAH) by review of the neurosurgical records. CFD was utilized to simulate CSF motion, and the integrated longitudinal impedance (ILI) was calculated for all patients. A receiver operating characteristic (ROC) curve was evaluated for its accuracy in predicting CAH. The ILI for CMI patients with CAH (776 dyn/cm5, 288-1444 dyn/cm5; median, interquartile range) was significantly larger compared to non-CAH (285 dyn/cm5, 187-450 dyn/cm5; p = 0.001). The ILI was more accurate in predicting CAH in CMI patients than the CTP when the comparison was made using the area under the ROC curve (AUC) (0.77 and 0.70, for ILI and CTP, respectively). ILI ≥ 750 dyn/cm5 had a sensitivity of 50% and a specificity of 95% in predicting CAH. ILI is a parameter that is used to assess CSF blockage in the spinal canal and can predict patients with and without CAH with greater accuracy than CTP.
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Affiliation(s)
- Alaaddin Ibrahimy
- Department of Mechanical Engineering, The University of Akron, 302 E Buchtel Avenue, Akron, OH 44325
| | - Chi-Wen Christina Huang
- Department of Radiology, Wan Fang Hospital, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City 110, Taiwan
| | - Abraham F. Bezuidenhout
- Beth Israel Deaconess Medical Center, Department of Radiology, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215
| | - Philip A. Allen
- Department of Psychology, The University of Akron, 302 E Buchtel Avenue, Akron, OH 44325
| | - Rafeeque A. Bhadelia
- Beth Israel Deaconess Medical Center, Department of Radiology, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215
| | - Francis Loth
- Department of Mechanical Engineering, The University of Akron, 302 E Buchtel Avenue, Akron, OH 44325
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34
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Impact of Surgical Status, Loneliness, and Disability on Interleukin 6, C-Reactive Protein, Cortisol, and Estrogen in Females with Symptomatic Type I Chiari Malformation. THE CEREBELLUM 2021; 20:872-886. [PMID: 33677786 DOI: 10.1007/s12311-021-01251-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 10/22/2022]
Abstract
Chiari malformation type I (CMI) provides an opportunity for examining possible moderators of allostatic load. CMI patients who had (n = 43) and had not (n = 19) undergone decompression surgery completed questionnaires regarding pain, disability, and loneliness, and provided serum samples for IL-6, CRP, estrogen, and free estradiol assays, and saliva samples to assess diurnal cortisol curves. ANOVAs examining surgical status (decompressed versus non-decompressed), loneliness (high vs. low), and disability (high vs. low) as independent variables and biomarker variables as dependent factors found that loneliness was associated with higher levels of cortisol, F(1, 37) = 4.91, p = .04, η2P = .11, and lower levels of estrogen, F(1, 36) = 7.29, p = .01, η2P = .17, but only in decompressed patients. Results highlight the possible impact of loneliness on biological stress responses and the need to intervene to reduce loneliness in patients with symptomatic CMI.
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Den Ottelander BK, Van Veelen MC, De Goederen R, Van De Beeten SDC, Dremmen MHG, Loudon SE, Versnel SL, Van Den Ouweland AMW, Van Dooren MF, Joosten KFM, Mathijssen IMJ. Saethre-Chotzen syndrome: long-term outcome of a syndrome-specific management protocol. Dev Med Child Neurol 2021; 63:104-110. [PMID: 32909287 PMCID: PMC7754116 DOI: 10.1111/dmcn.14670] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Abstract
AIM To assess the long-term outcomes of our management protocol for Saethre-Chotzen syndrome, which includes one-stage fronto-orbital advancement. METHOD All patients born with Saethre-Chotzen syndrome between January 1992 and March 2017 were included. Evaluated parameters included occipital frontal head circumference (OFC), fundoscopy, neuroimaging (ventricular size, tonsillar position, and the presence of collaterals/an abnormal transverse sinus), polysomnography, and ophthalmological outcomes. The relationship between papilledema and its associated risk factors was evaluated with Fisher's exact test. RESULTS Thirty-two patients (21 females, 11 males) were included. Median (SD) age at first surgery was 9.6 months (3.1mo) for patients who were primarily referred to our center (range: 3.6-13.0mo), the median (SD) age at last follow-up was 13 years (5y 7mo; range: 3-25y). Seven patients had papilledema preoperatively, which recurred in two. Two patients had papilledema solely after first surgery. Second cranial vault expansion was indicated in 20%. Thirteen patients had an OFC deflection, indicating restricted skull growth, one patient had ventriculomegaly, and none developed hydrocephalus. Eleven patients had emissary veins, while the transverse sinus was aberrant unilaterally in 13 (hypoplastic n=10 and absent n=3). Four patients had mild tonsillar descent, one of which was a Chiari type I malformation. Four patients had obstructive sleep apnoea (two mild, one moderate, and one severe). An aberrant transverse sinus was associated with papilledema (p=0.01). INTERPRETATION Single one-stage fronto-orbital advancement was sufficient to prevent intracranial hypertension for 80% of our patients with Saethre-Chotzen syndrome. Follow-up should focus on OFC deflection and venous anomalies.
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Affiliation(s)
- Bianca K Den Ottelander
- Department of Plastic and Reconstructive Surgery and Hand SurgeryDutch Craniofacial CenterErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Marie‐Lise C Van Veelen
- Department of NeurosurgeryErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Robbin De Goederen
- Department of Plastic and Reconstructive Surgery and Hand SurgeryDutch Craniofacial CenterErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Stephanie DC Van De Beeten
- Department of Plastic and Reconstructive Surgery and Hand SurgeryDutch Craniofacial CenterErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Marjolein HG Dremmen
- Department of RadiologyErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Sjoukje E Loudon
- Department of OphthalmologyErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Sarah L Versnel
- Department of Plastic and Reconstructive Surgery and Hand SurgeryDutch Craniofacial CenterErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Ans MW Van Den Ouweland
- Department of Clinical GeneticsErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Marieke F Van Dooren
- Department of Clinical GeneticsErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Koen FM Joosten
- Pediatric Intensive Care UnitErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Irene MJ Mathijssen
- Department of Plastic and Reconstructive Surgery and Hand SurgeryDutch Craniofacial CenterErasmus MC – Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
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den Ottelander BK, de Goederen R, de Planque CA, Baart SJ, van Veelen MLC, Corel LJA, Joosten KFM, Mathijssen IMJ, Dremmen MHG. Cervical Spinal Cord Compression and Sleep-Disordered Breathing in Syndromic Craniosynostosis. AJNR Am J Neuroradiol 2020; 42:201-205. [PMID: 33272949 DOI: 10.3174/ajnr.a6881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/19/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Cerebellar tonsillar herniation arises frequently in syndromic craniosynostosis and causes central and obstructive apneas in other diseases through spinal cord compression. The purposes of this study were the following: 1) to determine the prevalence of cervical spinal cord compression in syndromic craniosynostosis, and 2) to evaluate its connection with sleep-disordered breathing. MATERIALS AND METHODS This was a cross-sectional study including patients with syndromic craniosynostosis who underwent MR imaging and polysomnography. Measures encompassed the compression ratio at the level of the odontoid process and foramen magnum and the cervicomedullary angle. MR imaging studies of controls were included. Linear mixed models were developed to compare patients with syndromic craniosynostosis with controls and to evaluate the association between obstructive and central sleep apneas and MR imaging parameters. RESULTS One hundred twenty-two MR imaging scans and polysomnographies in 89 patients were paired; 131 MR imaging scans in controls were included. The mean age at polysomnography was 5.7 years (range, 0.02-18.9 years). The compression ratio at the level of the odontoid process was comparable with that in controls; the compression ratio at the level of the foramen magnum was significantly higher in patients with Crouzon syndrome (+27.1, P < .001). The cervicomedullary angle was significantly smaller in Apert, Crouzon, and Saethre-Chotzen syndromes (-4.4°, P = .01; -10.2°, P < .001; -5.2°, P = .049). The compression ratios at the level of the odontoid process and the foramen magnum, the cervicomedullary angle, and age were not associated with obstructive apneas (P > .05). Only age was associated with central apneas (P = .02). CONCLUSIONS The prevalence of cervical spinal cord compression in syndromic craniosynostosis is low and is not correlated to sleep disturbances. However, considering the high prevalence of obstructive sleep apnea in syndromic craniosynostosis and the low prevalence of compression and central sleep apnea in our study, we would, nevertheless, recommend a polysomnography in case of compression on MR imaging studies.
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Affiliation(s)
- B K den Ottelander
- From the Dutch Craniofacial Center (B.K.d.O., R.D.G., C.A.d.P., I.M.J.M.), Department of Plastic and Reconstructive Surgery and Hand Surgery
| | - R de Goederen
- From the Dutch Craniofacial Center (B.K.d.O., R.D.G., C.A.d.P., I.M.J.M.), Department of Plastic and Reconstructive Surgery and Hand Surgery
| | - C A de Planque
- From the Dutch Craniofacial Center (B.K.d.O., R.D.G., C.A.d.P., I.M.J.M.), Department of Plastic and Reconstructive Surgery and Hand Surgery
| | - S J Baart
- Department of Biostatistics (S.J.B.), Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - L J A Corel
- Pediatric Intensive Care Unit (L.J.A.C., K.F.M.J.)
| | | | - I M J Mathijssen
- From the Dutch Craniofacial Center (B.K.d.O., R.D.G., C.A.d.P., I.M.J.M.), Department of Plastic and Reconstructive Surgery and Hand Surgery
| | - M H G Dremmen
- Department of Radiology (M.H.G.D.), Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Rotterdam, the Netherlands
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Bragée B, Michos A, Drum B, Fahlgren M, Szulkin R, Bertilson BC. Signs of Intracranial Hypertension, Hypermobility, and Craniocervical Obstructions in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Front Neurol 2020; 11:828. [PMID: 32982905 PMCID: PMC7485557 DOI: 10.3389/fneur.2020.00828] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 07/02/2020] [Indexed: 12/24/2022] Open
Abstract
The pathophysiology of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is unknown. In this study, we test the hypothesis that hypermobility, signs of intracranial hypertension (IH), and craniocervical obstructions may be overrepresented in patients with ME/CFS and thereby explain many of the symptoms. Our study is a retrospective, cross-sectional study, performed at a specialist clinic for referred patients with severe ME/CFS as defined by the Canada Consensus Criteria. The first 272 patients with ME/CFS were invited to participate, and 229 who provided prompt informed consent were included. Hypermobility was assessed using the Beighton Score. IH was assessed indirectly by the quotient of the optic nerve sheet diameter (ONSD)/eyeball transverse diameter on both sides as measured on magnetic resonance imaging (MRI) of the brain. We also included assessment of cerebellar tonsil position in relation to the McRae line, indicating foramen magnum. Craniocervical obstructions were assessed on MRI of the cervical spine. Allodynia was assessed by quantitative sensory testing (QST) for pain in the 18 areas indicative of fibromyalgia syndrome (FMS). A total of 190 women, mean age 45 years, and 39 males, mean age 44 years, were included. Hypermobility was identified in 115 (50%) participants. MRI of the brain was performed on 205 participants of whom 112 (55%) had an increased ONSD and 171 (83%) had signs of possible IH, including 65 (32%) who had values indicating more severe states of IH. Cerebellar tonsils protruding under the McRae line into the foramen magnum were identified in 115 (56%) of the participants. MRI of the cervical spine was performed on 125 participants of whom 100 (80%) had craniocervical obstructions. Pain at harmless pressure, allodynia, was found in 96% of the participants, and FMS was present in 173 participants or 76%. Compared to a general population, we found a large overrepresentation of hypermobility, signs of IH, and craniocervical obstructions. Our hypothesis was strengthened for future studies on the possible relation between ME/CFS symptoms and hypermobility, IH, and craniocervical obstructions in a portion of patients with ME/CFS. If our findings are confirmed, new diagnostic and therapeutic approaches to this widespread neurological syndrome should be considered.
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Affiliation(s)
- Björn Bragée
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden.,ME-center, Bragée Clinics, Stockholm, Sweden
| | | | - Brandon Drum
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden.,ME-center, Bragée Clinics, Stockholm, Sweden
| | - Mikael Fahlgren
- ME-center, Bragée Clinics, Stockholm, Sweden.,Academic Primary Health Care Center, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Robert Szulkin
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden
| | - Bo C Bertilson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden.,ME-center, Bragée Clinics, Stockholm, Sweden.,Academic Primary Health Care Center, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Zuev AA. [Features of syringomyelia natural course]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:76-81. [PMID: 32649816 DOI: 10.17116/neiro20208403176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rarity of syringomyelia (SM), a small amount of information about this disease leads to the lack of a unified concept of treatment and continuity between neurologists and neurosurgeons. Currently, there is no objective information on the timing, goals and objectives of surgery for SM, as well as the risks associated with this treatment. AIM Of this article was to study the natural course of syringomyelia and to determine in which part of the patients the disease progresses with time, how do the cysts' size change, and does this affect the condition of the patients, what symptoms appear first when the disease progresses? We retrospectively analyzed the medical records of 40 patients with SM who did not undergo surgery for various reasons (lack of indications, patient refusal from surgery, surgery was not offered to the patient, etc.) Clinical manifestations of the disease at the time of diagnosis were registered in 28 (70%) patients. Despite the conservative treatment, in 17 (60.7%) of them, symptoms began to progress over time. In 8 (28.6%) patients, the symptoms did not change during the observation; in 5 patients in this group, the disease clinically manifested in childhood, and did not progress in time after that. Three patients (10.7%) noted an improvement in their general condition, in two of them the syringomyelic cysts did not change according to MRI, and in one patient it regressed 2.5 years after it was found. Of the 12 patients without symptoms of the disease, within 62±13 months, only one patient (8.3%) developed sensory disorders in the hands, which eventually began to progress. Based on the data obtained, indications for surgery for SM are determined.
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Affiliation(s)
- A A Zuev
- N.I. Pirogov National Medical and Surgical Center, Moscow, Russia
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Haller G, Sadler B, Kuensting T, Lakshman N, Greenberg JK, Strahle JM, Park TS, Dobbs MB, Gurnett CA, Limbrick DD. Obex position is associated with syringomyelia and use of posterior fossa decompression among patients with Chiari I malformation. J Neurosurg Pediatr 2020; 26:45-52. [PMID: 32276247 PMCID: PMC7554138 DOI: 10.3171/2020.2.peds19486] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 02/05/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chiari I malformation (CM-I) has traditionally been defined by measuring the position of the cerebellar tonsils relative to the foramen magnum. The relationships of tonsillar position to clinical presentation, syringomyelia, scoliosis, and the use of posterior fossa decompression (PFD) surgery have been studied extensively and yielded inconsistent results. Obex position has been proposed as a useful adjunctive descriptor for CM-I and may be associated with clinical disease severity. METHODS A retrospective chart review was performed of 442 CM-I patients with MRI who presented for clinical evaluation between 2003 and 2018. Clinical and radiological variables were measured for all patients, including presence/location of headaches, Chiari Severity Index (CSI) grade, tonsil position, obex position, clival canal angle, pB-C2 distance, occipitalization of the atlas, basilar invagination, syringomyelia, syrinx diameter, scoliosis, and use of PFD. Radiological measurements were then used to predict clinical characteristics using regression and survival analyses, with performing PFD, the presence of a syrinx, and scoliosis as outcome variables. RESULTS Among the radiological measurements, tonsil position, obex position, and syringomyelia were each independently associated with use of PFD. Together, obex position, tonsil position, and syringomyelia (area under the curve [AUC] 89%) or obex position and tonsil position (AUC 85.4%) were more strongly associated with use of PFD than tonsil position alone (AUC 76%) (Pdiff = 3.4 × 10-6 and 6 × 10-4, respectively) but were only slightly more associated than obex position alone (AUC 82%) (Pdiff = 0.01 and 0.18, respectively). Additionally, obex position was significantly associated with occipital headaches, CSI grade, syringomyelia, and scoliosis, independent of tonsil position. Tonsil position was associated with each of these traits when analyzed alone but did not remain significantly associated with use of PFD when included in multivariate analyses with obex position. CONCLUSIONS Compared with tonsil position alone, obex position is more strongly associated with symptomatic CM-I, as measured by presence of a syrinx, scoliosis, or use of PFD surgery. These results support the role of obex position as a useful radiological measurement to inform the evaluation and potentially the management of CM-I.
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Affiliation(s)
- Gabe Haller
- Department of Neurological Surgery, Washington University School of Medicine
- Department of Neurology, Washington University School of Medicine
| | - Brooke Sadler
- Department of Neurology, Washington University School of Medicine
| | | | - Nivan Lakshman
- Department of Neurological Surgery, Washington University School of Medicine
| | - Jacob K. Greenberg
- Department of Neurological Surgery, Washington University School of Medicine
| | - Jennifer M. Strahle
- Department of Neurological Surgery, Washington University School of Medicine
| | - Tae Sung Park
- Department of Neurological Surgery, Washington University School of Medicine
| | - Matthew B. Dobbs
- Department of Orthopaedic Surgery, Washington University School of Medicine
- Shriners Hospital for Children, St. Louis, Missouri
| | - Christina A. Gurnett
- Department of Neurology, Washington University School of Medicine
- Department of Orthopaedic Surgery, Washington University School of Medicine
- Department of Pediatrics, Washington University School of Medicine
| | - David D. Limbrick
- Department of Neurological Surgery, Washington University School of Medicine
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Clivus length distinguishes between asymptomatic healthy controls and symptomatic adult women with Chiari malformation type I. Neuroradiology 2020; 62:1389-1400. [PMID: 32418026 DOI: 10.1007/s00234-020-02453-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/29/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE While the presence of cerebellar tonsillar descent in radiological images has been used as evidence of Chiari malformation type I (CMI), tonsillar ectopia alone is insufficient to identify individuals with symptomatic CMI. This study sought to identify differences in brain morphology between symptomatic CMI and healthy controls in adult females. METHODS Two hundred and ten adult females with symptomatic CMI and 90 age- and body mass index-matched asymptomatic female controls were compared using seven brain morphometric measures visible on magnetic resonance images. The CMI and control groups were divided into four subgroups based on the tonsillar position (TP) relative to the foramen magnum: group 1 was made up of healthy controls with normal TP (TP < 0 mm); group 2 was comprised of control individuals with low-lying TP (1-5 mm); group 3 was comprised of symptomatic CMI patients with low-lying TP (1-5 mm); group 4 contained symptomatic CMI patients with severe tonsillar descent (6-13 mm). RESULTS All morphometrics for symptomatic CMI with severe tonsillar descent were significantly different than those for both control groups. The CMI group with low-lying TP was significantly different for four measures when compared to controls with normal TP. However, only clivus length was statistically different between the CMI and healthy control groups with low-lying TP. CONCLUSION This study demonstrates that clivus length distinguishes adult female healthy individuals with low-lying tonsils from those with symptomatic CMI. Further investigation is required to understand the importance of a shorter clivus length on CMI symptomatology and pathophysiology.
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Bogdanov EI, Faizutdinova AT, Mendelevich EG, Sozinov AS, Heiss JD. Epidemiology of Symptomatic Chiari Malformation in Tatarstan: Regional and Ethnic Differences in Prevalence. Neurosurgery 2020; 84:1090-1097. [PMID: 29788393 DOI: 10.1093/neuros/nyy175] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 04/09/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Epidemiology can assess the effect of Chiari I malformation (CM1) on the neurological health of a population and evaluate factors influencing CM1 development. OBJECTIVE To analyze the regional and ethnic differences in the prevalence of CM1. METHODS The population of the Republic of Tatarstan (RT) in the Russian Federation was evaluated for patients with CM1 symptoms over an 11-yr period. Typical symptoms of CM1 were found in 868 patients. Data from neurological examination and magnetic resonance imaging (MRI) measurement of posterior cranial fossa structures were analyzed. RESULTS MRI evidence of CM1, defined as cerebellar tonsils lying at least 5 mm inferior to the foramen magnum, was found in 67% of symptomatic patients. Another 33% of symptomatic patients had 2 to 4 mm of tonsillar ectopia, which we defined as "borderline Chiari malformation type 1 (bCM1)." The period prevalence in the entire RT for symptomatic CM1 was 20:100 000; for bCM1 was 10:100 000; and for CM1 and bCM1 together was 30:100 000. Prevalence of patients with CM1 symptoms was greater in the northern than southern districts of Tatarstan, due to a high prevalence (413:100 000) of CM1 in the Baltasy region in one of the northern districts. CONCLUSION One-third of patients with typical symptoms of CM1 had less than 5 mm of tonsillar ectopia (bCM1). Assessments of the health impact of CM1-type symptoms on a patient population should include the bCM1 patient group. A regional disease cluster of patients with Chiari malformation was found in Baltasy district of RT and needs further study.
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Affiliation(s)
- Enver I Bogdanov
- Department of Neurology and Rehabilitation, Kazan State Medical University, Kazan, Republic of Tatarstan, Russian Federation.,Department of Neurology, Republican Clinical Hospital, Kazan, Republic of Tatarstan, Russian Federation
| | - Aisylu T Faizutdinova
- Department of Neurology and Rehabilitation, Kazan State Medical University, Kazan, Republic of Tatarstan, Russian Federation.,Clinical Expert Department, Republican Clinical Hospital, Kazan, Republic of Tatarstan, Russian Federation
| | - Elena G Mendelevich
- Department of Neurology and Rehabilitation, Kazan State Medical University, Kazan, Republic of Tatarstan, Russian Federation
| | - Alexey S Sozinov
- Department of Biological and Medical Ethics, Kazan State Medical University, Kazan, Republic of Tatarstan, Russian Federation
| | - John D Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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Luciano MG, Batzdorf U, Kula RW, Rocque BG, Maher CO, Heiss J, Martin BA, Bolognese PA, Ashley-Koch A, Limbrick D, Poppe DJ, Esposito KM, Odenkirchen J, Esterlitz JR, Ala’i S, Joseph K, Feldman RS, Riddle R. Development of Common Data Elements for Use in Chiari Malformation Type I Clinical Research: An NIH/NINDS Project. Neurosurgery 2019; 85:854-860. [PMID: 30690581 PMCID: PMC7054710 DOI: 10.1093/neuros/nyy475] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Indexed: 12/28/2022] Open
Abstract
The management of Chiari I malformation (CMI) is controversial because treatment methods vary and treatment decisions rest on incomplete understanding of its complex symptom patterns, etiologies, and natural history. Validity of studies that attempt to compare treatment of CMI has been limited because of variable terminology and methods used to describe study subjects. The goal of this project was to standardize terminology and methods by developing a comprehensive set of Common Data Elements (CDEs), data definitions, case report forms (CRFs), and outcome measure recommendations for use in CMI clinical research, as part of the CDE project at the National Institute of Neurological Disorders and Stroke (NINDS) of the US National Institutes of Health. A working group, comprising over 30 experts, developed and identified CDEs, template CRFs, data dictionaries, and guidelines to aid investigators starting and conducting CMI clinical research studies. The recommendations were compiled, internally reviewed, and posted online for external public comment. In October 2016, version 1.0 of the CMI CDE recommendations became available on the NINDS CDE website. The recommendations span these domains: Core Demographics/Epidemiology; Presentation/Symptoms; Co-Morbidities/Genetics; Imaging; Treatment; and Outcome. Widespread use of CDEs could facilitate CMI clinical research trial design, data sharing, retrospective analyses, and consistent data sharing between CMI investigators around the world. Updating of CDEs will be necessary to keep them relevant and applicable to evolving research goals for understanding CMI and its treatment.
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Affiliation(s)
- Mark G Luciano
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Ulrich Batzdorf
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California
| | - Roger W Kula
- Chiari Neurosurgical Center at Neurological Surgery, P.C., Lake Success, New York
| | - Brandon G Rocque
- Department of Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - John Heiss
- Division of Intramural Research, National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Bryn A Martin
- Department of Biological Engineering, University of Idaho, Moscow, Idaho
| | - Paolo A Bolognese
- Chiari Neurosurgical Center at Neurological Surgery, P.C., Lake Success, New York
| | | | - David Limbrick
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Joanne Odenkirchen
- Division of Neuroscience, National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | | | | | | | | | - Robert Riddle
- Division of Neuroscience, National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
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Nwotchouang BST, Eppelheimer MS, Bishop P, Biswas D, Andronowski JM, Bapuraj JR, Frim D, Labuda R, Amini R, Loth F. Three-Dimensional CT Morphometric Image Analysis of the Clivus and Sphenoid Sinus in Chiari Malformation Type I. Ann Biomed Eng 2019; 47:2284-2295. [PMID: 31187348 DOI: 10.1007/s10439-019-02301-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023]
Abstract
This study evaluated three-dimensional (3D) volumetric image reconstructions to identify morphological differences of the clivus and sphenoid sinus on computed tomography (CT) scans of Chiari malformation type I (CMI) and control subjects. Axial CT images of adult females for 30 CMI subjects and 30 age and body mass index (BMI) matched controls were used for this retrospective study. 3D volumetric reconstructions were created from the bone windows of axial data following image registration for position and orientation correction of the head. The volume, surface area, linear dimensions and spatial position in the x, y, and z-axes were computed separately for the clivus and the sphenoid sinus for each subject. Eleven parameters were found to be significantly different between CMI subjects compared to controls. Most notably, clivus volume was reduced by 31% on average in CMI subjects. In contrast, we found that the sphenoid sinus volume was 38% greater on average in CMI subjects. Moreover, clivus length, height, width, and thickness were 3.7, 2.8, 3.0 and 9.4 mm reduced, respectively, in CMI subjects. This is the first study to demonstrate cephalometric differences in the 3D morphology of the clivus and sphenoid sinus between CMI subjects and controls.
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Affiliation(s)
| | - Maggie S Eppelheimer
- Department of Biomedical Engineering, University of Akron, Akron, OH, 44325-3903, USA
| | - Paul Bishop
- Department of Biomedical Engineering, University of Akron, Akron, OH, 44325-3903, USA
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Dipankar Biswas
- Department of Mechanical Engineering, University of Akron, Akron, OH, USA
| | | | - Jayapalli R Bapuraj
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - David Frim
- Department of Neurosurgery, University of Chicago, Chicago, IL, USA
| | | | - Rouzbeh Amini
- Department of Biomedical Engineering, University of Akron, Akron, OH, 44325-3903, USA
| | - Francis Loth
- Department of Biomedical Engineering, University of Akron, Akron, OH, 44325-3903, USA
- Department of Mechanical Engineering, University of Akron, Akron, OH, USA
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44
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Holly LT, Batzdorf U. Chiari malformation and syringomyelia. J Neurosurg Spine 2019; 31:619-628. [PMID: 31675698 DOI: 10.3171/2019.7.spine181139] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 07/25/2019] [Indexed: 11/06/2022]
Abstract
Chiari malformation was first described over a century ago, and consists of posterior fossa anomalies that generally share the feature of cerebellar tonsillar descent through the foramen magnum. Our understanding of this disorder was initially based on autopsy studies, and has been greatly enhanced by the advent of MRI. The surgical management of Chiari anomalies has also evolved in a parallel fashion. Although the exact surgical technique varies among individual surgeons, the goals of surgery remain constant and consist of relieving brainstem compression and cranial nerve distortion, restoring the normal flow of CSF across the foramen magnum, and reducing the size of any associated syrinx cavity. Syrinx cavities are most commonly associated with Chiari anomalies, yet primary spinal syringomyelia (PSS) can be caused by traumatic, infectious, degenerative, and other etiologies that cause at least a partial CSF flow obstruction in the spinal subarachnoid space. As with syringomyelia associated with Chiari anomalies, the main goal of PSS surgery is to reestablish CSF flow across the area of obstruction. In addition to MRI, myelography with CT can be very helpful in the evaluation and management of these patients by identifying focal regions of CSF obstruction that may be amenable to surgical intervention. Future directions for the treatment of Chiari anomalies and syringomyelia include the application of advanced imaging techniques, more widespread use of genetic evaluation, large-scale outcome studies, and the further refinement of surgical technique.
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45
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Delavari N, Wang AC, Bapuraj JR, Londy F, Muraszko KM, Garton HJ, Maher CO. Intraoperative Phase Contrast MRI Analysis of Cerebrospinal Fluid Velocities During Posterior Fossa Decompression for Chiari I Malformation. J Magn Reson Imaging 2019; 51:1463-1470. [DOI: 10.1002/jmri.26953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Nader Delavari
- Department of NeurosurgeryUniversity of Michigan Ann Arbor Michigan USA
| | - Anthony C. Wang
- Department of NeurosurgeryUniversity of California Los Angeles Los Angeles California USA
| | | | - Frank Londy
- Department of RadiologyUniversity of Michigan Ann Arbor Michigan USA
| | - Karin M. Muraszko
- Department of NeurosurgeryUniversity of Michigan Ann Arbor Michigan USA
| | - Hugh J.L. Garton
- Department of NeurosurgeryUniversity of Michigan Ann Arbor Michigan USA
| | - Cormac O. Maher
- Department of NeurosurgeryUniversity of Michigan Ann Arbor Michigan USA
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Jarski P, Zimny M, Linart M, Kozłowska Z, Mandera M. Results of the surgical treatment in children with Chiari malformation type I. Childs Nerv Syst 2019; 35:1911-1914. [PMID: 31209641 DOI: 10.1007/s00381-019-04247-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/30/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Our study aimed to evaluate the quality of life of the patients operated due to Chiari malformation type 1 (CM-1) in the Department of Pediatric Neurosurgery, Medical University of Silesia in Katowice. METHODS We performed a retrospective analysis of 11 patients diagnosed with CM-1 who were treated in our center in the years 2007 to 2016. There were 6 female and 5 male individuals. Short-term evaluation of the outcome was based on comparison of the presenting symptoms and radiological images before and after the surgical treatment. Long-term follow-up was carried out using survey questionnaires based on the Chicago Chiari Outcome Scale (CCOS) devised originally by Aliaga et al. RESULTS: Patients, based on their CCOS score were divided into three groups marked as "improved," "unchanged," and "worse," depending on a range of CCOS score: 13-16, 9-12, 4-8, respectively. The outcome of patients was as follows: 6 patients (55%) were evaluated as improved, and 5 (45%) as unchanged. No patient was classified as worse after surgery. Significant negative Spearman's correlation was found between the CCOS score and patients' age at the time of surgery (R = - 0.85, p = 0.0009). CONCLUSIONS The decision of whether to operate pediatric patients with CM-1 should be considered very carefully. In our department, the main indication for surgery was the occurrence of clinical symptoms. Our study revealed that in the symptomatic patients, surgery improves their quality of life measured with CCOS.
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Affiliation(s)
- Paweł Jarski
- Department of Pediatric Neurosurgery, Medical University of Silesia in Katowice, ul. Medykow 16, 40-752, Katowice, Poland
| | - Mikołaj Zimny
- Department of Pediatric Neurosurgery, Medical University of Silesia in Katowice, ul. Medykow 16, 40-752, Katowice, Poland
| | - Michał Linart
- Department of Pediatric Neurosurgery, Medical University of Silesia in Katowice, ul. Medykow 16, 40-752, Katowice, Poland
| | - Zofia Kozłowska
- Department of Pediatric Neurosurgery, Medical University of Silesia in Katowice, ul. Medykow 16, 40-752, Katowice, Poland
| | - Marek Mandera
- Department of Pediatric Neurosurgery, Medical University of Silesia in Katowice, ul. Medykow 16, 40-752, Katowice, Poland.
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47
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den Ottelander BK, de Goederen R, van Veelen MLC, van de Beeten SDC, Lequin MH, Dremmen MHG, Loudon SE, Telleman MAJ, de Gier HHW, Wolvius EB, Tjoa STH, Versnel SL, Joosten KFM, Mathijssen IMJ. Muenke syndrome: long-term outcome of a syndrome-specific treatment protocol. J Neurosurg Pediatr 2019; 24:415-422. [PMID: 31323628 DOI: 10.3171/2019.5.peds1969] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/14/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The authors evaluated the long-term outcome of their treatment protocol for Muenke syndrome, which includes a single craniofacial procedure. METHODS This was a prospective observational cohort study of Muenke syndrome patients who underwent surgery for craniosynostosis within the first year of life. Symptoms and determinants of intracranial hypertension were evaluated by longitudinal monitoring of the presence of papilledema (fundoscopy), obstructive sleep apnea (OSA; with polysomnography), cerebellar tonsillar herniation (MRI studies), ventricular size (MRI and CT studies), and skull growth (occipital frontal head circumference [OFC]). Other evaluated factors included hearing, speech, and ophthalmological outcomes. RESULTS The study included 38 patients; 36 patients underwent fronto-supraorbital advancement. The median age at last follow-up was 13.2 years (range 1.3-24.4 years). Three patients had papilledema, which was related to ophthalmological disorders in 2 patients. Three patients had mild OSA. Three patients had a Chiari I malformation, and tonsillar descent < 5 mm was present in 6 patients. Tonsillar position was unrelated to papilledema, ventricular size, or restricted skull growth. Ten patients had ventriculomegaly, and the OFC growth curve deflected in 3 patients. Twenty-two patients had hearing loss. Refraction anomalies were diagnosed in 14/15 patients measured at ≥ 8 years of age. CONCLUSIONS Patients with Muenke syndrome treated with a single fronto-supraorbital advancement in their first year of life rarely develop signs of intracranial hypertension, in accordance with the very low prevalence of its causative factors (OSA, hydrocephalus, and restricted skull growth). This illustrates that there is no need for a routine second craniofacial procedure. Patient follow-up should focus on visual assessment and speech and hearing outcomes.
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Affiliation(s)
- Bianca K den Ottelander
- Departments of1Plastic and Reconstructive Surgery and Hand Surgery, Dutch Craniofacial Center, and
| | - Robbin de Goederen
- Departments of1Plastic and Reconstructive Surgery and Hand Surgery, Dutch Craniofacial Center, and
| | | | | | - Maarten H Lequin
- 3Department of Radiology, University Medical Center-Wilhelmina Children's Hospital, Utrecht; and
| | | | | | | | | | - Eppo B Wolvius
- 7Oral and Maxillofacial Surgery, Special Dental Care and Orthodontics; and
| | - Stephen T H Tjoa
- 7Oral and Maxillofacial Surgery, Special Dental Care and Orthodontics; and
| | - Sarah L Versnel
- Departments of1Plastic and Reconstructive Surgery and Hand Surgery, Dutch Craniofacial Center, and
| | - Koen F M Joosten
- 8Pediatric Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Irene M J Mathijssen
- Departments of1Plastic and Reconstructive Surgery and Hand Surgery, Dutch Craniofacial Center, and
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48
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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.
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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
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Alexander H, Tsering D, Myseros JS, Magge SN, Oluigbo C, Sanchez CE, Keating RF. Management of Chiari I malformations: a paradigm in evolution. Childs Nerv Syst 2019; 35:1809-1826. [PMID: 31352576 DOI: 10.1007/s00381-019-04265-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/17/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Despite decades of experience and research, the etiology and management of Chiari I malformations (CM-I) continue to raise more questions than answers. Controversy abounds in every aspect of management, including the indications, timing, and type of surgery, as well as clinical and radiographic outcomes. This review aims to outline past experiences, consolidate current evidence, and recommend directions for the future management of the Chiari I malformation. METHODS A review of recent literature on the management of CM-I in pediatric patients is presented, along with our experience in managing 1073 patients who were diagnosed with CM-I over the past two decades (1998-2018) at Children's National Medical Center (CNMC) in Washington DC. RESULTS The general trend reveals an increase in the diagnosis of CM-I at younger ages with a significant proportion of these being incidental findings (0.5-3.6%) in asymptomatic patients as well as a rise in the number of patients undergoing Chiari posterior fossa decompression surgery (PFD). The type of surgical intervention varies widely. At our institution, 104 (37%) Chiari surgeries were bone-only PFD with/without outer leaf durectomy, whereas 177 (63%) were PFD with duraplasty. We did not find a significant difference in outcomes between the PFD and PFDD groups (p = 0.59). An analysis of failures revealed a significant difference between patients who underwent tonsillar coagulation versus those whose tonsils were not manipulated (p = 0.02). CONCLUSION While the optimal surgical intervention continues to remain elusive, there is a shift away from intradural techniques in favor of a simple, extradural approach (including dural delamination) in pediatric patients due to high rates of clinical and radiographic success, along with a lower complication rate. The efficacy, safety, and necessity of tonsillar manipulation continue to be heavily contested, as evidence increasingly supports the efficacy and safety of less tonsillar manipulation, including our own experience.
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Affiliation(s)
- H Alexander
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | - D Tsering
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - J S Myseros
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - S N Magge
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - C Oluigbo
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - C E Sanchez
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA. .,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA.
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50
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Abstract
PURPOSE To review the natural history of asymptomatic and symptomatic pediatric Chiari I malformations with and without syringomyelia. MATERIALS AND METHODS We reviewed the literature for case reports and case series describing the natural history of asymptomatic and symptomatic children with Chiari I malformations with and without syringomyelia. Our review included approximately 700 asymptomatic children without syringomyelia, 100 symptomatic children without syringomyelia, 22 asymptomatic children with syringomyelia, and 11 symptomatic children with syringomyelia. Symptomatic and imaging outcomes at the point of last reported follow-up were noted to describe the natural history of Chiari I malformations in children. RESULTS Our review of about 700 asymptomatic children with CM-I without syrinx revealed that most children do not exhibit new-onset symptoms (5-6%) or syrinx (2-3%). The nearly 100 published cases of symptomatic CM-I without syrinx suggest that about half of children report symptomatic improvement (48%) and few report symptomatic worsening (7%). New-onset syrinx is rarely observed (2%). Few cases have been published about asymptomatic and symptomatic CM-I with syrinx as syringomyelia are generally regarded to be an indication for surgical intervention. Nevertheless, all 22 children with asymptomatic CM-I with syringomyelia included in this study were asymptomatic at follow-up, with syrinx resolution observed in 18 children and tonsillar herniation improvement observed in 16 children. Overall, our review of asymptomatic pediatric CM-I with or without syringomyelia suggests that its natural history is much more favorable than previously acknowledged and that the literature generally favors conservative management of these cases. CONCLUSION Our review of asymptomatic pediatric CM-I with or without syringomyelia suggests that its natural history is much more favorable than previously acknowledged and that the literature generally favors conservative management of these cases. Further study of symptomatic pediatric CM-I is necessary to better understand its natural history.
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