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Perera IR, Zahed M, Moriarty S, Simmons Z, Rodriguez M, Botkin C, Dickson T, Kasper B, Fahmy K, Millard JA. Geometric morphometric analysis of the brainstem and cerebellum in Chiari I malformation. Front Neuroanat 2024; 18:1434017. [PMID: 39170851 PMCID: PMC11337868 DOI: 10.3389/fnana.2024.1434017] [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: 05/16/2024] [Accepted: 07/24/2024] [Indexed: 08/23/2024] Open
Abstract
Background Chiari I malformation (CMI) is characterized by inferior descent of the cerebellar tonsils through the foramen magnum and is associated with headache and neck pain. Many morphometric research efforts have aimed to describe CMI anatomy in the midsagittal plane using classical measurement techniques such as linear dimensions and angles. These methods are less frequently applied to parasagittal features and may fall short in quantifying more intricate anatomy with fewer distinct homologous landmarks. Methods Landmark-based geometric morphometric techniques were used to asses CMI morphology in five anatomical planes of interest. Results Significant shape differences between CMI and age/sex-matched controls were found in the midsagittal (Pseudo-F = 5.4841, p = 0.001) and axial planes through the rostral medulla (Pseudo-F = 7.6319, p = 0.001). In addition to tonsillar descent, CMI principal component 1 (PC1) scores in the midsagittal protocol were associated with marked anterior concavity of the brainstem and generalized verticality of the cerebellum with anterior rotation of its anterior lobe. In the axial medulla/cerebellum protocol, CMI PC1 scores were associated with greater anterior-posterior (A-P) dimension with loss of medial-lateral (M-L) dimension. Discussion These results suggest that CMI is associated with greater curvature of the brainstem and spinal cord, which may perturb normal neural activities and disrupt cerebrospinal fluid movements. Previous reports on the A-P diameter of the posterior fossa in CMI have conflicted; our findings of greater A-P cerebellar dimensionality with concomitant loss of width alludes to the possibility that more caudal aspects of the posterior cranial fossa are more bowl-like (homogenous in axial dimensions) and less trough-like or elongated in the M-L direction.
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Affiliation(s)
- Ishan R. Perera
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Malek Zahed
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Sydney Moriarty
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Zachary Simmons
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Maya Rodriguez
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Courtney Botkin
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Taylor Dickson
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Bradley Kasper
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Kendyl Fahmy
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
| | - Jonathan A. Millard
- Department of Biomedical Sciences, Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States
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Wang Z, Li Z, Han S, Hu X, Pang S, Li Y, Gao J. Magnetic Resonance Imaging-Related Anatomic and Functional Parameters for the Diagnosis and Prognosis of Chiari Malformation Type I: A Systematic Review and Meta-analysis. Neurospine 2024; 21:510-524. [PMID: 38955528 PMCID: PMC11224727 DOI: 10.14245/ns.2347150.575] [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: 10/30/2023] [Revised: 01/14/2024] [Accepted: 02/03/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVE Imaging parameters of Chiari malformation type I (CMI) development are not well established. This study aimed to collect evidence of general or specific imaging measurements in patients with CMI, analyze indicators that may assist in determining the severity of CMI, and guide its diagnosis and treatment. METHODS A comprehensive search was conducted across various databases including the Cochrane Library, PubMed, MEDLINE, Scopus, and Embase, covering the period from January 2002 to October 2023, following predefined inclusion criteria. Meta-analyses were performed using RevMan (ver. 5.4). We performed a quantitative summary and systematic analysis of the included studies. This study was registered in the PROSPERO (International Prospective Register of Systematic Reviews) prior to initiation (CRD42023415454). RESULTS Thirty-three studies met our inclusion criteria. The findings indicated that out of the 14 parameters examined, 6 (clivus length, basal angle, Boogard's angle, supraocciput lengths, posterior cranial fossa [PCF] height, and volume) exhibited significant differences between the CMI group and the control group. Furthermore, apart from certain anatomical parameters that hold prognostic value for CMI, functional parameters like tonsillar movement, obex displacement, and cerebrospinal fluid dynamics serve as valuable indicators for guiding the clinical management of the disease. CONCLUSION We collated and established a set of linear, angular, and area measurements deemed essential for diagnosing CMI. However, more indicators can only be analyzed descriptively for various reasons, particularly in prognostic prediction. We posit that the systematic assessment of patients' PCF morphology, volume, and other parameters at a 3-dimensional level holds promising clinical application prospects.
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Affiliation(s)
- Zairan Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhimin Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shiyuan Han
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xianghui Hu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Siyuan Pang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongning Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Department of International Medical Services, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Sachdev B, Najmi VS, Rodrigues D, Solanki GA, Afshari FT. Retroflexed dens in paediatric Chiari 1 patients and implications: Single centre retrospective study. Childs Nerv Syst 2024; 40:1449-1454. [PMID: 38217729 DOI: 10.1007/s00381-023-06264-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/19/2023] [Indexed: 01/15/2024]
Abstract
INTRODUCTION Chiari 1 malformation and hind brain hernia can be associated with skull base and craniocervical anomalies. One of the more recently associated anomalies is a retroverted or retroflexed odontoid process or dens. We conducted a retrospective study of our operated symptomatic and conservatively managed asymptomatic Chiari cohort to assess the impact of dens retroflexion on rate of revision or cerebrospinal fluid diversion following primary foramen magnum decompression (FMD). METHODS We undertook a retrospective study of all foramen magnum decompression (FMD) cases for Chiari type 1 malformation performed over a 15-year period in a single tertiary paediatric neurosurgical unit. For comparison, non-operated asymptomatic Chiari cases were considered as reference cohort. Information gathered included: demographics, age, sex, length of cerebellar tonsils below McRae's line, pB-C2 distance (a line drawn perpendicular to one drawn between the basion and the posterior aspect of the C2 body), angle of retroflexion (angle formed between a line drawn through the odontoid synchondrosis and its intersection with a line drawn from the tip of the odontoid process) and angle of retroversion (angle formed between the line drawn from the base of C2 and its intersection with a line drawn from the tip of the odontoid process). Grade of retroflexion was measured using pre-operative mid-sagittal MR images and classified as grade 0 (> 90°), grade 1 (85°-89°); grade 2 (80°-84°) and grade 3 (< 80°). The rates for redo surgery or need for cerebrospinal fluid (CSF) diversion were obtained from clinical records and compared in the operated and non-operated groups. RESULTS One hundred twenty-six Chiari 1 patients were included in this study with adequate imaging. Sixty-five patients were in the non-operated asymptomatic cohort with 61 patients in the operated symptomatic cohort. Mean age of non-operated cohort was 10.2 years with M:F ratio (30:35). Mean cerebellar tonsillar length below McRae's line was 10.3 mm. 7.7% of this cohort had associated syrinx. Mean angles of retroversion and retroflexion were 76 and 78°, respectively. Retroflexion grades included (9.2% grade 1, 35% grade 2 and 52.3% grade 3). pB-C2 distance was 6.8 mm. Mean age of operated cohort was 11.3 years, with M:F ratio (21:40). Mean cerebellar tonsillar length below McRae's line was 15 mm. 45.9% of this cohort had associated syrinx. Mean angles of retroversion and retroflexion were 73 and 74.5°, respectively. Retroflexion grades included (4.9% grade 1, 16.5% grade 2 and 78.6% grade 3). pB-C2 distance was 6.9 mm. No association was identified between retroflexion grade and rate of revision or CSF diversion following primary foramen magnum decompression. CONCLUSION The operated Chiari 1 cohort had more retroflexed dens, longer tonsils and associated syrinx compared to the non-operated asymptomatic cohort.
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Affiliation(s)
- Bobby Sachdev
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Vesta S Najmi
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Desiderio Rodrigues
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Guirish A Solanki
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Fardad T Afshari
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
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Spiessberger A, Dietz N, Gruter B, Virojanapa J. Ehlers-Danlos syndrome-associated craniocervical instability with cervicomedullary syndrome: Comparing outcome of craniocervical fusion with occipital bone versus occipital condyle fixation. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 11:287-292. [PMID: 33824558 PMCID: PMC8019109 DOI: 10.4103/jcvjs.jcvjs_166_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/11/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction: Ehlers–Danlos syndrome (EDS) predisposes to craniocervical instability (CCI) with resulting cranial settling and cervicomedullary syndrome due to ligamentous laxity. This study investigates possible differences in radiographic outcomes and operative complication rate between two surgical techniques in patients with EDS and CCI undergoing craniocervical fusion (CCF): occipital bone (OB) versus occipital condyle (OC) fixation. Methods: A retrospective search of the institutional operative database between January 07, 2017, and December 31, 2019, was conducted to identify EDS patients who underwent CCF with either OB (Group OB) or OC (Group OC) fixation. For each patient, pre- and post-operative radiographic measurements and operative complications were extracted and compared between groups (OB vs. OC): pB-C2, clivoaxial angle (CXA), tonsillar descent, C2C7 sagittal Cobb angle, C2 long axis, and operative complications. Results: Of a total of 26 patients, 13 underwent OV and 13 underwent OC fixation. Eighty-five percent of the patients underwent OC underwent fusion from occiput to C2, while the remaining 15% fusion from occiput to C3. Radiographic outcome in the OC versus OB group was preoperative measurements were similar between OC and OB group: pB-C2 8.8 mm (1.5, 6–11) versus 8.3 mm (1.7, 4–9.6), P = 0.43; CXA 128.2° (5.4, 122–136) versus 131.9° (6.8,122–141), P = 0.41; tonsillar descent 6.2 mm (4.8, 0–15) versus 2.9 mm (3.4, 0–8), P = 0.05; C2 long axis 75.2° (6.7, 58–85) versus 67.2° (21.4, 1–80), P = 0.21; postoperative change of CXA + 14.4° (8.8, 0–30) versus 16.2° (12.4, −4–38), P = 0.43; change of pB-C2 − 2.6 mm (1.8, −-5.3 to 0) versus − 1.2 mm (4, −4.6–8), P = 0.26; and postoperative C2C7 sagittal Cobb angle − 2.6° (19.5, −43–39) versus − 2.6° (11.4, −21–12). Operative complications were seen in 1 out of 13 patients (8%) versus 2 out of 13 patients (16%), P = 1. Conclusions: In EDS, patients with CCI undergoing CCF radiographic and clinical outcome were similar between those with OC versus OB fixation. Both techniques resulted in sufficient correction of pB-C2 and CXA measurements with a low complication rate.
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Affiliation(s)
- Alexander Spiessberger
- Department of Neurosurgery, Hofstra School of Medicine, North Shore University Hospital, Manhasset, NY, USA
| | - Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Basil Gruter
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Justin Virojanapa
- Department of Neurosurgery, Hofstra School of Medicine, North Shore University Hospital, Manhasset, NY, USA
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Hage D, Iwanaga J, Bui CJ, Dumont AS, Tubbs RS. Chiari 1.5 malformation, accessory odontoid synchondrosis, and ventral compression: case report. Anat Cell Biol 2021; 54:128-131. [PMID: 33191312 PMCID: PMC8017460 DOI: 10.5115/acb.20.264] [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: 10/07/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/27/2022] Open
Abstract
The pathogenesis of Chiari 1 malformations has been explained in several different ways, but extensive evidence suggests a relationship between loss of volume within the posterior cranial fossa and Chiari 1 presentations. It is important to be able to differentiate Chiari 1.5 from Chiari 1 malformations as they have similar clinical presentations, but the latter have progressed further and are characterized by caudal herniations of the brain stem through the foramen magnum. Despite the similarities of presentation, Chiari 1.5 malformations have greater rates of complications following posterior decompression surgeries, which are typically performed to relieve ventral compression. An improved understanding of the odontoid synchondroses could lead to better understanding of Chiari malformations and lead to improved treatment of patients with these presentations. Here we present a rare case of an accessory odontoid synchondrosis in a patient with a Chiari 1.5 malformation and ventral compression.
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Affiliation(s)
- Dany Hage
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - C J Bui
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
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6
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Aslan A, Rakip U, Boyacı MG, Yildizhan S, Kormaz S, Atay E, Coban N. Posterior Fossa Decompression and superficial durotomy rather than complete durotomy and duraplasty in the management of Chiari 1. Neurol Res 2020; 43:440-446. [PMID: 33357109 DOI: 10.1080/01616412.2020.1866386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective: We aimed to evaluate the effectiveness and reliability of posterior fossa decompression (PFD) and superficial durotomy in patients who underwent surgery for Chiari malformation type 1 (CM1).Materials and Methods: Our study included 54 patients with the diagnosis of CM1 who had surgery between January 2012 and June 2019. The patients were divided into two groups according to the surgical technique applied. Group 1 included 10 patients who underwent classic PFD and duraplasty, and Group 2 included 44 patients who underwent PFD and superficial durotomy surgery. Pre- and postoperative clinical signs and symptoms of each patient were recorded. Simultaneously, morphometric measurements were compared from computed tomography (CT) and magnetic resonance (MRI) images taken pre- and postoperatively. The data of the two groups were compared.Results: Of the 54 patients, 18 were male, and the mean age was 37.51 ± 15.14. A statistically significant difference was found between the pre- and postoperative morphometric measurements of the subarachnoid distance, craniocervical angle, syringomyelia, and hydrocephalus at the cerebellum level in Group 2 patients who underwent PFD and superficial durotomy surgery (p < 0.05). When morphometric measurements and clinical signs and symptoms of both groups were compared, no significant difference was found (p > 0.05). There was a 92% improvement in clinical signs and symptoms postoperatively. The complications seen in Group 1 decreased to a minimum in Group 2.Conclusion: We believe that a minimally invasive surgical method is superior to avoid major complications. We also found PFD and superficial durotomy shorten the duration of the patient's hospital stayAbbreviations: C1: cervical vertebra 1C2: cervical vertebra 2CM: Chiari malformationCM1: Chiari malformation type 1CSF: cerebrospinal fluidCT: computed tomographyMRI: magnetic resonance imagingPFD: posterior fossa decompressionUSG: ultrasonography.
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Affiliation(s)
- Adem Aslan
- Faculty of Medicine, Department of Neurosurgery, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Usame Rakip
- Faculty of Medicine, Department of Neurosurgery, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Mehmet Gazi Boyacı
- Faculty of Medicine, Department of Neurosurgery, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Serhat Yildizhan
- Faculty of Medicine, Department of Neurosurgery, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Serhat Kormaz
- Faculty of Medicine, Department of Neurosurgery, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Emre Atay
- Faculty of Medicine, Department of Anatomy, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Necmettin Coban
- Faculty of Medicine, Department of Neurosurgery, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
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Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis. Acta Neurochir (Wien) 2020; 162:1553-1563. [PMID: 32504118 PMCID: PMC7295832 DOI: 10.1007/s00701-020-04429-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/22/2020] [Indexed: 12/27/2022]
Abstract
Introduction Recently, a novel hypothesis has been proposed concerning the origin of craniovertebral junction (CVJ) abnormalities. Commonly found in patients with these entities, atlantoaxial instability has been suspected to cause both Chiari malformation type I and basilar invagination, which renders the tried and tested surgical decompression strategy ineffective. In turn, C1-2 fusion is proposed as a single solution for all CVJ abnormalities, and a revised definition of atlantoaxial instability sees patients both with and without radiographic evidence of instability undergo fusion, instead relying on the intraoperative assessment of the atlantoaxial joints to confirm instability. Methods The authors conducted a comprehensive narrative review of literature and evidence covering this recently emerged hypothesis. The proposed pathomechanisms are discussed and contextualized with published literature. Conclusion The existing evidence is evaluated for supporting or opposing sole posterior C1-2 fusion in patients with CVJ abnormalities and compared with reported outcomes for conventional surgical strategies such as posterior fossa decompression, occipitocervical fusion, and anterior decompression. At present, there is insufficient evidence supporting the hypothesis of atlantoaxial instability being the common progenitor for CVJ abnormalities. Abolishing tried and tested surgical procedures in favor of a single universal approach would thus be unwarranted.
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8
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Ishak B, Dhaliwal G, Rengifo R, McCormack E, Mathkour M, Iwanaga J, Bui CJ, Dumont AS, Tubbs RS. The Retroverted Dens: A Review of its Anatomy, Terminology, and Clinical Significance. World Neurosurg 2020; 137:304-309. [PMID: 32058112 DOI: 10.1016/j.wneu.2020.01.231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Little attention has been given to the retroverted dens within the existing medical literature. However, this finding can have a clinical impact, especially in patients with Chiari malformation type I (CM1), as it can have consequences for further treatment. METHODS Using standard search engines, we performed a literature review of anatomical, radiologic, and clinical studies as well as pathologic and surgical considerations related to the retroverted dens. Key words for our search included retroverted dens; retroflexed dens; odontoid retroflexion; posterior inclination; and tilted dens. RESULTS A retroverted dens is most commonly found in the pediatric population in relation to CM1. Research has demonstrated that high degree of dens angulation can result in significant anterior brain stem compression with the need for both anterior and posterior decompression in patients with symptomatic CM1. CONCLUSIONS A greater degree of dens angulation can lead to neurologic symptoms secondary to spinomedullary compression. Therefore, correct measurements are essential as such findings can influence presurgical planning.
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Affiliation(s)
- Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Gunveer Dhaliwal
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - Roxanne Rengifo
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - Erin McCormack
- Tulane University & Ochsner Clinic Neurosurgery Program, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mansour Mathkour
- Tulane University & Ochsner Clinic Neurosurgery Program, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA.
| | - C J Bui
- Department of Neurosurgery, Ochsner Health System, New Orleans, Louisiana, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada; Department of Neurosurgery, Tulane Center for Clinical Neurosciences, 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 Neurosurgery, Ochsner Health System, New Orleans, Louisiana, USA
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9
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Huang CWC, Chang YM, Brook A, Bezuidenhout AF, Bhadelia RA. Clinical utility of 2-D anatomic measurements in predicting cough-associated headache in Chiari I malformation. Neuroradiology 2020; 62:593-599. [PMID: 31996967 DOI: 10.1007/s00234-019-02356-0] [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: 11/21/2019] [Accepted: 12/27/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Cough-associated headache (CAH) is the most distinctive symptom of patients with Chiari I malformation (CMI) and indicates clinically significant disease. We determined the clinical utility of simple 2D anatomic measurements performed on a PACS workstation by assessing their diagnostic accuracy in predicting CAH in CMI patients. METHODS Seventy-two consecutive CMI patients (cerebellar tonsillar herniation > 5 mm) with headache seen by neurosurgeons over 6 years were included. Sagittal T1 images were used by two readers to measure: extent of tonsillar herniation, lengths of the clivus and supra-occiput, McRae and pB-C2 lines, as well as clivus-canal, odontoid retroversion, and skull base angles. Neurosurgery notes were reviewed to determine presence of CAH. Mann-Whitney test was used to compare measurements between patients with and without CAH. Predictive accuracy was assessed by receiver operating characteristic (ROC) curve. RESULTS 47/72 (65.3%) CMI patients reported CAH. Tonsillar herniation with CAH (10.2 mm, 7-14 mm; median, interquartile range) was significantly greater than those without CAH (7.9 mm, 6.3-10.9 mm; p = 0.02). Tonsillar herniation ≥ 10 mm showed sensitivity and specificity of 51% and 68%, and tonsillar herniation > 14 mm showed sensitivity and specificity of 30% and 100%, respectively, for predicting CAH. Other 2D measurements showed no statistically significant differences. CONCLUSIONS Among the 2D measurements used, only the extent of tonsillar herniation is different between CMI patients with and without CAH. Although CMI is diagnosed with tonsillar herniation of only 5 mm, we found that a much higher extent of herniation is needed to be predictive of CAH.
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Affiliation(s)
- Chi Wen C Huang
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Radiology, Wan Fang Hospital, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City, Taiwan, 110
| | - Yu-Ming Chang
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A Fourie Bezuidenhout
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rafeeque A Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. .,Department of Radiology, Beth Israel Deaconess Medical Center, WCB90, 330 Brookline Ave, Boston, MA, 02215, USA.
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10
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Hussain I, Winston GM, Goldberg J, Curri C, Williams N, Chazen JL, Greenfield JP, Baaj AA. Impact of imaging modality, age, and gender on craniocervical junction angles in adults without structural pathology. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 10:240-246. [PMID: 32089618 PMCID: PMC7008666 DOI: 10.4103/jcvjs.jcvjs_125_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/11/2020] [Indexed: 11/12/2022] Open
Abstract
Context: Multiple angles of the craniocervical junction (CCJ) are associated with pathological conditions and surgical outcomes, including the clivo-axial angle (CXA), clival slope (CS), and sagittal axis (XS). However, there are varying normative ranges reported and a paucity of data analyzing the effects of imaging modality, age, and gender on these angles. Setting and Design: A retrospective review of computed tomographic (CT) and magnetic resonance imaging (MRI) scans in fifty adults without CCJ pathology from 2014 to 2019. Methods: Age, gender, indication, and hours between scans were recorded. Two-blinded observers measured all angles. Analysis between angles from the same patient was performed using the Wilcoxon signed-rank test. Multivariable linear regression was used to test for associations between average angles and age or gender. Results: Average age and time between scans were 41.3 and 14.3 h, respectively, with 94% performed due to trauma. On CT, average CXA, CS, and XS were 162.1°, 118.4°, and 81.3°, respectively. On MRI, they were 159.8°, 117.2°, 85.3°, respectively. There were statistically significant differences between CXA and XS (P < 0.01) based on imaging modality. On CT, there was a significant increase in XS by 1.93°° and decrease in CS by 1.88°° and on MRI, there was a significant increase in CXA by 1.93°° and decrease in CS by 2.75°° corresponding with a 10-year advancement of age. Gender did not have an effect. Conclusion: There are significant differences in angular measurements of the CCJ between CT and MRI from the same patient, as well as changes in normative values based on age.
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Affiliation(s)
- Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Graham M Winston
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Jacob Goldberg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Cloe Curri
- Department of Paediatric Surgery and Transplant, Orthopaedic Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Nicholas Williams
- Department of Healthcare Policy and Research, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | - J Levi Chazen
- Department of Radiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Ali A Baaj
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
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11
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Eppelheimer MS, Biswas D, Braun AM, Houston JR, Allen PA, Bapuraj JR, Labuda R, Loth DM, Frim D, Loth F. Quantification of changes in brain morphology following posterior fossa decompression surgery in women treated for Chiari malformation type 1. Neuroradiology 2019; 61:1011-1022. [PMID: 31119343 DOI: 10.1007/s00234-019-02206-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/01/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE While 84% of patients surgically treated for Chiari malformation type 1 (CM1) demonstrate improved quality of life after posterior fossa decompression surgery, there are many risks associated with this surgery. Surgical planning to identify candidates likely to improve postoperatively may benefit from an improved understanding of morphological changes after decompression surgery. To evaluate these changes, we quantified 59 morphological parameters on 42 CM1 adult female patients before and after CM1 decompression surgery. METHODS Fifty-nine morphological parameters in the posterior cranial fossa, cranio-cervical, and intracranial regions in the midsagittal plane were evaluated using 42 T1-weighted magnetic resonance images of female CM1 patients before and after surgery, and 42 healthy female controls. Morphological differences before and after surgery were compared through the development of a technique to establish the opisthion location, a key reference point not present after surgery. RESULTS In addition to the expected reduction of the cranio-caudal dimension of the cerebellum, objective analyses showed a significant increase in the area of the cerebrospinal fluid spaces, posterior (6×) and inferior (2.6×) to the cerebellum (+ 112 ± 102 and + 140 ± 127 mm2, respectively). This increased area was primarily impacted by an average reduction in the occipital bone length of 24.5 ± 7.3 mm following surgery. Based on multiple angles, results demonstrated a 2°-4° anterior rotation of the cerebellum after surgery. CONCLUSION Our results show that decompression surgery results in significant changes in the cerebellum and cerebrospinal fluid spaces. Further investigation should determine how these morphological changes impact clinical outcomes.
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Affiliation(s)
- Maggie S Eppelheimer
- Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, OH, USA.
| | - Dipankar Biswas
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, OH, USA
| | - Audrey M Braun
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, OH, USA
| | - James R Houston
- Department of Psychology, Middle Tennessee State University, Murfreesboro, TN, USA
| | - Philip A Allen
- Conquer Chiari Research Center, Department of Psychology, The University of Akron, Akron, OH, USA
| | | | | | - Dorothy M Loth
- Conquer Chiari Research Center, Department of Psychology, The University of Akron, Akron, OH, USA
| | - David Frim
- Department of Neurosurgery, University of Chicago, Chicago, IL, USA
| | - Francis Loth
- Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, OH, USA
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, OH, USA
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12
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Lou Y, Yang J, Wang L, Chen X, Xin X, Liu Y. The clinical efficacy study of treatment to Chiari malformation type I with syringomyelia under the minimally invasive surgery of resection of Submeningeal cerebellar Tonsillar Herniation and reconstruction of Cisterna magna. Saudi J Biol Sci 2019; 26:1927-1931. [PMID: 31885484 PMCID: PMC6921303 DOI: 10.1016/j.sjbs.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/16/2019] [Accepted: 07/24/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose Discuss the clinical efficacy of treatment to Chiari malformation type I with syringomyelia under the minimally invasive surgery of resection of Submeningeal Cerebellar Tonsillar Herniation and reconstruction of Cisterna magna. Methods 130 Chiari malformation type I with syringomyelia patients, divided into treatment group, literature group and control group, were collected to be treated under the monitoring of ultrasound in the surgery. Results 6 months after operation, the lesions were decreased or disappeared, the symptoms were relieved obviously. According to MRI and Mimics 17.0 software, the volumes of Cisterna magna increased distinctly (P < 0.001), the proportions of brain in foramen magnum region were decreased (P < 0.001). Assessed by CCOS scale and Tator methods, the improvement rates of treatment group were 97.7% and 94.6%, the literature group and control group were 82.2% and 77.8%, respectively. Conclusion The efficacy of Chiari malformation type I with syringomyelia under the minimally invasive surgery of resection of Submeningeal Cerebellar Tonsillar Herniation and reconstruction of Cisterna magna is remarkable, and the complications are fewer. This surgery emphasizes recovery of tonsil of cerebellum and reconstruction of Cisterna magna and the circulation path of cerebrospinal fluid, which is a safe and efficient treatment.
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Affiliation(s)
- Yongli Lou
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Jichao Yang
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Liuxiang Wang
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Xi Chen
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Xin Xin
- Department of Neurospinal Surgery, The Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Yong Liu
- Department of Neurospinal Surgery, Yuquan Hospital of Tsinghua University, Beijing 10000, China
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He Y, Zheng T, Wu B, Wang J. Significance of Modified Clivoaxial Angles in the Treatment of Adult Chiari Malformation Type I. World Neurosurg 2019; 130:e1004-e1014. [PMID: 31306845 DOI: 10.1016/j.wneu.2019.07.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate the influence of modified clivoaxial angle (MCAA) on the surgical planning and outcome in adult patients with Chiari malformation type I. METHODS Clinical data of 268 adult patients undergoing posterior fossa decompression without (PFD) or with duraplasty (PFDD) or with resection of tonsils (RT) for Chiari malformation type I over 10 years were reviewed retrospectively, with outcome evaluated by Chicago Chiari Outcome Scale (CCOS) score. By means of receiver operating characteristic curve, the threshold of MCAA was calculated to stratify the patients. RESULTS MCAA was positively correlated with CCOS score. In the MCAA ≤ 127° group (n = 57) with severe ventral cervicomedullary compression (VCMC), CCOS score of PFD, PFDD, and RT was 11.00, 11.06, and 12.42 (P < 0.05), respectively. In the 127° < MCAA ≤ 138° group (n = 87) with moderate VCMC, CCOS score of PFD, PFDD, and RT was 11.71, 12.72, and 13.00 (P < 0.01), respectively. In the MCAA > 138° group (n = 124) with mild or no VCMC, CCOS score of PFD, PFDD, and RT was 13.19, 13.90, and 13.67 (P < 0.05), respectively. The mean MCAA increased by 4.4° postoperatively (P < 0.05), which was positively associated with syringomyelia shrinkage. CONCLUSIONS MCAA may play a role in guiding the surgical treatment and predicting the prognosis in adult CMI patients. The larger the MCAA, the less invasive surgery is preferred with higher CCOS. PFDD should be the first choice in patients with mild or no VCMC (MCAA >138°) and RT in patients with moderate VCMC (127° < MCAA ≤ 138°). For patients with severe VCMC (MCAA ≤ 127°), RT could be considered as the primary surgery with awareness of the possible insufficiency of posterior decompression alone.
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Affiliation(s)
- Yunsen He
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, People's Republic of China
| | - Tao Zheng
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, People's Republic of China
| | - Bo Wu
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, People's Republic of China.
| | - Jiyang Wang
- Department of Neurosurgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, People's Republic of China
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14
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Liu Z, Hao Z, Hu S, Zhao Y, Li M. Predictive value of posterior cranial fossa morphology in the decompression of Chiari malformation type I: A retrospective observational study. Medicine (Baltimore) 2019; 98:e15533. [PMID: 31083202 PMCID: PMC6531207 DOI: 10.1097/md.0000000000015533] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Posterior fossa decompression (PFD) is the standard procedure for the treatment of Chiari malformation type I (CMI). Although most patients have satisfactory surgical outcomes, some show no improvement or even a worsening of symptoms. Patient selection is thought to account for these different surgical outcomes. Our aim was to evaluate the predictive value of the preoperative posterior cranial fossa (PCF) morphology on the efficacy of PFD.Data from 39 CMI patients with CMI-related symptoms who underwent occipital foramen enlargement + C-1 laminectomy + enlarged duraplasty were retrospectively collected from January 2011 to May 2018. The patients were divided into improved and unimproved groups according to the modified Chicago Chiari Outcome Scale. Demographic information and clinical history, including preoperative comorbidities and clinical manifestations, were recorded for the 2 groups and compared. PCF morphology was assessed based on 13 linear, 8 angular, 4 areal parameters and 4 ratios related to these liner and areal parameters. The data were then analyzed statistically.Of the 39 patients with CMI, 24 showed improvement after PFD (61.5%), whereas the remaining 15 patients showed no improvement (38.5%). The preoperative symptoms lasted 1 to 240 months, with a median of 24 months. The follow-up period ranged from 2 to 82 months, with a median of 27 months. The improved and unimproved groups differed significantly with regard to upper limb numbness (OR = 10, P = .02) and upper limb weakness (OR = 4.86, P = .02). The 2 groups did not differ significantly with regard to any morphological parameters such as tonsillar descent, syrinx size.Preoperative upper limb numbness and upper limb weakness are unfavorable factors that influence the outcome of PFD in patients with CMI. However, the morphology of PCF cannot predict the response to PFD in patients with CMI.
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15
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Ottenhausen M, Alalade AF, Rumalla K, Nair P, Baaj A, Hartl R, Kacker A, Greenfield JP, Anand VK, Schwartz TH. Quality of Life After Combined Endonasal Endoscopic Odontoidectomy and Posterior Suboccipital Decompression and Fusion. World Neurosurg 2018; 116:e571-e576. [PMID: 29775769 DOI: 10.1016/j.wneu.2018.05.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/05/2018] [Accepted: 05/07/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Basilar invagination can result from systemic diseases that can weaken structural integrity of the craniocervical junction. Definitive treatment often requires ventral decompression and posterior decompression and fusion. Endonasal odontoidectomy is a relatively new minimal access procedure; quality of life (QOL) after this procedure has not been reported. METHODS We reviewed a consecutive database of endonasal odontoidectomy cases and identified patients having posterior decompression and fusion. Two QOL questionnaires were administered postoperatively: Sino-Nasal Outcome Test and 36-Item Short Form Survey. Comparisons with other endonasal or Chiari procedures were performed. RESULTS The study comprised 14 patients; 79% had Chiari malformation in addition to basilar invagination. Mean follow-up was 17.2 months. Symptomatic improvement occurred in 78.6% after surgery. Average postoperative Sino-Nasal Outcome Test scores were 39.2 ± 17.93, with worst scores in areas related to fatigue and sleep patterns but not nasal function. 36-Item Short Form Survey scores were lower in areas of physical function and general health but better for emotional health and pain. Compared with patients undergoing Chiari malformation surgery without endonasal odontoid resection or fusion, patients undergoing odontoidectomy had higher QOL in areas of role emotional, emotional well-being, and pain but worse QOL in general health and role physical. CONCLUSIONS Patients undergoing posterior decompression and fusion with endonasal odontoidectomy do well after surgery with respect to nasal function and emotional health. Patients who also have severe basilar invagination associated with systemic diseases demonstrate reduced QOL after surgery in areas of physical function and sleep leading to fatigue, irritability, and concentration difficulty, likely related to their systemic disease.
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Affiliation(s)
- Malte Ottenhausen
- Department of Neurosurgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA; Department of Neurosurgery, Universitätsmedizin Mainz, Mainz, Germany
| | - Andrew F Alalade
- Department of Neurosurgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Prakash Nair
- Department of Neurosurgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Ali Baaj
- Department of Neurosurgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Roger Hartl
- Department of Neurosurgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Ashutosh Kacker
- Department of Otolaryngology, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Jeffrey P Greenfield
- Department of Neurosurgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Vijay K Anand
- Department of Otolaryngology, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA; Department of Otolaryngology, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA; Department of Neuroscience, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA.
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16
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Eppelheimer MS, Houston JR, Bapuraj JR, Labuda R, Loth DM, Braun AM, Allen NJ, Heidari Pahlavian S, Biswas D, Urbizu A, Martin BA, Maher CO, Allen PA, Loth F. A Retrospective 2D Morphometric Analysis of Adult Female Chiari Type I Patients with Commonly Reported and Related Conditions. Front Neuroanat 2018; 12:2. [PMID: 29403363 PMCID: PMC5785719 DOI: 10.3389/fnana.2018.00002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/05/2018] [Indexed: 02/02/2023] Open
Abstract
Purpose: Researchers have sought to better understand Chiari type I malformation (CMI) through morphometric measurements beyond tonsillar position (TP). Soft tissue and bone structures within the brain and craniocervical junction have been shown to be different for CMI patients compared to healthy controls. Yet, several morphological characteristics have not been consistently associated with CMI. CMI is also associated with different prevalent conditions (PCs) such as syringomyelia, pseudotumor, Ehlers-Danlos syndrome (EDS), scoliosis, and craniocervical instability. The goal of this study was two-fold: (1) to identify unique morphological characteristics of PCs, and (2) to better explain inconsistent results from case-control comparisons of CMI. Methods: Image, demographic, and PC information was obtained through the Chiari1000, a self-report web-accessed database. Twenty-eight morphometric measurements (MMs) were performed on the cranial MR images of 236 pre-surgery adult female CMI participants and 140 female healthy control participants. Custom software was used to measure 28 structures within the posterior cranial fossa (PCF) compartment, craniocervical junction, oral cavity, and intracranial area on midsagittal MR images for each participant. Results: Morphometric analysis of adult females indicated a smaller McRae line length in CMI participants with syringomyelia compared to those without syringomyelia. TP was reduced in CMI participants with EDS than those without EDS. Basion to posterior axial line was significantly longer in CMI participants with scoliosis compared to those without scoliosis. No additional MMs were found to differ between CMI participants with and without a specific PC. Four morphometric differences were found to be consistently different between CMI participants and healthy controls regardless of PC: larger TP and a smaller clivus length, fastigium, and corpus callosum height in CMI participants. Conclusion: Syringomyelia, EDS, and scoliosis were the only PCs that showed significant morphometric differences between CMI participants. Additionally, four midsagittal MR-based MMs were found to be significantly different between healthy controls and CMI participants regardless of the presence of one or more PCs. This study suggests that the prevalence of comorbid conditions are not strongly related to CMI morphology, and that inconsistent findings in the radiographic literature cannot be explained by varying prevalence of comorbid conditions in CMI study samples.
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Affiliation(s)
- Maggie S Eppelheimer
- Department of Biomedical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, United States
| | - James R Houston
- Department of Psychology, Conquer Chiari Research Center, University of Akron, Akron, OH, United States
| | - Jayapalli R Bapuraj
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States
| | | | - Dorothy M Loth
- Department of Psychology, Conquer Chiari Research Center, University of Akron, Akron, OH, United States
| | - Audrey M Braun
- Department of Mechanical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, United States
| | - Natalie J Allen
- Department of Mechanical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, United States
| | - Soroush Heidari Pahlavian
- Department of Mechanical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, United States
| | - Dipankar Biswas
- Department of Mechanical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, United States
| | - Aintzane Urbizu
- Department of Mechanical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, United States.,Duke University Medical Center, Duke Molecular Physiology Institute, Durham, NC, United States
| | - Bryn A Martin
- Department of Biological Engineering, University of Idaho, Moscow, ID, United States
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Philip A Allen
- Department of Psychology, Conquer Chiari Research Center, University of Akron, Akron, OH, United States
| | - Francis Loth
- Department of Biomedical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, United States.,Department of Mechanical Engineering, Conquer Chiari Research Center, University of Akron, Akron, OH, United States
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17
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Thakar S, Sivaraju L, Jacob KS, Arun AA, Aryan S, Mohan D, Sai Kiran NA, Hegde AS. A points-based algorithm for prognosticating clinical outcome of Chiari malformation Type I with syringomyelia: results from a predictive model analysis of 82 surgically managed adult patients. J Neurosurg Spine 2017; 28:23-32. [PMID: 29125433 DOI: 10.3171/2017.5.spine17264] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although various predictors of postoperative outcome have been previously identified in patients with Chiari malformation Type I (CMI) with syringomyelia, there is no known algorithm for predicting a multifactorial outcome measure in this widely studied disorder. Using one of the largest preoperative variable arrays used so far in CMI research, the authors attempted to generate a formula for predicting postoperative outcome. METHODS Data from the clinical records of 82 symptomatic adult patients with CMI and altered hindbrain CSF flow who were managed with foramen magnum decompression, C-1 laminectomy, and duraplasty over an 8-year period were collected and analyzed. Various preoperative clinical and radiological variables in the 57 patients who formed the study cohort were assessed in a bivariate analysis to determine their ability to predict clinical outcome (as measured on the Chicago Chiari Outcome Scale [CCOS]) and the resolution of syrinx at the last follow-up. The variables that were significant in the bivariate analysis were further analyzed in a multiple linear regression analysis. Different regression models were tested, and the model with the best prediction of CCOS was identified and internally validated in a subcohort of 25 patients. RESULTS There was no correlation between CCOS score and syrinx resolution (p = 0.24) at a mean ± SD follow-up of 40.29 ± 10.36 months. Multiple linear regression analysis revealed that the presence of gait instability, obex position, and the M-line-fourth ventricle vertex (FVV) distance correlated with CCOS score, while the presence of motor deficits was associated with poor syrinx resolution (p ≤ 0.05). The algorithm generated from the regression model demonstrated good diagnostic accuracy (area under curve 0.81), with a score of more than 128 points demonstrating 100% specificity for clinical improvement (CCOS score of 11 or greater). The model had excellent reliability (κ = 0.85) and was validated with fair accuracy in the validation cohort (area under the curve 0.75). CONCLUSIONS The presence of gait imbalance and motor deficits independently predict worse clinical and radiological outcomes, respectively, after decompressive surgery for CMI with altered hindbrain CSF flow. Caudal displacement of the obex and a shorter M-line-FVV distance correlated with good CCOS scores, indicating that patients with a greater degree of hindbrain pathology respond better to surgery. The proposed points-based algorithm has good predictive value for postoperative multifactorial outcome in these patients.
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Affiliation(s)
- Sumit Thakar
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | - Laxminadh Sivaraju
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | | | - Aditya Atal Arun
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | - Saritha Aryan
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | - Dilip Mohan
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
| | | | - Alangar S Hegde
- 1Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore; and
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18
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Houston JR, Eppelheimer MS, Pahlavian SH, Biswas D, Urbizu A, Martin BA, Bapuraj JR, Luciano M, Allen PA, Loth F. A morphometric assessment of type I Chiari malformation above the McRae line: A retrospective case-control study in 302 adult female subjects. J Neuroradiol 2017; 45:23-31. [PMID: 28826656 DOI: 10.1016/j.neurad.2017.06.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 06/23/2017] [Accepted: 06/30/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Type I Chiari malformation (CMI) is a radiologically-defined structural dysmorphism of the hindbrain and posterior cranial fossa (PCF). Traditional radiographic identification of CMI relies on the measurement of the cerebellar tonsils in relation to the foramen magnum with or without associated abnormalities of the neuraxis. The primary goal of this retrospective study was to comprehensively assess morphometric parameters above the McRea line in a group of female CMI patients and normal controls. MATERIAL AND METHODS Twenty-nine morphological measurements were taken on 302 mid-sagittal MR images of adult female CMI patients (n=162) and healthy controls (n=140). All MR images were voluntarily provided by CMI subjects through an online database and control participant images were obtained through the Human Connectome Project and a local hospital system. RESULTS Analyses were performed on the full dataset of adult female MR images and a restricted dataset of 229 participants that were equated for age, race, and body mass index. Eighteen group differences were identified in the PCF area that we grouped into three clusters; PCF structures heights, clivus angulation, and odontoid process irregularity. Fourteen group differences persisted after equating our CMI and control groups on demographic characteristics. CONCLUSION PCF structures reliably differ in adult female CMI patients relative to healthy controls. These differences reflect structural abnormalities in the osseous and soft tissue structures of the clivus, odontoid process, and cerebellum. Clinical and pathophysiological implications are discussed.
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Affiliation(s)
- James R Houston
- Department of Psychology, Conquer Chiari Research Center, The University of Akron, Akron, OH, 44325, USA
| | - Maggie S Eppelheimer
- Department of Biomedical Engineering, Conquer Chiari Research Center, The University of Akron, Akron, OH, 44325, USA
| | - Soroush Heidari Pahlavian
- Department of Mechanical Engineering, Conquer Chiari Research Center, The University of Akron, Akron, OH, 44325, USA
| | - Dipankar Biswas
- Department of Mechanical Engineering, Conquer Chiari Research Center, The University of Akron, Akron, OH, 44325, USA
| | - Aintzane Urbizu
- Department of Mechanical Engineering, Conquer Chiari Research Center, The University of Akron, Akron, OH, 44325, USA; Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, 27703, USA
| | - Bryn A Martin
- Department of Biological Engineering, University of Idaho, Moscow, ID, 83844, USA
| | - Jayapalli Rajiv Bapuraj
- Department of Radiology, Division of Neuroradiology, University of Michigan Health System, Ann Arbor, MI, 48103, USA
| | - Mark Luciano
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Philip A Allen
- Department of Psychology, Conquer Chiari Research Center, The University of Akron, Akron, OH, 44325, USA
| | - Francis Loth
- Department of Biomedical Engineering, Conquer Chiari Research Center, The University of Akron, Akron, OH, 44325, USA; Department of Mechanical Engineering, Conquer Chiari Research Center, The University of Akron, Akron, OH, 44325, USA.
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19
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Gad KA, Yousem DM. Syringohydromyelia in Patients with Chiari I Malformation: A Retrospective Analysis. AJNR Am J Neuroradiol 2017; 38:1833-1838. [PMID: 28684453 DOI: 10.3174/ajnr.a5290] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 05/06/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The association of syringohydromyelia with Chiari I malformation has a wide range, between 23% and 80% of cases in the current literature. In our experience, this range might be overestimated compared with our observations in clinical practice. Because there is an impact of Chiari I malformation-associated syringohydromyelia on morbidity and surgical intervention, its diagnosis is critical in this patient population. Identifying related variables on the basis of imaging would also help identify those patients at risk of syrinx formation during their course of disease. MATERIALS AND METHODS We performed a retrospective analysis of the MR imaging studies of 108 consecutive cases of Chiari I malformation. A multitude of factors associated with syrinx formation were investigated, including demographic, morphometric, osseous, and dynamic CSF flow evaluation. RESULTS Thirty-nine of 108 (36.1%) patients with Chiari I malformation had syringohydromyelia. On the basis of receiver operating characteristic curve analysis, a skull base angle (nasion-sella-basion) of 135° was found to be a statistically significant classifier of patients with Chiari I malformation with or without syringohydromyelia. Craniocervical junction osseous anomalies (OR = 4.3, P = .001) and a skull base angle of >135° (OR = 4.8, P = .0006) were most predictive of syrinx formation. Pediatric patients (younger than 18 years of age) who developed syringohydromyelia were more likely to have associated skull base osseous anomalies than older individuals (P = .01). CONCLUSIONS Our findings support evidence of the role of foramen magnum blockage from osseous factors in the development of syringohydromyelia in patients with Chiari I malformation.
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Affiliation(s)
- K A Gad
- From the Division of Neuroradiology (K.A.G., D.M.Y.), The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland.,Radiology Department (K.A.G.), Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - D M Yousem
- From the Division of Neuroradiology (K.A.G., D.M.Y.), The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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