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Frič R, Bryne E, Warsza B, Due-Tønnessen BJ, Eide PK. Preoperative estimation of intracranial compliance in symptomatic children with Chiari malformation type 1: impact on outcome and risk of complications. Acta Neurochir (Wien) 2024; 166:22. [PMID: 38236374 PMCID: PMC10796482 DOI: 10.1007/s00701-024-05897-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/10/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND The role of reduced intracranial compliance (ICC) in the outcome after foramen magnum decompression (FMD) was demonstrated in adults with Chiari malformation Type 1 (CMI). However, similar observations from children treated for CMI are missing. METHODS We reviewed pediatric cases of CMI referred to FMD between 2006 and 2022. Children with clinical and/or radiological signs suggesting reduced ICC (Group A) underwent overnight measurements of the pulsatile intracranial pressure (ICP): mean ICP wave amplitude (MWA) served as a surrogate marker of ICC. Children with more typical symptoms of CMI (Group B) underwent FMD without preoperative ICC estimation. This study presents the clinical, radiological, and outcome differences between these groups. RESULTS Sixty-four children (mean age 11.1 ± 4.3 years) underwent FMD: In Group A (n = 30), the finding of reduced ICC as estimated from preoperative ICP measurement resulted in CSF diversion (ventriculoperitoneal shunt) before FMD in 11 children. Two patients required shunt due to complications after FMD (total shunt rate 43%). In Group B (n = 34) treated with FMD without preoperative ICC estimation, five children (15%) required shunting due to complications. In Group A, we found a significantly higher frequency of headache, nausea, fatigue, and dizziness. The outcome assessed by the modified Chicago Chiari Outcome Scale (mean follow-up 83 ± 57 months) was comparable between the groups, but the complication rate after FMD was significantly lower in Group A (7% vs. 32%; p = 0.011). The number of procedures (ICP measurement, FMD, shunt, re-do FMD, shunt revisions) was significantly higher in Group A (2.6 ± 0.9 vs. 1.5 ± 1.1 per patient; p < 0.001). CONCLUSION In symptomatic children with CMI, the preoperative estimation of ICC from the overnight measurement of pulsatile ICP was more reliable for identifying those with reduced ICC than clinical and radiological assessment alone. When children with abnormally reduced ICC were identified and treated with CSF diversion before FMD, the complication rate was significantly reduced.
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Affiliation(s)
- Radek Frič
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, N-0424, Oslo, Norway.
| | - Eline Bryne
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, N-0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bogna Warsza
- Department of Radiology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Bernt Johan Due-Tønnessen
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, N-0424, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, N-0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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2
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He Y, Liu P, Zhang M, Guo L, Zheng T, Yao Y, Zheng Q, Bao M, Jiang C, Wu B, Liu J. A Novel Craniocervical Junction Compression Severity Index-Based Grading System for Multidirectional Quantification of the Biomechanics at Foramen Magnum of Chiari Malformation Type I. J Neurol Surg B Skull Base 2023; 84:616-628. [PMID: 37854538 PMCID: PMC10581831 DOI: 10.1055/a-1932-8692] [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: 03/30/2022] [Accepted: 08/23/2022] [Indexed: 10/15/2022] Open
Abstract
Objective This study aimed to establish a novel grading system, based on the craniovertebral junction compression severity index (CVJCSI) for multidirectional quantification at the foramen magnum plane for Chiari malformation type I (CMI). Methods The CVJCSI grading system was established to stratify patients based on the ventral (modified clivoaxial angle < 138°), dorsal (tonsil herniation), and central (brainstem herniation) CVJ (craniovertebral junction) compression, the CVJCSI grading system was established to stratify patients. The optimal surgical method for each grade was recommended by intragroup comparisons regarding the efficacy of the three operations. Finally, according to the CVJCSI grading system, a prospective validation trial was performed and surgically treated for internal validation. Results Based on the retrospective study ( n = 310), the CVJCSI included six grades: I: syrinx alone without compression; II: dorsal compression; III: dorsal and central compression; IV: ventral compression; V: dorsal and ventral compression; and VI: ventral, dorsal, and central compression. Among all available variables, only the CVJCSI and surgical methods significantly affected the CCOS. The CCOS scores, overall and for each CVJCSI grade, increased in the prospective cohort ( n = 42) compared with that in the retrospective analysis. Conclusions The CVJCSI can be used to stratify CMI patients. The higher the CVJCSI grade, the more severe the CVJ compression and the worse posterior fossa deformity. Meanwhile, the CVJCSI was negatively correlated with the CCOS. The lower the CVJCSI grade, the better the response to surgery, and the less-invasive surgical procedures were warranted. Finally, the prospective cohort study validated the proposed CVJCSI-based surgical protocols.
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Affiliation(s)
- Yunsen He
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Ping Liu
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Mengjun Zhang
- Department of Neuropsychology, Sichuan Provincial Center for Mental Health, Sichuan, People's Republic of China
| | - Lili Guo
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Tao Zheng
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Yuanpeng Yao
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Qiang Zheng
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Mingbin Bao
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Chuan Jiang
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Bo Wu
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Jinping Liu
- Department of Neurosurgery, Sichuan Provincial People's Hospital Ringgold Standard Institution, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
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Akyuz ME, Karadag MK, Sahin MH. Effect of modified clivoaxial angle on surgical decision making and treatment outcomes in patients with Chiari malformation type 1. Front Surg 2023; 10:1143086. [PMID: 37215352 PMCID: PMC10196391 DOI: 10.3389/fsurg.2023.1143086] [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: 01/12/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Chiari malformation type 1 (CM1), a complex pathological developmental disorder of the craniovertebral junction, is typically characterized by herniation of the cerebellar tonsils from the foramen magnum. Treatment using posterior fossa decompression alone without taking the ventral cervico-medullary compression into consideration may lead to unsatisfactory treatment outcomes. The current study evaluated the utility of the modified clivoaxial angle (MCAA) in assessing ventral compression and also examined its effect on treatment outcomes. Method This retrospective study included 215 adult patients who underwent surgical treatment for CM1 at one medical center over a 10-year period. The following surgical techniques were used to decompress the posterior fossa: (a) PFD: bone removal only; (b) PFDwD: bone removal with duraplasty; and (c) CTR: cerebellar tonsil resection. The morphometric measurements of the craniovertebral junction (including MCAA) were recorded using preoperative images, and the postoperative clinical status was evaluated using the Chicago Chiari outcome scale (CCOS). Results MCAA was positively correlated with the CCOS score and also independently predicted treatment outcome. To enable Receiver operating characteristic (ROC) curve analysis of CCOS scores, the patients were divided into three groups based on the MCAA cut-off values, as follows: (a) severe (n = 43): MCAA ≤ 126; (b) moderate (n = 86): 126 < MCAA ≤ 138; and (c) mild (n = 86): MCAA > 138. Group a exhibited severe ventral cervico-medullary compression (VCMC), and their CCOS scores for the PFD, PFDwD, and CTR groups were 11.01 ± 1.2, 11.24 ± 1.3, and 13.01 ± 1.2, respectively (p < 0.05). The CCOS scores increased with widening of the MCAA angle in all surgical groups (p < 0.05). Furthermore, patients with mild MCAA (>138°) exhibited 78% regression of syringomyelia, and this was significantly greater than that observed in the other groups. Discussion MCAA can be used in the selection of appropriate surgical techniques and prediction of treatment outcomes, highlighting the importance of preoperative evaluation of ventral clivoaxial compression in patients with CM1.
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Karadag MK, Akyuz ME, Sahin MH. The role of ONSD in the assessment of headache associated with Chiari malformation type 1. Front Neurol 2023; 14:1127279. [PMID: 36824423 PMCID: PMC9941673 DOI: 10.3389/fneur.2023.1127279] [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: 12/19/2022] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Abstract
Background Cough associated headache is the most common symptom in Chiari malformation type 1 (CM1). However, its pathophysiology and treatment are not clear. The aim of this study was to investigate the relationship between optic nerve sheath diameter (ONSD), an indicator of intracranial pressure, and headache and to investigate its predictive value on postoperative outcome. Methods In symptomatic CM1 patients, craniovertebral junction morphometric measurements and ONSD measurements were made from preoperative MR images, and headache intensities and characteristics were evaluated. After different surgical procedures, the clinical characteristics of the patients were evaluated according to the Chicago Chiari Outcome Scale, the change in headache intensity was assessed and the relationship with ONSD was evaluated. Results Preoperative headache intensity was significantly correlated with ONSD measurement (p < 0.01). Modified clivoaxial angle and ONSD were independent predictors of postoperative clinical outcome (p < 0.01). The procedure that achieved the greatest surgical enlargement of the foramen Magnum stenosis provided the best clinical outcome. Postoperative reduction in headache intensity and ONS diameter were correlated (p < 0.01). Conclusion The fact that ONSD is found to be wide in the preoperative period in CM1 patients indicates that the intracranial pressure is permanently high. This diameter increase is correlated with headache and is a valuable guide in the selection of the appropriate treatment method.
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Soleman J, Roth J, Constantini S. Chiari Type 1 Malformation and Syringomyelia in Children: Classification and Treatment Options. Adv Tech Stand Neurosurg 2023; 48:73-107. [PMID: 37770682 DOI: 10.1007/978-3-031-36785-4_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Chiari type 1 malformation (CIM) is defined as tonsillar ectopia of >5 mm, while syringomyelia (SM) is defined as a cerebrospinal fluid (CSF)-filled cavity larger than 3 mm dissecting the spinal cord. Over the last decades, our understanding of these pathologies has grown; however, many controversies still exist almost in every aspect of CIM and SM, including etiology, indication for treatment, timing of treatment, surgical technique, follow-up regime, and outcome. This chapter provides a comprehensive overview on different aspects of CIM and SM and on the still existing controversies, based on the evidence presently available. Future directions for clinical research concerning CIM and SM treatment and outcome are elaborated and discussed as well.
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Affiliation(s)
- Jehuda Soleman
- Department of Pediatric Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Children's University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel.
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Das KK, Gosal JS, Khatri D, Srivastava AK. Letter to the Editor. Outcome prediction and assessment after surgery in CM-I: there is more to it than meets the eye. J Neurosurg 2022; 136:934-935. [PMID: 34653975 DOI: 10.3171/2021.5.jns211329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Kuntal Kanti Das
- 1Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | | | - Arun K Srivastava
- 4Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Savchuk S, Jin MC, Choi S, Kim LH, Quon JL, Bet A, Prolo LM, Hong DS, Mahaney KB, Grant GA. Incorporating patient-centered quality-of-life measures for outcome assessment after Chiari malformation type I decompression in a pediatric population: a pilot study. J Neurosurg Pediatr 2022; 29:200-207. [PMID: 34715646 PMCID: PMC10193496 DOI: 10.3171/2021.8.peds21228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Optimal management of pediatric Chiari malformation type I (CM-I) is much debated, chiefly due to the lack of validated tools for outcome assessment, with very few tools incorporating patient-centered measures of health-related quality of life (HRQOL). Although posterior fossa decompression (PFD) benefits a subset of patients, prediction of its impact across patients is challenging. The primary aim of this study was to investigate the role of patient-centered HRQOL measures in the assessment and prediction of outcomes after PFD. METHODS The authors collected HRQOL data from a cohort of 20 pediatric CM-I patients before and after PFD. The surveys included assessments of selected Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and were used to generate the PROMIS preference (PROPr) score, which is a measure of HRQOL. PROMIS is a reliable standardized measure of HRQOL domains such as pain, fatigue, depression, and physical function, which are all relevant to CM-I. The authors then compared the PROPr scores with Chicago Chiari Outcome Scale (CCOS) scores derived from time-matched clinical documentation. Finally, the authors used the PROPr scores as an outcome measure to predict postsurgical HRQOL improvement at 1 year on the basis of patient demographic characteristics, comorbidities, and radiological and physical findings. The Wilcoxon signed-rank test, Mann-Whitney U-test, and Kendall's correlation were used for statistical analysis. RESULTS Aggregate analysis revealed improvement of pain severity after PFD (p = 0.007) in anatomical patterns characteristic of CM-I. Most PROMIS domain scores trended toward improvement after surgery, with anxiety and pain interference reaching statistical significance (p < 0.002 and p < 0.03, respectively). PROPr scores also significantly improved after PFD (p < 0.008). Of the baseline patient characteristics, preexisting scoliosis was the most accurate negative predictor of HRQOL improvement after PFD (median -0.095 vs 0.106, p < 0.001). A correlation with modest magnitude (Kendall's tau range 0.19-0.47) was detected between the patient-centered measures and CCOS score. CONCLUSIONS The authors observed moderate improvement of HRQOL, when measured using a modified panel of PROMIS question banks, in this pilot cohort of pediatric CM-I patients after PFD. Further investigations are necessary to validate this tool for children with CM-I and to determine whether these scores correlate with clinical and radiographic findings.
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Affiliation(s)
- Solomiia Savchuk
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael C. Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Stephanie Choi
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Lily H. Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Jennifer L. Quon
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Anthony Bet
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Laura M. Prolo
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - David S. Hong
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Kelly B. Mahaney
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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Thakar S, Kanneganti V, Talla Nwotchouang BS, Salem SJ, Eppelheimer M, Loth F, Allen PA, Aryan S, Hegde AS. Are Two-Dimensional Morphometric Measures Reflective of Disease Severity in Adult Chiari I Malformation? World Neurosurg 2022; 157:e497-e505. [PMID: 34710575 PMCID: PMC8692430 DOI: 10.1016/j.wneu.2021.10.138] [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: 06/18/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Two-dimensional (2D) morphometric measures have been previously used to diagnose Chiari I malformation (CMI) and distinguish patients from healthy subjects. There is, however, a paucity of literature regarding whether morphometric differences exist across the range of CMI disease severity. We evaluated whether 2D morphometrics demonstrate significant changes across standardized grades of CMI severity in adults. METHODS This retrospective observational study comprised 76 patients with symptomatic CMI with or without syringomyelia. Patients matched for age, sex, and body mass index were selected from each of the 3 severity grades of the Chiari Severity Index (CSI). The study used 17 2D craniocervical and posterior fossa morphometric variables that were previously found to differentiate patients with CMI from healthy subjects. The measurements were performed on midsagittal T1-weighted magnetic resonance imaging sequences using 2 custom in-house software tools, MorphPro and CerePro, and compared across CSI grades. RESULTS Analysis of variance showed that none of the 17 morphometric variables were significantly different across the 3 CSI grades (P > 0.003). Bayes factor 10 scores ranged from 0.11 to 0.82. Of variables, 9 had Bayes factor 10 scores between 0.10 and 0.30, while 8 had scores between 0.30 and 1. None of the Bayes factor 10 scores provided support for the alternative hypothesis that the morphometric measures differed across the CSI grades. CONCLUSIONS Our study indicated that 2D morphometrics are not reflective of CMI disease severity as indicated by the CSI grading system. The findings of our study support the need for further investigation into whether non-2D morphometric variables can be used as markers of disease severity.
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Affiliation(s)
- Sumit Thakar
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Vidyasagar Kanneganti
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | | | - Sara J. Salem
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, Ohio, United States
| | - Maggie Eppelheimer
- Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, Ohio, United States
| | - Francis Loth
- Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Akron, Ohio, United States,Conquer Chiari Research Center, Department of Biomedical Engineering, The University of Akron, Akron, Ohio, United States
| | - Philip A. Allen
- Conquer Chiari Research Center, Department of Psychology, The University of Akron, Akron, Ohio, United States
| | - Saritha Aryan
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Alangar S Hegde
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
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Greenberg JK, Limbrick DD. Letter to the Editor. The Chiari Severity Index and the role of external validation. J Neurosurg Pediatr 2021; 27:241-242. [PMID: 33307522 DOI: 10.3171/2020.9.peds20796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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