[Clinical evaluation methods for craniovertebral junction abnormalities]

Craniovertebral junction malformation is a congenital malformation located in the foramen magnum and upper cervical spine, including bone and nerve malformation, resulting in motor and sensory disorders, cerebellar and lower cranial nerves, etc. The evaluation methods of clinical symptoms and efficacy of craniovertebral junction malformation are important for the surgical indications and effects, mainly including the evaluation of clinical symptoms and the quality of life. At present, the commonly used methods in clinical work and literature are the Japanese orthopaedic association scores, visual analogue scales, 36-item short-form health survey, etc. Most of these clinical evaluations are not aimed at craniovertebral junction diseases but focus on the description of a certain type of clinical symptoms. Chicago Chiari outcome scale and syringomyelia outcome scale of Xuanwu hospital are dedicated to Craniovertebral junction malformation, but more clinical studies are needed to prove their effectiveness. Based on the literature reports, this article reviewed the previous clinical evaluation methods of craniovertebral junction malformation and discusses their applications and limitations.

Prenatal diagnosis of non-typical Chiari malformation type I associated with de novo Nuclear Factor I A gene mutation: a case report

BACKGROUND

Chiari malformation is one of the most common Central nervous system (CNS) abnormalities that can be detected in routine fetal scanning. Chiari malformation type I (CMI) is a congenital defect characterized by a displacement of the cerebellar tonsils through the foramen magnum. The etiology of CMI has not been well established and suggested having multifactorial contributions, especially genetic deletion. Clinical characteristics of this anomaly may express in different symptoms from neurological dysfunction and/or skeletal abnormalities in the later age, but it is rarely reported in pregnancy.

CASE PRESENTATION

We present a case in which the Chiari malformation type I was diagnosed with comorbidities of facial anomalies (flatting forehead and micrognathia) and muscular-skeletal dysmorphologies (clenched hands and clubfeet) at the 24+6 weeks of gestation in a 29-year-old Vietnamese pregnant woman. The couple refused an amniocentesis, and the pregnancy was followed up every 4 weeks until a spontaneous delivery occurred at 38 weeks. The newborn had a severe asphyxia and seizures at birth required to have an emergency resuscitation at delivery. He is currently being treated in the intensive neonatal care unit. He carries the novel heterozygous NFIA gene mutation confirmed after birth. No further postnatal malformation detected.

CONCLUSION

CMI may only represent with facial abnormalities and muscle-skeletal malformations at the early stage of pregnancy, which may also alert an adverse outcome. A novel heterozygous NFIA gene mutation identified after birth helps to confirm prenatal diagnosis of CMI and to provide an appropriate consultation.

Non-invasive Intracranial Pressure Waveform Analysis in Chiari Malformation Type 1: A Pilot Trial

OBJECTIVE

This pilot study aimed to investigate the role of Posterior Fossa Decompression (PFD) on the intracranial pressure (ICP) waveform in patients with Chiari Malformation type 1 (CM1). It also sought to explore the relationship between symptom improvement and ICP waveform behavior.

METHODS

This exploratory cohort study evaluated adult patients diagnosed with CM1. The patients underwent PFD using a standard technique at our institution, which involved a 3 × 3 cm posterior craniectomy and excision of the posterior arch of C1. The ICP waveform was measured using an external strain-gauge device connected to a pin attached to the skull. Measurements were collected pre- and post-PFD, and the P2/P1 ratio was calculated pre- and postoperatively.

RESULTS

The pilot study comprised 6 participants, 3 men and 3 women, with ages ranging from 39 to 68 years. The primary symptoms were cerebellar ataxia and typical headaches. The study found that most patients who showed clinical improvement, as judged by the Gestalt method, had a postoperative decrease in the P2/P1 ratio. However, 1 patient did not show an improvement in the P2/P1 ratio despite a good clinical outcome.

CONCLUSIONS

This study suggests that the P2/P1 ratio may decrease after PFD. However, we highlight the need for further research with a larger sample size to confirm these preliminary results.

Chiari III malformation in a neonate

Chiari malformation (CM) is a group of complex deformities of the posterior fossa and hindbrain, of which CMIII is the rarest. We report a term neonate, with an antenatal diagnosis of occipital encephalocele, who underwent resection of the encephalocele and ligation of vessels, with repair of a large scalp defect and dural reconstruction on day 4 of life. The parents of the child had been counselled for a guarded and poor prognosis on initial diagnosis. The child has had a good postoperative course without complications but suffers from cortical visual impairment and global developmental delay.

Chiari Type 1 Malformation: An Unusual Cause of Tinnitus

Chiari Malformations are a group of conditions defined in 1891 with 5 degrees being described. These malformations present with several symptoms such as cervical protrusion and are associated with hydrocephalus. Also, they can also present with different clinical signs and symptoms, such as deafness and tinnitus. We present a case of a 45-year-old man with unilateral tinnitus evaluated in otolaryngology office. No other symptoms on otolaryngological physical exam were detected in the audiogram performed it was described a significant unilateral sensorineural hearing loss. During the study of this patient, Magnetic Resonance Imaging was requested, showing a type I Chiari malformation. The patient was then observed by Ophthalmology, Neurology, and Neurosurgery. No other neurological symptoms of malformation Chiari syndrome or cranial nerve abnormalities were presented at the respective exam. The surgical management of these pathologies takes into account an adequate CSF and venous blood flow - that was seen in this patient, therefore, there was no surgical indication for decompression. The patient maintains its follow-up in the otolaryngology, neurology, and neurosurgery office, and tinnitus was minimized after prosthetic adaptation was recommended to optimize the quality of life, which was achieved.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Diagnosis

BACKGROUND

Chiari I malformation (CIM) is characterized by descent of the cerebellar tonsils through the foramen magnum, potentially causing symptoms from compression or obstruction of the flow of cerebrospinal fluid. Diagnosis and treatment of CIM is varied, and guidelines produced through systematic review may be helpful for clinicians.

OBJECTIVE

To perform a systematic review of the medical literature to answer specific questions on the diagnosis and treatment of CIM.

METHODS

PubMed and Embase were queried between 1946 and January 23, 2021, using the search strategies provided in Appendix I of the full guidelines.

RESULTS

The literature search yielded 567 abstracts, of which 151 were selected for full-text review, 109 were then rejected for not meeting the inclusion criteria or for being off-topic, and 42 were included in this systematic review.

CONCLUSION

Three Grade C recommendations were made based on Level III evidence. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/1-imaging .

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Symptoms

BACKGROUND

Chiari I malformation (CIM) is characterized by descent of the cerebellar tonsils through the foramen magnum, potentially causing symptoms from compression or obstruction of the flow of cerebrospinal fluid. Diagnosis and treatment of CIM is varied, and guidelines produced through systematic review may be helpful for clinicians.

OBJECTIVE

To perform a systematic review of the medical literature to answer specific questions on the diagnosis and treatment of CIM.

METHODS

PubMed and Embase were queried between 1946 and January 23, 2021, using the search strategies provided in Appendix I of the full guidelines.

RESULTS

The literature search yielded 430 abstracts, of which 79 were selected for full-text review, 44 were then rejected for not meeting the inclusion criteria or for being off-topic, and 35 were included in this systematic review.

CONCLUSION

Four Grade C recommendations were made based on Class III evidence, and 1 question had insufficient evidence. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/2-symptoms .

Encephalitis Associated With SARS-CoV-2 Infection in a Child With Chiari Malformation Type I

BACKGROUND/AIM

There is increasing evidence that patients infected with SARS-CoV-2 develop neurological manifestations such as encephalitis. The purpose of this article was to present a case of viral encephalitis associated with SARS-CoV-2 in a 14-year-old child with Chiari malformation type I.

CASE REPORT

The patient manifested frontal headache, nausea, vomiting, skin pallor, right side Babinski sign and was diagnosed with Chiari malformation type I. He was admitted with generalized seizures and suspected encephalitis. Brain inflammation and viral RNA in the cerebrospinal fluid suggested SARS-CoV-2 encephalitis. These findings indicate that the SARS-CoV-2 test in CSF of patients with neurological manifestations, confusion, and fever during the COVID-19 pandemic should be carried out even when there is no evidence of respiratory infection. To our knowledge, this presentation of encephalitis associated with COVID-19 has not yet been reported in a patient with a congenital syndrome such as Chiari malformation type I.

CONCLUSION

Further clinical data are needed to determine the complications of encephalitis due to SARS-CoV-2 in patients with Chiari malformation type I to standardize diagnosis and treatment.

Social impairment and snoring: a unique presentation of pediatric Chiari I malformation

Symptomatic progression of Chiari malformation type 1 (CM-1) can be difficult to recognize in children because of the slow progressive nature of the disorder and highly varied neurological symptoms. We present a case of an obese 11-year-old girl seeking an evaluation of snoring. Progressive social impairment and academic difficulties were also endorsed. The past medical history was remarkable for absence seizures at an earlier age with an incidental finding of CM-1 on brain imaging. No headaches, vision changes, or swallowing dysfunction were endorsed in the acute presentation. The patient underwent a polysomnogram, which revealed the unexpected finding of severe central sleep apnea. Magnetic resonance imaging of the brain revealed further herniation of the cerebellar tonsils and a cervical syrinx, which was not present on initial imaging. Posterior fossa decompression resulted in the successful resolution of symptoms. It was postulated that the social impairment and academic problems were manifestations of CM-1. There are no current standard protocols for disease surveillance of pediatric CM-1. Annual polysomnograms may serve as a useful tool.

CITATION

Kanney ML, Spear J, Hsu DP. Social impairment and snoring: a unique presentation of pediatric Chiari I malformation. J Clin Sleep Med. 2022;18(12):2867-2870.

Chiari Malformation Presenting as Headaches Associated with Laughter

Presentation We describe the case of a 5 year old boy, referred to our outpatient department with a one year history of headaches associated with laughter. Diagnosis Investigation with MRI Brain revealed Chiari Type 1 Malformation (CM-1), with cerebellar tonsillar descent of 19mm below the foramen magnum. Treatment He is being managed conservatively with serial neuroimaging and symptom monitoring. Discussion CM-1 is a hindbrain malformation characterised by ≥5mm herniation of the cerebellar tonsils.1,2 It is diagnosed radiographically, and is increasingly being detected incidentally.3,4 The natural history of asymptomatic patients is usually to remain asymptomatic, and symptomatic patients often show symptom improvement, particularly in paediatric populations.3,5 Neurosurgical interventions may be offered based on symptoms and radiographic findings, but carries a complication rate of 8.2%.6.

Diagnosis and treatment of Chiari malformation type 1 in children: the International Consensus Document

BACKGROUND

Chiari malformation type 1 (CM1) is a rare condition where agreed classification and treatment are still missing. The goal of this study is to achieve a consensus on the diagnosis and treatment of CM1 in children.

METHODS

A multidisciplinary panel formulated 57 provisional statements based on a review of the literature. Thirty-four international experts (IE) participated in a Delphi study by independently rating each statement on a 4-point Likert scale ("strongly disagree," "disagree," "agree," "strongly agree"). Statements that were endorsed ("agree" or "strongly agree") by < 75% of raters were re-formulated, or new statements were added, and another Delphi round followed (up to a maximum of three).

RESULTS

Thirty-five IE were contacted and 34 agreed to participate. A consensus was reached on 30/57 statements (52.6%) after round 1. Three statements were added, and one removed. After round 2, agreement was reached on 56/59 statements (94.9%). Finally, after round 3, which took place during the 2019 Chiari Consensus Conference (Milan, Italy), agreement was reached on 58/59 statements (98.3%) about four main sections (Definition and Classification, Planning, Surgery, Isolated Syringomyelia). Only one statement did not gain a consensus, which is the "definition of radiological failure 24 month post-surgery."

CONCLUSIONS

The consensus document consists of 58 statements (24 on diagnosis, 34 on treatment), serving clinicians and researchers following children with CM1. There is a clear need for establishing an international network and registry and to promote collaborative studies to increase the evidence base and optimize the long-term care of this patient population.

An 8-Month Old With Choking Episodes

This case report presents a female infant whose chief complaint of choking episodes resulted in a diagnosis of Chiari malformation type I and subsequent neurosurgical decompression. Although feeding difficulties and irritability are common complaints in pediatric primary care, dysphagia requires a more significant workup to identify a cause. This case report highlights red flags in the history and diagnostic studies and provides details for managing an unusual presentation of Chiari malformation type I.

Chiari Malformation in Children

Chiari malformation type 1 (CM1) is often found incidentally. However, patients with symptoms or signs referable to CM1 or an associated syrinx will likely benefit from surgical intervention. Patients who are not symptomatic from CM1 at presentation are unlikely to become symptomatic at follow-up.

A Case of Luscan-Lumish Syndrome: Possible Involvement of Enhanced GH Signaling

CONTEXT

Luscan-Lumish syndrome (LLS) is characterized by postnatal overgrowth, obesity, Chiari I malformation, seizures, and intellectual disability. SET domain-containing protein 2 (SETD2) is a histone methyltransferase, where mutations in the gene are associated with the development of LLS. However, mechanisms underlying LLS remain unclear.

CASE DESCRIPTION

A 20-year-old man was referred to our hospital because of tall stature. His body height was 188.2 cm (+3.18 SD) and he showed obesity with a body mass index of 28.4 kg/m2. He exhibited acral overgrowth, jaw malocclusion, and prognathism, but no history of seizures, intellectual disability, or speech delay. Serum growth hormone (GH), insulin-like growth factor 1 (IGF-1), and nadir GH levels after administration of 75 g oral glucose were within normal range. Pituitary magnetic resonance imaging showed no pituitary adenoma, but Chiari I malformation. Whole exome sequencing analysis of the proband revealed a de novo heterozygous germline mutation in SETD2 (c.236T>A, p.L79H). Skin fibroblasts derived from the patient grew faster than those from his father and the control subject. In addition, these cells showed enhanced tyrosine phosphorylation and transcriptional activity of signal transducer and activator of transcription 5b (STAT5b) and increased IGF-1 expression induced by GH.

CONCLUSION

This is a mild case of LLS with a novel mutation in SETD2 without neurological symptoms. LLS should be differentiated in a patient with gigantism without pituitary tumors. Although further investigation is necessary, this is the first study to suggest the involvement of aberrant GH signaling in the development of LLS.

Chiari I malformation and pregnancy: a comprehensive review of the literature to address common questions and to guide management

BACKGROUND

The optimal management of Chiari I malformation during pregnancy remains uncertain. Labor contractions, which increase intracranial pressure, and neuraxial anesthesia both carry the theoretical risk of brainstem herniation given the altered CSF dynamics inherent to the condition. Mode of delivery and planned anesthesia, therefore, require forethought to avoid potentially life-threatening complications. Since the assumed potential risks are significant, we seek to systematically review published literature regarding Chiari I malformation in pregnancy and, therefore, to establish a best practice recommendation based on available evidence.

METHODS

The English-language literature was systematically reviewed from 1991 to 2018 according to PRISMA guidelines to assess all pregnancies reported in patients with Chiari I malformation. After analysis, a total of 34 patients and 35 deliveries were included in this investigation. Additionally, a single case from our institutional experience is presented for illustrative purposes but not included in the statistical analysis.

RESULTS

No instances of brain herniation during pregnancy in patients with Chiari I malformation were reported. Cesarean deliveries (51%) and vaginal deliveries (49%) under neuraxial blockade and general anesthesia were both reported as safe and suitable modes of delivery. Across all publications, only one patient experienced a worsening of neurologic symptoms, which was only later discovered to be the result of a previously undiagnosed Chiari I malformation. Several patients underwent decompressive suboccipital craniectomy to treat the Chiari I malformation during the preconception period (31%), during pregnancy (3%), and after birth (6%). Specific data regarding maternal management were not reported for a large number (21) of these patients (60%). Aside from one abortion in our own institutional experience, there was no report of any therapeutic abortion or of adverse fetal outcome.

CONCLUSIONS

Although devastating maternal complications are frequently feared, very few adverse outcomes have ever been reported in pregnant patients with a Chiari I malformation. The available evidence is, however, rather limited. Based on our survey of available data, we recommend vaginal delivery under neuraxial blockade for truly asymptomatic patients. Furthermore, based on our own experience and physiological conceptual considerations, we recommend limiting maternal Valsalva efforts either via Cesarean delivery under regional or general anesthesia or by choosing assisted vaginal delivery under neuraxial blockade. There is no compelling reason to offer suboccipital decompression for Chiari I malformation during pregnancy. For patients with significant neurologic symptoms prior to conception, decompression prior to pregnancy should be considered.

Ventrolateral Tonsillar Position Defines Novel Chiari 0.5 Classification

BACKGROUND

Cervicomedullary compression in young children has been described in the context of Chiari type 1 malformation, with symptoms associated with the extent of tonsillar herniation below McRae line. Historically, Chiari type 1 malformation has been defined by tonsillar herniation of at least 5 mm. However, in certain populations, including very young children, Chiari symptoms may be present without this finding. A new Chiari classification is thus necessary.

METHODS

Cases involving patients up to 5 years of age evaluated for possible posterior fossa decompression were retrospectively reviewed. Preoperative symptoms, magnetic resonance imaging findings, surgical management, and short- and long-term outcome and follow-up were recorded. Tonsillar descent and presence of ventral herniation (VH) were recorded. We define VH as the tonsils crossing a line that bisects the caudal medulla at the level of the foramen magnum, thus creating a novel entity, Chiari type 0.5 malformation. Patients with ventrally herniated tonsils were compared with patients exhibiting more typical Chiari morphology.

RESULTS

Of 41 cases retrospectively reviewed, 20 met criteria for VH. These differed from cases without VH because of the predominance of medullary symptoms. In the VH cohort, 11 patients underwent surgical decompression with symptom resolution; 9 were initially managed conservatively, but 3 subsequently required surgery.

CONCLUSIONS

We define a novel Chiari entity, Chiari type 0.5 malformation, characterized by ventral tonsillar wrapping around the medulla in young children in the absence of classic Chiari type 1 malformation imaging findings. These patients are more likely to present with medullary symptoms than patients without VH. They are also more likely to require surgical decompression and respond favorably to intervention.

Chiari 1 malformation management: the Red Cross War Memorial Hospital approach

PURPOSE

In this paper, we aimed to review our institutional opinions and experience with Chiari 1 malformation management to determine physician practice and outcomes.

METHODS

Discussion between 3 clinicians about practice preferences and the management of Chiari 1 worldwide. Retrospective review of clinical cases over a 10-year period (2009-2018).

RESULTS

Although there are some minor differences between clinicians in our practice, our approach is broadly similar. We treat incidental Chiari 1 malformations conservatively, with clinical and radiological surveillance, reserving intervention for patients who develop clinical signs or radiological deterioration. We prefer surgical intervention for patients with typical symptoms or a Chiari 1 malformation with radiological progression. If symptoms are atypical, we prefer surveillance. Our preferred operation is a conservative suboccipital craniectomy with expansion duraplasty and adhesiolysis. Our operative complication rate was low and there was no mortality or major morbidity in our series. Surveillance for incidentally discovered Chiari 1 malformations has been a safe practice in our experience.

CONCLUSION

Clinical practice among three clinicians in our institution is broadly consistent. We have a conservative approach to Chiari 1 malformation management and our approach appears to have a low morbidity.

Jacqueline du Pré and her alternative diagnosis

JacquelineduPré (26 January 1945-19 October 1987) is one of the greatest cellists in the 20th century. Her musical career was terminated at age 28, allegedly due to multiple sclerosis (MS). MS is an immune-mediated demyelinating disease of the central nervous system with axonal involvement, characterized by the dissemination in time and space of the lesions (plaques). Diverse neurological symptoms may occur in MS, and a variety of symptoms relentlessly accumulated in her case after the diagnosis in 1973, which is concordant with primary progressive rather than relapsing-remitting form of MS. No radiological confirmation was however possible in her days and the diagnosis should be reconsidered, because her symptoms had some unusual features in MS. First, her principal symptoms, aside from transient visual and urological problems noticed earlier, began in the upper and lower limbs, often only in the upper limbs, then followed by the involvement of lower cranial nerves, and by the cognitive decline with changes in character. Hence the pattern of progression was ascending from the cervical spinal cord to the brainstem and to the cerebrum, which is not the pattern of dissemination in space typical of MS. Her clinical status appeared steroid-dependent temporarily in the early stage of the disease, which is also unusual in MS and some different etiology deserves consideration. We suppose that Uhthoff phenomenon, i.e. worsening of symptoms by the elevation of body temperature, may have been negative contrary to the previous interpretation, and if we are correct the absence of this sign does not support the demyelinating pathophysiology of her disease. Now that there is no objective medical information sufficiently disclosed, another scenario may be hypothesized, although MS is still a likely possibility. We discuss that syringomyelia/syringobulbia associated with Chiari malformation type I and obstructive hydrocephalus can be an alternative diagnosis.

Spontaneous Resolution of Chiari 1-Associated Syringomyelia: A Report of Two Cases

BACKGROUND

Traditional teaching is that Chiari 1 malformations with syrinx should be operated as soon as possible. We present 2 cases of a radiologically proven Chiari 1 malformation with syrinx which were treated nonoperatively and improved radiologically.

METHODS

Two children with an MRI-proven Chiari 1 malformations were followed up nonoperatively for 7 years (2010-2017). One was a boy aged 8 years and the other a girl aged 9 years at first presentation. Their parents were not interested in a surgical option and so it was decided to adopt a wait-and-watch policy. Both patients were followed up with a regular half-yearly clinical examination and yearly MRI studies (2010-2017).

RESULTS

It was found that, in both of them, the initial cough during swallowing and the headache improved. Serial MRI showed that the hind-brain protrusion was reduced and syrinx diminished or resolved well.

CONCLUSIONS

Some children with Chiari I and syringomyelia may show spontaneous resolution of symptoms and syringomyelia. Large registry studies will be needed to determine how likely it is that Chiari-associated syringes will resolve, and whether there are particular anatomic or neurologic differences between those who require surgery and those who don't.

[INSPIRATORY STRIDOR OF A NON-TRADITIONAL CAUSE]

INTRODUCTION

Stridor is a respiratory sound caused by turbulent air flow through narrow airways. The most common cause for acute inspiratory stridor is a viral infection of the upper airways, causing laryngotracheitis (Croup). Other common causes include an allergic reaction, foreign body aspiration and trauma.

BACKGROUND

A nine week old infant with a history of meningomyelocele repair perinatally presented to the emergency room with alternating inspiratory stridor. The infant did not have a history of a recent febrile illness, and he did not suffer from cough or any other symptoms suggesting a foreign body aspiration. After the common causes of stridor were ruled out, an MRI was performed - demonstrating Chiari malformation Type 2, with herniation of the cerebellar tonsils and medullary compression. Bronchoscopy demonstrated the rare cause of the intermittent stridor - intermittent vocal cord paralysis, caused by the raised intracranial pressure and medullary compression. Due to rapid clinical deterioration, emergent surgical decompression was performed with complete recovery.

CONCLUSIONS

This case report raises a rare and important cause of inspiratory stridor. Physicians should be alert to the symptoms suggesting a Chiari malformation in every child with a relevant medical history presenting with stridor.

DISCUSSION

Intermittent stridor is mostly caused by an upper respiratory infection in a child with narrowed airways, allergic laryngotracheitis, or laryngomalacia. A less common cause of stidor of this kind is vocal cord paralysis, which may be caused by a symptomatic Chiari malformation.

Current Concepts in the Pathogenesis, Diagnosis, and Management of Type I Chiari Malformations

Type 1 Chiari malformations (CMs) are a group of congenital or acquired disorders which include the abnormal presence of the cerebellar tonsils in the upper spinal canal, rather than the posterior fossa. The resulting anatomic abnormality causes crowding of the structures at the craniocervical junction and can impair the normal flow of cerebral spinal fluid (CSF) in this region. This impairment in CSF flow dynamics can led to the development of syringomyelia or hydrocephalus. Type 1 CMs have been associated with a wide array of symptoms resulting from either cerebellar and brainstem compression and distortion or disturbances in CSF dynamics, and can affect both children and adults. The clinical diagnosis may be difficult. Age usually matters in the clinical presentation, and in symptomatic patients, surgical intervention is usually required. [Full article available at http://rimed.org/rimedicaljournal-2017-06.asp].

[Type I Chiari malformation associated with cerebellar atrophy. Case report]

Chiari malformation is characterized by caudal displacement of the cerebellar tonsils that penetrate into the spinal canal through the foramen magnum, achieving reach the atlas or axis. trunk and any drop of the fourth ventricle is observed. Typically is seen in young adults. In some cases scoliosis and Syringomyelic cavities may occur. The authors present (as far as they know) the first case in the literature with long term follow-up, of a caucasian woman with an unusual form of cerebellar atrophy and Chiari Type I malformation, suffering from weakness in his upper and lower extremities with rapidly progression. The patient was successfully treated with suboccipital decompression and C1 laminectomy.

Arnold Chiari Malformation With Sponastrime (Spondylar and Nasal Changes, With Striations of the Metaphyses) Dysplasia: A Case Report

SPOndylar and NAsal changes, with STRIations of the Metaphyses (SPONASTRIME) dysplasia (SD) is a dwarfing autosomal recessive syndrome, characterized by a variety of clinical and radiographic features, which form the basis for diagnosis. We describe the presentation of an Arnold Chiari malformation in a patient with a clinical diagnosis of SD. The malformation was successfully treated by decompression of the foramen magnum and elevation of the cerebellum, with complete resolution of pain.We report a rare case of Arnold Chiari malformation in a patient presenting with clinical and radiographic features strongly suggestive of SD and be successfully treated.

Autism Spectrum Disorder and Chiari 1 Malformation Co-occurring in a Child

Very few studies have shown associations between autism spectrum disorder, attention deficit hyperactivity disorder and Chiari 1 malformation. Here, we report an 10-year-old male that presented after having seizures with a history of Chiari 1 malformation, autism spectrum disorder and ADHD with moderate mental retardation and speech delay. This case highlights the fact that autism spectrum disorder as biologically based neurodevelopmental disorder with altered brain growth may be associated with Chiari 1 malformation and ADHD.

Chiari malformations: diagnosis, treatments and failures

Chiari malformations refer to abnormalities of the hindbrain originally described by the Austrian pathologist Hans Chiari in the early 1890s. These malformations range from herniation of the cerebellar tonsils through the foramen magnum to complete agenesis of the cerebellum. In this review, we review the different classification schemes of Chiari malformations. We discuss the different signs and symptoms that the two most common malformations present with and diagnostic criteria. We next discuss current treatment paradigms, including the new measure of possible in utero surgery to help decrease the incidence of Chiari type II malformations. There is also a small discussion of treatment failures and salvage procedures in these difficult cases. Chiari malformations are a difficult clinical entity to treat. As more is learned about the genetic and environmental factors relating to their characteristics, it will be interesting if we are able to predict which treatments are better suited for different patients. Similarly, with the evolution of in utero techniques especially for Chiari II malformations, it will be interesting to see if the incidence and practice of treating these difficult patients will change.

[Oropharyngeal dysphagia associated with Chiari I malformation and syringomyelia J]

BACKGROUND

Dysphagia associated with neurological disease is an important clinical manifestation in the diagnosis of injury that justifies the compression of the brainstem and lower cranial nerves.

OBJECTIVE

To emphasize the study of dysphagia in a patient with Chiari I malformation associated with syringomyelia in the absence of primary gastroenterological symptoms.

CLINICAL CASE

We describe the case of a 62 year-old woman with oropharyngeal dysphagia of six years of evolution, cervicobrachialgia, ptosis and facial diplexia.

CONCLUSIONS

Magnetic resonance imaging is an essential element for establishing the etiologic diagnosis of neurogenic dysphagia.

Morning glory disc anomaly with Chiari type I malformation

Morning glory disc anomaly is a rare optic nerve dysplasia associated with various neovascular abnormalities. Due to these associations, children with morning glory disc anomaly have brain imaging and angiography to detect other congenital defects. The authors report the case of an infant with morning glory disc anomaly and coexisting Chiari type I malformation.

Cerebrospinal fluid flow impedance is elevated in Type I Chiari malformation

Diagnosis of Type I Chiari malformation (CMI) is difficult because the most commonly used diagnostic criterion, cerebellar tonsillar herniation (CTH) greater than 3-5 mm past the foramen magnum, has been found to have little correlation with patient symptom severity. Thus, there is a need to identify new objective measurement(s) to help quantify CMI severity. This study investigated longitudinal impedance (LI) as a parameter to assess CMI in terms of impedance to cerebrospinal fluid motion near the craniovertebral junction. LI was assessed in CMI patients (N = 15) and age-matched healthy controls (N = 8) using computational fluid dynamics based on subject-specific magnetic resonance imaging (MRI) measurements of the cervical spinal subarachnoid space. In addition, CTH was measured for each subject. Mean LI in the CMI group (551 ± 66 dyn/cm5) was significantly higher than in controls (220 ± 17 dyn/cm5, p < 0.001). Mean CTH in the CMI group was 9.0 ± 1.1 mm compared to -0.4 ± 0.5 mm in controls. Regression analysis of LI versus CTH found a weak relationship (R2 = 0.46, p < 0.001), demonstrating that CTH was not a good indicator of the impedance to CSF motion caused by cerebellar herniation. These results showed that CSF flow impedance was elevated in CMI patients and that LI provides different information than a standard CTH measurement. Further research is necessary to determine if LI can be useful in CMI patient diagnosis.

[Brainstem auditory evoked potentials and somatosensory evoked potentials in Chiari malformation]

INTRODUCTION

Chiari malformations (CM) include a series of congenital anomalies involving the descent of the cerebellar tonsils below the foramen magnum, which may be associated with compression in the brainstem, upper spinal cord, and cranial nerves, consequently altering the responses of brainstem auditory evoked potentials (BAEP) and somatosensory evoked potentials (SSEP). However, only a small number of authors have described the indications of these tests in CM, and study groups to date have been small and heterogeneous.

AIM

To review the results of BAEPs and SSEPs in published studies of patients with Chiari type 1 malformation (CM-1) or Chiari type 2 malformation (CM-2) as well as the indications of both tests in the diagnosis, treatment, and monitoring of both diseases, especially CM-1.

DEVELOPMENT

We present a review article analyzing data from all published studies in Medline starting in 1966, located through PubMed, using combinations of the following keywords: 'Chiari malformation', 'Arnold-Chiari malformation', 'Chiari type 1 malformation', 'Arnold-Chiari type 1 malformation', 'evoked potentials', 'brainstem auditory evoked potentials' and 'somatosensory evoked potentials' as well as records of patients with CM-1 from the neurosurgery and neurophysiology departments at the Hospital Universitari Vall d'Hebron.

CONCLUSIONS

Common findings of SSEP are a reduction in cortical amplitude from the posterior tibial nerve, a reduction or absence of cervical median nerve potential, and an increased N13-N20 interval. In BAEP, the most frequent findings are an increased I-V interval and a peripheral or cochlear auditory disturbance.

[Selected aspects of social cognition in patient with total agenesis of the corpus callosum (ACC) and Arnold-Chiari desease--case study]

AIM

The goal of the research was a characteristic of emotional-social competencies and communicative abilities in a 16-years old patient with ACC and Arnold-Chiari disease and higher than average intelligence.

METHOD

RHLB-PL was applied.

RESULTS

Total score in RHLB-PL suggested language and communication impairment. The greatest problems were observed in the field of behavioral self-control and discourse abilities. The patient had difficulties in the topic of the discourse maintaining, resisting from production of unconnected topics and comments, interject inappropriate remarks. Problems in humor comprehension and the dissociation between relative high level of written metaphors analysis abilities and low level of Picture Metaphors perception and explanation were observed. Linguistic Prosody was average.

CONCLUSION

Patient M.J. with agenesis of corpus callosum presented high number of deficits typical in right hemisphere damage patients. It is possible to explain that fact in the context of interhemispheric transfer disorders, specially when complex material was processed.

Short lasting activity-related headaches with sudden onset in children: a case-based reasoning on classification and diagnosis

BACKGROUND

Short lasting headaches related to activity or cough are rare, particularly in childhood, and can be difficult to diagnose, especially in young children who are not able to describe their symptoms. In the literature there are few data on this topic in adults and the paediatric cases reported are even more rare.

FINDINGS

We present the clinical history of a 7-year-old child and a 3-year-old child both diagnosed as having activity-related headaches, characterized by sudden onset of short lasting (few seconds) attacks, that were triggered by cough or exercise. There were no accompanying symptoms and the neurological examination was normal in both cases. Brain magnetic resonance imaging showed, in the first case, a cerebellar pilocytic astrocytoma and, in the second case, a Chiari 1 malformation. Both cases received an early diagnosis, were surgically treated and had a good prognosis at follow-up.

CONCLUSIONS

When headache has a recent onset, it presents suddenly, and it is triggered by strain, even with normal neurological examination, neuroimaging is mandatory in order to exclude secondary headaches, especially in children.

Anophthalmia-plus syndrome with unusual findings. A clinical report and review of the literature

We present a male child at 3 years old with Anophthalmia-Plus Syndrome (APS). He has asymmetry of the face and head, left choanal atresia, a sunken facial appearance, microphthalmia in the right eye, severe microphthalmia in the left eye, bilateral low-set ears, scarring from cleft palate surgery. Magnetic resonance imaging (MRI) sections revealed decreased right globe volume, an undeveloped left globe, decreased left optical nerve thickness, Chiari type 2 malformation, left choanal atresia and cleft palate. Echocardiography and abdominal ultrasonography were normal. The patient has a 45 dB conductive hearing loss in the left ear. Repeated thyroid function tests were evaluated as compatible with central hypothyroidism. We report a Fryns Anophthalmia-Plus Syndrome in a child with unusual findings including central hypothyroidism, chiari type 2 malformation, conductive hearing loss and developmental regression. Summary of the features reported in the present case and all 14 previous cases that might be defined as APS.

Progressive, asymptomatic papilledema as the presenting sign of a Chiari I malformation

BACKGROUND

Chiari I malformation (CM1) is the caudal herniation of the cerebellar tonsils into the foramen magnum. It can cause several neurological signs and symptoms, or be asymptomatic. Papilledema is a potential, but unusual, manifestation of CM1. While CM1 is often asymptomatic, papilledema is less likely to be. We present the first reported case of a progressive, asymptomatic papilledema as the sole presenting sign of a CM1;

CASE REPORT

A 39 year old woman presented without neurological symptoms and was found to have optic disc edema. Humphrey visual fields were normal and B-scan showed no drusen. On a subsequent visit, optical coherence tomography showed advanced disc edema. Neuroimaging revealed a CM1. The patient was referred for neurological consultation for the management of the papilledema secondary to CM1;

CONCLUSIONS

This case represents the importance of a thorough ocular examination, as the patient's asymptomatic neurologic condition would not have been diagnosed without the discovery of the papilledema.

Chiari I malformation presenting as downbeat nystagmus: clinical presentation, diagnosis, and management

INTRODUCTION

Chiari I malformation is a congenital, neurological condition that is characterized by defects of the skull base resulting in herniation of the cerebellum through the foramen magnum into the cervical spinal canal. Because the condition can result in visual symptoms, patients will often search for answers from their eye care providers;

CASE REPORT

A 28-year-old Hispanic diabetic male with a 10-year history of nystagmus was referred to the neuro-ophthalmic disease clinic following the initiation of oscillopsia 1 year previous. Downbeat nystagmus, which worsened in right and down gaze, was evident. Cranial nerve testing was unremarkable, but the patient did report trouble with choking on food and drink. Neuroimaging revealed Chiari I malformation. The patient underwent a suboccipital craniectomy which resulted in lessened nystagmus and improved symptoms;

DISCUSSION

The majority of patients with Chiari I malformation have an onset of symptoms in the second or third decade of life. Most commonly, a suboccipital headache that worsens with Valsalva maneuver is present. Visual symptoms include retro-orbital pain, flashing lights or floaters, blurred vision, photophobia, diplopia, transient vision loss, and peripheral vision loss. Objective evidence is often lacking in these patients; however, horizontal or vertical nystagmus is present in up to 45% of those with Chiari I malformation. Surgery has proven to be an effective and safe method to treat symptomatic Chiari I malformation.

Is curve direction correlated with the side of dominant displacement of cerebellar tonsil and syrinx deviation in thoracic scoliosis secondary to Chiari malformation type I and syringomyelia?

The patho-mechanism of scoliosis in patients with syringomyelia (SM) secondary to Chiari malformation type I (CMI) remains unknown up till now. In small sample studies published recently, there was an observation that curve direction tended to be on the same side as the dominant side of tonsillar displacement or the deviated side of syrinx location. Herein, a large-sample study of patients with single thoracic scoliosis secondary to CMI and SM was performed to validate these findings. The clinical and radiographic data of patients with scoliosis secondary to SM and CMI were reviewed. And patients who met the inclusion criteria were included. Based on the imaging presentation, the asymmetry of tonsillar displacement, syrinx location and scoliosis were judged by quantitative method. Then the imaging association among asymmetrically displaced tonsil, eccentrically located syrinx and curve direction were further analyzed. Thirty-nine patients with single thoracic scoliosis secondary to CMI and SM were included. 80% subjects showed concordance between the deviated side of eccentrically located syrinx and the dominant side of asymmetrically displaced tonsil. In 86% patients with asymmetrically displaced tonsil, thoracic curve was convex to the dominant side of tonsillar displacement. In 68% of patients with eccentrically located syrinx, the convex side of thoracic curve was on the same side as the deviated side of syrinx location. Asymmetrically displaced tonsils and eccentrically located syrinx are common imaging presentations in patients with SM secondary to CMI. The thoracic scoliosis in these patients was usually convex not only to the dominant side of asymmetrically displaced tonsils, but also to the side of eccentrically located syrinx, indicating that the asymmetry of tonsillar displacement and syrinx location might be involved in the regulation of curve direction.