1
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Vagianou F, Khirani S, de Saint Denis T, Beccaria K, Amaddeo A, Breton S, James S, Paternoster G, Arnaud E, Zerah M, Fauroux B. The utility of poly(somno)graphy in evaluating children with Chiari malformation type II before and after surgical intervention: a case series. Br J Neurosurg 2024; 38:125-127. [PMID: 34747686 DOI: 10.1080/02688697.2021.1999392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Children with Chiari Malformation type II (CM-II) have an increased risk of sleep apnoea. The aim of the study was to describe the management of patients with CM-II in relation to sleep apnoea syndrome, clinical symptoms and magnetic resonance imaging (MRI) findings. CASE SERIES PRESENTATION The paper reports 8 consecutive patients with CM-II followed between September 2013 and April 2017. The prevalence of sleep apnoea syndrome was high with 6 out of 8 patients having mild-to-severe sleep apnoea. Patients with severe sleep apnoea syndrome (3 patients) were treated with upper airway surgery and/or noninvasive ventilation. CONCLUSION Our findings highlight the importance of respiratory polygraphy in the management of patients with CM-ΙΙ. Poly(somno)graphy is recommended in the follow-up care of children with CM-II.
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Affiliation(s)
- Foteini Vagianou
- Paediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Sonia Khirani
- Paediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- ASV Santé, Gennevilliers, France
| | - Timothée de Saint Denis
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Kevin Beccaria
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Alessandro Amaddeo
- Paediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- Université de Paris, VIFASOM, Paris, France
| | - Sylvain Breton
- Paediatric radiology department, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Syril James
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- Clinique Marcel Sembat, Ramsay Générale de Santé, Boulogne Billancourt, France
| | - Giovanna Paternoster
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Eric Arnaud
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- Clinique Marcel Sembat, Ramsay Générale de Santé, Boulogne Billancourt, France
| | - Michel Zerah
- Paediatric Neurosurgery department, Centre de référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de référence des malformations craniofaciales - CRMR CRANIOST, AP-HP, Hôpital Necker-Enfants malades, Paris, France
| | - Brigitte Fauroux
- Paediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- Université de Paris, VIFASOM, Paris, France
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2
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Craniocervical Junction and Cervical Spine Anatomy. Neuroimaging Clin N Am 2022; 32:875-888. [DOI: 10.1016/j.nic.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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3
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Moosavi A, Kanekar S. Congenital Malformations of Cerebellum. Clin Perinatol 2022; 49:603-621. [PMID: 36113925 DOI: 10.1016/j.clp.2022.04.003] [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: 11/16/2022]
Abstract
Advances in pre and postnatal neuroimaging techniques, and molecular genetics have increased our understanding of the congenital malformation of the brain. Correct diagnosis of these malformations in regards to embryology, and molecular neurogenetics is of paramount importance to understand the inheritance pattern and risk of recurrence. Lesions detected on prenatal imaging require confirmation either with postnatal ultrasound and/or with MR imaging. With the advent of the faster (rapid) MRI techniques, which can be conducted without sedation, MRI is commonly used in the evaluation of congenital malformation of the brain. Based on neuroimaging pattern, the congenital malformations of the posterior fossa are classified into 4 main categories: (a) predominantly cerebellar, (b) cerebellar and brainstem, (c) predominantly brainstem, and (d) predominantly midbrain malformations.
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Affiliation(s)
- Ali Moosavi
- Radiology Research, Division of Neuroradiology, Penn State Health, Penn State College of Medicine, Mail Code H066 500 University Drive, Hershey, PA 17033, USA
| | - Sangam Kanekar
- Radiology Research, Division of Neuroradiology, Penn State Health, Penn State College of Medicine, Mail Code H066 500 University Drive, Hershey, PA 17033, USA.
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4
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Wahl L, Iwanaga J, Chabot AB, Dumont AS, Tubbs RS. Hypoplasia of the Tentorium Cerebelli: Case Report and Review of the Literature. Kurume Med J 2022; 67:49-52. [PMID: 35095020 DOI: 10.2739/kurumemedj.ms671009] [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: 11/23/2022]
Abstract
The second largest intracranial specialization of the dura mater, the tentorium cerebelli, is a transverse fold that partially separates the cerebellum and cerebral hemispheres. During routine dissection of the posterior cranial fossa, a left-sided hypoplastic region of the tentorium cerebelli was observed. This fenestration was seen at the posterior portion of the tentorium as a posteromedial strip of tissue rising vertically to interface with the falx cerebri. Although isolated cases of tentorial hypoplasia have been reported in, for example, cases of Chiari II malformation, we believe isolated fenestration of this membrane is very rare, especially in the absence of the Chiari II malformation. The current case adds to the sparse literature on isolated tentorial defects and might be of interest to neurosurgeons or clinicians who review intracranial imaging.
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Affiliation(s)
- Lauren Wahl
- Department of Cell and Developmental Biology, University of Colorado
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine.,Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine
| | - A Bert Chabot
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine.,Department of Structural & Cellular Biology, Tulane University School of Medicine.,Department of Anatomical Sciences, St. George's University.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System
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5
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Bogdanov EI, Faizutdinova AT, Heiss JD. Posterior cranial fossa and cervical spine morphometric abnormalities in symptomatic Chiari type 0 and Chiari type 1 malformation patients with and without syringomyelia. Acta Neurochir (Wien) 2021; 163:3051-3064. [PMID: 34448046 DOI: 10.1007/s00701-021-04941-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND To better understand how anatomical features of Chiari malformation type 0 (CM0) result in the manifestation of Chiari malformation type 1 (CM1) signs and symptoms, we conducted a morphometric study of the posterior cranial fossa (PCF) and cervical canal in patients with CM1 and CM0. METHODS This retrospective study had a STROBE design and included 120 adult patients with MRI evidence of a small PCF (SPCF), typical clinical symptoms of CM1, and a diagnosis of CM1, CM0, or SPCF-TH0-only (SPCF with cerebellar ectopia less than 2 mm and without syringomyelia). Patients were divided by MRI findings into 4 groups: SPCF-TH0-only, SPCF-TH0-syr (CM0 with SPCF and syringomyelia), SPCF-CM1-only (SPCF with cerebellar ectopia 5 mm or more without syringomyelia), and SPCF-CM1-syr (CM1 with syringomyelia). Neurological examination data and MRI parameters were analyzed. RESULTS All patient cohorts had morphometric evidence of a small, flattened, and overcrowded PCF. The PCF phenotype of the SPCF-TH0-only group differed from that of other CM cohorts in that the length of clivus and supraocciput and the height of the PF were longer, the upper CSF spaces of PCF were taller, and the area of the foramen magnum was smaller. The SPCF-TH0 groups had a more significant narrowing of the superior cervical canal and a smaller decrease in PCF height than the SPCF-CM1 groups. CONCLUSIONS Patients with SPCF-TH0 with and without syringomyelia developed Chiari 1 symptoms and signs. Patients with SPCF-TH0-syr (Chiari 0) had more constriction of their CSF pathways in and around the foramen magnum than patients with SPCF-TH0-only.
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6
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Carsky K, Iwanaga J, Dumont AS, Tubbs RS. Case of simultaneous Chiari 1.5 malformation and syringobulbia. Childs Nerv Syst 2021; 37:2409-2411. [PMID: 33044616 DOI: 10.1007/s00381-020-04924-9] [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: 07/19/2020] [Accepted: 10/05/2020] [Indexed: 11/27/2022]
Abstract
Chiari 1.5 malformation (C1.5) is a rare condition characterized by caudal descent of the brain stem, together with descent of the cerebellar tonsils characteristic of Chiari I malformation (CIM). Syringobulbia (SB) is rarely associated with CIM and to date has not been reported in a patient with C1.5. An adolescent female presented with Valsalva-induced headaches and a left abducens nerve palsy. Imaging revealed C1.5 and a huge syringomyelia extending cranially into the herniated medulla oblongata as syringobulbia. Simultaneous cases of C1.5 and syringomyelia (SM) have been described, but, to our knowledge, this is the first reported case of simultaneous C1.5 and SB. As SB can have life altering consequences, the clinician should keep this possibility in their differential diagnosis.
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Affiliation(s)
- Katie Carsky
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA.
- Department of Neurology, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA
- Department of Neurology, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
- 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
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7
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Hatano K, Ohashi H, Kawamura D, Isoshima A, Nagashima H, Tochigi S, Ohashi S, Takei J, Teshigawara A, Tani S, Murayama Y, Abe T. MRI characteristics of syringomyelia associated with foramen magnum arachnoiditis: differentiation from Chiari malformation. Acta Neurochir (Wien) 2021; 163:1593-1601. [PMID: 33881607 DOI: 10.1007/s00701-021-04845-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is important to distinguish foramen magnum arachnoiditis (FMA) from Chiari malformation (CM) before surgery because the operative strategies for these diseases differ. In the current study, we compared pretreatment magnetic resonance imaging (MRI) of FMA with CM and investigated the MRI findings useful to differentiate between these diseases. METHODS We retrospectively reviewed patients with FMA or CM aged ≥ 18 years who underwent surgeries at our institution between 2007 and 2019. The morphologies of the syrinx, neural elements, and posterior cranial fossa were preoperatively evaluated with MRI. We used the receiver operating characteristic (ROC) curve for the fourth ventricle-to-syrinx distance (FVSD). RESULTS Ten patients with FMAs and 179 with CMs were included. FVSD in the FMA group was significantly shorter than that in the CM group (7.5 mm [IQR, 2.8-10 mm] in FMA vs. 29.9 mm [IQR, 16.3-52.9 mm] in CM, p < 0.0001). The other MRI findings that showed the height, size, and length of the syrinx; size of the foramen magnum; degree of cerebellar tonsillar descent; shape of the cerebellar tonsil; and dorsal subarachnoid space at the foramen magnum differed significantly between the two groups. The ROC curve analysis showed that patients whose FVSD was less than 11 mm could be diagnosed with FMA with a specificity of 90% and sensitivity of 96%. CONCLUSIONS A more cranial syrinx development (FVSD < 11 mm) appears to be the characteristic MRI finding in FMA.
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Affiliation(s)
- Keisuke Hatano
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Hiroki Ohashi
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Daichi Kawamura
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Akira Isoshima
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
- Department of Neurosurgery, Omori Red Cross Hospital, 4-30-1 Chuo, Ota-ku, Tokyo, 143-8527, Japan
| | - Hiroyasu Nagashima
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
- Department of Neurosurgery, The Jikei University Katsushika Medical Center, 6-41-2 Aoto, Katsushika-ku, Tokyo, 125-8506, Japan
| | - Satoru Tochigi
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
- Department of Neurosurgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa-shi, Chiba, 277-8567, Japan
| | - So Ohashi
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
- Department of Neurosurgery, Kawasaki Saiwai Hospital, 31-27 Omiyacho, Kawasaki-shi Saiwai-ku, Kanagawa, 212-0014, Japan
| | - Jun Takei
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Akihiko Teshigawara
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
- Department of Neurosurgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa-shi, Chiba, 277-8567, Japan
| | - Satoshi Tani
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toshiaki Abe
- Department of Neurosurgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
- Department of Neurosurgery, Mishima Central Hospital, 1-3 Midoricho, Mishima-shi, Shizuoka, 411-0848, Japan
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8
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Miyake S, Suenaga J, Nakamura T, Akimoto T, Suzuki R, Ohtake M, Takase H, Tateishi K, Shimizu N, Murata H, Funakoshi K, Sawamura Y, Yamamoto T. Practical Arachnoid Anatomy for the Technical Consideration of Galen Complex Dissection: Cadaveric and Clinical Evaluation. World Neurosurg 2021; 151:e372-e378. [PMID: 33887497 DOI: 10.1016/j.wneu.2021.04.041] [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: 12/01/2020] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The occipital transtentorial approach (OTA) is a very useful but challenging approach to expose the pineal region because the deep-seated arachnoid membranes usually fold and extend over the great vein of Galen (GVG), leading to dense and poor visibility. In addition, the practical aspects of arachnoid anatomy are not well understood. We aimed to develop a safe surgical procedure for the OTA according to the practical aspects of arachnoid anatomy. METHODS The procedure is shown through an illustrative video of surgery and cadaver. Five cadavers were analyzed for their arachnoid structures and the surgical procedures via the OTA, in strict compliance with legal and ethical requirements. RESULTS All cadavers showed a 2-layered arachnoid structure-one belonging to the occipital lobe, and the other to the cerebellum. According to our cadaveric analysis, the arachnoid attachment of the tentorial apex can be peeled bluntly, with an average distance of 10.2 mm. For our clinical presentation, a pineal tumor with hydrocephalus was detected in a 14-year-old boy. While using the OTA and expanding the deep surgical field, we detached the membrane from the tentorial apex and bluntly peeled it to reveal the deep veins. Finally, gross total removal of the tumor was achieved. CONCLUSIONS A 2-layered arachnoid structure interposes the GVG from above and below the tentorium. The arachnoid membrane below the tentorium can be peeled off bluntly from the GVG to the attachment bundle limited by the penetrating veins. This detachment technique is useful for safe enlargement of the surgical field for the OTA.
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Affiliation(s)
- Shigeta Miyake
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
| | - Jun Suenaga
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan.
| | - Taishi Nakamura
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
| | - Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
| | - Ryosuke Suzuki
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
| | - Makoto Ohtake
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
| | - Hajime Takase
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
| | - Kensuke Tateishi
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
| | - Nobuyuki Shimizu
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
| | - Hidetoshi Murata
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
| | - Kengo Funakoshi
- Department of Neuroanatomy, Yokohama City University, Yokohama, Japan
| | | | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University, Yokohama, Japan
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9
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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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10
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Newton E, Iwanaga J, Dumont AS, Tubbs RS. Chiari I malformation with craniosynostosis and persistent falcine sinus draining into the straight sinus. Morphologie 2020; 105:323-326. [PMID: 33288422 DOI: 10.1016/j.morpho.2020.11.009] [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: 09/24/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
Owing to the interconnected nature of the brain, anatomical variations in one area often coincide with, or are caused by, abnormalities in another. During dissection of a specimen with both Chiari I malformation and craniosynostosis, a persistent falcine sinus was observed to drain into the straight sinus. Such a variant should be noted by physicians as it could alter treatment plans and require more detailed imaging procedures prior to surgical correction. Herein, we report the case and discuss the possible embryological origins and clinical significance of the variant.
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Affiliation(s)
- E Newton
- Department of neurosurgery, Tulane center for clinical neurosciences, Tulane university School of Medicine, 131 S. Robertson St. Suite, 1300 New Orleans, LA 70112, USA
| | - J Iwanaga
- Department of neurosurgery, Tulane center for clinical neurosciences, Tulane university School of Medicine, 131 S. Robertson St. Suite, 1300 New Orleans, LA 70112, USA; Department of neurology, Tulane center for clinical neurosciences, Tulane university School of Medicine New Orleans, USA.
| | - A S Dumont
- Department of neurosurgery, Tulane center for clinical neurosciences, Tulane university School of Medicine, 131 S. Robertson St. Suite, 1300 New Orleans, LA 70112, USA
| | - R S Tubbs
- Department of neurosurgery, Tulane center for clinical neurosciences, Tulane university School of Medicine, 131 S. Robertson St. Suite, 1300 New Orleans, LA 70112, USA; Department of neurology, Tulane center for clinical neurosciences, Tulane university School of Medicine New Orleans, 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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11
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Job van Meekeren (1611-1666) and his descriptions of posterior craniocervical masses in children. Childs Nerv Syst 2020; 36:1819-1820. [PMID: 31377912 DOI: 10.1007/s00381-019-04324-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 10/26/2022]
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12
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Guan J, Yuan C, Zhang C, Ma L, Yao Q, Cheng L, Liu Z, Wang K, Duan W, Wang X, Wu H, Chen Z, Jian F. Intradural Pathology Causing Cerebrospinal Fluid Obstruction in Syringomyelia and Effectiveness of Foramen Magnum and Foramen of Magendie Dredging Treatment. World Neurosurg 2020; 144:e178-e188. [PMID: 32805463 DOI: 10.1016/j.wneu.2020.08.068] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/09/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This article discusses the procedure of foramina magnum and Magendie dredging, summarizing the pathologic changes in the intradural region of the craniocervical junction in patients with syringomyelia and the pathophysiologic mechanism of cerebrospinal fluid (CSF) circulation obstruction. METHODS Clinical data from 50 adult patients with syringomyelia treated at Xuanwu Hospital from July 2018 to January 2019 were collected and retrospectively analyzed. All operations were performed with foramina magnum and Magendie dredging, and all intradural factors that may have induced the obstruction of CSF circulation were recorded. RESULTS Intradural pathology was found in all patients. The pathologic changes that may have caused obstruction of the CSF circulation include tonsil occupying the foramen magnum and overlying foramen of Magendie in 88% (44/50), intertonsillar arachnoid adhesions in 36% (18/50), tonsil to medulla arachnoid adhesions in 18% (9/50), medialized tonsils in 70% (35/50), vermian branch of posterior inferior cerebellar artery in 22% (11/50), arachnoid veil in 16% (8/50), cisterna magna cyst in 4% (2/50), and tonsil to dura mater arachnoid adhesions in 8% (4/50). Mean duration of follow-up was 13.3 months. The long-term effective rate was 96.0%. Postoperative magnetic resonance imaging revealed that the size of the syringomyelia was reduced or completely resolved in 88% of patients. The mean preoperative Japanese Orthopaedic Association score was 12.9 ± 3.1, which improved to 14.7 ± 3.2 (P < 0.05) at last clinical follow-up. CONCLUSIONS Intradural pathology that causes CSF circulation obstruction exists in many forms. Relieving the obstruction of the foramen magnum and foramen of Magendie is key to surgical treatment.
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Affiliation(s)
- Jian Guan
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chenghua Yuan
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Can Zhang
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Longbing Ma
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingyu Yao
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lei Cheng
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhenlei Liu
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kai Wang
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wanru Duan
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xingwen Wang
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zan Chen
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fengzeng Jian
- Division of Spine, Department of Neurosurgery, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.
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13
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Lower cranial nerve syndromes: a review. Neurosurg Rev 2020; 44:1345-1355. [PMID: 32638140 DOI: 10.1007/s10143-020-01344-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/09/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
The purpose of this paper is to provide a comprehensive review encompassing the syndromes associated with the lower cranial nerves (LCNs). We will discuss the anatomy of some of these syndromes and the historical contributors after whom they were named. The LCNs can be affected individually or in combination, since the cranial nerves at this level share their courses through the jugular foramen and hypoglossal canal and the extracranial spaces. Numerous alterations affecting them have been described in the literature, but much remains to be discovered on this topic. This paper will highlight some of the subtle differences among these syndromes. Symptoms and signs that have localization value for LCN lesions include impaired speech, deglutition, sensory functions, alterations in taste, autonomic dysfunction, neuralgic pain, dysphagia, head or neck pain, cardiac or gastrointestinal compromise, and weakness of the tongue, trapezius, or sternocleidomastoid muscles. To assess the manifestations of LCN lesions correctly, precise knowledge of the anatomy and physiology of the area is required. Treatments currently used for these conditions will also be addressed here. Effective treatments are available in several such cases, but a precondition for complete recovery is a correct and swift diagnosis.
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14
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Effects of growth hormone therapy in pediatric patients with growth hormone deficiency and Chiari I malformation: a retrospective study. Childs Nerv Syst 2020; 36:835-839. [PMID: 31502034 DOI: 10.1007/s00381-019-04370-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 09/02/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The safety and efficacy of growth hormone replacement therapy (GHRT) on pediatric patients with growth hormone deficiency (GHD) and Chiari I malformation (CIM) are not well investigated within the current body of literature. With no clear indication of the effects of GHRT on CIM disease progression, we sought to determine the effect of GHRT on tonsillar herniation and progression of CIM symptomatology. METHODS From a previously established database of 465 patients with radiologically confirmed CIM defined as > 5 mm of tonsillar descent on head magnetic resonance imaging (MRI), we identified 20 patients who also had GHD. Using the imaging analysis software package, ANALYZE, the degree of change in tonsillar herniation was documented between initial and final MRI measurements. The radiologic and clinical changes over time were examined via a proportional odds model, Student's t test, Mann-Whitney test, or a mixed model corresponding to the outcomes measured either on an ordinal scale or on a quantitative scale. RESULTS Incidence of GHD in our CIM population was 4.3%. There was no significant effect of GHRT on the degree of tonsillar herniation in patients with GHD and CIM. No patient became symptomatic, developed syringomyelia, or required surgical intervention for CIM. CONCLUSION Based on our findings with a larger sample size, along with recent reports, the incidence of patients with CIM and GHD we reported (0.86-5%) is likely more indicative of the actual incidence of GHD and CIM than the prior findings within the literature (9.1-20%). We also suggest that GHRT does not significantly affect CIM morphology or symptomatology. Therefore, neurosurgeons should have no hesitation clearing these patients for GHRT.
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15
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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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16
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Dorcas Padget (1906-1973) and her contributions to spinal dysraphism and Chiari II malformations. Childs Nerv Syst 2020; 36:1-2. [PMID: 30066163 DOI: 10.1007/s00381-018-3933-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
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17
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Gutierrez S, Huynh T, Iwanaga J, Dumont AS, Bui CJ, Tubbs RS. A Review of the History, Anatomy, and Development of the C1 Spinal Nerve. World Neurosurg 2019; 135:352-356. [PMID: 31838236 DOI: 10.1016/j.wneu.2019.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 11/25/2022]
Abstract
The C1 spinal nerve is a fascinating anatomic structure owing to its wide range of variations. Throughout history, understanding of the cranial and spinal nerves has probably influenced the current conception of this nerve among anatomists. Located at the craniocervical junction, the C1 spinal nerve contributes to the motor innervation of deep cervical muscles through the cervical (anterior) and Cruveilhier's (posterior) plexuses. Sensory functions of this nerve are more enigmatic; despite investigations into its dorsal rootlets, a dorsal root ganglion, and the relationships between this nerve and adjacent cranial and spinal nerves, there is still no consensus regarding its true anatomy. In this article, we review the available literature and discuss some of the developmental models that could potentially explain the wide range of variations and functions of the C1 nerve.
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Affiliation(s)
| | - Trong Huynh
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, USA.
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - C J Bui
- Department of Neurosurgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
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18
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Nascimento JJ, Araújo-Neto SA, Diniz PR. Letter to the Editor Regarding “Basilar Invagination: A Craniocervical Kyphosis”. World Neurosurg 2019; 131:299-300. [DOI: 10.1016/j.wneu.2019.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/01/2019] [Indexed: 11/29/2022]
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19
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Bordes S, Jenkins S, Tubbs RS. Defining, diagnosing, clarifying, and classifying the Chiari I malformations. Childs Nerv Syst 2019; 35:1785-1792. [PMID: 31049667 DOI: 10.1007/s00381-019-04172-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/21/2019] [Indexed: 01/03/2023]
Abstract
PURPOSE Chiari malformations (CM) have been traditionally classified into four categories: I, II, III, and IV. In light of more recent understandings, variations of the CM have required a modification of this classification. METHODS This article discusses the presentation, diagnostics, and treatment of the newer forms of hindbrain herniation associated with the CM type I. RESULTS The CM 1 is a spectrum that includes some patients who do not fall into the exact category of this entity. CONCLUSIONS While CM have been categorically recognized as discrete and individual conditions, newer classifications such as CM 0 and CM 1.5 exhibit some degree of continuity with CM 1; however, they require distinct and separate classification as symptoms and treatments can vary among these clinical subtypes.
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Affiliation(s)
- Stephen Bordes
- Seattle Science Foundation, Seattle, WA, USA.,Department of Anatomical Sciences, St. George's University, Saint George's, Grenada
| | - Skyler Jenkins
- Seattle Science Foundation, Seattle, WA, USA.,Department of Anatomical Sciences, St. George's University, Saint George's, Grenada
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20
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Pfeiffer type 2 syndrome: review with updates on its genetics and molecular biology. Childs Nerv Syst 2019; 35:1451-1455. [PMID: 31222448 DOI: 10.1007/s00381-019-04244-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 01/29/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Pfeiffer syndrome is a rare autosomal dominant inherited disorder associated with craniosynostosis, midfacial hypoplasia, and broad thumbs and toes. The syndrome has been divided into three clinical subtypes based on clinical findings. METHODS This review will specifically examine the most severe type, Pfeiffer syndrome type 2, focusing on its genetics and molecular biology. CONCLUSION This subtype of the syndrome is caused by de novo sporadic mutations, the majority of which occur in the fibroblast growth factor receptor type 1 and 2 (FGFR1/2) genes. There is not one specific mutation, however. This disorder is genetically heterogeneous and may have varying phenotypic expressions that in various cases have overlapped with other similar craniosynostoses. A specific missense mutation of FGFR2 causing both Pfeiffer and Crouzon syndromes has been identified, with findings suggesting that gene expression may be affected by polymorphism within the same gene. Compared to other craniosynostosis-related disorders, Pfeiffer syndrome is the most extreme phenotype, as the underlying mutations cause wider effects on the secondary and tertiary protein structures and exhibit harsher clinical findings.
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21
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Dupont G, Altafulla J, Iwanaga J, Watanabe K, Tubbs RS. Ossification of the roof of the porus trigeminus with duplicated abducens nerve. Anat Cell Biol 2019; 52:211-213. [PMID: 31338240 PMCID: PMC6624332 DOI: 10.5115/acb.2019.52.2.211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 11/27/2022] Open
Abstract
Ossification of parts of the intracranial dura mater is common and is generally accepted as an age-related finding. Additionally, duplication of the abducens nerve along its course to the lateral rectus muscle is a known, although uncommon anatomical variant. During routine cadaveric dissection, an ossified portion of dura mater traveling over the trigeminal nerve's entrance (porus trigeminus) into the middle cranial fossa was observed unilaterally. Ipsilaterally, a duplicated abducens nerve was also observed, with a unique foramen superolateral to the entrance of Dorello's canal. To our knowledge, there has been no existing report of a simultaneous ossified roof of the porus trigeminus with an ipsilateral duplicated abducens nerve. Herein, we discuss this case and the potential clinical and surgical applications. We believe this case report will be informative for the skull base surgeon in the diagnosis of neuralgic pain in the frontomaxillary, andibular, orbital, and external and middle ear regions.
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Affiliation(s)
| | - Juan Altafulla
- Seattle Science Foundation, Seattle, WA, USA.,Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, WA, USA.,Seattle Science Foundation, Seattle, WA, USA
| | - Koichi Watanabe
- Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, WA, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
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22
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Bordes S, Jenkins S, Loukas M, Iwanaga J, Curé J, Tubbs RS. Drainage of the basal vein of Rosenthal into the confluence of sinuses. Anat Cell Biol 2019; 52:214-216. [PMID: 31338241 PMCID: PMC6624337 DOI: 10.5115/acb.2019.52.2.214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 11/29/2022] Open
Abstract
An adult female was found to have a variation of the left basal vein of Rosenthal after presenting with complaints of headache. The vein, in this case, drained directly into the confluence of sinuses instead of the great vein of Galen. Variation of the basal vein is likely due to the embryonic development of the deep cerebral venous system as primitive structures either differentiate further or regress with age. Such changes may result in the uncommon presentation seen in this case. To our knowledge, this is the first case reported of the basal vein draining into the confluence of sinuses.
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Affiliation(s)
- Stephen Bordes
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
| | - Skyler Jenkins
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, WA, USA
| | - Joel Curé
- Division of Neuroradiogy, University of Alabama, Birmingham, AL, USA
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23
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Altafulla J, Bordes S, Jenkins S, Litvack Z, Iwanaga J, Loukas M, Tubbs RS. The Basal Subarachnoid Cisterns: Surgical and Anatomical Considerations. World Neurosurg 2019; 129:190-199. [PMID: 31136838 DOI: 10.1016/j.wneu.2019.05.087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 10/26/2022]
Abstract
The basal subarachnoid cisterns are expansions of the subarachnoid space and transmit cranial nerves and intracranial vessels. Providing neurosurgeons with key concepts, anatomical landmarks, and techniques can result in safer procedures and better patient outcomes. In this review, we discuss the major basal subarachnoid cisterns including their embryology, history, anatomical descriptions, and use during surgical approaches.
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Affiliation(s)
- Juan Altafulla
- Seattle Science Foundation, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Stephen Bordes
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - Skyler Jenkins
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - Zachary Litvack
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington, USA.
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington, USA; Department of Anatomical Sciences, St. George's University, St. George's, Grenada
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24
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Jenkins S, Bordes S, Aly I, Jeyamohan S, Ishak B, Iwanaga J, Loukas M, Tubbs RS. Internal Morphology of the Odontoid Process: Anatomic and Imaging Study with Application to C2 Fractures. World Neurosurg 2019; 127:e1120-e1126. [PMID: 30980977 DOI: 10.1016/j.wneu.2019.04.052] [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: 02/23/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Fracture of the odontoid process is a critical injury to diagnose and often treat. The aim of this anatomic study was to present a comprehensive understanding of this part of the C2 vertebra. METHODS We used 20 C2 vertebrae. Samples underwent imaging (computed tomography [CT] with and without three-dimensional reconstruction, micro-CT, 1.5T magnetic resonance imaging) and sagittal and coronal sectioning using a bone saw. Sectioned specimens were imaged under a digital handheld microscope, and transillumination of the bone was used to highlight its internal trabecular pattern. Three samples underwent infusion of the odontoid process with a hardening substance and were then decalcified. RESULTS Internal trabecular patterns of the odontoid process of all specimens were discernible. In sagittal and coronal sections, trabecular patterns were highlighted with transillumination, but the patterns were much clearer using the digital microscope. Magnetic resonance imaging and CT provided the least detail of the imaging methods, but the trabecular patterns could be identified. Three-dimensional reconstruction of CT data was the preferred imaging method over magnetic resonance imaging and CT without three-dimensional reconstruction. The most distinct trabecular and cortical patterns were seen using micro-CT. Osteoporosis was seen in 2 specimens (10%). Five specimens (25%) were found to have a subdental synchondrosis. For most specimens, the trabeculae were found throughout the odontoid process. CONCLUSIONS Improved knowledge of the anatomy, structural composition, and variations within the C2 vertebra may allow for better treatment options and patient care.
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Affiliation(s)
- Skyler Jenkins
- Department of Anatomical Sciences, St. George's University, Grenada, West Indies
| | - Stephen Bordes
- Department of Anatomical Sciences, St. George's University, Grenada, West Indies
| | - Islam Aly
- Seattle Science Foundation, Seattle, Washington, USA
| | | | - Basem Ishak
- Seattle Science Foundation, Seattle, Washington, USA
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington, USA.
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, Grenada, West Indies
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington, USA
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25
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Frank D, Sela-Donenfeld D. Hindbrain induction and patterning during early vertebrate development. Cell Mol Life Sci 2019; 76:941-960. [PMID: 30519881 PMCID: PMC11105337 DOI: 10.1007/s00018-018-2974-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 12/28/2022]
Abstract
The hindbrain is a key relay hub of the central nervous system (CNS), linking the bilaterally symmetric half-sides of lower and upper CNS centers via an extensive network of neural pathways. Dedicated neural assemblies within the hindbrain control many physiological processes, including respiration, blood pressure, motor coordination and different sensations. During early development, the hindbrain forms metameric segmented units known as rhombomeres along the antero-posterior (AP) axis of the nervous system. These compartmentalized units are highly conserved during vertebrate evolution and act as the template for adult brainstem structure and function. TALE and HOX homeodomain family transcription factors play a key role in the initial induction of the hindbrain and its specification into rhombomeric cell fate identities along the AP axis. Signaling pathways, such as canonical-Wnt, FGF and retinoic acid, play multiple roles to initially induce the hindbrain and regulate Hox gene-family expression to control rhombomeric identity. Additional transcription factors including Krox20, Kreisler and others act both upstream and downstream to Hox genes, modulating their expression and protein activity. In this review, we will examine the earliest embryonic signaling pathways that induce the hindbrain and subsequent rhombomeric segmentation via Hox and other gene expression. We will examine how these signaling pathways and transcription factors interact to activate downstream targets that organize the segmented AP pattern of the embryonic vertebrate hindbrain.
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Affiliation(s)
- Dale Frank
- Department of Biochemistry, Faculty of Medicine, The Rappaport Family Institute for Research in the Medical Sciences, Technion-Israel Institute of Technology, 31096, Haifa, Israel.
| | - Dalit Sela-Donenfeld
- Koret School of Veterinary Medicine, The Robert H Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, 76100, Rehovot, Israel.
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Kikuta S, Iwanaga J, Oskouian RJ, Tubbs RS. A new variant ligament of the atlantooccipital joint: the lateral oblique atlantooccipital ligament. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1188-1191. [PMID: 30783803 DOI: 10.1007/s00586-019-05919-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/05/2019] [Accepted: 02/12/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE During routine dissection of the anterior craniocervical junction (CCJ), a variant ligament just anterior to the articular capsule of the atlantooccipital joint was observed. To our knowledge, no literature has previously described this ligament. Therefore, the aim of this study was to clarify the anatomy, incidence, and biomechanics of this undescribed structure of the anterior atlantooccipital joint. METHODS Twenty-six sides from 13 fresh-frozen adult cadavers were used for this study and the morphology of the variant ligament examined. When present, its length, width, thickness, and the angle from the midline of the CCJ were measured. RESULTS The variant ligament identified, when present, is distinct and located anterior to the atlantooccipital joint capsule traveling between the occipital bone and the transverse process of the atlas. The ligament was found on 12 of 26 sides (46.2%). The mean length of the ligament was 32.0 ± 5.5 mm. The ligament became taut with contralateral lateral flexion and the ipsilateral rotation of the atlantooccipital joint. CONCLUSIONS We propose that this ligament may be termed the lateral oblique atlantooccipital ligament. To date, this structure has not been described in any textbooks or reports in the extant medical literature. Although its function is not clear, based on its course and connections, it might function as a secondary stabilizer of the atlantooccipital joint. As the stability of the craniocervical junction is of paramount importance, knowledge of normal and variant anatomical structures in this region is important for the surgeon treating patients with pathology of this region. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Shogo Kikuta
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
- Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Joe Iwanaga
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA.
- Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Fukuoka, Japan.
- Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Fukuoka, Japan.
| | - Rod J Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - R Shane Tubbs
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
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Rai R, Iwanaga J, Dupont G, Oskouian RJ, Loukas M, Oakes WJ, Tubbs RS. Pfeiffer type 2 syndrome: review with updates on its genetics and molecular biology. Childs Nerv Syst 2019:10.1007/s00381-019-04082-7. [PMID: 30740633 DOI: 10.1007/s00381-019-04082-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 01/29/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pfeiffer syndrome is a rare autosomal dominant inherited disorder associated with craniosynostosis, midfacial hypoplasia, and broad thumbs and toes. The syndrome has been divided into three clinical subtypes based on clinical findings. METHODS This review will specifically examine the most severe type, Pfeiffer syndrome type 2, focusing on its genetics and molecular biology. CONCLUSION This subtype of the syndrome is caused by de novo sporadic mutations, the majority of which occur in the fibroblast growth factor receptor type 1 and 2 (FGFR1/2) genes. There is not one specific mutation, however. This disorder is genetically heterogeneous and may have varying phenotypic expressions that in various cases have overlapped with other similar craniosynostoses. A specific missense mutation of FGFR2 causing both Pfeiffer and Crouzon syndromes has been identified, with findings suggesting that gene expression may be affected by polymorphism within the same gene. Compared to other craniosynostosis-related disorders, Pfeiffer syndrome is the most extreme phenotype, as the underlying mutations cause wider effects on the secondary and tertiary protein structures and exhibit harsher clinical findings.
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Affiliation(s)
- Rabjot Rai
- Seattle Science Foundation, 550 17th Ave, James Tower, Suite 600, Seattle, WA, 98122, USA
| | - Joe Iwanaga
- Seattle Science Foundation, 550 17th Ave, James Tower, Suite 600, Seattle, WA, 98122, USA.
| | - Graham Dupont
- Seattle Science Foundation, 550 17th Ave, James Tower, Suite 600, Seattle, WA, 98122, USA
| | - Rod J Oskouian
- Seattle Science Foundation, 550 17th Ave, James Tower, Suite 600, Seattle, WA, 98122, USA
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | | | - R Shane Tubbs
- Seattle Science Foundation, 550 17th Ave, James Tower, Suite 600, Seattle, WA, 98122, USA
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
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Vetter M, Iwanaga J, Choi PJ, Yilmaz E, Oskouian RJ, Tubbs RS. A Novel Microsurgical Procedure for Revascularization of the Vertebral Artery. World Neurosurg 2019; 122:e302-e306. [DOI: 10.1016/j.wneu.2018.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 12/29/2022]
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Ishak B, Gnanadev R, Dupont G, Kikuta S, Altafulla J, Iwanaga J, Tubbs RS. Gerber's Ligament-A Forgotten Structure of the Craniocervical Junction. World Neurosurg 2019; 124:e707-e709. [PMID: 30660889 DOI: 10.1016/j.wneu.2018.12.198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/24/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ligaments of the craniocervical junction play a critical role in stabilizing this region. Gerber's ligament has more or less been forgotten and, to our knowledge, never studied. METHODS Dissection of the craniocervical junction was performed in 15 fresh frozen cadavers. In the prone position, the posterior elements of the upper cervical vertebrae and occiput were removed. After removing the contents of the spinal canal and posterior cranial fossa, the dura mater and tectorial membrane were reflected. The superior band of the cruciform ligament was reflected. When Gerber's ligament was identified, its attachments and morphometry were recorded. Lastly, Gerber's ligament was observed while range of motion of the craniocervical junction was performed. RESULTS Gerber's ligament was identified in 7 specimens (46.7%). This structure arose anteriorly from the junction of the superior band and transverse part of the cruciform ligament. Gerber's ligament was always found to be just deep to the superior band of the cruciform ligament but traveled more anteriorly to attach onto the posterior aspect of the dens approaching, but not attaching onto, its apex. Mean length was 11 mm, and mean width was 7 mm. Thickness of the ligament was 0.5-1.1 mm. The ligament was found to become taut with minimal rotation of the atlantoaxial joint and extension of the craniocervical junction. CONCLUSIONS A good understanding of all ligaments of the craniocervical junction is important to surgeons and physicians treating patients with injury to the upper cervical spine.
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Affiliation(s)
- Basem Ishak
- Seattle Science Foundation, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Raja Gnanadev
- Seattle Science Foundation, Seattle, Washington, USA
| | - Graham Dupont
- Seattle Science Foundation, Seattle, Washington, USA
| | - Shogo Kikuta
- Seattle Science Foundation, Seattle, Washington, USA
| | | | - Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington, USA.
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington, USA; Department of Anatomical Sciences, St. George's University, St. George's, Grenada
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Takeshima Y, Matsuda R, Nishimura F, Nakagawa I, Motoyama Y, Park YS, Nakase H. Sequential Enlargement of Posterior Fossa After Duraplasty for Chiari Malformation Type 1. World Neurosurg X 2019; 2:100004. [PMID: 31218279 PMCID: PMC6580881 DOI: 10.1016/j.wnsx.2018.100004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 12/10/2018] [Indexed: 11/24/2022] Open
Abstract
Objective There are several material options for duraplasty in surgery for foramen magnum decompression (FMD). We retrospectively analyzed surgical results and the impact of sequential alteration of posterior fossa (PF) size in patients with Chiari malformation type 1 after duraplasty using local fascia. Methods The patients with Chiari malformation type 1 who underwent FMD with duraplasty using local fascia at our institution between 2004 and 2015 were included in the study. Some pediatric patients who underwent FMD without duraplasty and patients with insufficient follow-up data were excluded. Improvement of clinical signs, regression of syrinx, and temporal alteration of PF size were analyzed with perioperative magnetic resonance imaging. Postoperative clinical outcomes were evaluated at the final follow-up using the Chicago Chiari Outcome Scale. Correlations between the PF size alteration and size of dural patch or Chicago Chiari Outcome Scale were statistically analyzed. Results Twelve patients were included in this study. The mean age of the patients was 31.9 (range, 18–48) years. Syrinx was incorporated in 11 patients and regressed postoperatively in all patients. The PF was significantly enlarged sequentially over time (P < 0.05). The degree of enlargement was positively correlated with size of the fascial patch (r = 0.540). Postoperative clinical outcomes at final follow-up were positively correlated with the degree of PF enlargement (r = 0.678). Conclusions The PF was enlarged sequentially over time after duraplasty using local fascia. The degree of enlargement was positively correlated with the size of the fascial patch and the likelihood of a favorable postoperative outcome.
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Affiliation(s)
- Yasuhiro Takeshima
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Fumihiko Nishimura
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Young-Soo Park
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
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Comparison decompression by duraplasty or cerebellar tonsillectomy for Chiari malformation-I complicated with syringomyelia. Clin Neurol Neurosurg 2019; 176:1-7. [DOI: 10.1016/j.clineuro.2018.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 10/25/2018] [Accepted: 11/08/2018] [Indexed: 11/16/2022]
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Entezami P, Gooch MR, Poggi J, Perloff E, Dupin M, Adamo MA. Current management of pediatric chiari type 1 malformations. Clin Neurol Neurosurg 2018; 176:122-126. [PMID: 30557765 DOI: 10.1016/j.clineuro.2018.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/03/2018] [Accepted: 12/09/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Pediatric Chiari Type 1 Malformations (CM1) are commonly referred for neurosurgical opinion. The ideal management in children regarding surgical and radiographic decision making is not clearly delineated. PATIENTS AND METHODS We retrospectively reviewed our cohort of patients age 18 years and younger referred to a single neurosurgeon for CM1. Baseline MRIs of the spine were obtained. Non-operative patients had repeat imaging at 6-12 months. Patients who underwent an operation (decompression with/without duraplasty) had repeat imaging at 6 months. RESULTS One hundred and thirty-two patients with mean age of 10 years met inclusion criteria. All patients had post-operative symptomatic improvement. We identified 26 patients with syrinx, 8 with scoliosis, 3 with hydrocephalus, and one had tethered cord. The average tonsillar descent was 8.1 mm in the non-operative group and 11.9 mm in the operative group. Ninety-five patients were managed conservatively (72%). Thirty-seven were offered surgery (28%), and 33 patients underwent intervention; 21 with duraplasty (64%) and 12 without (36%). CONCLUSIONS Pediatric patients with CM1 require both clinical and radiographic follow-up. Duraplasty may be performed if decompression fails to relieve symptomatology, but is not always needed. CM1 continues to present a challenge in surgical decision making. Adhering to a treatment paradigm may help alleviate difficult decision-making.
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Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA.
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jonathan Poggi
- Department of Neurosurgery, Brown University, Providence, RI, USA
| | - Eric Perloff
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Melissa Dupin
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
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Transclival Venous Circulation: Anatomic Study. World Neurosurg 2018; 121:e136-e139. [PMID: 30236809 DOI: 10.1016/j.wneu.2018.09.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The clivus is a small, central area of the basal cranium with limited surgical access and high morbidity associated with pathologies of its surrounding structures. Therefore thorough knowledge and understanding of the anatomy in this region are crucial for the success of treatments and interpretation of imaging. As to our knowledge, there is no extant cadaveric examination of the transclival veins, so the present study was performed. METHODS Fifteen lightly embalmed adult heads underwent blue latex injection of the left and right internal jugular veins. Special attention was given to the presence or absence of transclival vessels. When transclival veins were identified, their intracranial source, point of penetration of the clivus and anterior connections were documented. RESULTS Ten (66.7%) specimens were found to have transclival veins. These connected the basilar venous plexus to the retropharyngeal venous plexus on all specimens. Eight of the 10 specimens had multiple transclival veins, and 2 had only 1 vessel. The majority of the transclival veins were found penetrating the clivus at its lower one third. However, 2 specimens also had transclival veins that pierced the clivus at its upper one third. CONCLUSIONS An improved understanding of the skull base and its venous drainage can assist clinicians and surgeons in better understanding normal, pathologic, and variant anatomy in this region.
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Lake S, Altafulla JJ, Iwanaga J, Oskouian RJ, Loukas M, Tubbs RS. A Cadaveric Case of a Circular Torcular Herophili. Cureus 2018; 10:e3099. [PMID: 30338175 PMCID: PMC6173274 DOI: 10.7759/cureus.3099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The torcular Herophili is formed by the joining of the straight sinus, superior sagittal sinus, and transverse sinus. The anatomic configuration of the torcular Herophili is highly variable. In the current literature, classification systems define up to nine subtypes of the torcular Herophili. The frequency of prevalence of these anatomical variants is also variable. Herein is a case report of a circularly-shaped torcular Herophili found during cadaveric dissection.
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Affiliation(s)
- Sasha Lake
- Anatomical Studies, St. George's, St. George, GRD
| | | | - Joe Iwanaga
- Medical Education and Simulation, Seattle Science Foundation, Seattle, USA
| | - Rod J Oskouian
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - Marios Loukas
- Anatomical Sciences, St. George's University, St. George's, GRD
| | - R Shane Tubbs
- Neurosurgery, Seattle Science Foundation, Seattle, USA
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