1
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Frič R, Eide PK. Chiari type 1-a malformation or a syndrome? A critical review. Acta Neurochir (Wien) 2020; 162:1513-1525. [PMID: 31656982 DOI: 10.1007/s00701-019-04100-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/08/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE As the understanding of pathophysiology behind Chiari malformation still is limited, the treatment of Chiari malformation type 1 remains rather empirical. This may result in suboptimal treatment strategy and outcome in many cases. In this review, we critically address whether the condition known today as Chiari malformation type I should rather be denoted Chiari syndrome. METHODS The current knowledge of Chiari malformation type 1 is summarized from the historical, etymological, genetic, clinical, and in particular pathophysiological perspectives. RESULTS There are several lines of evidence that Chiari malformation type 1 represents a condition significantly different from types 2 to 4. Unlike the other types, the type 1 should rather be considered a syndrome, thus supporting the reasons to reappraise the traditional classification of Chiari malformations. CONCLUSION We propose that Chiari malformation type 1 should rather be denoted Chiari syndrome, while the notation malformation is maintained for types 2-4.
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Affiliation(s)
- Radek Frič
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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2
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Tonsillectomy with modified reconstruction of the cisterna magna with and without craniectomy for the treatment of adult Chiari malformation type I with syringomyelia. Acta Neurochir (Wien) 2020; 162:1585-1595. [PMID: 31897729 DOI: 10.1007/s00701-019-04177-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND In light of the controversies regarding the surgical treatment of adult Chiari malformation type I (CM-I) with syringomyelia, a retrospective study was conducted to evaluate the safety and efficacy of tonsillectomy followed by modified reconstruction of the cisterna magna with or without craniectomy. METHODS Between 2008 and 2017, 78 adult CM-I patients (36 males and 42 females, mean age 40.6 years old) with syringomyelia were treated with posterior fossa decompression (PFD) with tonsillectomy and modified reconstruction of the cisterna magna. Patients were divided into two study groups: group A (n = 40) underwent cranioplasty with replacement of the bone flap; group B (n = 38) underwent suboccipital craniectomy. Neurological outcomes were evaluated by traditional physician assessment (improved, unchanged, and worsened) and the Chicago Chiari Outcome Scale (CCOS). Syringomyelia outcomes were assessed radiologically. RESULTS The procedure was successfully performed in all patients, and restoration of normal cerebrospinal fluid (CSF) flow was confirmed by intraoperative ultrasonography. The median postoperative follow-up was 20.3 months (range 18-60 months). Clinical improvement was evident in 66 (84.6%) patients, with no significant differences between the two groups (85.0% vs. 84.2%, P = 0.897). According to the CCOS, 36 patients (90.0%) in group A were labeled as "good" outcome, compared with that of 34 (86.8%) in group B (P = 0.734). Improvement of syringomyelia was also comparable between the groups, which was observed in 35 (87.5%) vs. 33 (86.8%) patients (P = 0.887). The postoperative overall (7.5% vs. 23.7%, P = 0.048) and CSF-related (2.5% vs. 18.4%, P = 0.027) complication rates were significantly lower in group A than group B. CONCLUSIONS Tonsillectomy with modified reconstruction of the cisterna magna without craniectomy seems to be a safe and effective surgical option to treat adult CM-I patients with syringomyelia, though future well-powered prospective randomized studies are warranted to validate these findings.
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Koueik J, Sandoval-Garcia C, Kestle JRW, Rocque BG, Frim DM, Grant GA, Keating RF, Muh CR, Oakes WJ, Pollack IF, Selden NR, Tubbs RS, Tuite GF, Warf B, Rajamanickam V, Broman AT, Haughton V, Rebsamen S, George TM, Iskandar BJ. Outcomes in children undergoing posterior fossa decompression and duraplasty with and without tonsillar reduction for Chiari malformation type I and syringomyelia: a pilot prospective multicenter cohort study. J Neurosurg Pediatr 2019; 25:21-29. [PMID: 31628281 DOI: 10.3171/2019.8.peds19154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite significant advances in diagnostic and surgical techniques, the surgical management of Chiari malformation type I (CM-I) with associated syringomyelia remains controversial, and the type of surgery performed is surgeon dependent. This study's goal was to determine the feasibility of a prospective, multicenter, cohort study for CM-I/syringomyelia patients and to provide pilot data that compare posterior fossa decompression and duraplasty (PFDD) with and without tonsillar reduction. METHODS Participating centers prospectively enrolled children suffering from both CM-I and syringomyelia who were scheduled to undergo surgical decompression. Clinical data were entered into a database preoperatively and at 1-2 weeks, 3-6 months, and 1 year postoperatively. MR images were evaluated by 3 independent, blinded teams of neurosurgeons and neuroradiologists. The primary endpoint was improvement or resolution of the syrinx. RESULTS Eight clinical sites were chosen based on the results of a published questionnaire intended to remove geographic and surgeon bias. Data from 68 patients were analyzed after exclusions, and complete clinical and imaging records were obtained for 55 and 58 individuals, respectively. There was strong agreement among the 3 radiology teams, and there was no difference in patient demographics among sites, surgeons, or surgery types. Tonsillar reduction was not associated with > 50% syrinx improvement (RR = 1.22, p = 0.39) or any syrinx improvement (RR = 1.00, p = 0.99). There were no surgical complications. CONCLUSIONS This study demonstrated the feasibility of a prospective, multicenter surgical trial in CM-I/syringomyelia and provides pilot data indicating no discernible difference in 1-year outcomes between PFDD with and without tonsillar reduction, with power calculations for larger future studies. In addition, the study revealed important technical factors to consider when setting up future trials. The long-term sequelae of tonsillar reduction have not been addressed and would be an important consideration in future investigations.
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Affiliation(s)
- Joyce Koueik
- 1Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin
| | | | - John R W Kestle
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Brandon G Rocque
- 3Department of Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - David M Frim
- 4Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Gerald A Grant
- 5Department of Pediatric Neurosurgery, Stanford Health Care, Palo Alto, California
| | - Robert F Keating
- 6Department of Neurosurgery, Children's National Health System, Washington, DC
| | - Carrie R Muh
- 7Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - W Jerry Oakes
- 3Department of Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - Ian F Pollack
- 8Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, Pennsylvania
| | - Nathan R Selden
- 9Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - R Shane Tubbs
- 3Department of Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - Gerald F Tuite
- 10Department of Neurosurgery, Johns Hopkins All Children's Hospital, Tampa, Florida
| | - Benjamin Warf
- 11Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Victor Haughton
- 13Radiology, University of Wisconsin-Madison, Wisconsin; and
| | - Susan Rebsamen
- 13Radiology, University of Wisconsin-Madison, Wisconsin; and
| | - Timothy M George
- 14Department of Neurosurgery, Dell Medical School, Austin, Texas
| | - Bermans J Iskandar
- 1Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin
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Coll G, El Ouadih Y, Abed Rabbo F, Jecko V, Sakka L, Di Rocco F. Hydrocephalus and Chiari malformation pathophysiology in FGFR2-related faciocraniosynostosis: A review. Neurochirurgie 2019; 65:264-268. [PMID: 31525395 DOI: 10.1016/j.neuchi.2019.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/25/2019] [Accepted: 09/03/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with syndromic faciocraniosynostosis due to the mutation of the fibroblast growth factor receptor (FGFR) 2 gene present premature fusion of the coronal sutures and of the cranial base synchondrosis. Cerebrospinal fluid (CSF) circulation disorders and cerebellar tonsil prolapse are frequent findings in faciocraniosynostosis. OBJECTIVE We reviewed the medical literature on the pathophysiological mechanisms of CSF disorders such as hydrocephalus and of cerebellar tonsil prolapse in FGFR2-related faciocraniosynostosis. DISCUSSION Different pathophysiological theories have been proposed, but none elucidated all the symptoms present in Apert, Crouzon and Pfeiffer syndromes. The first theory that addressed CSF circulation disruption was the constrictive theory (cephalocranial disproportion): cerebellum and brain stem are constricted by the small volume of the posterior fossa. The second theory proposed venous hyperpressure due to jugular foramens stenosis. The most recent theory proposed a pressure differential between CSF in the posterior fossa and in the vertebral canal, due to foramen magnum stenosis.
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Affiliation(s)
- G Coll
- Service de Neurochirurgie, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Université Clermont Auvergne, CNRS, SIGMA, Institut Pascal, Clermont-Ferrand, France.
| | - Y El Ouadih
- Service de Neurochirurgie, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - F Abed Rabbo
- Service de Neurochirurgie, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - V Jecko
- Service de Neurochirurgie, CHU Bordeaux, Bordeaux, France
| | - L Sakka
- Service de Neurochirurgie, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Laboratoire d'Anatomie et d'Organogenèse, Laboratoire de Biophysique Sensorielle, NeuroDol, Faculté de Médecine, Université Clermont Auvergne, 63000 Clermont-Ferrand, France
| | - F Di Rocco
- Service de Neurochirurgie Pédiatrique, Hôpital Femme Mère Enfant, Lyon, France; Université Claude Bernard, INSERM 1033, Lyon, France
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Morphometric analysis of posterior fossa and craniovertebral junction in subtypes of Chiari malformation. Clin Neurol Neurosurg 2018; 169:1-11. [DOI: 10.1016/j.clineuro.2018.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/12/2018] [Accepted: 03/19/2018] [Indexed: 11/19/2022]
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Woodward JA, Adler DE. Chiari I malformation with acute neurological deficit after craniocervical trauma: Case report, imaging, and anatomic considerations. Surg Neurol Int 2018; 9:88. [PMID: 29740509 PMCID: PMC5926209 DOI: 10.4103/sni.sni_304_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 01/01/2018] [Indexed: 11/27/2022] Open
Abstract
Background: In patients with Chiari I malformation (CMI), the occurrence of acute neurologic deficit after craniocervical trauma is rare. However, the pathologic potential of exacerbating anatomic overcrowding of the posterior fossa has immense clinical consequences and prompt recognition is essential. Case Description: This case study describes a 41-year-old male who sustained a single blow to the face, fell, and struck the occiput. On admission, neurological examination revealed a profound paraparesis, upper extremity diplegia, a C4 sensory level and apnea that required intubation. On arrival, computerized axial tomography of the head showed a small amount of contrecoup left frontal traumatic subarachnoid hemorrhage. Magnetic resonance imaging (MRI) performed 19 h after admission was negative except for the presence of a CMI. He acutely declined on post injury day 2, prompting emergent decompression of the posterior fossa where anatomic overcrowding was observed. At 19 weeks post injury, his motor function had significantly improved. Conclusion: The constellation of severe neurologic deficit in patients with CMI after relatively minor craniocervical trauma has been previously described. In our patient, neurologic deficit disproportionate to the mechanism of injury was observed and likely in part attributed to the presence of a Chiari malformation. Unfortunately, MRI has not yet been able to clearly define the underlying pathoanatomy, help understand the mechanism of injury, and delineate when operative intervention is indicated in these patients. Here, we review similar cases from the literature, examine findings on MRI, and evaluate mechanisms of injury following craniocervical trauma in patients with CMI to help clarify these questions.
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Affiliation(s)
- Josha A Woodward
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - David E Adler
- Section of Neurological Surgery, Legacy Emanuel Hospital, Portland, Oregon, USA
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Galarza M, Gazzeri R, Alfieri A, Martínez-Lage JF. "Triple R" tonsillar technique for the management of adult Chiari I malformation: surgical note. Acta Neurochir (Wien) 2013; 155:1195-201. [PMID: 23695377 DOI: 10.1007/s00701-013-1749-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 04/29/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Chiari type I malformation is a congenital disorder that is characterized by the caudal extension of the cerebellar tonsils through the foramen magnum into the cervical canal and by a reduced posterior fossa volume. METHODS We report our surgical technique of reposition, reduction, or resection of the cerebellar tonsils for the management of Chiari I malformation. The procedure was performed in 22 adult patients, in three different centers, with a mean age of 37 years. Clinical complaints included headaches, nuchalgia, vertigo, and upper-limb weakness or numbness. Seven patients had cervical syringomyelia. Symptoms developed within a mean time of 36 months (range, 12-70 months). RESULTS The cerebellar tonsils were exposed through a dura mater-arachnoid incision at the atlanto-occipital space after a 0.5-cm rimming craniectomy of the occipital bone in all patients. In seven patients the tonsils were resected, in other seven were reduced by subpial coagulation and aspiration, and in the remaining eight patients the tonsils were repositioned after coagulating their surfaces. Three patients had also a posterior fossa arachnoid cyst that was fenestrated in two of them. All patients improved postoperatively. Syringomyelia was reduced in five of seven patients. The mean length of the follow-up period was 12 months. CONCLUSIONS Selective reposition, reduction, or resection of herniated cerebellar tonsils may improve symptoms in adult patients with Chiari I malformation.
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Affiliation(s)
- Marcelo Galarza
- Regional Service of Neurosurgery, Virgen de la Arrixaca University Hospital, Murcia, Spain
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Shah S, Haughton V, del Río AM. CSF flow through the upper cervical spinal canal in Chiari I malformation. AJNR Am J Neuroradiol 2011; 32:1149-53. [PMID: 21511868 DOI: 10.3174/ajnr.a2460] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies have quantified CSF flow in patients with Chiari I at the foramen magnum with single-axial or single-sagittal PCMR. The goal of this study was to measure CSF velocities at multiple cervical spinal levels in patients with Chiari I malformation. MATERIALS AND METHODS In a patient registry, consecutive patients without surgery who had PCMR flow images in 5-8 axial planes between the foramen magnum and C4 were identified. Four contiguous regions were defined from the foramen magnum to C4. In each region, the fastest positive flow (PSV) and fastest negative flow (PDV) were tabulated. Changes in peak velocity by cervical spinal level and age and sex were tested for significance with linear mixed-effects models. RESULTS In 17 patients studied, PSV increased progressively and significantly from the foramen magnum to C4. PDVs increased slightly from the foramen magnum to C3. The changes in velocity over the 4 regions tended to be smaller in the 13 patients with tonsilar ectopia than in the 4 patients without it. Age and sex had an effect on peak velocities. CONCLUSIONS Peak diastolic and systolic CSF velocities are significantly greater below than at the foramen magnum.
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Affiliation(s)
- S Shah
- From New York Medical College, Valhalla, New York, USA
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11
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Grant RA, Heuer GG, Carrión GM, Adzick NS, Schwartz ES, Stein SC, Storm PB, Sutton LN. Morphometric analysis of posterior fossa after in utero myelomeningocele repair. J Neurosurg Pediatr 2011; 7:362-8. [PMID: 21456906 DOI: 10.3171/2011.1.peds10234] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Myelomeningocele (MMC) is characterized by a defect in caudal neurulation and appears at birth with a constellation of neuroanatomical abnormalities, including Chiari malformation Type II. The authors investigated the effects of antenatal versus postnatal repair of MMC through a quantitative analysis of morphometric changes in the posterior fossa (PF). METHODS The authors retrospectively reviewed the records of 29 patients who underwent in utero MMC repair, 24 patients who underwent postnatal repair, and 114 fetal and pediatric controls. Tonsillar displacement, cerebellum length, pons length, clivus-supraocciput (CSO) angle, and PF area were compared in antenatal and postnatal MMC repair groups as well as in controls without neural tube defects by using t-tests and correlation coefficients. RESULTS Initially, the in utero CSO angle was significantly more acute in all patients with MMC--prenatally and postnatally repaired--as compared with controls (57.8° vs 75.4°, p < 0.001); however, the angle rapidly changed and became similar to that in controls between 30 and 31 weeks' gestation to approximately 80°, with antenatal repair having little effect. Postnatally, the CSO angle decreased in controls (R = -0.58) and in the antenatal repair group (R = -0.17). The cerebellum and pons length demonstrated no significant differences in any group. Overall, tonsil descent was corrected in the antenatal repair group as compared with postnatal repair (p < 0.001), and the PF area increased in all 3 groups in utero. Growth was less rapid in patients with MMC compared with controls, but this was corrected by antenatal repair (p = 0.015). CONCLUSIONS Myelomeningocele was associated with tonsillar herniation and a smaller PF than in control fetuses. Antenatal surgical repair corrected both abnormalities. The CSO angle began significantly more acutely in patients with MMC, but normalized with development regardless of when surgery was performed. Determining the clinical effects of antenatal repair requires further follow-up.
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Affiliation(s)
- Ryan A Grant
- Department of Neurosurgery, Yale-New Haven Medical Center, New Haven, Connecticut, USA
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Krueger KD, Haughton VM, Hetzel S. Peak CSF velocities in patients with symptomatic and asymptomatic Chiari I malformation. AJNR Am J Neuroradiol 2010; 31:1837-41. [PMID: 20884747 DOI: 10.3174/ajnr.a2268] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE PCMR is used to evaluate the Chiari I malformation. We compared quantitative PCMR in symptomatic and asymptomatic patients with Chiari I. MATERIALS AND METHODS PCMR image data in an axial section near the foramen magnum in a consecutive series of patients with Chiari I malformations were evaluated. Patients were classified as symptomatic for a Chiari I if they had apnea spells and/or exertional headaches and as asymptomatic if they had symptoms not considered specific for a Chiari I malformation. The PCMR CSF flow study was obtained with the same protocol for all patients and with the neck in neutral, flexed, and extended positions. Images were inspected for CSF flow jets and synchronous bidirectional flow. Peak CSF flow velocities were calculated with commercial software. Differences between the 2 groups were tested with mixed-effects ANOVA and Wilcoxon rank sum or Fisher exact probability tests with significance set at the .05 level. RESULTS Twenty-six patients with Chiari I were classified as symptomatic, and 24, as asymptomatic. Abnormal flow jets tended to occur more often in the symptomatic than in the asymptomatic patients (P = .054). Peak CSF velocities ranged from 2 to 20 cm/s in the symptomatic and the asymptomatic groups and did not differ significantly between the 2 groups or with neck position. CONCLUSIONS Peak CSF flow velocities near the foramen magnum did not differentiate symptomatic and asymptomatic patients with Chiari I.
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Affiliation(s)
- K D Krueger
- University of Wisconsin, Madison, 53792, USA
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Ranger A, Al-Hayek A, Matic D. Chiari Type 1 Malformation in an Infant With Type 2 Pfeiffer Syndrome. J Craniofac Surg 2010; 21:427-31. [DOI: 10.1097/scs.0b013e3181cfa792] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Carrera I, Dennis R, Mellor DJ, Penderis J, Sullivan M. Use of magnetic resonance imaging for morphometric analysis of the caudal cranial fossa in Cavalier King Charles Spaniels. Am J Vet Res 2009; 70:340-5. [PMID: 19254145 DOI: 10.2460/ajvr.70.3.340] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To perform morphometric analysis of the caudal cranial fossa in Cavalier King Charles Spaniels (CKCSs), to assess the relationship between caudal fossa dimensions and the frequency of magnetic resonance imaging (MRI) features of occipital abnormalities in CKCSs (with and without syringomyelia), and to compare caudal cranial fossa measurements in CKCSs with measurements of 2 groups of mesaticephalic dogs. ANIMALS 70 CKCSs and 80 mesaticephalic (control) dogs. PROCEDURES Dogs were placed into 4 groups as follows: Labrador Retrievers (n = 40), spaniel-type dogs (40; English Springer Spaniels and Cocker Spaniels), CKCSs with syringomyelia (55), and CKCSs without syringomyelia (15). Multiple morphometric measurements (linear, angular, and area) were obtained from cranial midsagittalT2-weighted magnetic resonance images including the brain and cervical portion of the spinal cord. Several specific MRI findings were also recorded for CKCSs that appeared to affect the occipital bone and cervicomedullary junction. RESULTS No significant difference was identified among breeds in control groups and between sexes in any of the groups for all morphometric measurements. Significant differences were identified in CKCSs, compared with mesaticephalic dogs, in the area of the caudal cranial fossa and for several linear measurements that reflected the length of the ventral aspect of the occipital bone. These differences were greater in CKCSs with syringomyelia. All CKCSs had abnormalities in occipital bone shape. CONCLUSIONS AND CLINICAL RELEVANCE CKCSs had a shallower caudal cranial fossa and abnormalities of the occipital bone, compared with those of mesaticephalic dogs. These changes were more severe in CKCSs with syringomyelia.
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Affiliation(s)
- Inés Carrera
- Institute of Comparative Medicine, University of Glasgow, Glasgow G61 1QH, Scotland
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Rekate HL. Basioccipital hypoplasia in Chiari malformation type I. J Neurosurg 2009; 111:1043. [PMID: 19463047 DOI: 10.3171/2009.3.jns09211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Botelho RV, Neto EB, Patriota GC, Daniel JW, Dumont PAS, Rotta JM. Basilar invagination: craniocervical instability treated with cervical traction and occipitocervical fixation. Case report. J Neurosurg Spine 2007; 7:444-9. [PMID: 17933321 DOI: 10.3171/spi-07/10/444] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The upward odontoid displacement observed in basilar invagination (BI) is generally associated with a horizontal clivus and craniocervical kyphosis, conditions that exert ventral compression at the spinomedullary junction. Ventral brainstem decompression by reduction or elimination of the odontoid invagination is part of the desired treatment. The authors describe a case of BI in an adult, who was effectively treated with the easy and safe reduction of odontoid invagination via cervical traction. Normalization of kyphosis at the craniovertebral junction and the vertical position of both a previously horizontal clivus and the cerebellar tentorium demonstrated that these conditions were not part of the original malformation but instead were caused by a reducible craniovertebral instability.
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Affiliation(s)
- Ricardo V Botelho
- Spinal Group, Neurosurgical Service, Hospital do Servidor Público Estadual de São Paulo, Brazil.
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Weisfeld-Adams JD, Carter MR, Likeman MJ, Rankin J. Three sisters with Chiari I malformation with and without associated syringomyelia. Pediatr Neurosurg 2007; 43:533-8. [PMID: 17992048 DOI: 10.1159/000108803] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Accepted: 12/04/2006] [Indexed: 11/19/2022]
Abstract
Two daughters of non-consanguineous Ashkenazi Jewish parentage presented with occipital headaches in the second decade of life. Each had a symptomatic Chiari I malformation (CMI) and a large cervicothoracic syrinx. A third sister was diagnosed as having CMI without syrinx after MR screening of first-degree relatives. A fourth (the eldest) sister was asymptomatic and did not have CMI or syrinx. The girls' mother had platybasia on screening MR and a history of cough headaches. All four sisters also had demonstrable platybasic features on MR. The girls' father was asymptomatic and radiologically normal. This family represents the first reported case of three siblings in one family with confirmed CMI with or without syrinx. We discuss the possible genetic and mechanical mechanisms for the development of these abnormalities in this family.
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Ito Y, Tsuboi K, Akutsu H, Ihara S, Matsumura A. Advanced Chiari malformation type I with marked spinal cord atrophy. Case report. J Neurosurg Spine 2005; 3:324-7. [PMID: 16266075 DOI: 10.3171/spi.2005.3.4.0324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors discuss the results obtained in patients who underwent foramen magnum decompression for longstanding advanced Chiari I malformation in which marked spinal cord atrophy was present. This 50-year-old woman presented with progressive quadriparesis and sensory disorders. Magnetic resonance imaging revealed the descent of cerebellar tonsils and medulla associated with remarkable C1-L2 spinal cord atrophy. After a C-1 laminectomy-based foramen magnum decompression, arachnoid dissection and duraplasty were undertaken. These procedures resulted in remarkable neurological improvement, even after 40 years of clinical progression. Spinal cord atrophy may be caused by chronic pressure of entrapped cerebrospinal fluid in the spinal canal.
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Affiliation(s)
- Yoshiro Ito
- Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
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Cinalli G, Spennato P, Sainte-Rose C, Arnaud E, Aliberti F, Brunelle F, Cianciulli E, Renier D. Chiari malformation in craniosynostosis. Childs Nerv Syst 2005; 21:889-901. [PMID: 15875201 DOI: 10.1007/s00381-004-1115-z] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Chiari malformation (CM) is a frequent finding in multisutural and syndromic craniosynostosis, occurring in 70% of patients with Crouzon's syndrome, 75% with oxycephaly, 50% with Pfeiffer's syndrome and 100% with the Kleeblattschädel deformity. The pathogenesis of this condition and rationale for treatment are still controversial. DISCUSSION Since its first description in 1972, several factors have been cited to play a role in inducing CM. In the light of recent publications, the roles of premature fusion of cranial vault and cranial base sutures, of congenital anomalies of the cerebellum and brain stem, of raised intracranial pressure, of venous hypertension and of hydrocephalus are reviewed. Evaluation and management of CM are also discussed. CONCLUSION Chiari malformation appears to be an acquired and progressive condition that develops in the first months of life, because of a disproportion between hindbrain growth and an abnormally small posterior fossa, a consequence of the premature fusion of lambdoid and cranial base sutures. Venous hypertension caused by stenosis of the jugular foramen can also be present in these patients, resulting in intracranial hypertension and/or hydrocephalus. Careful MRI evaluation is recommended for the forms of craniosynostosis at a high risk of developing hindbrain herniation. The selection of posterior cranial vault expansion as the first surgical procedure is advocated. In selected cases, treatment of the posterior cranial deformity by occipital vault remodelling and treatment of the Chiari-like deformity by suboccipital decompression can be carried out using the same surgical procedure.
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Affiliation(s)
- Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy.
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Aydin S, Hanimoglu H, Tanriverdi T, Yentur E, Kaynar MY. Chiari type I malformations in adults: a morphometric analysis of the posterior cranial fossa. ACTA ACUST UNITED AC 2005; 64:237-41; discussion 241. [PMID: 16099255 DOI: 10.1016/j.surneu.2005.02.021] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2004] [Accepted: 02/14/2005] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Chiari type I malformation (CMI) is a congenital disorder characterized by caudal displacement of the cerebellar tonsils through the foramen magnum into the spinal canal. Recent studies suggest that overcrowding in the posterior cranial fossa (PCF) because of underdeveloped bony structures in the intrauterine life is the main cause of this malformation. For this reason, the authors want to contribute to the current literature, which focuses on bone abnormalities in the PCF in patients with CMIs. METHODS We examined a retrospective cohort of 60 adult patients with CMIs, and multiple measurements were made on magnetic resonance imaging. The results were compared to 30 healthy adult control subjects. Mann-Whitney U test was used as a statistical method. RESULTS All measurements except mean anteroposterior diameter of the foramen magnum were reduced in patients compared to control. An increase in the anteroposterior mid-sagittal distance of the foramen magnum in patients reached statistically significant difference compared to control. All patients had tonsillar herniation at least 5 mm below the plane of the foramen magnum. Chiari type I malformation in this study was associated with syringomyelia in 46 patients. CONCLUSION This study with a limited number of patients suggests that the bony components of the PCF are not developed fully, supporting the current concept that CMI is a disorder of the para-axial mesoderm.
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Affiliation(s)
- Sabri Aydin
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul 34301, Turkey
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Abstract
Chronic hydrocephalus is a complex condition, the incidence of which increases with increasing age. It is characterised by the presence of ventricular enlargement in the absence of significant elevations of intracranial pressure. The clinical syndrome may develop either as a result of decompensation of a "compensated" congenital hydrocephalus, or it may arise de novo in adult life secondary to a known acquired disturbance of normal CSF dynamics. The latter may be due to late onset acqueductal stenosis or disruption of normal CSF absorptive pathways following subarachnoid hemorrhage or meningitis ("secondary" normal pressure hydrocephalus (NPH)). In some cases the cause of the hydrocephalus remains obscure ("idiopathic" NPH). In all forms of chronic hydrocephalus the clinical course of the disease is heavily influenced by changes in the brain associated with aging, in particular cerebrovascular disease. Recent research has challenged previously held tenets regarding the CSF circulatory system and this in turn has led to a radical rethinking of the pathophysiological basis of chronic hydrocephalus.
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Affiliation(s)
- Richard J Edwards
- Department of Neurosurgery, Frenchay Hospital, Bristol, United Kingdom.
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Lazareff JA, Galarza M, Gravori T, Spinks TJ. Tonsillectomy without craniectomy for the management of infantile Chiari I malformation. J Neurosurg 2002; 97:1018-22. [PMID: 12450021 DOI: 10.3171/jns.2002.97.5.1018] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECT The authors report their experience with 15 pediatric patients who underwent resection or shrinkage of the cerebellar tonsils without craniectomy or laminectomy, for the management of Chiari I malformation. METHODS The procedure was performed in six boys and nine girls with a mean age of 10 years. Thirteen patients presented with the congenital form of this disorder and two patients with Chiari I malformation caused by lumboperitoneal shunting. Clinical complaints included headaches (seven patients), scoliosis (four patients), numbness of the extremities (four patients), and upper-limb weakness (two patients). Two patients presented with failure to thrive and one with vocal cord palsy. Eight patients (six girls and two boys) had syringomyelia. The patients' symptoms had developed within a mean time period of 21 months (range 1-70 months). In all patients the cerebellar tonsils were exposed through a dura mater-arachnoid incision at the occipitoatlantal space. In seven patients the tonsils were resected and in the remaining eight patients the tonsils were shrunk by coagulating their surfaces. All patients improved postoperatively. Gliosis with cortical atrophy was observed in the resected neural tissue. Syringomyelia was reduced in seven of eight patients. The mean length of the follow-up period was 7 months. CONCLUSIONS Removal of herniated cerebellar tonsils can be sufficient for alleviating symptoms in patients with Chiari I malformations.
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Affiliation(s)
- Jorge A Lazareff
- Division of Neurosurgery, University of California at Los Angeles School of Medicine, 90095-7039, USA.
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Dagnew E, van Loveren HR, Tew JM. Acute Foramen Magnum Syndrome Caused by an Acquired Chiari Malformation after Lumbar Drainage of Cerebrospinal Fluid: Report of Three Cases. Neurosurgery 2002. [DOI: 10.1227/00006123-200209000-00043] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Acute Foramen Magnum Syndrome Caused by an Acquired Chiari Malformation after Lumbar Drainage of Cerebrospinal Fluid: Report of Three Cases. Neurosurgery 2002. [DOI: 10.1097/00006123-200209000-00043] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Goel A, Desai K, Bhatjiwale M, Muzumdar DP. Basilar invagination and Chiari malformation associated with cerebellar atrophy: report of two treated cases. J Clin Neurosci 2002; 9:194-6. [PMID: 11922714 DOI: 10.1054/jocn.2001.0958] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We report two patients with an unusual complex of anomalies wherein the basilar invagination and Chiari malformation was associated with marked cerebellar atrophy. Both patients presented with relatively severe lower cranial nerve deficits and showed clinical improvement following a posterior foramen magnum bony decompression. The pathogenesis of the anomalies is discussed and the rationale of treatment is analysed.
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Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Seth G.S. Medical College & King Edward Memorial Hospital, Parel, Mumbai, India.
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Mesiwala AH, Shaffrey CI, Gruss JS, Ellenbogen RG. Atypical hemifacial microsomia associated with Chiari I malformation and syrinx: further evidence indicating that chiari I malformation is a disorder of the paraaxial mesoderm. Case report and review of the literature. J Neurosurg 2001; 95:1034-9. [PMID: 11765819 DOI: 10.3171/jns.2001.95.6.1034] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The authors present the first known reported case of hemifacial microsomia associated with a Chiari I malformation and syrinx. A 14-year-old girl presented with progressive torticollis of 3 years' duration and headaches exacerbated by exercise. Computerized tomography scanning and magnetic resonance imaging revealed extensive craniofacial and vertebral abnormalities, including aplasia of the floor of the left middle fossa and posterior fossa cranium, articulation of the left mandibular condyle with the left temporal lobe, and progressive development of a Chiari I malformation with associated syringomyelia. The patient first underwent posterior fossa decompression, duraplasty, and occipitocervical fusion. This procedure was later followed by reconstruction of the floor of the left middle fossa and temporomandibular joint. The patient's outcome was excellent. In this case report the authors review the complex embryological development of craniofacial and craniovertebral structures, and emphasize the use of a staged approach to treat pathophysiological consequences of this congenital anomaly.
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Affiliation(s)
- A H Mesiwala
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
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Decq P, Le Guérinel C, Sol JC, Brugières P, Djindjian M, Nguyen JP. Chiari I malformation: a rare cause of noncommunicating hydrocephalus treated by third ventriculostomy. J Neurosurg 2001; 95:783-90. [PMID: 11702868 DOI: 10.3171/jns.2001.95.5.0783] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECT Hydrocephalus associated with Chiari I malformation is a rare entity related to an obstruction in the flow of cerebrospinal fluid (CSF) in the foramen of Magendie. Like all forms of noncommunicating hydrocephalus. it can be treated by endoscopic third ventriculostomy (ETV). The object of this study is to report a series of five cases of hydrocephalus associated with Chiari I malformation and to evaluate the use of ETV in the treatment of this anomaly. METHODS Five patients (four women and one man with a mean age of 29.6 years) underwent ETV for hydrocephalus associated with Chiari I malformation between April 1991 and February 1997. All patients had presented with paroxysmal headaches, which in two cases were associated with visual disorders. All patients had also presented with hydrocephalus (mean transverse diameter of the third ventricle 12.79 mm; mean sagittal diameter of the fourth ventricle 18.27 mm) with a mean herniation of the cerebellar tonsils at 13.75 mm below the basion-opisthion line. Surgery was performed in all patients by using a rigid endoscope. No complications occurred either during or after the procedure, except in one patient who experienced a wound infection that was treated by antibiotic medications. The mean duration of follow up in this study was 50.39 months. Four patients became completely asymptomatic and remained stable throughout the follow-up period. One patient required an additional third ventriculostomy after I year, due to secondary closure, and has remained stable since that time. Postoperative magnetic resonance images demonstrated a significant reduction in the extent of hydrocephalus in all patients (mean transverse diameter of the third ventricle 6.9 mm [p = 0.0035]; mean sagittal diameter of the fourth ventricle 10.32 mm [p = 0.007]), with a mean ascent of the cerebellar tonsils from 13.75 mm below the basion-opisthion line to 7.76 mm below it (p = 0.01). In addition, CSF flow was identified on either side of the orifice of the third ventriculostomy in all patients postoperatively. CONCLUSIONS Results in this series confirm the efficacy of ETV in the treatment of hydrocephalus associated with Chiari I malformation. It is a reliable, minimally invasive technique that also provides a better understanding of the pathophysiology of this malformation.
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Affiliation(s)
- P Decq
- Service de Neurochirurgie et de Neuroradiologie, Hôpital Henri Mondor, Créteil, France.
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Abstract
With the widespread use of newer neuroimaging techniques and modalities, significant tonsillar herniation is being diagnosed in more than 0.5% of patients, some of whom are asymptomatic. This puts the definition of the adult Chiari malformation to the test. The author provides a historical review of the evolution of the definition of the adult Chiari malformation in the neurosurgery, radiology, and pathology literature.
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Affiliation(s)
- G K Bejjani
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Affiliation(s)
- A L Rhoton
- Department of Neurological Surgery, University of Florida, Gainesville, USA
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Milhorat TH, Chou MW, Trinidad EM, Kula RW, Mandell M, Wolpert C, Speer MC. Chiari I malformation redefined: clinical and radiographic findings for 364 symptomatic patients. Neurosurgery 1999; 44:1005-17. [PMID: 10232534 DOI: 10.1097/00006123-199905000-00042] [Citation(s) in RCA: 805] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Chiari malformations are regarded as a pathological continuum of hindbrain maldevelopments characterized by downward herniation of the cerebellar tonsils. The Chiari I malformation (CMI) is defined as tonsillar herniation of at least 3 to 5 mm below the foramen magnum. Increased detection of CMI has emphasized the need for more information regarding the clinical features of the disorder. METHODS We examined a prospective cohort of 364 symptomatic patients. All patients underwent magnetic resonance imaging of the head and spine, and some were evaluated using CINE-magnetic resonance imaging and other neurodiagnostic tests. For 50 patients and 50 age- and gender-matched control subjects, the volume of the posterior cranial fossa was calculated by the Cavalieri method. The families of 21 patients participated in a study of familial aggregation. RESULTS There were 275 female and 89 male patients. The age of onset was 24.9+/-15.8 years (mean +/- standard deviation), and 89 patients (24%) cited trauma as the precipitating event. Common associated problems included syringomyelia (65%), scoliosis (42%), and basilar invagination (12%). Forty-three patients (12%) reported positive family histories of CMI or syringomyelia. Pedigrees for 21 families showed patterns consistent with autosomal dominant or recessive inheritance. The clinical syndrome of CMI was found to consist of the following: 1) headaches, 2) pseudotumor-like episodes, 3) a Meniere's disease-like syndrome, 4) lower cranial nerve signs, and 5) spinal cord disturbances in the absence of syringomyelia. The most consistent magnetic resonance imaging findings were obliteration of the retrocerebellar cerebrospinal fluid spaces (364 patients), tonsillar herniation of at least 5 mm (332 patients), and varying degrees of cranial base dysplasia. Volumetric calculations for the posterior cranial fossa revealed a significant reduction of total volume (mean, 13.4 ml) and a 40% reduction of cerebrospinal fluid volume (mean, 10.8 ml), with normal brain volume. CONCLUSION These data support accumulating evidence that CMI is a disorder of the para-axial mesoderm that is characterized by underdevelopment of the posterior cranial fossa and overcrowding of the normally developed hindbrain. Tonsillar herniation of less than 5 mm does not exclude the diagnosis. Clinical manifestations of CMI seem to be related to cerebrospinal fluid disturbances (which are responsible for headaches, pseudotumor-like episodes, endolymphatic hydrops, syringomyelia, and hydrocephalus) and direct compression of nervous tissue. The demonstration of familial aggregation suggests a genetic component of transmission.
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Affiliation(s)
- T H Milhorat
- Department of Neurosurgery, State University of New York Health Science Center at Brooklyn, The Long Island College Hospital, 11203-2098, USA
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32
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Death Following Minor Head Trauma in Two Adult Individuals with the Chiari I Deformity. J Forensic Sci 1998. [DOI: 10.1520/jfs14394j] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
OBJECTIVE To determine if slight descent of the cerebellar tonsils (< 5 mm below the foramen magnum; tonsillar ectopia) may cause surgically treatable symptomatology. METHODS A consecutive series of nine symptomatic patients with tonsillar ectopia seen between December 1990 and March 1993 are reported on. The same number of age and sex matched controls were selected at random from outpatients. Twelve asymptomatic subjects with tonsillar ectopia were found among 5000 people between January 1991 and March 1996. Diagnosis of tonsillar ectopia was based on midsagittal MRI. RESULTS Patients presented mainly with chronic intractable occipital dull pain, vertigo, and dysequilibrium. In all patients MRI showed normal brain structure except for tonsillar ectopia (-2.9 (SD 0.8) mm), which has historically been thought to be of no clinical relevance. In the control group the tonsilar position was +2.1 (SD 2.8) mm (p<0.01). Neurotologically abnormal findings were detected with a monaural speech integration test (100%), eye tracking test (56%), optokinetic nystagmus test (89%), and visual suppression test (67%) which strongly suggested a CNS lesion. In accordance with the results of MRI and precise neurotological examination, posterior fossa decompression surgery was carried out, followed by improvement of preoperative symptoms and less severity of neurotological abnormalities in all patients. CONCLUSION Tonsillar ectopia could cause neurological symptoms in small populations, which were surgically treatable. Neurotological assessment was necessary to verify the aetiological relation between tonsillar ectopia and various symptoms.
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Affiliation(s)
- K Furuya
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya City, Shizuoka Prefecture, Japan
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Nishikawa M, Sakamoto H, Hakuba A, Nakanishi N, Inoue Y. Pathogenesis of Chiari malformation: a morphometric study of the posterior cranial fossa. J Neurosurg 1997; 86:40-7. [PMID: 8988080 DOI: 10.3171/jns.1997.86.1.0040] [Citation(s) in RCA: 367] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To investigate overcrowding in the posterior cranial fossa as the pathogenesis of adult-type Chiari malformation, the authors studied the morphology of the brainstem and cerebellum within the posterior cranial fossa (neural structures consisting of the midbrain, pons, cerebellum, and medulla oblongata) as well as the base of the skull while taking into consideration their embryological development. Thirty patients with Chiari malformation and 50 normal control subjects were prospectively studied using neuroimaging. To estimate overcrowding, the authors used a "volume ratio" in which volume of the posterior fossa brain (consisting of the midbrain, pons, cerebellum, and medulla oblongata within the posterior cranial fossa) was placed in a ratio with the volume of the posterior fossa cranium encircled by bony and tentorial structures. Compared to the control group, in the Chiari group there was a significantly larger volume ratio, the two occipital enchondral parts (the exocciput and supraocciput) were significantly smaller, and the tentorium was pronouncedly steeper. There was no significant difference in the posterior fossa brain volume or in the axial lengths of the hindbrain (the brainstem and cerebellum). In six patients with basilar invagination the medulla oblongata was herniated, all three occipital enchondral parts (the basiocciput, exocciput, and supraocciput) were significantly smaller than in the control group, and the volume ratio was significantly larger than that in the Chiari group without basilar invagination. These results suggest that in adult-type Chiari malformation an underdeveloped occipital bone, possibly due to underdevelopment of the occipital somite originating from the paraxial mesoderm, induces overcrowding in the posterior cranial fossa, which contains the normally developed hindbrain. Basilar invagination is associated with a more severe downward herniation of the hindbrain due to the more severely underdeveloped occipital enchondrium, which further exacerbates overcrowding of the posterior cranial fossa.
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Affiliation(s)
- M Nishikawa
- Department of Neurosurgery, Osaka City University Medical School, Japan
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Reardon W, Harding B, Winter RM, Baraitser M. Hemihypertrophy, hemimegalencephaly, and polydactyly. AMERICAN JOURNAL OF MEDICAL GENETICS 1996; 66:144-9. [PMID: 8958320 DOI: 10.1002/(sici)1096-8628(19961211)66:2<144::aid-ajmg4>3.0.co;2-r] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We present clinical and neuropathological details of a patient with hemihypertrophy and hemimegalencephaly who may have Proteus syndrome. The observation of polysyndactyly in the case indicates either that polysyndactyly is a rare manifestation in Proteus syndrome, or that a separate condition, mimicking Proteus syndrome and pursuing a similar clinical course, might exist.
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Affiliation(s)
- W Reardon
- Department of Clinical Genetics, Hospital for Children, London, United Kingdom
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Byard RW. Mechanisms of sudden death and autopsy findings in patients with Arnold-Chiari malformation and ventriculoatrial catheters. Am J Forensic Med Pathol 1996; 17:260-3. [PMID: 8870879 DOI: 10.1097/00000433-199609000-00015] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Neurological and vascular complications of Arnold-Chiari malformation treated with ventriculoatrial shunting may result in sudden or unexpected death. Two patients with Arnold-Chiari malformation and ventriculoatrial shunting had variable clinical manifestations and diagnostic difficulties. A 3-year-old girl with a 1-day history of right-sided heart failure died unexpectedly soon after cardiac catheterization. At autopsy examination an adherent thrombus around the ventriculoatrial catheter tip, pulmonary infarction, and embolic pulmonary arterial hypertensive changes were found. In the second case, a 21-year-old man died suddenly after a brief episode of dyspnea. He had a 1-year history of "asthma" before death. Autopsy examination confirmed pulmonary infarction and embolic pulmonary arterial hypertensive changes. There was no histological evidence of asthma. Deaths in both cases were due to pulmonary infarction stemming from thromboemboli derived from ventriculoatrial catheterization. Both patients had evidence of long-standing clinically unsuspected vascular disease, which may have contributed to death. Cardiac catheterization may also have precipitated death in the first patient. Other possible problems leading or contributing to sudden death in such patients include pulmonary hypertension with chronic cor pulmonale, airway obstruction from recurrent laryngeal nerve paralysis, and shunt blockage with acute hydrocephalus. Lethal brainstem compression may also accompany relatively minor trauma associated with chronic cerebellar tonsillar herniation in these patients.
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Affiliation(s)
- R W Byard
- Department of Paediatrics, University of Adelaide, Australia
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Abstract
The Chiari I malformation is a congenital abnormality of the cerebellum strongly associated with syringomyelia and also associated with bony abnormalities of the base of the skull and the cervical spine. This review examines the case of a 25 year old man who collapsed and died following a blow to the face and was found at post mortem to have a Chiari I malformation and syringomyelia but no gross or microscopic evidence of fresh brain or spinal cord injury. The occurrence of sudden and unexpected deaths in this condition is discussed especially in the context of apparently minor coincident trauma.
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Affiliation(s)
- D S James
- Wales Institute of Forensic Medicine, Cardiff Royal Infirmary, UK
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Norman MG, Taylor GP, Clarke LA. Sudden, unexpected, natural death in childhood. PEDIATRIC PATHOLOGY 1990; 10:769-84. [PMID: 2235762 DOI: 10.3109/15513819009064711] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
One thousand nine hundred and fifty four autopsies performed at British Columbia's Children's Hospital during a 7-year period were reviewed to determine the causes of sudden unexpected natural death in the age group from birth to 17 years. Of the 126 cases found, the largest group, 86 cases, was sudden infant death syndrome (SIDS). Nine deaths were the result of infection: 4 cases of H. influenza meningitis, 2 cases of meningococcemia, 2 cases of acute epiglottitis, and 1 case of necrotizing tracheobronchitis. Epilepsy, ruptured AV malformations, and brain tumors combined to make up an equally large group of 9 cases. Cardiac lesions were the third largest group, 6 cases. The three groups that posed the most difficulty in assigning a cause of death were (a) the group that were like SIDS yet had other confounding features, (b) the group in which metabolic death was suspected but not proven, and (c) death in epilepsy.
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Affiliation(s)
- M G Norman
- Department of Pathology, British Columbia's Children's Hospital Vancouver, Canada
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de Oliveira E, Rhoton AL, Peace D. Microsurgical anatomy of the region of the foramen magnum. SURGICAL NEUROLOGY 1985; 24:293-352. [PMID: 4023912 DOI: 10.1016/0090-3019(85)90042-4] [Citation(s) in RCA: 218] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The anatomy needed to plan microoperative approaches to the region of the foramen magnum was examined in 25 cadaveric heads. The structures examined included the lower cranial and upper spinal nerves, the caudal brain stem and rostral spinal cord, the vertebral artery and its branches, the veins and dural sinuses at the craniovertebral junction, and the ligaments and muscles uniting the atlas, axis, and occipital bone. The transoral, transpalatal, labiomandibular, glossolabiomandibular, transsphenoidal, transcranial-transbasal, transcervical, and suboccipital operative approaches to the region are also reviewed.
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Tomaszek DE, Tyson GW, Bouldin T, Hansen AR. Sudden death in a child with an occult hindbrain malformation. Ann Emerg Med 1984; 13:136-8. [PMID: 6691617 DOI: 10.1016/s0196-0644(84)80579-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Chiari type I malformation in previously asymptomatic children can contribute to sudden death. We report a case of a 3-year-old child with this syndrome who died 48 hours after an apparently mild head injury. The case illustrates that, in children with abnormal head size or shape, it may be important to obtain skull films after even minimal craniocerebral trauma.
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