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Xiao Y, Liu Y, Wang Z, He K, Zhang Z, Chen S, Dai J, Luo Y, Gui Y, Xiao X. Combined Cerebrospinal Fluid Hydrodynamics and Fourth Ventricle Outlet Morphology to Improve Predictive Efficiency of Prognosis for Chiari Malformation Type I Decompression. World Neurosurg 2023; 176:e208-e218. [PMID: 37187345 DOI: 10.1016/j.wneu.2023.05.031] [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: 02/09/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To identify the morphological characteristics together with cerebrospinal fluid (CSF) hydrodynamics on preoperative magnetic resonance imaging that improve the prediction of foramen magnum decompression (FMD) treatment outcome for Chiari malformations type I (CM-I) patients compared with the CSF hydrodynamics-based model. METHODS This retrospective study included CM-I patients who underwent FMD, phase-contrast cine magnetic resonance, and static MR between January 2018 and March 2022. The relationships of the preoperative CSF hydrodynamic quantifications derived from phase-contrast cine magnetic resonance and morphological measurements from static magnetic resonance imaging, clinical indicators with different outcomes, were analyzed with logistic regression analysis. The outcomes were determined using the Chicago Chiari Outcome Scale. The predictive performance was evaluated with receiver operating characteristic, calibration, decision curves and area under the receiver operating characteristic curve, net reclassification index, and integrated discrimination improvement and was compared with CSF hydrodynamics-based model. RESULTS A total of 27 patients were included. 17 (63%) had improved outcomes and 10 (37%) had poor outcomes. The peak diastolic velocity of the aqueduct midportion (odd ratio, 5.17; 95% confidence interval: 1.08, 24.70; P = 0.039) and the fourth ventricle outlet diameter (odd ratio, 7.17; 95% confidence interval: 1.07, 48.16; P = 0.043) were predictors of different prognoses. The predictive performance improved significantly than the CSF hydrodynamics-based model. CONCLUSIONS Combined CSF hydrodynamic and static morphologic MR measurements can better predict the response to FMD. A higher peak diastolic velocity of the aqueduct midportion and broader fourth ventricle outlet were associated with satisfying outcomes after decompression in CM-I patients.
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Affiliation(s)
- Yawen Xiao
- Department of Radiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuanyuan Liu
- Department of Radiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenhua Wang
- Department of Intensive Care Unit, Qiandongnan People's Hospital, Kaili, China
| | - Keng He
- Department of Radiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhaotao Zhang
- Department of Radiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shiqi Chen
- Department of Radiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jiankun Dai
- GE Healthcare, MR Research China, Beijing, China
| | - Yi Luo
- Department of Radiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yifei Gui
- Department of Radiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xinlan Xiao
- Department of Radiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.
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Akyuz ME, Karadag MK, Sahin MH. Effect of modified clivoaxial angle on surgical decision making and treatment outcomes in patients with Chiari malformation type 1. Front Surg 2023; 10:1143086. [PMID: 37215352 PMCID: PMC10196391 DOI: 10.3389/fsurg.2023.1143086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Chiari malformation type 1 (CM1), a complex pathological developmental disorder of the craniovertebral junction, is typically characterized by herniation of the cerebellar tonsils from the foramen magnum. Treatment using posterior fossa decompression alone without taking the ventral cervico-medullary compression into consideration may lead to unsatisfactory treatment outcomes. The current study evaluated the utility of the modified clivoaxial angle (MCAA) in assessing ventral compression and also examined its effect on treatment outcomes. Method This retrospective study included 215 adult patients who underwent surgical treatment for CM1 at one medical center over a 10-year period. The following surgical techniques were used to decompress the posterior fossa: (a) PFD: bone removal only; (b) PFDwD: bone removal with duraplasty; and (c) CTR: cerebellar tonsil resection. The morphometric measurements of the craniovertebral junction (including MCAA) were recorded using preoperative images, and the postoperative clinical status was evaluated using the Chicago Chiari outcome scale (CCOS). Results MCAA was positively correlated with the CCOS score and also independently predicted treatment outcome. To enable Receiver operating characteristic (ROC) curve analysis of CCOS scores, the patients were divided into three groups based on the MCAA cut-off values, as follows: (a) severe (n = 43): MCAA ≤ 126; (b) moderate (n = 86): 126 < MCAA ≤ 138; and (c) mild (n = 86): MCAA > 138. Group a exhibited severe ventral cervico-medullary compression (VCMC), and their CCOS scores for the PFD, PFDwD, and CTR groups were 11.01 ± 1.2, 11.24 ± 1.3, and 13.01 ± 1.2, respectively (p < 0.05). The CCOS scores increased with widening of the MCAA angle in all surgical groups (p < 0.05). Furthermore, patients with mild MCAA (>138°) exhibited 78% regression of syringomyelia, and this was significantly greater than that observed in the other groups. Discussion MCAA can be used in the selection of appropriate surgical techniques and prediction of treatment outcomes, highlighting the importance of preoperative evaluation of ventral clivoaxial compression in patients with CM1.
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3
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He Y, Zhang M, Huang C, Qin X, Zhang Z, Wang Y, Guo L, Zheng Q, Bao M, Tao Y, Wu B. Prevalence and treatment of typical and atypical headaches in patients with Chiari I malformation: A meta-analysis and literature review. Cephalalgia 2023; 43:3331024221131356. [PMID: 36694433 DOI: 10.1177/03331024221131356] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE A meta-analysis was conducted to analyze the incidence of typical and atypical headaches and outcomes following various treatments in patients with Chiari I malformation. BACKGROUND Headache is the most common symptom of Chiari malformation, which can be divided into typical and atypical subgroups to facilitate management. Much controversy surrounds the etiology, prevalence and optimal therapeutic approach for both types of headaches. METHOD We identified relevant studies published before 30 July 2022, with an electronic search of numerous literature databases. The results of this study were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULT A total of 1913 Chiari malformation type I CIM patients were identified, 78% of whom presented with headache, within this group cephalgia was typical in 48% and atypical in 29% of patients, and migraine was the most common type of atypical headache. The ratio of typical/atypical headaches with international classification of headache disorders diagnosis was 1.53, and without international classification of headache disorders diagnosis was 1.56, respectively. The pooled improvement rates of typical headaches following conservative treatment, extradural decompression and intradural decompression were 69%, 88%, and 92%, respectively. The corresponding improvement rates for atypical headaches were 70%, 57.47%, and 69%, respectively. The complication rate in extradural decompression group was significantly lower than in intradural decompression group (RR, 0.31; 95% CI: 0.06-1.59, I2 = 50%, P = 0.14). Low reoperation rates were observed for refractory headaches in extradural decompression and intradural decompression groups (1%). CONCLUSION The International Classification of Headache Disorders can assist in screening atypical headaches. extradural decompression is preferred for typical headaches, while conservative therapy is optimal for atypical headaches. A definite correlation exists between atypical headaches and Chiari Malformation Type I patients with higher prevalence than in the general population. Importantly, decompression is effective in relieving headaches in this particular patient population.
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Affiliation(s)
- Yunsen He
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Mengjun Zhang
- Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China.,Sichuan Provincial Center for Mental Health, Center of Psychosomatic Medicine of Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Caiquan Huang
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Xiaohong Qin
- Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China.,Sichuan Provincial Center for Mental Health, Center of Psychosomatic Medicine of Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhou Zhang
- Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China.,Department of Rehabilitation, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yishuang Wang
- Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China.,Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lili Guo
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Qiang Zheng
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Mingbin Bao
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Ye Tao
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Bo Wu
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, China
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4
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Makoshi Z, Leonard JR. Clinical Manifestations of Chiari I Malformation. Neurosurg Clin N Am 2023; 34:25-34. [DOI: 10.1016/j.nec.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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5
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Thunstedt DC, Schmutzer M, Fabritius MP, Thorsteinsdottir J, Kunz M, Ruscheweyh R, Straube A. Headache characteristics and postoperative course in Chiari I malformation. Cephalalgia 2022; 42:879-887. [PMID: 35236163 PMCID: PMC9315190 DOI: 10.1177/03331024221079296] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Chiari I malformation typically presents with cough headache. However,
migraine-like or tension-type-like headaches may also occur. There are
limited publications on Chiari I malformation-associated headache
semiologies and the effect of foramen magnum decompression on different
headache types. Methods A retrospective analysis complemented by structured phone interviews was
performed on 65 patients with Chiari I malformation, treated at our hospital
between 2010 and 2021. Headache semiology (according to ICHD-3), frequency,
intensity, and radiological characteristics were evaluated pre- and
postoperatively. Results We included 65 patients. 38 patients were female and 27 male. Mean age was
43.9 ± 15.7 years. Headache was predominant in 41 patients (63.0%).
Twenty-one patients had cough headache and 20 had atypical headache (12
migrainous, eight tension-type headache-like). Thirty-five patients with
headache underwent surgery. Frequency, intensity, and analgesic use was
significantly reduced in cough headache (p < 0.001).
Atypical headaches improved less (p = 0.004 to 0.176).
Exploratory analysis suggested that larger preoperative tonsillar descent
correlated with larger postoperative headache intensity relief
(p = 0.025). Conclusion Decompression was effective in Chiari I malformation-related cough headache.
Atypical headache responded less well, and the causal relation with Chiari I
malformation remains uncertain. For atypical headache, decompression should
only be considered after failed appropriate preventive therapy and within an
interdisciplinary approach involving a neurologist.
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Affiliation(s)
- Dennis C Thunstedt
- Department of Neurology, University Hospital, Ludwig Maximilians University (LMU), Munich, Germany
| | - Michael Schmutzer
- Department of Neurosurgery, University Hospital, Ludwig Maximilians University (LMU), Munich, Germany
| | - Matthias P Fabritius
- Department of Radiology, University Hospital, Ludwig Maximilians University (LMU), Munich, Germany
| | - Jun Thorsteinsdottir
- Department of Neurosurgery, University Hospital, Ludwig Maximilians University (LMU), Munich, Germany
| | - Mathias Kunz
- Department of Neurosurgery, University Hospital, Ludwig Maximilians University (LMU), Munich, Germany
| | - Ruth Ruscheweyh
- Department of Neurology, University Hospital, Ludwig Maximilians University (LMU), Munich, Germany
| | - Andreas Straube
- Department of Neurology, University Hospital, Ludwig Maximilians University (LMU), Munich, Germany
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6
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Kotaki Y, Hattori G, Uchikado H, Komaki S, Takeshige N, Miyahara T, Hasegawa Y, Morioka M. "Motion-specific Headache": A Predictor for Diagnosis and Favorable Prognosis after Surgery in Young Patients with Chiari Malformation Type 1. Neurol Med Chir (Tokyo) 2021; 61:577-582. [PMID: 34321386 PMCID: PMC8531875 DOI: 10.2176/nmc.oa.2020-0427] [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] [Indexed: 11/25/2022] Open
Abstract
As headache is known as one of the most common symptoms in the patients with Chiari malformation type 1 (CM1), it is difficult to find out CM1-related headache among the symptoms because headache itself is commonly seen. Herein, we retrospectively review the cases of six CM1 patients complaining only of headache by which they complained of deterioration in daily life activities. The symptom of headache worsened during anteflexion (n = 2; 33%), retroflexion (n = 1; 17%), jumping (n = 3; 50%), going up the stairs (n = 1; 17%), and running (n = 1; 17%). Mean age at the onset was 15.7 years old (ranging 11–18) and four out of six were female. These inductive factors were clearly different from “Valsalva-like maneuvers,” although the mechanism might originate from dynamic tonsil changes. We named these headaches as “motion-specific.” These headaches radiated to the posterior side. MRI revealed that the extent of tonsillar ectopia was 11.3 mm, while syringomyelia was observed in three out of six patients (50%). All patients underwent surgical treatment, with the “motion-specific headache” completely disappearing 12.5 days thereafter. Although headaches are common, “motion-specific headache” may be a good candidate symptom to distinguish CM1 patients, especially among teenagers with headaches, and a good predictor for favorable outcomes after surgical treatment.
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Affiliation(s)
- Yoshikuni Kotaki
- Department of Neurosurgery, Kurume University School of Medicine
| | - Gohsuke Hattori
- Department of Neurosurgery, Kurume University School of Medicine
| | - Hisaaki Uchikado
- Department of Neurosurgery, Kurume University School of Medicine
| | - Satoru Komaki
- Department of Neurosurgery, Kurume University School of Medicine
| | | | | | - Yu Hasegawa
- Department of Neurosurgery, Kurume University School of Medicine.,Department of Pharmaceutical Sciences, School of Pharmacy at Fukuoka, International University of Health and Welfare
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine
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7
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Ciaramitaro P, Rota E, Ferraris M, Stura I, Migliaretti G, Cocito D. Migraine in Chiari 1 Malformation: a cross-sectional, single centre study. Acta Neurol Belg 2021; 122:947-954. [PMID: 34047952 DOI: 10.1007/s13760-021-01716-z] [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: 04/17/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022]
Abstract
In Chiari 1 Malformation (CM1) the most frequent symptom is exertional headache, but other headache types have been reported, such as migraine. This cross-sectional study is aimed to examine the prevalence of migraine in a group of CM1 headache patients and to compare clinical-demographic characteristics between migraine and non-migraine patients. 427 adults were enrolled at the multidisciplinary Chiari Center in Torino. 230 headache patients were classified, based on radiological criteria. Frequencies (absolute/percentage values) were calculated in the whole sample for: migraine presence (with and without aura), gender, age, radiologic phenotypes and headache clinical characteristics. The association between CM1 diagnosis and headache characteristics (independent variables) and migraine diagnosis (dependent variable) was estimated by logistic regression models. Seventy-eight patients (67 females) out of 230 presenting headache had a migraine (34%), 44/78 (56%) with aura; in 58/78 (74%) migraine was comorbid with secondary headache attributable to CM1. Migraine prevalence in patients with isolated CM1 (52/120, 43.3%) was higher (p = 0.0016) than in all the other patients (26/110, 23.6%). Although migraine was prevalent in females (86%; 6:1 female:male ratio), age classes and gender were not risk factors for migraine at multivariate analysis, while migraine was associated with isolated CM1 phenotype (OR = 2.6). This study shows a high prevalence of migraine in CM1 patients and a significant association between migraine and isolated CM1. In patients with radiological evidence of CM1, particularly in the absence of neurological signs, a careful headache clinical characterization, according to the International Headache Society criteria, may be advised.
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Affiliation(s)
- Palma Ciaramitaro
- Centro Regionale Esperto Siringomielia e Sindrome di Chiari (CRESSC), Department of Neuroscience, AOU Città della Salute e della Scienza di Torino, Presidio CTO, Via Zuretti, 29, 10126, Turin, Italy.
| | - Eugenia Rota
- Neurology Unit, San Giacomo Hospital, Novi Ligure, ASL Alessandria, Novi Ligure, Italy
| | - Marilena Ferraris
- Diagnostic Imaging Department, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Ilaria Stura
- Department of Public Health and Paediatric Sciences, University of Torino, Torino, Italy
| | - Giuseppe Migliaretti
- Department of Public Health and Paediatric Sciences, University of Torino, Torino, Italy
| | - Dario Cocito
- Centro Regionale Esperto Siringomielia e Sindrome di Chiari (CRESSC), Department of Neuroscience, AOU Città della Salute e della Scienza di Torino, Presidio CTO, Via Zuretti, 29, 10126, Turin, Italy
- Istituti Clinici Scientifici Maugeri, Pavia, Italy
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8
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Ibrahimy A, Huang CWC, Bezuidenhout AF, Allen PA, Bhadelia RA, Loth F. Association Between Resistance to Cerebrospinal Fluid Flow Near the Foramen Magnum and Cough-Associated Headache in Adult Chiari Malformation Type I. J Biomech Eng 2021; 143:051003. [PMID: 33454731 PMCID: PMC8086178 DOI: 10.1115/1.4049788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/18/2020] [Indexed: 01/03/2023]
Abstract
Cough-associated headaches (CAHs) are thought to be distinctive for Chiari malformation type I (CMI) patients and have been shown to be related to the motion of cerebrospinal fluid (CSF) near the foramen magnum (FM). We used computational fluid dynamics (CFD) to compute patient-specific resistance to CSF motion in the spinal canal for CMI patients to determine its accuracy in predicting CAH. Fifty-one symptomatic CMI patients with cerebellar tonsillar position (CTP) ≥ 5 mm were included in this study. The patients were divided into two groups based on their symptoms (CAH and non-CAH) by review of the neurosurgical records. CFD was utilized to simulate CSF motion, and the integrated longitudinal impedance (ILI) was calculated for all patients. A receiver operating characteristic (ROC) curve was evaluated for its accuracy in predicting CAH. The ILI for CMI patients with CAH (776 dyn/cm5, 288-1444 dyn/cm5; median, interquartile range) was significantly larger compared to non-CAH (285 dyn/cm5, 187-450 dyn/cm5; p = 0.001). The ILI was more accurate in predicting CAH in CMI patients than the CTP when the comparison was made using the area under the ROC curve (AUC) (0.77 and 0.70, for ILI and CTP, respectively). ILI ≥ 750 dyn/cm5 had a sensitivity of 50% and a specificity of 95% in predicting CAH. ILI is a parameter that is used to assess CSF blockage in the spinal canal and can predict patients with and without CAH with greater accuracy than CTP.
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Affiliation(s)
- Alaaddin Ibrahimy
- Department of Mechanical Engineering, The University of Akron, 302 E Buchtel Avenue, Akron, OH 44325
| | - Chi-Wen Christina Huang
- Department of Radiology, Wan Fang Hospital, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City 110, Taiwan
| | - Abraham F. Bezuidenhout
- Beth Israel Deaconess Medical Center, Department of Radiology, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215
| | - Philip A. Allen
- Department of Psychology, The University of Akron, 302 E Buchtel Avenue, Akron, OH 44325
| | - Rafeeque A. Bhadelia
- Beth Israel Deaconess Medical Center, Department of Radiology, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215
| | - Francis Loth
- Department of Mechanical Engineering, The University of Akron, 302 E Buchtel Avenue, Akron, OH 44325
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9
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Morgenstern PF, Tosi U, Uribe-Cardenas R, Greenfield JP. Ventrolateral Tonsillar Position Defines Novel Chiari 0.5 Classification. World Neurosurg 2020; 136:444-453. [PMID: 32204296 DOI: 10.1016/j.wneu.2020.01.147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/15/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cervicomedullary compression in young children has been described in the context of Chiari type 1 malformation, with symptoms associated with the extent of tonsillar herniation below McRae line. Historically, Chiari type 1 malformation has been defined by tonsillar herniation of at least 5 mm. However, in certain populations, including very young children, Chiari symptoms may be present without this finding. A new Chiari classification is thus necessary. METHODS Cases involving patients up to 5 years of age evaluated for possible posterior fossa decompression were retrospectively reviewed. Preoperative symptoms, magnetic resonance imaging findings, surgical management, and short- and long-term outcome and follow-up were recorded. Tonsillar descent and presence of ventral herniation (VH) were recorded. We define VH as the tonsils crossing a line that bisects the caudal medulla at the level of the foramen magnum, thus creating a novel entity, Chiari type 0.5 malformation. Patients with ventrally herniated tonsils were compared with patients exhibiting more typical Chiari morphology. RESULTS Of 41 cases retrospectively reviewed, 20 met criteria for VH. These differed from cases without VH because of the predominance of medullary symptoms. In the VH cohort, 11 patients underwent surgical decompression with symptom resolution; 9 were initially managed conservatively, but 3 subsequently required surgery. CONCLUSIONS We define a novel Chiari entity, Chiari type 0.5 malformation, characterized by ventral tonsillar wrapping around the medulla in young children in the absence of classic Chiari type 1 malformation imaging findings. These patients are more likely to present with medullary symptoms than patients without VH. They are also more likely to require surgical decompression and respond favorably to intervention.
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Affiliation(s)
- Peter F Morgenstern
- Department of Neurological Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Umberto Tosi
- Department of Neurological Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Rafael Uribe-Cardenas
- Department of Neurological Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA.
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10
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Huang CWC, Chang YM, Brook A, Bezuidenhout AF, Bhadelia RA. Clinical utility of 2-D anatomic measurements in predicting cough-associated headache in Chiari I malformation. Neuroradiology 2020; 62:593-599. [PMID: 31996967 DOI: 10.1007/s00234-019-02356-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/27/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Cough-associated headache (CAH) is the most distinctive symptom of patients with Chiari I malformation (CMI) and indicates clinically significant disease. We determined the clinical utility of simple 2D anatomic measurements performed on a PACS workstation by assessing their diagnostic accuracy in predicting CAH in CMI patients. METHODS Seventy-two consecutive CMI patients (cerebellar tonsillar herniation > 5 mm) with headache seen by neurosurgeons over 6 years were included. Sagittal T1 images were used by two readers to measure: extent of tonsillar herniation, lengths of the clivus and supra-occiput, McRae and pB-C2 lines, as well as clivus-canal, odontoid retroversion, and skull base angles. Neurosurgery notes were reviewed to determine presence of CAH. Mann-Whitney test was used to compare measurements between patients with and without CAH. Predictive accuracy was assessed by receiver operating characteristic (ROC) curve. RESULTS 47/72 (65.3%) CMI patients reported CAH. Tonsillar herniation with CAH (10.2 mm, 7-14 mm; median, interquartile range) was significantly greater than those without CAH (7.9 mm, 6.3-10.9 mm; p = 0.02). Tonsillar herniation ≥ 10 mm showed sensitivity and specificity of 51% and 68%, and tonsillar herniation > 14 mm showed sensitivity and specificity of 30% and 100%, respectively, for predicting CAH. Other 2D measurements showed no statistically significant differences. CONCLUSIONS Among the 2D measurements used, only the extent of tonsillar herniation is different between CMI patients with and without CAH. Although CMI is diagnosed with tonsillar herniation of only 5 mm, we found that a much higher extent of herniation is needed to be predictive of CAH.
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Affiliation(s)
- Chi Wen C Huang
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Radiology, Wan Fang Hospital, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City, Taiwan, 110
| | - Yu-Ming Chang
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A Fourie Bezuidenhout
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rafeeque A Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. .,Department of Radiology, Beth Israel Deaconess Medical Center, WCB90, 330 Brookline Ave, Boston, MA, 02215, USA.
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11
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Management: opinions from different centers-the Istituto Giannina Gaslini experience. Childs Nerv Syst 2019; 35:1905-1909. [PMID: 31073684 DOI: 10.1007/s00381-019-04162-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Describe presentation and management of Chiari type 1 malformation. We report our surgical case series proposing a decision making scheme for helping surgeons decide which surgical procedure to perform and when. METHODS We retrospectively examined a series of surgically treated patients with Chiari type 1 malformation. Treatment of associated anomalies, surgical complications, and need for reintervention for insufficient decompression at first surgery are discussed. RESULTS A total of 172 patients have been surgically treated for Chiari type 1 malformation at the Neurosurgery Unit of IRCCS Giannina Gaslini Children Hospital of Genoa, Italy, in a period between 2006 and 2017. The first treatment addressing Chiari type 1 malformation was bone and ligamentous decompression alone in 104 patients (65%), associated with dural delamination in 3 patients (1.9%) and associated with duraplasty with autologous graft in 53 patients (33.1%). Postoperative complications occurred in 5 patients (2.9%). Reintervention for insufficient decompression at follow-up was needed in 6 patients (3.5%). CONCLUSIONS Surgical decompression of the posterior cranial fossa (PCF) is indicated in symptomatic patients while asymptomatic patients must be followed in a wait and see fashion. Different types of surgical decompression of different invasiveness have been proposed from only bone and ligamentous decompression to coagulation of cerebellar tonsils. Intraoperative ultrasonography is a useful tool to define when a decompression is sufficient. We did not find correlation between the need for reintervention for insufficient decompression and different invasiveness of the techniques. We believe that this finding suggests that our proposed scheme leads to the best tailored treatment for the single patient.
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Varon A, Whitt Z, Kalika PM, Potocki L, Barbouth DS, Walz K. Arnold‐Chiari type 1 malformation in Potocki–Lupski syndrome. Am J Med Genet A 2019; 179:1366-1370. [DOI: 10.1002/ajmg.a.61187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Alberto Varon
- Dr. John T. Macdonald Foundation Department of Human Genetics, Miller School of MedicineUniversity of Miami Miami Florida
| | - Zachary Whitt
- Medical College of Georgia, Augusta University Augusta Georgia
| | - Paige M. Kalika
- Department of Neurology, Miller School of MedicineUniversity of Miami Miami Florida
| | - Lorraine Potocki
- Department of Molecular and Human Genetics Baylor College of MedicineTexas Children's Hospital Houston Texas
| | - Deborah S. Barbouth
- Dr. John T. Macdonald Foundation Department of Human Genetics, Miller School of MedicineUniversity of Miami Miami Florida
| | - Katherina Walz
- Dr. John T. Macdonald Foundation Department of Human Genetics, Miller School of MedicineUniversity of Miami Miami Florida
- John P. Hussman Institute for Human Genomics, University of Miami Miami Florida
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Abstract
PURPOSE OF REVIEW With increasing use of MRI, more patients are being diagnosed with Chiari I malformation (CM1), many of whom are asymptomatic. When symptoms are present, headache is the most frequent presenting feature, although symptoms can be variable. The purpose of this review is to help primary care clinicians better understand the relationship between an individual's presenting symptoms and the presence of radiographic CM1, and to describe the expected outcomes for patients who undergo decompression surgery. RECENT FINDINGS Recent literature has shown that asymptomatic patients with CM1 tend to have a benign natural history. For symptomatic Chiari malformation, headache is the most common presenting symptom and the majority of patients that present with headache will have symptom improvement after foramen magnum decompression. This improvement is most reliable for patients with classic Chiari-type headache, which are described as occipital or cervical and tussive in nature, but has also been shown in patients with atypical headaches who have undergone surgery. SUMMARY CM1 is a common radiographic finding and associated symptoms can be variable. The relevance of this finding to a particular patient and need for intervention must be made on an individual basis.
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