Arnold-Chiari I malformation association with generalized anxiety disorder: a case report

Enrichment and Correlation Analysis of Serum miRNAs in Comorbidity Between Arnold-Chiari and Tourette Syndrome Contribute to Clarify Their Molecular Bases

Due to its rarity, coupled to a multifactorial and very heterogeneous nature, the molecular etiology of Arnold-Chiari (AC) syndrome remains almost totally unknown. Its relationship with other neuropsychiatric disorders such as Tourette syndrome (TS) is also undetermined. The rare comorbid status between both disorders (ACTS) complicates the framework of diagnosis and negatively affects the patients' quality of life. In this exploratory study, we aimed to identify serum microRNA expression profiles as molecular fingerprints for AC, TS, and ACTS, by using a high-throughput approach. For this aim, 10 AC patients, 11 ACTS patients, 6 TS patients, and 8 unaffected controls (NC) were recruited. Nine miRNAs resulted significantly differentially expressed (DE): let-7b-5p (upregulated in ACTS vs. TS); miR-21-5p (upregulated in ACTS vs. AC; downregulated in AC vs. TS); miR-23a-3p (upregulated in TS vs. NCs; downregulated in AC vs. TS); miR-25-3p (upregulated in AC vs. TS and NCs; downregulated in ACTS vs. AC); miR-93-5p (upregulated in AC vs. TS); miR-130a-3p (downregulated in ACTS and TS vs. NCs); miR-144-3p (downregulated in ACTS vs. AC; upregulated in AC vs. TS); miR-222-3p (upregulated in ACTS vs. NCs); miR-451a (upregulated in AC vs. TS and NCs; in ACTS vs. NCs). Altered expression of miRNAs was statistically correlated to neuroimaging and neuropsychological anomalies. Furthermore, computational analyses indicated that DE miRNAs are involved in AC and TS pathomechanisms. Finally, we propose the dysregulation of the miRNA set as a potential molecular tool for supporting the current diagnosis of AC, TS, and ACTS by using liquid biopsies, in an unbiased and non-invasive way.

Chiari I malformation-neuropsychological functions and quality of life

OBJECTIVE

To assess the neuropsychological (NP) functioning and quality of life (QOL) before and 3 months after surgery on adults with Chiari I malformation (CMI).

PATIENTS AND METHODS

All adult patients who had been diagnosed with CMI were invited to participate. Those who participated were assessed using a Hospital Anxiety and Depression scale (HAD) and NP examinations. Their QOL was assessed using the self-reported life satisfaction checklist, LiSat-11 and the five-dimensional EuroQol measurement of health outcome, EQ-5D-5L. All assessments were carried out both before and 3 months after surgery was performed. Demographic data and comorbidities were also registered.

RESULTS

Of the 11 patients who underwent NP assessment, the majority demonstrated cognitive functioning within the normal range. However, postoperatively, their performance in verbal learning, psychomotor speed, colour naming speed and the ability to manage interference through response selection and inhibition (aspects of executive functioning) was significantly improved. Thirteen patients completed QOL assessments. When LiSat-11 item domains were compared with those of healthy subjects, patients reported a lower level of satisfaction with their life quality both before and after surgery. However, the EQ-5D-5L measurements, i.e., the descriptive system and the visual analogue, indicated that their QOL of life was significantly improved after surgery.

CONCLUSION

There is scarcely any literature documenting effects of surgery on the QOL of CMI patients. The study we present here breaks new ground by comparing pre- and postoperative NP functions in CMI. We also examine the value of surgery for improving both NP functions and QOL in CMI.

Clinical diagnosis-part II: what is attributed to Chiari I

PURPOSE

Chiari malformation type I is identified as radiological appearance of cerebellar tonsil herniation below the foramen magnum. The wide spectrum of clinical manifestations variably associated sometimes encompasses signs and symptoms whose correlation with the malformation remains debatable. However, a correct clinical framework is relevant in tailoring the strategy of management, and in particular, establishing the appropriate surgical intervention.

METHODS

An analysis of relevant articles on this issue was performed, involving both single case reports and case series. The papers were obtained from electronic databases including PubMed/MEDLINE and Google Scholar, as well as direct contact with some authors.

RESULTS

This review focuses on those unusual clinical pictures attributed to Chiari malformation type I (CMI), investigating their actual relationship with the morphological condition. Supposed physiopathogenetic mechanisms and clinical relevance are discussed along with an analysis on the surgical indications and results.

CONCLUSION

There is no clear explanation on why some patients may exhibit uncommon symptoms, often in association with the most frequent ones, but even reported as single initial clinical occurrence. Their actual incidence may have been roughly underestimated in the literature so far, because of wide heterogeneity of selection and analysis among different studies. Most of the authors appear sharing the impression that CMI surgical decompression plays a significant role in controlling the majority of these unusual symptoms, stressing their actual occurrence in relation with the malformation. A routinely multidisciplinary clinical approach has become advisable to encompass the diversity of conditions potentially associated with CMI and improve the care of CMI patients.

Resolution of Postsurgical Diplopia, Paresthesia, and Weakness Following Inpatient Massage Therapy: A Case Report

Massage therapy is utilized in hospitals for patients experiencing pain, anxiety, sleeplessness, among other symptoms. Postsurgical pain is one of the most common reasons massage therapy is ordered. We present a case of a 45-year-old woman who underwent ventral hernia repair. Postoperative day 2, she began to experience multiple symptoms, including double-vision, left-sided facial numbness, tremors, pain, and weakness in her left fingers, arm, and leg. A static magnetic resonance image of the brain and cervical spine were obtained, which revealed disc protrusions at C3/C4, C5/C6, C6/C7, and mild deformity of the spinal cord. The patient's pain was difficult to control and she was unable to be weaned from intravenous pain medication. Massage therapy was ordered on postoperative days 6 and 7. During both massage sessions, as upper neck muscle tension was reduced, the therapist and patient observed several audible "pops" of the cervical spine with immediate relief of symptoms. In this particular case, massage therapy, though requested to address pain, had a secondary benefit in relieving her diplopia, left-sided facial numbness, tremors, and weakness. Although the mechanism of action is not clear, this case highlights the significant secondary beneficial effects that often occur with massage therapy.

A Systematic Review of Cognition in Chiari I Malformation

Displacement of the cerebellar tonsils in Chiari type I malformation (CMI) can affect functions controlled by the cerebellum and brainstem. While playing an integral role in the control of movement, the cerebellum also has widespread cortical connections, influencing a range of cognitive process. A systematic literature review was conducted to examine the relationship between cognition and CMI, assessing evidence for general or domain-specific cognitive change. The search protocol examined the AMED, CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Scopus databases. Articles meeting the following criteria were included in this review (i) examined children or adults with a clinically defined diagnosis of CMI, (ii) assessed cognitive function with a prospective examination, (iii) included at least one standardized instrument designed to measure general or specific domains of cognitive function, and (iv) were published in English in a peer-reviewed journal. Twelve articles were identified, including 783 cases aged 3 months to 64 years. General cognition, processing speed, and learning and memory appeared less affected, while language deficits appeared to diminish with age. Executive dysfunction was the most commonly reported cognitive impairment, while attention and working memory, and visuospatial and perceptual skills also appeared vulnerable. Numerous methodological limitations were identified that should be considered in interpreting the impact of CMI and planning future investigations. Overall, there is currently insufficient evidence to describe a valid and reliable profile of cognitive impairment in CMI. Further research is required to confirm these preliminary psychometric results and integrate them with pathophysiological models.

Parent-Reported Executive Dysfunction in Children and Adolescents with Chiari Malformation Type 1

BACKGROUND

Children with Chiari malformation type 1 (CM1) have increasingly presented to neurosurgery clinics. Limited research relating to the cognitive dysfunction experienced by this population has been completed. In adults, inhibition problems and executive dysfunction have been documented.

METHODS

Seventy-seven parental reports of children with CM1 were included in the study. Parents completed questions on a scale rating daily executive functioning as well as reporting on common neurological symptoms.

RESULTS

The sample consisted of 41 males and 36 females with a mean age of 133.57 ± 42.18 months. Thirty-eight subjects had had decompression surgery. The most common neurological symptoms included: headache (69%), a history of pain (31%) and gait disturbance (20%). One third of the sample demonstrated overall executive functioning impairment, with working memory elevations being most prevalent (44%). Depression, gender, age and decompression surgery were not related to executive dysfunction.

CONCLUSIONS

The parental report of executive dysfunction in children with CM1 was higher than the standardized healthy sample. Metacognitive problems, especially working memory and initiation problems were most prevalent. A quick parental rating scale identifying children with executive dysfunction may be beneficial for neurosurgeons and assist with referrals for a more comprehensive neuropsychological assessment.

The quality of life and psychiatric morbidity in patients operated for Arnold-Chiari malformation type I

BACKGROUND

There are some case reports that highlight the association of Arnold-Chiari malformation (ACM) with psychiatric symptoms. We assessed the association between ACM and psychiatric symptoms and risk factors in terms of psychiatric morbidity and evaluated the quality of life after surgery.

METHODS

This study consisted of sixteen patients who underwent decompression operation at the Department of Neurosurgery of Sisli Etfal Hospital. The MINI plus, Short-Form McGill Pain Questionnaire and WHOQOL-BREF-TR were administered to patients.

RESULTS

About 43.8% of the patients had a psychiatric disorder. About 50% of the patients had co-existing syringomyelia of which 50% with syringomyelia had a psychiatric disorder. Patients with syringomyelia without any psychiatric disorder had significantly lower scores on physical domain of WHOQOL-BREF-TR (p = 0.02) than the patients without syringomyelia and psychiatric disorder. Subjects with a psychiatric disorder had lower scores on four domains of WHOQOL-BREF-TR. The patients with psychiatric diagnoses had significantly higher scores on affective pain index (p = 0.021) and total pain index (p = 0.037) than the patients without any psychiatric disorder.

CONCLUSION

The presence of a psychiatric condition influences not only the physical aspect but also deteriorates the psychological and social relations and environmental aspect. Moreover the presence of a psychiatric disorder increases the perception of pain and causes more discomfort.

Psychosis risk syndrome comorbid with panic attack disorder in a cannabis-abusing patient affected by Arnold-Chiari malformation type I

OBJECTIVE

An 18-year-old man with Arnold-Chiari malformation (ACM) type I developed sudden panic attacks. He also manifested sleep disorder, cannabis abuse, and psychosis-risk syndrome (PRS). Although with average-superior intelligence, he had executive dysfunction. This prompted us to explore the relation between ACM, cannabis abuse, PRS and panic disorder.

METHOD

We report the case and briefly review the literature focusing on ACM and psychiatric disorders.

RESULTS

Behavior therapy led to gradual abstinence from cannabis with disappearance of anxiety symptoms. The patient is currently well and maintained on omega-3 polyunsaturated fatty acids.

CONCLUSIONS

Locus coeruleus compression and cannabis abuse may have triggered the symptoms, and the latter might also be PRS-related. PRS and anxiety symptoms should be explored in ACM patients to allow better prevention of psychosis and anxiety disorders.

Chiari type I malformation in children

The diagnosis of Chiari type I malformation (CIM) is more and more frequent in clinical practice due to the wide diffusion of magnetic resonance imaging. In many cases, such a diagnosis is made incidentally in asymptomatic patients, as including children investigated for different reasons such as mental development delay or sequelae of brain injury. The large number of affected patients, the presence of asymptomatic subjects, the uncertainties surrounding the pathogenesis of the malformation, and the different options for its surgical treatment make the management of CIM particularly controversial.This paper reports on the state of the art and the recent achievements about CIM aiming at providing further information especially on the pathogenesis, the natural history, and the management of the malformation, which are the most controversial aspects. A historial review introduces and explains the current classification. Furthermore, the main clinical, radiological, and neurophysiological findings of CIM are described to complete the picture of this heterogeneous and complex disease.