Cerebellar contusion associated with type I Chiari malformation following supratentorial head trauma: case report

Complete early regression of asymptomatic hindbrain herniation caused by minor head trauma

Very few cases of cerebellar tonsillar herniation resulting from head trauma have previously been reported. We present a case of an 11-month-old girl who suffered a minor head trauma. Computed tomography (CT) scan of the head showed an occipital bone fracture and blood in the fourth ventricle. Magnetic resonance imaging (MRI) scan of the brain 2 days later revealed cerebellar edema and displacement of the cerebellar tonsils 6 mm below the foramen magnum. She was discharged from the hospital without neurological deficits. Repeat brain MRI scan, 1 month after trauma, demonstrated complete regression of the hindbrain herniation. During the hospital stay and at follow-up, no symptoms and signs related to posterior fossa involvement were noted.

Chiari I malformation with acute neurological deficit after craniocervical trauma: Case report, imaging, and anatomic considerations

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.

Tonsillar contusion associated with benign tonsillar ectopia following minor head trauma

PURPOSE

The relationship between tonsil position and symptomatic cerebellar contusion is unclear. To date, there are no reports of symptomatic traumatic brain injury associated with benign tonsillar ectopia. Reported cases are limited to prominent cerebellar tonsillar displacement by ≥5 mm (i.e., Chiari malformations).

METHODS

The authors describe a case of symptomatic concussion in a toddler with unusual computerized tomography (CT) presentation and incidental finding of benign tonsillar ectopia, hemorrhagic contusion of the tonsils, blood-brain barrier (BBB) disruption and delayed atrophy shown using magnetic resonance imaging (MRI) studies. The radiological presentation and the clinical challenges are discussed through a review of the literature.

CONCLUSION

This case suggests that damage to cerebellar structures is not limited only to overt tonsillar herniation. Benign tonsillar ectopia may predispose to cerebellar contusion even after minor concussion and thus has a clinical significance. The current paradigm viewing only noticeable tonsillar herniation as a risk factor for hindbrain injury should be revisited.

Sports participation with Chiari I malformation

OBJECT There is currently no consensus on the safety of sports participation for patients with Chiari I malformation (CM-I). The authors' goal was to define the risk of sports participation for children with the imaging finding of CM-I. METHODS A prospective survey was administered to 503 CM-I patients at 2 sites over a 46-month period. Data were gathered on imaging characteristics, treatment, sports participation, and any sport-related injuries. Additionally, 81 patients completed at least 1 subsequent survey following their initial entry into the registry and were included in a prospective group, with a mean prospective follow-up period of 11 months. RESULTS Of the 503 CM-I patients, 328 participated in sports for a cumulative duration of 4641 seasons; 205 of these patients participated in contact sports. There were no serious or catastrophic neurological injuries. One patient had temporary extremity paresthesias that resolved within hours, and this was not definitely considered to be related to the CM-I. In the prospective cohort, there were no permanent neurological injuries. CONCLUSIONS No permanent or catastrophic neurological injuries were observed in CM-I patients participating in athletic activities. The authors believe that the risk of such injuries is low and that, in most cases, sports participation by children with CM-I is safe.

Sudden onset of Chiari malformation type 1 in a young child after trauma

INTRODUCTION

Chiari 1 malformation is a rare craniovertebral junction malformation accounting up to 1 case in every 1000 newborns per year. It is characterized by herniation of cerebellar tonsils below the foramen magnum sometimes with syringomyelia. Usually, patients have a long history of slowly progressive neurological symptoms. Uncommonly, Chiari 1 malformation could present with a sudden onset, also after trauma. Few cases are reported about young children.

METHODS

The authors report a case of a 6-month child with symptoms at onset after a mild trauma. The pertinent literature is reviewed.

CONCLUSIONS

Symptoms of Chiari 1 malformation are usually slowly progressive. Few cases have been reported of the sudden onset of symptoms, some of these after trauma. In young children, the clinical setting could be insidious and potentially lethal. A sudden onset of Chiari 1 malformation must be considered as a consequence of trauma, usually after performing a brain MRI. Management of these cases is still controversial, and surgery may be indicated in managing symptoms; however, it seems to not affect clinical outcome.

Chiari malformation type I: related conditions

Chiari malformation type I (CMI) is a morphological diagnosis defined as the inferior displacement of the cerebellum through the foramen magnum. In parallel to this basic definition of CMI, there are diagnoses that co-exist with CMI in selected patients. In addition, there are specific constellations of clinical symptoms and signs reported in the literature that occur non-randomly in patients affected by CMI. There is no established system that categorizes these CMI-related conditions or even defines them as causes or consequences of CMI. Identifying the relationship between CMI and these associated disorders may allow greater understanding of CMI etiology and potentially inform CMI management.

Shunt malfunction causing acute neurological deterioration in 2 patients with previously asymptomatic Chiari malformation Type I. Report of two cases

Patients with symptomatic Chiari malformation Type I (CM-I) typically exhibit a chronic, slowly progressive disease course with evolution of symptoms. However, some authors have reported acute neurological deterioration in the setting of CM-I and acquired Chiari malformations. Although brainstem dysfunction has been documented in patients with CM-II and hydrocephalus or shunt malfunction, to the authors' knowledge only 1 report describing ventriculoperitoneal (VP) shunt malfunction causing neurological deterioration in a patient with CM-I exists. The authors report on their experience with the treatment of previously asymptomatic CM-I in 2 children who experienced quite different manifestations of acute neurological deterioration secondary to VP shunt malfunction. Presumably, VP shunt malfunction created a positive rostral pressure gradient across a stenotic foramen magnum, resulting in tetraparesis from foramen magnum syndrome in 1 patient and acute ataxia and cranial nerve deficits from syringobulbia in the other. Although urgent shunt revisions yielded partial recovery of neurological function in both patients, marked improvement occurred only after posterior fossa decompression.

CONVERSION TO SYMPTOMATIC CHIARI I MALFORMATION AFTER MINOR HEAD OR NECK TRAUMA

OBJECTIVE

The Chiari I malformation is a rare disorder characterized by downward herniation of the brainstem and cerebellar tonsils through the foramen magnum. Many individuals with the Chiari I malformation do not become symptomatic until adulthood, and the factors that contribute to the onset of symptoms have not been well characterized. The purpose of this systematic chart review was to determine the incidence and validity of minor head or neck trauma as precipitating factors for the onset of symptomatic Chiari I malformation.

METHODS

The charts of all patients seen by the senior author (CHT) between January 1985 and July 2006 were reviewed to identify patients who had presented with symptomatic Chiari I malformation after minor head or neck trauma. Specific inclusion criteria were used to determine whether the onset of symptoms could be reliably attributed to the minor trauma.

RESULTS

Of the 85 patients with symptomatic Chiari I malformation seen by the senior author during this time, 11 (12.9%) had a history of minor head or neck trauma preceding the onset of symptoms. Of these, there were 3 patients (3.5%) in whom the onset of symptoms could be attributed to the trauma based on strict inclusion criteria.

CONCLUSION

Minor head or neck trauma can precipitate the onset of symptoms in a small number of previously asymptomatic patients with Chiari I malformation. Health care professionals must be aware that neurological symptoms that persist or worsen after minor head or neck trauma could indicate an underlying Chiari I malformation.

Acute deterioration in occult Chiari malformation following missile spinal trauma

✓Patients with Chiari malformation (CM) Type I typically experience chronic, slowly progressive symptoms. Rarely, however, do they suffer acute neurological deterioration following an iatrogenic decrease in caudal cerebrospinal fluid pressure due to, for example, a lumbar puncture. To our knowledge, acute neurological deterioration following missile spinal injury in CM has not been previously described.

The authors report on a 16-year-old girl who was shot in the abdomen and lumbar spine. Although neurologically intact on initial workup, she developed precipitous quadriplegia and apnea in a delayed fashion. Tonsillar herniation with medullary compression and cerebellar infarction was diagnosed on magnetic resonance imaging. Suboccipital decompression resulted in significant neurological improvement. Well-formed tonsillar ectopia diagnosed at surgery suggested a preexisting CM.

The authors conclude that missile spinal trauma can precipitate medullary compression and acute neurological decline, especially in patients with preexisting tonsillar ectopia. Immediate operative decompression to relieve impaction at the cervicomedullary junction can result in significant neurological recovery.

Incidental finding of Chiari I malformation with progression of symptoms after head trauma: Case report

Chiari I malformation (CMI) is a neurologic structural anomaly involving cerebellar herniation through the foramen magnum. It is most commonly diagnosed in adult patients who are often asymptomatic. Although there are several case reports of sudden death and neurologic deficits after minor head trauma in patients with CMI, little is known about the effects of trauma on CMI. This case describes a woman with chronic headaches who had an incidental finding of CMI with obstructive hydrocephalus and progression of symptoms after minor head trauma.

[Chiari type I malformation in children: presentation in 34 cases]

Incidental diagnoses of Chiari I malformation are more and more frequent in pauci or asymptomatic children. The value of neurophysiological investigations for surgical indications is discussed.

OBJECTIVE

To determine clinical presentations of Chiari I malformation and relative frequencies of severe and incidental forms, and to evaluate the usefulness of neurophysiological investigations for surgical indications.

METHODS

This retrospective study included 34 patients admitted from 1984 to 2000, with Chiari I malformation diagnosis in different pediatric (intensive care, neurology and neurosurgery) units of a university hospital.

RESULTS

The clinical presentation was severe (two children died) in four cases (12%). Signs of brain stem compression were found in 41% of cases, scoliosis in 21%, and incidental diagnosis in 26%. The polysomnography, performed in 12 cases, showed sleep-apneas in six cases. One child with an incidental diagnosis of Chiari I malformation had many sleep-apneas which required a surgical treatment. A surgical decompression was performed in 69% of cases, with clinical improvement in 77%.

CONCLUSION

The high incidence (12%) of severe forms revealing Chiari I malformations justifies systematic neurophysiological investigations for the initial evaluation and the follow-up of Chiari 1 malformations, including the less symptomatic forms.