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Abstract
Pfeiffer syndrome (PS) is a rare autosomal dominant craniofacial disorder characterized by primary craniosynostosis, midface hypoplasia, and extremities' abnormalities including syndactyly. The purpose of this article was to review the current knowledge regarding how PS affects the nervous system. Methodologically, we conducted a systematic review of the existing literature concerning involvement of the nervous system in PS. Multiple-suture synostosis is common, and it is the premature fusion and abnormal growth of the facial skeleton's bones that cause the characteristic facial features of these patients. Brain abnormalities in PS can be primary or secondary. Primary anomalies are specific developmental brain defects including disorders of the white matter. Secondary anomalies are the result of skull deformity and include intracranial hypertension, hydrocephalus, and Chiari type I malformation. Spinal anomalies in PS patients include fusion of vertebrae, "butterfly" vertebra, and sacrococcygeal extension. Different features have been observed in different types of this syndrome. Cloverleaf skull deformity characterizes PS type II. The main neurological abnormalities are mental retardation, learning difficulties, and seizures. The tricky neurological examination in severely affected patients makes difficult the early diagnosis of neurological and neurosurgical complications. Prenatal diagnosis of PS is possible either molecularly or by sonography, and the differential diagnosis includes other craniosynostosis syndromes. Knowing how PS affects the nervous system is important, not only for understanding its pathogenesis and determining its prognosis but also for the guidance of decision-making in the various critical steps of its management. The latter necessitates an experienced multidisciplinary team.
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Fuell W, Elwy R, Harkey T, Carey M, Albert GW. Soft tissue density within the foramen magnum, a predictor for surgical intervention in pediatric patients with Chiari malformation type I. J Neurosurg Pediatr 2020; 26:671-675. [PMID: 33007749 DOI: 10.3171/2020.6.peds19744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chiari malformation type I (CMI) is diagnosed as herniation of the cerebellar tonsils by at least 5 mm below the foramen magnum. However, the degree of tonsillar herniation is a poor predictor of the need for decompression surgery. Exploration for an alternative morphological predictor for surgical intervention could provide greater insight into the development of an appropriate treatment plan for these patients. To investigate this issue, the authors calculated the soft tissue density within the foramen magnum as a measure of impaction of the cerebellar tonsils. Soft tissue density within the foramen magnum and degree of tonsillar herniation were then assessed for their correlation with the need for surgical intervention. METHODS The authors conducted a retrospective, longitudinal chart review of pediatric patients with CMI. Those who had undergone surgical intervention were considered symptomatic and those who had been treated conservatively, as asymptomatic. Soft tissue density was found by dividing the soft tissue occupancy of the foramen magnum (brainstem and cerebellar tonsils) by the total area of the bony foramen magnum. The predictive value of these two measurements for the need of surgery was determined. RESULTS Of the 465 patients seen for CMI at the authors' institution between July 1, 2011, and May 31, 2017, 80 underwent surgical intervention and 385 were asymptomatic. The average tissue density was significantly greater in the surgical group than in the asymptomatic group (83.3% and 78.6%, respectively, p < 0.0001). The average tonsillar descent for surgical patients was 10.8 mm compared to 9.8 mm for asymptomatic patients (p = 0.140). The point-biserial correlation coefficient was assessed, and soft tissue density was found to positively correlate with the need for surgical intervention (rpb = 0.199, p = 0.0001), whereas tonsillar herniation did not correlate with the need for surgery (rpb = 0.083, p = 0.115). Additionally, the degree of tonsillar herniation did not correlate with soft tissue density (r = 0.09), indicating that soft tissue density is an independent morphological parameter. CONCLUSIONS The study findings suggest that the need for surgical intervention in CMI patients is positively correlated with increasing soft tissue density within the foramen magnum, whereas the degree of tonsillar herniation did not show a correlation with the need for surgical intervention. Additionally, soft tissue density is a factor independent of the degree of tonsillar herniation. Further investigation of tissue density within the foramen magnum is needed in the hope of discovering a clinically applicable parameter that would indicate a need for surgical intervention in patients with CMI.
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Affiliation(s)
- William Fuell
- 1Division of Neurosurgery, Arkansas Children's Hospital; and
| | - Reem Elwy
- 1Division of Neurosurgery, Arkansas Children's Hospital; and
| | - Thomas Harkey
- 1Division of Neurosurgery, Arkansas Children's Hospital; and
| | - Matthew Carey
- 1Division of Neurosurgery, Arkansas Children's Hospital; and
| | - Gregory W Albert
- 1Division of Neurosurgery, Arkansas Children's Hospital; and.,2Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Chiari I malformation-neuropsychological functions and quality of life. Acta Neurochir (Wien) 2020; 162:1575-1582. [PMID: 30955083 DOI: 10.1007/s00701-019-03897-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/28/2019] [Indexed: 12/11/2022]
Abstract
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.
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Joshi M, Krishnakumar A. Hypoglycemia causes dysregulation of Neuregulin 1, ErbB receptors, Ki67 in cerebellum and brainstem during diabetes: Implications in motor function. Behav Brain Res 2019; 372:112029. [PMID: 31195035 DOI: 10.1016/j.bbr.2019.112029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 05/08/2019] [Accepted: 06/08/2019] [Indexed: 12/09/2022]
Abstract
Hypoglycemia induced brain injury poses a major setback to optimal blood glucose regulation during diabetes. It causes irreversible injury in several brain regions culminating in improper function. Neuregulin 1 and ErbB receptors are involved in regeneration during adulthood as well as in glucose homeostasis. We intended to understand the influence of extreme discrepancies in glycemic levels on Neuregulin 1, ErbB receptor subtypes and Ki67 expression in relation to motor deficits as a consequence of cellular dysfunction/degeneration in the cerebellum and brainstem during diabetes. Elevated oxidative stress and compromised antioxidant system havocs cerebellum and brainstem related function. Cellular alteration of Purkinje neurons in the cerebellum and presence of axonal spheroids in the brainstem are suggestive of impairment to neural circuits involved in motor function. Down regulation of Neuregulin 1, ErbB 2, ErbB 3, ErbB 4 and Ki67 expression observed during diabetes and hypoglycemia may critically cause regenerative deficiency in cerebellum. The coincident up regulation of Neuregulin 1, ErbB 2, ErbB 3 and ErbB 4 in brainstem during diabetes is an attempt to maintain regenerative homeostasis to ensure its function. However, hypoglycemic insults results in down regulation of Neuregulin 1, ErbB 4 expression that severely compromises their role in brainstem. Grid walking test confirmed motor impairment during diabetes that showed further deterioration due to hypoglycemic stress. Thus altered expression of Neuregulin 1, ErbB receptor subtypes and Ki67 during diabetes and hypoglycemia contributes to reduced cellular proliferation and deficits in motor function.
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Affiliation(s)
- Madhavi Joshi
- Institute of Science, Nirma University, Sarkhej- Gandhinagar Highway Ahmedabad 382481, Gujarat, India.
| | - Amee Krishnakumar
- Institute of Science, Nirma University, Sarkhej- Gandhinagar Highway Ahmedabad 382481, Gujarat, India.
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Önal H, Ersen A, Gemici H, Adal E, Güler S, Sander S, Albayram S. Acquired Chiari I Malformation Secondary to Spontaneous Intracranial Hypotension Syndrome and Persistent Hypoglycemia: A Case Report. J Clin Res Pediatr Endocrinol 2018. [PMID: 29513222 PMCID: PMC6280325 DOI: 10.4274/jcrpe.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Spontaneous intracranial hypotension (SIH) is a rare and potentially serious condition in childhood. Cerebrospinal fluid (CSF) volume depletion is thought to be the main causative feature for intracranial hypotension and results from a spontaneous CSF leak, often at the spine level. SIH is increasingly diagnosed in clinical practice, although it manifests a varied symptomatology. The downward displacement of the brain, sometimes mimicking a Chiari I malformation, has rarely been reported. We present a case of a SIH with Chiari I malformation accompanied by an unusual clinical presentation of persistent hypoglycemia.
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Affiliation(s)
- Hasan Önal
- University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, Clinic of Pediatric Endocrinology and Metabolism, İstanbul, Turkey,* Address for Correspondence: University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, Clinic of Pediatric Endocrinology and Metabolism, İstanbul, Turkey Phone: +90 532 509 29 88 E-mail:
| | - Atilla Ersen
- University of Health Sciences, Okmeydanı Training and Research Hospital, Clinic of Pediatrics, İstanbul, Turkey
| | - Hakan Gemici
- University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, Clinic of Pediatrics, İstanbul, Turkey
| | - Erdal Adal
- University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, Clinic of Pediatric Endocrinology and Metabolism, İstanbul, Turkey
| | - Serhat Güler
- Bezmialem Vakıf University Faculty of Medicine, Department of Pediatric Neurology, İstanbul, Turkey
| | - Serdar Sander
- University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, Clinic of Pediatric Surgery, İstanbul, Turkey
| | - Sait Albayram
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Radiology, İstanbul, Turkey
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The role of central nervous system on hypoglycemia and the feasibility of the brain theory in traditional Chinese medicine on treatment of diabetes mellitus. JOURNAL OF INTEGRATIVE MEDICINE-JIM 2014; 12:1-6. [DOI: 10.1016/s2095-4964(14)60008-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Carew CL, Prasad A, Tay KY, de Ribaupierre S. Unusual presentation of Chiari I in toddlers: case reports and review of the literature. Childs Nerv Syst 2012; 28:1965-70. [PMID: 22661147 DOI: 10.1007/s00381-012-1826-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 05/23/2012] [Indexed: 11/25/2022]
Abstract
Toddlers with Chiari malformations can present with common symptoms, such as cough or drooling, which are associated with respiratory illnesses, delaying a correct diagnosis. Presentation does vary with age, and therefore can be different in older children when compared to infants. We present two cases of unusual presentations in toddlers and review the literature with an emphasis on acute presentation of Chiari in different age groups in children.
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Affiliation(s)
- Caitlin L Carew
- Schulich School of Medicine and Dentistry, University of Western Ontario, Victoria Hospital, B1-181, 800 Commissionners Rd E, London, ON N6A 5W9, Canada
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Tarani L, Del Balzo F, Costantino F, Properzi E, D'Eufemia P, Liberati N, Spalice A. Chiari type I malformation, syncope, headache, hypoglycemia and hepatic steatosis in an 8-year old girl: a causal association? Pediatr Rep 2010; 2:e8. [PMID: 21589844 PMCID: PMC3094011 DOI: 10.4081/pr.2010.e8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 02/18/2010] [Accepted: 02/19/2010] [Indexed: 11/24/2022] Open
Abstract
Chiari type I malformation (CMI) is a congenital hindbrain anomaly characterized by downward displacement of the cerebellar tonsils through the foramen magnum. Chiari type I malformation often presents with a complex clinical picture and can be sporadic or linked to a variety of genetic conditions. We report on a girl in whom Chiari type I malformation was associated with hypoglycemia, headache, vertigo, syncope and hepatic steatosis. We hypothesize that these symptoms are primarily a consequence of Chiari type I malformation.
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Affiliation(s)
- Luigi Tarani
- Chair of Paediatrics, Department of Paediatrics, University "La Sapienza", Rome, Italy
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Greenlee JDW, Donovan KA, Hasan DM, Menezes AH. Chiari I malformation in the very young child: the spectrum of presentations and experience in 31 children under age 6 years. Pediatrics 2002; 110:1212-9. [PMID: 12456921 DOI: 10.1542/peds.110.6.1212] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The entity of hindbrain herniation without myelodysplasia in the very young child has been poorly described. A retrospective analysis of children diagnosed with Chiari I malformation (CM I) before their sixth birthday is presented. METHODS Since 1985, 31 children with CM I (0.3-5.8) years of age have been diagnosed at University of Iowa Hospitals and Clinics. Their records were reviewed for presenting symptoms, signs, radiographic findings, treatment, complications, and outcome. RESULTS The average age at diagnosis was 3.3 years. Sixteen patients were under age 3. Chief presenting complaints included impaired oropharyngeal function (35%), scoliosis (23%), headache or neck pain (23%), sensory disturbance (6%), weakness (3%), and other (10%). Sixty-nine percent of children under age 3 had abnormal oropharyngeal function. Three patients under age 3 (19%) had undergone fundoplication and/or gastrostomy before diagnosis of CM I. Common physical findings included abnormal tendon reflexes (68%), scoliosis (26%), abnormal gag reflex (13%), and normal examination (13%). Vocal cord dysfunction (26%, all under age 3) and syringohydromyelia (52%) were also seen. Twenty-five patients were treated surgically at our institution with posterior fossa decompression, duraplasty, and cerebellar tonsillar shrinkage. Three patients were lost to follow-up. Ninety-one percent of patients reported improved symptomatology at last follow-up (mean: 3.9 years). Three patients required reoperation for recurrence of symptoms. Syringomyelia improved in all patients. Scoliosis resolved in 2 of 8 patients, improved in 5, and stabilized in 1. There was no permanent morbidity from surgery. DISCUSSION We show that children with Chiari I abnormality are very likely to present with oropharyngeal dysfunction if under age 3, and either scoliosis or headache or neck pain worsened by valsalva if age 3 to 5. These symptoms are very likely to improve after Chiari decompression, which can be done with low morbidity. CONCLUSIONS Very young children presenting with oropharyngeal dysfunction, pain worsened by valsalva, or scoliosis should prompt the clinician to consider CM I as a possible cause.
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Affiliation(s)
- Jeremy D W Greenlee
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA
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Brown H. Anatomy of the spinal accessory nerve plexus: relevance to head and neck cancer and atherosclerosis. Exp Biol Med (Maywood) 2002; 227:570-8. [PMID: 12192098 DOI: 10.1177/153537020222700804] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The term spinal accessory nerve plexus may be defined as the spinal accessory nerve with all its intra- and extracranial connections to other nerves, principally cranial, cervical, and sympathetic. The term is not new. This review examines its applied anatomy in head and neck cancer and atherosclerosis. Over the centuries, general studies of neural and vascular anatomy and embryology formed a basis for the understanding upon which the plexus is described. During the past century, its anatomy and blood supply have come to be better understood. The importance of almost all of the plexus to head, neck, and upper extremity motor and sensory functions has come to be realized. Because of this understanding, surgical neck dissection has become progressively more conservative. This historical progression is traced. Even the most recent anatomic studies of the spinal accessory nerve plexus reveal configurations, new to many of us. They were probably known to classical anatomists, and not recorded in readily available literature, or not recorded at all. Human and comparative anatomic studies indicate that the composition of this plexus and its blood supply vary widely, even though within the same species their overall function is very nearly the same. Loss of any of these structures, then, may have very different consequences in different individuals. As a corollary to this statement, data are presented that the spinal accessory nerve itself need not be cut during surgical neck dissections for severe impairment to occur. In addition, data are presented supporting the theory that atherosclerosis by obstructing vessels to this plexus and its closely connected brachial plexus will very likely result in their ischemic dysfunction, often painful. Finally evidence, as well as theory, is stated concerning anatomic issues, methodology, outcome, and possible improvements in surgical procedures emphasizing conservatism.
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Affiliation(s)
- Henry Brown
- The Harvard University School of Medicine, Boston, Massachusetts 02115, USA.
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Sirikci A, Bayazit YA, Bayram M. The Chiari III malformation: an unusual and asymptomatic variant in an 11-year old child. Eur J Radiol 2001; 39:147-50. [PMID: 11566240 DOI: 10.1016/s0720-048x(01)00334-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chiari III malformation is an extremely rare condition, and is characterized by the hindbrain herniation into a low occipital or high cervical encephalocele together with the pathologic and imaging features of the Chiari II malformation. In this report, an unusual variant of the Chiari III malformation was diagnosed in an 11-year-old girl. She had an encephalocele operation when she was a newborn, and has been asymptomatic since then. The clinical and imaging findings of this case were presented.
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Affiliation(s)
- A Sirikci
- Department of Radiology, Faculty of Medicine, Gaziantep University, Koljtepe, 27070 Gaziantep, Turkey.
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Alden TD, Ojemann JG, Park TS. Surgical treatment of Chiari I malformation: indications and approaches. Neurosurg Focus 2001; 11:E2. [PMID: 16724812 DOI: 10.3171/foc.2001.11.1.3] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chiari I malformation is a well-described entity characterized by hindbrain herniation through the foramen magnum. Although the exact origin of congenital Chiari I malformation is unknown, it appears to be caused by a mismatch between the volume of the posterior fossa neural elements and the posterior fossa cranial content. Several theories have been proposed to describe the resultant pathophysiology of this mismatch. It is clear, however, that abnormal cerebrospinal fluid flow and velocity play a role in the symptoms and signs associated with this disorder. The authors will review the pathophysiology, clinical presentation, and treatment options for patients with Chiari I malformation.
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Affiliation(s)
- T D Alden
- Department of Neurosurgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
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Abstract
OBJECT The authors describe a series of children with Chiari I malformation who presented with fulminating symptoms of "cerebellar fits" characterized by drop attacks with or without deterioration of consciousness, opisthotonic posturing, and varying degrees of respiratory compromise. METHODS A retrospective analysis was undertaken of the medical records of 47 consecutive patients undergoing surgery for symptomatic Chiari I malformations at Rainbow Babies and Children's Hospital. Thirteen (28%) of the 47 patients presented with complaints consistent with cerebellar fits. Before the correct diagnosis was made, nine (69%) of the 13 children had previously undergone evaluation with electroencephalography and/or electrocardicography and Holter monitoring because of suspected cortical epilepsy or cardiogenic syncope. In each of the 13 children magnetic resonance imaging demonstrated pegged cerebellar tonsils herniated below the foramen magnum. A deep indentation or blanched discoloration of the cerebellar tonsils was noted in five (38%) of these 13 patients at the time of surgery. Of patients with symptomatic Chiari I malformations, the mean degree of tonsillar herniation was significantly less for those in whom cerebellar fits occurred than those in whom they were absent (8.8 mm and 13.9 mm, respectively; p = 0.007). In only one of the patients with cerebellar fits was a syrinx present, and this was a small focal lower thoracic collection. Spells resolved after surgery in all patients who presented with cerebellar fits. CONCLUSIONS Cerebellar fits may mimic other disorders such as cardiogenic syncope and epileptic seizures. The correct diagnosis may be delayed or the conditions may be misdiagnosed by those who fail to consider Chiari I malformation as a cause of drop attacks, abnormal extensor posturing, and apneic spells in children. The response to decompressive surgery in these patients is gratifying.
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Affiliation(s)
- A Pandey
- Division of Pediatric Neurological Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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