1
|
Abraham AP, Vora TK, Selvi BT, Rajshekhar V. Characterizing syringomyelia and its clinical significance in 140 patients with lipomyelomeningocele. J Neurosurg Pediatr 2022; 30:349-356. [PMID: 35901676 DOI: 10.3171/2022.6.peds2286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aims of this study were to characterize syringomyelia in patients with lipomyelomeningocele (LMMC) and investigate the association between the presence of a syrinx and patient neurological deficits. METHODS Patients with LMMC who had been admitted between 2007 and 2020 were included in the study. Syringomyelia on magnetic resonance imaging (MRI) was classified into three groups: true syrinx, early syrinx, and presyrinx. The correlation of clinical deficits (at birth, new onset, and progressive) and type of lipoma with the presence and type of syrinx was studied. RESULTS Among a total of 140 patients, the median age was 2.5 (IQR 1.3-9) years. Neurological deficits were present at birth in 75 (53.6%) patients, but 67 (47.9%) had new-onset deficits or progression of their birth deficits. The most common type of spinal lipoma was the transitional type (75.7%). Thirty-nine (27.9%) patients had a syrinx (37 with a true syrinx, 2 with an early syrinx), and 25 (17.9%) patients had a presyrinx. There was no significant correlation between the presence of a syrinx and patient neurological deficits. However, patients with a syrinx that was not adjacent to the lipoma (≥ 1 vertebral level away) had a higher incidence of deficits at birth (p = 0.045), whereas those with a syrinx spanning ≥ 5 vertebral levels had a higher incidence of progressive neurological deficits (p = 0.04). Six (75%) of 8 patients in whom serial MRI had shown syrinx progression had clinical worsening. CONCLUSIONS Syrinx location with respect to the spinal lipoma, syrinx length, and progressive syringomyelia may have clinical significance in patients with LMMC.
Collapse
Affiliation(s)
| | | | - Bernice T Selvi
- 2Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | | |
Collapse
|
2
|
Hiremath SB, Fitsiori A, Boto J, Torres C, Zakhari N, Dietemann JL, Meling TR, Vargas MI. The Perplexity Surrounding Chiari Malformations - Are We Any Wiser Now? AJNR Am J Neuroradiol 2020; 41:1975-1981. [PMID: 32943418 DOI: 10.3174/ajnr.a6743] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/23/2020] [Indexed: 11/07/2022]
Abstract
Chiari malformations are a diverse group of abnormalities of the brain, craniovertebral junction, and the spine. Chiari 0, I, and 1.5 malformations, likely a spectrum of the same malformation with increasing severity, are due to the inadequacy of the para-axial mesoderm, which leads to insufficient development of occipital somites. Chiari II malformation is possibly due to nonclosure of the caudal end of the neuropore, with similar pathogenesis in the rostral end, which causes a Chiari III malformation. There have been significant developments in the understanding of this complex entity owing to insights into the pathogenesis and advancements in imaging modalities and neurosurgical techniques. This article aims to review the different types and pathophysiology of the Chiari malformations, along with a description of the various associated abnormalities. We also highlight the role of ante- and postnatal imaging, with a focus on the newer techniques in the presurgical evaluation, with a brief mention of the surgical procedures and the associated postsurgical complications.
Collapse
Affiliation(s)
- S B Hiremath
- From the Division of Diagnostic and Interventional Neuroradiology (S.B.H., A.F., J.B., M.I.V.).,Division of Neuroradiology (S.B.H., C.T., N.Z.), Department of Radiology, University of Ottawa, The Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada
| | - A Fitsiori
- From the Division of Diagnostic and Interventional Neuroradiology (S.B.H., A.F., J.B., M.I.V.)
| | - J Boto
- From the Division of Diagnostic and Interventional Neuroradiology (S.B.H., A.F., J.B., M.I.V.)
| | - C Torres
- Division of Neuroradiology (S.B.H., C.T., N.Z.), Department of Radiology, University of Ottawa, The Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada
| | - N Zakhari
- Division of Neuroradiology (S.B.H., C.T., N.Z.), Department of Radiology, University of Ottawa, The Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada
| | - J-L Dietemann
- University of Strasbourg (J.-L.D.), Strasbourg, France
| | - T R Meling
- Division of Neurosurgery (T.R.M.), Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - M I Vargas
- From the Division of Diagnostic and Interventional Neuroradiology (S.B.H., A.F., J.B., M.I.V.) .,Faculty of Medicine (M.I.V.), University of Geneva, Geneva, Switzerland
| |
Collapse
|
3
|
Pandey S, Li L, Wan RH, Gao L, Xu W, Cui DM. A retrospective study on outcomes following posterior fossa decompression with dural splitting surgery in patients with Chiari type I malformation. Clin Neurol Neurosurg 2020; 196:106035. [DOI: 10.1016/j.clineuro.2020.106035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 11/27/2022]
|
4
|
Ha JH, Hwang SC. Presyrinx Associated with Post-Traumatic Hydrocephalus Successfully Treated by Ventriculoperitoneal Shunt. Korean J Neurotrauma 2019; 15:187-191. [PMID: 31720275 PMCID: PMC6826087 DOI: 10.13004/kjnt.2019.15.e22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/13/2019] [Accepted: 08/14/2019] [Indexed: 11/15/2022] Open
Abstract
Presyrinx consists of reversible spinal cord swelling without frank cavitation, as observed on T2 weighted magnetic resonance imaging (MRI). The condition may evolve into syringomyelia, but timely surgical interventions have achieved meaningful results. Here, we report the case of a 27-year-old woman who presented with headache, dizziness, and diplopia 2 months after suffering a mild head trauma. On MRI, hydrocephalus, downward herniation of the cerebellar tonsil, and a diffuse high signal change in the cervical spinal cord were detected. After insertion of a ventriculoperitoneal shunt, her neurological symptoms resolved, and she has had no signs of presyrinx recurrence for >4 years.
Collapse
Affiliation(s)
- Jong-Ho Ha
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sun-Chul Hwang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| |
Collapse
|
5
|
Rusbridge C, Stringer F, Knowler SP. Clinical Application of Diagnostic Imaging of Chiari-Like Malformation and Syringomyelia. Front Vet Sci 2018; 5:280. [PMID: 30547039 PMCID: PMC6279941 DOI: 10.3389/fvets.2018.00280] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 10/22/2018] [Indexed: 12/18/2022] Open
Abstract
Chiari-like malformation (CM) and syringomyelia (SM) is a frequent diagnosis in predisposed brachycephalic toy breeds since increased availability of MRI. However, the relevance of that MRI diagnosis has been questioned as CM, defined as identification of a cerebellar herniation, is ubiquitous in some breeds and SM can be asymptomatic. This article reviews the current knowledge of neuroanatomical changes in symptomatic CM and SM and diagnostic imaging modalities used for the clinical diagnosis of CM-pain or myelopathy related to SM. Although often compared to Chiari type I malformation in humans, canine CM-pain and SM is more comparable to complex craniosynostosis syndromes (i.e., premature fusion of multiple skull sutures) characterized by a short skull (cranial) base, rostrotentorial crowding with rostral forebrain flattening, small, and ventrally orientated olfactory bulbs, displacement of the neural tissue to give increased height of the cranium and further reduction of the functional caudotentorial space with hindbrain herniation. MRI may further reveal changes suggesting raised intracranial pressure such as loss of sulci definition in conjunction with ventriculomegaly. In addition to these brachycephalic changes, dogs with SM are more likely to have craniocervical junction abnormalities including rostral displacement of the axis and atlas with increased odontoid angulation causing craniospinal junction deformation and medulla oblongata elevation. Symptomatic SM is diagnosed on the basis of signs of myelopathy and presence of a large syrinx that is consistent with the neuro-localization. The imaging protocol should establish the longitudinal and transverse extent of the spinal cord involvement by the syrinx. Phantom scratching and cervicotorticollis are associated with large mid-cervical syringes that extend to the superficial dorsal horn. If the cause of CSF channel disruption and syringomyelia is not revealed by anatomical MRI then other imaging modalities may be appropriate with radiography or CT for any associated vertebral abnormalities.
Collapse
Affiliation(s)
- Clare Rusbridge
- Fitzpatrick Referrals, Godalming, United Kingdom.,School of Veterinary Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | | | - Susan P Knowler
- School of Veterinary Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| |
Collapse
|
6
|
Zukin VD, Grigimalsky YV, Garga AY. Choosing an anesthetic technique in pregnant women with Arnold – Chiari malformation. PAIN MEDICINE 2018. [DOI: 10.31636/pmjua.v3i2.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We want to present the clinical case of a female patient with the asymptomatic Chiari I type malformation, without surgical correction and with concomitant epilepsy who underwent planned C-section under epidural anesthesia. A 29-year old pregnant women on the 39 week of pregnancy entered the maternity hospital for the delivery. It was decided to conduct a planned caesarean section. The epidural anesthesia with 0.75 % solution of the ropivacaine was chosen as the method of anesthesia. The patient did not receive antiepileptic treatment due to her implacable refusal. She underwent surgery and anesthesia well. On the third day after surgery, the patient suffered of a convulsive as sault, which was stopped by intravenous administration of diazepam. This article briefly describes the genetic background, classification, clinical manifestations and treatment tactics for patients with Chiari malformation and the features of C-section anesthesia in pregnant women with this pathology.
Collapse
|
7
|
Vadivelu S, Vadivelu S, Mealy M, Patel S, Kosnik-Infinger L, Becker D. Chiari I malformation in children with transverse myelitis. Dev Neurorehabil 2018; 21:402-407. [PMID: 28537458 DOI: 10.1080/17518423.2017.1323972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Transverse myelitis (TM) is an acute inflammatory spinal cord injury. Asymptomatic Chiari I malformation (CMI) management is highly controversial, particularly when associated with a spinal syrinx. Here, we assess the occurrence of CMI in the pediatric TM population and management outcomes. METHODS We performed a retrospective cohort study based on 61 consecutively identified pediatric TM cases over an -8-year period. We reviewed demographic characteristics, radiographic findings, presenting symptoms, and long-term outcomes. RESULTS Eight CMI cases were identified within the TM cohort; all presented with TM by 16 months of age and affecting the cervical spinal cord. In three cases, CMI developed 15 months to 6 years after the onset of TM. One in 10 children with TM had CMI. CONCLUSION These findings demonstrate a high prevalence of CMI in patients with TM. Large prospective clinical studies are needed to further investigate the natural history and recovery strategies of CMI involved with neuroinflammatory disorders.
Collapse
Affiliation(s)
- Sathya Vadivelu
- a Department of Pediatric Rehabilitation Medicine , Johns Hopkins University and the Kennedy Krieger Institute , Baltimore , MD , USA
| | - Sudhakar Vadivelu
- b Division of Pediatric Neurosurgery , Cincinnati Children's Hospital Medical Center , Cincinnati , OH , USA.,c Department of Neurosurgery , University of Cincinnati School of Medicine , Cincinnati , OH , USA
| | - Maureen Mealy
- d Department of Neurology , Johns Hopkins University and the Kennedy Krieger Institute , Baltimore , MD , USA
| | - Smurti Patel
- c Department of Neurosurgery , University of Cincinnati School of Medicine , Cincinnati , OH , USA
| | - Libby Kosnik-Infinger
- b Division of Pediatric Neurosurgery , Cincinnati Children's Hospital Medical Center , Cincinnati , OH , USA
| | - Daniel Becker
- d Department of Neurology , Johns Hopkins University and the Kennedy Krieger Institute , Baltimore , MD , USA
| |
Collapse
|
8
|
Gadde JA, Shah V, Liebo GB, Ringstad GA, Pomeraniec IJ, Bakke SJ, Fric R, Ksendzovsky A, Jane JA, Schwartz ES, Haughton V. Anatomical features of the cervical spinal canal in Chiari I deformity with presyrinx: A case-control study. Neuroradiol J 2017; 30:405-409. [PMID: 28691569 DOI: 10.1177/1971400917718842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose The relationship between syringomyelia and presyrinx, characterized by edema in the spinal cord, has not been firmly established. Patients with syringomyelia have abnormal spinal canal tapering that alters cerebrospinal fluid flow dynamics, but taper ratios in presyrinx have never been reported. We tested the hypothesis that presyrinx patients have abnormal spinal canal tapering. Materials and methods At six medical institutions, investigators searched the PACS system for patients with Chiari I and spinal cord edema unassociated with tumor, trauma, or other evident cause. In each case taper ratios were calculated for C1 to C4 and C4 to C7. In two age- and gender-matched control groups, Chiari I patients with no syringomyelia and patients with normal MR scans, the same measurements were made. Differences between groups were tested for statistical significance with t tests. Results The study enrolled 21 presyrinx patients and equal numbers of matched Chiari I and normal controls. C4 to C7 taper ratios were positive and steeper in presyrinx patients than in the normal controls ( p = 0.04). The upper cervical spine, C1 to C4, tapered negatively in cases and controls without significant differences between the groups. The difference in degree of tonsillar herniation was statistically significant between presyrinx patients and Chiari I controls ( p = 0.01). Conclusions Presyrinx patients have greater than normal positive tapering in the lower cervical spine and greater degree of tonsillar herniation than the controls.
Collapse
Affiliation(s)
- Judith A Gadde
- 1 Department of Radiology, The Children's Hospital of Philadelphia, USA
| | - Vinil Shah
- 2 Department of Radiology, University of California San Francisco, USA
| | | | - Geir A Ringstad
- 4 Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway
| | - I Jonathan Pomeraniec
- 5 Department of Neurological Surgery, University of Virginia Health System, USA.,6 Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, USA
| | - Soren J Bakke
- 7 Department of Neuroradiology, Oslo University Hospital, Norway
| | - Radek Fric
- 8 Department of Neurosurgery, Oslo University Hospital, Norway
| | - Alexander Ksendzovsky
- 5 Department of Neurological Surgery, University of Virginia Health System, USA.,6 Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, USA
| | - John A Jane
- 5 Department of Neurological Surgery, University of Virginia Health System, USA
| | - Erin S Schwartz
- 1 Department of Radiology, The Children's Hospital of Philadelphia, USA
| | | |
Collapse
|
9
|
Abstract
The posterior skull base can be involved by a variety of pathologic processes. They can be broadly classified as: traumatic, neoplastic, vascular, and inflammatory. Pathology in the posterior skull base usually involves the lower cranial nerves, either as a source of pathology or a secondary source of symptoms. This review will categorize pathology arising in the posterior skull base and describe how it affects the skull base itself and surrounding structures.
Collapse
Affiliation(s)
- Joici Job
- Department of Radiology, University of Pittsburgh Medical Center, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Barton F Branstetter
- Department of Radiology, University of Pittsburgh Medical Center, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| |
Collapse
|
10
|
Serlin Y, Benifla M, Shelef I. Tonsillar contusion associated with benign tonsillar ectopia following minor head trauma. Childs Nerv Syst 2016; 32:881-5. [PMID: 26438549 DOI: 10.1007/s00381-015-2924-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 09/28/2015] [Indexed: 10/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Yonatan Serlin
- The Laboratory for Experimental Neurosurgery, Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, 8410501, Israel.
| | - Mony Benifla
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem, 91120, Israel
| | - Ilan Shelef
- Department of Radiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, 8410501, Israel
| |
Collapse
|
11
|
Nixon JN, Stanescu LA, Weinberger E. Presyrinx in a child with acquired Chiari I malformation. Pediatr Radiol 2013; 43:506-11. [PMID: 22932962 DOI: 10.1007/s00247-012-2488-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 07/16/2012] [Accepted: 07/26/2012] [Indexed: 10/27/2022]
Abstract
Spinal cord signal abnormality resulting from alterations in cerebrospinal fluid flow at the craniocervical junction has been termed a presyrinx state. This condition has been described in the adult literature in association with a variety of conditions that cause obstruction to normal cerebrospinal fluid flow. We present a case of presyrinx in a child in the setting of acquired Chiari I malformation caused by lumboperitoneal overshunting. Awareness of the potentially reversible nature of this condition might allow for intervention before irreversible neurological damage has occurred.
Collapse
Affiliation(s)
- Jason N Nixon
- Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| | | | | |
Collapse
|
12
|
Bunck AC, Kroeger JR, Juettner A, Brentrup A, Fiedler B, Crelier GR, Martin BA, Heindel W, Maintz D, Schwindt W, Niederstadt T. Magnetic resonance 4D flow analysis of cerebrospinal fluid dynamics in Chiari I malformation with and without syringomyelia. Eur Radiol 2012; 22:1860-70. [PMID: 22569996 DOI: 10.1007/s00330-012-2457-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 02/15/2012] [Accepted: 02/27/2012] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To analyse cerebrospinal fluid (CSF) hydrodynamics in patients with Chiari type I malformation (CM) with and without syringomyelia using 4D magnetic resonance (MR) phase contrast (PC) flow imaging. METHODS 4D-PC CSF flow data were acquired in 20 patients with CM (12 patients with presyrinx/syrinx). Characteristic 4D-CSF flow patterns were identified. Quantitative CSF flow parameters were assessed at the craniocervical junction and the cervical spinal canal and compared with healthy volunteers and between patients with and without syringomyelia. RESULTS Compared with healthy volunteers, 17 CM patients showed flow abnormalities at the craniocervical junction in the form of heterogeneous flow (n = 3), anterolateral flow jets (n = 14) and flow vortex formation (n = 5), most prevalent in patients with syringomyelia. Peak flow velocities at the craniocervical junction were significantly increased in patients (-15.5 ± 11.3 vs. -4.7 ± 0.7 cm/s in healthy volunteers, P < 0.001). At the level of C1, maximum systolic flow was found to be significantly later in the cardiac cycle in patients (30.8 ± 10.3 vs. 22.7 ± 4.1%, P < 0.05). CONCLUSIONS 4D-PC flow imaging allowed comprehensive analysis of CSF flow in patients with Chiari I malformation. Alterations of CSF hydrodynamics were most pronounced in patients with syringomyelia.
Collapse
Affiliation(s)
- Alexander C Bunck
- Department of Clinical Radiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, building A1, 48149 Muenster, Germany.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Strahle J, Muraszko KM, Kapurch J, Bapuraj JR, Garton HJL, Maher CO. Natural history of Chiari malformation Type I following decision for conservative treatment. J Neurosurg Pediatr 2011; 8:214-21. [PMID: 21806365 DOI: 10.3171/2011.5.peds1122] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The natural history of the Chiari malformation Type I (CM-I) is incompletely understood. The authors report on the outcome of a large group of patients with CM-I that were initially selected for nonsurgical management. METHODS The authors identified 147 patients in whom CM-I was diagnosed on MR imaging, who were not offered surgery at the time of diagnosis, and in whom at least 1 year of clinical and MR imaging follow-up was available after the initial CM-I diagnosis. These patients were included in an outcome analysis. RESULTS Patients were followed clinically and by MR imaging for a mean duration of 4.6 and 3.8 years, respectively. Of the 147 patients, 9 had new symptoms attributed to the CM-I during the follow-up interval. During this time, development of a spinal cord syrinx occurred in 8 patients; 5 of these patients had a prior diagnosis of a presyrinx state or a dilated central canal. Spontaneous resolution of a syrinx occurred in 3 patients. Multiple CSF flow studies were obtained in 74 patients. Of these patients, 23 had improvement in CSF flow, 39 had no change, and 12 showed worsening CSF flow at the foramen magnum. There was no significant change in the mean amount of cerebellar tonsillar herniation over the follow-up period. Fourteen patients underwent surgical treatment for CM-I. There were no differences in initial cerebellar tonsillar herniation or CSF flow at the foramen magnum in those who ultimately underwent surgery compared with those who did not. CONCLUSIONS In patients with CM-Is that are selected for nonsurgical management, the natural history is usually benign, although spontaneous improvement and worsening are occasionally seen.
Collapse
Affiliation(s)
- Jennifer Strahle
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | | | | | | |
Collapse
|
14
|
Furtado SV, Thakar S, Hegde AS. Correlation of Functional Outcome and Natural History With Clinicoradiological Factors in Surgically Managed Pediatric Chiari I Malformation. Neurosurgery 2011; 68:319-27; discussion 328. [DOI: 10.1227/neu.0b013e31820206e5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Chiari I malformation occurs because of an underdeveloped posterior fossa with reduced volume that cannot accommodate the normally developed hindbrain.
OBJECTIVE:
To study the clinical presentation and surgical outcome of pediatric Chiari I malformation and to correlate outcome with demographic and clinical factors and radiological changes in the syrinx, spinal cord, and preoperative intracranial, posterior fossa, and foramen magnum dimensions.
METHODS:
This retrospective study spanning 9 years included 20 symptomatic patients who underwent foramen magnum decompression, shrinkage of tonsils, and duraplasty. Improvement at follow-up was assessed with a modified Asgari scoring system. Mean differences in the dimensions of the syrinx and cord, foramen magnum morphometry, and intracranial and posterior fossa for 2 groups (with or without improvement) were analyzed with the independent-sample Student t test. Correlation of outcome in relation to change in radiological factors and influence of variables such as age, type and duration of symptoms, and presence of syrinx were evaluated with the Pearson χ2 test.
RESULTS:
Sixty percent of patients showed functional improvement at follow-up. Of various demographic and radiological factors assessed, there was significant difference in mean values of change in cord diameter for the entire cohort (P = .05) and for the subgroup with preoperative syringes (P = .03). There was no correlation between change in any of these factors and functional improvement (χ2 range, 0-4.673; P > .05).
CONCLUSION:
More than half the pediatric patients with Chiari I malformation improve after surgery. The age at presentation, duration and type of symptoms, cranial and foramen magnum morphometry, and syrinx-related changes have no bearing on outcome at short-term follow-up. The spinal cord diameter differs significantly in patients with and without functional improvement.
Collapse
Affiliation(s)
- Sunil V. Furtado
- Departments of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Sumit Thakar
- Departments of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Alangar S. Hegde
- Departments of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| |
Collapse
|
15
|
Preysyrinx state and shunt dysfunction: an underrecognized entity? Acta Neurochir (Wien) 2010; 152:1969-73. [PMID: 20669036 DOI: 10.1007/s00701-010-0753-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Accepted: 07/14/2010] [Indexed: 10/19/2022]
Abstract
Presyrinx state is a relatively recently recognized condition. Prompt identification of this condition and appropriate treatment leads to reversal of the radiological and clinical findings with a good prognosis. Failure to identify this condition in a timely fashion leads to fully established syringomyelia. To date, presyrinx state has not been described as a feature of shunt dysfunction. One such rare case is being reported. A 14-year-old boy who was shunted for postmeningitic hydrocephalus at the age of 2 years and subsequently underwent shunt revision presented for routine follow-up and was found to have shunt dysfunction. CT scan showed panventriculomegaly and MRI studies showed panventriculomegaly with a "presyrinx" state extending from the fourth ventricle up to the thoracic region. Shunt revision led to prompt radiological reversal of the presyrinx state. This case is being reported to highlight the hitherto unreported association of shunt dysfunction and presyrinx state. The literature on presyrinx state is being reviewed with reference to the 20 cases reported earlier.
Collapse
|
16
|
Abstract
BACKGROUND Treatment options for Chiari I malformations include posterior fossa decompression (PFD) with additional techniques including laminectomy, intradural exploration, and duraplasty. Neuroimaging findings of cisterna magna volume, syringomyelia, and intraoperative ultrasonography may tailor surgical intervention. METHODS We developed an algorithm classifying symptomatic Chiari I patients into three groups to define minimum operation. Without syringomyelia, the presence of cisterna magna defined Group A and the absence defined Group B. Patients with syrinx formed Group C. Mild structural pathology (Group A) or adequate space following PFD (Group B, normal intraoperative ultrasound (IOUS)) should be treated by PFD alone. Conversely, presence of syringomyelia (Group C) or inadequate space following PFD (Group B, abnormal IOUS) should additionally have duraplasty. We applied this algorithm to patients treated at a single institution over 16 years. RESULTS Twenty-four symptomatic Chiari I malformation patients were divided into three groups that did not differ by age, gender, or extent of tonsillar ectopia. All patients treated by this algorithm experienced clinical and radiographic improvement. This included eight Group B patients who underwent PFD only (n=6) or additional duraplasty (n=2) decided by IOUS. CONCLUSION Treatment of symptomatic Chiari I malformation may have inadequate outcome with conservative strategy or complications with aggressive strategy. This algorithm utilizes preoperative neuroimaging and intraoperative ultrasound to tailor intervention, with excellent clinical outcome and radiographic syrinx resolution on application to 24 patients. Further validation requires prospective multicenter evaluation with larger patient population.
Collapse
|
17
|
Pathogenesis of syringomyelia associated with Chiari type 1 malformation: review of evidences and proposal of a new hypothesis. Neurosurg Rev 2010; 33:271-84; discussion 284-5. [PMID: 20532585 DOI: 10.1007/s10143-010-0266-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 03/23/2010] [Accepted: 05/02/2010] [Indexed: 02/08/2023]
Abstract
The exact pathogenesis of syringomyelia associated with Chiari type 1 malformation is unknown, although a number of authors have reported their theories of syrinx formation. The purpose of this review is to understand evidences based on the known theories and to create a new hypothesis of the pathogenesis. We critically review the literatures on clinicopathological, radiological, and clinical features of this disorder. The previously proposed theories mainly focused on the driven mechanisms of the cerebrospinal fluid (CSF) into the spinal cord. They did not fully explain radiological features or effects of surgical treatment such as shunting procedures. Common findings of the syrinx in clinicopathological studies were the communication with the central canal and extracanalicular extension to the posterior gray matter. Most of the magnetic resonance imaging studies demonstrated blockade and alternated CSF dynamics at the foramen magnum, but failed to show direct communication of the syrinx with the CSF spaces. Pressure studies revealed almost identical intrasyrinx pressure to the subarachnoid space and decreased compliance of the spinal CSF space. Recent imaging studies suggest that the extracellular fluid accumulation may play an important role. The review of evidences promotes a new hypothesis of syrinx formation. Decreased absorption mechanisms of the extracellular fluid may underlie the pathogenesis of syringomyelia. Reduced compliance of the posterior spinal veins associated with the decreased compliance of the spinal subarachnoid space will result in disturbed absorption of the extracellular fluid through the intramedullary venous channels and formation of syringomyelia.
Collapse
|