Cough-associated headache in patients with Chiari I malformation: CSF Flow analysis by means of cine phase-contrast MR imaging

Association Between Resistance to Cerebrospinal Fluid Flow Near the Foramen Magnum and Cough-Associated Headache in Adult Chiari Malformation Type I

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.

Prevalence and characteristics of cough headache in a Chinese respiratory clinic

BACKGROUND

To evaluate the prevalence, predictive factors and clinical characteristics of cough headache in our respiratory clinic and to investigate the coexistence between cough headache, migraine and tension-type headache.

METHOD

We consecutively investigated patients referred to our respiratory clinic with complaints of cough and selected patients with cough headaches to complete a structured interview and examination.

RESULTS

Six hundred and seventy-nine patients with cough were studied and 122 patients were diagnosed with cough headache. The prevalence of cough headache was 18.0% in these coughing patients. According to multivariate analysis, being of an age between 31-50 years was a risk factor for cough headache (OR 2.0). Cough headache was associated with cough severity: Compared with the mild group, the moderate group (OR 2.3) and the severe group (OR 3.3) were more vulnerable to cough headache. Headache severity had a positive correlation with cough severity (ρ = 0.301, p = 0.028), age (ρ = 0.199, p = 0.029), and headache duration (ρ = 0.242, p = 0.008). In cough headache patients, 30.3% had tension-type headache and 10.7% had migraine in the preceding year.

CONCLUSIONS

Cough headache is not rare in respiratory clinics and the characteristics are somewhat different from those in headache clinics. An age of between 31-50 years and cough severity were risk factors for cough headache. Headache severity was related to cough severity, age and headache duration.

Clinical utility of 2-D anatomic measurements in predicting cough-associated headache in Chiari I malformation

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.

Imaging of cerebrospinal fluid flow: fundamentals, techniques, and clinical applications of phase-contrast magnetic resonance imaging

Cerebrospinal fluid (CSF) is a dynamic compartment of the brain, constantly circulating through the ventricles and subarachnoid space. In recent years knowledge about CSF has expended due to numerous applications of phase-contrast magnetic resonance imaging (PC-MRI) in CSF flow evaluation, leading to the revision of former theories and new concepts about pathophysiology of CSF disorders, which are caused either by alterations in CSF production, absorption, or its hydrodynamics. Although alternative non-invasive techniques have emerged in recent years, PC-MRI is still a fundamental sequence that provides both qualitative and quantitative CSF assessment. PC-MRI is widely used to evaluate CSF hydrodynamics in normal pressure hydrocephalus (NPH), Chiari type I malformations (CMI), syringomyelia, and after neurosurgical procedures. In NPH precisely performed PC-MRI provides reliable clinical information useful for differential diagnosis and selection of patients benefiting from surgical operation. Patients with CMI show abnormalities in CSF dynamics within the subarachnoid space, which are pronounced even further if syringomyelia coexists. Another indication for PC-MRI may be assessment of post-surgical CSF flow normalisation. The aim of this review is to highlight the significance of CSF as a multifunctional entity, to outline both the physical and technical background of PC-MRI, and to state current applications of this technique, not only in the diagnosis of central nervous system disorders, but also in the further clinical monitoring and prognosis after treatment.

The Choroid Plexus of the Lateral Ventricle As the Origin of CSF Pulsation Is Questionable

The advent of magnetic resonance imaging (MRI) enables noninvasive measurement of cerebrospinal fluid (CSF) motion, and new information about CSF motion has now been acquired. The driving force of the CSF has long been thought to be choroid plexus (CP) pulsation, but to investigate whether this phenomenon actually occurs, CSF motion was observed in the ventricular system and subarachnoid space using MRI. Eleven healthy volunteers, ranging in age from 23 to 58 years, participated in this study. The MRI sequences used were four-dimensional phase-contrast (4D-PC) and time-spatial labeling inversion pulse (t-SLIP). The 4D-PC images included sagittal images in the cranial midline, coronal images focusing on the foramen of Monro (FOM), and oblique coronal images of the trigone to quantify CSF velocity and acceleration. These values were compared and analyzed as non-parametric data using the Kolmogorov-Smirnov test and the Mann-Whitney U test. 4D-PC showed that the median CSF velocity was significantly lower in the posterior part of the lateral ventricle than in other regions. The quantitative analysis of velocity and acceleration showed that they were decreased around the CP in the trigone. Image analysis of both velocity mapping and t-SLIP showed suppressed CSF motion around the CP in the trigone. These findings cast doubt on CP pulsation being the driving force for CSF motion.

Advances in High-Field MRI

MRI techniques and systems have evolved dramatically over recent years. These advances include higher field strengths, new techniques, faster gradients, improved coil technology, and more robust sequence protocols. This article reviews the most commonly used advanced MRI techniques, including diffusion-weighted imaging, magnetic resonance spectrography, diffusion tensor imaging, and cerebrospinal fluid flow tracking.

Laugh-Induced Headache: Clinical Features and Literature Review

BACKGROUND

Laughing is a rare precipitating factor for headaches, and the pathogenesis underlying laugh-induced headache (LH) remains unclear.

METHODS

Two cases of headache triggered predominantly by laughing were presented in this article. We also reviewed the published English literature regarding LH, summarized the clinical characteristics of LH, and discussed the probable pathophysiological mechanisms.

RESULTS

In the first patient, magnetic resonance imaging of the brain revealed cerebellar tonsillar herniation through the foramen magnum. In the second patient, we did not find any evidence of intracranial disease. The literature review showed that LH is a mild to severe, non-pulsating headache. In most cases, the duration of each attack was limited to a few minutes. The headache usually bursts after laughing and reaches its peak almost immediately. In some cases, the headache can only be induced by mirthful laughing rather than by fake laughing.

CONCLUSION

LH can be categorized as primary LH and secondary LH. Changes in the spatial structure in the posterior cranial fossa and cerebrospinal fluid circulation may contribute to the development of secondary LH. Primary LH, primary cough headache, and primary exercise headache may share some common pathogenesis. And we speculate that the regions of the brain associated with the expression of mirth might be associated with LH.

The association between the pulse pressure gradient at the cranio-cervical junction derived from phase-contrast magnetic resonance imaging and invasively measured pulsatile intracranial pressure in symptomatic patients with Chiari malformation type 1

BACKGROUND

In symptomatic Chiari malformation type 1 (CMI), impaired intracranial compliance (ICC) is associated with an increased cranio-spinal pulsatile pressure gradient. Phase-contrast magnetic resonance imaging (MRI) represents a non-invasive modality for the assessment of the pulse pressure gradient at the cranio-cervical junction (CCJ). We wished to explore how the MRI-derived pulse pressure gradient (MRI-dP) compares with invasively measured pulsatile intracranial pressure (ICP) in CMI, and with healthy controls.

METHODS

From phase-contrast MRI of CMI patients and healthy controls, we computed cerebrospinal fluid (CSF) flow velocities and MRI-dP at the CCJ. We assessed bidirectional flow and compared the flow between the anterior and the posterior subarachnoid space at the CCJ. We computed total intracranial volume (ICV), ventricular CSF volume (VV), and posterior cranial fossa volume (PCFV). We analyzed the static and pulsatile ICP scores from overnight monitoring in CMI patients.

RESULTS

Five CMI patients and four healthy subjects were included. The CMI group had a significantly larger extent of tonsillar ectopia, smaller PCFV, and a smaller area of CSF in the FM. The pulsatile ICP (mean ICP wave amplitude, MWA) was abnormally increased in 4/5 CMI patients and correlated positively with MRI-dP. However, the MRI-dP as well as the CSF flow velocities did not differ significantly between CMI and healthy subjects. Moreover, bidirectional flow was observed in both CMI as well as healthy subjects, with no significant difference.

CONCLUSIONS

In symptomatic CMI patients, we found a significant association between the pulse pressure gradient at the CCJ derived from phase-contrast MRI and the pulsatile ICP (MWA) measured invasively. However, the MRI-dP was close to identical in CMI patients and healthy subjects. Moreover, the CSF flow velocities at the CCJ and the occurrence of bidirectional flow were not different in CMI patients and healthy individuals. Further studies are required to determine the diagnostic role of phase-contrast MRI in CMI patients.

Multimodal evaluation of CSF dynamics following extradural decompression for Chiari malformation Type I

OBJECT

Extradural decompression is a minimally invasive technique for treating Chiari malformation Type I (CM-I) that avoids the complications of dural opening. While there is no agreement on which surgical method is optimal, mounting evidence demonstrates that extradural decompression effectively treats clinical symptoms, with a minimal reoperation rate. Neurological symptoms such as headache may be related to obstructed flow of CSF, and one aspect of successful extradural decompression is improved CSF dynamics. In this series, the authors report on their use of phase-contrast cine flow MRI to assess CSF flow as well as satisfactory decompression.

METHODS

The authors describe their first surgical series of 18 patients with CM-I undergoing extradural decompression and correlate clinical improvement with radiological changes. Patients were categorized as having complete, partial, or no resolution of their symptoms. Posterior fossa area, cisterna magna area, and tonsillar herniation were assessed on T2-weighted MRI, whereas improvement of CSF flow was evaluated with phase-contrast cine flow MRI. All patients received standard pre- and postoperative MRI studies; 8 (44.4%) patients had pre- and postoperative phase-contrast cine, while the rest underwent cine studies only postoperatively.

RESULTS

All 18 patients presented with symptomatic CM-I, with imaging studies demonstrating tonsillar herniation ≥ 5 mm, and 2 patients had associated syringomelia. All patients underwent suboccipital decompression and C-1 laminectomy with splitting of the dura. Patients with complete resolution of their symptoms had a greater relative increase in cisterna magna area compared with those with only partial improvement (p = 0.022). In addition, in those with complete improvement the preoperative cisterna magna area was smaller than in those who had either partial (0.020) or no (0.025) improvement. Ten (91%) of the 11 patients with improved flow also had improvement in their symptoms. There was 1 postoperative complication of dysphagia and dysphonia. None of the patients have required a second operation.

CONCLUSIONS

Extradural decompression has the potential to be the first-line treatment for CM-I but has been lacking an objective measure by which to assess surgical success as well as the need for reoperation. An increase in the CSF spaces and improved CSF dynamics may be associated with resolution of clinical symptoms. Including cine imaging as part of routine pre- and postoperative evaluation can help identify which patients are most likely to benefit from surgery.

Audio-vestibular signs and symptoms in Chiari malformation type i. Case series and literature review

INTRODUCTION

Chiari malformation is an alteration of the base of the skull with herniation through the foramen magnum of the brain stem and cerebellum. Although the most common presentation is occipital headache, the association of audio-vestibular symptoms is not rare. The aim of our study was to describe audio-vestibular signs and symptoms in Chiari malformation type i (CM-I).

MATERIALS AND METHODS

We performed a retrospective observational study of patients referred to our unit during the last 5 years. We also carried out a literature review of audio-vestibular signs and symptoms in this disease.

RESULTS

There were 9 patients (2 males and 7 females), with an average age of 42.8 years. Five patients presented a Ménière-like syndrome; 2 cases, a recurrent vertigo with peripheral features; one patient showed a sudden hearing loss; and one case suffered a sensorineural hearing loss with early childhood onset. The most common audio-vestibular symptom indicated in the literature in patients with CM-I is unsteadiness (49%), followed by dizziness (18%), nystagmus (15%) and hearing loss (15%). Nystagmus is frequently horizontal (74%) or down-beating (18%). Other audio-vestibular signs and symptoms are tinnitus (11%), aural fullness (10%) and hyperacusis (1%). Occipital headache that increases with Valsalva manoeuvres and hand paresthesias are very suggestive symptoms.

CONCLUSIONS

The appearance of audio-vestibular manifestations in CM-I makes it common to refer these patients to neurotologists. Unsteadiness, vertiginous syndromes and sensorineural hearing loss are frequent. Nystagmus, especially horizontal and down-beating, is not rare. It is important for neurotologists to familiarise themselves with CM-I symptoms to be able to consider it in differential diagnosis.

Chiari-like malformation and syringomyelia in American Brussels Griffon dogs

Background

Although Chiari‐like malformation (CM) and syringomyelia (SM) have been described in many small breed dogs, the prevalence and clinical manifestations of this complex have not been documented in a large cohort of American Brussels Griffon (ABG) dogs.

Objectives

To characterize the clinical and magnetic resonance imaging (MRI) features of CM and SM in the ABG breed.

Animals

Eighty‐four American Kennel Club registered ABG dogs were recruited.

Methods

Prospective study. Complete histories and neurologic examinations were obtained before MRI. Images were blindly reviewed and calculations were made by using OsiriX. All analyses were performed by Student's t‐test, Spearman's correlation, ANOVA, and chi‐square test where appropriate.

Results

Chiari‐like malformation and SM were present in 65% and 52% of dogs, respectively. Twenty‐eight percent of dogs had neurologic deficits and 20% had neck pain. Mean central canal (CC) transverse height was 2.5 mm with a mean length of 3.6 cervical vertebrae. Neurologic deficits were significantly associated with a larger syrinx (P = .04, P = .08) and syrinx size increased with age (P = .027). SM was associated with a smaller craniocervical junction (CCJ) height (P = .04) and larger ventricles (P = .0001; P < .001).

Conclusions and Clinical Importance

Syringomyelia and CM are prevalent in American Brussels Griffon dogs. Syrinx size is associated with neurologic deficits, CM, larger ventricles, a smaller craniocervical junction height, neurologic deficits, and cerebellar herniation. Fifty‐two percent of dogs with a SM were clinically normal.

Spinal fluid biomechanics and imaging: an update for neuroradiologists

Flow imaging with cardiac-gated phase-contrast MR has applications in the management of neurologic disorders. Together with computational fluid dynamics, phase-contrast MR has advanced our understanding of spinal CSF flow. Phase-contrast MR is used to evaluate patients with Chiari I malformation who are candidates for surgical treatment. In theory, abnormal CSF flow resulting from the abnormal tonsil position causes syringomyelia and other neurologic signs and symptoms in patients with Chiari I. CSF flow imaging also has research applications in syringomyelia and spinal stenosis. To optimize MR acquisition and interpretation, neuroradiologists must have familiarity with healthy and pathologic patterns of CSF flow. The purpose of this review is to update concepts of CSF flow that are important for the practice of flow imaging in the spine.

Physiology-based MR imaging assessment of CSF flow at the foramen magnum with a valsalva maneuver

BACKGROUND AND PURPOSE

MR imaging is currently not used to evaluate CSF flow changes due to short-lasting physiological maneuvers. The purpose of this study was to evaluate the ability of MR imaging to assess the CSF flow response to a Valsalva maneuver in healthy participants.

MATERIALS AND METHODS

A cardiac-gated fast cine-PC sequence with ≤15-second acquisition time was used to assess CSF flow in 8 healthy participants at the foramen magnum at rest, during, and immediately after a controlled Valsalva maneuver. CSF mean displacement volume VCSF during the cardiac cycle and CSF flow waveform App were determined. A work-in-progress real-time pencil-beam imaging method with temporal resolution ≤56 ms was used to scan 2 participants for 90 seconds during which resting, Valsalva, and post-Valsalva CSF flow, respiration, and HR were continuously recorded. Results were qualitatively compared with invasive craniospinal differential pressure measurements from the literature.

RESULTS

Both methods showed 1) a decrease from baseline in VCSF and App during Valsalva and 2) an increase in VCSF and App immediately after Valsalva compared with values measured both at rest and during Valsalva. Whereas fast cine-PC produced a single CSF flow waveform that is an average over many cardiac cycles, pencil-beam imaging depicted waveforms for each heartbeat and was able to capture many dynamic features of CSF flow, including transients synchronized with the Valsalva maneuver.

CONCLUSIONS

Both fast cine-PC and pencil-beam imaging demonstrated expected changes in CSF flow with Valsalva maneuver in healthy participants. The real-time capability of pencil-beam imaging may be necessary to detect Valsalva-related transient CSF flow obstruction in patients with pathologic conditions such as Chiari I malformation.

[Different headache forms of chapter 4 of the International Headache Classification]

Chapter 4 of the International Classification of Headaches contains a group of clinically very heterogeneous primary headache forms. Little is known about the pathogenesis of these headache types and therapy is usually based on isolated case reports and uncontrolled studies. The forms include primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua and the new daily persistent headache. Some of these headache forms may be of a symptomatic nature and require careful examination, imaging and further tests. Primary and secondary headache forms must be carefully distinguished.

Magnetic resonance 4D flow analysis of cerebrospinal fluid dynamics in Chiari I malformation with and without syringomyelia

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.