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Liu P, Owashi K, Monnier H, Metanbou S, Capel C, Balédent O. Validating the accuracy of real-time phase-contrast MRI and quantifying the effects of free breathing on cerebrospinal fluid dynamics. Fluids Barriers CNS 2024; 21:25. [PMID: 38454518 PMCID: PMC10921772 DOI: 10.1186/s12987-024-00520-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Understanding of the cerebrospinal fluid (CSF) circulation is essential for physiological studies and clinical diagnosis. Real-time phase contrast sequences (RT-PC) can quantify beat-to-beat CSF flow signals. However, the detailed effects of free-breathing on CSF parameters are not fully understood. This study aims to validate RT-PC's accuracy by comparing it with the conventional phase-contrast sequence (CINE-PC) and quantify the effect of free-breathing on CSF parameters at the intracranial and extracranial levels using a time-domain multiparametric analysis method. METHODS Thirty-six healthy participants underwent MRI in a 3T scanner for CSF oscillations quantification at the cervical spine (C2-C3) and Sylvian aqueduct, using CINE-PC and RT-PC. CINE-PC uses 32 velocity maps to represent dynamic CSF flow over an average cardiac cycle, while RT-PC continuously quantifies CSF flow over 45-seconds. Free-breathing signals were recorded from 25 participants. RT-PC signal was segmented into independent cardiac cycle flow curves (Qt) and reconstructed into an averaged Qt. To assess RT-PC's accuracy, parameters such as segmented area, flow amplitude, and stroke volume (SV) of the reconstructed Qt from RT-PC were compared with those derived from the averaged Qt generated by CINE-PC. The breathing signal was used to categorize the Qt into expiratory or inspiratory phases, enabling the reconstruction of two Qt for inspiration and expiration. The breathing effects on various CSF parameters can be quantified by comparing these two reconstructed Qt. RESULTS RT-PC overestimated CSF area (82.7% at aqueduct, 11.5% at C2-C3) compared to CINE-PC. Stroke volumes for CINE-PC were 615 mm³ (aqueduct) and 43 mm³ (spinal), and 581 mm³ (aqueduct) and 46 mm³ (spinal) for RT-PC. During thoracic pressure increase, spinal CSF net flow, flow amplitude, SV, and cardiac period increased by 6.3%, 6.8%, 14%, and 6%, respectively. Breathing effects on net flow showed a significant phase difference compared to the other parameters. Aqueduct-CSF flows were more affected by breathing than spinal-CSF. CONCLUSIONS RT-PC accurately quantifies CSF oscillations in real-time and eliminates the need for cardiac synchronization, enabling the quantification of the cardiac and breathing components of CSF flow. This study quantifies the impact of free-breathing on CSF parameters, offering valuable physiological references for understanding the effects of breathing on CSF dynamics.
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Affiliation(s)
- Pan Liu
- CHIMERE UR 7516, Jules Verne University of Picardy, Amiens, 80000, France.
- Medical Image Processing Department, Amiens Picardy University Medical Center, Amiens, 80000, France.
| | - Kimi Owashi
- CHIMERE UR 7516, Jules Verne University of Picardy, Amiens, 80000, France
- Medical Image Processing Department, Amiens Picardy University Medical Center, Amiens, 80000, France
| | - Heimiri Monnier
- CHIMERE UR 7516, Jules Verne University of Picardy, Amiens, 80000, France
| | - Serge Metanbou
- Radiology Department, Amiens Picardy University Medical Center, Amiens, 80000, France
| | - Cyrille Capel
- CHIMERE UR 7516, Jules Verne University of Picardy, Amiens, 80000, France
- Neurosurgery Department, Amiens Picardy University Medical Center, Amiens, 8000, France
| | - Olivier Balédent
- CHIMERE UR 7516, Jules Verne University of Picardy, Amiens, 80000, France
- Medical Image Processing Department, Amiens Picardy University Medical Center, Amiens, 80000, France
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Kedia N, McDowell MM, Yang J, Wu J, Friedlander RM, Kainerstorfer JM. Pulsatile microvascular cerebral blood flow waveforms change with intracranial compliance and age. NEUROPHOTONICS 2024; 11:015003. [PMID: 38250664 PMCID: PMC10799239 DOI: 10.1117/1.nph.11.1.015003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 01/23/2024]
Abstract
Significance Diffuse correlation spectroscopy (DCS) is an optical method to measure relative changes in cerebral blood flow (rCBF) in the microvasculature. Each heartbeat generates a pulsatile signal with distinct morphological features that we hypothesized to be related to intracranial compliance (ICC). Aim We aim to study how three features of the pulsatile rCBF waveforms: the augmentation index (AIx), the pulsatility index, and the area under the curve, change with respect to ICC. We describe ICC as a combination of vascular compliance and extravascular compliance. Approach Since patients with Chiari malformations (CM) (n = 30 ) have been shown to have altered extravascular compliance, we compare the morphology of rCBF waveforms in CM patients with age-matched healthy control (n = 30 ). Results AIx measured in the supine position was significantly less in patients with CM compared to healthy controls (p < 0.05 ). Since physiologic aging also leads to changes in vessel stiffness and intravascular compliance, we evaluate how the rCBF waveform changes with respect to age and find that the AIx feature was strongly correlated with age (R healthy subjects = - 0.63 , R preoperative CM patient = - 0.70 , and R postoperative CM patients = - 0.62 , p < 0.01 ). Conclusions These results suggest that the AIx measured in the cerebral microvasculature using DCS may be correlated to changes in ICC.
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Affiliation(s)
- Nikita Kedia
- University of Pittsburgh School of Medicine, Department of Neurological Surgery, Pittsburgh, Pennsylvania, United States
- Carnegie Mellon University, Department of Biomedical Engineering, Pittsburgh, Pennsylvania, United States
| | - Michael M. McDowell
- University of Pittsburgh School of Medicine, Department of Neurological Surgery, Pittsburgh, Pennsylvania, United States
| | - Jason Yang
- Carnegie Mellon University, Department of Biomedical Engineering, Pittsburgh, Pennsylvania, United States
| | - Jingyi Wu
- Carnegie Mellon University, Department of Biomedical Engineering, Pittsburgh, Pennsylvania, United States
| | - Robert M. Friedlander
- University of Pittsburgh School of Medicine, Department of Neurological Surgery, Pittsburgh, Pennsylvania, United States
| | - Jana M. Kainerstorfer
- Carnegie Mellon University, Department of Biomedical Engineering, Pittsburgh, Pennsylvania, United States
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Han S, Hou B, Li Z, Feng F, Li Y, Gao J. Individualized Functional Decompression Options for Adult Chiari Malformation With Syringomyelia and A Novel Scale for Syringomyelia Resolution: A Single-Center Experience. Neurospine 2023; 20:1501-1512. [PMID: 38171316 PMCID: PMC10762401 DOI: 10.14245/ns.2346626.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/30/2023] [Accepted: 08/01/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE To compare outcomes of posterior fossa bony decompression alone (PFD) versus PFD with duraplasty (PFDD) versus PFDD with additional obex exploration (PFDDO) in patients with Chiari malformation type I (CMI) combining syringomyelia. METHODS Clinical records of adult patients who underwent decompressions from 2014 to 2022 were retrospectively analyzed. The decompression procedure was individualized based on the cerebrospinal fluid pulse in the surgical field. The Chicago Chiari Outcome Scale (CCOS) was used to assess the prognosis of the patients and a novel syringomyelia resolution scale, based on 3-dimensional volume, was introduced. The percentage change in the cervical syrinx volume was classified as follows by resolution: ≥ 70%, 30%-70%, and < 30%. RESULTS Seventy-eight individuals were enrolled, of which 22, 20, and 36 underwent PFD, PFDD, and PFDDO, respectively. The three decompression groups had no significant difference in the preoperative characteristics and postoperative prognosis. Multivariate analyses revealed that better CCOS was significantly correlated with younger age at surgery (p = 0.018), syrinx originated from lower cervical levels (p = 0.037), narrower preoperative cerebral aqueduct (p = 0.005), and better syrinx volume resolution (p = 0.004). Additionally, a better cervical syrinx volume resolution was significantly correlated with higher CCOS (p = 0.017), narrower cerebral aqueduct (p = 0.035), and better tonsillar descent resolution (p = 0.007). CONCLUSION Individualized functional decompression induced an equal effect on CCOS and syrinx volume resolution for all CMI patients with syringomyelia. Our syringomyelia resolution scale facilitates communication and prediction of CMI prognosis.
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Affiliation(s)
- Shiyuan Han
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bo Hou
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhimin Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yongning Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Department of International Medical Service, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jun Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Capel C, Lantonkpode R, Metanbou S, Peltier J, Balédent O. Hemodynamic and Hydrodynamic Pathophysiology in Chiari Type 1 Malformations: Towards Understanding the Genesis of Syrinx. J Clin Med 2023; 12:5954. [PMID: 37762895 PMCID: PMC10532137 DOI: 10.3390/jcm12185954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/29/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The pathophysiology of this association of type 1 Chiari malformation (CM1) and syrinxes is still unknown. There is an alteration in the dynamics of neurofluids (cerebrospinal fluid, arterial and venous blood) during the cardiac cycle in CM1. Our objective is to quantify CSF or arterial blood or venous blood flow in patients with Chiari syndrome (CS) with and without syrinxes using phase-contrast MRI (PCMRI). METHODS We included 28 patients with CM1 (9 with syrinxes, 19 without). Morphological MRI with complementary PCMRI sequences was performed. We analyzed intraventricular CSF, subarachnoid spaces CSF, blood, and tonsillar pulsatility. RESULTS There is a highly significant correlation (p < 0.001) between cerebral blood flow, cerebral vascular expansion volume and venous drainage distribution. Venous drainage distribution is significantly inversely correlated with oscillatory CSF volume at the level of the foramen magnum plane [-0.37 (0.04)] and not significantly correlated at the C2C3 level [-0.37 (0.05)] over our entire population. This correlation maintained the same trend in patients with syrinxes [-0.80 (<0.01)] and disappeared in patients without a syrinx [-0.05 (0.81)]. CONCLUSION The distribution of venous drainage is an important factor in intracranial homeostasis. Impaired venous drainage would lead to greater involvement of the CSF in compensating for arterial blood influx, thus contributing to syrinx genesis.
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Affiliation(s)
- Cyrille Capel
- Department of Neurosurgery, Hospital University Center of Amiens-Picardie, 80054 Amiens, France (J.P.)
- Chimère UR 7516, Jules Verne University, 80000 Amiens, France;
| | - Romaric Lantonkpode
- Department of Neurosurgery, Hospital University Center of Amiens-Picardie, 80054 Amiens, France (J.P.)
| | - Serge Metanbou
- Radiology Department, Hospital University Center of Amiens-Picardie, 80054 Amiens, France
| | - Johann Peltier
- Department of Neurosurgery, Hospital University Center of Amiens-Picardie, 80054 Amiens, France (J.P.)
- Chimère UR 7516, Jules Verne University, 80000 Amiens, France;
| | - Olivier Balédent
- Chimère UR 7516, Jules Verne University, 80000 Amiens, France;
- Image Processing Department, Hospital University Center of Amiens-Picardie, 80054 Amiens, France
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Li YF, Wei RX, Yang KQ, Hack GD, Chi YY, Tang W, Sui XJ, Zhang ML, Sui HJ, Yu SB. A valuable subarachnoid space named the occipito-atlantal cistern. Sci Rep 2023; 13:12096. [PMID: 37495633 PMCID: PMC10372020 DOI: 10.1038/s41598-023-38825-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 07/15/2023] [Indexed: 07/28/2023] Open
Abstract
The cisterna magna has been defined as the space between the inferior margin of the cerebellar vermis to the level of the foramen magnum, while an enlarged dorsal subarachnoid space at the occipito-cervical junction extending from the foramen magnum to the upper border of the axis (C2) is still ignored. Recently, the myodural bridge complex is proved to drive the cerebral spinal fluid flowing via this region, we therefore introduce the "occipito-atlantal cistern (OAC)" to better describe the subarachnoid space and provide a detailed rationale. The present study utilized several methods, including MRI, gross anatomical dissection, P45 sheet plastination, and three-dimensional visualization. OAC was observed to be an enlarge subarachnoid space, extending from the foramen magnum to the level of the C2. In the median sagittal plane, OAC was a funnel shape and its anteroposterior dimensions were 15.92 ± 4.20 mm at the level of the C0, 4.49 ± 1.25 mm at the level of the posterior arch of the C1, and 2.88 ± 0.77 mm at the level of the arch of the C2, respectively. In the median sagittal plane, the spino-dural angle of the OAC was calculated to be 35.10 ± 6.91°, and the area of OAC was calculated to be 232.28 ± 71.02 mm2. The present study provides OAC is a subarachnoid space independent from the cisterna magna. Because of its distinctive anatomy, as well as theoretical and clinical significance, OAC deserves its own name.
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Affiliation(s)
- Yun-Fei Li
- Department of Anatomy, College of Zhongshan, Dalian Medical University, Dalian, 116085, China
| | - Rui-Xue Wei
- Second Affiliated Hospital, Dalian Medical University, Dalian, 116052, China
| | - Kai-Qi Yang
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China
| | - Gary D Hack
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD, 21201, USA
| | - Yan-Yan Chi
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China
| | - Wei Tang
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China
| | - Xue-Jun Sui
- Dalian Hoffen Preservation Technique Institution, Dalian, 116052, China
| | - Meng-Liang Zhang
- Department of Molecular Medicine, University of Southern Denmark, 5000, Odense C, Denmark
| | - Hong-Jin Sui
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China.
- Dalian Hoffen Preservation Technique Institution, Dalian, 116052, China.
| | - Sheng-Bo Yu
- Department of Anatomy, College of Basic Medical Sciences, Dalian Medical University, Dalian, 116044, China.
- China Denmark Joint Research Center for Biological Plastination Technique, Dalian Medical University, Dalian, 116044, China.
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Ciaramitaro P, Migliaretti G, Ferraris M, Garnero A, Morana G, Carucci P, Stura I, Massaro F, Garbossa D. Syringomyelia Associated with Chiari 1 Malformation in Adults: Positive Outcome Predictors after Posterior Fossa Decompression with Duraplasty. J Clin Med 2023; 12:jcm12083019. [PMID: 37109355 PMCID: PMC10143011 DOI: 10.3390/jcm12083019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Syringomyelia (Syr) in patients with Chiari 1 malformation (CM1) may be attributable to abnormal dynamics of cerebrospinal fluid (CSF) in the upper cervical segment; fourth ventricle enlargement has been reported in association with a worse clinical and radiological presentation, independently of the posterior fossa volume. In this study, we analyzed presurgery hydrodynamic markers to evaluate if their changes could be associated with clinical and radiological improvement after posterior fossa decompression and duraplasty (PFDD). As a primary endpoint, we aimed to correlate improvement in the fourth ventricle area with positive clinical outcomes. METHODS In total, in this study, we enrolled 36 consecutive adults with Syr and CM1 who were followed by a multidisciplinary team. All the patients were prospectively evaluated with clinical scales and neuroimaging, including CSF flow, the fourth ventricle area, and the Vaquero Index by using a phase-contrast MRI before (T0) and after surgical treatment (T1-Tlast, with a range of 12-108 months). The CSF flow at the craniocervical junction (CCJ), the fourth ventricle area, and the Vaquero Index changes were statistically analyzed and compared to the clinical and quality of life improvement after surgery. The good outcome prediction ability of presurgical radiological variables was tested. RESULTS Surgery was associated with positive clinical and radiological outcomes in more than 90% of cases. The fourth ventricle area significantly reduced after surgery (T0-Tlast, p = 0.0093), but no significant associations with clinical improvement were found. The presurgical presence of CSF flow at the CCJ was able to predict a good outcome (AUC = 0.68, 95% CI 0.50-0.87 and LH+ = 2.1, IC 95% 1.16-3.07) and was also significantly associated with post-surgical pain relief (rho = 0.61 and p = 0.0144). CONCLUSIONS Presurgery CSF flow at the CCJ is proposed as a radiological marker with the ability to predict a positive outcome after PFDD in adults with syringomyelia and CM1. Measurements of the fourth ventricle area could be useful additional information for evaluating surgical long-term follow-up; further experience on larger cohorts is required to better define the prognostic yield of this radiological parameter.
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Affiliation(s)
- Palma Ciaramitaro
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- CRESSC, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Giuseppe Migliaretti
- Department of Public Health and Paediatric Sciences, University of Torino, 10126 Torino, Italy
| | - Marilena Ferraris
- Diagnostic Imaging Department, AOU Citta' della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Andrea Garnero
- Diagnostic Imaging Department, AOU Citta' della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Giovanni Morana
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- Diagnostic Imaging Department, AOU Citta' della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Paolo Carucci
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- CRESSC, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Ilaria Stura
- Neuroscience Department, University of Torino, 10126 Torino, Italy
| | - Fulvio Massaro
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- Neurosurgery Unit, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Diego Garbossa
- Neuroscience Department, University of Torino, 10126 Torino, Italy
- Neurosurgery Unit, AOU Città della Salute e della Scienza di Torino, 10126 Torino, Italy
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Zhang M, Hu Y, Song D, Duan C, Wei M, Zhang L, Lei S, Guo F. Exploring the prognostic differences in patients of Chiari malformation type I with syringomyelia undergoing different surgical methods. Front Neurol 2023; 13:1062239. [PMID: 36686516 PMCID: PMC9846178 DOI: 10.3389/fneur.2022.1062239] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/12/2022] [Indexed: 01/05/2023] Open
Abstract
Background The best surgical treatment of Chiari malformation patients with syringomyelia remains controversial, and whether cerebellar tonsillectomy should be performed has not been decided. Objective To evaluate the efficacy of posterior fossa decompression with duraplasty (PFDD) and Posterior fossa decompression with resection of tonsils (PFDRT) in patients of Chiari malformation type I (CM-I) with syringomyelia and explore relevant factors affecting prognosis. Patients and methods We retrospectively analyzed 182 adult patients of CM-I with syringomyelia who underwent PFDD or PFDRT over a 6-year period, and analyzed their clinical manifestations, imaging features, and follow-up data. Clinical outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS), and imaging outcomes were assessed using the syrinx remission rate. Difference comparisons were performed to compare the differences between different surgical groups. Influencing factors associated with outcome were investigated using bivariate analysis and multiple linear regression analysis. Results There were statistically significant differences in CCOS score (p = 0.034) and syrinx remission rates (p = 0.046) between the PFDRT group and the PFDD group after surgery. Regression analysis showed that preoperative motor dysfunction, cerebellar-related symptoms and different surgical methods may have influenced the CCOS score and that brainstem-related symptoms and age may have influenced the syrinx remission rates in the total patient group (p < 0.05). Regression analysis showed that the duration of symptoms, cerebellar-related symptoms and preoperative syrinx diameter may have influenced the CCOS score and that the preoperative cerebellar tonsillar hernia distance may have influenced the postoperative syrinx remission rate in the PFDRT group (p < 0.05). Age and length of hospital stay may have influenced the CCOS score, and brainstem-related symptoms and age may have influenced the syrinx remission rates in the PFDD group (p < 0.05). Conclusion This study showed that the CCOS score in the PFDRT group was better than that in the PFDD group. Preoperative motor dysfunction, cerebellar-related symptoms, and different surgical methods in patients of CM-I with syringomyelia affected postoperative CCOS score. Both the duration of symptoms and the age of the patients should be actively considered as factors influencing prognosis. Symptomatic CM-I patients with syringomyelia should undergo surgical treatment as early as possible.
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Affiliation(s)
- Mingchu Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Yan Hu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Dengpan Song
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Chengcheng Duan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Mingkun Wei
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Longxiao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China
| | - Shixiong Lei
- Department of Neurosurgery, Beijing Hospital, Beijing, China
| | - Fuyou Guo
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China,International Joint Laboratory of Chiari Malformation, Zhengzhou, Henan, China,*Correspondence: Fuyou Guo ✉
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