A combined approach for stabilization and endoscopic/ endonasal odontoid and clivus resection for treatment of basilar invagination

Background: Basilar invagination (BI) is a complex condition characterized by prolapse of the odontoid into the brain stem/upper cervical cord. This lesion is often associated with Chiari malformations, and rheumatoid arthritis (RA). Treatment options for BI typically include cervical traction, an isolated anterior transoral odontoidectomy, anterior endonasal odontoidectomy, an isolated posterior fusion, or combined anterior/ posterior surgical approach. Case Description: A 45-year-old female with a Chiari I malformation and RA underwent a combined posterior C0-C5 posterior decompression/fusion, followed by an anterior odontoidectomy (i.e. endoscopic/endonasal under neuronavigation). Postoperatively, the patient’s symptoms and neurological signs resolved. Conclusion: BI in was successfully managed with a combined posterior C0-C5 decompression/fusion followed by an anterior endoscopic/endonasal odontoidectomy performed under neuronavigation.

Course of papilloedema following surgical decompression in CHIARI I malformation with raised intracranial pressure

Arnold-Chiari malformations (ACM) is a rare congenital hindbrain maldevelopment, leading to downward herniation of the cerebellar tonsils. Clinical features relates to cerebrospinal fluid disturbances, manifesting as symptoms of headaches, pseudotumour-like episodes, cranial nerve palsies and cerebellar dysfunction. Ocular manifestations includes varying ophthalmoloplegia and accommodation abnormalities. Papilloedema has been rarely implicated and remains an uncommon feature of ACM. We report a case of ACM who developed papilloedema and visual disturbance, that was successfully treated with suboccipital decompression. The presentation of patients with ACM-I and papilloedema unaccompanied by localising signs may resemble that of IIH. Neuroimaging with special attention to the craniocervical junction in saggital and transverse planes is crucial. Surgical decompression of the posterior fossa seems to improve headache symptoms and clinical signs of papilloedema.

Hypothesis on the pathophysiology of syringomyelia based on analysis of phase-contrast magnetic resonance imaging of Chiari-I malformation patients

Background: Despite a number of hypotheses, our understanding of the pathophysiology of syringomyelia is still limited. The current prevailing hypothesis assumes that the piston-like movement of the cerebellar tonsils drives the cerebrospinal fluid (CSF) into the syrinx through the spinal perivascular space. However, it still needs to be verified by further experimental data. A major unexplained problem is how CSF enters and remains in the syrinx that has a higher pressure than the subarachnoid space. Methods: I analyzed phase-contrast MRI scans of 18 patients with Chiari-I malformation with syringomyelia undergoing foramen magnum decompression and 21 healthy volunteers. I analyzed the velocity waveforms of the CSF and the brain in various locations. The obtained velocity waveforms were post-processed using a technique called synchronization in situ. I compared between the preoperative data and the control data (case-control study), as well as between the preoperative and postoperative data (cohort study). Results: The syrinx shrank in 17 (94%) patients with good clinical improvement. In Chiari-I patients, the velocity of the tonsil was significantly larger than controls, but was significantly smaller than that of the CSF in the subarachnoid space, suggesting passive rather than active movement. The abnormal tonsillar movement disappeared after surgery, but the velocity waveform of the spinal subarachnoid CSF did not change. These results, contradicting the above mentioned hypothesis, required an alternative explanation. I thus hypothesized that there is a CSF channel between the fourth ventricle and the syrinx. This channel assumes one-way valve function when mildly compressed by the cyclical movement of the cerebellar tonsil. The decompression of the tonsils switches off the one-way valve, collapsing the syrinx. Conclusions: My hypothesis reasonably explained my data that clearly contradicted the existing hypothesis, and successfully addressed the above-mentioned theoretical problem. It will serve as a working hypothesis for further study of syringomyelia pathophysiology.

Chiari I malformation and Noonan’s syndrome: Shared manifestations of RASopathy

Neurologic sequalae of Noonan syndrome have been postulated in the literature. A topic of significance is the role of RASopathy in the shared pathophysiology of Noonan Syndrome and Chiari I malformation. In this unique case report, we present a patient with concomitant Noonan Syndrome and Chiari I with 4th ventricular outflow obstruction. The case highlights the importance of close clinical suspicion in this patient population. We utilize the case to delve into intricacies of the known pathophysiology and encourage ongoing investigation. Keywords: Noonan syndrome; Chiari I malformation; RASopathy.

Superficial siderosis associated with an iatrogenic posterior fossa dural leak identified on CT cisternography

Superficial siderosis refers to hemosiderin deposition along the pial surface of the brain and spinal cord. It results from chronic and repetitive low-grade bleeding into the subarachnoid space. Dural tears are a common cause of superficial siderosis. Although such tears typically occur in the spine, dural tears can also occur in the posterior fossa. In many cases, posterior fossa dural tears are iatrogenic, and patients may present with neuroimaging evidence of postoperative pseudomeningoceles. We present a case of superficial siderosis caused by a persistent posterior fossa dural leak. The patient presented with superficial siderosis 30 years after a Chiari I malformation repair. A pinhole-sized dural tear was identified preoperatively using computed tomography cisternography. The dural defect was successfully repaired. An additional small tear that was not seen on imaging was also identified at surgery and successfully repaired.

Diagnostic utility of parasagittal measurements of tonsillar herniation in Chiari I malformation

Background and purpose Although the cerebellar tonsils are parasagittal structures, the extent of tonsillar herniation (ETH) in Chiari I malformation (CMI) is currently measured in the midsagittal plane. We measured the ETH of each cerebellar tonsil in the parasagittal plane and assessed their diagnostic utility by comparing them to the midsagittal ETH measurements in predicting cough-associated headache (CAH), an indicator of clinically significant disease in CMI. Methods Eighty-five CMI patients with 3D-MPRAGE images were included. Neurosurgeons determined the presence of CAH. Sagittal images were used to measure ETH in the midsagittal (MS_ETH) and parasagittal planes (by locating tonsillar tips on each side on reformatted coronal images). Given the parasagittal ETH (PS_ETH) asymmetry in the majority of cases, they were considered Smaller_PS_ETH or Larger_PS_ETH. The accuracy of ETH measurements was assessed by the receiver operating characteristic (ROC) curve. Results Of 85 patients, 46 reported CAH. ROC analysis showed an area under the curve (AUC) of 0.78 for Smaller_PS_ETH significantly better than 0.65 for MS-ETH in predicting CAH ( p = 0.001). An AUC of 0.68 for Larger_PS_ETH was not significantly different from MS_ETH. The sensitivity and specificity of predicting CAH were 87% and 28% for MS_ETH >6 mm versus 90% and 46% for Smaller_PS_ETH >6 mm, and 52% and 67% for MS_ETH >9 mm versus 48% and 87% for Smaller_PS_ETH >9 mm. At ETH >15 mm, no differences were seen between the measurements. Conclusions Diagnostic utility of ETH measurements in detecting clinically significant CMI can be improved by parasagittal measurements of the cerebellar tonsillar herniation.

Endoscopic Endonasal Resection of Cranio-Cervical Junction Chordoma and Ventral Chiari Decompression: A Case Report

BACKGROUND Chiari I malformations secondary to other causes represent a small subset of presenting symptomatic cases. Typically, the primary cause of the malformation is addressed first and results in resolution of the malformation and symptoms. However, in some cases, a patient may present with both a primary Chiari I malformation and another unrelated neurosurgical lesions. OBJECTIVE To present a unique case in which resection of a ventral tumor allowed for spontaneous resolution of a simultaneously noted dorsal Chiari I malformation. METHODS Pertinent data, including presenting symptoms, hospital course, surgical notes, preoperative images, and postoperative images, were collected using the electronic medical record. RESULTS We present a case of a 46-yr-old man with a Chiari I malformation in conjunction with a ventral cranio-cervical junction chordoma. Endoscopic endonasal resection of the chordoma and ventral foramen magnum decompression resulted in radiographic resolution of the Chiari malformation and resolution of his symptoms. Our report represents a rare case of ventral foramen magnum decompression as a treatment for Chiari I malformation. CONCLUSION It is felt that the chordoma mass effect was not the source of the Chiari I malformation. Thus, both ventral and dorsal decompressions of the posterior fossa may be considered for Chiari I decompression in select circumstances.

The “Three on a Stick” Incision—A Curvilinear Solution for the Occipital and Suboccipital Region

BACKGROUND Different conditions of the posterior fossa such as Chiari malformations, tumors, and arachnoid cysts require surgery through a suboccipital approach, for which a typical midline vertical linear incision is used. Curvilinear incisions have been carried in all other scalp regions other than the sub region for better cosmetic outcomes; a vertical curvilinear incision in the occipital and suboccipital region has not been reported. OBJECTIVE To evaluate the cosmetic value and safety of the “3 on a stick” vertical suboccipital curvilinear incision. METHODS We compared curvilinear to linear incisions, considering the scar's width, color, how conspicuous, and how well the scar could be covered by hair naturally. RESULTS Between 2010 and 2016, 68 children with Chiari I malformation were surgically intervened. The curvilinear incision was performed in 56 (82.4%) while a linear incision in 12 (17.6%) children. There were only 2 (2.9%) wound related complications (superficial dehiscences) in the curvilinear group and 1 additional dehiscence in a linear incision case. There were no neural or vascular complications. Scars were very similar among the 2 groups; both were equally conspicuous but curvilinear ones seemed to get covered better by hair. CONCLUSION The “3 on a stick” curvilinear incision of the suboccipital region is safe and allows for better hair coverage of the scar. It can be used for multiple conditions requiring a midline suboccipital or even occipital approach, such as Chiari malformations, tumors, and cysts.