Acm Power Pressed

Arnold Chiari MalformationArnold Chiari Malformation

Liew Boon Seng

20 SEPTEMBER 2006

Continuous Medical Education

Department of Neurosurgery, Hospital Kuala Lumpur

Chiari Malformation

• Group of CNS developmental anomalies primarily afflicting the posterior fossa

• Hans Chiari (1815 -1916)

Chiari Malformation

• Clinical complaints – headache, sensory changes, difficulty swallowing, vertigo, ataxia, imbalance, hearing loss.

• Others include cranial nerve palsy, nystagmus, syringomyelia, scoliosis, hydrocephalus

• Spinal cord involvement include hydromyelia, syringomyelia, compression, and/or herniation

Classification of Chiari Malformation

• Type I

• Type II

• Type III

• Type IV

Type I

• Congenital tonsil ectopia– 10 y.o – 6mm– 2nd -3rd decade – 5mm– 4th and 5th decade – 4mm– Rarely below C2

• 4th ventricle normal• Associated with syringomyelia, hydromyelia, or

syringohydromyelia• Not associated with myelomeningocele• Hydrocephalus in 10%

Signs of Chiari I malformation

• Related to the area of compression:– if the cerebellar tonsils are primarily involved,

the patient may present with signs related to cerebellar compromise and/or dural irritation (Lhermitte sign)

– If there is pressure on the posterior aspect of the cervical cord, one may find hypo- or hyperreflexia, or a Babinski sign.

Type II• Herniation of cerebellar tonsils and all the contents of posterior

fossa into foramen magnum (brainstem, 4th ventricle, cerebellar vermis)– Commonly below C2

• Vascular structures, which may also be displaced and are of surgical concern, are the posterior inferior cerebral arteries and the basilar artery.

• Multiple posterior fossa and cerebral anomalies– “beaking of the dorsal midbrain– Enlargement of the massa intermedia– Medullary “kinking”– Hypoplasia of the tentorium

• Lower brainstem and cranial nerve palsy• Associated with myelomeningocele and hydrocephalus (always

present)• Shunt-treated cases with Chiari II are often difficult to manage. In

these patients with preexisting hindbrain herniation, a shunt malfunction might become rapidly symptomatic and fatal if not treated

Type III

• Protrusion of a sac from the craniocervical junction that contains portions of the cerebellum and brainstem

• Have an encephalocele

• Commonly associated with hydrocephalus

Type IV

• Complex cerebellar hypoplasia and dysplasia

• Associated with diminutive posterior fossa

Diagnosis

• High resolution MRI

• Degree of tonsillar descent in ACM

• Significant mass lesions at the craniocervical junction in conjunction with syringomyelia

• Plain SXR of craniocervical junction

• Computed tomography (CT) scan

• Myelography with water-soluable contrast

Posterior Fossa Decompression

• Main goals:1) decompression of the inferior aspect of the

cerebellum;

2) enlargement of the total volume of the posterior fossa; and

3) establishment of CSF flow.

Posterior Fossa Decompression

• Indications– Chiari I associated with occipital headache,

sensory disturbances, weakness,ataxia, spasticity, bulbar signs, syringomyelia, or scoliosis

– Chiari II with apnea, bradycardia, stridor in infancy

– Chiari II with progressive motor or sensory disturbance, syringomyelia, scoliosis in adolescence or adulthood

Posterior Fossa Decompression

• Contraindications– Asymptomatic Chiari I or II– Symptomatic Chiari II with possible shunt

malfunction or tethered spinal cord

Teo C, Parker EC, Aureli S, et al: The Chiari II Malformation:

a surgical series. Pediatr Neurosurg 27:223–229, 1997

• Magnetic resonance images of the craniocervical junction should be obtained in all three planes (coronal, sagittal and axial) to evaluate the CSF signal around the medulla within the foramen magnum.If there is no CSF signal around

• the cord at the level of the foramen magnum, or if a restrictive band of fibrous tissue is apparent, then decompression should be undertaken.

Posterior Fossa Decompression

• Steps: 1) positioning of the patient; 2) incision; 3) craniotomy or craniectomy; 4) dural opening;

5) decompression; 6) resection of arachnoid adhesions; 7) removal of inferior tonsils;8) opening of the obex; 9) syrinx decompression (if desired); 10) dural closure; 11) closure of the craniotomy;12) fascial and skin closure

Position of Surgery : suboccipital approaches

• Prone position– Risk of air embolism less than sitting position– No risk of subdural hematoma when CSF is drained intraoperatively– Easily to apply fibrin glue to entire dura graft– Faster positioning– More comfortable to surgeon

• Head position fixed with Mayfield pin-fixation• Avoid excessive neck flexion• Neck in neutral or slightly flexed

Incision

• Midline incision -inion to approximately C-3• The incision is brought down through the skin

and midline nuchal fascia.• Meticulous hemostasis – avoid pooling of blood

in the intradural and subrachnoid space

Craniotomy or craneictomy• Posterior fossa craniotomy 2.5-3.0cm

– Just below transverse sinus to foramen magnum– Enough bone should be resected to provide adequate access to the

cerebellar tonsils and the obex below.• Removal of posterior arch of atlas• Laminectomy C2

Dura Opening• “Y” shaped incision• Preferable to preserve the arachnoid• It is often helpful to clamp across the occipital sinus, with fine

hemostats, prior to cutting across the sinus, between the two hemostats. The sinus can then be ligated using No. 4-0 nonabsorbable suture.

• note the position of a low lying sinus in patients with Chiari II malformation.

Decompression : Resection of arachnoid adhesions

• Arachnoid bands or adhesions may be cut sharply by using microscissors or a microdissector.

Removal of inferior tonsils

• The inferior cerebellar tonsils may either be removed using cavitating ultrasonic aspiration, or they may be shrunk using bipolar coagulation.

• PICA situated behind the tonsil

Opening of the obex

• The obex may be checked to determine if it is open and if CSF flows easily from the fourth ventricle.

• Gardner* has described “plugging” of the obex, with muscle or fascia, to obliterate pulsations from the fourth ventricle transmitted to the central canal

*Gardner WJ: Hydrodynamic mechanism of syringomyelia: itsrelationship to myelocele. J Neurol Neurosurg Psychiatry 28:247–259, 1965

Opening of the obex

• A shunt may be placed between the fourth ventricle and the subarachnoid space if there is concern about maintaining an open CSF conduit

• The tubing may become displaced or cause the formation of arachnoid adhesions.

Syrinx decompression• Feldstein and Munshi reported that suboccipital craniectomy with

duraplasty, in most patients, will be sufficient treatment and that the syrinx will resolve after the initial decompression

• Simple dorsal midline myelotomy or DREZ myelotomy, can be performed at the time of the initial procedure.

• Opening the syrinx to drain its contents or placement of a stent to maintain the CSF conduit are acceptable means to decompress a syrinx.

• There are various stents available: syringosubarachnoid, syringopleural, and syringoperitoneal.

1Feldstein NA, Choudhri TF: Management of Chiari I malformations with holocord syringohydromyelia. Pediatr Neurosurg 31:143–149, 19992Munshi I, Frim D, Stine-Reyes R, et al: Effects of posterior fossa decompression with and without duraplasty on Chiari malformation-associated hydromyelia. Neurosurgery 46: 1384–1390, 2000

Dura Closure of the Posterior Fossa

• If the dura is left open, the muscle and fascia must be carefully closed in two watertight layers.

• If the dura is closed, use a dural graft to increase the intracranial volume of the posterior fossa (auto- and allografts)

Closure of the craniotomy

• The bone is replaced, in some cases, with suture, miniplates, or other cranial fixation devices. In other cases, the bone is left out.

Fascial and skin closure

• The fascia is closed using absorbable suture, and the skin is closed using absorbable or nonabsorbable suture.

• Surgical staples may also be used for skin closure.

Position of Surgery : CSF Diversion Procedures

• Syringopleural shunt – prone

• Syringoperitoneal shunt – lateral

Early Postoperative Care

• Head elevated 30º

• Antibiotics are discontinued within 24 hours of the operation

• Corticosteroids are generally avoided/ discontinued within 72 hours to reduce risk of impaired dural healing

• Observed for 24 hours in the ICU – care of aspiration and respiratory problems

Late Postoperative Care

• Avoid lifting and straining for 3 months – reduce chance of creating dural leak – use of cough suppressant

• Post-operative MRI few days to 1 week post surgery

Complications Related to Conservative Surgery

(Persistent Compression)• 1) inadequate craniectomy;

• 2) persistent occipitoatlantal membrane;

• 3) inadequate dural opening/duraplasty;

• 4) residual arachnoid adhesions; and

• 5) residual tonsillar compression.

Recurrent symptoms post-operation

• When recurrent symptoms develop or if symptoms persist, MR imaging of the brain and cervical spine is performed.

• Persistent compression of the cerebellar tonsils may be apparent on sagittal and axial images, with inadequate CSF spaces around the inferior aspect of the cerebellum.

• This may be in part due to inadequate osseous decompression, persistent occipitoatlantal membrane, or an excessively tight, or restenotic, dural closure.

• If symptoms are mild, the patient may be followed conservatively. If clear compression exists, however, reoperation should be considered with extension of the decompressed region.

Complications of Surgery

• Immediate– Intraoperative air embolism, Intraoperative

vasospasm, Vertebral artery injury, bleeding, failure to open the fourth ventricular CSF pathways, coma, autonomic instability

– Aseptic meningitis

• Delayed– CSF leak, pseudomeningocele, cerebellar sag,

occipital cervical instability, hydrocephalus, recurrent or residual syringomyelia

Outcome and Follow-up

• Good outcome– Asymptomatic or only one residual component of

disease (e.g sensory loss)– Syrinx collapse more than 75%– Return to normal lifestyles without restrictions

• Improved outcome– Marked overall symptomatic improvement– Syrinx collapse of 50 to 75%– Only one major residual deficit (e.g scoliosis, pain,

weakness)– Return to normal lifestyle but may restrict their sports

activity

Outcome and Follow-up

• Poor outcome– No change in the syrinx size– Presence of residual severe pain that is

recalcitrant to therapy or restriction of lifestyle

• Long-term follow-up needed

Algorithm For Symptomatic Chiari I Malformation

Algorithm For Asymptomatic Chiari I Malformation

Algorithm For Symptomatic Chiari II Malformation

Algorithm For Asymptomatic Chiari II Malformation

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