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Chiari Malformations: Dr. Sourabh Jain Medical College & Hospital Trivandrum
Chiari Malformations: Dr. Sourabh Jain Medical College & Hospital Trivandrum
• Four types
• Chiari type IV
hypoplasia / aplasia of cerebellum with no hindbrain herniation
Transitional forms of Chiari malformations
• Chiari type 1.5
tonsillar herniation as seen in Chiari I with addition of an elongated brainstem and fourth
ventricle.
( Iskandar B,1999 )
• Chiari type 0
– Hydrocephalus (3-10%)
– Elongated 4th ventricle
– Retrocerebellar CSF space are obliterated or
diminished
Associated anomalies – Chiari l
• Meninges
-- Elevated slope of tentorium
– Thickening of arachnoid at foramen magnum
– Constricting dural bands at level of foramen
magnum and posterior arch of atlas
– Veils of arachnoid that obstruct fourth ventricular
outlet
Associated anomalies – Chiari l
• Spinal cord
– Syrinx (50-75%)
Associated anomalies – Chiari l
• Brain
syringohydromyelia common
Chiari II Malformation
Associated anomalies – Chiari ll
• Skull
– Craniolcunia or luckenschadel- copper beaten appearance
of calvaria
– Anterior scalloped frontal bone (lemon sign )
– Scalloping of pterous and jugular tubercle
– Enlarged FM
– Notched opisthion
– Elongated clivus with concavity
– Lower inion
– Basilar impression
– Assimilation of atlas
Chiari II Supratentorial pathology
• Luckenschadel or Lacunar skull
– result of abnormal radial growth of the skull, seen in upto 85% of cases
– Focal areas of cortical thinning and scalloped appearance of the skull
– most prominent at birth, may resolve with age
– not a result of raised ICP and hydrocephalus
Banana sign Normal fetus
Associated anomalies – Chiari ll
• Spine
– Elongated cervical spine
– Scalloping of odontoid processes
– Incomplete C1 posterior arch
– Klippel-Feil deformity
Associated anomalies – Chiari ll
• Ventricle and cistern
– Hydrocephalus (90%)
– Asymmetry of
ventricle
– Colpocephaly-
enlargement of atria
and occipital horns
– Shark tooth
deformity of 3rd
ventricle
– Elongated, flat and
small 4th ventricle
– Absent inferior
Associated anomalies – Chiari ll
• Meninges
– Abnormal tentorium cerebelli
– Elongated incisura
– Low lying tentorium
– Vertical straight sinus
– low lying torculla
– Fenestrated or hypoplastic falx cerebri
– Thickened arachnoid
– Thickened cephalad dentate ligament
– Arachnoid cyst
Associated anomalies – Chiari ll
• Brain
– Telencephalon
• Corpus callosal agenesis
• Absent septum pellucidum
• Polygyria
• Chinese lettering of occipital and parietal lobe
• Agenesis of olfactory tract/bulb
• Absent cingulate gyrus
Associated anomalies – Chiari ll
• Brain
– Diencephalon
• Interthalamic adhesions
• Elevated hypothalamus
• Elongated pineal gland
• Elongated habenular commissure
Associated anomalies – Chiari ll
• Brain
– Mesencephalon
• Elongated mid brain
• Shortened quadrigeminal plate
• Tectal beaking
• Forked , kinked shortened aqueduct
• Dysgenesis of cranial nerve nuclei
Associated anomalies – Chiari ll
• Brain
– Metancephalon
• Smaller cerebellum
• Towering of cerebellum
• Tonsillar and vermian herniation
• Dysplasia of cerebellum
• Banana sign- curved cerebellum
• Cerebellar inversion
• Elongated and flattened pons
• Dysplastic cranial nerve nuclei
Chiari II Malformation
Associated anamolies – Chiari ll
• Brain
– Myelencephalon
• Elongated and flattened medulla (trumpet like )
• Cervicomedullary kink
• Cephalad pyramidal decussation
Genetics of Chiari
• Familial occurrence
• Concordance in twins and triplets
• Association with other genetic disorder
– Spondyloepiphyseal dysplasia tarda
– Hadelu-Cheney syndrome
– Klippel-Fiel syndrome
– achondroplasia
Genetics of Chiari
• Risk of inheritence
– No data available
– Incidence of familial syringomyelia – 2%
– Incidence of familial CM l – 12%
• Pattern of inheritence
– Autosomal dominant with reduced penetrance
– Autosomal recessive
(Milhort et al.Neurosurgery.44:1005-1017,1999)
Acquired Chiari Malformation
• Acquired Chiari I malformation secondary to
spontaneous spinal cerebrospinal
fluid leakage and chronic intracranial
hypotension
syndrome in seven cases.
(Atkinson JL et al. J Neurosurgery. Feb;88(2):237-242,1998)
– Ataxia: appendicular
– Dysmetria
Chiari II
• Commonly presents in infancy, childhood and adolescence
cerebellar
Brain stem
7%
45%
spinal cord
48%
Chiari II
Chiari II
• Brain stem
– Nystagmus: first, coarse, lat gaze evoked
– Poor sucking/ dysphagia/ aspiration
– Arching of head/ fixed retrocollis/ ophistotonus
– “Good baby” – feeble cry
– Inspiratory wheeze or stridor on agitation (cf: epiglottitis)
– Apneic spells – cyanosis/anoxic seizures – exhausted- sleeps
– Vocal cord abductor palsy (b/w cyanotic attacks)
– Gag: blunted or absent
– VII nerve paresis
– Dysconjugate eye movements
– Mirror movements
Chiari II
• Spinal cord/ syrinx
↑ICT conditions
Acquired ↓Skull vol
Pressure gradient
Theories
• Hydrocephalus theory (Chiari, 1891)
attributed the congenital hindbrain herniation to ‘ chronic
hydrocephalus of the cerebrum’
with ‘pushing out ‘ of the cerebellum and the
brainstem through the foramen magnum
* hydrocephalus not universal and children with
hydrocephalus and no dysraphism do not have
herniation
*upward herniation through tentorial notch along with
caudal displacement of hindbrain in Chiari II with
hydrocephalus
•
• Cerebral Dysgenesis theory ( Cleland,1883 )
dysplastic changes in brainstem,, cerebellum,, corpus callosum based on
chick embryo studies.
dissipated through a patent obex into the central canal resulting in progressive spinal cord
cavitation.
Pros:
* animal studies to support the same by occlusion of the fourth ventricular outlet.
*compensated hydrocephalus with communicating syringomyelia in 14/15 patients of
myelodysplasia in whom VP shunt resulted in neurological improvement with resolution of
the syrinx . ( Hall et al.)
Cons :
* hydrocephalus present in some.
* fourth ventricular obstruction not present in all.
*obex rarely communicates with syrinx.
• Craniospinal Pressure Dissociation theory ( William ,
1969)
Attributed venous pressure changes rather than arterial pulsations as the driving
force for hydromyelia.
Proposed that
- increase in the subarachnoid fluid pressures resulted from increase in venous
pressure during coughing and Valsalva ‘s maneuver due to distended epidural
venous plexus resulting in the cranial flow of CSF with dissipation of pressure
difference.
-hindbrain herniation prevents this caudal flow of CSF due to ball valve effect of
the tonsils which impact at the foramen magnum
Pros:
-explained the association of foramen magnum obstruction with progression of
syrinx.
-experimental evidence to demonstrate significant craniospinal pressure
difference which normalized following decompression.
Cons:
-Only 10% had radiological evidence of communicating syrinx .
- myelography evidence shows cord compression not dilatation
during increase in spinal venous pressure.
Theories
• Du Boulay modification of Gardner ‘s theory ,1974.
Pros:
- metrizamide scan suggests transneural migration into the cavity.
- communication of syrinx with spinal subarachnoid space.
Cons:
-documentation of venous hypertension in spinal cord
not convincing.
• .
Theories
• Taylor’s theory ,1975
Pros:
- explained the separation of syrinx cavity from the central canal
-communication of syrinx with spinal subarachnoid space demonstrated
using metrizamide myelogram.
Cons:
-pressure external to syrinx would tend to collapse rather than enlarge
it.
Aboulker –fluid enter along dorsal nerve roots.
Theories
• Mclone and Knepper’s Unified theory (1989)
-based on assumption that neural tube defect primary with secondary
manifestations of Chiari and hydrocephalus.
- CSF leak through defect results in lack of distension of cranial ventricular system
which is a prerequisite for normal development of cerebral cortex and overlying
skull.
• Oldfield’s theory ( 1994)
• It is currently a widely accepted theory.
- hypothesized that CSF in spinal cord acts from outside the spinal cord and not from within.
- systolic pressure wave imparted to intracranial CSF due to blood flow to the brain is normally
adjusted by sudden CSF movement from basal cisterns to upper spinal canal.
- In Chiari I , piston like movement of the cerebellar tonsils down the foramen magnum results
in systolic pressure wave in spinal CSF .
-pressure waves act on the surface of the cord and forces CSF into the parenchyma along the
perivascular and interstitial spaces.
-once syrinx formed ,longitudinal propulsion of fluid with
propagation of cavity
– Hydrocephalus
– Shunting of syrinx
Selection of Surgical Procedure
• Depends on whether chiari is associated with
syrinx or not.
• Also on the type and degress of tonsillar
descent.
• The key is to decompress the posterior fossa and
CVJ adequately, and to establish normal CSF flow
across the region of formen magnum.
• Any associated pathology like hcp and BI will
determine the type and modification of the
procedure
Various procedures adopted
• FMD alone
• FMD with lax duroplasty
• FMD with arachnoid adhesiolysis and lax
duroplasty
• FMD with tonsillar resection, pexy etc and lax
durplasty
• FMD with any of the above and additional
removal of C2.
FMD = Suboccipital craniectomy encompassing the
foramen magnum rim and C1 posterior arch excision
Additional procedures for associated
problems
• Hydrocephalus
– VP shunt
– ETV (Missimi et al - NS 2011)
• Ventral Bony CMJ compression
– Ventral decompression with or without fusion
• CVJ instability
– Posterior fusion
Surgical Technique
• Bony decompression
• Dural procedures
• Arachnoid handling
• Control
– Proceed slowly
– Bipolar
– Metal Clips
– Figure of 8 stiches
Intradural exploration
• Arachnoid opening
– Under magnification
– Midline
• Layered closure
– Muscle
– Facia
– Subcuticular
– Skin
Postoperative complications
• Early
– CSF Leak
• Address HCP
• Resuture
• Lumbar drain
– Meningitis – Infective / Chemical
• Non autologous graft
• Dura not closed
• Meticulous and clean procedure
Postoperative Complications
• Early
– Brainstem dysfuctions
– Hematoma
Postoperative Complications
• Late
– Symptom recurrence
• Occur after initial improvement
• Due to:
– New or enlarging syrinx
– CSF obstruction due to scarring
– Cerebellar ptosis
– Pain
– Instability
Shunting of syrinx
• Indication:
– Persistent symptoms
• Non resolution of syrinx
– PCMR shows normal flow study
• Options:
– SSS
– SPS
– TPS
– Terminal ventriculostomy
Recurrent or Unresolved Chiari
Failed procedure
• Causes:
– Inadequate decompression
• Bony
• Soft tissue
– Reformation of arachnoid scars
– Lack of CSF flow normalization despite adquate
soft tissue and bony decompression
• Management
– Revision surgery
– Shunting of the syrinx
Intraoperative adjuncts for adequate
posterior fossa decompression
Intraoperative color doppler after FMD
– Adequacy of CSF flow
• Bidirectional flow across FM
– respiratory