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Surgical management of Chiari I malformation based on different cerebrospinal fluid flow patterns at the cranial-vertebral junction

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Abstract

Chiari I malformation has been shown to present different cerebrospinal fluid (CSF) flow patterns at the cranial-vertebral junction (CVJ). Posterior fossa decompression is the first-line treatment for symptomatic Chiari I malformation. However, there is still controversy on the indication and selection of decompression procedures. This research aims to investigate the clinical indications, outcomes, and complications of the decompression procedures as alternative treatments for Chiari I malformation, based on the different CSF flow patterns at the cranial-vertebral junction. In this study, 126 Chiari I malformation patients treated with the two decompression procedures were analyzed. According to the preoperative findings obtained by using cine phase-contrast MRI (cine PC-MRI), the abnormal CSF flow dynamics at the CVJ in Chiari I malformation was classified into three patterns. After a preoperative evaluation and an intraoperative ultrasound after craniectomy, the two procedures were alternatively selected to treat the Chiari I malformation. The indication and selection of the two surgical procedures, as well as their outcomes and complications, are reported in detail in this work. Forty-eight patients underwent subdural decompression (SDD), and 78 received subarachnoid manipulation (SAM). Ninety patients were diagnosed as having Chiari I malformation with a syrinx. Two weeks after the operation, the modified Japanese Orthopedic Association (mJOA) scores increased from the preoperative value of 10.67 ± 1.61 to 12.74 ± 2.01 (P < 0.01). The mean duration of follow-up was 24.8 months; the mJOA scores increased from the postoperative value of 12.74 ± 2.01 to 12.79 ± 1.91 at the end of follow-up (P = 0.48). More complications occurred in the patients who underwent SAM than in those who received SDD (SAM 11 of 78 (9.5%) vs SDD 2 of 48 (3.5%)). The abnormal CSF flow dynamics at the CVJ in Chiari I malformation can be classified into three patterns. A SAM procedure is more feasible in Chiari I malformation (CM1) patients with pattern III CSF flow dynamics, whereas a SDD procedure is more suitable for CM1 patients with pattern I CSF flow dynamics. In CM1 patients with pattern II CSF flow dynamics, an intraoperative ultrasound after craniectomy could play an important role in the selection of an effective decompression procedure.

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Abbreviations

CM1:

Chiari I malformation

CSF:

Cerebrospinal fluid

Cine PC-MRI:

Cine phase-contrast MRI

SPS:

Syringo-pleural shunting

mJOA:

Modified Japanese Orthopedic Association

CCOS:

Chicago Chiari Outcome Scale

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Authors and Affiliations

  1. Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China

    Tao Fan, XinGang Zhao, Cong Liang, YinQian Wang & QiFei Gai

  2. Capital Medical University, Beijing, China

    Tao Fan & HaiJun Zhao

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  1. Tao Fan
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  2. HaiJun Zhao
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  3. XinGang Zhao
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Correspondence to Tao Fan.

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Financial support

This study was funded by Construction Project of National Clinical Key Specialties of People’s Republic of China [Ministry of Health of People’s Republic of China 873(2011)] and the Capital Health Research and Development of Special 2014-2-8011. And the corresponding author Tao Fan received the support of those funding.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required. This article does not contain any studies with human participants performed by any of the authors.

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Informed consent was obtained from all individual participants included in the study.

Additional information

Tao Fan and HaiJun Zhao contributed equally to this work.

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Fan, T., Zhao, H., Zhao, X. et al. Surgical management of Chiari I malformation based on different cerebrospinal fluid flow patterns at the cranial-vertebral junction. Neurosurg Rev 40, 663–670 (2017). https://doi.org/10.1007/s10143-017-0824-1

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  • DOI: https://doi.org/10.1007/s10143-017-0824-1

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