Chiari Bridges

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  • Brain Under Pressure – Understanding Intracranial Hypertension [Archived]

    Brain Under Pressure – Understanding Intracranial Hypertension [Archived]

    INTRACRANIAL HYPERTENSION (IH) AND IDIOPATHIC INTRACRANIAL HYPERTENSION (IIH) ARE CONNECTED, BUT ARE NOT THE SAME THING AND THEREFORE SHOULD NOT BE USED INTERCHANGEABLY.

    Intracranial Hypertension (IH) means high pressure inside the skull. Intracranial Pressure (ICP) is measured in millimeters of mercury (mmHg). Most scholars agree that on average, “normal pressure” should be between 5-15 mmHg and that 20-25 mmHg is when the ICP crosses the line into being IH. Pressure can be brought on by several different means: space-occupying masses such as hydrocephalus and cranial cysts/tumors; cranial edema (Encephalitis); trauma; stroke; aneurysm; certain infections/diseases (Meningitis), liver failure[1], kidney failure[2]; or as a side-effect of certain medications (such as: Tetracycline[3][5], Sulfasalazine[4], Lithium[5], excess amounts of Vitamin A, steroid use[6], growth hormone treatments[6], and the hormonal Intrauterine Device (IUD), “Mirena”[7]); however, sometimes the cause of the pressure is completely unknown. When an etiological cofactor exists, it is considered Secondary Intracranial Hypertension (SIH); when no other cause is identified, it is known as Idiopathic Intracranial Hypertension (IIH) or Primary Intracranial Hypertension (PIH).

    “Idiopathic Intracranial Hypertension (IIH) was first noticed in 1893, by the German physician Heinrich Quincke, who named it Serous Meningitis. As its absence of space occupying masses/lesions began to draw more thought, it was renamed Pseudotumor Cerebri (PTC) by Max Nonne in 1904. Sometime later, the term “Benign Intracranial Hypertension” began being used interchangeably with Pseudotumor Cerebri, to describe the fact that while it is sharing some of the same characteristics that a cranial tumor would cause, it is benign (not harmful), but arguments were made against it in that blindness is not indicative of being benign.”[6] The name finally settled as “Idiopathic Intracranial Hypertension,” which means IH of an unknown cause. No matter what you choose to call it, the pain and damage remains the same for those who have it.

     

    UNDERSTANDING IDIOPATHIC INTRACRANIAL HYPERTENSION
    IIH is a neurological disorder where the cerebrospinal fluid within the skull is elevated, without the presence of a space-occupying mass, edema (brought on by things such as trauma, infection, or disease), or any adverse reactions to certain medications. Studies show that IIH is more common amongst women between the ages of 20 and 50,[8] and there is a slight increase amongst those that are overweight. Some studies also suggest a connection between obstructive sleep apnea and transverse cerebral venous sinus stenosis.[9] Amongst the general population, IIH is believed to exist in 1/100,000 (0.00001). Amongst those that are 10% above their ideal body weight, the numbers increase to 13/100,000 (0.00013), and rising to 19/100,000 (0.00019) in those 20% above their ideal body weight.[10] Although doctors often tend to pass this off as merely a side effect of weight gain, the increase is slim and seems to decrease as the percentage of weight gain above ideal weight continues to rise above the 10% margin. Additionally, the weight factor excludes men and children under the age of 10, which may simply be because women are more likely than men to have comorbid conditions that would lead to Intracranial Hypertension. Studies show that the women to men ratio for Chiari Malformation is believed to be 3:1 and those with both Chiari Malformation and Ehlers-Danlos Syndromes 9:1[11]). However weight is not irrelevant with IIH, the overweight/obese patient population report finding improvement of some symptoms when weight loss of 5-10% of one’s overall body weight, when accompanied by a low-salt diet[12]. 

     

    UNDERSTANDING THE IH/IIH CONNECTION: THE MONRO-KELLIE DOCTRINE
    The association between IH/IIH and Chiari Malformation, appears to be a malicious intricate pathological circle. The cranium (skull) consists of brain matter, cerebrospinal fluid, and both venous and arterial blood. A hypothesis, referred to as the Monro-Kellie Hypothesis (or Monro-Kellie Doctrine), states, “The sum of volumes of brain, CSF, and intracranial blood is constant. An increase in one should cause a decrease in one or both of the remaining two.”[13] Therefore, if there is an abundance of cerebrospinal fluid (IIH or hydrocephalus), both cranial blood volume and brain matter should be forced to deplete. This depletion is usually directed in the path of least resistance – through the foramen magnum and into the spinal canal. When the cranial brain matter closest to the bottom of the skull (cerebellar tonsils) goes through the foramen magnum and into the spinal canal (an Acquired Chiari Malformation), it blocks the flow of cerebrospinal fluid, which in turn, continues to raise intracranial pressure.

     

    SYMPTOMS OF INTRACRANIAL HYPERTENSION
    Intracranial Hypertension (IH) can be either acute or chronic and comes with a variety of symptoms, many of which can help distinguish IH pain from typical pain associated with Chiari Malformation. A typical Chiari headache originates at the back of the skull (at the occiput), but IH headaches are usually described as pressure at the top of the head, that radiates downward. Headaches tend to be worse when laying down (which is opposite of low pressure headaches that are often relieved by laying down). Those that suffer from IH, often report waking up from sleep with a bad headache, and often a slight incline can help alleviate the headache pain. Pulsatile Tinnitus occurs when you hear a ringing in your ears that coincides with your heart beat. The tale-tell symptom of IH involves the damage done to the optical nerves.  Papilledema is when the optic discs swell in response to the increased cranial pressure.[14] Symptoms of Papilledema include: headaches behind the eyes, blurred vision, fleeting vision, dimmed vision, double vision, visual obscurations, decreased peripheral vision, and photopsia. Another source of IH damage is seen in the pituitary gland and is known as Empty Sella Syndrome (ESS). As the high intracranial pressure (ICP) tries to take over, cerebrospinal fluid finds its way to the sella turcica and starts filling it with spinal fluid (partially or completely)[15]. The intruding CSF attempts to envelope this depression in the sphenoid bone, and squeezes the pituitary gland, flattening it until it appears “empty.” While some initially suffer no symptoms of the damage done to the pituitary gland, most eventually develop a variety of hormonal issues, known as hypopituitarism.

     

    DIAGNOSIS CRITERIA
    Diagnosis of Intracranial Hypertension usually begins with investigating either the headaches or the vision problems. The least invasive test is having a neuro-ophthalmologist check behind your eyes for Papilledema. It is not considered conclusive in testing for IH, but it is essential in determining the extent of the damage to the optical nerves. Magnetic Resonance Imaging (MRI) of the brain can be useful in showing signs of Intracranial Hypertension. In cases where one or more space-occupying masses exists, further imaging and often biopsy may be required. The type of mass, its exact location, and the amount of damage that it is believed to be doing, will be used to determine the best treatment. If imaging gives an indication that the intracranial pressure is high, but no space-occupying mass exists, additional testing is usually necessary to confirm, some of which can be potentially be dangerous for those with Heritable Disorders of Connective Tissue (HDCT), such as Ehlers-Danlos Syndromes (EDS). Lumbar punctures (LP), also known as a spinal tap, are often used to test the opening CSF pressure, but by puncturing the dura (which is thinner than normal with Connective Tissue Disorders), the risk of a CSF leak is high. When an LP causes a CSF leak, the first indication is usually a post-dural-puncture headache (PLPH) and eventually, the intracranial hypertension will decrease, as the leak causes intracranial hypotension.[16] CSF leaks can escalate very quickly and can be difficult to identify and treat; therefore, we recommend that LPs be done only when absolutely necessary, and that they be done only under fluoroscopy, by qualified surgeons that fully understand the likelihood of Connective Tissue Disorders, the symptoms of leaks, and have a plan of action should those symptoms occur. Sometimes, ICP can fluctuate and have high spikes that cause problems, rendering LPs useless unless they are done at the precise time. When these spikes are suspected ICP monitoring bolts might be the better option, but still poses a risk of leaks.[17] 

     

    TRANSVERSE SINUS STENOSIS (TSS)

    Transverse sinus stenosis (TSS) occurs when there is a narrowing of the transverse sinus (dural venous sinus), which in turn can compromise cerebral venous outflow. TSS is common in idiopathic intracranial hypertension (IIH). Depending on the study that you are reading, it is proving to be present in 65-100% of those diagnosed specifically with IIH. Its direct connection seems relatively obscure, and there is no indication of its prevalence in intracranial hypertension (IH), but it is worth looking for and treating if found. While scholars remain undecided as to whether TSS is a cause or consequence of IH, if it does prove to be a cause of high pressure, IIH will likely no longer have an idiopathic element to it and it will become another etiology of Intracranial Hypertension. TSS can often be undetectable with standard Magnetic Resonance Imaging (MRI). The correct procedure would be Magnetic Resonance Venography (MRV, with the ATECO technique [18]), specifically looking for signs of stenosis, to include looking for fistula(s) and aneurysm(s). The lack of a fistula or aneurysms however, does not exclude the possibility of a TSS existing (remember it’s being found in 65-100% of those with IIH). Even with MRV, TSS can often be misinterpreted as “flow-related artifacts.” [18] Because the prevalence of TSS in IIH patients is high (some studies call it “universal”) [19], we recommend that all IIH patients have a MRV with the ATECO technique done before surgical treatment and that venous stenting be considered as a viable surgical treatment.

     

    TREATMENT OPTIONS
    Treatments for Idiopathic Intracranial Hypertension usually starts with weight loss and/or medicinal options; Diamox (Acetazolamide) and Topamax (Topiramate) are most frequently prescribed. Those with IH/IIH should avoid consuming caffeine, as it can increase pressure and therefore is counter-productive to treatment measures. Diamox is a carbonic anhydrase inhibitor and Topamax can also inhibit carbonic anhydrase, but is an anticonvulsant, often prescribed for the treatment of neuropathy and seizure disorders. Both are believed to successfully lower the production of cerebrospinal fluid. Topamax can also help suppress the appetite, which can help with weight loss, but it also comes with many side-effects like all nerve meds do. When medication fails to decrease ICP, a Ventriculoperitoneal Shunt (VP Shunt) or Ventriculoatrial Shunt (VA Shunt) are surgically placed to drain cerebrospinal fluid straight from the ventricle. Shunts are known for failing and often need a multitude of revisions. Venous stenting is not a new procedure, yet it is not readily offered. While there are studies indicating that the successful reduction of intracranial pressure can help with TSS. Stenting is not only a surgical treatment for the stenosis (which could significantly reduce the possibility of a life-threatening aneurysm in patients with a connective tissue disorder), but it is also a surgical treatment for intracranial hypertension as it “improves CSF resorption in the venous system.” [18] Therefore, it seems illogical to shunt (just dealing with the pressure) and leave such a potentially life-threatening condition untreated. [20] Studies are indicating as high as a 94% of patients being cured of all IIH symptoms as a direct result of venous stenting. [18] While all surgeries pose a risk of complications, and the statistics for stenting are likely inflated and skewed (like that of decompression surgeries), these statistics on stenting are definitely encouraging!

    Intracranial Hypertension is a complex issue that should be explored whenever a Chiari Malformation exists, before a decompression surgery is performed. When both Intracranial Hypertension and Chiari Malformation are found to co-exist, the treatment should be in consideration of the correlation of the two, as they both are pathological co-factors of one another. Failure to recognize and treat Intracranial Hypertension before or soon after decompression surgery, will increase the likelihood of a failed decompression. While a decompression surgery can lower Intracranial Hypertension, as cerebrospinal fluid is once again allowed to flow, if space-occupying masses or a case of Idiopathic Intracranial Hypertension (where too much cerebrospinal fluid is being created) are left untreated, those problems will still exist after decompression surgery and the high pressure is likely to cause the cerebellar tonsils to fall once again.

    *Revised October 2018

     

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    References:

    1 Jalan, R. “Intracranial Hypertension in Acute Liver Failure: Pathophysiological Basis of Rational Management.” Seminars in Liver Disease., U.S. National Library of Medicine, Aug. 2003, <www.ncbi.nlm.nih.gov/pubmed/14523680>.

    2 Chang, D, et al. “Benign Intracranial Hypertension and Chronic Renal Failure.” Cleveland Clinic Journal of Medicine., U.S. National Library of Medicine, <www.ncbi.nlm.nih.gov/pubmed/1525975>.

    3 Holst, Anders Vedel, et al. “A Severe Case of Tetracycline-Induced Intracranial Hypertension.”Dermatology Reports, PAGEPress Publications, 31 Jan. 2011, <www.ncbi.nlm.nih.gov/pmc/articles/PMC4211491/>.

    4 Sevgi, E, et al. “Drug Induced Intracranial Hypertension Associated with Sulphasalazine Treatment.” Headache., U.S. National Library of Medicine, Feb. 2008, <www.ncbi.nlm.nih.gov/pubmed/18070060>.

    5 Kelly, S J, et al. “Pseudotumor Cerebri Associated with Lithium Use in an 11-Year-Old Boy.”Journal of AAPOS : the Official Publication of the American Association for Pediatric Ophthalmology and Strabismus., U.S. National Library of Medicine, Apr. 2009, <www.ncbi.nlm.nih.gov/pubmed/19393521>.

    6 Aylward, Shawn C. “Intracranial Hypertension: Is It Primary, Secondary, or Idiopathic?”Journal of Neurosciences in Rural Practice, Medknow Publications & Media Pvt Ltd, 2014, <www.ncbi.nlm.nih.gov/pmc/articles/PMC4173226/>.

    7 Etminan, Mahyar, et al. “Risk of Intracranial Hypertension with Intrauterine Levonorgestrel.”Therapeutic Advances in Drug Safety, SAGE Publications, June 2015, <www.ncbi.nlm.nih.gov/pmc/articles/PMC4519742/>.

    8  “Pseudotumor Cerebri Information Page.” National Institute of Neurological Disorders and Stroke, U.S. Department of Health and Human Services, <www.ninds.nih.gov/Disorders/All-Disorders/Pseudotumor-Cerebri-Information-Page>.

    9 Thurtell, Matthew J., et al. “An Update on Idiopathic Intracranial Hypertension.” Reviews in Neurological Diseases, U.S. National Library of Medicine, 2010, <www.ncbi.nlm.nih.gov/pmc/articles/PMC3674489/>.

    10 Wani, Irfan Yousuf, et al. “Complete Ophthalmoplegia: A Rare Presentation of Idiopathic Intracranial Hypertension.” Annals of Indian Academy of Neurology, Medknow Publications & Media Pvt Ltd, 2015, <www.ncbi.nlm.nih.gov/pmc/articles/PMC4683894/>.

    11 Henderson, Fraser C., et al. “Neurological and Spinal Manifestations of the Ehlers–Danlos Syndromes.” American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 21 Feb. 2017, <www.onlinelibrary.wiley.com/doi/10.1002/ajmg.c.31549/full>.

    12 Thurtell, Matthew J., and Michael Wall. “Idiopathic Intracranial Hypertension (Pseudotumor Cerebri): Recognition, Treatment, and Ongoing Management.” Current Treatment Options in Neurology, U.S. National Library of Medicine, Feb. 2013,<www.ncbi.nlm.nih.gov/pmc/articles/PMC3554852/>.

    13 Mokri, B. “The Monro-Kellie Hypothesis: Applications in CSF Volume Depletion.” Neurology., U.S. National Library of Medicine, 26 June 2001, <www.ncbi.nlm.nih.gov/pubmed/11425944>.

    14 Schirmer, Clemens M, and Thomas R Hedges. “Mechanisms of Visual Loss in Papilledema.”Journal of Neurosurgery, <www.thejns.org/doi/full/10.3171/FOC-07/11/E5>.

    15 “Empty Sella Syndrome Information Page.” National Institute of Neurological Disorders and Stroke, U.S. Department of Health and Human Services, <www.ninds.nih.gov/Disorders/All-Disorders/Empty-Sella-Syndrome-Information-Page>.

    16 Panikkath, Ragesh, et al. “Intracranial Hypertension and Intracranial Hypotension Causing Headache in the Same Patient.” Proceedings (Baylor University. Medical Center), Baylor Health Care System, July 2014, <www.ncbi.nlm.nih.gov/pmc/articles/PMC4059569/>.

    17 Abraham, Mary, and Vasudha Singhal. “Intracranial Pressure Monitoring.” Journal of Neuroanaesthesiology,  <www.jnaccjournal.org/article.asp?issn=2348-0548;year=2015;volume=2;issue=3;spage=193;epage=203;aulast=Abraham>.

    18 Ahmed, Wilkinson, et al. “Transverse Sinus Stenting for Idiopathic Intracranial Hypertension: A Review of 52 Patients and of Model Prediction.” American Society of Neuroradiology, July 2011. <www.ajnr.org/content/32/8/1408.long>.

    19 Riggeal, Bruce, et al. “Clinical course of idiopathic intracranial hypertension with transverse sinus stenosis.” American Academy of Neurology, 2012. <www.ncbi.nlm.nih.gov/pmc/articles/PMC3589184/>.

    20 Patel, et al. “Evaluating and treating venous outflow stenoses is necessary for the successful open surgical treatment of arteriovenous fistula aneurysms.” Society for Clinical Vascular Surgery, Volume 61, Issue 2. February 2015. <www.sciencedirect.com/science/article/pii/S0741521414014116>.

     

     

  • Overview: Chiari Malformation [Revised]

    Overview: Chiari Malformation [Revised]

    CHIARI MALFORMATIONS (PRONOUNCED: KEE-AH-REE) ARE STRUCTURAL DEFECTS IN WHICH THE CEREBELLUM, THE HIND PART OF THE BRAIN, DESCENDS BELOW THE FORAMEN MAGNUM INTO THE SPINAL CANAL.

    While Arnold Chiari Malformation (Type 2) was first identified in the late 19th century by the Austrian pathologist Hans Chiari, much of the current medical knowledge has developed since 1985 with the expanded use of Magnetic Resonance Imaging (MRI). The number of patients diagnosed with Chiari malformations continues to increase, and with that increase Chiari Malformation is getting some of the attention the condition has always demanded.

    Chiari malformations (“CMs”) are neurological disorders in which the cerebellum extends out of the skull and into the spinal canal, which in turn blocks the flow of cerebrospinal fluid, puts pressure on the brainstem and spine, and may result in varying degrees of nerve compression. Once thought to occur in 1 in 1000 people, it is now believed to be much more frequent of an occurrence. A 2016 pediatric study found it to occur in 1 in 100 children[1]. However, since the most common type (Type 1) tends to become symptomatic during late teens and early adulthood, it is likely to be much more common when adults are factored in. Females are more likely than males to have a Chiari Malformation (at a ratio of 3:1), and significantly higher amongst those with both Chiari Malformation and Ehlers-Danlos Syndrome (9:1)[2]. We affectionately refer to those that live with this condition, including the attendant pain and frequent disregard from the medical community, as Chiarians (regardless of whether they have had surgical intervention or not).

    While some Chiarians are symptomatic throughout their lifetime, the vast majority of Chiarians (those with Type 1) develop symptoms in their late teens or early adulthood. Those symptoms can range from mild to crippling, and can become severe enough to cause paralysis (often associated with syringomyelia) or death.


    WHAT CAUSES A CHIARI MALFORMATION?

    Multiple factors have been identified which can either cause or attribute to Chiari malformations. Although they too were once thought to be rare, Acquired Chiari malformations are now being diagnosed in increasing numbers. A brief overview of what each of these labels entail, together with a summary of the different types of CM’s, is provided below:

    • Congenital Chiari, is believed to be caused by a posterior cranial fossa hypoplasia (PCFH)[3], which can also be caused by a connective tissue disorder such as Ehlers-Danlos.[4] While the cerebellum continued to grow in utero, the posterior skull failed to grow proportionately. Problems resulting from this size discrepancy continue and eventually the overcrowding of the hindbrain squeezes the cerebral tonsils downward into the opening of the spinal canal (cranial constriction). While the herniation of the cerebellar tonsil(s) can take place during gestation or after birth, because the cause is 100% congenital, and the process most likely began in utero, it is usually considered a Congenital Chiari Malformation when the only pathology found is a small posterior cranial fossa. In one large study, they found those with a Chiari Malformation and no associated etiological/pathological co-factors, with only slightly over 52% having a small PCF. When other co-factors were present, the number of Chiarians found with a small PCF plummeted, and therefore it should be considered acquired until proven otherwise.[5]

    • Acquired Chiari can have one or more possible pathological co-factors; any of which can result in the descent of the cerebellar tonsils. Many Chiarians often mistakenly conceptualize an Acquired Chiari Malformation as being brought on only by trauma; however, “acquired” is an antonym for “congenital,” so an Acquired Chiari Malformation in medical terms is one that a person was not born with. While this can include Acquired Chiari malformations resulting from trauma, it can also include Acquired Chiari malformations resulting from a variety of other medical conditions:
      • Heritable Disorders of Connective Tissue (HDCTs), most commonly Ehlers-Danlos Syndromes (EDS), make the tonsils more prone to prolapse below the foramen magnum.
      • Multiple conditions are known to create a pushing/pulling effect that can result in a tonsillar herniation. These conditions include: Intracranial Hypertension (IH), Atlantoaxial Instability and Craniocervical Instability (AAI/CCI), Tethered Cord Syndrome (TCS), and Intracranial Hypotension (cerebrospinal fluid leaks), Hydrocephalus, and a variety of cysts and brain tumors.[2]

      Special care should be taken when any of these co-morbid conditions exist in conjunction with a Chiari Malformation. Before the consideration of decompression surgery, a plan should be developed which addresses each possible comorbid condition before decompression. This can reduce the likelihood of complications and/or a failed decompression surgery.

    SEVEN TYPES OF CHIARI MALFORMATIONS WORTH DISCUSSING (asterisks “*” indicate commonly known types)

    Chiari Zero:  The lower part of the cerebellum (the cerebral tonsils) are blocking the foramen magnum, but are not descended through. Because of the cerebellum’s position, it blocks the flow of cerebrospinal fluid and all the effects of that blockage are comparable to Type 1.

    Diagnosis Requirements: Symptomology; MRI showing no herniation but the low-lying tonsils that are pressing against the top of the foramen magnum; MRI showing a syrinx (despite the name, Chiari Zero is classified under Syringomyelia and not Chiari Malformation – so a syrinx is technically required for diagnoses). [6][7]

    Treatment Options: With few symptoms, non-surgical treatments might be recommended. When a syrinx is present, a decompression is often recommended before the syrinx has a chance to further develop and cause additional damage to the spine. However, even when a syrinx is present, all pathological cofactors should be explored and addressed prior to decompression surgery.

    Chiari 0.5: In cases of Chiari 0.5, the lower part of the cerebellum (the cerebral tonsils) are descended through the foramen magnum, but descends < 5mm (which is the measurement that some doctors use to define Chiari). Usually labeled “tonsillar ectopia” on radiology reports, the symptoms and effects of the obstruction are generally the same as those experienced with Type 1 or Chiari 1.5.[3]

    Diagnosis Requirements: Symptomology; MRI showing a herniation of < 5mm, unless already properly diagnosed with a Type 1 or Chiari 1.5; presence of a syrinx is not “required” for diagnosis, but as with Chiari Zero, it illustrates that it is causing a problem obstructing the flow of cerebrospinal fluid and may be relevant when deciding between various courses of treatment.

    Treatment Options: The same as Type 1 or Chiari 1.5, respectively.

    *Chiari Malformation Type 1: The most common type of Chiari Malformation, Type 1 is diagnosed when the cerebral tonsils descend below the foramen magnum. Medical professionals unfamiliar with current research surrounding Chiari Zero and Chiari 0.5 (and the symptomology surrounding the blockage of cerebrospinal fluid), believe that a tonsillar herniation of less than 5mm is simply a tonsillar ectopia and only diagnose a Chiari Malformation when the descent is > 5mm. However, the 5mm requirement is controversial, and many doctors now base their diagnoses not solely on measurements, but rather on symptomology and a combination of other factors, including cine MRI’s, a patient’s symptoms, and other relevant factors.[6] Many people with a Chiari Zero, Chiari 0.5, or Type 1 can be asymptomatic for a lifetime: one large study found that approximately 30% of those with a CM measuring between 5-10mm were asymptomatic.[8] If symptoms develop, they often present in adolescence or early adulthood. Anecdotal evidence supports the proposition that once symptoms start, the symptoms often progress rapidly until the damage is stopped surgically.

    Diagnosis Requirements: Symptomology; MRI indicating at least one herniated tonsil (without the brainstem descending as well).[9]

    Treatment Options: Prior to surgery any/all comorbidities should be explored and treated especially if you are found to have a normal sized posterior fossa. However, if you have classic Chiari 1 Malformation with a small posterior fossa, the risks of surgery should be weighed against the severity of symptoms and the impact that symptoms are having on the patient’s quality of life. It is often recommended to treat mild symptoms with medication, with surgical options typically reserved for cases in which symptoms cause more serious medical and quality of life problems. However, symptoms do tend to progress, and studies have shown a correlation between successful decompression surgery and the amount of time between the onset of any symptoms and surgical intervention[10]. See “Decompression Surgery” below.

    Chiari 1.5: This type of CM (often referred to as a “Complex Chiari”) is often acquired as opposed to congenital.  Chiari 1.5 should be the diagnosis when the tonsil(s) and all/part of the lower brainstem (the medulla oblongata) has descended past the foramen magnum. This is usually indicative of another comorbid condition pushing the brainstem downward from above or pulling downward from below.[5][11][12]

    Diagnosis Requirements: symptomology; MRI indicating at least one herniated tonsil AND a downward displacement of all/part of the brainstem; without the other radiological findings associated with Type 2.

    Treatment Options: Treatment options can vary significantly from patient to patient depending on the cause of the Chiari 1.5. While a variety of medical options might initially be used to treat symptoms, it is extremely important that all possible causes and/or comorbidities are thoroughly investigated and treated prior to the consideration of decompression surgery. Failure to identify and treat any such conditions can increase the likelihood of a failed decompression and further complications such as brain slumping, increased cervical instability, etc.

    *Chiari Malformation Type 2 (also known as Arnold Chiari Malformation): Type 2 involves a herniation of the cerebellar tonsils and lower part of the brainstem (the medulla oblongata). Unlike in Chiari 1.5, in Type 2 the fourth ventricle is usually herniated, all/part of the cerebellar vermis (the tissue connecting both halves of the cerebellum) is missing or herniated, the corpus callosum (nerve fibers connecting both hemispheres of the brain) is fully/partially absent (agenesis), and it is almost always accompanied by a myelomeningocele (the most serious form of Spina Bifida, a congenital neural tube defect where the spinal canal does not close properly).[13][14][15]

    Diagnosis Requirements: While a myelomeningocele is usually evident and diagnosed at birth, a brain MRI should confirm the radiological aspects of Type 2.

    Treatment Options: Myelomeningocele is usually treated surgically at birth. If other related problems develop, such as hydrocephalus and/or tethered cord, they are often dealt with surgically as they become problematic. While some with Type 2 are decompressed, anecdotal evidence reflects a general trend of an increased failure rate with decompression surgeries as compared to those with Type 1. Because of this, some neurosurgeons choose not to decompress those with Type 2.

    *Chiari Malformation Type 3: Type 3 is a serious type of Chiari Malformation involving herniated cerebellar tonsils, brainstem, and fourth ventricle. However, in most cases of Type 3, a sac forms out of the back of the skull (encephalocele) that contains brain matter from the cerebellum and the meninges. Type 3 causes severe neurological problems that are evident at birth and has a high infant mortality rate.[16][17]

     *Chiari Malformation Type 4: Type 4 is the most severe type of Chiari Malformation, but does not involve a hindbrain herniation (and therefore arguments have been made that it is not a Chiari Malformation). Instead, it consists of an undeveloped or underdeveloped cerebellum. Most infants born with Type 4 die in infancy.[16][17]


    S    URGICAL INTERVENTION 

    Decompression surgery is currently the only available means of attempting to stop the progression of symptoms of a congenital chiari (with no other pathological cofactors), but decompression is not a cure (not even close). Statistics show that up to 69% of decompressed patients find some measure of relief from surgery (usually headaches)[18]. Most neurosurgeons will give only a 50% chance of helping each individual symptom. Some of the symptoms are irreversible once they develop. Recent studies show that there is a correlation between early surgical intervention and positive post-surgical outcomes.[19] However, we cannot over emphasize the importance of your doctors taking time to find, diagnose, and treat co-morbid conditions BEFORE decompression surgery. If they are not willing to consider comorbidities, they are probably not the doctor for you!

     

     

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    *Original version released January 2018, revised October 2018.

     

    References:

    1     Eltorai, Ibrahim M. “Rare Diseases and Syndromes of the Spinal Cord” Cham: Springer International Publishing: Imprint: Springer, 2016. Page 43, 15.2, <www.springer.com/us/book/9783319451466>.

    2 Henderson, Fraser C., et al. “Neurological and Spinal Manifestations of the Ehlers–Danlos Syndromes.” American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 21 Feb. 2017, <www.onlinelibrary.wiley.com/doi/10.1002/ajmg.c.31549/full>.

    3 Sekula, Raymond F, et al. “Dimensions of the Posterior Fossa in Patients Symptomatic for Chiari I Malformation but without Cerebellar Tonsillar Descent.” Cerebrospinal Fluid Research, BioMed Central, 2005, <www.ncbi.nlm.nih.gov/pmc/articles/PMC1343586>.

    4 Stagi, Stefano, et al. “The Ever-Expanding Conundrum of Primary Osteoporosis: Aetiopathogenesis, Diagnosis, and Treatment.” Italian Journal of Pediatrics, BioMed Central, 2014, <www.ncbi.nlm.nih.gov/pmc/articles/PMC4064514>.

    5 Milhorat, Thomas H., et al. “Mechanisms of Cerebellar Tonsil Herniation in Patients with Chiari Malformations as Guide to Clinical Management.” Acta Neurochirurgica, Springer Vienna, July 2010, <www.ncbi.nlm.nih.gov/pmc/articles/PMC2887504>.

    6 Isik, N, et al. “A New Entity: Chiari Zero Malformation and Its Surgical Method.” Turkish Neurosurgery., U.S. National Library of Medicine, <www.ncbi.nlm.nih.gov/pubmed/21534216>.

    7 “JNS JOURNAL OF Neurosurgery OFFICIAL JOURNALS OF THE AANS since 1944.” The Resolution of Syringohydromyelia without Hindbrain Herniation after Posterior Fossa Decompression | Journal of Neurosurgery, Vol 89, No 2, <www.thejns.org/doi/abs/10.3171/jns.1998.89.2.0212?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed>.

    8 Elster, A D, and M Y Chen. “Chiari I Malformations: Clinical and Radiologic Reappraisal.”Radiology., U.S. National Library of Medicine, May 1992, <www.ncbi.nlm.nih.gov/pubmed/1561334>.

    9 Wilson, Eugene. “Chiari.” CEDSA Home, <www.cedsa.org/index.php/59-quick-reference/73-chiari.html>.

    10 Hindawi. “Surgical Management of Patients with Chiari I Malformation.” International Journal of Pediatrics, Hindawi, 28 June 2012, <www.hindawi.com/journals/ijpedi/2012/640127>.

    11 Kim, In-Kyeong, et al. “Chiari 1.5 Malformation : An Advanced Form of Chiari I Malformation.”Journal of Korean Neurosurgical Society, The Korean Neurosurgical Society, Oct. 2010, <www.ncbi.nlm.nih.gov/pmc/articles/PMC2982921>.

    12 Malik, Amita, et al. Chiari 1.5: A Lesser Known Entity. Annals of Indian Academy of Neurology, <www.annalsofian.org/article.asp?issn=0972-2327;year=2015;volume=18;issue=4;spage=449;epage=450;aulast=Malik>.

    13 Wolpert, Samuel M, et al. “Chiari II Malformation: MR Imaging.” American Journal of Roentgenology, <www.ajronline.org/doi/pdf/10.2214/ajr.149.5.1033>.

    14 Yumer, M H, et al. “Chiari Type II Malformation: a Case Report and Review of Literature.”Folia Medica., U.S. National Library of Medicine, <www.ncbi.nlm.nih.gov/pubmed/16918056>.

    15 Kim, Irene. “Chiari II Decompression in Patients with Myelomeningocele in the National Spina Bifida Patient Registry (NSBPR).” <http://spinabifidaassociation.org/sbworldcongress/wp-content/uploads/sites/10/2017/04/B.4-Kim-Neurosurgery.pdf>.

    16 “Chiari Malformation Fact Sheet.” National Institute of Neurological Disorders and Stroke, U.S. Department of Health and Human Services, <www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Chiari-Malformation-Fact-Sheet>.

    17 “Chiari Malformations.” NORD (National Organization for Rare Disorders), <www.rarediseases.org/rare-diseases/chiari-malformations>.

    18 14 Aliaga, L, et al. “A Novel Scoring System for Assessing Chiari Malformation Type I Treatment Outcomes.” Neurosurgery., U.S. National Library of Medicine, Mar. 2012, <www.ncbi.nlm.nih.gov/pubmed/21849925>.

    19  Siasios, John, et al. “Surgical Management of Patients with Chiari I Malformation” International Journal of Pediatrics, Article ID 640127, Hindawi, 2012, <www.hindawi.com/journals/ijpedi/2012/640127>.

  • A Bruised Mind – Chiari & Depression

    A Bruised Mind – Chiari & Depression

    Depression is more than simply “feeling sad.” It is a deep dark tunnel of despair that seems to have no end. It manifests as a cohort of symptoms, seeking to wreak havoc in every facet of your life. The activities that you once found enjoyable seem to take more energy than it promises to be worth. Your energy levels plummet, often resembling that of a slug crawling through peanut butter. Insomnia, restlessness, changes in appetite, and memory loss are often present. Mood swings that change without permission, rational and irrational guilt, endless chronic pain, and suppressed emotions (“I’m fine, really.”), create an enormous obstacle that seems impossible to overcome. The chronic illness, loss of identity, and indifferent medical community make treatment challenging. The depression Chiarians feel can be overwhelming and isolating.

    Chronic pain is something Chiarians face on a daily basis. Disabling pain that reduces your quality of life can make once simple tasks difficult to accomplish. Things like taking a shower or cooking become incredibly challenging. Fatigue can set in quickly, that even when we have plans that we’re excited about, just getting ready for them can be enough to put us back in bed. All of this can give us an altered self-perception of feeling useless, which enhances the depression. Chronic pain is both a physical and psychological condition, thus making treatment complex and difficult. Pain can cause depression and depression causes pain; it’s a vicious cycle.[1]

    Beyond the pain aspect, damage to one’s cerebellum is known to have cognitive consequences as well, and that includes emotions. While much of the research is based on the cognitive effects of decompression surgery,[2] many Chiarians have reported a noticeable cognitive decline years before surgery. In some cases, they complained of cognitive issues even before their Chiari diagnosis. One study pinpoints a “reciprocal connection between the cerebellum and hypothalamus” that govern “intellect, emotion, autonomic function, and sensorimotor control.” Another article on Secondary ADHD (Attention Deficit and Hyperactivity Disorder) speaks of the cerebellum and its known connection to ADHD, and even though the cerebellum is almost exclusively thought of in terms of its motor control, “it is the most consistently implicated and also the most robustly abnormal structure in the pathophysiology of ADHD.”[3] The article attributes it to the fact that, the cerebellum is “second in size to only the cerebral cortex, contains more neurons than the rest of the brain combined, and is massively connected to the cerebral cortex.” Among Chiarians, we have long-known that we all suffer from memory issues (both long and short term), anomic aphasia (repeated trouble remembering words), and various other cognitive struggles, and it’s important to remember that all of our thoughts, including those that are depressive in nature, stem from our brains (even our cerebellum).

    Adjusting to the new normal is always a challenge, not only for us, but the ones we love as well. The loss of our former selves and our careers is very hard. Maybe you were a full-time parent or provider, caring for your family and you find yourself the one being cared for by loved ones. You find yourself depending on family and friends to do for you things that you once did for yourself, making you feel like a burden on those you love most. You may experience a sense of helplessness when trying to get friends and family to understand what you are going through. There will be friends and family who cannot or will not try to understand. They will think you are lazy or seeking attention. We must mourn the loss of old selves, careers, sometimes family and friends, as others must mourn their loss of your former self, and learn to embrace the new you in your new normal.

    The struggle to have the medical community work with us, rather than against us, feels like an impossible feat. The worst thing that happens to us when dealing with doctors is being told that everything is in our head (which at least isn’t 100% wrong, but not in the way they mean it). In their ignorance, our doctors often dismiss our symptoms as mere depression, being a hypochondriac, or a drug seeker. They tell you that losing weight will alleviate your problems. That may be true for some things, but no amount of weight loss is going to put your brain back into your skull and it’s hard to focus on exercise when every single step makes you feel like your neck is literally breaking. Instead of admitting that they have limited knowledge on Chiari, they attempt to make you feel stupid, inferior, and a bother to them. It’s so frustrating when those who are have taken an oath to help you and are charging you for that help, are not willing to learn about your condition. You become the educator, teaching those who are interested and willing to learn. You become your own best advocate!

    There is hope. There is a light in the tunnel. The depression may not go away completely, but it can be managed. There are things you can do to help alleviate the symptoms. Joining a support group (in person or online) to connect to those who experience the same things you do can be a tremendous source of support. Encourage family and friends to join support groups to get a better understanding of your condition and to join groups for caregivers so that they have somewhere they can connect with people that are going through the same fears and frustrations that they’re going through (because the Chiari isn’t just affecting you). Get to know others that are fighting your fight, learn from them, stand with them, and maybe even volunteer to help others new in their fight!

    There will be times when your body rails against you, making it difficult to get out of the house. But try to stay as active as you can with something! Try to continue with your favorite hobbies: reading, writing, crocheting and coloring books. Keep your memory working by utilizing crossword puzzles, Sudoku, puzzles (the box kind) and card games like Solitaire. The most important thing is keep talking with people: call a friend or make new ones if you need to. Find a therapist that you like. Share about what you’re going through and show concern for what others are going through. You are worth the fight!

     

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    References:

    1 “Depression and Chronic Pain.” Self Help Center, <www.selfhelpcenter.org/pdf-publications/Depression%20and%20Chronic%20Pain.pdf>.

    2 Allen, Philip A., et al. “Task-Specific and General Cognitive Effects in Chiari Malformation Type I.” PLoS ONE, Public Library of Science, 15 Apr. 2014, <www.ncbi.nlm.nih.gov/pmc/articles/PMC3988081/>.

    3 Eme, Robert, and Erin Sheffer. “The Cerebellum and Attention Deficit Hyperactivity Disorder A Case Study of a Cerebellar Chiari 1 Malformation.” The Practitioner Scholar: Journal of Counseling and Professional Psychology, 2012, <www.thepractitionerscholar.com/article/view/10503/7232>.

     

  • Overview: Craniocervical Instability and Related Disorders

    Overview: Craniocervical Instability and Related Disorders

    Craniocervical Instability and related pathologies of the craniocervical junction are an important topic for anyone diagnosed with Chiari 1 malformation. “Complex Chiari,” or the presence of craniovertebral abnormalities or instability in addition to the presence of cerebellar tonsillar herniation, is present in approximately one fourth of all cases of Chiari 1 malformation[1]. These cases usually involve the presence of a genetic connective tissue disorder and are thought by experts to be the cause of most Chiari decompression failures[2]. When the doctor and patient alike are not knowledgeable about these conditions and the additional symptoms that often accompany them, these more complex cases are often treated with a standard decompression, which can actually weaken the stability of the craniocervical junction more, and result in an increase of symptoms rather than a clinical improvement. Understanding what signs and symptoms to look for that may indicate that your Chiari is more complex, is vital in receiving the appropriate treatment the first time. This is especially important considering that, according to Chiari expert Paolo Bolognese, M.D., “[with revision surgeries], the results are not as good as if you had done the posterior decompression well the first time.”[3]

    Punjabi and White define instability as the “loss of the ability of the spine under physiological loads to maintain relationships between vertebrae in such a way that there is no damage or subsequent irritation of the spinal cord, (brain stem) or nerve roots, and in addition that there is development of deformity or incapacitating pain due to structural changes.”[4] This means that the ligaments and muscles that normally hold the spine together, are too weak or damaged to handle the normal range of motion and weight of anatomic structures. For example, in Craniocervical Instability, the neck is not strong enough to support the normal weight of the head, without elements of the spine moving in such a way that it causes pain or damage to the nervous system (spinal cord, brain stem, and even cranial nerves). The result is that the bones that make up the lower skull and upper spine get pushed out of their normal anatomic location and begin to impinge on or cause stretching of these parts of the nervous system.

    Craniocervical Instability can result from or be exacerbated by a trauma, such as a severe whiplash injury. However, many cases of CCI are associated with some sort of connective tissue disorder, such as a heritable disorder of connective tissue (HDCT, like Ehlers-Danlos Syndrome or Marfan’s), or an autoimmune condition that affects the connective tissue (such as Rheumatoid Arthritis), or a few other rarer conditions that affect the integrity of bony structures in the skull and spine. Instability can result either from lax ligaments and other connective tissues, soft bones (also seen in HDCTs) or from something like pannus formation, where repeated rubbing together of the joints causes a build-up of granulated tissue around bony structures and changes the way certain bones lie in relationship to one another[5]. Craniocervical Instability can also result as a complication of Chiari decompression surgery, when too much bone is removed from the skull, resulting in the instability of the skull on the top of the spine[6].

    In the patient community, the term “CCI” is often used in reference to both Craniocervical Instability and Atlantoaxial Instability (AAI). CCI is often used to refer to the commonly seen combination of issues with the craniocervical junction, that include the instability of the joints where the skull meets the C1 vertebrae (which is true CCI), the instability of the joints between C1 and C2 (true AAI), a retroflexed odontoid, pannus formation, and a kyphotic clivo-axial angle (which are all forms of basilar impression/invagination). But CCI really should refer to the movement of the skull with respect to the spine. This sliding is referred to as “translation” and is measured on dynamic imaging in millimeters. The pathological threshold for the degree of translation of the basion with respect to the odontoid process between flexion and extension is 2mm, and any amount of translation greater than 1mm is capable of producing symptoms7. Likewise, at the C1-C2 joint, instability in the form of AAI can cause an excessive uncovering of the joint facets. Facets are the surfaces of the vertebrae that articulate with next vertebra. An uncovering of the facets that exceeds 20% is considered pathological.

    The occipito-atlantic joint allows for about half of the cervical spine’s ability to flex and extend (tilt forward and backward). Likewise, the atlantoaxial joint [the articulation between C1 (atlas) and C2 (axis)] accounts for about half of the cervical spine’s ability to rotate the head. Because of this, these vertebrae lack the same amount of stability as the remainder of the spine, and ligaments are largely responsible for their stability[8]. Therefore, ligamentous laxity, as seen in connective tissue disorders, make these areas of the spine particularly prone to pathologic instability. Symptoms of AAI may include visual changes, syncope (fainting) or near-syncopal episodes, dizziness, nausea, facial pain, difficulty swallowing, choking, respiratory issues, and upper cervical tenderness. These symptoms will usually improve with the use of a neck brace[9]. For patients with connective tissue disorders, as are seen in 12-20% of patients diagnosed with Chiari, dynamic imaging is very important in identifying potential instability. The ideal tests to diagnose CCI and AAI are an upright MRI with flexion and extension and a 3D CT with rotational views, respectively[10]. It is important to note that ventral brain stem compression may not be seen on traditional supine MR imaging, while it may be very evident on dynamic imaging.

    Basilar Invagination and Basilar Impression are also often seen with instability. They are almost identical to one another, and refer to upward displacement of the bones of the spine. However, technically, Basilar Invagination is caused by this deformation with normal bone, while Basilar Impression results from softening of bone[11]. For our purposes, this distinction is less important, but we will discuss any displacement in terms of “Basilar Invagination,” or “BI” for short. Forms of Basilar Invagination now include the prolapse of the odontoid process through the foramen magnum (the original condition described by the term), cranial settling, a kyphotic clivo-axial angle, and a retroflexed odontoid[12]. The kyphotic clivo-axial angle is an important and relatively easy measurement to indicate potential deformative stress on the brain stem. The clivus is a wedge-shaped bone that normally lies above and ventral to the top of spine. When it lies more horizontally, it creates a sharp angle that results in a bending of the brainstem. The odontoid peg (also called the odontoid process or the dens) is the part of the C2 vertebrae, or Axis, that the skull pivots upon, so named because of its tooth-like shape. A retroflexed odontoid occurs when the odontoid is bent backwards, often compressing the front of the brain stem. Other important measurements involving ventral brain stem compression for a kyphotic clivo-axial angle and/or retroflexed odontoid include the Grabb-Oakes and Harris measurements.

    • The clivoaxial angle is measured by drawing a line along the posterior (back, or when lying more horizontal, the top) side of the lower clivus and intersecting that line with a line drawn on the posterior side of the axis.  If the angle created is less than 135°, it is considered pathological.  Like instability, a kyphotic clivoaxial angle is often seen in patients with connective tissue disorders and degenerative rheumatoid disease[13].  See figure 1 below.
    Left – Clivoaxial Angle (CXA). Right – Grabb-Oakes measurement.

    For the Grabb-Oakes measurement, a line is drawn from the basion (the midpoint of the anterior margin of the foramen magnum) to the inferior posterior C2. A perpendicular line is then drawn from the center of this line to the dura of the brain stem. A Grabb-Oakes measurement greater than 9 mm denotes a form of basilar invagination. This is a very helpful measurement for determining how much a retroflexed odontoid is compressing the brain stem. See Figure 2 above.

    The Harris measurement is the distance between the basion and the Posterior Axial Line. This distance should not be more than 12 mm. A measurement of more than 12 mm also denotes instability. This measurement can also be used to measure the translation between flexion and extension in dynamic imaging[14]. See Figure 3.

    Harris measurement

    Symptoms of ventral brain stem compression can occur with various types of BI and instability. They may be referred to together as a “cervicomedullary syndrome” and may include[15]:

    • A heavy headache (often referred to as feeling like a “bobblehead” or feeling like the head is a “bowling ball”)
    • A Chiari-type pressure headache aggravated by Valsalva maneuvers (because these conditions, like Chiari, can also cause flow issues)
    • Dysautonomia (including tachycardia, heat intolerance, orthostatic intolerance, syncope (fainting), polydipsia (extreme thirst), delayed gastric emptying, chronic fatigue)
    • Neck pain (often severe)
    • Central or mixed sleep apnea
    • Facial pain or numbness – Occasionally, including Trigeminal Neuralgia
    • Balance and coordination impairment
    • Muscle weakness
    • Dizziness and vertigo
    • Vision problems, including double vision and downward nystagmus
    • Reduced gag reflex and dysphagia (difficulty swallowing)
    • Tinnitus (ringing in the ears) and hearing loss
    • Nausea and vomiting
    • Paralysis
    • In more severe cases, non-epiform seizures have also been documented

    In addition to producing significant pain and neurological symptoms, the compression and kinking of the brain stem can cause significant injury to the brain stem neurons by stretching the axons of the nerves to the point that they break and recoil, producing what are called “axon retraction bulbs” that can be seen on microscopic examination of the cells. The stress placed on the brain stem by both compressing and stretching simultaneously is much greater than the mere sum of these two mechanisms. Interestingly, during the flexion of the normal spine, it stretches 17% of its length. Research has shown that the axon of a giant squid fails when stretched to 20% if its length. Therefore, the normal motion of the human neck brings us very close to injuring our brain stem. Consequently, it only takes a slight alteration of our normal anatomy to cause injury to these delicate nervous tissues[16].

    Treatment of Craniocervical Instability typically begins with more conservative medical management, such as neck bracing, activity limitation, physical therapy (including isometrics, sagittal balance, core strengthening and cardio), and pain management. Other causes of symptoms such as co-morbid conditions, multiple sclerosis, dystrophy, mitochondrial disorders, vitamin deficiencies and Lyme disease should be ruled out or treated. However, surgical intervention via a craniocervical fusion is indicated when the following criteria are met:

    Severe headache or neck pain >7/10
    AND cervicomedullary syndrome
    AND neurological deficits referable to the craniocervical junction
    AND radiological findings indicative of instability

    Surgeons and patients alike should consider surgery after medical management has been maximized and the patient has shown a positive response to neck bracing[10].

    Various specific surgical techniques are applied in craniocervical fusions. A more common technique is the open reduction and fusion stabilization procedure. This procedure involves stabilizing the head with screws, making an incision that exposes the occiput through C2, and fixing plates to the occiput which attach to the C1 and C2 (and sometimes C3) vertebrae with rods. A newer technique adapted by Dr. Paolo Bolognese is using a less invasive Chiari decompression surgery known as MIST (minimally invasive subpial tonsillectomy) along with a fusion using screws placed in the occipital condyles. Although the dura is opened to partially resect the tonsils, a duraplasty is not done. Advantages of this procedure include a smaller incision, smaller hardware, less bone removal, and a thicker bone for which to insert screws in the occiput. Risks of both methods include vertebral artery injury, and a slightly increased risk for segmental instability below the fusion, along with the standard risks of any surgical procedure, such as bleeding, infection, and complications from anesthesia. Both procedures demand the hands of a very skilled and experienced surgeon because vital structures lie in and around the area. Using condylar screws may increase the risk of injury to major vessels, particularly in the hands of a less experienced surgeon. An important cranial nerve also lies just deep to the occipital condyles, making precise screw placement extremely important. This may limit the procedure in becoming more widely used, but the resulting fusion may be stronger, despite the reduced amount of hardware[17].

    In the presence of a retroflexed odontoid, an open reduction, fusion and stabilization procedure may be enough to relieve ventral brain stem compression. However, in more severe cases, a further surgery called an odontoidectomy may be needed to remove the odontoid process. This surgery may be done through the mouth or the nose[18].

    Every Chiari patient should be aware of hereditary connective tissue disorders and the signs and symptoms of Craniocervical Instability and Basilar Invagination. Many neurosurgeons do not evaluate their patients for these conditions prior to performing Chiari decompression surgery, often resulting in the need for revision surgeries and poor results. Being an educated patient can help you ask the right questions and insist on the proper evaluation and testing to avoid the pitfalls that many other patients have faced.

    References:

    1 Bolognese, Paolo A, director. Surgical Techniques for Chiari Malformations. YouTube, American Syringomyelia Chiari Alliance Project, 16 Mar. 2015, <www.youtu.be/KfYmJnB6sPQ>.

    2 Bolognese, Paolo A. “Modern Classification and Subclassification of Chiari Malformations.”YouTube, American Syringomyelia Chiari Alliance Project, 16 Mar. 2015, <www.youtu.be/ZQ9ZmquN-M0>.

    3 Bolognese, Paolo A. “2016 ASAP CM/SM Conference – ‘Complex Posterior Fossa’ – Bolognese.” YouTube, American Syringomyelia Chiari Alliance Project, 7 Dec. 2016, <www.youtu.be/3jKH_DHadO8>.

    4 Augustus A. White III, Manohar M. Panjabi, et al. “Clinical Biomechanics of the Spine.” By Augustus A. White III, <www.leomed.at/listhoscan/white_90.pdf>

    5 The Pain Relief Foundation, The Pain Relief Foundation, <www.thepainrelieffoundation.com/craniocervical-instability/>.

    6 Bolognese, Paolo. Complex Posterior Fossa revisions. YouTube. December 7, 2016. <www.youtu.be/3jKH_DHadO8>.

    7 Menezes, Arnold H. “Craniovertebral Junction Anomalies: Diagnosis and Management.”Seminars in Pediatric Neurology, vol. 4, no. 3, Sept. 1997, <www.sempedneurjnl.com/article/S1071-9091(97)80038-1/fulltext>.

    8 Yang, Sun Y., et al. “A Review of the Diagnosis and Treatment of Atlantoaxial Dislocations.”Global Spine Journal, Georg Thieme Verlag KG, Aug. 2014, <www.ncbi.nlm.nih.gov/pmc/articles/PMC4111952/>.

    9 Henderson, Fraser C., et al. “Neurological and Spinal Manifestations of the Ehlers–Danlos Syndromes.” American Journal of Medical Genetics Part C: Seminars in Medical Genetics, <www.onlinelibrary.wiley.com/doi/10.1002/ajmg.c.31549/full>.

    10 Henderson, Sr. , Fraser C. “Neurological Management of Hereditary Disoders of Hypermobility Connective Tissue Disorders.” Ehlers-Danlos Society Annual Conference 2015. Ehlers-Danlos Society Annual Conference 2015, 14 Aug. 2015, Baltimore, <www.ehlers-danlos.com/2015-annual-conference-files/Henderson_0.pdf>.

    11 Hain, Timothy C. “Basilar Invagination, Basilar Impression and Atlantoaxial Subluxation.”Basilar Invagination, Basilar Impression and Atlantoaxial Subluxation, 19 Apr. 2013, <https://dizziness-and-balance.com/disorders/central/cerebellar/basilar_invagination.htm>.

    12 Kim, Louis J., et al. “JNS JOURNAL OF Neurosurgery OFFICIAL JOURNALS OF THE AANS since 1944.” Treatment of Basilar Invagination Associated with Chiari I Malformations in the Pediatric Population: Cervical Reduction and Posterior Occipitocervical Fusion | Journal of Neurosurgery: Pediatrics, Vol 101, No 2, Nov. 2004, <www.thejns.org/doi/abs/10.3171/ped.2004.101.2.0189?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed>.

    13 Henderson, Sr. , Fraser C. “Cranio-Cervical Instability in Patients with Hypermobility Connective Disorders.” OMICS International, OMICS International, 18 Apr. 2016, <www.omicsgroup.org/journals/craniocervical-instability-in-patients-with-hypermobility-connective-disorders-2165-7939-1000299.php?aid=71754#11>.

    14 Bono, C M, et al. “Measurement Techniques for Upper Cervical Spine Injuries: Consensus Statement of the Spine Trauma Study Group.” Spine., U.S. National Library of Medicine, 1 Mar. 2007, <www.ncbi.nlm.nih.gov/pubmed/17334296>.

    15 Henderson, Sr. , Fraser C. “Diagnosis and Treatment of Craniocervical Instability in the Chiari Patient.” Chiari and Syringomyelia Foundation Educational Lecture. 20 July 2011, Greater Metropolitan Washington Area, Greater Metropolitan Washington Area, <www.youtu.be/U33T8JFXvk0>.

    16 Henderson, F C, et al. “Neuropathology of the Brainstem and Spinal Cord in End Stage Rheumatoid Arthritis: Implications for Treatment.” Annals of the Rheumatic Diseases, U.S. National Library of Medicine, Sept. 1993, <www.ncbi.nlm.nih.gov/pmc/articles/PMC1005138/>.

    17 Bolognese, Paolo A. “Surgical Techniques for Chiari Malformations.” YouTube, American Syringomyelia Chiari Alliance Project, 16 Mar. 2015, <www.youtube.com/watch?v=KfYmJnB6sPQ>.

    18 Hwang, Steven W., et al. “C1–C2 Arthrodesis after Transoral Odontoidectomy and Suboccipital Craniectomy for Ventral Brain Stem Compression in Chiari I Patients.”European Spine Journal, Springer-Verlag, Sept. 2008, <www.ncbi.nlm.nih.gov/pmc/articles/PMC2527411/>.