Endolymphatic sac tumor: An urgent case presenting acute intracranial hypertension successfully treated with suboccipital decompressive craniectomy - 8 years of follow-up.

Background: Endolymphatic sac tumor (ELST) is a rare lesion. It may be sporadically or associated with Von Hippel-Lindau syndrome. Progressive audiovestibular symptoms characterize the typical clinical presentation. Here, we report a unique case of ELST with acute intracranial hypertension (IH) due to tumor compression, successfully treated with an urgent suboccipital decompressive craniectomy (SDC). Case Description: A 33-year-old woman previously underwent a biopsy and ventriculoperitoneal shunt. The histopathological finding revealed an ELST. One year later, she developed headache, vomiting, and somnolence due to brainstem compression. An urgent SDC was performed. One month later, preoperative endovascular embolization and partial tumor resection were carried out. After 6 months adjuvant radiotherapy (RT) therapy was administered. She has been under follow-up for 8 years since the last surgical procedure, and the tumor remains stable. Conclusion: ELST generally has a progressive clinical course. This is a unique case with acute IH due to tumor compression. The tumor's high vascularity and the unavailability of endovascular embolization precluded its resection. SDC was an alternative approach. The final treatment included tumor embolization, surgical resection, and RT. No progression was observed for 8 years after the last procedure, and long-term follow-up is warranted.

Predictors of poor functional outcomes in adults with type I Chiari Malformation: Clinical and surgical factors assessed with the Chicago Chiari Outcome Scale over long-term follow-up.

OBJECTIVE: This study aimed to identify clinical and surgical features associated with poor long-term postoperative outcomes in patients diagnosed with Type I Chiari Malformation (CMI) treated with posterior fossa decompression with duroplasty (PFDD), with or without tonsillar coagulation. METHODS: This retrospective, single-center study included 107 adult patients with CMI surgically treated between 2010 and 2021. The surgical technique involved a midline suboccipital craniectomy, C1 laminectomy, durotomy, arachnoid dissection, duroplasty, and tonsillar coagulation until 2014, after which tonsillar coagulation was discontinued. Postoperative outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) at a median follow-up of 35 months. Clinical, surgical, and neuroimaging data were analyzed using the Wilcoxon signed-rank test, Cox regression analysis, and Kaplan-Meier survival curves to identify predictors of poor functional outcomes. RESULTS: Of the 107 patients (mean age 43.9 years, SD 13), 81 (75.5 %) showed functional improvement, 25 (23.4 %) remained unchanged, and 1 (0.9 %) experienced worsened outcomes. Cephalalgia, bilateral motor weakness, and bilateral paresthesia were the most frequent initial symptoms. Tonsillar coagulation was performed in 31 cases (28.9 %) but was clinically associated with higher rates of unfavorable outcomes. The Wilcoxon signed-rank test indicated that long-term follow-up CCOS was significantly higher than postoperative CCOS (Z = -7.678, p < 0.000). Multivariate Cox analysis identified preoperative bilateral motor weakness (HR 6.1, 95 % CI 1.9-18.9; p = 0.002), hydrocephalus (HR 3.01, 95 % CI 1.3-6.9; p = 0.008), and unilateral motor weakness (HR 2.99, 95 % CI 1.1-8.2; p = 0.033) as significant predictors of poor outcomes on a long-term follow-up. CONCLUSION: This study highlights the high rate of functional improvement in CMI patients following PFDD. Preoperative motor weakness and hydrocephalus were significant predictors of poor long-term outcomes. Tonsillar coagulation did not demonstrate a clear clinical benefit and may be associated with worse outcomes. Our findings suggest that careful preoperative assessment and selection of surgical techniques are crucial for optimizing patient outcomes.

Minimally Invasive Technique for Chiari I Decompression Without Durotomy: Surgical Technique and Preliminary Case Series.

BACKGROUND: Chiari I malformation, marked by severe headaches and potential brainstem/spinal cord issues, often requires surgical intervention when conservative methods fail. This study introduces a minimally invasive surgery (MIS) Chiari decompression technique utilizing a 3-blade retractor, aiming to reduce postoperative discomfort and optimize outcomes. METHODS: Chiari type I malformation patients who underwent a MIS technique were included. Technique consisted of a minimal-soft tissue opening using a 3-blade retractor, suboccipital craniectomy, C1 laminectomy, and resection of the atlantooccipital band without a durotomy. RESULTS: Ten patients were treated. Mean age was 43.3 years, with 7 female patients. All patients presented with occipital headaches; 50% retroorbital pain; 40% neck, upper back, or shoulder pain; and 30% limb paresthesias. Median pre-surgical modified Rankin Scale (mRS) was 3 (2-4) and pain visual analog score (VAS) was 7 (5-9). Mean operative time was 59 (59-71) minutes, with mean blood loss of 88.5 (50-140) mL. In our sample, 90% of patients were discharged the same surgical day (mean 7.2 [5.3-7.7] hours postoperative). No immediate or delayed postoperative complications were evidenced. At 6 months, 90% of patients had mRS 0-1. At last follow-up the mean VAS was 1.5 (range: 0-4, P < 0.001). CONCLUSIONS: The MIS 3-blade flexible retractor technique for Chiari decompression is feasible, provides wide visualization angles of the suboccipital region and C1 arch, allows 2-surgeon work, and minimizes skin and soft tissue disruption. This combination may diminish postoperative discomfort, reduce the risk of surgical site infections, and optimize outcomes.

Neurosurgical management of patients with Ehlers-Danlos syndrome: A descriptive case series.

Introduction: Ehlers-Danlos syndrome (EDS) is a connective tissue disorder that has been linked to several neurological problems including Chiari malformations, atlantoaxial instability (AAI), craniocervical instability (CCI), and tethered cord syndrome. However, neurosurgical management strategies for this unique population have not been well-explored to date. The purpose of this study is to explore cases of EDS patients who required neurosurgical intervention to better characterize the neurological conditions they face and to better understand how neurosurgeons should approach the management of these patients. Methods: A retrospective review was done on all patients with a diagnosis of EDS who underwent a neurosurgical operation with the senior author (FAS) between January 2014 and December 2020. Demographic, clinical, operative, and outcome data were collected, with additional radiographic data collected on patients chosen as case illustrations. Results: Sixty-seven patients were identified who met the criteria for this study. The patients experienced a wide array of preoperative diagnoses, with Chiari malformation, AAI, CCI, and tethered cord syndrome representing the majority. The patients underwent a heterogeneous group of operations with the majority including a combination of the following procedures- suboccipital craniectomy, occipitocervical fusion, cervical fusion, odontoidectomy, and tethered cord release. The vast majority of patients experienced subjective symptomatic relief from their series of procedures. Conclusions: EDS patients are prone to instability, especially in the occipital-cervical region, which may predispose these patients to require a higher rate of revision procedures and may require modifications in neurosurgical management that should be further explored.

Massive Congestive Facial and Submandibular Oedema Due to Extreme Neck Flexion Following Suboccipital Craniectomy: A Case Report.

A variety of factors could contribute to facial oedema during a prone neurosurgical procedure. For optimal surgical exposure, suboccipital cranial surgeries frequently necessitate extreme neck flexion. Extreme neck flexion in the prone position can impair venous drainage of the facial and oropharyngeal structures, leading to life-threatening oedema, so a two-fingerbreadth space between the chin and the sternum is critical. We present a case of massive facial oedema with submandibular swelling in a patient who underwent foramen magnum decompression in the prone position for Arnold Chiari malformation.

Craniocervical Stabilization After Failed Chiari Decompression: A Case Series of a Population with High Prevalence of Ehlers-Danlos Syndrome.

BACKGROUND: In the treatment of Chiari malformation type I (CM-I), posterior fossa decompression is achieved via suboccipital craniectomy (SOC); however, some patients continue to experience symptoms after treatment, which may be due to craniocervical instability (CCI). The purposes of this study were to analyze data from patients who required an occipitocervical fusion (OCF) for the management of CCI after having previously undergone SOC for CM-I to determine if OCF is a safe and effective option and to determine any identifiable risk factors for CCI in these patients. METHODS: A retrospective review was done on all patients who underwent an OCF performed by the senior author between November 2013 and June 2020 after having previously undergone SOC for CM-I. Demographic, radiographic, perioperative, and outcome data were collected and clivoaxial angles (CXAs) were measured pre- and postoperatively. RESULTS: Fifteen patients were identified who developed symptomatic CCI after previously undergoing a suboccipital craniectomy for the treatment of CM-I. All 15 patients were treated by OCF with good outcome. Of these, 12 patients had a known diagnosis of Ehlers-Danlos syndrome (EDS). Overall, the CXAs of these patients were found to be corrected to a more anatomical alignment. CONCLUSIONS: Symptomatic CCI should be recognized as a delayed postoperative complication in the surgical treatment of CM-I, with an underlying connective tissue hypermobility disorder such as EDS serving as a potential risk factor its development. CCI can be managed with OCF as a safe and effective treatment option for this patient population.

Foramen magnum decompression in adults with Chiari type 1 malformation: use of intraoperative ultrasound to guide extent of surgery.

BACKGROUND: Foramen magnum decompression (FMD) is an established technique for patients with Chiari-1 malformation. However, the extent of decompressive surgery is controversial, in particular whether dural opening is undertaken. OBJECTIVE: In this study, we report outcomes with our technique utilising intraoperative ultrasound (iOU) findings. Decision to proceed for further decompression was based on CSF flow around foramen magnum and visualisation of tip of tonsils. METHODS: Review of adults with CM-1 undergoing FMD 2013-2018. Patients underwent a suboccipital craniectomy ± partial C1 superior laminectomy ± duraplasty in a stepwise manner. Favourable iOU findings of CSF flow around the foramen magnum and pulsation of the tonsillar tips were sought at each step. Post-operative outcomes were assessed using the Chicago Chiari Outcome Score (CCOS). RESULTS: Fifty-seven patients were included. The mean age was 47 years (range 18-77 years). There was a strong female preponderance (48 females to nine males). The mean follow-up was 3.2 years (range 1-5 years). Surgery included: suboccipital craniectomy (52/57, 91%), plus partial C1 superior laminectomy (2/57, 4%), and plus duraplasty (3/57, 6%). Redo surgery was undertaken in 7/57 patients (12%). At final follow-up, 56/57 (98%) patients achieved a good (CCOS 13-16) or satisfactory (CCOS 9-12) outcome based on COSS. CONCLUSIONS: A patient centred approach to surgery utilising findings from iOU can achieve favourable outcomes. Dural opening is not routinely required.

Cryptococcal meningitis presenting as anterior spinal cord syndrome with accessory nerve palsy in immunocompetent patient: A case report.

BACKGROUND: Cryptococcus has a tropism for the nervous system with a higher prevalence of infection in immunosuppressed patients; it remains a major cause of human immunodeficiency virus (HIV)-related mortality worldwide. Neurological compromise caused by this microorganism mainly debuts as a meningeal syndrome, spinal involvement has been reported in literature, neuropathological assessments have found Cryptococci in spinal roots and meninges, with perineuritic adhesions probably explaining compromise lower cranial nerves and even spinal nerve roots. CASE DESCRIPTION: 39-year-old male seronegative for HIV, with a surgical history of hydrocephalus treated with ventriculoperitoneal shut 1 year before, he presented with progressive weakness in the four extremities evolving to be disabling with bilateral accessory nerve palsy and loss of sensation below his neck. The MR imaging showed diffuse leptomeningeal thickening both supra and infratentorial and over the spinal canal up to C5 with a cystic formation shown in the craniocervical union causing compression of the medullary bulb. The patient underwent a medial suboccipital craniectomy with resection of the posterior arch of c1 for sampling and decompression, pathologically appears numerous spherical organisms that have a thick clear capsule and are surrounded by histiocytes forming a granuloma compatible with Cryptococcus. Postoperatively, the patient's prior neurological deficits resolved. CONCLUSION: It is an infrequently suspected pathology in immunocompetent patients, usually requiring only antifungal treatment with adjustment of immunosuppressive or antiretroviral management. In special and rare situations like our case as presenting with lower cranial nerve and spinal involvement, surgical treatment is a priority for the resolution of the pathology and improves disabling neurological deficit.

Clinical and radiological evaluation of treated Chiari I adult patients: retrospective study from two neurosurgical centers.

Chiari malformation type I (CM1) is a common neurosurgical disorder. It often causes debilitation in the affected patients. CM1 is a herniation of the caudal cerebellum into the spinal canal. This study aimed to evaluate the clinical and radiological outcomes of posterior fossa decompression and duraplasty (PFDD) in treated CM1 patients. In retrospective design, we reviewed the medical records of diagnosed patients with CM1 at two neurosurgical centers spanning 8 years from 2010 to 2017. We selected all CM1 patients who underwent PFDD surgery (n = 72) as the core sample for this study. We used the Chicago Chiari Outcome Scale (CCOS) to evaluate clinical outcomes. Pre- and postoperatively, we assessed the syrinx/cord ratio, the syrinx length, and the improvement of aqueductal stroke volume (ASV) on CSF flow MRIs. The mean value of CCOS was 14.1 ± 2.1. On midsagittal MRIs, the mean regression in ectopia tonsils was 9.4 ± 1.9 mm (i.e., mean pre- and postoperative tonsil herniation was 13.1 ± 3.1 mm and 4.0 ± 1.6 mm, respectively; p < 0.001). On coronal MRIs, the mean regression in ectopia tonsils was 8.4 ± 1.5 mm (i.e., mean pre- and postoperative tonsil herniation was 13.9 ± 2.4 mm and 5.8 ± 1.0 mm, respectively; p < 0.001). A strong positive correlation was observed between clinical improvement and the increase in ASV values. CSF flow MRIs can help in the surgical decision and follow-up of CM1 patients. ASV ≤ 12 µl is a significant predictor for surgical intervention. Full clinical and radiological evaluation utilizing CSF flow MRI are essential. Most syrinx cavities have regressed following PFDD.

First-in-man craniectomy and asportation of solitary cerebellar metastasis in COVID-19 patient: A case report.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak has an impact on the delivery of neurosurgical care, and it is changing the perioperative practice worldwide. We present the first case in the literature of craniectomy procedure and asportation of a solitary cerebellar metastasis of the oesophagus squamous carcinoma in a 77 years old woman COVID-19 positive. In these particular circumstances, we show that adequate healthcare resources and risk assessments are essential in the management of COVID-19 patients referred to emergency surgery. PRESENTATION OF CASE: The case here presented was treated in 2019 for squamous carcinoma of the oesophagus. In April 2020, she presented a deterioration of her clinical picture consisting of dysphagia, abdominal pain, hyposthenia and ataxia. A Head CT scan was performed, which showed the presence of a solitary cerebellar metastasis. Her associated SARS-CoV-2 positivity status represented the principal clinical concern throughout her hospitalisation. DISCUSSION: The patient underwent a suboccipital craniectomy procedure with metastasis asportation. She tested positive for SARS-CoV-2 in the pre- and post-operative phases, but she was not admitted to the intensive care unit because she did not present any respiratory complications. Her vital parameters and inflammation indexes fell within the reference ranges, and she was kept in isolation for 16 days in our neurosurgical unit following strict COVID-19 measures. She was asymptomatic and not treated for any of the specific and non-specific symptoms of COVID-19. CONCLUSION: This is the first case reported of solitary cerebellar metastasis of oesophagus carcinoma operated on a COVID-19 positive patient. It shows that asymptomatic COVID-19 positive patients can undergo major emergency surgeries without the risk of infecting the operating team if adequate Personal Protection Equipment (PPE) is used. The patient remained asymptomatic and did not develop the disease's active phase despite undergoing a stressful event such as a major emergency neurosurgical procedure. In the current crisis, a prophylactic COVID-19 screening test can identify asymptomatic patients undergoing major emergency surgery and adequate resource planning and Personal Protective Equipment (PPE) for healthcare workers can minimise the effect of the COVID-19 pandemic.

Idiopathic fourth ventricular outlet obstruction misdiagnosed as normal pressure hydrocephalus: A cautionary case.

BACKGROUND: Fourth ventricular outlet obstruction is an infrequent but well-established cause of tetraventricular hydrocephalus characterized by marked dilatation of the ventricular system with ballooning of the foramina of Monro, Magendie, and Luschka. Multiple processes including inflammation, infection, hemorrhage, neoplasms, or congenital malformations are known to cause this pathological obstruction. However, true idiopathic fourth ventricular outlet obstruction is a rare phenomenon with only a limited number of cases reported in the literature. CASE DESCRIPTION: A 61-year-old female presented with several months of unsteady gait, intermittent headaches, confusion, and episodes of urinary incontinence. Conventional magnetic resonance imaging demonstrated tetraventricular hydrocephalus without transependymal flow, but with ventral displacement of the brainstem and dorsal displacement of the cerebellum without an obvious obstructive lesion on pre- or post-contrast imaging prompting a diagnosis of normal pressure hydrocephalus. However, constructive interference in steady state (CISS) and half-Fourier acquisition single-shot turbo spin echo (HASTE) sequences followed by fluoroscopic dynamic cisternography suggested encystment of the fourth ventricle with thin margins of arachnoid membrane extending through the foramina of Luschka bilaterally into the pontocerebellar cistern. Operative intervention was pursued with resection of an identified arachnoid web. Postoperative imaging demonstrated marked reduction in the size of ventricular system, especially of the fourth ventricle. The patient's symptomatology resolved a few days after the procedure. CONCLUSION: Here, we describe an idiopathic case initially misdiagnosed as normal pressure hydrocephalus. The present case emphasizes the necessity of CISS sequences and fluoroscopic dynamic cisternography for suspected cases of fourth ventricular outlet obstruction as these diagnostic tests may guide surgical management and lead to superior patient outcomes.

Pedicled, vascularized occipital bone graft to supplement atlantoaxial arthrodesis for the treatment of pseudoarthrosis.

Atlantoaxial pseudoarthrosis is a challenging postoperative complication. The use of a local, vascularized bone graft, without free tissue transfer, to support a revision atlantoaxial fusion has not been previously described. We report the first surgical patient who received a semispinalis capitis muscle pedicled, occipital bone graft for supplementation of a revision atlantoaxial arthrodesis. A 72-year-old female had a failed atlantoaxial fusion and developed neck pain from continued instability and fractured hardware. The fixation and fusion were revised and supplemented with a novel, pedicled occipital bone graft. A craniectomy was performed in the occipital bone while still attached to the semispinalis capitis muscle to provide graft vascularity. This graft was rotated inferiorly from the skull base to the C1 arch and C2 spinous process in order to supplement a revision atlantoaxial arthrodesis. The patient had excellent clinical recovery over 18-month clinical follow up. The bone graft harvesting and rotation were performed safely and without complication. The 6-month postoperative CT scan showed partial fusion into the graft. This novel surgical technique leverages the advantages of vascularized structural autograft without adding extensive time or morbidity to the procedure as observed in free-tissue transfers. It is a safe and useful salvage technique to supplement revision atlantoaxial fusion surgeries.

Decompressive craniectomy for acute ischemic stroke.

Malignant stroke occurs in a subgroup of patients suffering from ischemic cerebral infarction and is characterized by neurological deterioration due to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique aiming to open the "closed box" represented by the non-expandable skull in cases of refractory intracranial hypertension. It is a valuable modality in the armamentarium to treat patients with malignant stroke: the life-saving effect has been proven for both supratentorial and infratentorial DC in virtually all age groups. This leaves physicians with the difficult task to decide who will require early or preemptive surgery and who might benefit from postponing surgery until clear evidence of deterioration evolves. Together with the patient's relatives, physicians also have to ascertain whether the patient will have acceptable disability and quality of life in his or her presumed perception, based on preoperative predictions. This complex decision-making process can only be managed with interdisciplinary efforts and should be supported by continued research in the age of personalized medicine.

Evaluation of clinical significance of decompressive suboccipital craniectomy on the prognosis of cerebellar infarction.

OBJECTIVE: The decision of whether and/or when to treat cerebellar infarction surgically remains controversial. We investigated the effectiveness of decompressive suboccipital craniectomy (DSC) for treating cerebellar infarction and the prognostic factors that affect the surgical results. METHODS: From October 2006 to June 2017, a total of 14 consecutive patients (12 men, 2 women; mean±SD age 65±12 years, range 42-84 years) were admitted to our hospital and underwent DSC at the time of admission or during their hospitalization. Inclusion criteria were (1) a level of consciousness below Glasgow Coma Scale (GCS) 13, and/or (2) brainstem compression and/or obstructive hydrocephalus caused by brain edema due to cerebellar infarction. Ventricular drainage was performed simultaneously or later, according to the surgeon's decision. RESULTS: At the 90-day point, 12 of the 14 patients (85.7%) had survived, 10 (71.4%) of whom were independent (modified Rankin scale ≤2). Four (28.6%) were either completely dependent or dead. Comparisons between good and poor prognoses showed that the factors affecting the prognosis were lesions other than the cerebellar infarction (p<0.01) and/or obstructive hydrocephalus (p<0.05). CONCLUSIONS: Early DSC should be considered for treating cerebellar infarction in patients with GCS 13 or worse. A poor prognosis is inevitable in patients whose infarction is combined with other location than the cerebellum but in those who already have obstructive hydrocephalus at the time of surgery.

Familial Chiari Type 1: A Molecular Karyotyping Study in a Turkish Family and Review of the Literature.

BACKGROUND: The etiology of Chiari I malformation (CMI) has not been fully elucidated. Therefore, we performed a genetic study of a Turkish family in which 3 sisters had a diagnosis of CMI with or without syringomyelia. METHODS: In a family with 7 children, 4 daughters complained of occipital headaches. In 2 of these daughters, CMI had been diagnosed during their 30s, and CMI plus syrinx had been diagnosed in the other daughter in her 40s. Cranial magnetic resonance imaging of the fourth daughter who had developed headaches during her 30s showed normal findings. Because the other siblings in the family were asymptomatic, radiological examinations were not performed. The family had a history of distant consanguineous marriage between parents. Additionally, the father had died, and the mother was asymptomatic, with radiologically normal findings. Array comparative genome hybridization studies were performed for 12 persons from 3 generations of this family. RESULTS: None of the 12 cases examined harbored copy number variations. CONCLUSIONS: This family with 3 sisters having CMI suggested a possible autosomal recessive single-gene etiology. Cases of familial CMI are unusual but important to study because they could reveal the specific genes involved in posterior fossa/foramen magnum structure and function and provide insights into the cause of sporadic cases.

Challenges in the Management of a Ruptured Bihemispheric Posterior Inferior Cerebellar Artery Aneurysm.

BACKGROUND: Bihemispheric posterior inferior cerebellar artery (PICA) is a rare anatomic variant wherein a single PICA supplies both cerebellar hemispheres. Inasmuch as it is the only PICA, treatment of aneurysms arising from this anatomic variant is more complex. We present a case of a ruptured bihemispheric PICA aneurysm and the challenges encountered in its management. CASE DESCRIPTION: A 54-year-old man presented with giddiness and nausea. Otherwise, he was neurologically intact. Computed tomography of the brain showed a right cerebellar hematoma and intraventricular hemorrhage. Cerebral angiography revealed a dissecting aneurysm in the retromedullary segment of a right bihemispheric PICA with a prominent saccular component. Initially, the patient refused to undergo any invasive treatment. However, when a follow-up angiogram showed an increase in the size of the aneurysm sac, he consented to treatment. Although parent vessel occlusion (PVO) was the clinical recommendation, in view of the patient's apprehensions, only the saccular component of the aneurysm was coil embolized without sacrifice of the parent vessel. Fifteen days after the coiling, there was a rebleed from this dissecting aneurysm, which was treated with PVO followed by suboccipital craniectomy. The patient made a reasonable recovery, and his modified Rankin score was 1 at his 6-month follow-up visit. CONCLUSIONS: In dissecting aneurysms of a bihemispheric PICA, isolated endosaccular occlusion provides uncertain protection from a rebleed, whereas a more reliable treatment with PVO carries an unpredictable risk of ischemic complications. The risks of a PVO may be rationalized as a life-saving measure; however, the subsequent threshold for posterior fossa decompression should be low.

Current management of pediatric chiari type 1 malformations.

OBJECTIVES: Pediatric Chiari Type 1 Malformations (CM1) are commonly referred for neurosurgical opinion. The ideal management in children regarding surgical and radiographic decision making is not clearly delineated. PATIENTS AND METHODS: We retrospectively reviewed our cohort of patients age 18 years and younger referred to a single neurosurgeon for CM1. Baseline MRIs of the spine were obtained. Non-operative patients had repeat imaging at 6-12 months. Patients who underwent an operation (decompression with/without duraplasty) had repeat imaging at 6 months. RESULTS: One hundred and thirty-two patients with mean age of 10 years met inclusion criteria. All patients had post-operative symptomatic improvement. We identified 26 patients with syrinx, 8 with scoliosis, 3 with hydrocephalus, and one had tethered cord. The average tonsillar descent was 8.1 mm in the non-operative group and 11.9 mm in the operative group. Ninety-five patients were managed conservatively (72%). Thirty-seven were offered surgery (28%), and 33 patients underwent intervention; 21 with duraplasty (64%) and 12 without (36%). CONCLUSIONS: Pediatric patients with CM1 require both clinical and radiographic follow-up. Duraplasty may be performed if decompression fails to relieve symptomatology, but is not always needed. CM1 continues to present a challenge in surgical decision making. Adhering to a treatment paradigm may help alleviate difficult decision-making.

Hemorrhagic transformation of posterior fossa ischemia after antithrombotic therapy for a blunt vertebral artery injury: a case report.

We describe a rare case of a 69-year-old male who developed a hemorrhagic transformation of a posterior fossa ischemia after the initiation of antithrombotic therapy for the management of blunt vertebral artery injury (BVAI). To the best of our knowledge, this is the first reported case in the literature so far. Thus, we present our diagnostic approach, its associated treatment challenges, and its overall outcome.

Effects of Posterior Fossa Decompression in Patients with Hunt and Hess Grade 5 Subarachnoid Hemorrhage After Endovascular Trapping of Ruptured Vertebral Artery Dissecting Aneurysms.

BACKGROUND: A ruptured vertebral artery dissecting aneurysm (VADA) with a high clinical grade (Hunt and Hess grade 5) has a devastating prognosis. Because of the high rebleeding rate and location, rapid mortality can occur in patients owing to brainstem compression. Adjuvant decompression of the posterior fossa after securing the aneurysm may improve the outcomes of these patients. METHODS: Between January 2011 and December 2016, 22 patients who presented with Hunt and Hess grade 5 ruptured VADA underwent endovascular treatment. Patients were divided into 2 groups: group 1 (n = 12) received conventional endovascular treatment of VADA and external ventricular drainage, and group 2 (n = 10) received external ventricular drainage and suboccipital craniectomy for posterior fossa decompression after rapid endovascular trapping of VADA. RESULTS: In group 2, the survival rate and good clinical outcome rate (modified Rankin scale score ≤2) were 80% and 60%, respectively, which were favorable to the corresponding rates in group 1 (66.67% and 16.67%). Moreover, 80% of patients (8/10) in group 2 regained consciousness compared with 50% of patients in group 1. CONCLUSIONS: Adjuvant decompression of the posterior fossa can improve outcomes in patients with Hunt and Hess grade V ruptured VADA.

Adult Chiari I Malformations: An Analysis of Surgical Risk Factors and Complications Using an International Database.

BACKGROUND: Chiari I malformations are common in adults and a frequent procedure in neurosurgical practice. Despite several studies, there is no consensus about the indications or surgical technique for this common condition. Increasing emphasis on value-based care has emphasized reduction of readmissions and reoperations and is particularly relevant in Chiari, which has traditionally been associated with a high complication rate. OBJECTIVE: To provide a contemporary surgical profile of risk factors and complications for Chiari I malformations in adults. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to determine 30-day outcomes after surgery for Chiari I malformations in adults between 2005 and 2016. Demographics, clinical risk factors, and postoperative events were analyzed, along with reoperation and readmission reasons. RESULTS: A total of 672 adult patients were identified in the cohort, with a female predominance (80%). The overall cohort readmission rate was 9.3%, and 6.8% of patients returned to the operating room. Obesity (45.7%) was predictive of both readmission and reoperation risk. Male sex and American Society of Anesthesiologists class were predictive for reoperations. The most common reason for reoperation was cerebrospinal fluid leak, which was responsible for nearly two thirds of reoperations and 4% of the cohort. CONCLUSIONS: Surgery for Chiari in adults is common and carries a definitive risk profile, including rates of readmission and reoperation higher than other common neurosurgical procedures. This cohort provides a representative sample of contemporary neurosurgical outcomes in surgery for Chiari I malformations.