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Treatment of failed Adult Chiari Malformation decompression with CSF drainage: observations in six patients
G K Bejjani1, K P Cockerham, W E Rothfus
1Tristate Neurosurgical Associates-UPMC, University of Pittsburgh Medical Center, PA 15213, USA.
Insights
Cerebrospinal fluid (CSF) drainage can help manage failed Adult Chiari Malformation (ACM) decompression. This approach, using lumbar punctures or shunting, improved symptoms in patients with recurrent ACM after initial surgery.
Area of Science:
- Neurosurgery
- Neurology
- Hydrodynamics
Background:
- Adult Chiari Malformation (ACM) can recur after initial decompression surgery.
- Management of recurrent ACM presents challenges, necessitating alternative therapeutic strategies.
Purpose of the Study:
- To evaluate the efficacy of cerebrospinal fluid (CSF) drainage in managing failed Adult Chiari Malformation (ACM) decompression.
- To explore potential reasons for surgical failure in ACM patients.
Main Methods:
- Retrospective study of 6 patients with recurrent ACM after initial decompression.
- Inclusion criteria: >1 year follow-up post-treatment for failed ACM.
- Therapeutic interventions included lumbar puncture (LP) and ventriculo-peritoneal shunting (VPS).
Main Results:
- All 6 patients experienced symptom recurrence 1.5-9 months postoperatively.
- CSF drainage via LP showed opening pressures ranging from 17-31 cm H2O (average 23 cm).
- All patients improved after CSF drainage; 4 received VPS, others managed with repeat LP +/- Acetazolamide.
Conclusions:
- CSF drainage is a viable treatment option for select patients with failed ACM surgery.
- Potential causes for surgical failure include surgical complications, inadequate initial surgery, or coexisting intracranial hypertension.
- Further prospective and hydrodynamic studies are required to elucidate the mechanisms and optimize treatment.
Objective:
We report the use of CSF drainage for the management of failed Adult Chiari Malformation (ACM) decompression.
Methods:
All patients with more than one year follow-up after treatment of their failed ACM were included in this study. They underwent initial decompression between September 1998 and April 2000. Clinical and radiological data were collected initially and at recurrence. Lumbar punctures (LP) were done at recurrence for diagnostic and therapeutic purposes. Opening pressures and symptomatic relief were recorded. Therapeutic options included intermittent LP and ventriculo-peritoneal shunting (VPS).
Results:
There were 6 patients (5 females and one male). Their age ranged from 19 to 43 years. Tonsillar descent ranged from 5 to 21 mm. The symptoms recurred 1.5 to 9 months postoperatively (average 5.6 months). Postoperative imaging revealed the presence of CSF flow behind the tonsils and the formation of a retrotonsillar neocistern in all patients. On LP, the opening pressure ranged from 17 to 31 cm of water (average 23 cm). All patients improved after CSF drainage, and four patients underwent VPS. The other patients were treated with repeat LP+/-Acetazolamide. There was significant improvement in all patients, with 18 months follow-up after CSF drainage (range 16-21 months).
Conclusions:
Our results suggest a role for CSF drainage in the treatment of some patients with failed ACM surgery. Possible explanations for the failure of ACM surgery in this subgroup include: surgical complications leading to neural hydrodynamic alteration, inadequate initial surgery, and coexistence with another pathology, possibly a mild form of intracranial hypertension. More prospective and hydrodynamic studies are needed to further clarify these issues.
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