Use of Intraoperative Neuromonitoring in Surgical Treatment of Acute Presentation of Chiari I Malformation: A Case Report

Abstract

Intraoperative neuromonitoring (IONM) has been used in neurosurgical procedures to assess patient safety and minimize risk of neurological deficit. However, its use in decompressive surgeries of Chiari malformation type I (CM-I) remains a topic of debate. Here we present the case of a 5-year-old girl who presented with acute right lower extremity monoplegia after accidental self-induced hyperflexion of the neck while playing. Imaging revealed 15 mm of tonsillar ectopia with cervical and upper thoracic spinal cord edema. She was taken to surgery for a suboccipital decompression with expansile duraplasty. IONM demonstrated improvement in motor evoked potentials during the decompression. Postoperatively, she had full recovery of strength and mobility. This is a case of acute weakness after mild trauma in the setting of previously asymptomatic CM-I that showed close correlation with IONM, clinical findings, and imaging. IONM during decompressive surgery for CM-I may be useful in patients who present acutely with cervical cord edema.

Keywords

acute chiari - intraoperative neuromonitoring - decompression - chiari I malformation

Publikationsverlauf

Eingereicht: 04. Juli 2022

Angenommen: 26. Januar 2023

Accepted Manuscript online:
04. Februar 2023

Artikel online veröffentlicht:
13. März 2023

• References

• 1 Jussila MP, Nissilä J, Vakkuri M. et al. Preoperative measurements on MRI in Chiari 1 patients fail to predict outcome after decompressive surgery. Acta Neurochir (Wien) 2021; 163 (07) 2005-2014
• 2 Langridge B, Phillips E, Choi D. Chiari malformation type 1: a systematic review of natural history and conservative management. World Neurosurg 2017; 104: 213-219
• 3 Atchley TJ, Alford EN, Rocque BG. Systematic review and meta-analysis of imaging characteristics in Chiari I malformation: does anything really matter?. Childs Nerv Syst 2020; 36 (03) 525-534
• 4 Talamonti G, Marcati E, Gribaudi G, Picano M, D'Aliberti G. Acute presentation of Chiari 1 malformation in children. Childs Nerv Syst 2020; 36 (05) 899-909
• 5 Tubbs RS, Lyerly MJ, Loukas M, Shoja MM, Oakes WJ. The pediatric Chiari I malformation: a review. Childs Nerv Syst 2007; 23 (11) 1239-1250
• 6 Khatib MY, Elshafei MS, Shabana AM. et al. Arnold-Chiari malformation type 1 as an unusual cause of acute respiratory failure: a case report. Clin Case Rep 2020; 8 (10) 1943-1946
• 7 Florou C, Andreanos K, Georgakoulias N. et al. Acute visual loss secondary to Arnold Chiari type I malformation completely resolving after decompressive posterior fossa surgery. Int Med Case Rep J 2020; 13: 657-661
• 8 Carew CL, Prasad A, Tay KY, de Ribaupierre S. Unusual presentation of Chiari I in toddlers: case reports and review of the literature. Childs Nerv Syst 2012; 28 (11) 1965-1970
• 9 Miranda SP, Kimmell KT, Silberstein HJ. Acute presentation of Chiari I malformation with hemiparesis in a pediatric patient. World Neurosurg 2016; 85 (366) 366.e1-366.e4
• 10 Young CC, Ellenbogen RG, Hauptman JS. Acute traumatic presentation of Chiari I malformation with central cord syndrome and presyrinx in an infant. Surg Neurol Int 2019; 10 (253) 253
• 11 Strike SA, Hassanzadeh H, Jain A. et al. Intraoperative neuromonitoring in pediatric and adult spine deformity surgery. Clin Spine Surg 2017; 30 (09) E1174-E1181
• 12 Fehlings MG, Brodke DS, Norvell DC, Dettori JR. The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference?. Spine 2010; 35 (9, Suppl): S37-S46
• 13 Ferguson J, Hwang SW, Tataryn Z, Samdani AF. Neuromonitoring changes in pediatric spinal deformity surgery: a single-institution experience. J Neurosurg Pediatr 2014; 13 (03) 247-254
• 14 Barzilai O, Roth J, Korn A, Constantini S. The value of multimodality intraoperative neurophysiological monitoring in treating pediatric Chiari malformation type I. Acta Neurochir (Wien) 2016; 158 (02) 335-340
• 15 Roser F, Ebner FH, Liebsch M, Tatagiba MS, Naros G. The role of intraoperative neuromonitoring in adults with Chiari I malformation. Clin Neurol Neurosurg 2016; 150: 27-32
• 16 Rasul FT, Matloob SA, Haliasos N, Jankovic I, Boyd S, Thompson DNP. Intraoperative neurophysiological monitoring in paediatric Chiari surgery-help or hindrance?. Childs Nerv Syst 2019; 35 (10) 1769-1776
• 17 Heffez DS, Golchini R, Ghorai J, Cohen B. Operative findings and surgical outcomes in patients undergoing Chiari 1 malformation decompression: relationship to the extent of tonsillar ectopia. Acta Neurochir (Wien) 2020; 162 (07) 1539-1547
• 18 Anderson RCE, Dowling KC, Feldstein NA, Emerson RG. Chiari I malformation: potential role for intraoperative electrophysiologic monitoring. J Clin Neurophysiol 2003; 20 (01) 65-72
• 19 Kawasaki Y, Uchida S, Onishi K, Toyokuni M, Okanari K, Fujiki M. Intraoperative neurophysiologic monitoring for prediction of postoperative neurological improvement in a child with Chiari type I malformation. J Craniofac Surg 2017; 28 (07) 1837-1841
• 20 Chen JA, Coutin-Churchman PE, Nuwer MR, Lazareff JA. Suboccipital craniotomy for Chiari I results in evoked potential conduction changes. Surg Neurol Int 2012; 3 (165) 165
• 21 Zamel K, Galloway G, Kosnik EJ, Raslan M, Adeli A. Intraoperative neurophysiologic monitoring in 80 patients with Chiari I malformation: role of duraplasty. J Clin Neurophysiol 2009; 26 (02) 70-75
• 22 Anderson RCE, Emerson RG, Dowling KC, Feldstein NA. Improvement in brainstem auditory evoked potentials after suboccipital decompression in patients with Chiari I malformations. J Neurosurg 2003; 98 (03) 459-464
• 23 Kennedy BC, Kelly KM, Phan MQ. et al. Outcomes after suboccipital decompression without dural opening in children with Chiari malformation Type I. J Neurosurg Pediatr 2015; 16 (02) 150-158
• 24 Almotairi FS, Tisell M. Acute deterioration of adults with Chiari I malformation associated with extensive syrinx. Br J Neurosurg 2020; 34 (01) 13-17