- Department of Neurosurgery, Kanazawa University, Kanazawa, Ishikawa, Japan
- Department of Neurology, Kanazawa University, Kanazawa, Ishikawa, Japan
- Surgical Neurology Branch, National Institute of Neurological Disorders and Strokes, National Institutes of Health, Bethesda, Maryland
Correspondence Address:
Yasuhiko Hayashi
Department of Neurosurgery, Kanazawa University, Kanazawa, Ishikawa, Japan
DOI:10.4103/2152-7806.113355
Copyright: © 2013 Oishi M This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Oishi M, Hayashi Y, Kita D, Fukui I, Shinohara M, Heiss JD, Hamada J. Rapidly progressing monoparesis caused by Chiari malformation type I without syringomyelia. Surg Neurol Int 12-Jun-2013;4:79
How to cite this URL: Oishi M, Hayashi Y, Kita D, Fukui I, Shinohara M, Heiss JD, Hamada J. Rapidly progressing monoparesis caused by Chiari malformation type I without syringomyelia. Surg Neurol Int 12-Jun-2013;4:79. Available from: http://sni.wpengine.com/surgicalint_articles/rapidly-progressing-monoparesis-caused-by-chiari-malformation-type-i-without-syringomyelia/
Abstract
Background:Patients with Chiari malformation type I (CM-I) can manifest neurological symptoms, such as headache, neck pain, dysesthesia, swallowing disturbance, and paresis, which are usually stable or slowly progressive even if syringomyelia is coexistent. In some instances, however, acute onset of neurological symptoms has been reported but the pathogenetic mechanism and subsequent clinical course have not been explained. In those cases, it was reported that urgent treatment of foramen magnum decompression (FMD) was very effective. This work reports that an 11-year-old girl with CM-I subacutely developed unique symptoms and that urgent treatment of FMD was very effective.
Case Description:We present here an 11-year-old girl with CM-I who subacutely developed dysphagia, left upper extremity monoparesis and sensory dysesthesia, with the limb assuming a peculiar posture at rest, with the wrist in extension and the elbow joint in flexion. Although her symptoms were assumed to be due to previously diagnosed CM-I without syringomyelia, no differences on magnetic resonance imaging (MRI) could be found except for slight change in the shape of tonsils compared with the previous ones. FMD and C1 removal with duraplasty was performed and resulted in an excellent neurological recovery.
Conclusion:This case is a reminder that the presence of a new neurological deficit referable to nuclei within, or tracts that traverse, the cerebromedullary junction is a firm surgical indication for FMD in a patient with CM-I. MRI was nearly identical during the asymptomatic and symptomatic periods in this case, and did not explain the timing of symptom onset.
Keywords: Acute onset, Chiari malformation type I, monoparesis, syringomyelia
INTRODUCTION
Chiari malformation type I (CM-I) is typically defined as cerebellar tonsillar herniation of more than 5 mm from the foramen magnum and may be associated with syringomyelia, hydrocephalus, and/or scoliosis.[
Some symptoms of CM-I patients initially appear variable and nonspecific, including headache, neck pain, brainstem or cerebellar dysfunction, cranial nerve signs, and spinal cord dysfunction.[
The widespread availability and use of magnetic resonance imaging (MRI) allow earlier and more frequent detection of CM-I during the developmental stage of this disease, when no or minimal neurological deficits have emerged.[
We report a case of an 11-year-old girl with CM-I diagnosed when she was aged 1 year and remained asymptomatic for 10 years before manifesting acute focal symptoms, including motor and sensory deficits in left upper forearm and dysphagia. Despite her new neurological deficits, MRI could detect only minute change from previous imaging.
CASE REPORT
An 11-year-old girl presented with the gradual onset over one day of sensory dysesthesia of her left forearm followed the day of admission by severe monoparesis of the ipsilateral forearm, increasing dysesthesia, and dysphagia. She recalled that the day the symptoms developed, she swam faster and for a longer duration than usual. She was referred to our hospital one week from the onset because her symptoms had not resolved. Her past history was significant for hydrocephalus from aqueductal stenosis that was diagnosed and treated when she was aged 1 year. Her ventriculomegaly and symptoms at that time resolved completely following endoscopic third ventriculoscopy. CM-I was diagnosed by radiographic criteria. During the subsequent 10 years, she received annual MRI and neurological examinations that documented persistent tonsillar ectopia but no neurological deficits.
On admission, her physical examination revealed spastic paresis of left upper limb, with the limb assuming a peculiar posture at rest, with the wrist in extension and the elbow joint in flexion [
MRI a week from the onset showed cerebellar tonsillar herniation of 8 mm below McRae's (basion-opisthion) line, which was the same amount as on previous imaging. No recurrence of hydrocephalus was demonstrated [Figure
Figure 2
(a) Preoperative sagittal T1-weighted MRI revealing the cerebellar tonsillar herniation of 8 mm. (b) Axial T1-weighted MRI 6 months before the onset and (c) one week after the onset, and (d) sagittal T2-weighted MRI 6 months before the onset and (e) one week after the onset manifesting no progression of cerebellar tonsillar herniation and no syringomyelia
After the operation, dysesthesia and monoparesis of left forearm and dysphagia improved steadily. She was discharged on the 14th postoperative day with complete neurological recovery. At the follow-up 6 months after FMD, she maintained her recovery. Postoperative MRI demonstrated an ascent of the cerebellar tonsil of 4 mm compared with before FMD [
DISCUSSION
We report on a child presenting with the acute onset of focal neurological findings attributed to CM-I despite having asymptomatic CM-I for the preceding 10 years. There was no apparent difference between MRI before and after onset of symptoms, except for slight change in the shape of tonsils. Patients with CM-I who have remained asymptomatic for a long period usually would be expected to have relatively benign outcomes.[
The papers about acute onset of CM-I implied that acute onset of symptoms was quite sporadic and infrequent. Some authors proposed a mechanism in which mild head and/or neck injury triggers the abrupt onset of CM-I and neurological deterioration.[
Most of the subjects in those papers had syringomyelia, and patients with CM-I and syringomyelia may be at higher risk of acute onset and serious neurological deterioration than those without syrinx.[
One of the most common acute manifestations of CM-I is the respiratory distress, which is followed by dysphagia and hemiparesis [
Although the surgical treatment of CM-I is well known among neurosurgeons, the decision whether to operate on asymptomatic patients with CM-I is quite difficult and controversial.[
In spite of the initial severity, the outcome of the patients surviving after an abrupt onset of neurological deficit is generally good with early FMD.[
CONCLUSION
It is very important to recognize that acute neurological decline in a previously asymptomatic patient with CM-I is an indication for urgent treatment with FMD, even if MRI is unchanged between the symptomatic and asymptomatic state. The outcome of FMD appears to be excellent even for the patients with acute neurological deterioration.
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