Acute deterioration in occult Chiari malformation following missile spinal trauma

Case report

Restricted access

✓Patients with Chiari malformation (CM) Type I typically experience chronic, slowly progressive symptoms. Rarely, however, do they suffer acute neurological deterioration following an iatrogenic decrease in caudal cerebrospinal fluid pressure due to, for example, a lumbar puncture. To our knowledge, acute neurological deterioration following missile spinal injury in CM has not been previously described.

The authors report on a 16-year-old girl who was shot in the abdomen and lumbar spine. Although neurologically intact on initial workup, she developed precipitous quadriplegia and apnea in a delayed fashion. Tonsillar herniation with medullary compression and cerebellar infarction was diagnosed on magnetic resonance imaging. Suboccipital decompression resulted in significant neurological improvement. Well-formed tonsillar ectopia diagnosed at surgery suggested a preexisting CM.

The authors conclude that missile spinal trauma can precipitate medullary compression and acute neurological decline, especially in patients with preexisting tonsillar ectopia. Immediate operative decompression to relieve impaction at the cervicomedullary junction can result in significant neurological recovery.

Abbreviations used in this paper: CM-I = Chiari malformation Type I; CMJ = cervicomedullary junction; CSF = cerebrospinal fluid; CT = computed tomography; ICP = intracranial pressure; LP = lumboperitoneal; MR = magnetic resonance.
Article Information

Contributor Notes

Address correspondence to: Rudolph J. Schrot, M.D., Department of Neurological Surgery, School of Medicine, University of California, Davis, 4860 Y Street, Suite 3740, Sacramento, California 95817. email: rudolph.schrot@ucdmc.ucdavis.edu.

© AANS, except where prohibited by US copyright law.

Headings
References
  • 1

    Atkinson JLDWeinshenker BGMiller GMPiepgras DGMokri B: Acquired Chiari I malformation secondary to spontaneous spinal cerebrospinal fluid leakage and chronic intracranial hypotension syndrome in seven cases. J Neurosurg 88:2372421998

    • Search Google Scholar
    • Export Citation
  • 2

    Bunc GVorsic M: Presentation of a previously asymptomatic Chiari I malformation by a flexion injury to the neck. J Neurotrauma 18:6456482001

    • Search Google Scholar
    • Export Citation
  • 3

    Callaway GHO'Brien SJTehrany AM: Chiari I malformation and spinal cord injury: cause for concern in contact athletes?. Med Sci Sports Exerc 28:121812201996

    • Search Google Scholar
    • Export Citation
  • 4

    Chumas PDArmstrong DCDrake JMKulkarni AVHoffman HJHumphreys RP: Tonsillar herniation: the rule rather than the exception after lumboperitoneal shunting in the pediatric population. J Neurosurg 78:5685731993

    • Search Google Scholar
    • Export Citation
  • 5

    Chumas PDDrake JMdel Bigio M: Death from chronic tonsillar herniation in a patient with lumboperitoneal shunt and Crouzon's disease. Br J Neurosurg 6:5955991992

    • Search Google Scholar
    • Export Citation
  • 6

    Couldwell WTZhang WAllen RArce DStillerman CB: Cerebellar contusion associated with type I Chiari malformation following supratentorial head trauma: case report. Neurol Res 20:93961998

    • Search Google Scholar
    • Export Citation
  • 7

    Dagnew Evan Loveren HRTew JM Jr: Acute foramen magnum syndrome caused by an acquired Chiari malformation after lumbar drainage of cerebrospinal fluid: report of three cases. Neurosurgery 51:8238292002

    • Search Google Scholar
    • Export Citation
  • 8

    Erbay SHO'Callaghan MGBhadelia R: Is lumbar puncture contraindicated in patients with Chiari I malformation?. AJNR Am J Neuroradiol 26:9852005

    • Search Google Scholar
    • Export Citation
  • 9

    Hammoud MAHaddad FSMoufarrij NA: Spinal cord missile injuries during the Lebanese civil war. Surg Neurol 43:4324421995

  • 10

    Hoffman HJTucker WS: Cephalocranial disproportion. A complication of the treatment of hydrocephalus in children. Childs Brain 2:1671761976

    • Search Google Scholar
    • Export Citation
  • 11

    Karabatsou KQuigley GBuxton NFoy PMallucci C: Lumboperitoneal shunts: are the complications acceptable?. Acta Neurochir (Wien) 146:119311972004

    • Search Google Scholar
    • Export Citation
  • 12

    Khurana RK: Intracranial hypotension. Semin Neurol 16:5101996

  • 13

    Kurup HLawrence THargreaves D: Transient quadriparesis following neck injury: presentation of a Chiari I malformation. Eur J Orthop Surg Traumatol 15:3193212005

    • Search Google Scholar
    • Export Citation
  • 14

    Lancione RR JrKosmorsky GS: When does low mean high? Isolated cerebral ventricular increased intracranial pressure in a patient with a Chiari I malformation. J Neuroophthalmol 21:1181202001

    • Search Google Scholar
    • Export Citation
  • 15

    Mampalam TJAndrews BTGelb DFerriero DPitts LH: Presentation of type I Chiari malformation after head trauma. Neurosurgery 23:7607621988

    • Search Google Scholar
    • Export Citation
  • 16

    Martinot AHue VLeclerc FVallee LClosset MPruvo JP: Sudden death revealing Chiari type 1 malformation in two children. Intensive Care Med 19:73741993

    • Search Google Scholar
    • Export Citation
  • 17

    Meadows JKraut MGuarnieri MHaroun RICarson BS: Asymptomatic Chiari Type I malformations identified on magnetic resonance imaging. J Neurosurg 92:9209262000

    • Search Google Scholar
    • Export Citation
  • 18

    Milhorat THChou MWTrinidad EMKula RWMandell MWolpert C: Chiari I malformation redefined: clinical and radiographic findings for 364 symptomatic patients. Neurosurgery 44:100510171999

    • Search Google Scholar
    • Export Citation
  • 19

    Murano TRella J: Incidental finding of Chiari I Malformation with progression of symptoms after head trauma: case report. J Emerg Med 30:2952982006

    • Search Google Scholar
    • Export Citation
  • 20

    Olivero WCDinh DH: Chiari I malformation with traumatic syringomyelia and spontaneous resolution: case report and literature review. Neurosurgery 30:7587601992

    • Search Google Scholar
    • Export Citation
  • 21

    Paul KSLye RHStrang FADutton J: Arnold-Chiari malformation. Review of 71 cases. J Neurosurg 58:1831871983

  • 22

    Payner TDPrenger EBerger TSCrone KR: Acquired Chiari malformations: incidence, diagnosis, and management. Neurosurgery 34:4294341994

    • Search Google Scholar
    • Export Citation
  • 23

    Samii CMöbius EWeber WHeienbrok HWBerlit P: Pseudo Chiari type I malformation secondary to cerebrospinal fluid leakage. J Neurol 246:1621641999

    • Search Google Scholar
    • Export Citation
  • 24

    Sathi SStieg PE: “Acquired” Chiari I malformation after multiple lumbar punctures: case report”. Neurosurgery 32:3063091993

    • Search Google Scholar
    • Export Citation
  • 25

    Sullivan HC: Fatal tonsillar herniation in pseudotumor cerebri. Neurology 41:114211441991

  • 26

    Sullivan LPStears JCRingel SP: Resolution of syringomyelia and Chiari I malformation by ventriculoatrial shunting in a patient with pseudotumor cerebri and a lumboperitoneal shunt. Neurosurgery 22:7447471988

    • Search Google Scholar
    • Export Citation
  • 27

    Tomaszek DETyson GWBouldin THansen AR: Sudden death in a child with an occult hindbrain malformation. Ann Emerg Med 13:1361381984

    • Search Google Scholar
    • Export Citation
  • 28

    Vernooij MWIkram MATanghe HLVincent AJHofman AKrestin GP: Incidental findings on brain MRI in the general population. N Engl J Med 357:182118282007

    • Search Google Scholar
    • Export Citation
  • 29

    Welch KShillito JStrand RFischer EGWinston KR: Chiari I “malformations”—an acquired disorder?. J Neurosurg 55:6046091981

    • Search Google Scholar
    • Export Citation
  • 30

    Wolf DAVeasey SP IIIWilson SKAdame JKorndorffer WE: Death following minor head trauma in two adult individuals with the Chiari I deformity. J Forensic Sci 43:124112431998

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 170 169 22
Full Text Views 39 26 0
PDF Downloads 41 27 0
EPUB Downloads 0 0 0
PubMed
Google Scholar