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|NI FEATURE: THE EDITORIAL DEBATE IV-- PROS AND CONS
|Year : 2019 | Volume
| Issue : 3 | Page : 664
Cerebrospinal fluid studies in Chiari I malformation: Do we go with the flow?
Department of Neurosurgery and Gamma-Knife Centre, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||23-Jul-2019|
Dr. Deepak Agrawal
Department of Neurosurgery and Gamma-Knife Centre, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Agrawal D. Cerebrospinal fluid studies in Chiari I malformation: Do we go with the flow?. Neurol India 2019;67:664
Chiari I malformation remains a challenging entity to treat. Its management is associated with significant complication rates and less-than-satisfactory clinical outcomes. It was, therefore, not surprising that the introduction of magnetic resonance imaging (MRI) cerebrospinal fluid (CSF) flow study, a few decades back, was considered the 'holy grail' for the holistic management of patients with Chiari I malformation. Much water has since flown under the fabled bridge, with the use of CSF flow studies in the current era being limited to the research domain. Even the flow of research studies is down to a trickle, with only a handful of studies published on Chiari I malformation in the last decade. The reasons are not hard to find: Difficulty in the performance and interpretation of CSF flow studies, with significant operator dependence. There also remains ambiguity regarding the correct location for performing the flow analysis, with some studies performing the analysis at the level of foramen magnum and others at various cervical levels.
I read with interest the article by Drs. Abhishek Kumar, Samarendra Nath Ghosh, Sadique Shahid Iftekaar. The authors have lucidly put across the usefulness of CSF flow studies in symptomatic patients with Chiari I malformation. Interestingly, the authors used a purely extradural procedure in all their patients. From the research perspective, this is indeed commendable as the surgical group remained homogenous. Although all operative procedures for Chiari malformation More Details have their pros and cons, an 'one shoe fits all' philosophy may be misplaced- especially in Chiari malformation, wherein a more tailored approach based on the degree of cerebellar extopia and the surrounding craniovertebral junction anomalies, may be warranted.
A word of caution- conclusions can only be drawn from the observations and subsequent results of a study. The authors' conclusion that “…degree of CSF flow obstruction rather than the degree of tonsillar herniation can better select patients who are most responsive to surgery” is not based on any concrete data. To arrive at this conclusion, one would need to have a control group of symptomatic patients with significant Chiari I malformation and a normal or mildly abnormal CSF flow study with a poor clinic-radiological outcome. This group is obviously missing in the study. In the end, the study raises more questions than it answers, which is the paradox of research…and life!
| » References|| |
Hentschel S, Mardal KA, Løvgren AE, Linge S, Haughton V. Characterization of cyclic CSF flow in the foramen magnum and upper cervical spinal canal with MR flow imaging and computational fluid dynamics. AJNR Am J Neuroradiol 2010;3:997-1002.
Kumar A, Ghosh SN, Iftekaar SS. Clinicoradiological study of adult Chiari malformation type 1 patients with emphasis on cerebrospinal fluid peak flow velocity at foramen magnum level. Neurol India 2019;67:744-8. [Full text]