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Perioperative monitoring of pulsatile and static intracranial pressure in patients with Chiari malformation type 1 undergoing foramen magnum decompression

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Abstract

Background

Patients with Chiari malformation type 1 (CMI) often present with elevated pulsatile and static intracranial pressure (ICP). The preferred treatment of CMI, foramen magnum decompression (FMD), is assumed to normalise ICP and craniospinal pressure dissociation. In order to further explore the mechanisms behind FMD, the present study investigated whether or not pulsatile and static ICP normalises immediately after FMD.

Method

The study included CMI patients undergoing FMD with perioperative ICP monitoring as a part of clinical management. The pulsatile and static ICP scores were retrieved from the department’s ICP database, and the clinical and radiological data from the patient records.

Results

Eleven patients were included in the study. During the first 3 days following FMD, mixed model analysis revealed no significant time-dependent differences of preoperatively elevated either pulsatile (mean wave amplitude, MWA; p = 0.85) and/or static (mean ICP, p = 0.90) ICP. Percentage of mean ICP >15 mmHg increased during days 2 and 3 after FMD. Two patients from the present series had to receive ventriculoperitoneal shunt after FMD in the early postoperative period.

Conclusions

The present observations suggest that anatomical restoration of cerebrospinal fluid pathways by FMD does not lead to immediate normalisation of preoperatively altered pulsatile and static ICP in patients with CMI. This finding may explain persistent symptoms during the early period after FMD.

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Acknowledgments

The authors thank Are Hugo Pripp, PhD, Department of Biostatistics, Epidemiology and Health Economics, Oslo University Hospital, Oslo, for performing the statistical mixed model analysis. We thank also Matthew Spreadbury for kindly reviewing the text of this manuscript.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Oslo University Hospital—Rikshospitalet, P.O.Box 4950, Nydalen, 0424, Oslo, Norway

    Radek Frič & Per Kristian Eide

  2. Faculty of Medicine, University of Oslo, Oslo, Norway

    Per Kristian Eide

Authors
  1. Radek Frič
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  2. Per Kristian Eide
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Corresponding author

Correspondence to Radek Frič.

Ethics declarations

Funding

No funding was received for this research.

Conflict of interest

The first author (R.F.) certifies that he has no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria, educational grants, participation in speakers’ bureaus, membership, employment, consultancies, stock ownership, or other equity interest, and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. The software used for analysis of the ICP recordings (Sensometrics Software) is manufactured by a software company (dPCom AS, Oslo, Norway), in which the second author (P.K.E.) has a financial interest.

Ethical approval

For this type of (retrospective) study formal consent is not required. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Additional information

Comments

In this small and well-written study the authors analyse the ICP pressure pattern (pulsatile and static) in patients with Chiari I malformation, treated with foramen magnum decompression (FMD). The main finding of the study is a delay normalisation of the ICP in those patients with abnormal pre-operative ICP. Chiari I malformation is a different pathophysiological entity from Chiari II. Alteration of the CSF dynamic can be the primary cause of the Chiari I malformation with tonsillar herniation (and other symptoms) as epiphenomena. Identification of those patients with primary raised CSF pressure is of primary importance because a simple CSF diversion procedure can be sufficient [1]. On the other hand, the findings of the authors with delay normalisation of the ICP waveform indicate the necessity to closely monitor post-decompression patients to minimise CSF-related post-operative complication. Should we routinely ICP monitor patients with Chiari malformation following FMD? Should we consider pre-operative ICP monitoring in patient with Chiari I? Possibly the answer is yes, but a larger cohort of patients will be necessary before reaching a final conclusion. The authors should be complimented for the low rate of complication reported as well.

Jibril Osman Farah

Liverpool, UK

1. Hayhurst C, Osman-Farah J, Das K, Mallucci C (2008) Initial management of hydrocephalus associated with Chiari malformation Type I-syringomyelia complex via endoscopic third ventriculostomy: an outcome analysis. J Neurosurg 108:1211–1214

This is a rather preliminary paper on perioperative monitoring of pulsatile and static ICP parameters in patients with Chiari malformation in which the authors investigated the hypothesis that respective values normalise immediately after FMD for patients with CMI 1, and this is the first study also describing changes in pulsatile ICP. ICP waveform monitoring via an intraparenchymal monitor was performed for all patients. A specific automated software algorithm was used for analysis. ICP scores were retrieved from the department’s ICP database. Clinical outcome was reassessed after a mean follow-up of 12 months. The authors’ observations suggest that anatomical restoration of CSF pathways by FMD does not lead to immediate normalisation of preoperatively altered pulsatile and static ICP in patients with CMI. This finding may explain persistent symptoms after FMD. This observation is surprising and deserves further investigation—especially when made in combination with comprehensive imaging studies utilising modern radiographic CSF flow techniques.

Ekkehard Matthias Kasper

Boston, USA

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Frič, R., Eide, P.K. Perioperative monitoring of pulsatile and static intracranial pressure in patients with Chiari malformation type 1 undergoing foramen magnum decompression. Acta Neurochir 158, 341–347 (2016). https://doi.org/10.1007/s00701-015-2669-0

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  • DOI: https://doi.org/10.1007/s00701-015-2669-0

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