• HPI: The patient is a 21-year-old female with a longstanding history headaches primarily located in the suboccipital region. Her headaches were exacerbated by coughing and last about 30 minutes. She also complained of dizziness. An MRI was obtained to evaluate these headaches and demonstrated cerebellar tonsil herniation of 9 mm below the foramen magnum (Figures 1 and 2) consistent with a Chiari I malformation. 

    PMH: 
    Chronic headaches, obesity 

    Family Hx: 
    Noncontributory 

    Social History: 
    Patient works at a local fast food restaurant. She smokes 1 pack of cigarettes per day but does not drink or use illegal drugs. 

    Neurological Exam: 
    Neurologic exam revealed mild right end gaze nystagmus and a decreased gag reflex. 

    Figure 1. Sagittal T1-weighted MRI demonstrates cerebellar tonsillar herniation 9 mm below the foramen magnum. On closer inspection, note lack of the central portion of the posterior ring of C1 (CT cervical spine not available).

    Figure 2. Coronal post-contrast T1-weighted MRI demonstrates right > left cerebellar tonsillar herniation.

    1. Would you decide to perform a Chiari I decompression based on the history and imaging alone?

    2. If you answered “no” to the previous question, what other tests would you order?

    3. If you decided on a decompressive operation, what would you do?

    4. Which best describes you?

    5. I practice in one of the following states.

    6. Please add any suggestions or comments regarding this case:

    • I practice in Peru
    • I practice in Spain.
    • I would perform a Brainstem evoked potentials preoperatively for this patient.
    • We use intraoperative ultrasound to guide us whether patient with no syrinx and presumably (based on MRI) has a concomitant small PF, will require duraplasty. We published our small series on surgical classification of management of Chiari 1 based on 3 parameters - presence of syrinx, cine flow and cisterna magna size (the latter as direct inference of size of posterior fossa) i have used this classification in about 15+/- or so patients prospectively, so far the results are consistent with the conclusion of that retro review.
    • intra op ultrasound before open dura MRI cervical thoraci no contrast pre op to rule out syringomelia
    • I would like to see the bony anatomy(for proatlas segmentation anamolies) and course of vertebral artery (dizziness) around the foramen magnum that may coexist with bifid C1 posterior arch. Additionally I would like to study dynamic views on X rays. Further plan would be dependent on the investigations.
    • I would perform surgery based on imaging alone. However, I would also image the spine to rule out syrinx. Although Cine MRI is of academic interest in this case, it would not factor into my surgical decision making.
    • I work in Caracas, Venezuela.
    • Patient is symptomatic and tonsillar herniation is more than five mm.She should be benefitted by decompression and posterior fossa reconstruction.
    • I practice in Bahía Blanca, Argentina.
    • i practice in India. ct cervical spine with magnified ct of the c.v. junction is mandatory in my practice . most of the times duroplasty is not rquired, many times due to long standing compression or congenitally there is thick fibrous band needs to be released.
    • I practice in Australia. I would not decide to operate. Rather I would recommend the operation to the patient. I would tell her that there would be a 85-90% chance that she would be substantially improved, but a 10-15% chance that she may not feel greatly improved post-op. The final decision would be hers.
    • I practice in Merida, Yucatan, Mexico
    • I am a mexican neurosurgery pivate practice di solo. Michoacan State
    • need to check for syrinx as well
    • Subocciptal decompression with duroplasty with fascia lata Mri spine with contrast
    • I practice in India. I always do stress view X-rays to exclude Atlanto-axial instability before surgery at CV Junction.
    • FMD (Foramen magnum decompression)+C1 laminectomy with dural plasty is recommended
    • I also agree with the need for an MRI scan of the spine and the use of an autograph.

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