Macquarie Neurosrgery Evidence Based Surgery
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Transcript of Macquarie Neurosrgery Evidence Based Surgery
MACQUARIE NEUROSURGERYEVIDENCE BASED SURGERY
Is cine phase-contrast MRI able to predict resolution of headache in patients with Chiari malformation type 1 undergoing posterior fossa decompression
Bryden Dawes13/09/2016
Clinical case
46 year old femaleFamily history – CM-1 daughter
Headaches since childhood5 year history occipital headacheValsalva headache
Lumbar puncture – opening pressure 20cmH20
No Neurological deficit
MRI – 8mm caudal descentCrowding of foramen magnumNo syrinx
Clinical case
Phase contrast - Reduced flow dorsal to cerebellum- Normal ventral flow
Posterior fossa decompression
3 month follow up – no further headaches
Cine Phase - contrast MRI
• Cine MR technique that demonstrates biphasic CSF flow
- Cranial flow black- Caudal flow white
• CM-1 - CSF flow at level of foramen magnum• Qualitative and quantitative assessments• Qualitative assessment - interobserver and
intraobserver variability• Dichotomised or 3 point scale
- Absent flow - Reduced flow
- Normal flow • Quantitative flow velocities can be measured –
point measurement
PICO question
P – Type 1 Chiari malformation with headache undergoing surgeryI – CSF flow abnormality on FC MRIC – Normal CSF flow on FC MRIO – Post operative headache
‘In a patient with a CM-1 and headache undergoing surgery does a CSF flow abnormality on FC MRI compared with normal CSF flow lead to better post operative headache’.
Search Strategy
• Ovid medline• EMBASE• Scopus• Reference / citation review of key papers
Inclusion criteria• CM-1 with and without syrinx• Paediatric and adult• Minimum 10 patients – surgical cases• Post surgical data• Clinical correlation
Ovid Medline
Ovid Medline
Ovid Medline
EMBASE
Scopus
PRIS
MA
Summary of papers
Autor Title Year Journal Institution
McGirt et al (1)Correlation of CSF fluid flow
dynamics and headache in Chiari 1 malformation
2005 Neurosurgery Duke UMC
McGirt et al (2)Relationship of cine phase-
contrast MRI to outcome after decompression for CM1
2006 Neurosurgery Duke UMC
Koc et alChiari 1 malformation with
syringmyelia: correlation of phase contrast cine MR imaging and
outcome2007 Turkish
NeurosurgeryKocalli Medical Centre, Turkey
McGirt et al (3)Correlation of hindbrain CSF flow
and outcome after surgical decompression for Chiari 1
malformation2008 Child's Nervous
system John Hopkins
Ovid Medline
McGirt Papers
Matthew J McGirt
• Associate Professor - University North Carolina
• MD at Duke• Residency at John Hopkins• Complex Spine
Summary of papers
Autor Design Number of surgical patient Mean age Syrinx Headache
McGirt et al (1) Retrospective 17 (30 included) 14 (3 - 26) 0 17/17
McGirt et al (2) Retrospective 130 16 (3-29) 46/130 104/130
Koc et al Not specified 18 34.5 (19 -56) 18/18 14/18
McGirt et al (3) Retrospective 44 8 (2-14)* 8/44 35/44
* Paediatric hospital
Summary of papers
Autor MR analysis Operation Follow - up Outcome Assessment
McGirt et al (1)Qualitative –
dichotomised Craniectomy, C1 laminectomy &
duroplasty 12 months No scale
McGirt et al (2) Qualitative – dichotomised
Craniectomy, C1 laminectomy &
duroplasty 19 months (Mean) No scale
Koc et al Qualitative and fCSF velocity
Craniectomy, C1 laminectomy &
duroplasty (lyophilised)
26 months Functional scoring system
McGirt et al (3)
Qualatative (presence of biphasic flow
ventral and dorsal to brainstem)
Craniectomy, C1 laminectomy &
duroplasty (Synthetic)
27 months (Mean) No scale
Results
• N = 30 (17 surgical cases)• 12 patients with headache and
PC abnormality• 100% improvement
Results
• N = 130 • 81 % abnormal CSF flow• 33% symptom recurrence at
Results
• N = 18 • 100 % abnormal CSF flow• 11% symptom recurrence• Poor analysis and difficult to interpret
Results
• N = 44• 68 % abnormal CSF flow• 30% symptom recurrence at
follow up• Abnormal dorsal CSF not
significant• Abnormal ventral flow RR 2.6
Conclusions
• Evidence poor quality• Small number of studies• Author bias• MR assessment - qualitative
assessment• Clinical outcome – records review• Phase contrast abnormality appears to
be an independent predictor of good outcome following surgery