macquarie neurosrgery evidence based surgery
TRANSCRIPT
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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
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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
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Clinical case
Phase contrast - Reduced flow dorsal to cerebellum- Normal ventral flow
Posterior fossa decompression
3 month follow up – no further headaches
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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
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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’.
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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
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Ovid Medline
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Ovid Medline
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Ovid Medline
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EMBASE
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Scopus
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PRIS
MA
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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
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Ovid Medline
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McGirt Papers
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Matthew J McGirt
• Associate Professor - University North Carolina
• MD at Duke• Residency at John Hopkins• Complex Spine
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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
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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
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Results
• N = 30 (17 surgical cases)• 12 patients with headache and
PC abnormality• 100% improvement
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Results
• N = 130 • 81 % abnormal CSF flow• 33% symptom recurrence at
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Results
• N = 18 • 100 % abnormal CSF flow• 11% symptom recurrence• Poor analysis and difficult to interpret
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Results
• N = 44• 68 % abnormal CSF flow• 30% symptom recurrence at
follow up• Abnormal dorsal CSF not
significant• Abnormal ventral flow RR 2.6
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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