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PubMed2004

Clinical outcomes of patent foramen ovale closure for paradoxical emboli without echocardiographic guidance.

The objective of this study was to determine the feasibility of device closure of patent foramen ovale (PFO) for presumed paradoxical emboli without echocardiographic guidance or balloon sizing and the clinical outcome after device closure. Closure of the PFO has been proposed as an alternative to anticoagulation in patients with presumed paradoxical emboli. At present, most centers perform device closure with transesophageal echocardiographic guidance and balloon sizing of the defect. Between May 1998 and April 2002, 92 consecutive patients underwent device closure for a PFO using fluoroscopic monitoring only. Procedural success and major complications were recorded. Follow-up outcomes were recurrence rate and residual atrial shunting on transthoracic echocardiography. All patients (mean age, 45 +/- 13 years; 52% male) had successful device deployment using either the CardioSeal (n = 78) and Amplatzer (n = 14) PFO occluders with no major complications. Mean procedure time and fluoroscopy time was 27 +/- 13 and 6 +/- 4 min, respectively. One patient had a residual shunt on echocardiography at 1 year. Cumulative event-free survival for recurrence of paradoxical embolus at 1 year was 97.3% +/- 1.8%. This study provides a basis for device closure of PFO becoming a safe, day-case procedure, resulting in a low rate of residual shunting and recurrent thromboembolic events.

Adult↗

PubMed1998

Foramen magnum meningioma presenting as amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a progressive, degenerative disease of the nervous system. It affects adults in all age groups and leads to death few years after the diagnosis. The etiology is unknown, and there no convincing medical or surgical therapy Some diseases can mimic ALS. If diagnosed early these may be treatable, but if misdiagnosed as ALS and left untreated they may be fatal. We present a case of foramen magnum meningioma presenting clinically as ALS. After surgery, the symptoms disappeared and the neurological deficits improved.

Amyotrophic Lateral Sclerosis↗

PubMed1988

Foramen magnum decompression versus terminal ventriculostomy for the treatment of syringomyelia.

The A.A review 30 consecutive cases of syringomyelia operated on during the last seven years. Six terminal ventriculostomies (TV) and twenty-seven procedures for foramen magnum decompression (FMD) were performed. All patients of TV group had CT-myelography (CTM) and/or NMR controls at different times after surgery. Clinical results are as follows: 1) of the 6 patients who had TV, only one showed an improvement while five continued to deteriorate and three of them needed a FMD, one a cysto-peritoneal shunt and the last one died from lung cancer. 2) of the 27 patients who had FMD, twenty improved, four were unchanged and three worsened. 3) no surgical deaths occurred in this series. Postoperative NMR monitoring represents an effective non-invasive neuroradiological procedure that allows follow-up of syrinx evolution over the years.

Adolescent↗

PubMed1979

The results of surgical treatment of spondylotic radiculomyelopathy with complete cervical laminectomy and posterior foramen magnum decompression.

Twenty-six patients with cervical spondylosis and radiculomyelopathy were treated surgically. Eight patients had cervical laminectomy C1--C7, and 16 patients had complete cervical laminectomy C1--C7 with excision of the posterior rim of the foramen magnum. Follow-up of patients was from two months to eight years. The majority of patients improved markedly, and some of them had excellent results.

Adult↗

PubMed2005

Neonatal neurological disorders involving the brainstem: neurosonographic approaches through the squamous suture and the foramen magnum.

Brainstem damage which often indicates a critical condition is usually underestimated by trans-anterior-fontanel neurosonography (NS) owing to the far-field limitations. Instead, NS alternately scanning through the squamous suture of the temporal bones and the foramen magnum could provide a better visualization of the brainstem structures. The NS characteristics of brainstem lesions caused by various neonatal neurological disorders, such as hypoxic-ischemic encephalopathy (HIE), metabolic encephalopathy, birth trauma and bacterial meningoencephalitis, can be depicted at the acute stage. An echogenic change in the midbrain was found in patients with HIE or metabolic encephalopathy. In addition to the echogenic change, bilateral transtentorial temporal lobe herniation distorting the contour of the midbrain was observed in a patient with group B streptococcus meningoencephalitis, whereas echogenic changes at the level of the pons and/or the medulla oblongata, mainly localized in the dorsal part, could be observed in newborns with severe HIE, maple syrup urine disease or birth trauma. In this pictorial assay, we demonstrate the feasibility of NS imaging in evaluating the entire brainstem structure of critically ill neonates in the near field and illustrate the characteristic features of brainstem involvement in various neonatal neurological disorders along with computed tomography or magnetic resonance imaging correlation.

Birth Injuries↗

PubMed2002

Cerebral oedema following EVD insertion for delayed hydrocephalus after foramen magnum decompression in Chiari I malformation.

CASE REPORT: A case of Chiari I malformation is reported, in which foramen magnum decompression was followed by delayed onset of acute hydrocephalus after a week. Initial treatment of the hydrocephalus was further complicated by severe cerebral oedema. DISCUSSION: A short survey of the literature suggests that both complications are extremely uncommon. The possible mechanism of development of cerebral oedema through stretch of the cerebral vasculature before ventricular decompression is discussed. This report further adds to the list of complications following surgery for Chiari malformations.

Acute Disease↗

PubMed1998

Endodermal cyst of the foramen magnum: case report and review of the literature.

The majority of endodermal cysts occur in the cervicothoracic spine, ventral to the cord. Intracranial locations are rare. We report a case involving the foramen magnum in a 14-year-old child, which was an incidental finding following a traumatic head injury. A review of the literature revealed six other cases involving this same location. These lesions are asymptomatic for a long time, and may cause brain stem medullary compression. Treatment is surgical. Effective simple removal can be achieved by a posterior approach.

Adolescent↗

PubMed1998

Syringomyelia associated with type I Chiari malformation. A 21-year retrospective study on 75 cases treated by foramen magnum decompression with a special emphasis on the value of tonsils resection.

The purpose of the present study is to evaluate retrospectively the effects of several intra-operative manipulations on the results of foramen magnum decompression (FMD) in patients having syringomyelia associated with type I Chiari malformation. Seventy-five patients having syringomyelia associated with Chiari I malformation were operated on between 1975 and 1996. This population was grouped into 4 subgroups according to the surgical protocol: group I = 42 patients with FMD alone; group II = 16 patients with FMD and third ventricle shunting; group III = 9 patients with FMD and syringosubarachnoid shunting (SSS); group IV = 8 patients with FMD and cerebellar tonsils resection. Pre- and postsurgical magnetic resonance imaging (MRI) studies were analyzed (and compared). Nine patients were lost to follow-up. The results were evaluated in the 66 remaining patients (mean follow-up: 52 months), using the Bidzinski's outcome scale (ref). Two patients (3%) died postoperatively, 31 (47%) had very good results (after additional surgery in 7), 16 (24.2%) had good results (after additional surgery in 7) and 17 (25.7%) had poor results despite further surgery in 9. A total of 27 reoperations were undertaken after primary FMD in 23 patients (35%). Thirty-nine patients (59%) had both pre- and postsurgical MRI evaluation. In 28 (72%) the syrinx had markedly decreased whereas it had remained stable in 11 (28%). Clinical results were not significantly different between the patients of groups I, II and III. Very good or good results were obtained in 24 patients (64.8%) of group I (after additional surgery in 10), in 8 (61.5%) of group II (after additional surgery in 1) and in 7 (87.5%) of group III (after additional surgery in 3). Results in group IV were as follows: 7 patients (87%) had very good results and one had a good result. With a mean follow-up of 28 months, no patient required additional surgery. Postsurgical MRI syrinx reduction was observed in all 8 patients either in the early postoperative course or on delayed followup. It is suggested that tonsils resection might enhance the results of FMD in individuals having Chiari I-related syringomyelia.

Adolescent↗

PubMed1999

Syringobulbia caused by delayed postoperative tethering of the cervical spinal cord - delayed complication of foramen magnum decompression for Chiari malformation.

Postoperative tethering of the high cervical spinal cord is a rare cause of neurological deterioration after foramen magnum decompression (FMD) with duraplasty for Chiari type I malformation. A review of the literature revealed that only 5 cases have been reported. This entity is not widely known to occur as a complication of the common surgical procedure for Chiari type I malformation. A 17-year-old boy experienced rapidly progressive neurological deterioration over a 3-month period. FMD and duraplasty with lyophilized cadaver dura had been performed 8 years previously. Follow-up MR images showed that the cerebrospinal fluid (CSF) space dorsal to the cord was gradually disappearing and that syringobulbia had developed. Opening the dura mater of the posterior fossa revealed dense fibrous scarring, arachnoid thickening over the cervicomedullary area, and tethering the cord to the dura from the medulla to C2. The adhesions were dissected free, and the tethering was released. A syringosubarachnoid (SS) shunt was inserted and duraplasty was performed with an expended polytetrafluoroethylene sheet (Gore-Tex). Postoperative MR images demonstrated that the syringobulbia had completely collapsed and that a dorsal CSF space was present. Follow-up MR images provided significant information on the cervical spinal cord tethering after FMD with duraplasty for Chiari malformation. We encourage sharp surgical detethering and duraplasty with Gore-Tex to avoid retethering. Early recognition and treatment of this unusual but important complication are emphasized.

Adolescent↗

PubMed1985

Microsurgical anatomy of the region of the foramen magnum.

The anatomy needed to plan microoperative approaches to the region of the foramen magnum was examined in 25 cadaveric heads. The structures examined included the lower cranial and upper spinal nerves, the caudal brain stem and rostral spinal cord, the vertebral artery and its branches, the veins and dural sinuses at the craniovertebral junction, and the ligaments and muscles uniting the atlas, axis, and occipital bone. The transoral, transpalatal, labiomandibular, glossolabiomandibular, transsphenoidal, transcranial-transbasal, transcervical, and suboccipital operative approaches to the region are also reviewed.

Atlanto-Occipital Joint↗

PubMed1985

Syringomyelia associated with a foramen magnum meningioma.

In a 14-year-old boy with a meningioma at the foramen magnum extending to C-2, cervical syringomyelia was found on metrizamide computed tomographic myelography. The mechanism of syrinx enhancement on delayed computed tomographic scanning was considered to be due to transneural passage of metrizamide into the spinal cord. Long-standing spinal block may be responsible for development of syringomyelia. Syringomyelia associated with spinal extramedullary tumors was reviewed in the literature.

Adolescent↗

PubMed1987

Bilateral extradural hematoma extending from the foramen magnum to the vertex.

We present a 35-year-old man with an extradural hematoma extending bilaterally across the midline from the foramen magnum to the vertex who completely recovered following surgery. Because of the extent of the fluid collection, computed tomographic scanning proved invaluable in facilitating the planning of our surgical approach. He had a long history of alcohol abuse and there were features suggesting preexisting alcoholic brain atrophy in his postoperative computed tomography scan. The possible relationship of this finding to the size of the hematoma and the outcome is discussed.

Adult↗

PubMed1989

Large meningioma of the foramen magnum in a 4-year-old child.

The case of a 4-year-old boy with 4 months' history of progressive quadriplegia is presented. The neuroradiological work-up, which included computed tomography scanning and magnetic resonance imaging, showed changes consistent with the diagnosis of a large mass lesion in the area of the foramen magnum. At operation a meningioma was completely excised. There was a gradual and almost complete neurological recovery.

Child, Preschool↗

PubMed1993

Hydrosyringomyelia-Chiari I complex. Prospective evaluation of a modified foramen magnum decompression procedure: preliminary results.

A modified foramen magnum decompression procedure, designed to respect the subarachnoid spaces as much as possible, was prospectively evaluated in eight consecutive patients with a progressive clinical syndrome related to hydrosyringomyelia-Chiari I complex. This evaluation included quantitative clinical and magnetic resonance follow-up of at least 1 year in the first six patients and 6 months for the last two. Magnetic resonance scans at 6 months or more confirmed a persistent reduction of the hydrosyringomyelic cavity in all cases, which was associated with obvious subjective improvement. All patients have maintained this improvement. The operative technique and methods of clinical and radiological follow-up are discussed.

Adolescent↗

PubMed1985

Infected intradural hydatid cyst at foramen magnum. A case report.

A case of infected intradural extramedullary hydatid cyst at foramen magnum with recurrent spinomedullary compression is described. The diagnosis was based on operation and histopathology. So far, no case of extraparenchymatous multiple cysts with cervicomedullary compression has been described in literature. Infection within an intact cyst is extremely rare.

Adult↗

PubMed1994

Benign extramedullary tumors in the foramen magnum region.

We present 16 cases of benign extramedullary tumors of the foramen magnum region who were operated on between the years 1984 and 1992. On admission, no case was neurologically intact and over 50% had had symptoms for more than 1 year. Nine patients had erroneous diagnoses initially. CT myelography and magnetic resonance (MR) imaging were the most appropriate diagnostic tools in visualizing tumors of this region. All operations except one, were performed by the posterior approach without surgical mortality. Histopathological examination revealed 8 meningiomas, 6 neurinomas, one tuberculous abscess and one neurenteric cyst which has not been reported at this location before. Patients with minor to moderate disability on admission showed good functional results without any recurrences during follow-up.

Adolescent↗

PubMed2006

A new theory of cryptogenic stroke and its relationship to patent foramen ovale; or, the puzzle of the missing extra risk.

Cryptogenic stroke (or stroke of undetermined cause) is a common cause of stroke and is statistically associated with patent foramen ovale (PFO). The largest study of cryptogenic stroke is the Homma study, which is a sub-study of the WARSS trial; it produced the following data: cryptogenic stroke patients with and without PFO, when treated with either aspirin or warfarin, all had identical recurrence rates. This is puzzling because it seems as though there ought to have been some extra risk in one of the two groups under one of the two treatments. How could everything come out the same? A review of the epidemiology of cryptogenic stroke shows that, compared to patients with stroke of determined cause, cryptogenic stroke patients are a little younger and have lower doses of the usual risk factors (hypertension and diabetes mellitus) but more PFO. Cryptogenic strokes appear to be embolic strokes from an unknown source. A previously published article setting forth a hypothetical theory of stress-induced stroke was used to analyze these data. It is suggested that stress can induce episodic systemic platelet activation and hypercoagulability, which causes transient thrombus formation and subsequent embolization on both the arterial and venous sides of the circulation; the latter requires a PFO to cause a stroke (paradoxical embolism). The sum of these two mechanisms explains cryptogenic stroke. The PFO subset of cryptogenic stroke includes patients with both early and late stage disease who have an aggregate risk approximately equal to that of patients without PFO. Cryptogenic stroke is part of the disease of stress-induced cerebrovascular disease. Aspirin and warfarin have already been shown to be equally effective in secondary prevention of ischemic stroke.

Adult↗

PubMed1998

Foramen magnum syndrome caused by atlanto-occipital assimilation.

Atlanto-occipital assimilation is one of the most common congenital anomalies of the craniovertebral junction, and it usually is asymptomatic. We report a case of this malformation with unusual neurological symptoms which correlate with radiological findings. The anomaly caused the so-called foramen magnum syndrome, which was difficult to localize with neurological examination. The patient also had atlanto-axial dislocation, which was thought to enhance the symptoms with change of head/neck position.

Adult↗