Download to read offline
Uploaded byMQ_Library
Macquarie Neurosrgery Evidence Based Surgery
This document summarizes 4 studies that evaluate whether abnormal cerebrospinal fluid (CSF) flow on cine phase-contrast magnetic resonance imaging (MRI) can predict resolution of headache in patients with Chiari malformation type 1 undergoing posterior fossa decompression surgery. The studies found that 68-81% of patients had abnormal CSF flow pre-operatively and post-operative headache resolution rates were 66-90% in those with abnormal flow compared to 30-33% in those with normal flow. However, the quality of evidence was limited due to small study sizes, potential author bias, and variability in MRI and clinical outcome assessments between studies.
More Related Content
Similar to Macquarie Neurosrgery Evidence Based Surgery
Macquarie Neurosrgery Evidence Based Surgery
- 1. MACQUARIE NEUROSURGERY EVIDENCE BASEDSURGERY Is cine phase-contrast MRI able to predict resolution of headache in patients with Chiari malformation type 1 undergoing posterior fossa decompression Bryden Dawes 13/09/2016
- 2. Clinical case 46 yearold female Family history – CM-1 daughter Headaches since childhood 5 year history occipital headache Valsalva headache Lumbar puncture – opening pressure 20cmH20 No Neurological deficit MRI – 8mm caudal descent Crowding of foramen magnum No syrinx
- 3. Clinical case Phase contrast -Reduced flow dorsal to cerebellum - Normal ventral flow Posterior fossa decompression 3 month follow up – no further headaches
- 4. 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
- 5. PICO question P –Type 1 Chiari malformation with headache undergoing surgery I – CSF flow abnormality on FC MRI C – Normal CSF flow on FC MRI O – 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’.
- 6. Search Strategy • Ovidmedline • 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
- 7.
- 8.
- 9.
- 10.
- 11.
- 13. Summary of papers AutorTitle 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 al Chiari 1 malformation with syringmyelia: correlation of phase contrast cine MR imaging and outcome 2007 Turkish Neurosurgery Kocalli Medical Centre, Turkey McGirt et al (3) Correlation of hindbrain CSF flow and outcome after surgical decompression for Chiari 1 malformation 2008 Child's Nervous system John Hopkins
- 14.
- 15.
- 16. Matthew J McGirt •Associate Professor - University North Carolina • MD at Duke • Residency at John Hopkins • Complex Spine
- 17. Summary of papers AutorDesign 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
- 18. Summary of papers AutorMR 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
- 19. Results • N =30 (17 surgical cases) • 12 patients with headache and PC abnormality • 100% improvement
- 20. Results • N =130 • 81 % abnormal CSF flow • 33% symptom recurrence at
- 21. Results • N =18 • 100 % abnormal CSF flow • 11% symptom recurrence • Poor analysis and difficult to interpret
- 22. Results • N =44 • 68 % abnormal CSF flow • 30% symptom recurrence at follow up • Abnormal dorsal CSF not significant • Abnormal ventral flow RR 2.6
- 23. Conclusions • Evidence poorquality • 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
Editor's Notes
- #3 Please ensure that no identifying features are included
- #4 Please ensure that no identifying features are included
- #5 Please ensure that no identifying features are included
- #6 Difficulties with putting clinical question into PICO
- #8 Combined with headaches out of interest
- #9 Combined with treatment outcome and MESH terms form key papers
- #10 Make note of arnold chiari Discuss there MRI key terms with MRI and MRI – cine
- #15 Combined with headaches out of interest
- #16 All taken retrospective from database 1997 – 2003 Paper 1 – all patients who had PFD (Duke) Paper 2 – All patients who presented with headache alone (Duke) Paper 3 - All (John Hopkins database) consectutive cases of PFD
- #17 All taken retrospective from database 1997 – 2003 Paper 1 – all patients who had PFD (Duke) Paper 2 – All patients who presented with headache alone (Duke) Paper 3 - All (John Hopkins database) consectutive cases of PFD
- #20 Please ensure that no identifying features are included
- #21 Please ensure that no identifying features are included
- #22 Please ensure that no identifying features are included
- #23 Please ensure that no identifying features are included
- #24 Please ensure that no identifying features are included