Relationship between Cough-Associated Changes in CSF Flow and Disease Severity in Chiari I Malformation: An Exploratory Study Using Real-Time MRI

Bezuidenhout, Abraham F.; Khatami, David; Heilman, Carl B.; Kasper, Ekkehard M.; Patz, Samuel; Madan, Neel; Zhao, Yongbo; Bhadelia, Rafeeque A.

doi:10.3174/ajnr.a5670

Cited by 12 publications

(13 citation statements)

References 40 publications

(66 reference statements)

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“…CSF movement is driven by pressure changes in CNS vascular system due to cardiac pulsation (~ 1 Hz) 2 , 7 , 24 – 32 and respiration (0.1–0.3 Hz) 12 – 16 , 33 – 38 , and is influenced by transient effects such as coughing 14 , 39 – 41 , and body posture 42 , 43 . A topic of current interest involving CSF dynamics is identifying the primary regulator(s) of CNS fluids or solute movement within subarachnoid spaces, ventricles, and deep brain parenchyma 2 , 7 , 12 , 14 , 36 , 37 , 44 .…”

Section: Introductionmentioning

confidence: 99%

Immediate impact of yogic breathing on pulsatile cerebrospinal fluid dynamics

Yıldız

Grinstead

Hildebrand

et al. 2022

Sci Rep

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Cerebrospinal fluid (CSF), a clear fluid bathing the central nervous system (CNS), undergoes pulsatile movements. Together with interstitial fluid, CSF plays a critical role for the removal of waste products from the brain, and maintenance of the CNS health. As such, understanding the mechanisms driving CSF movement is of high scientific and clinical impact. Since pulsatile CSF dynamics is sensitive and synchronous to respiratory movements, we are interested in identifying potential integrative therapies such as yogic breathing to regulate CSF dynamics, which has not been reported before. Here, we investigated the pre-intervention baseline data from our ongoing randomized controlled trial, and examined the impact of four yogic breathing patterns: (i) slow, (ii) deep abdominal, (iii) deep diaphragmatic, and (iv) deep chest breathing with the last three together forming a yogic breathing called three-part breath. We utilized our previously established non-invasive real-time phase contrast magnetic resonance imaging approach using a 3T MRI instrument, computed and tested differences in single voxel CSF velocities (instantaneous, respiratory, cardiac 1st and 2nd harmonics) at the level of foramen magnum during spontaneous versus yogic breathing. In examinations of 18 healthy participants (eight females, ten males; mean age 34.9 ± 14 (SD) years; age range: 18–61 years), we observed immediate increase in cranially-directed velocities of instantaneous-CSF 16–28% and respiratory-CSF 60–118% during four breathing patterns compared to spontaneous breathing, with the greatest changes during deep abdominal breathing (28%, p = 0.0008, and 118%, p = 0.0001, respectively). Cardiac pulsation was the primary source of pulsatile CSF motion except during deep abdominal breathing, when there was a comparable contribution of respiratory and cardiac 1st harmonic power [0.59 ± 0.78], suggesting respiration can be the primary regulator of CSF depending on the individual differences in breathing techniques. Further work is needed to investigate the impact of sustained training yogic breathing on pulsatile CSF dynamics for CNS health.

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Section: Introductionmentioning

confidence: 99%

Immediate impact of yogic breathing on pulsatile cerebrospinal fluid dynamics

Yıldız

Grinstead

Hildebrand

et al. 2022

Sci Rep

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“…This review does not touch on emerging neuroimaging research such as functional neuroimaging, 57 or studies generally used to investigate secondary headache disorders such as CSF flow studies 58 or MRI venograms to assess for the presence of transverse sinus stenosis. 59 Recommendations.-It is not necessary to do neuroimaging in patients with headaches consistent with migraine who have a normal neurologic examination.…”

Section: Discussionmentioning

confidence: 99%

Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence‐Based Guideline

et al. 2019

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Objective.-To provide updated evidence-based recommendations about when to obtain neuroimaging in patients with migraine.Methods.-Articles were included in the systematic review if they studied adults 18 and over who were seeking outpatient treatment for any type of migraine and who underwent neuroimaging (MRI or CT). Medline, Web of Science, and Cochrane Clinical Trials were searched from 1973 to August 31, 2018. Reviewers identified studies, extracted data, and assessed the quality of the evidence in duplicate. We assessed study quality using the Newcastle-Ottawa Scale.Results.-The initial search yielded 2269 publications. Twenty three articles met inclusion criteria and were included in the final review. The majority of studies were retrospective cohort or cross-sectional studies. There were 4 prospective observational studies. Ten studies evaluated the utility of CT only, 9 MRI only, and 4 evaluated both. Common abnormalities included chronic ischemia or atrophy with CT and MRI scanning, and non-specific white matter lesions with MRI. Clinically meaningful abnormalities requiring intervention were relatively rare. Clinically significant neuroimaging abnormalities in patients with headaches consistent with migraine without atypical features or red flags appeared no more common than in the general population.Recommendations.-There is no necessity to do neuroimaging in patients with headaches consistent with migraine who have a normal neurologic examination, and there are no atypical features or red flags present. Grade A Neuroimaging may be considered for presumed migraine for the following reasons: unusual, prolonged, or persistent aura; increasing frequency, severity, or change in clinical features, first or worst migraine, migraine with brainstem aura, migraine with confusion, migraine with motor manifestations (hemiplegic migraine), late-life migraine accompaniments, aura without headache, side-locked headache, and posttraumatic headache. Most of these are consensus based with little or no literature support. Grade C.(Headache 2020;60:318-336) OBJECTIVESThe American Headache Society (AHS) develops guidelines and practice parameters for clinicians. This guideline summarizes evidence from the existing literature about when to recommend neuroimaging in patients with migraine. We specifically reviewed Headache Maximum scores: Selection = 5, Comparability = 2, Outcome = 3, Total Quality Score = 10.

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“…Chiari I malformation (CMI) is defined as ≥5 mm downward displacement/herniation of the cerebellar tonsils below the level of foramen magnum 1,2 . Cough‐associated headache (CAH) and syringomyelia are the most common indications for surgery in CMI and are both believed to result from abnormal CSF flow and pressure dynamics between the head and spine secondary to foramen magnum obstruction from crowding of neural structures 3–21 . In the past, several invasive studies with simultaneous pressure measurements in the head and spinal canal have been performed to both elucidate pathophysiology of CAH and syringomyelia and to develop objective assessments of CMI severity 13–15,21–24 .…”

Section: Figurementioning

confidence: 99%

Cerebrospinal Fluid Flow and Brain Motion in Chiari I Malformation: Past, Present, and Future

Bhadelia

Chang

Oshinski

et al. 2023

Magnetic Resonance Imaging

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Cranio-spinal volume and pressure changes associated with the cardiac-cycle and respiration are altered in Chiari I malformation (CMI) due to obstruction of cerebrospinal fluid (CSF) flow at the foramen magnum. With the introduction of motion-sensitive MRI sequences, it was envisioned that these could provide noninvasive information about volumepressure dynamics at the cranio-cervical junction in CMI hitherto available only through invasive pressure measurements. Since the early 1990s, multiple studies have assessed CSF flow and brain motion in CMI. However, differences in design and varied approaches in the presentation of results and conclusions makes it difficult to fully comprehend the role of MR imaging of CSF flow and brain motion in CMI. In this review, a cohesive summary of the current status of MRI assessment of CSF flow and brain motion in CMI is presented. Simplified versions of the results and conclusions of previous studies are presented by dividing the studies in distinct topics: 1) comparing CSF flow and brain motion between healthy subjects (HS) and CMI patients (before and after surgery), 2) comparing CSF flow and brain motion to CMI severity and symptoms, and 3) comparing CSF flow and brain motion in CMI with and without syringomyelia. Finally, we will discuss our vision of the future directions of MR imaging in CMI patients. Evidence Level: 2. Technical Efficacy: 5.

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Relationship between Cough-Associated Changes in CSF Flow and Disease Severity in Chiari I Malformation: An Exploratory Study Using Real-Time MRI

Abstract: Our exploratory study suggests that assessment of CSF flow response to a coughing challenge has the potential to become a valuable objective noninvasive test for clinical assessment of disease severity in patients with Chiari I malformation.

Cited by 12 publications

References 40 publications

Immediate impact of yogic breathing on pulsatile cerebrospinal fluid dynamics

Immediate impact of yogic breathing on pulsatile cerebrospinal fluid dynamics

Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence‐Based Guideline

Cerebrospinal Fluid Flow and Brain Motion in Chiari I Malformation: Past, Present, and Future

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