Role of Cranioplasty in Management of Chiari Malformation

Abstract

Chiari malformations (CM) are a set of enigmatic congenital anomalies, owing to their complex pathology, varied presentations and management dilemma. Because of the daunting nature of this disease, a universal definitive treatment protocol is yet to be established. Diverse surgical procedures are in practice with various philosophies, aiming to resolve different sections of the pathologies of this disorder, either singly or in combination. However, outcomes are quite variable. Though not a well-recognized and commonly practiced paradigm of managing CM, different techniques of cranioplasty for CM has been described by many authors with variable rates of success. Cranioplasty for Chiari has been found to be helpful in different circumstances with the objective to address different predicaments. Initially, it has been exercised as one of the modalities to manage some particular situations, mostly in cases to solve complications following surgery. Now in some centers, different types of methods of cranioplasty are practiced routinely to treat particular set of Chiari patients with specifically set criteria and some have shown success in those certain scenarios. In this chapter, different methods of cranioplasty for Chiari malformation by different authors, strategies behind the techniques and their results are described in brief. "Stealth cranioplasty", a technique devised by our team is also portrayed.

Symptomatic Cerebellar Ptosis After Wide Foramen Magnum Decompression for Chiari I Malformation

“…Various alternative techniques have been reported in the literature by different authors, which attempt to prevent the occurrence of cerebellar ptosis. These include expansile suboccipital cranioplasty, stealth cranioplasty, expansile cranioplasty with meshassisted dural tenting, and decompressive techniques such as "barrel staving" [8,9].…”

Stealth cranioplasty in symptomatic adult chiari 1 malformations: Experience at Bangabandhu Sheikh Mujib Medical University

“…They range from bony decompression with or without duraplasty; preserving or breaching the arachnoid; not touching, dissecting or resecting the tonsils; dural graft tenting or performing cranioplasties. [15][16][17][18][19][20][21][22][23] Each of the surgical procedures has their own debatable advantages and disadvantages. All the techniques ultimately are adapted to alleviate the symptoms and signs, manage syringomyelia and reduce complications.…”

“…15,19,20 Few years back, we developed a surgical technique, the "Stealth Cranioplasty (SC)". [21][22][23] We addressed some aspects of pathophysiology to overcome some limitations related to outcomes seen in the traditional surgical approaches by combining and modifying some of the techniques together, particularly to reduce complications and recurrence by performing a smaller craniectomy, arachnoid preserving linear durotomy and duraplasty by investing layer of the deep cervical fascia, a titanium mesh cranioplasty in the shape of the cockpit of a stealth bomber and finally, dural graft tenting with the titanium implant. However, a full proof procedure is yet to come.…”

A Novel Technique to Assess the Outcome of Adult Chiari Malformation 1 Radiologically Following Stealth Cranioplasty, Posterior Fossa Decompression, and Posterior Fossa Decompression with Duraplasty

“…However, the tonsils were not manipulated. All the cases of the stealth Cranioplasty (SC), which we described in detail a few years back [9][10][11], comprised 3 cm X 3 cm suboccipital craniectomy with C1 laminectomy (Figure 1A), midline linear arachnoid preserving durotomy (Figure 1B), duraplasty with the superficial layer of the deep cervical fascia (Figure 1C), cranioplasty with pre-shaped 5 cm X 5 cm titanium mesh which is of the shape of the canopy with flat wings of a Stealth bomber (Figure 1D), fixation of the cranioplasty along the margins of the craniectomy with screws to cover the craniectomy gap and tacking of the duraplasty with the titanium mesh to maintain the enlargement of the posterior fossa and the foramen magnum AP diameter (Figure 1E) which can be appreciated well in the postoperative CT scan (Figure 1F 2) which is pretty straightforward as the new opisthion is created by the lower margin of stealth cranioplasty which can be well detected in CT or MRI images. However, in cases of PFD and PFDD, where the posterior bony margin of the foramen magnum is deficient, we adopted a novel technique.…”