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. 2018 Aug 3:9:153.
doi: 10.4103/sni.sni_70_18. eCollection 2018.

Effectiveness of modified dural incision to preserve the patency of the occipital sinus in foramen magnum decompression for a patient with Chiari malformation type I

Yasuhiko Hayashi  1 , Issei Fukui  1 , Yasuo Sasagawa  1 , Kouichi Misaki  1 , Masahiro Oishi  1 , Mitsutoshi Nakada  1
Affiliations

Effectiveness of modified dural incision to preserve the patency of the occipital sinus in foramen magnum decompression for a patient with Chiari malformation type I

Yasuhiko Hayashi et al. Surg Neurol Int. .

Abstract

Background: Foramen magnum decompression (FMD) has been acknowledged as a standard surgical procedure for symptomatic patients with Chiari malformation type I (CM-I). However, even if dural incision is necessary during FMD, the procedure of cutting off the occipital sinus has not been regarded as a safe option.

Case description: A 27-year-old woman with intractable occipital headache was diagnosed with CM-I without syringomyelia. Preoperative examination revealed a large oblique occipital sinus on her right side. During the first FMD, the dura mater was not incised to preserve the occipital sinus. However, her headache was not relieved with painkillers and cerebellar tonsillar ectopia remained. During the second FMD, two dural incisions were made, while preserving the occipital sinus patency. The dural patch was made using an autologous fascia for both dural incisions. Postoperatively, headache was completely resolved immediately, and cerebellar tonsil was elevated without any complication.

Conclusion: This dural incision, which is a modification of the method introduced by Pritz, would be a useful FMD option for patients of CM-I with dominant occipital sinus, which would lead to the serious neurological sequelae if the sinus flow is disturbed.

Keywords: Chiari malformation; dura; foramen magnum decompression; incision; occipital sinus.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
(a) Preoperative T2-weighted magnetic resonance image on the sagittal section clearly demonstrated the decent of the cerebellar tonsil and tightness of the cerebellar hemisphere in the posterior fossa. (b) The three-dimensional contrasted enhanced venography on the computed tomography scan clearly revealed the dominant occipital sinus on the right side, and undeveloped transverse and sigmoid sinuses on the same side
Figure 2
Figure 2
(a) Compared with the preoperative image, a T2-weighted magnetic resonance image on the sagittal section after the first foramen magnum decompression (FMD) showed no apparent change. (b) A T2-weighted MR-image of the sagittal section after the second FMD revealed the elevation of the cerebellar tonsil and opening of the retrocerebellar space over the cerebellar convexity, indicating that CM-1 findings were remarkably improved
Figure 3
Figure 3
(a) The intraoperative picture revealed the confirmation of the occipital sinus (arrows) with micro-doppler. (b) The dural incision consisted of two parts as follows: a midline incision from the level of C1 to that of the cervicomedullary junction, and an incision over the left cerebellar hemisphere. (c) The scheme of the dural incisions in the present case. OS, occipital sinus; SSS, superior sagittal sinus; TS, transverse sinus
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