Pituitary Problems???

I am looking for information regarding Pituitary problems before and after surgery?? Please post if you have any!

Type Of Headache May Indicate If Surgery Is Required...

With no objective test to say when decompression surgery is necessary, it is no surprise that there is little agreement on this topic in the medical community. A recent, worldwide survey (Survey Shows How Doctors Worldwide Treat Chiari) of neurosurgeons highlighted the controversies surrounding the management of this disease. While some cases are easy - a syrinx with progressive symptoms - cases where headaches are the only symptom are particularly troublesome. The question boils down to, are the risks of the highly invasive surgery worth the benefit in these cases? According to Dr. Mathew McGirt of Johns Hopkins Medical Center, and his colleagues at Duke University, the answer may depend on the type of headache the Chiari patient has. This was the finding of a study the team performed on 33 pediatric Chiari patients whose only symptoms were headaches. They reported their results in the April, 2005 issue of the journal Neurosurgery. Between 1998 and 2002, the researchers identified children who had a Chiari malformation greater than 5mm and who were suffering only from headaches. Children with syringomyelia, hydrocephalus, scoliosis, or other abnormalities in the region of the skull/spine junction were excluded from the study. Thirty-three children were identified, with an average age of 14. There were 14 girls and 19 boys with an average tonsillar herniation of 8.8mm Each child's headaches were classified as being frontal, generalized, or occipital, based on where they started. In addition, each child underwent a cine-MRI to examine their CSF flow. From this test, each child was also classified as having obstructed flow (if flow was completely blocked in one of several areas), or having non-obstructed flow. Seventeen of the children then underwent a standard decompression surgery, including lamiectomy and duraplasty, and were evaluated again one year later. Of the 33 patients, 11 suffered from frontal headaches, 7 from generalized headaches, and 15 from occipital headaches. When the researchers compared headache types to CSF flow, they found a significant relationship between occipital headaches and both obstructed CSF flow, and a greater degree of tonsillar herniation (see Table 1). In fact, patients with occipital headaches were ten times more likely to have obstructed CSF flow and 8 times more likely to have herniations greater than 7mm, than patients with either frontal or generalized headaches. In contrast, there was no association between headache type and age, sex, or length of symptoms. As stated previously, 17 patients were selected to undergo decompression surgery. They included 7 patients with frontal headaches and 10 patients with occipital headaches. The surgical group was evaluated one year later to determine if the surgery had eliminated the headaches. The researchers found that the surgery was completely successful for all 10 of the patients with occipital headaches, but was only successful for 3 out of 7 of the frontal headache group (see Table 2). In looking at the frontal headache group more closely, the two patients who also had obstructed flow improved with surgery. This means that in the surgical group as a whole, 12 out of 12 (100%) of patients with obstructed CSF flow improved with surgery, whereas only 1 patient out of 5 (20%) with normal flow improved. The authors interpret these results as indicating that occipital headaches - which are associated with obstructed CSF flow - are likely a direct result of the Chiari malformation; whereas frontal and generalized headaches may have several causes which may not be linked to the tonsillar herniation at all. They go on to say that this means that surgery should be considered to treat occipital headaches (when Chiari is demonstrated), but other treatments should be considered for frontal and generalized headaches. In comments published in the same journal, Dr. Thomas Milhorat - a Chiari pioneer - points out that the study has several limitations. Age and sex matched controls were not used to identify the general rate of headaches and the classification of headaches based solely on location is of limited value. Despite it's limitations, this study does support previous research findings on a number of fronts. A recent study by Heiss (What causes the dreaded Chiari cough headache?) showed that a cough related headache is a strong predictor of CSF blockage. In addition, a recent study from India (Studying CSF Flow To Predict Surgical Outcome) demonstrated that Chiari patients with blocked CSF flow improved more with surgery than Chiari patients with normal CSF flow. While it is likely that the management of Chiari cases - especially ones where headaches are the only symptom - will remain controversial for quite some time, it is encouraging for patients to see research which attempts to link symptoms to objective tests. Given recent imaging advances, and a focus on the importance of parameters beyond simple CSF flow (Intracranial Compliance Linked To Surgical Success), perhaps the elusive goal of an objective "Chiari" test is at last on the horizon. Back to Table of Contents Key Points There is controversy over when to perform surgery for Chiari, especially if headaches are the only symptoms Study looked at 33 pediatric Chiari patients with headaches as only symptom Headaches were classified as frontal, occipital, or generalized; cine MRI was used to also classify CSF flow as obstructed or normal Patients with occipital headaches were 10 times more likely to have obstructed CSF flow and 8 times more likely to have tonsillar herniation greater than 7mm 17 patients underwent decompression surgery Surgery was successful for all 10 with occipital headaches Table 1Characteristics of Headache Only Chiari Patients (33) Characteristic Frontal or Generalized Headache (18) Occipital Headache (15) Significant? Avg. Age 14 15 N Female 39% 46% N Male 61% 54% N Length of symptoms (mo's) 14 15 N Herniation >7mm 33% 80% Y Obstructed CSF flow 17% 66% Y Note: Significant refers to whether there is a statistically significant correlation between the characteristic and the type of headache Table 2Surgical Outcome One Year Post-Op (17 Patients) Headache No Headache Occipital, Obstructed Flow 0 10 Frontal, Obstructed Flow 0 2 Frontal, Normal Flow 4 1 Source: McGirt MJ, Nimjee SM, Floyd J, Bulsara KR, George TM. Correlation of cerebrospinal fluid flow dynamics and headache in Chiari I malformation. Neurosurgery. 2005 Apr;56(4):716-21. Related Articles: Studying CSF Flow To Predict Surgical Outcome Survey Shows How Doctors Worldwide Treat ChiariThe Importance Of Cine MRI Decompression Surgery Reduces CSF Velocity. What causes the dreaded Chiari cough headache?

Abnormal EEG's Non-Specific Abnormal Finding

April 20, 2006 -- Many Chiari patients ask whether Chiari has cognitive effects. In other words, can it effect critical thinking, problem solving, finding the right words, organizing thoughts, and other types of cognitive functions. This is not an easy question to answer. On the one hand, many doctors dismiss a link between Chiari and problems with higher order thinking. They focus on the fact that Chiari tends to impact the cerebellum, which traditionally has been thought to control movement and not be involved in higher order thinking. On the other hand, many adults with Chiari do report cognitive difficulties. These can range from difficulty in articulating thoughts to a general brain fog. In addition, many parents have reported that their children with Chiari may have learning difficulties or developmental delays. Unfortunately, anecdotal evidence such as this can often be misleading, and is not sufficient to say whether Chiari is the cause of the reported cognitive symptoms. The best way to determine if Chiari is the culprit in cognition would be to evaluate a large number of Chiari patients, both adults and children, with a battery of cognitive and emotional tests to see if on average they score lower than the general population. and if specific problems can be identified. Such tests, known as neuropsycological evaluations (NPE's) are expensive however, and to date research in this area has been essentially non-existent. Until such research occurs, with no direct evidence of Chiari's role in cognitive problems, indirect evidence is all there is to go on. As this publication has reported on previously, some researchers are beginning to believe that the cerebellum, once relegated to the basement of brain functions, actually plays a large role in a myriad of brain activities. Studies of children with tumors in the cerebellum region, through NPE's, have demonstrated widespread cognitive deficits. In fact, one researcher has gone so far as to propose the existence of a Cognitive Affective Disorder, where diseases or pathologies in the cerebellum result in a variety of problems with higher-order thinking and emotion. Another factor to consider when evaluating the possible role of Chiari in cognitive problems is that the effects of Chiari are not always limited to the cerebellum. For most Chiari patients, the malformation blocks the natural flow of cerebrospinal fluid (CSF) between the brain and spinal areas. This blockage can lead to an increase in intracranial pressure (the pressure of the CSF inside the head). Some research has shown that sustained, elevated ICP can lead to long-lasting cognitive problems. Finally, one has to wonder about the lack of CSF flow itself. CSF bathes the brain and spinal cord and is continuously replaced. What effects does interfering with this natural process have? A recent study out of the University of Siena, Italy (Buoni et al.) may shed some light on this exact question. In a report posted on-line in March, 2006 in the journal Clinical Neurophysiology, the Italian research team discuss three pediatric Chiari patients treated at their hospital (see Table 1). What makes these patients different is that they were not at first suspected of having Chiari - they didn't have any of the classic symptoms - but rather were being seen for more general problems, such as developmental delays, seizures, and neuromotor delays. As part of their diagnostic work-up, and before they were found to have Chiari, all three children were given EEG's. An EEG is a device which measures and records the brain's electrical activity through sensors placed on a patient's scalp. In all three cases, the EEG's were abnormal. Specifically, the tests showed what is called intermittent rhythmic delta activity (IRDA), which is considered a non-specific abnormal result (see Figure 1). In addition, the second patient's EEG showed abnormal spiking as well. The EEG's were recorded at several times for each child and under varying conditions, such as awake, asleep, etc. Figure1: EEG Of Patient 1 Before And After Chiari Decompression Surgery All three children were subsequently given MRI's and found to have Chiari malformations of varying sizes; one child had a syrinx as well. Despite the lack of symptoms directly attributable to Chiari, the physicians decided to operate, and the children underwent Chiari decompression surgery. During surgery, it was noted with ultrasound that CSF flow was severely or completely blocked in each case. Ultrasound also was used to ensure the restoration of normal CSF flow during the course of the procedure. EEG's were given several times in the year following surgery, and for each child, were completely normal (see Figure 1). The researchers believe that the EEG results indicate a subtle level of distress of the brain tissue due to the lack of CSF flow, which resolved following surgery. It should be noted that the specific type of EEG result seen, namely IRDA, is thought by some people to represent elevated intracranial pressure. However, the researchers in this study do not believe that is the case here, because the children showed no signs of raised ICP. In addition, evidence has to come light which casts doubt on whether IRDA is linked to elevated ICP at all, further bolstering the author's contention that the EEG findings are likely due to lack of CSF flow. While it is only three patients, the fact that the EEG's normalized after decompression surgery and the restoration of CSF flow, is pretty compelling. The indirect evidence that Chiari can have a wide-ranging impact on brain function is mounting. Hopefully, someone will soon look directly at the neuropsychological effects of Chiari so that patients may be properly evaluated and treated. Of course when that research does take place, at least based on this study, it should include EEG's before and after surgery. -- Rick Labuda Back to Table of Contents Key Points Patients often wonder if Chiari has cognitive effects Many adults report "brain fog"; some pediatric patients seem to have learning and developmental delays Many doctors dismiss a link between Chiari and cognitive problems However, indirect evidence indicates Chiari may cause cognitive problems This study reports three cases of children with Chiari and abnormal EEG's All three children were found to have blocked CSF flow during surgery EEG's after surgery were normal Authors believe the abnormal EEG's indicate subtle distress of the brain tissue due to blocked CSF flow Table 1Description of 3 Patients With Abnormal EEG Results Age CM SM EEG Before Surgery EEG After Surgery 12 5mm N IRDA Normal 10 4mm Y IRDA w/spikes Normal 1 8mm N IRDA Normal Note: IRDA is considered a non-specific abnormal EEG finding Source: Buoni S, Zannolli R, Bartolo RM, Donati PA, Mussa F, Giordano F, Genitori L. Surgery removes EEG abnormalities in patients with Chiari type I malformation and poor CSF flow. Clin Neurophysiol. 2006 Mar 15; [Epub ahead of print] Related C&S News Articles: What Is Cerebellar Affective Disorder And What Does It Mean For Chiari Damage To Cerebellum Affects Cognitive Ability In Children Total CSF Flow May Predict Surgical Outcome

Chiari Cough Headache - From Chiari & Syringomyelia News

Post from link above! Headache is one of the most frequently reported symptoms associated with Chiari, and for many people the most troublesome. A particularly unpleasant variation of the Chiari headache is the one associated with coughing. I speak from experience. I underwent corrective surgery during the winter, and I remember dreading every cough brought on by the dry winter air leading up to the surgery. Some researchers have speculated that headaches are aggravated during a cough by tonsillar movement compressing nerve roots in the spine. Another headache theory is based on a difference in pressure between inside the skull and inside the spinal area. However, neither of these theories has substantial data to back them and they are not well accepted by the research community. Now, a new theory has emerged involving a sharp increase in pressure in the spinal area during a cough. Dr. Sansur, Dr. Heiss and their colleagues at NIH (National Institute of Health) reported on their theory in the March, 2003 issue of the Journal of Neurosurgery in a study titled, Pathophysiology of headache associated with cough in patients with Chiari I malformation. The NIH group hypothesized that the peak intrathecal pressure during coughing would be higher in Chiari patients who suffer from cough headaches than in Chiari patients who don't get cough headaches and in healthy people. As part of an ongoing NIH study, the researchers evaluated a group which included: 26 adults with Chiari I and syringomyelia, 4 adults with just Chiari I, and 15 adult, healthy volunteers. Of the 30 patients, 11 suffered from cough headaches (interestingly, all 4 Chiari only patients had cough headaches, but only 7 of the CM/SM patients had cough headaches). At the start of the study, the participants were evaluated by measuring their internal spinal pressure using lumbar puncture. First, a baseline pressure was established, then measurements were taken during coughing, jugular compression [Ed. Note: I can't even stand to button the top buttons of my shirt and these poor people had a cuff placed around their neck and inflated for 10s!], and while blowing into a tube (Valsalva maneuver). Patients subsequently underwent a suboccipital craniectomy, C-1 laminectomy, and duraplasty. Six months after the surgery, the patients intrathecal pressure was measured again at baseline, during cough, during jugular compression and during Valsalva maneuver. What the researchers found is that before surgery, the intrathecal pressure in Chiari patients who suffered from cough headaches was significantly higher during coughing than in both Chiari patients without headaches and the healthy volunteers. In addition, the Chiari cough patients had the highest baseline pressures. The pressure during jugular compression and the Valsalva maneuver was not that different among the groups. After corrective surgery, both the baseline pressure, and pressure during cough, for the group with headaches had come down to essentially the same level as the other groups. Perhaps more importantly, the cough headaches completely went away in 10 of 11 patients and improved in the last patient. Despite strong evidence that supports their original theory, Dr. Heiss believes this is the true value of the study for patients, "For patients with headaches that are made worse with coughing, [surgical decompression] was shown to be very effective for relieving or improving the headaches. Neurosurgeons and neurologists tend to focus on neurological deficits such as paralysis, weakness, and loss of sensation, and pay less attention to symptoms of headache, which are very frequent in Chiari patients...[patients] are thankful when their headaches are relieved after surgery." As for why some people with Chiari get cough headaches and some don't, Dr. Heiss says, "The narrowness of the CSF pathways at the foramen magnum varies among patients with Chiari I and syringomyelia...people with cough headache have more narrowing of the CSF pathways than those without. In addition, some people are just more prone to headaches in general." While the NIH research revealed a possible cough headache mechanism, i.e. a spike in pressure during cough, testing pressure this way is impractical in a clinical setting. But the research also showed that having the symptom of cough associated headache is a strong predictor of CSF blockage and should be considered by physicians when evaluating patients. Unfortunately, many Chiari patients go years suffering from these types of headaches before being properly diagnosed; maybe now physicians will be more aware of the Chiari-cough headache connection. Meet The Surgeon: John D. Heiss, M.D.Staff PhysicianSurgical Neurology BranchNINDS, NIH Education: Neurosurgical ResidencyUniversity of CincinnatiCollege of MedicineCincinnati, OH; 1981-87 Surgical Internship:University of CincinnatiCollege of MedicineCincinnati, OH; 1980-81 Medical School: University of MichiganAnn Arbor, MI; 1976-80 BS Biomedical Sciences:University of MichiganAnn Arbor, MI; 1974-77 Selected Publications: Heiss JD, Oldfield EH: Pathophysiology and Treatment of Syringomyelia. Contemporary Neurosurgery 25(3):1-8, 2003 Heiss JD, Oldfield EH: Syringomyelia and related diseases. In: Weatherall D, Nathan D, editors. Encyclopedia of Life Sciences (Nature, Scientific American). London: Macmillan Reference Limited, 2001. Heiss JD, Oldfield EH: The Chiari type I malformation: suboccipital and upper cervical decompression with duraplasty. In: Benzel EC, editor. Controversies in spine surgery. St. Louis, Quality Medical Publishing, Inc., 2001. Patsalides AD, Heiss JD, Butman JA, DeVroom HL, Oldfield EH, Patronas NJ: MRI in syringomyelia due to trauma or arachnoiditis: Prediction of surgical outcome. Radiology 225 Suppl. S: 1491, 2002 Koch CA, Heiss JD, Pacak K, Krakoff J, Winer KK, Wassermann EM: Chiari malformation type 1 and osteoporosis. Neurosurg Rev 23:171-172, 2000 Editor's Note: While at NIH, Dr. Sansur was a senior level medical student participating in a clinical research training program. He is now a neurosurgical resident at the University of Virginia Neurosurgery Department.