Management: opinions from different centers—the Istituto Giannina Gaslini experience

Purpose Describe presentation and management of Chiari type 1 malformation. We report our surgical case series proposing a decision making scheme for helping surgeons decide which surgical procedure to perform and when. Methods We retrospectively examined a series of surgically treated patients with Chiari type 1 malformation. Treatment of associated anomalies, surgical complications, and need for reintervention for insufficient decompression at first surgery are discussed. Results A total of 172 patients have been surgically treated for Chiari type 1 malformation at the Neurosurgery Unit of IRCCS Giannina Gaslini Children Hospital of Genoa, Italy, in a period between 2006 and 2017. The first treatment addressing Chiari type 1 malformation was bone and ligamentous decompression alone in 104 patients (65%), associated with dural delamination in 3 patients (1.9%) and associated with duraplasty with autologous graft in 53 patients (33.1%). Postoperative complications occurred in 5 patients (2.9%). Reintervention for insufficient decompression at follow-up was needed in 6 patients (3.5%). Conclusions Surgical decompression of the posterior cranial fossa (PCF) is indicated in symptomatic patients while asymptomatic patients must be followed in a wait and see fashion. Different types of surgical decompression of different invasiveness have been proposed from only bone and ligamentous decompression to coagulation of cerebellar tonsils. Intraoperative ultrasonography is a useful tool to define when a decompression is sufficient. We did not find correlation between the need for reintervention for insufficient decompression and different invasiveness of the techniques. We believe that this finding suggests that our proposed scheme leads to the best tailored treatment for the single patient.