Presentation
Headache and clear fluid discharge from the surgical wound with underlying swelling three weeks after craniocervical decompression for Chiari 1 malformation.
Patient Data
Post-operative changes at the cervical-occipital junction with evidence of adjacent CSF leak at CSF flow Study.
Abnormal signal intensity and herniation are noted in the cerebellar tonsil, possibly related to postoperative changes.
A retention cyst in the right maxillary sinus.
Cervical syrinx measuring about 7.5 cm in CC dimension; extending from lower C2 till upper C7 vertebral bodies.
Case Discussion
The patient was exposed to a road traffic accident weeks before the surgery, before which he started to complain of progressive occipital headache exacerbated by cough, associated with upper and lower limbs paresthesia more on lower limbs.
Investigations including CT and MRI scans were performed and a diagnosis of Chiari 1 malformation was made.
Surgical correction including craniocervical decompression, duraplasty and cerebellar tonsillectomy was performed.
Soon after, the patient started to develop pseudomeningocele with CSF leak through the operation site. The aspiration of CSF through this leads to headache relief. So, a decision was made for ventriculoperitoneal (VP) shunt insertion.
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