Revista de Medicina Desportiva (English) September 2018 - Page 22

Rev. Med. Desp. informa, 2018; 9(5):20–21. Chiari Malformation and Sports Practice Dr. João P. Pinheiro 1 , Prof. Doctor João Páscoa Pinheiro 2 , Prof. Doctor Armando Rocha 3 , Prof. Doctor Marcos Barbosa 4 1 Resident on neurosurgery; 2 Physicoian. Physical medicine and rehabilitation, Sports medicine; 3 Senior Hospital assistant of neurosurgery; 4 CHUC Neurosurgery Service Director. Coimbra, Portugal ABSTRACT The diagnosis of Chiari malformation type 1 (CH1) is usually based on imaging characteristics observed on computed tomography (CT) or magnetic resonance imaging (MRI). The greater acces- sibility to these tests makes the diagnosis of MC1 more common. MC1 is a rare clinical entity in sports. The diagnosis in athletes should motivate their referral to a neurosurgical department. The morphological changes of MC1 predispose athletes, especially in contact sports, to an increased risk of neurological damage or even sudden death. We also referred to the importance of the diagnosis of MC1, valuing some clinical aspects in the sports-medical examination, such as mechanical neck pain, headache or unexplained dysesthesias and paresthesias. PALAVRAS-CHAVE / KEYWORDS Chiari malformation 1, sports Introduction The Chiari Type 1 (MM1) is an uncommon clinical entity in the population and very rarely approached in the sport con- text. This malformation carries an increased risk of neurological pathology or even sudden death, particularly in contact sports (CS). 1 This diagnosis conditions and restricts some gestures and modali- ties in order to protect the athlete. Some symptoms and signs should be considered, particularly in the context of the sports-medical exami- nation. In the CM1 the posterior fossa has a smaller volume than the normal. The decrease of the physical space promotes caudal displacement to the cervical canal of the cerebellar tonsils. Relative to the level of the foramen magnum, the amygdalin her- niation is five or more millimeters. 3 The alteration of the normal flow of the cerebrospinal fluid may be asso- ciated with syringomyelia, observed in 30-70% of patients with CM1, and to an increased risk of cerebral con- cussion due to decreased damping capacity of the cerebral parenchyma after a cranioencephalic trauma (CET). 4,5 Most carriers of CM1 are asymp- tomatic. The most common symp- tom is the occipital headache (65%), usually associated with cervical pain. The cervical extension and the Valsalva maneuver exacerbate the pain. Also, neurological signs and symptoms associated with the compression of the cerebellum and of the bulbous, such as ataxia, nys- tagmus and decreased gag reflex may be present. 3 The syringomyelia may be asymp- tomatic or be associated with signs of injury of the first neuron, such as tetraparesis predominating distally, hyper reflex and sensitivity dissocia- tion syndrome. 6 Sports Practice and Chiari 1 The restrictions of the athletes with CM1 to practice contact sports have been the subject of discussion and controversy, given the absence of guidelines. After a CET or a cervical trauma, the likelihood of bulbous or medullary contusion is higher in the athlete with MC1, where the risk of severe neurological lesions or sud- den death is increased. 7 There are two dozen of cases of subjects diagnosed with CM1 that suffered TCE or cervical trauma during sporting practice or in similar situations. In 1995 James DS described the case of a 25-year-old male fight sportsman. After a coup, he suddenly died with cardiorespi- ratory arrest. The autopsy revealed CM1 associated with syringomyelia from C1 to C7. 8 In 1998 and 2013, two cases of sudden death were What is Chiari type 1? Chiari’s malformations were described in 1890 by the anatomist Dr. Hans Chiari, they include a set of hindbrain anomalies, ranging from a simple herniation of cerebel- lar tonsils to a complete agenesis of the cerebellum (figure 1 and 2). Four types of malformations are described in the literature. The malformations of Chiari II, III and IV are rare. 2 20 september 2018 Figure 1 – Chiari chiari-malformations-and-cranial-nerves/ Figure 2 – Chiari malformation with syringomyelia case/15819/studies/15469