1615 - Concussion Conspiracy: Arnold-Chiari Malformation I in the Setting of Concussion from Forklift Injury

Arnold-Chiari Malformation, Type I

Case Description: Patient is a 31-year-old w/ PMHx of ADHD and anxiety who presents to the outpatient clinic for a second opinion after sustaining a concussion at work after striking a steel pole while operating a forklift nine months ago. Extensive workup, including neuro-imaging, labwork, and EEG revealed Type I Arnold-Chiari Malformation. Patient was managed non-operatively by neurosurgery, sports medicine, and neurology but continued to have persistent left frontotemporal headaches, neck/shoulder pain, and balance dysfunction despite therapies targeting vision and balance therapy regimen was adjusted to address cervical strain; however, it was cancelled since it increased neck pain and paresthesia in neck/arms. Through shared decision making, patient underwent suboccipital craniectomy and then resumed physical therapy (PT) after neurosurgical clearance. At 2 month follow-up, patient had near complete resolution of his symptoms. 

Discussions: Chiari Type I malformations (CM-I) are characterized by abnormally shaped cerebellar tonsils that are displaced below the level of the foramen magnum. In the majority of cases, CM-I does not become symptomatic until adolescence or adulthood, with pain or headache the most common presentation. Other symptoms include nystagmus, ataxia, vomiting, and lethargy. With headache being the most common presentation in older children and adults, it is reasonable to assume that the patient's symptoms could be multifactorial from the CM-I and posttraumatic headache. Acute posttraumatic headache may last up to three months, and is labeled chronic past three months. Treatment for symptomatic CM-I is posterior fossa decompression.

Conclusions: Headaches secondary to concussions that are refractory to pharmacological and therapeutic modalities may be multifactorial. In this case, patient had headaches secondary to combination of neck/shoulder strain, vestibular dysfunction, and CM-I. Neck PT flared up symptoms from CM-I which prompted the team to proceed with surgical intervention.