- ADHD is a neurodevelopmental disorder with symptoms of inattention, impulsivity and hyperactivity.
- Whereas chiari malformation was first described a hundred years ago, a hindbrain malformation characterised with cerebellar herniation through the foramen magnum.
- This case describes ADHD and concurrent chiari malformation type I in a 28-year-old patient.
A 28-year-old Caucasian college student was referred to the outpatient clinic for evaluation and treatment of ADHD. Doctors diagnosed her with ADHD at 12 years of age. In addition, she was academically weak, had difficulty concentrating, had attention deficits, got distracted easily and was impulsive with a lack of organisational skills. The student almost failed in her first year of high school. Therefore, she was on a trial of psychostimulants. By the age of 28 she had been on several long-acting formulations of methylphenidate and norepinephrine reuptake inhibitor. This triggered her anxiety in social gatherings, causing significant dysphoria. The patient was diagnosed with chiari malformation and ADHD.
She was not on any medication when she first consulted the psychiatrist. She had no significant medical or surgical history, except for a concussion that she had at the age of 15. Her mother also had depression and anxiety. Similarly, her brother had a borderline personality disorder.
Chiari Malformation With ADHD
A month before the patient presented to the clinic she experienced a concussion with migraines, ataxia, nausea and vomiting. Cerebral CT ruled out hemorrhage, ischemia or any lesions. The CT, however, showed a downward displacement of the cerebellar tonsils compatible with CM type I. At the time the patient presented to the clinic, most of her symptoms had resolved. However, she still felt dizzy during physical exertion.
Evaluation confirmed postconcussion syndrome and ADHD. The patient’s lifelong symptoms of ADHD may have been because of chiari malformation. Months after her initial evaluation, she showed extreme sensitivity to the side effects of the stimulants. Therefore, it limited the possibility of using the usual therapeutic dose range. Her physician stabilised her on 10 mg of lisdexamfetamine dimesylate daily. She showed some improvement at this dose, though, continued to have difficulty with concentration and impulsivity as reported a year after. In conclusion, there is growing evidence that a cerebellar malformation may impact neurological circuitry.
References
Chiari Malformation and Attention Deficit Hyperactivity Disorder https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527903/
