Introduction- Chiari malformation type 1 (CM-1) is defined by the caudal displacement of cerebellar tonsils through the foramen magnum (cut off of 5 mm from McRae line.) In Chiari malformation type 1.5 (CM-1.5) both cerebellar tonsils and brainstem result herniated. Patient with CM may exhibit a variety of symptoms: the most common are headache and cervical pain. Associated anomalies such as syringomyelia (67-80%), hydrocephalus (10 %), craniosynostosis or tethered spinal cord may be present. Surgical treatment is not performed in asymptomatic patients, while the presence of syringomyelia represents an indication for surgical decompression. In this paper we report our experience with the use of intra-operative ultrasonography in orienting surgical decompression with or without dural opening. Methods- We retrospectively examined and selected pediatric patients with CM-1/ CM-1.5 who were managed between 2006-2020 at Giannina Gaslini Hospital. Exclusion criteria were the association with achondroplasia and with spina bifida. Results- A total of 211 pediatric patients were identified for evaluation: CM-1 accounted for 83.9% of patients and CM-1.5 for 16.1%. Syringomyelia was associated in 28.4% of cases and hydrocephalus in 8%. According to findings at the intra-operative ultrasonography, a bony and ligamentous decompression alone was sufficient in 59.8% patients, a simple opening of dura mater was performed in 3% and a duraplasty in 27.1%. Seven patients experience post-operative complications, and 3 patients needed a second surgical operation for insufficient decompression, found at follow-up. Discussion and conclusion- The standard surgical treatment of CM-1/ CM-1.5 consists in decompression of posterior cranial fossa. Whether to perform a simple bony decompression or to associate the opening of the dura mater with duraplasty has always been controversial in pediatric population. Our case series, where good radiological findings were achieved with a limited number of reoperations, shows how intra-operative ultrasound may be a real-time helpful tool in orienting the surgical strategy, if we consider as surgical endpoint the restoration of cerebrospinal fluid (CSF) flux. However, there is the need to standardize this method, using quantitative variables.

Extrauterine growth restriction (EUGR) is a common complication and a known risk factor for impaired development in very low birth weight (VLBW) preterms. We report a population of 288 patients with no or with low grade MRI lesions scanned at term equivalent age (TEA) born between 2012 and 2018. Griffiths mental development scale II (GMDS II) at 2 and 3 years, preterm complications and weight growth were retrospectively analysed. EUGR was defined for weigth z-score ˂10th percentile at TEA, 6 and 12 months of correct age or as z-score decreased by 1-point SDS from birth to TEA and from TEA to 6 months. Multivariate analysis showed that a higher weight z-score at 6 months is protective for global developmental quotient (DQ) at 2 years (OR 0.74; CI 95% 0.59-0.93; p=0,01). EUGR at 6 months was associated with worse locomotor, personal-social, language and performance DQ at 2 years and worse language and practical reasoning DQ at 3 years. In conclusion a worse weight z-score at 6 months of age seems to be an independent risk factor for significantly reduced GMDS in many areas. These results suggest to better invest on post-discharge nutritional, optimizing family nutritional education.