# Leadership & Professional Development — GCMD Library living collection

Updated: n/a · 2 episodes · 52 cited statements

## Episodes
### Professional Presentations
- [Dr. Francesco Mangano's candidacy statement for ACOS Board of Governors](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821) — video · 2:18 · [machine version](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821.md)
- [Pediatric Chiari malformation: presentation and indications for treatment](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823) — video · 38:54 · [machine version](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823.md)

## Chapters
- [0:01](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=1) Introduction and Current Roles (Ep 1)
- [0:29](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=29) Rationale for Running (Ep 1)
- [1:01](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=61) Primary Goals for Next Term (Ep 1)
- [1:25](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=85) Commitment and Closing (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=0) Introduction and Historical Perspective (Ep 2)
- [2:43](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=163) Chiari Malformation Definitions and Classification (Ep 2)
- [7:00](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=420) Natural History and Epidemiology (Ep 2)
- [8:58](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=538) Clinical Presentation and Syringomyelia (Ep 2)
- [11:02](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=662) Radiographic Imaging Modalities (Ep 2)
- [13:30](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=810) Hydrocephalus Association (Ep 2)
- [17:07](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1027) Scoliosis Association (Ep 2)
- [19:44](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1184) Craniocervical Abnormalities and Measurements (Ep 2)
- [23:10](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1390) Surgical Options and Decision-Making Complexity (Ep 2)
- [27:22](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1642) General Surgical Principles (Ep 2)
- [28:25](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1705) Surgical Technique and Intraoperative Ultrasound (Ep 2)
- [32:51](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1971) Complications and Reoperation (Ep 2)
- [34:55](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=2095) Conclusions and Future Directions (Ep 2)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Dr. Francesco Mangano is the current division chief and professor of neurosurgery and pediatrics at Cincinnati Children's Hospital Medical Center. — Francesco Mangano (clinical) [Ep 1 · 0:02](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=2)
- Dr. Mangano is the current representative to the neurosurgery section on the Board of Governors. — Francesco Mangano (clinical) [Ep 1 · 0:13](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=13)
- Dr. Mangano has done volunteer work for the college for the last 20 years in a number of different committees, including the Board of Governors. — Francesco Mangano (opinion) [Ep 1 · 0:31](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=31)
- Engagement of ACOS membership is important for the organization's survival. — Francesco Mangano (opinion) [Ep 1 · 0:42](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=42)
- Primary goals for the next term include membership retention, increasing resident membership, and strengthening the ACOS conference to make it the most important meeting for all ACOS members. — Francesco Mangano (opinion) [Ep 1 · 1:01](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=61)
- Dr. Mangano has the opportunity and time to travel and attend all meetings, to be engaged and present, and to lead and follow leadership within Board of Governors initiatives. — Francesco Mangano (opinion) [Ep 1 · 1:27](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=87)
- There will be engagement with other medical societies that will collaborate with ACOS. — Francesco Mangano (opinion) [Ep 1 · 1:49](https://library.globalcastmd.com/watch/dr-francesco-mangano-s-candidacy-statement-for-acos-board-of-governors-16821?t=109)
- The first described case of Chiari malformation occurred in 1883 with Dr. Cleland, followed by Dr. Chiari reporting on hindbrain herniations and identifying three types, and later Dr. Arnold describing a Chiari 2 case, leading to the term Arnold Chiari malformation. — Francesco Mangano (clinical) [Ep 2 · 2:43](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=163)
- Chiari 1 through 4 definitions do not represent a continuous spectrum of malformations despite sharing the same name. — Francesco Mangano (clinical) [Ep 2 · 3:13](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=193)
- Chiari 2 malformations are associated with open neural tube defects and involve caudal displacement of cerebellar vermis, fourth ventricle, and lower brainstem into the foramen magnum. — Francesco Mangano (clinical) [Ep 2 · 3:28](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=208)
- Chiari 1 malformation is an imaging diagnosis defined as downward displacement of cerebellar tonsils usually to a level of about 5 millimeters below the foramen magnum. — Francesco Mangano (clinical) [Ep 2 · 4:38](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=278)
- Chiari 1 is generally thought to be congenital, but there is no specific gene; it is probably multigenetic and multifactorial, with familial association reported between 3 and 21% in the literature. — Francesco Mangano (clinical) [Ep 2 · 4:52](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=292)
- Chiari 1 can be associated with spinal and skull base abnormalities in up to 50% of cases, and has associations with hydrocephalus and tethered cord. — Francesco Mangano (epidemiological) [Ep 2 · 5:20](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=320)
- Chiari 0 malformation is described as tonsillar herniation of less than 3 millimeters with a symptomatic syrinx that improves after decompression. — Francesco Mangano (clinical) [Ep 2 · 6:00](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=360)
- Chiari 1.5 is defined by increased crowding at the foramen magnum with displacement of the brainstem and obex below the foramen magnum level; these patients are more likely to fail and have persistent syrinx after decompression. — Francesco Mangano (clinical) [Ep 2 · 6:31](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=391)
- The imaging incidence of Chiari 1 in the pediatric population is roughly 3.6%, with approximately 70% of identified patients not symptomatic at presentation. — Francesco Mangano (epidemiological) [Ep 2 · 7:04](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=424)
- Syringomyelia occurs in roughly 20 to 75% of Chiari 1 patients on initial imaging, with the majority having cervical spine syrinx and approximately one in five having holocord syrinx at presentation. — Francesco Mangano (epidemiological) [Ep 2 · 7:21](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=441)
- Tonsillar displacement prevalence is higher in younger children and decreases as patients reach younger adulthood. — Francesco Mangano (epidemiological) [Ep 2 · 7:42](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=462)
- A 2023 review of 700 asymptomatic children without syrinx found roughly 5-6% developed symptoms over time during observation, and about 2-3% developed a syrinx over time. — Francesco Mangano (epidemiological) [Ep 2 · 7:52](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=472)
- Published cases of 100 symptomatic patients show improvement over time with observation, with only about 7% worsened with observation only. — Francesco Mangano (epidemiological) [Ep 2 · 8:18](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=498)
- There is enough data in the medical literature to warrant watchful observation for patients with non-symptomatic Chiari 1 presenting as children, with natural history more favorable than previously acknowledged. — Francesco Mangano (guideline) [Ep 2 · 8:33](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=513)
- Most commonly Chiari 1 is an incidental finding; symptomatic patients generally present with headaches and high cervical pain associated with activity or Valsalva maneuvers. — Francesco Mangano (clinical) [Ep 2 · 9:00](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=540)
- In pediatric populations, typical presentation includes children who must stop playing after short periods due to discomfort, then resume after brief rest. — Francesco Mangano (clinical) [Ep 2 · 9:22](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=562)
- Other Chiari 1 symptoms include upper motor neuron weakness, incoordination, and brainstem symptoms (swallowing difficulty, central sleep apnea, nystagmus or abnormal eye movements) typically seen more in younger versus older populations. — Francesco Mangano (clinical) [Ep 2 · 9:50](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=590)
- Syringomyelia is described as enlargement of the central canal, a normal anatomic structure within the spinal cord, generally associated with pain and sensory deficits when symptomatic and can be associated with progressive scoliosis. — Francesco Mangano (clinical) [Ep 2 · 10:20](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=620)
- General treatment for patients presenting with syringomyelia is surgical decompression at the craniocervical junction, not direct management of the syrinx, though some advocate watchful observation for asymptomatic patients with small syrinx. — Francesco Mangano (guideline) [Ep 2 · 10:39](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=639)
- MRI of brain and spine is the test of choice to evaluate Chiari 1, providing detailed information about brainstem, cervical spine bones, and brain itself including conditions like hydrocephalus. — Francesco Mangano (guideline) [Ep 2 · 12:50](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=770)
- Hydrocephalus was identified in Dr. Chiari's first case on postmortem evaluation and is generally reported to be associated with 7-10% of Chiari 1 patients, with literature range between 2 and 18%. — Francesco Mangano (epidemiological) [Ep 2 · 13:38](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=818)
- Hydrocephalus has higher association with craniosynostosis and other craniofacial syndromes in Chiari 1 patients. — Francesco Mangano (epidemiological) [Ep 2 · 14:00](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=840)
- A six-center study of 549 patients who had decompression for symptomatic Chiari 1 reported 5.1% occurrence of hydrocephalus developing after decompression, typically presenting with headaches, nausea, vomiting, and some with CSF leaks. — Francesco Mangano (epidemiological) [Ep 2 · 15:59](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=959)
- Most patients who developed post-decompression hydrocephalus required permanent CSF diversion (ETV or VP shunt) and did quite well ultimately. — Francesco Mangano (clinical) [Ep 2 · 16:30](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=990)
- The first description of scoliosis association with Chiari 1 was in 1988, with enough evidence in literature to support a relationship between the conditions. — Francesco Mangano (clinical) [Ep 2 · 17:13](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1033)
- Patients with both Chiari 1 and scoliosis tend to present with atypical features: earlier onset, left apical curve, kyphotic curve, and more commonly with neurologic deficits. — Francesco Mangano (clinical) [Ep 2 · 17:29](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1049)
- A 2023 study of 825 patients with radiological scoliosis and Chiari with syrinx found roughly 31% had scoliosis, associated with wider and longer syrinxes compared to those without scoliosis. — Francesco Mangano (epidemiological) [Ep 2 · 18:35](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1115)
- Regression analysis determined cervical syrinxes and holocord syrinxes were more predictive of scoliosis than other syrinx locations, with average curve of about 30 degrees; tonsillar position was not associated with scoliosis. — Francesco Mangano (epidemiological) [Ep 2 · 19:03](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1143)
- Surgical management for Chiari 1 with scoliosis is reserved for patients who progress, fail conservative scoliosis management, or require treatment of syrinx. — Francesco Mangano (guideline) [Ep 2 · 19:28](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1168)
- Radiographic measurements for craniocervical abnormalities include: posterior base of C2 line (>9mm indicates retroflexed odontoid), McRae's line for basilar invagination (dens should be up to 5mm below line), and clivoaxial angle of 125 degrees. — Francesco Mangano (clinical) [Ep 2 · 19:56](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1196)
- Complex Chiari 1 patients with BC2 line >9mm and clivoaxial angle <125 degrees progress to fusion roughly 83% of the time, while those with BC2 <9mm and angle >125 degrees progress to fusion only 13% of the time. — Francesco Mangano (epidemiological) [Ep 2 · 22:02](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1322)
- There is no known medical treatment for Chiari 1 malformation. — Francesco Mangano (clinical) [Ep 2 · 27:22](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1642)
- If a patient is identified as not symptomatic after careful history and physical, watchful observation is a good general rule; if a patient presents with appropriate symptoms, surgery is usually recommended. — Francesco Mangano (guideline) [Ep 2 · 27:28](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1648)
- The goal of surgery for Chiari 1 is identical regardless of technique chosen: restore CSF dynamics, alleviate symptoms, reduce or stabilize syrinx cavity, and halt progression of associated conditions like scoliosis. — Francesco Mangano (guideline) [Ep 2 · 27:53](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1673)
- Cincinnati Children's Hospital recommends approximately 3x3cm decompression (size-adjusted for pediatric patients), generally removes posterior arch of C1, and thins the dura before using intraoperative ultrasound. — Francesco Mangano (clinical) [Ep 2 · 29:01](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1741)
- Intraoperative ultrasound evaluates tonsillar anatomy including CSF space (looking for rounded vs pointed tonsils) and dynamic motion; pistonning of tonsils down into C1 region indicates inadequate bony decompression and may require opening and shrinking tonsils. — Francesco Mangano (clinical) [Ep 2 · 29:35](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1775)
- Important anatomic considerations when opening dura include the tonsils, vertebral arteries coming up through back of cervical spine, and posterior inferior cerebellar arteries that loop around and often obstruct the obex or bottom of fourth ventricle. — Francesco Mangano (clinical) [Ep 2 · 31:29](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1889)
- Watertight dural closure is one of the most important aspects when opening the dura during Chiari decompression. — Francesco Mangano (clinical) [Ep 2 · 32:01](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1921)
- CSF leak is the most important complication when opening the dura because it can lead to further symptoms and puts the patient at risk for meningitis or infection if CSF leaks through the skin. — Francesco Mangano (clinical) [Ep 2 · 33:10](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=1990)
- Meta-analysis of 145 articles reports surgical complication rate for Chiari 1 decompression is approximately 3-5%, with worsening symptoms in 5-18% of patients and reoperation rate of roughly 16%. — Francesco Mangano (epidemiological) [Ep 2 · 33:58](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=2038)
- Common reasons for reoperation include hydrocephalus, craniovertebral junction instability, arachnoid scarring that closes opened areas causing recurring symptoms, and dural graft complications. — Francesco Mangano (clinical) [Ep 2 · 34:24](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=2064)
- The majority of Chiari 1 patients are not symptomatic and are generally watched with repeat images every year to every couple of years while growing to ensure they don't develop symptoms or changes warranting different approach. — Francesco Mangano (guideline) [Ep 2 · 35:35](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=2135)
- For symptomatic patients with appropriate workup (MRI of brain and total spine), surgical decompression is usually successful in relieving general typical symptoms. — Francesco Mangano (clinical) [Ep 2 · 35:51](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=2151)
- Specific and optimum surgical management for Chiari 1 is very controversial and is subject of much ongoing current research, with hope for better recommendations within 5-10 years based on patient presentation. — Francesco Mangano (opinion) [Ep 2 · 36:07](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=2167)
- A small subset of patients present with complex constellation of symptoms (syrinx, scoliosis, hydrocephalus, genetic syndromes, craniocervical abnormalities) that make clinical decision-making very difficult and raise management difficulty to a much different level. — Francesco Mangano (clinical) [Ep 2 · 36:27](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=2187)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Dr. Francesco Mangano is the Mary Jane and Bob Tritsch Chair and Professor of Neurological Surgery and Pediatrics at Cincinnati Children's Hospital Medical Center, joining in July 2005 after neurosurgical residency at Long Island Jewish Medical Center (2004) and pediatric neurosurgery fellowship at St. Louis Children's Hospital. — The host summarizes what Dr. Francesco Mangano said [Ep 2 · 0:30](https://library.globalcastmd.com/watch/pediatric-chiari-malformation-presentation-and-indications-for-treatment-16823?t=30)

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