Wolff–Parkinson–White syndrome in a patient with type I Chiari malformation: management of an unusual association

Introduction and importance: Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac conduction disorder caused by an accessory pathway that predisposes patients to potentially life-threatening tachyarrhythmias. Chiari malformation type I is a congenital hindbrain anomaly characterized by the herniation of the cerebellar tonsils through the foramen magnum, often associated with syringomyelia and progressive neurological deficits. These two conditions are unrelated and rarely coexist; however, their concurrence presents significant anesthetic and perioperative challenges during neurosurgical procedures. Case presentation: A 21-year-old man presented with a 1-month history of lower back pain radiating to both lower limbs, accompanied by electric shock-like sensations, progressive weakness, and sensory loss. Magnetic resonance imaging revealed Chiari malformation type I with a large spinal syrinx, and posterior fossa decompression was planned. Routine preoperative electrocardiography unexpectedly demonstrated WPW syndrome. An electrophysiological study identified a right free-wall accessory pathway with inducible orthodromic atrioventricular re-entrant tachycardia. Successful radiofrequency catheter ablation eliminated preexcitation and rendered tachycardia non-inducible. Clinical discussion: WPW syndrome poses a substantial anesthetic risk due to the potential for perioperative life-threatening arrhythmias. Early detection and definitive treatment with catheter ablation enabled safe neurosurgical intervention. A multidisciplinary approach facilitated uncomplicated posterior fossa decompression, resulting in marked neurological improvement. Conclusion: This case underscores the importance of comprehensive preoperative assessment to identify rare but clinically significant comorbidities. Timely recognition and management of WPW syndrome allowed safe neurosurgical treatment, highlighting the critical role of multidisciplinary collaboration in optimizing patient outcomes.