Fronto-ethmoidal encephalocele in a historical skull with artificial deformation and no signs of chronic elevated intracranial pressure

The intentional deformation of human skulls in the living being was one of the most curious rituals performed in historical and ancient times. It is thought that these practices cause chronic elevated intracranial pressure and subsequent symptoms of cognitive impairment. In this report, we examine such an artificially deformed skull dating from the sixteenth century that in addition shows a fronto-ethmoidal encephalocele. However, although the mild encephalocele was already manifest at birth and deformation practices were performed over years, the encephalocele did not progress into a more severe status. We conclude that the intentional deformation of skulls does not lead to chronic elevated intracranial pressure and mental retardation.

Autologous stem cell regeneration in craniosynostosis

Craniosynostosis occurs in one of 2500 live human births and may manifest as craniofacial disfiguration, seizure, and blindness. Craniotomy is performed to reshape skull bones and resect synostosed cranial sutures. We demonstrate for the first time that autologous mesenchymal stem cells (MSCs) and controlled-released TGFbeta3 reduced surgical trauma to localized osteotomy and minimized osteogenesis in a rat craniosynostosis model. Approximately 0.5 mL tibial marrow content was aspirated to isolate mononucleated and adherent cells that were characterized as MSCs. Upon resecting the synostosed suture, autologous MSCs in collagen carriers with microencapsulated TGFbeta3 (1 ng/mL) generated cranial suture analogs characterized as bone-soft tissue-bone interface by quantitative histomorphometric and microCT analyses. Thus, surgical trauma in craniosynostosis can be minimized by a biologically viable implant. We speculate that proportionally larger amounts of human marrow aspirates participate in the healing of craniosynostosis defects in patients. The engineered soft tissue-bone interface may have implications in the repair of tendons, ligaments, periosteum and periodontal ligament.

A newly recognized craniosynostosis syndrome with features of Aarskog-Scott and Teebi syndromes

We present two unrelated boys with craniosynostosis and similar facial features including hypertelorism, down-slanted palpebral fissures, ptosis, broad mouth with a thin upper lip, and preauricular pits. Both patients had short, broad first digits as well as short, broad hands. Both also had respiratory difficulties and umbilical abnormalities. Although, many of these features are seen in Aarskog-Scott and in Teebi hypertelorism syndromes, both children had craniosynostosis, which has not been previously reported in either syndrome. We propose that these children may have a previously unreported syndrome consistent with X-linked inheritance, although an autosomal dominant mode of transmission cannot be excluded.

Vestibular orientation for craniofacial surgery: application to the management of unicoronal synostosis

BACKGROUND

Standardized cephalometric measurements are necessary to compare skulls of different ages and sizes, in normal and diseased subjects, and in different species. In diseases involving the skull base, classical cephalometry is often impossible because the cranial landmarks are modified. In vestibular orientation (VO), the plane of the lateral semicircular canal (LSCC) of the inner ear, which has a constant relation to gravity, defines the horizontal plane of reference. Defining a reference plane independent of external landmarks is especially important in unicoronal craniosynostosis (UCCS), because the skull base is asymmetrical.

AIM OF THE STUDY

To illustrate the interest of VO in clinical practice, we report on our experience with VO-based correction of UCCS.

MATERIALS AND METHODS

Since 1992, we have used VO-3D computed tomography scanner for surgical planning of all patients with UCCS, measuring the required correction as the discrepancy between the theoretical and the observed midline.

RESULTS

Thirty-eight children were operated under the age of 2 years for UCCS and evaluated after a mean follow-up of 66 months. Thirty-two (84%) were considered perfect, four (11%) had mild imperfection not requiring reoperation, and two (5%) required reoperation because of progressive craniosynostosis involving the sagittal suture. Good surgical results were obtained when the orbits were correctly oriented relative to the plane of the LSCC.

CONCLUSIONS

VO is a useful reference system for the evaluation and surgical planning of UCCS. We hypothesize that the mismatch between the visual and labyrinthic sensorial inputs plays a role in the pathophysiology of UCCS.

Significance of beaten copper appearance on skull radiographs in children with isolated sagittal synostosis

AIMS AND OBJECTIVES

The significance of beaten copper appearance (BCA) on skull radiographs in children following surgery for isolated sagittal craniosynostosis has not been studied. This study was designed to look for any correlation between BCA and symptoms suggestive of intracranial hypertension in this group of patients.

MATERIALS AND METHODS

Forty-eight consecutive children, who were operated for isolated sagittal synostosis from 1987 to 2000 and had postoperative skull radiographs, were included. Patients were divided into: (a) BCA group (n = 20), consisting of children who had beaten copper appearance on skull radiographs at last follow up, and (b) Non-BCA group (n = 28), consisting of children who did not have this finding. Records were reviewed to look for symptoms suggestive of intracranial hypertension, such as headache, head banging, and irritability.

RESULTS

Median age at surgery was 4.8 months for BCA group and 4 months for the non-BCA group. Follow up ranged from 4 to 156 months with a mean of 36.2 months. Total of 28.6% (n = 6) of the children with follow up radiographs done at < or =18 months of age had BCA. The incidence of BCA increased to 83.3% in children with skull radiographs performed after 48 months of age. In 18 (90%) children, the BCA was 'diffuse' with 5 (25%) children having the maximum possible score of 8. In the BCA group, 45% (n = 9) had symptoms compared to 10.7% (n = 3) in the control group (p = 0.0068).

CONCLUSIONS

This study suggests a significant number of children with BCA on radiographs develop symptoms suggestive of raised ICP following surgical treatment in infancy and prolonged follow up may be warranted in this group of patients.

Morphometric analysis of untreated adult skulls in syndromic and nonsyndromic craniosynostosis

The aim of this study was to perform a morphometric analysis of untreated adult skulls displaying syndromic and nonsyndromic craniosynostosis. We analyzed, in detail, 42 adult craniosynostoses (18 scaphocephaly, 11 anterior plagiocephaly, 2 trigonocephaly, 9 oxycephaly, and 2 brachycephaly) from archeological (three skulls) and pathoanatomical samples (39 skulls). The univariate and bivariate measurements from the pathological skulls were compared with 40 anatomical skulls with normal cranial vault morphology. Bony signs of chronic elevated intracranial pressure (ICP) are (1) diffuse beaten copper pattern, (2) dorsum sellae erosion, (3) suture diastasis, and (4) abnormalities of venous drainage that particularly affect the sigmoid-jugular sinus complex. The mean cranial length was significantly greater in scaphocephaly than in anatomical skulls (20.3 vs 18.0 cm), and the sagittal suture was also longer (14.3 vs 11.8 cm). There were three types of suture course in the bregma region in scaphocephaly: anterior spur (28%), normal configuration (61%), and posterior spur (11%). The plagiocephaly measurements showed nonsignificant differences, and there was no correlation between the length of the anterior and middle skull base (ipsilateral anterior-posterior shortening of the skull) and incomplete or complete suture synostosis. Bony signs of chronic elevated ICP were found in 82% of cases of oxycephaly and brachycephaly. In three such cases of oxycephaly, we found a marked (1.8-2.1 cm) elevation of bregma region. One skull (Saethre-Chotzen syndrome) yielded human DNA sufficient for polymerase chain reaction (PCR)-based amplification procedures. Mutation analyses in the FGFR3 gene revealed nucleotide alterations located in the mutational hot spot at amino acid residue 250 (g.C749). The mean cranial length in adult scaphocephaly was 12% greater than anatomical skulls. A unilateral complete or incomplete coronal synostosis can be found with or without plagiocephalic deformation. Elevation of the bregma region is a bony sign of chronic elevated ICP. These data on adult craniosynostosis could be of interest for physicians dealing with craniosynostotic children.

Clinical dividends from the molecular genetic diagnosis of craniosynostosis

A dozen years have passed since the first genetic lesion was identified in a family with craniosynostosis, the premature fusion of the cranial sutures. Subsequently, mutations in the FGFR2, FGFR3, TWIST1, and EFNB1 genes have been shown to account for approximately 25% of craniosynostosis, whilst several additional genes make minor contributions. Using specific examples, we show how these discoveries have enabled refinement of information on diagnosis, recurrence risk, prognosis for mental development, and surgical planning. However, phenotypic variability can present a significant challenge to the clinical interpretation of molecular genetic tests. In particular, the difficulty of analyzing the complex interaction of genetic background and prenatal environment in determining clinical features, limits the value of identifying low penetrance mutations.

An 11q11-q13.3 duplication, including FGF3 and FGF4 genes, in a patient with syndromic multiple craniosynostoses

Interstitial duplications of 11q are very rare and seldom reported. In this paper we describe the first case of a duplication involving bands 11q11 and 11q12. This newly described patient has multiple craniosynostoses, congenital heart defect and developmental delay, and is a carrier of a mosaic duplication: 46,XY,dup(11)(q11-->q13.3)(29)/46,XY(6). The breakpoints were further delimited by comparative genomic hybridization microarray. We also performed fluorescent in situ hybridization analysis to determine the extension of the duplication in a patient described earlier with a duplication 11q13.5-q21. An overlapping region of less than 1.2 Mb was identified and included the duplication of genes FGF3 and FGF4 in both individuals. We discuss the possible implications of dosage effects of these genes in the onset of craniosynostosis.

3D visualization and simulation of frontoorbital advancement in metopic synostosis

OBJECTIVES

Current multislice computed tomography (CT) technology can be used for diagnosis and surgical planning applying computer-assisted three-dimensional (3D) visualization and surgical simulation. The usefulness of a technique for surgical simulation of frontoorbital advancement is demonstrated here in a child with metopic synostosis.

MATERIALS AND METHODS

Postprocessing of multi-slice CT data was performed using the software 3D slicer. 3D models were created for the purpose of surgical simulation. These allow planning the course of the osteotomies and individually placing the different bony fragments by an assigned matrix to simulate the surgical result. Photo documentation was obtained before and after surgery. Surgical simulation of the procedure allowed determination of the osteotomy course and assessment of the positioning of the individual bony fragments.

CONCLUSIONS

Computer-assisted postprocessing and simulation is a useful tool for surgical planning in craniosynostosis surgery. The time-effort for segmentation currently limits the routine clinical use of this technique.

Predicting neuropsychological development from skull imaging

Craniosynostosis is a serious and common pediatric disease caused by the premature fusion of sutures of the skull. Although studies have shown an increase in risk for cognitive deficits in patients with isolated craniosynostosis, the causal basis for this association is still unclear. It is hypothesized that an abnormally shaped skull produces a secondary deformation of the brain that results in the disruption of normal neuropsychological development. In this paper, we conduct a comparative analysis of our newly developed shape descriptors in an attempt to understand the impact of skull deformations on neurobehavior. In particular, we show that our scaphocephaly severity indices and symbolic shape signatures are predictive of mental ability and psychomotor functions, respectively, which suggests the possibility that secondary deformation could influence neuro-developmental status.

Familial whole-arm translocations (1;19), (9;13), and (12;21): a review of 101 constitutional exchanges

We report here on 3 familial whole-arm translocations (WATs), namely the 8th instance of t(1;19)(p10;q10) and 2 novel exchanges: t(9;13)(p10;q10) and t(12;21)(p10;q10). The exchanges (1;19) and (12;21) were ascertained through a balanced carrier, whereas the t(9;13) was first diagnosed in a boy with a trisomy 9p syndrome and der(9p13p). Results of FISH analyses with the appropriate ?-satellite probes were as follows. Family 1, t(1;19): the D1Z5 probe gave a strong signal on both the normal chromosome 1 and the der(1q19p) as well as a weak signal on the der(1p19q). Family 2, t(9;13): the centromere-9 alphoid and D13Z1/D21Z1 probes under standard stringency gave no signal on the der(9p13p) in both the proband and a carrier brother, whereas the der(9q13q) was labelled only with the centromere-9 alphoid repeat in the latter; yet, this probe under low stringency revealed a residual amount of alphoid DNA on the der(9p13p) in the carrier. Family 3, t(12;21): the D12Z3 probe gave a signal on the normal chromosome 12 and the der(12p21q), whereas the D13Z1/D21Z1 repeat labelled the der(12q21p), the normal chromosome 21, and both chromosomes 13. Out of 101 WATs compiled here, 73 are distinct exchanges, including 32 instances between chromosomes with common alphoid repeats. Moreover, 7/9 of recurrent WATs involved chromosomes from the same alphoid family. Thus constitutional WATs appear to recur more frequently than other reciprocal exchanges, often involve chromosomes with common alphoid repeats, and can mostly be accounted for the great homology in alphoid DNA that favours mispairing and illegitimate nonhomologous recombination.

Pansynostosis: a review

INTRODUCTION

Although rare, pansynostoses are seen and treated by the craniofacial surgeon. To date, a single source that reviews these more severe forms of craniosynostosis is lacking in the literature.

MATERIALS AND METHODS

The present paper outlines and reviews the associations of both syndromic and nonsyndromic cases, potential mechanisms, and the anatomy involved with such forms of premature fusion of the cranial sutures.

RESULTS

Pansynostosis is seen in a myriad of syndromes but can also be identified in nonsyndromic cases. Raised intracranial pressure is a concern in these patients.

CONCLUSIONS

Early recognition and treatment of patients with pansynostosis of the cranial sutures is important.

Superelastic NiTi springs for corrective skull operations in children with craniosynostosis

This paper concerns the formation and characterization of superelastic springs and rings of NiTi alloys for long-term skull correction. Superelastic properties of the rings were induced in the process of ageing of the already formed rings which cause hardening of parent phase by the precipitation of coherent Ni(4)Ti(3) particles. The efficacy of the worked out springs and rings were successfully proved in several clinical applications.

RNA interference and inhibition of MEK-ERK signaling prevent abnormal skeletal phenotypes in a mouse model of craniosynostosis

Premature fusion of one or more of the cranial sutures (craniosynostosis) in humans causes over 100 skeletal diseases, which occur in 1 of approximately 2,500 live births. Among them is Apert syndrome, one of the most severe forms of craniosynostosis, primarily caused by missense mutations leading to amino acid changes S252W or P253R in fibroblast growth factor receptor 2 (FGFR2). Here we show that a small hairpin RNA targeting the dominant mutant form of Fgfr2 (Fgfr2(S252W)) completely prevents Apert-like syndrome in mice. Restoration of normal FGFR2 signaling is manifested by an alteration of the activity of extracellular signal-regulated kinases 1 and 2 (ERK1/2), implicating the gene encoding ERK and the genes downstream of it in disease expressivity. Furthermore, treatment of the mutant mice with U0126, an inhibitor of mitogen-activated protein (MAP) kinase kinase 1 and 2 (MEK1/2) that blocks phosphorylation and activation of ERK1/2, significantly inhibits craniosynostosis. These results illustrate a pathogenic role for ERK activation in craniosynostosis resulting from FGFR2 with the S252W substitution and introduce a new concept of small-molecule inhibitor-mediated prevention and therapy for diseases caused by gain-of-function mutations in the human genome.

Delayed development of frontal mucocele after fronto-orbital advancement in a child with craniosynostosis

BACKGROUND

Sinus mucoceles rarely develop as a consequence of inadequate sinus ventilation that arises due to inflammation, allergy, polyps, tumors, surgery, and trauma. The development of frontal sinus is delayed until older than 6 years. Therefore, the development of the mucocele in the frontal sinus after fronto-orbital advancement surgery in young children with craniosynostosis may provide essential information for the development of the frontal sinus.

CASE DESCRIPTION

We report a rare case of a 22-year-old man presenting with a frontal mucocele manifested by dull headache, proptosis, and diplopia, and which developed 16 years after fronto-orbital advancement surgery for craniosynostosis. Magnetic resonance imaging demonstrated that a multiple cystic mass extended from the frontal sinus to the retro-orbital space along the optic nerve. During surgery, we found that the cyst consisted of mostly thin, yellow mucosa, which developed from an anomalously overdeveloped frontal sinus containing yellow pus-like intracystic fluid. There was no gross local invasion by the cyst. We easily dissected and removed the mucosal cyst from the large frontal sinus completely with frontal sinus obliteration. We cranialized the anomalously large frontal sinus by removal of the posterior wall of the frontal sinus and then widening the ethmoidal drainage with endoscopic ethmoidectomy.

CONCLUSION

We report the first case of a frontal sinus mucocele that developed after fronto-orbital advancement surgery in the literature and suggest that the mucocele development after fronto-orbital advancement supports the hypothesis of frontal bone-inducing role in frontal sinus development.

Craniofacial morphology in Muenke syndrome

The purpose of this study was to test whether the severity of the cranial phenotype in Muenke syndrome infants with unicoronal synostosis is greater than in infants with nonsyndromic unicoronal synostosis. A total of 23 infants were included in the study. All infants included in the study had a computed tomography (CT)-verified synostosis of the coronal suture. The patients were either placed into the "Muenke" group (n=11) or the "non-Muenke" control group (n=12) on the basis of a test for the P250R mutation in the FGFR3 gene. On the basis of CT scans, a three-dimensional surface model corresponding to bone was created for each individual. The sutures were inspected for synostosis, and the degree of synostosis was assessed. Increased digital markings were recorded for both groups. Craniofacial morphology was assessed quantitatively using bony landmarks and recording of the midsagittal surface of the calvaria, cranial base, and maxillary complex. Increased digital markings were more severe posteriorly in Muenke patients than in non-Muenke patients. The Muenke patients with unilateral coronal synostosis showed a somewhat more severe asymmetry in the anterior part of the skull than the non-Muenke patients. The study indicates differences with regard to severity of increased digital markings and craniofacial asymmetry between the infants with Muenke syndrome and the infants with nonsyndromic unilateral coronal synostosis.

Intracranial volume measurement of sagittal craniosynostosis

We report 41 cases of non-syndromic isolated sagittal synostosis in which evaluation of intracranial volumes was undertaken. Twenty-six were male and fifteen were female. The measured intracranial volumes were then compared with normal age-corrected values. We have found that intracranial volumes were significantly larger than the normal population intracranial volumes in both sexes. However the statistical significance of this finding was much greater in females, (p<0.00002), than males (p<0.040), which was only of borderline significance. The results confirm smaller, earlier studies that intracranial volumes in sagittal synostosis patients are larger than average for age-corrected normal values. Analysis of a sub-set of six patients with sagittal synostosis who were found to have a common polymorphism 294C>T (Asn294Asn) in FGFR3 (fibroblast growth factor Receptor 3) on genetic testing were compared to age and sex matched cases of non-syndromic sagittal synostosis (without an underlying mutation) which confirmed that there were no discernable differences in intracranial volumes between the two groups. We conclude that this investigation supports the role of cranial re-shaping to improve cosmesis as the primary aim of surgical correction in this condition, in the absence of raised intracranial pressure.

Isolation and characterization of posterofrontal/sagittal suture mesenchymal cells in vitro

BACKGROUND

Craniosynostosis, the premature fusion of cranial sutures, affects one in 2500 children. In the mouse, the posterofrontal suture is programed to fuse postnatally, but the adjacent sagittal suture remains patent throughout life. To study the cellular process of suture fusion, the authors isolated and studied suture-derived mesenchymal cells.

METHODS

Skulls were harvested from 80 mice (2 to 5 days old), and posterofrontal and sagittal sutures were dissected meticulously. Suture mesenchymal tissue was separated from the underlying dura mater and overlying pericranium and cultured in growth media. After the cells migrated from the explant tissues, the morphologies of the two cell populations were studied carefully, and quantitative real-time polymerase chain reaction was performed to evaluate gene expression.

RESULTS

Both posterofrontal and sagittal cells exhibited highly heterogeneous morphologies, and the posterofrontal cells migrated faster than the sagittal cells. Accordingly, growth factors such as transforming growth factor-beta1 and fibroblast growth factor (FGF)-2 were expressed significantly more highly in posterofrontal compared with sagittal suture mesenchymal cells. In contrast, FGF receptor 2 and FGF-18 were expressed significantly more in sagittal than in posterofrontal suture cells. Importantly, bone morphogenic protein-3, the only osteogenic inhibitor in the bone morphogenic protein family, and noggin, a bone morphogenic protein antagonist, were expressed significantly more in sagittal than in posterofrontal suture cells, suggesting a possible mechanism of suture patency.

CONCLUSIONS

To the authors' knowledge, this is the first analysis of mouse suture-derived mesenchymal cells. The authors conclude that isolation of suture-derived mesenchymal cells will provide a useful in vitro system with which to study the mechanisms underlying suture biology.

Spring-Assisted Correction of Hypotelorism in Metopic Synostosis

BACKGROUND

Metopic synostosis, apart from the pointed forehead, typically is characterized by hypotelorism with egg-shaped orbits on cephalography and the frontoorbital axis parallel or even converging superiorly. The frontoorbital axis angle is a novel parameter for analyzing and describing the orientation of the orbits. Current methods of surgery often result in undercorrection of the almost ever-present hypotelorism. The present study was performed to analyze a new technique, capable in this respect, using steel wire springs in conjunction with a cranioplasty.

METHODS

A retrospective study of 23 metopic synostosis patients operated on between 1999 and 2004 was conducted. A strip midline craniectomy and frontal reshaping were combined with the insertion of a steel wire spring across the midline craniectomy, forcing lateral displacement of the orbits. Preoperative and postoperative follow-up cephalograms were obtained, and the bony medial interorbital distance was measured and compared with the bony medial interorbital distance of a control group. Perioperative data and complications were noted.

RESULTS

Preoperative mean bony interorbital distance was 10.6 mm (range, 7.7 to 13.2 mm). It increased to 15.7 mm (range, 10.4 to 22 mm) at 1.5 months postoperatively and to 16.2 mm (range, 10.9 to 24.5 mm) 5 months postoperatively. Results as judged clinically ranged from little effect to a definitive overcorrection. The frontoorbital axis was improved in every case. Average frontoorbital axis was -4 degrees (range, -33 to 23 degrees) preoperatively and 28 degrees (range, 11 to 46 degrees) postoperatively.

CONCLUSION

It was concluded that a spring used together with a cranioplasty is a powerful tool for the correction of both hypotelorism and orbital shape in trigonocephaly.

Somatic FGFR and TWIST Mutations are not a Common Cause of Isolated Nonsyndromic Single Suture Craniosynostosis

Pathogenic mutations in FGFR2 and TWIST genes are detected in the majority of individuals with Crouzon, Pfeiffer, Apert, and Saethre-Chotzen syndromes. In contrast, mutations have been identified rarely in cases of nonsyndromic, single suture craniosynostosis. Recently, two studies confirming somatic mosaicism with local expression of an FGFR mutation have been reported. This study investigates whether somatic mosaicism could account for nonsyndromic, single suture craniosynostosis. Eight individuals with single suture craniosynostosis who were negative for known mutations in FGFR1-3 and TWIST after screening in their leucocyte DNA were tested for the presence of pathogenic mutations in suture cell-derived DNA. Five had sagittal synostosis, two had metopic synostosis, and the other unicoronal synostosis. Osteoprogenitor cells from surgically excised fusing sutures and an adjacent open suture were cultured. DNA from the cultured cells grown to passage 3 was then examined for underlying FGFR and TWIST mutations. No mutations within the exons of the FGFR or TWIST genes studied were identified in any suture cells. This study found no evidence to support the notion that mosaicism for FGFR or TWIST mutations, normally associated with syndromal forms of craniosynostosis, occur in single suture craniosynostosis. Thus, any underlying genetic defects must occur in regions outside those normally implicated in syndromal craniosynostosis, or this disorder could arise as a consequence of some other epigenetic modification.

Distraction vs remodeling surgery for craniosynostosis

OBJECTS

We designed several distraction devices and applied these instruments in 14 patients with varying types of craniosynostosis. The aim of this report is to clarify the advantages and disadvantages of these surgical methods and to discuss current concepts for the surgical strategy in the treatment of craniosynostosis.

METHODS

From January 2000 to July 2005, 28 patients with craniosynostosis were retrospectively analyzed. Surgical treatment was performed on 14 patients using the distraction method with internal distraction devices that we designed, in which 5 patients had plagiocephaly, 3 brachycephaly, and 6 scaphocephaly. All patients underwent preoperative and postoperative evaluations, which included the patient's neurological state, and three-dimensional CT.

RESULTS

With distraction devices, the time required for the surgery could be shortened almost 3 1/3 h; the bleeding during the surgery was decreased with reduced requirement of more than 200 ml of blood transfusion as compared with remodeling surgery. Postoperatively achieved distraction distances varied from 30.0 to 47.5 mm (mean, 42.99 mm). The average increased volume percent of cranium in distraction surgery group was 20.9% (range, -11.5 to 58.9%) after full distraction.

CONCLUSION

With distraction surgery, satisfactory cranial volume expansion and aesthetically pleasing morphological states were achieved in all cases, and the efficacy was statistically significantly high as compared with remodeling method.