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Abstract
OBJECTIVE This article describes the clinical aspects for both operated and non-operated patients with a cloverleaf skull deformity treated in our service, focusing on hydrocephalus. METHODS We describe 13 cases of cloverleaf skull deformity treated in our services between 1977 and 2008. Among them, ten were operated (9 out of 13 for the craniofacial stenosis and 7 out of 13 for hydrocephalus). RESULTS Hydrocephalus was present in all patients with bilateral lambdoid stenosis. There was no case of hydrocephalus among the patients with unilateral or absent lambdoid stenosis. Associated malformations and severe faciostenosis were associated with higher mortality and morbidity. CONCLUSION The development of hydrocephalus seems to be closely related to a bilateral lambdoid stenosis. The optimal treatment must be tailored individually considering the degree of the malformation and the presence of complications and comorbidities.
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Manjila S, Chim H, Eisele S, Chowdhry SA, Gosain AK, Cohen AR. History of the Kleeblattschädel deformity: origin of concepts and evolution of management in the past 50 years. Neurosurg Focus 2011; 29:E7. [PMID: 21121721 DOI: 10.3171/2010.9.focus10212] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The history and evolution of surgical strategies for the treatment of Kleeblattschädel deformity are not well described in the medical literature. Kleeblattschädel anomaly is one of the most formidable of the craniosynostoses, requiring a multidisciplinary team for surgical treatment. The initial descriptions of this cloverleaf deformity and the evolution of surgical treatment are detailed in the present report. Two illustrative cases of Kleeblattschädel deformity, syndromic and nonsyndromic craniosynostoses treated by the senior authors, are also described along with insights into operative strategies.
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Affiliation(s)
- Sunil Manjila
- Division of Pediatric Neurosurgery, Rainbow Babies and Children's Hospital, Cleveland, Ohio 44106, USA
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Wilcox WR, Tavormina PL, Krakow D, Kitoh H, Lachman RS, Wasmuth JJ, Thompson LM, Rimoin DL. Molecular, radiologic, and histopathologic correlations in thanatophoric dysplasia. AMERICAN JOURNAL OF MEDICAL GENETICS 1998; 78:274-81. [PMID: 9677066 DOI: 10.1002/(sici)1096-8628(19980707)78:3<274::aid-ajmg14>3.0.co;2-c] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Various mutations in the fibroblast growth factor receptor 3 (FGFR3) gene have recently been reported in thanatophoric dysplasia (TD). We examined the clinical, radiographic, and histologic findings in 91 cases from the International Skeletal Dysplasia Registry and correlated them with the specific FGFR3 mutation. Every case of TD examined had an identifiable FGFR3 mutation. Radiographically, all of the cases with the Lys650Glu substitution demonstrated straight femora with craniosynostosis, and frequently a cloverleaf skull (CS) was demonstrated. In all other cases, the femora were curved, and CS was infrequently present but was occasionally as severe as TD with the Lys650Glu substitution. Histopathologically, all of the cases shared similar abnormalities, but cases with the Lys650Glu substitution had better preservation of the growth plate. Cases with the Tyr373Cys substitution tended to have more severe radiographic manifestations than the Arg248Cys cases, but there was overlap in the phenotypic spectrum between them. One common classification of TD distinguishes affected infants based on the presence or absence of CS. In contrast, and as originally proposed by Langer et al. [1987: Am J Med Genet 3: 167-179], our data suggest that TD can be divided into at least two groups (TD1 and TD2) based on the presence of straight or curved femora. The variable presence of CS and severity of the radiologic and histologic findings in the other substitutions may be due to other genetic, environmental, or stochastic factors.
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Affiliation(s)
- W R Wilcox
- Medical Genetics Birth Defects Center, Steven Spielberg Pediatrics Research Center, Cedars-Sinai Burns and Allen Research Institute, Los Angeles, California 90048, USA.
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Andersen PE. Prevalence of lethal osteochondrodysplasias in Denmark. AMERICAN JOURNAL OF MEDICAL GENETICS 1989; 32:484-9. [PMID: 2789000 DOI: 10.1002/ajmg.1320320411] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The point prevalence at birth of lethal osteochondrodysplasias in a subregion of Denmark was estimated by a study of all children born January 1970 through December 1983. Two cases of thanatophoric dysplasia, one case of thanatophoric dysplasia with cloverleaf skull, two cases of micromelic bone dysplasia with cloverleaf skull, two cases of achondrogenesis type III, and three cases of achondrogenesis type IV were found. Two cases were unclassifiable due to lack of radiographs. In total, the point prevalence at birth was 15.4 per 100,000. Thus lethal osteochondrodysplasias seem to be more common than is generally assumed. The clinical and radiographic findings in micromelic bone dysplasia with cloverleaf skull are discussed in relation to thanatophoric dysplasia and achondrogenesis type IV.
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Affiliation(s)
- P E Andersen
- Department of Diagnostic Radiology, Odense University Hospital, Denmark
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Abstract
Micromelic bone dysplasia with cloverleaf skull is a well-described entity with short, straight tubular bones, hydrocephalus and cloverleaf deformity of the skull, narrow chest and platyspondyly. A further two unrelated patients are presented, in whom the shape of the head varied. Both cases also showed a narrow foramen magnum, hypoplastic cerebellum, atrial septal defect, hypoplastic adrenals, and ureteric malformations. The findings in the skeleton show similarities to other types of generalised bone dysplasias but are distinguishable from these. This well-defined bone dysplasia should probably be regarded as a separate entity. Visceral malformations may be associated.
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Affiliation(s)
- P E Andersen
- Department of Diagnostic Radiology, Odense University Hospital, Denmark
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Kozlowski K, Jequier S, Sillence D, Moir DH. Cloverleaf skull and bone dysplasias (report of four cases). AUSTRALASIAN RADIOLOGY 1987; 31:309-14. [PMID: 3435350 DOI: 10.1111/j.1440-1673.1987.tb01838.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Kroczek RA, Mühlbauer W, Zimmermann I. Cloverleaf skull associated with Pfeiffer syndrome: pathology and management. Eur J Pediatr 1986; 145:442-5. [PMID: 3792393 DOI: 10.1007/bf00439257] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The clinical and radiological findings in an infant with severe cloverleaf skull associated with a Pfeiffer syndrome are presented. The skull anomaly resulted in raised intracranial pressure and proptosis of the right eye within several weeks of birth. The child died at 3 months of age after subtotal craniectomy. At autopsy a detailed macroscopical and histological analysis of the skull base was conducted. The timing and value of surgery are discussed as well as the pathology of the cloverleaf skull anomaly.
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Ornoy A, Adomian GE, Eteson DJ, Burgeson RE, Rimoin DL. The role of mesenchyme-like tissue in the pathogenesis of thanatophoric dysplasia. AMERICAN JOURNAL OF MEDICAL GENETICS 1985; 21:613-30. [PMID: 4025393 DOI: 10.1002/ajmg.1320210402] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We have studied the light microscopic, transmission, and scanning electron microscopic (SEM) findings in 13 cases of thanathophoric dysplasia (TD) and 4 control infants. In the TD growth plate, areas with less abnormal cartilage and bone alternated with areas of severely abnormal cartilage and bone. These latter abnormal areas were always found around tongues of apparent mesenchymal tissue that appeared to penetrate from the investing perichondrium and periosteum. The ultrastructure of the less abnormal areas was similar to that of the control infants, including cell and matrix structure as well as mineralization. The abnormal cartilage and bone had many ultrastructural abnormalities that were also found in the adjacent mesenchymal tissue. The mesenchymal cells, adjacent chondrocytes, and osteoblasts contained dilated endoplasmic reticulum and moderately large intracytoplasmic vacuoles. In the area adjacent to the cartilage, the matrix of the apparent mesenchyme contained thin collagen fibers and proteoglycan granules, whereas the matrix adjacent to the bone contained thick bundles of short collagen fibers. The matrix of the surrounding cartilage and bone resembled the adjacent matrix in the mesenchyme. In addition, many vesicular structures or osmiophilic particles were found in the matrix of the mesenchyme and adjacent cartilage and bone. SEM examination showed normal and abnormal bone trabeculae adjacent to each other. In the abnormal trabeculae, there were large, densely packed osteoblastic and osteocytic lacunae. The calcified collagen fibers had a random orientation, in contrast to the longitudinal orientation in the relatively normal bone. Chemical studies of collagen in the metaphyses of bones from five infants with TD showed a small amount of collagen type III (less than 5%), which was not found in three control infants. Thus, a basic pathogenetic mechanism in the skeletal abnormalities of TD appears to be the focal replacement of the growth plate and periosteum by persisting abnormal mesenchymal-like tissue from which the abnormal bone originates.
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Kozlowski K, Warren PS, Fisher CC. Cloverleaf skull with generalised bone dysplasia. Report of a case with short review of the literature. Pediatr Radiol 1985; 15:412-4. [PMID: 4058967 DOI: 10.1007/bf02388364] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A case of cloverleaf skull with generalised bone dysplasia is reported. The authors believe that bone dysplasia associated with cloverleaf is neither identical with thanatophoric dysplasia nor achondroplasia. Until identity of thanatophoric dysplasia and cloverleaf skull with generalised bone dysplasia is proved the diseases should be looked upon as separate entities and the wording "thanatophoric dysplasia with cloverleaf skull" should be abolished.
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Kremens B, Kemperdick H, Borchard F, Liebert UG. Thanatophoric dysplasia with cloverleaf-skull. Case report and review of the literature. Eur J Pediatr 1982; 139:298-303. [PMID: 7182189 DOI: 10.1007/bf00442186] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The radiologic and morphologic features of thanatophoric dysplasia with cloverleaf-skull could be demonstrated in a neonate who died from asphyxia shortly after birth. Occipital bone hemangiomatosis, a typical histomorphologic finding in cloverleaf-skull, is reported for the first time in a thanatophoric dwarf. Our investigations and the discussion of 26 observations of thanatophoric dysplasia with cloverleaf-skull reported since 1967 do not yet allow complete understanding of the pathogenetic relationship of both malformations. They serve, however, to elucidate some crucial unanswered questions which it is suggested should be studied in future observations of thanatophoric dysplasia with cloverleaf-skull.
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Woon KC, Kokich VG, Clarren SK, Cohen MM. Craniosynostosis with associated cranial base anomalies: a morphologic and histologic study of affected like-sexed twins. TERATOLOGY 1980; 22:23-35. [PMID: 7444800 DOI: 10.1002/tera.1420220105] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A set of like-sexed male twins with the same malformation syndrome and exhibiting identical anomalous alterations of the craniofacial complex were studied in detail. The right and left coronal and left lamboidal sutures were prematurely synostosed in both specimens. The cranial base exhibited a mediolateral asymmetry, with the right half larger than the left. The occipital bone demonstrated the greatest abnormality, including bilateral clefting of the basioccipital component and alterations in the size and shape of the exoccipital bone. In lateral view, the cranial base was flattened and the ventral flexure occurred between the two components of the basioccipital. The odontoid process of the second cervical vertebra was rotated anteroinferiorly and formed part of the cranial floor. Histologically, the bilateral clefts of the basioccipital bone were united by fibrous connective tissue, and the central area of union contained chondroid-like bone. The cartilaginous spheno-occipital synchondrosis and the epiphyseal cartilage of the finger demonstrated similar dystrophic alterations. The brain was normal but exhibited external cerebral deformation secondary to aberrant skull shape.
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Giuffrè R, Vagnozzi R, Savino S. Infantile craniosynostosis: clinical, radiological, and surgical considerations based on 100 surgically treated cases. Acta Neurochir (Wien) 1978; 44:49-67. [PMID: 726961 DOI: 10.1007/bf01401630] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
One hundred children affected by craniosynostosis were operated on from January 1952 to February 1977. Forty-six patients were operated on within the first year of life, and only 9 after six years of age. In 27 cases only one cranial suture was synostotic (mostly the coronal: 15 cases). In 36 cases two sutures were involved (mostly coronal plus sagittal: 25 cases). In 28 cases all the cranial sutures were involved. Also included in this series are seven cases of Crouzon's, one of Apert's, and one of Carpenter's syndromes. The clinical, radiological, and surgical features of this condition are discussed, and the long-term results are reported.
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Abstract
The authors report a case of cloverleaf skull syndrome (Kleeblattschädel) and describe how early surgical management of this condition appears to offer hope for a reasonable cosmetic results, as well as improvement in cerebral function to the point where children with this syndrome may avoid institutional care.
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Hodach RJ, Viseskul C, Gilbert EF, Herrmann JP, Wolfson JJ, Kaveggia EG, Opitz JM. Studies of malformation syndromes in man XXXVI: the Pfeiffer syndrome, association with Kleeblattschädel and multiple visceral anomalies. Case report and review. ZEITSCHRIFT FUR KINDERHEILKUNDE 1975; 119:87-103. [PMID: 1136537 DOI: 10.1007/bf00443563] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This paper reports sporadic occurrence of the Pfeiffer syndrome with Kleeblattschädel (KS) in a male infant who died at 6 months of pneumonia with signs of increased intracranial pressure and who was found to have hydrocephalus, polymicrogyria, cerebellar herniation, bicuspid aortic valve, a common mesentery, absence of lesser omentum, hypoplasia of gallbladder, a single umbilical artery, and multiple eye defects. This case is presumed to represent a new mutation: in other families the Pfeiffer syndrome has been dominantly inherited. The Pfeiffer syndrome is a form of acrocephalosyndactyly and impresses clinically as a mild form of the Apert syndrome. The Kleeblattschädel is an etiologically non-specific developmental field defect (DFC); about two fifths of 51 known cases have apparent thanatophoric dwarfism and about one fifth are probable or possible examples of the Pfeiffer syndrome. The KS-DFC has also been seen in the syndromes of Carpenter, Apert and Crouzon.
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