Pansynostosis: a review

Long-term sequelae of normocephalic pansynostosis: a rare but insidious entity

OBJECTIVE

Patients with normocephalic pansynostosis, who have a grossly normal head shape, are often overlooked early in life and present late with elevated intracranial pressure (ICP) requiring timely cranial vault expansion. This study evaluates the long-term clinical outcomes of patients with normocephalic pansynostosis.

METHODS

We retrospectively reviewed patients with a clinical and radiographic diagnosis of primary pansynostosis who underwent vault reconstruction between 2000 and 2023. Clinical and treatment course after craniofacial interventions was followed in patients with normocephaly to assess outcomes.

RESULTS

Thirty-five patients with primary pansynostosis were identified, of which eight (23.5%) had normocephaly and underwent initial vault expansion at a mean age of 5.0 ± 2.4 years. All eight patients (50.0% male) presented with symptoms of elevated ICP including headaches (50.0%), nausea and vomiting (50.0%), and developmental delay (62.5%) and/or signs of elevated ICP including papilledema (75.0%) and radiologic thumbprinting on head computed tomography scan (87.5%). Three of the four normocephalic patients who had over 7 years of postoperative follow-up developed subjective headaches, vision changes, or learning and behavioral issues in the long-term despite successful vault reconstruction.

CONCLUSIONS

Our longitudinal experience with this rare but insidious entity demonstrates the importance of timely intervention and frequent postoperative monitoring, which are critical to limiting long-term neurological sequelae. Multidisciplinary care by craniofacial surgery, neurosurgery, ophthalmology, and neuropsychology with follow-up into adolescence are recommended to assess for possible recurrence of elevated ICP secondary to cranio-cerebral disproportion.

Posterior cranial vault distraction in children with syndromic craniosynostosis: the era of biodegradable materials-a comprehensive review of the literature and proposed novel global application

Distraction osteogenesis is utilized to increase intracranial volume in the treatment of restrictive pathologies, most commonly syndromic synostosis. Children too young for open calvarial vault expansion or other systemic or local contraindications to a direct reconstructive approach benefit greatly from distraction osteogenesis, typically addressing posterior vault expansion. Wound infection, cerebrospinal fluid (CSF) leak, device failure, need for a second surgery for removal, and cost, are issues that can limit the use of this approach. These challenges are more pronounced in low- and middle-income countries (LMICs) due to lack of access to the device, the financial burden of the need for a second surgery, and the severity of the implications of infection and CSF leak. Over the last five decades, there has been an increased acceptance of bioresorbable instrumentation in craniofacial surgery. Poly L-lactic acid, polyglycolic acid, and polydioxanone are the most commonly used polymers. New resorbable fixation tools such as ultrasound-activated pins and heat-activated pins are superior to conventional bioresorbable screws in allowing attachment to thinner bone plates. In this paper, we present a review of the literature on cranial vault distraction and the use of bioresorbable materials and propose a novel design of a fully absorbable cranial distractor system using external magnetic distraction control, eliminating the need for external activation ports and a second surgery to remove the hardware. The application of this technology in LMIC settings could advance access to care and treatment options for patients with syndromic synostosis.

Craniosynostosis in primary metabolic bone disorders: a single-institution experience

PURPOSE

The incidence of metabolic bone diseases in pediatric neurosurgical patients is rare. We examined our institutional experience of metabolic bone diseases along with a review of the literature in an effort to understand management for this rare entity.

METHODS

Retrospective review of the electronic medical record database was performed to identify patients with primary metabolic bone disorders who underwent craniosynostosis surgery between 2011 and 2022 at a quaternary referral pediatric hospital. Literature review was conducted for primary metabolic bone disorders associated with craniosynostosis.

RESULTS

Ten patients were identified, 6 of whom were male. The most common bone disorders were hypophosphatemic rickets (n = 2) and pseudohypoparathyroidism (n = 2). The median age at diagnosis of metabolic bone disorder was 2.02 years (IQR: 0.11-4.26), 2.52 years (IQR: 1.24-3.14) at craniosynostosis diagnosis, and 2.65 years (IQR: 0.91-3.58) at the time of surgery. Sagittal suture was most commonly fused (n = 4), followed by multi-suture craniosynostosis (n = 3). Other imaging findings included Chiari (n = 1), hydrocephalus (n = 1), and concurrent Chiari and hydrocephalus (n = 1). All patients underwent surgery for craniosynostosis, with the most common operation being bifronto-orbital advancement (n = 4). A total of 5 patients underwent reoperation, 3 of which were planned second-stage surgeries and 2 of whom had craniosynostosis recurrence.

CONCLUSIONS

We advocate screening for suture abnormalities in children with primary metabolic bone disorders. While cranial vault remodeling is not associated with a high rate of postoperative complications in this patient cohort, craniosynostosis recurrences may occur, and parental counseling is recommended.

Craniosynostosis in Isfahan, Iran: A Cross-Sectional Study

Background

Craniosynostosis is the premature closure of cranial sutures. According to the literature, several factors are related to this disorder. Due to the relatively high prevalence in Iran and a lack of related studies in this region, this study was designed to determine the characteristics of a group of these patients in this region.

Methods

This cross-sectional study was performed from 2016 to 2019 at two tertiary referral hospitals for children in Isfahan, Iran. Studied variables included: age, sex, birth weight, type of craniosynostosis, concurrent anomalies, parents' age, father's job, fetus position, maternal parity, history of maternal smoking during the pregnancy, use of fertility assistant treatments, and history of maternal endocrine disorders.

Results

We had 125 infants, including 82 (65.6%) males and 43 (34.4%) females. The most common type was metopic (29%). The most common concurrent disorder was congenital heart defects (43.2% of patients). The mean age of infants was 0.62SD0.59 years. Gender distribution showed a significant difference (p value = 0.006). While the metopic (n = 31) type was significantly more common in boys, the coronal type was female predominant (n = 14). The mean age of fathers was 33.08SD5.66 and mothers, was 29.02SD5.70 with no significant difference (p value = 0.669 and 0.149, respectively). Other evaluated factors also didn't show a significant difference.

Conclusion

Craniosynostosis is more prevalent in boys, especially the metopic type. Coronal type has a female predilection. The most common subtype is metopic. The most common concurrent congenital disorder is congenital heart defects.

Postnatal Progressive Craniosynostosis in Syndromic Conditions: Two Patients With Saethre-Chotzen Due to TWIST1 Gene Deletions and Review of the Literature

Saethre-Chotzen syndrome (SCS) is a known craniosynostosis syndrome with a variable presentation of craniofacial and somatic involvement. Congenital coronal craniosynostosis is most commonly observed in SCS; however, progressive postnatal craniosynostosis of other sutures has been reported. The authors present 2 infants with progressive postnatal craniosynostosis and SCS caused by chromosome 7p deletions including the TWIST1 gene. The evolution of their clinical features and a literature review of patients with syndromic, postnatal progressive craniosynostosis illustrate the importance of longitudinal observation and management of these patients.

Síndrome de Apert: alternativas de tratamiento ortodóntico - quirúrgico y tiempos de ejecución. Una revisión de la literatura

Objetivo: realizar una revisión de la literatura acerca de los tratamientos ortodónticos y quirúrgicos del síndrome de Apert durante las diferentes etapas de crecimiento y desarrollo. Métodos: se llevó a cabo una búsqueda en las bases de datos MedLine (PubMed), Science Direct, Scopus y Wiley Online Library con la combinación de los siguientes términos: Syndromic craniosynostosis, Dental treatment, orthodontic treatment, Apert Syndrome, surgical treatment, dental care. Se incluyeron revisiones sistemáticas y de literatura, estudios retrospectivos, longitudinales y de cohorte, series y revisiones de caso publicados entre 1990 y 2020 en español o inglés; se excluyeron artículos relacionados con otros síndromes, así como estudios en animales. Los artículos fueron seleccionados según su pertinencia y disponibilidad de texto completo; hallazgos repetidos fueron eliminados; adicionalmente, se utilizó el sistema bola de nieve en los artículos seleccionados; la calidad de la evidencia fue evaluada mediante el sistema GRADE. Resultados: 34 artículos fueron incluidos (calidad alta: 2, moderada: 1, baja: 19 y muy baja: 12). Entre estos, se identificaron discusiones relacionadas con la etapa de crecimiento a la que se recomienda realizar los procedimientos quirúrgicos requeridos para minimizar sus impactos negativos. La mayoría de los artículos apoyan el manejo terapéutico ejecutado por equipos multidisciplinarios. Conclusiones: un plan de tratamiento combinado de ortodoncia y cirugía ortognática se presentó como la mejor opción para obtener los mejores resultados funcionales y estéticos para la población en cuestión. El momento adecuado durante el crecimiento y desarrollo de los individuos para implementar cada fase de tratamiento fue decidido por cada equipo multidisciplinario.

Fronto-Orbital Advancement and Posterior Cranial Vault Expansion Using Distraction Osteogenesis in Patients With Multiple Craniosynostosis

ABSTRACT

This study aimed to evaluate the treatment outcomes and the efficiency of techniques of fronto-orbital advancement (FOA) and posterior cranial vault expansion (PCVE) using distraction osteogenesis in patients with multiple craniosynostosis. We assessed the treatment results and outcomes of 8 patients with multiple craniosynostosis at the Kagoshima University Hospital between 2005 and 2019. Each 4 patients underwent FOA and PCVE, respectively, using distraction osteogenesis. The cranial volume and developmental quotient (DQ) were measured at the preoperative period and 1 year after surgery. The mean patient age at surgery was 22 months. The mean preoperative cranial volume was 1027 and 1071 cm3 in the FOA and PCVE groups, respectively. The mean preoperative DQ scores were 74 and 67, respectively. After 1-year of follow-up, the corresponding mean cranial volume became 1108 and 1243 cm3, respectively. The corresponding mean DQ scores also improved to 74 and 81, respectively. The postoperative follow-ups in all cases were uneventful, except for persistent epilepsy in 1 patient. Fronto-orbital advancement and PCVE using distraction osteogenesis might contribute to good outcomes in expanding cranial volume, cosmetic osteogenesis, and infantile development in patients with multiple craniosynostosis. Regarding the cranial volume expansion, especially, PCVE using distraction osteogenesis is more effective than FOA.

Craniosynostosis: Posterior Cranial Vault Remodeling

Posterior cranial vault distraction osteogenesis is a powerful, reliable, low-morbidity method to achieve intracranial expansion. It is particularly useful in treating turribrachycephaly seen in syndromic craniosynostosis, allowing for gradual expansion of the bone while stretching the soft tissues over several weeks allowing greater volumetric expansion than conventional techniques. Posterior cranial vault distraction osteogenesis constitutes a more gradual remodeling modality, with infrequent complications. As a first step in intracranial expansion, it preserves the frontal cranium for future frontofacial procedures. A drawback is the need for a second surgery to remove the device, and this must be taken into account during counseling.

A rare case of pancraniosynostosis observed in a historical skull from the 19 th century cranial collection named “Królestwo Polskie” (“Polish Kingdom”)

Rare diseases are a challenge in paleopathological research, mainly due to the ambiguity of skeletal signs, bad preservation state of the material, and lack of the reference material. The aim of our article is to present the skull characterized by the decreased values of the metrical traits and numerous pathological features of the cranial morphology and make an attempt to determine the possible cause of the observed anomalies.

The subject of our study is a cranium No KP 131 belonging to Polish skeletal collection named „Polish Kingdom”. We used both standard anthropometric methods, as well as the imaging techniques to detect the probable causes of the observed pathological changes.

This specimen presents a complex of pathologies. Decreased values of the metrical features, thinning of the lateral walls of the neurocranium and the presence of platybasia were probably caused by premature closure of all main cranial sutures.

Pathologies observed in cranium No 131 XIX might have had a common cause in some form of syndromic disorders.

Cranial Suture Regeneration Mitigates Skull and Neurocognitive Defects in Craniosynostosis

Craniosynostosis results from premature fusion of the cranial suture(s), which contain mesenchymal stem cells (MSCs) that are crucial for calvarial expansion in coordination with brain growth. Infants with craniosynostosis have skull dysmorphology, increased intracranial pressure, and complications such as neurocognitive impairment that compromise quality of life. Animal models recapitulating these phenotypes are lacking, hampering development of urgently needed innovative therapies. Here, we show that Twist1+/- mice with craniosynostosis have increased intracranial pressure and neurocognitive behavioral abnormalities, recapitulating features of human Saethre-Chotzen syndrome. Using a biodegradable material combined with MSCs, we successfully regenerated a functional cranial suture that corrects skull deformity, normalizes intracranial pressure, and rescues neurocognitive behavior deficits. The regenerated suture creates a niche into which endogenous MSCs migrated, sustaining calvarial bone homeostasis and repair. MSC-based cranial suture regeneration offers a paradigm shift in treatment to reverse skull and neurocognitive abnormalities in this devastating disease.

Classification of Subtypes of Crouzon Syndrome Based on the Type of Vault Suture Synostosis

BACKGROUND

Patients with Crouzon syndrome develop various types of anatomic deformities due to different forms of craniosynostosis, yet they have similar craniofacial characteristics. However, exact homology is not evident. Different pathology then may be best treated by different forms of surgical technique. Therefore, precise classification of Crouzon syndrome, based on individual patterns of cranial suture involvement is needed.

METHODS

Ninety-five computed tomography (CT) scans (Crouzon, n = 33; control, n = 62) were included in this study. All the CT scans are divided into 4 types based on premature closure of sutures: class I = coronal and lambdoidal synostosis; class II = sagittal synostosis; class III = pansynostosis; and class IV = "Others." The CT scan anatomy was measured by Materialise software.

RESULTS

The class III, pansynostosis, is the most prevalent (63.6%). The classes I, III, and IV of Crouzon have significantly shortened entire anteroposterior cranial base length, with the shortest base length in class III. The external cranial measurements in class I show primarily a decreased posterior facial skeleton, while the class III presented with holistic facial skeleton reduction. Class II has the least severe craniofacial malformations, while class III had the most severe.

CONCLUSION

The morphology of patients with Crouzon syndrome is not identical in both cranial base and facial characteristics, especially when they associated with different subtypes of cranial suture synostosis. The classification of Crouzon syndrome proposed in this study, summarizes the differences among each subgroup of craniosynostosis suture involvement, which, theoretically, may ultimately influence both the timing and type of surgical intervention.

Identifying the Misshapen Head: Craniosynostosis and Related Disorders

Pediatric care providers, pediatricians, pediatric subspecialty physicians, and other health care providers should be able to recognize children with abnormal head shapes that occur as a result of both synostotic and deformational processes. The purpose of this clinical report is to review the characteristic head shape changes, as well as secondary craniofacial characteristics, that occur in the setting of the various primary craniosynostoses and deformations. As an introduction, the physiology and genetics of skull growth as well as the pathophysiology underlying craniosynostosis are reviewed. This is followed by a description of each type of primary craniosynostosis (metopic, unicoronal, bicoronal, sagittal, lambdoid, and frontosphenoidal) and their resultant head shape changes, with an emphasis on differentiating conditions that require surgical correction from those (bathrocephaly, deformational plagiocephaly/brachycephaly, and neonatal intensive care unit-associated skill deformation, known as NICUcephaly) that do not. The report ends with a brief discussion of microcephaly as it relates to craniosynostosis as well as fontanelle closure. The intent is to improve pediatric care providers' recognition and timely referral for craniosynostosis and their differentiation of synostotic from deformational and other nonoperative head shape changes.

A Novel Frameshift Mutation in KAT6A Is Associated with Pancraniosynostosis

De novo heterozygous mutations in the KAT6A gene give rise to a distinct intellectual disability syndrome, with features including speech delay, cardiac anomalies, craniofacial dysmorphisms, and craniosynostosis. Here, we reported a 16-year-old girl with a novel pathogenic variant of the KAT6A gene. She is the first case to possess pancraniosynostosis, a rare suture fusion pattern, affecting all her major cranial sutures. The diagnosis of KAT6A syndrome is established via recognition of its inherent phenotypic features and the utilization of whole exome sequencing. Thorough craniofacial evaluation is imperative, craniosynostosis may require operative intervention, the delay of which may be detrimental.

Multidisciplinary care for a patient with syndromic craniosynostosis: A case report with 20 years of special care

AIM

The functional and structural complexities accompanying syndromic craniosynostosis make dental care for these patients particularly challenging. We report a case of long-term care for a syndromic craniosynostosis patient. The objective of this report is to introduce special care guidance and clinical recommendation, so that oral health care providers, as key members of a multidisciplinary care team, can provide optimal diagnosis, treatment, and management for the patient with syndromic craniosynostosis.

CASE REPORT

The patient of this case report had a medical history of syndromic craniosynostosis involving multiple comorbidities. Over the past 20 years, a multidisciplinary care team has successfully treated the patient. Dental and medical procedures that the patient has received include cranial surgeries, prophylactic dental care, caries control, growth hormone therapy, comprehensive orthodontic treatment in conjunction with orthognathic surgeries, and plastic surgery.

CONCLUSION

Oral health care providers can play essential roles in multidisciplinary care for patients with craniosynostosis by understanding the patients' unique oral health conditions and dentofacial deformities. To provide optimal oral health care in a multidisciplinary team, clear communication between the members of the care team is crucial.

Posterior Vault Distraction Osteogenesis in Nonsyndromic Patients: An Evaluation of Indications and Safety

PURPOSE

The purpose of this study was to evaluate the indications, safety, and short-term outcomes of posterior vault distraction osteogenesis (PVDO) in patients with no identified acrocephalosyndactyly syndrome (study) and to compare those to a syndromic cohort (controls).

METHODS

Demographic and perioperative data were recorded and compared across the study and control groups for those who underwent PVDO between January 2009 and December 2016. Univariate analysis was conducted using χ and Fisher exact tests for categorical variables, and Mann-Whitney U test for continuous variables.

RESULTS

Sixty-three subjects were included: 19 in the nonsyndromic cohort, 44 in the syndromic cohort. The cohorts had similar proportion of subjects exhibiting pansynostosis (42.1% of nonsyndromic versus 36.4% of syndromic, P = 0.667). The nonsyndromic cohort was significantly older (4.04 ± 3.66 years versus 2.55 ± 3.34 years, P = 0.046) and had higher rate of signs of raised intracranial pressure (68.4% versus 25.0%, P = 0.001) than the syndromic cohort. There was no significant difference in perioperative variables or rate of complications (P > 0.05). The mean total advancement distance achieved was similar, 27 ± 6 mm in the nonsyndromic versus 28 ± 8 mm in the syndromic cohort (P = 0.964). All nonsyndromic subjects with signs of raised intracranial pressure demonstrated improvement at an average follow-up of 22 months.

CONCLUSION

As in the syndromic patient, PVDO is a safe and, in the short-term, effective modality for cranial vault expansion in the nonsyndromic patient. The benefits and favorable perioperative profile of PVDO may therefore be extended to patient populations other than those with syndromic craniosynostosis.

Increases in Cranial Volume with Posterior Cranial Vault Distraction in 31 Consecutive Cases

BACKGROUND

Posterior cranial vault distraction (PCVD) is a technique widely used in surgical treatment of craniosynostosis when cranial expansion is required. It has proven to be safe and to allow a significant increase of intracranial volume.

OBJECTIVE

To evaluate increases in intracranial volume as a result of PCVD performed in Oulu Craniofacial center using 2 different methods based on 3-dimensional (3-D) photogrammetric imaging or plain skull radiographs.

METHODS

All children less than 16 yr of age who were treated by PCVD (n = 31) from 2009 to 2015 at the Oulu Craniofacial Center were included. All patients were followed at outpatient clinics with plain radiographs performed for follow-up. In 5 patients, additional 3-D photogrammetric imaging was done pre- and postoperatively.

RESULTS

The mean intracranial volume increase was 25.0%, ranging from 16.9% to 39.4%. In 5 patients, the increase in volume was calculated from the photogrammetric 3-D images comprising a mean of 17.4%. Volume calculations from cephalograms in the same patients gave a mean of 20.8%. Whether the distraction was a primary operation or patient had undergone previous cranioplasty did not influence the achieved volumetric results. There were no statistically significant differences in the distraction results between different diagnostic groups.

CONCLUSION

PCVD is an effective surgical method to increase intracranial volume in a variety of clinical entities. Volumetric results of this procedure could be easily evaluated using 3-D photogrammetric imaging or plane radiographs that expose the patients to only low ionizing radiation doses.

Normocephalic Pancraniosynostosis: A Report of a Surgical Technique

Normocephalic pancraniosynostosis is defined as the premature fusion of 3 or, more major sutures in the absence of another primary etiology, including primary, microcephaly, ventriculoperitoneal shunting, hypothyroidism, rickets, mucopolysaccharidoses, or other lysosomal storage diseases. It is very rare, thus far only 6 patients have been reported in the literature. Patients tend to present much later than those with single sutural, synostoses, and up to half have evidence of elevated intracranial pressure. The authors wish to present another patient, with emphasis on a unique treatment approach.

A Patient With Pansynostosis and Williams-Beuren Syndrome

BACKGROUND

Williams-Beuren syndrome (WBS) is a multisystemic genetic disorder caused by a gene deletion at gene locus 7q11.23. This article presents the first described case of a patient with WBS and simultaneous pansynostosis.

CASE PRESENTATION

This article presents the management of this young Caucasian boy from birth until the age of 12 years and provides an overview of previously described manifestations of WBS in the craniofacial region.

CONCLUSIONS

This case demonstrates the surgical treatment of pansynostosis in a child with WBS and might provide interesting aspects in the diagnostics and management of this rare malformation.

Pancraniosynostosis following endoscopic-assisted strip craniectomy for sagittal suture craniosynostosis in the setting of poor compliance with follow-up: a case report

Introduction

There is limited craniofacial literature on the complications of helmet therapy and controversy regarding the effects of inadequate orthotic helmet therapy. The authors present a case of inadvertently prolonged orthotic helmet therapy after endoscopic strip craniectomy for isolated sagittal synostosis.

Case presentation

A two-month-old Caucasian baby underwent uncomplicated endoscopic-assisted strip craniectomy to treat synostosis of the sagittal suture and was fitted for an orthotic helmet two weeks postoperatively. He presented to the craniofacial clinic eight weeks postoperatively with occipital flattening and increased posterior vault height, so the helmet was refitted. During the next 18 months, the helmet was used inconsistently without follow-up. Upon re-presentation, the patient had developed pansynostosis, requiring a subsequent open total cranial vault reconstruction for correction for this secondary deformity.

Conclusions

Although it remains unclear whether postoperative development of pansynostosis is the result of prolonged helmeting or the consequence of progressive synostotic disease, this report highlights the importance of parent education and judicious scheduled follow-up for the avoidance of potential helmet therapy complications.

Odilon Marc Lannelongue (1840–1911) and strip craniectomy for craniosynostosis

In the 19th century, Dr. Odilon Marc Lannelongue was a pioneering French surgeon who introduced a surgical technique for the treatment of craniosynostosis. In 1890, Dr. Lannelongue performed correction of sagittal synostosis by strip craniectomy. From his procedure, multiple techniques have been developed and endorsed for this condition, ranging from simple suturectomies to extensive calvarial vault remodeling. In addition, even today, endoscopically aided strip craniectomy is performed as a surgical treatment of craniosynostosis. This article describes the life and works of the surgeon who revolutionized the management of craniosynostosis.

Identification of skull base sutures and craniofacial anomalies in children with craniosynostosis: utility of multidetector CT

PURPOSE

Craniosynostosis is a condition characterised by the premature fusion of one or more of the cranial sutures. The aim of the study was to identify, by multidetector computed tomography (CT), the involvement of vault sutures as well as of the skull base sutures (named "minor" sutures). The latter ones are involved in development of craniofacial and skull base deformities.

MATERIALS AND METHODS

We retrospectively reviewed 27 children with complex synostosis (n = 21) and anterior synostotic plagiocephaly (n = 6). High-resolution CT images with bone definition algorithm and tridimensional volume rendering reconstructions were assessed.

RESULTS

In 27 children we found different sutures involved in the synostotic process, including both major and minor skull suture synostosis, and synostosis of synchondroses. Superior orbital rim deformity, nasal root deviation, anterior endocranial axis deviation (ethmoidal axis) are found in children with coronal arch synostosis, while reduced size of the posterior fossa and Chiari 1 malformation are noted in children with lambdoid arch synostosis.

CONCLUSIONS

High-resolution CT allows an accurate identification of both "major" and "minor" skull base suture synostosis and it represents the gold standard for the diagnosis of craniostenosis and for planning the proper surgical approach.

Experience with craniosynostosis treatment using posterior cranial vault distraction osteogenesis

BACKGROUND

Craniosynostosis compromises the cranial vault volume, severely impede growth, and may lead to increased intracranial pressure (ICP). Posterior cranial vault (PCV) distraction osteogenesis (DO) offers an excellent treatment opportunity for this condition. This article intends to describe the outcomes of PCV DO.

MATERIALS AND METHODS

Nine males and seven female children indicated for PCV DO were included in the study. The single vector distraction devices with quick-disconnect distraction rods, a type of miniaturized hardware, was used in all cases.

RESULT

Seven of the 16 patients had a history of one or more prior cranioplasty. All reoperations in this series were performed for the indication of raised ICP including five of the scaphocephaly patients and the syndromic patients. Clinical signs of raised ICP were present in all patients with either measured raised intracranial pressure or those with clinical signs of raised ICP preoperatively. There was substantial decrease in the ICP postoperatively.

DISCUSSION

The outcomes of this study were encouraging. Placing the distractor stems as flat as possible against the outer layer of the cranial bone seems to be a very important maneuver. This keeps the distractor stem less proud and less likely to sustain future trauma. Removal of the distractor stems keeps the devices further away from the risk of later traumatic dislodgement. Moreover, miniaturized distractors allow precise control of the rate and the amount of distraction.

Complex craniosynostoses: a review of the prominent clinical features and the related management strategies

The protocols for clinical evaluation and management of children with complex craniosynostoses are significantly different from those used in single suture forms. The time at which the various anatomical and functional anomalies observed in the affected subjects become clinically relevant varies from patient to patient, consequently requiring a tailored approach. The clinical course is variable and influenced by multiple factors, acting at different steps of the children growth. Intracranial hypertension is a major concern already in the first months of life; active cerebrospinal fluid (CSF) dynamics disorders, venous hypertension, and progressive craniocerebral disproportion are considered the main pathogenetic factors. Cranial vault and skull base sutures synostoses account for the frequently observed increased venous pressure. Skull base abnormalities lead to upper airways obstruction, which, on one side, might create significant upper airways obstructive problems and, on the other, contribute to the increase in the intracranial pressure. Secondary Chiari malformation is common and considered as a progressive disorder, mainly due to progressive craniocerebral disproportion, venous hypertension, and CSF dynamics disorders. Optic nerve and orbit-related eye-globe diseases are also a major concern. Papilledema is mostly related to increased intracranial pressure. The skull base synostotic process is the base of significant abnormalities of the orbital space, ending in the common feature of significant proptosis with the consequent risk of corneal ulcers. Aims of this paper are to analyze the physiopathogenetic mechanisms at the base of the clinical manifestations presented by children with complex craniosynostoses, and the therapeutic options currently available.

Craniofacial reconstruction as a treatment for elevated intracranial pressure

INTRODUCTION

Craniofacial procedures may be needed to address symptomatic intracranial hypertension. The authors review their institutional experience in the treatment of children with symptomatic increased intracranial pressure (ICP) utilizing craniofacial reconstructive procedures.

METHODS

The senior authors' (HSM, SRC) craniofacial experience of 222 patients over a 7-year period from 2000 to 2007 at a single institution (Rady Children's Hospital, San Diego) is reviewed. Seventeen patients were identified who were felt to be candidates for craniofacial surgery with symptomatic increased ICP.

RESULTS

Patient diagnoses included single-suture craniosynostosis, craniofacial dysostoses, shunt-induced craniostenosis, and shunt-associated intracranial hypertension (slit-ventricle syndrome). Seventeen patients underwent 21 craniofacial procedures. Age at surgery ranged from 3 months to 13 years with a mean of 5 years. Preoperative symptoms and signs included headaches, unexplained irritability, seizures, papilledema, and visual loss. All patients had diagnostic neuroimaging. Seven patients had preoperative invasive ICP measurements. Surgery was deferred on three of these patients based on these measurements. The mean total operative (including anesthetic preparation) and surgical times were 3 h 12 min and 2 h 20 min, respectively. Percentage operative blood loss averaged 11.3%. In six procedures, no transfusions were required. Average hospital stay was 4 days. There was no perioperative mortality or significant surgery associated morbidity. All patients have had postoperative clinical improvement in signs and symptoms of increased ICP.

CONCLUSIONS

Using modern diagnostic and surgical techniques, including invasive ICP monitoring, increased intracranial pressure can be successfully managed by an experienced, multidisciplinary, craniofacial team. Our treatment paradigm and operative management scheme is discussed.

Posterior cranial vault distraction osteogenesis in craniosynostosis: estimated increases in intracranial volume

PURPOSE

To study distraction osteogenesis of the posterior cranial vault in children requiring increased intracranial volume.

MATERIALS AND METHODS

Ten patients were treated with cranial distractors. Five children had previously been operated for scaphocephaly and one child for Saether-Chotzen syndrome. Two patients had bilateral coronal suture synostosis with Muenke syndrome and two patients had Apert syndrome. At surgery, the cranial bones were mobilized, the head was widened during surgery, and the segments fixed to each other with distractors. Further expansion at a rate of 1 mm/day was performed over 2-4 weeks. The cranium was distracted posteriorly from 20 to 30 mm.

RESULTS

The patients all tolerated surgery and distraction well. In all cases, the parents were able to perform the distraction at home. There were no technical problems with the distraction devices. Two cases had minor cutaneous problems, where the distractor penetrated the skin. These cases responded to gentle local wound care measures. At the time of distractor removal, ossification had occurred sufficiently in one of these two cases. In the other case, the device was removed and replaced with a resorbable plate, without any harmful effect on the result. In all cases, sufficient expansion was achieved without causing more cosmetic deformity. Ossification occurred in all cases. This method seems effective, as the calculated increase in intracranial volume was a mean of 20.2% (range 10.2-28.5%).

CONCLUSIONS

This preliminary series shows that cranial bone distraction is a useful method for cranial expansion with low morbidity in children with craniosynostosis.

Posterior calvarial vault expansion using distraction osteogenesis

OBJECTIVES

Management of raised intracranial pressure in syndromic multi-suture craniosynostosis by cranial vault expansion can be achieved by a number of techniques. We present our initial experience in treating this group of patients with posterior calvarial distraction.

MATERIALS AND METHODS

Six patients underwent distraction osteogenesis of their posterior calvarial vault.

RESULTS

The mean period of distraction was 28 days. The mean consolidation period was 49 days. The mean distance of advancement was 24 mm. Five out of six patients completed their period of distraction and three of these cases also completed their period of consolidation. Significant calvarial expansion and improvement of head shape was achieved in all cases.

CONCLUSIONS

Posterior calvarial distraction is a safe and more efficient method of calvarial expansion than conventional techniques. These are early promising results, and future modification of the distraction devices will be needed if the effective consolidation time is to be increased.