Anterior plagiocephaly: epidemiology, clinical findings,diagnosis, and classification. A review

UCSQ Method Applied on 3D Photogrammetry: Non-Invasive Objective Differentiation Between Synostotic and Positional Plagiocephaly

OBJECTIVE

Objective differentiation between unilateral coronal synostosis (UCS) and positional posterior plagiocephaly (PPP) based on 3D photogrammetry according to Utrecht Cranial Shape Quantificator (UCSQ).

DESIGN

Retrospective study.

SETTING

Primary craniofacial center.

PATIENTS, PARTICIPANTS

Thirty-two unoperated patients (17 UCS; 15 PPP) (age < 1 year).

INTERVENTIONS

Extraction of variables from sinusoid curves derived using UCSQ: asymmetry ratio forehead and occiput peak, ratio of gradient forehead and occiput peak, location forehead and occiput peak.

MAIN OUTCOME MEASURE(S)

Variables, derived using 3D photogrammetry, were analyzed for differentiation between UCS and PPP.

RESULTS

Frontal peak was shifted to the right side of the head in left-sided UCS (mean x-value 207 [192-220]), and right-sided PPP (mean x-value 210 [200-216]), and to the left in right-sided UCS (mean x-value 161 [156-166]), and left-sided PPP (mean x-value 150 [144-154]). Occipital peak was significantly shifted to the right side of the head in left-sided PPP (mean x-value 338 [336-340]) and to the left in right-sided PPP (mean x-value 23 [14-32]). Mean x-value of occipital peak was 9 (354-30) in left- and 2 (350-12) in right-sided UCS. Calculated ratio of gradient of the frontal peak is, in combination with the calculated asymmetry ratio of the frontal peak, a distinctive finding.

CONCLUSIONS

UCSQ objectively captures shape of synostotic and positional plagiocephaly using 3D photogrammetry, we therefore developed a suitable method to objectively differentiate UCS from PPP using radiation-free methods.

3-Dimensional Morphometric Outcomes After Endoscopic Strip Craniectomy for Unicoronal Synostosis

BACKGROUND

Endoscopic strip craniectomy with postoperative helmeting (ESCH) for unicoronal synostosis has shown to be a less morbid procedure when compared with fronto-orbital remodeling (FOR). We aim in this pilot study to report objective methods and quantitative morphologic outcomes of endoscopically treated unicoronal synostosis using 3-dimensional surface scans.

METHODS

Our electronic records were reviewed for ophthalmological, neurodevelopmental outcomes, and helmet-related complications. For morphologic outcomes, the following parameters were used: Cranial Index, Cranial Vault Asymmetry Index, Anterior Symmetry Ratio (ASR), and Root Mean Square between the normal and synostotic sides of the head. Three-dimensional stereophotogrammetry scans were evaluated at 3 time points preoperative, 6 months post-op, and at the end of the treatment, which was compared with age-matched scans of normal controls and FOR patients. Nonparametric tests were used for statistical analysis.

RESULTS

None of the ESCH cases developed strabismus, major neurodevelopmental delay, or helmet complications. All morphologic parameters improved significantly at 6 months post-op except for the Cranial Vault Asymmetry Index. The ASR was the only parameter to change significantly between 6 months post-op and final scans. At end of helmet treatment, ASR and Root Mean Square differed significantly between the ESCH and both FOR and control groups.

CONCLUSIONS

Endoscopic strip craniectomy with postoperative helmeting for single unicoronal synostosis had excellent clinical outcomes. Most of the improvement in head morphology occurred in the first 6 months of treatment. Despite the normalization of the overall head shape, there was residual asymmetry in the frontal and temporal regions of the head.

Positional Plagiocephaly and Craniosynostosis

Along with the decrease in sudden infant death syndrome due to the successful "Back to Sleep" Campaign, there was a reciprocal increase in cases of positional plagiocephaly (PP). The prevalence of PP significantly rose from approximately 5% to upward of 46% at age 7 months. Consequently, clinicians have seen a surge in the number of patients presenting with head shape abnormalities. Not only does this increase in patient volume pose a logistical problem to clinics, but it also poses a potential risk to patients with craniosynostosis, whose head shape anomalies are similar to a "needle in a haystack" of patients with more common PP. This review explores the causes, risk factors, and treatment options of PP and craniosynostosis, along with the differential of head shape anomalies based on phenotypic presentation. In doing so, we hope to provide pediatric care clinicians with the tools necessary to effectively evaluate and manage patients with head shape abnormalities. [Pediatr Ann. 2023;52(1):e10-e17.].

Anterior Synostotic Plagiocephaly: A Quantitative Analysis of Craniofacial Features Using Computed Tomography

The premature fusion of one coronal suture causes anterior synostotic plagiocephaly (ASP), which results in overt craniofacial dysmorphology that could be challenging to correct. This study aimed to document and compare the morphometry of the anterior cranial fossa (ACF), orbit, and ear on the ipsilateral (synostotic) and contralateral (nonsynostotic) sides in a select cohort of South African patients with ASP, using computed tomography (CT) scans. The dimensions of the ACF, orbit and the position of the ear on the ipsilateral and contralateral sides were measured using a set of anatomical landmarks on 2-dimensional CT scans of 18 consecutive patients diagnosed with nonsyndromic ASP. The differences between the ipsilateral and contralateral sides were calculated and expressed as a percentage of the contralateral side. All ACF parameters decreased significantly on the ipsilateral side when compared to the contralateral side, resulting in the volume of the ACF being the most affected (-27.7%). In terms of the orbit, on the ipsilateral side, the length-infraorbital rim, height, and surface area parameters increased significantly, with the height being the most affected (24.6%). The remaining orbital parameters (length-supraorbital rim, breadth and volume) decreased significantly, with the length-supraorbital rim parameter being the most affected (-10.8%). The ipsilateral ear was found to be displaced anteriorly (9.33 mm) and caudally (5.87 mm) from the contralateral ear. These measures may be useful to surgeons during corrective surgery by indicating the degree of the asymmetry on each side, making it easier to plan the technique and extent of surgical correction of the affected structures.

Epidemiology, Genetics, and Pathophysiology of Craniosynostosis

Craniosynostosis, the premature fusion of the infant cranial skulls, can be recognized by characteristic head shape differences that worsen with head growth. Craniosynostosis can be syndromic or nonsyndromic and can involve one suture or multiple sutures. Timely cranial vault surgery is recommended to expand and reshape the skull, with a goal of preventing increased intracranial pressure and providing sufficient space for brain growth. Several gene variants and environmental exposures are known to increase the risk of single suture craniosynostosis (SSC), including in utero constraint, exposure to specific toxins and medications, and medical conditions such as thyroid dysregulation and metabolic bone disorders.

Ophthalmological findings in children with unicoronal craniosynostosis

INTRODUCTION

Among non-syndromic, single-suture craniosynostoses, unicoronal craniosynostosis (UCS) presents the highest rate of ophthalmic manifestations requiring a visual follow-up, due to the high risk of amblyopia. After birth or during childhood, children with UCS have a high risk to present an aniso-astigmatism and a strabismus. The aim of this study was to characterize clinical ophthalmologic findings associated with UCS in a paediatric cohort.

METHODS

This retrospective study included children admitted in our unit between 2015 and 2021, with isolated UCS treated in our institution and complete ophthalmological assessment comprising visual assessment, refractive status and oculomotor examination. Children with associated craniofacial disorders were excluded.

RESULTS

A total of 28 children met the inclusion criteria. Median age was 62 [13-192] months with a large proportion of girls (86%) and 71% of right-sided UCS. The mean best corrected visual acuity was 0.07 (±0.13) LogMAR, including 10 (36%) children with an amblyopia or history of amblyopia. Astigmatism was significantly higher on the contralateral side of the UCS than on the ipsilateral side, with a refractive cylinder error of 0.97 (±1.06) vs 0.56 (±0.68) diopters, respectively (p = 0.03). Strabismus was observed in 20 patients (71%) with a main pattern of esotropia with a vertical component. A pseudo-superior oblique palsy was found in 13 children (65%) with a median cyclodeviation of 8.7° [-5,4°-20.6°].

CONCLUSION

Children with UCS experience a high rate of various visual manifestations. This study highlights their need for a strict ophthalmological follow-up, in order to early diagnose and prevent visual complications.

A Cohort Study of Strabismus Rates Following Correction of the Unicoronal Craniosynostosis Deformity: Conventional Bilateral Fronto-Orbital Advancement Versus Fronto-Orbital Distraction Osteogenesis

BACKGROUND

The purpose of this prospective study is to compare perioperative morbidity and strabismus rates between traditional fronto-orbital advancement reconstruction (FOAR) and fronto-orbital distraction osteogenesis (FODO) in unicoronal craniosynostosis (UCS).

METHOD

A consecutive group of 15 patients undergoing FODO for isolated UCS were compared to a contemporaneous group of 15 patients undergoing traditional FOAR for UCS. Patient age, operative time, blood loss, blood replacement, technical details of the surgery, length of stay, complications, and strabismus rates were documented and compared statistically using chi-square and Student t test with a significance value of 0.05.

RESULTS

The 15 patients undergoing FODO were younger (6.3 and 9.8 months, P < 0.05), experienced less operative time for the initial procedure (111 versus 190 minutes, P < 0.01), less blood loss (26% versus 50% of total blood volume, P < 0.01), and less blood replacement (40% versus 60% of total blood volume, P < 0.05). One patient in the FODO group experienced a new-onset strabismus postoperatively compared with 5 in the FOAR group (P < 0.05). There were no complications requiring a return to the operating room in either group.

CONCLUSIONS

Fronto-orbital distraction osteogenesis for the treatment of isolated UCS is associated with a favorable perioperative morbidity profile and a decreased incidence of postoperative strabismus compared with traditional FOAR. These positive factors are tempered by the need for an additional procedure for removal of the device and lack of long-term outcomes data on the technique.

Occipitofrontal switch for correction of anterior plagiocephaly planned through virtual mock surgery

Background:

Unilateral coronal synostosis causing anterior plagiocephaly can result in restricted brain development and severe facial deformities. Various surgical procedures have been described for the correction of this deformity. Cranial vault remodeling, however, is associated with several complications. Occipitofrontal switching is a novel technique which utilizes a part of the contralateral occipital bone to reconstruct the frontal area. This is the first such case reported from India and first report where virtual mock surgery has been utilized for precision and improving outcome in this elegant procedure.

Case Description:

A 5-year-old girl presented with left anterior plagiocephaly. 3D image of her skull was reconstructed using Geomagic Freeform software (3D Systems, Rock Hill, SC). Measurements were accurately drawn and the procedure was practised virtually before performing the occipitofrontal switch on the patient. There were minimal blood loss and postoperative morbidity. One year follow-up of the patient showed optimal correction of the defect in the forehead region, symmetrical shape of the frontal and occipital region and symmetrical brows.

Conclusion:

The technique of occipitofrontal switch for correction of anterior plagiocephaly is an elegant procedure with good functional and aesthetic outcome.

Orbital volume, ophthalmic sequelae and severity in unilateral coronal synostosis

PURPOSE

Unilateral coronal synostosis (UCS) results in an asymmetrical skull, including shallow and asymmetrical orbits, associated with reduced orbital volume and high prevalences of ophthalmic sequelae. Aim is to link orbital volumes in patients with UCS to severity according to UCSQ (Utrecht Cranial Shape Quantifier) and presence of ophthalmic sequelae.

METHODS

We included preoperative patients with UCS (≤ 18 months). Orbital volume was measured on CT scans by manual segmentation (Mimics software (Materialise, Leuven, Belgium)), and severity of UCS was determined by UCSQ. Orbital volume of affected side was compared to unaffected side using Wilcoxon signed rank test. Orbital volume ratio was calculated (affected/unaffected volume) and compared to the category of UCSQ by Kruskal-Wallis test. Opthalmic sequelae were noted.

RESULTS

We included 19 patients (mean age 7 months). Orbital volume on affected side was significantly lower (p = 0.001), mean orbital volume ratio was 0.93 (SD 0.03). No significant differences in group means of orbital volume ratio between different levels of severity of UCSQ were found (Kruskal-Wallis H (2) = 0.873; p > 0.05). Ophthalmic sequelae were found in 3 patients; one had adduction impairment and strabismus (mild UCS), one had astigmatism (moderate UCS), and one had abduction impairment (on both ipsi- and contralateral side) and vertical strabismus (severe UCS).

CONCLUSION

No association between orbital volume ratio and severity of UCS was found. Side-to-side asymmetry in orbital volume was noted. No association between either preoperative orbital volume ratio or severity of UCS and the presence of preoperative ophthalmic sequelae was found.

A protocol of situation-dependent transfusion, erythropoietin and tranexamic acid reduces transfusion in fronto-orbital advancement for metopic and coronal craniosynostosis

PURPOSE

Assess the effect of a protocol of preoperative erythropoietin (EPO) and ferrous sulfate in addition to perioperative tranexamic acid (TXA) on blood transfusions in patients with coronal or metopic craniosynostosis undergoing cranial vault remodeling (CVR) with fronto-orbital advancement (FOA).

METHODS

Retrospective review of all coronal and metopic craniosynostosis patients undergoing CVR and FOA from March 2010 to June 2019 was performed. Before 2014 ("Control group"), all patients received blood transfusion at the start of surgery. In 2014, a protocol of preoperative EPO and ferrous sulfate with perioperative TXA and non-automatic transfusion was instituted ("Study group"). Patient demographics and anthropometrics, perioperative hemoglobin (Hb) levels, and transfusion details were collected and compared.

RESULTS

Thirty-six patients met inclusion criteria. Twenty-one patients were in the control group, and 15 in the Study group. Nineteen patients had metopic synostosis, 11 had unicoronal synostosis, and 6 had bicoronal synostosis. There were no significant differences between groups in demographics, operative time, intraoperative crystalloid volume, craniofacial syndromes, or sutures affected. The Study group had higher preoperative Hb (13.9 ± 1.0 vs. 12.6 ± 0.8 g/dL, p < 0.001), lower intraoperative Hb nadir (7.4 ± 1.8 vs. 9.2 ± 1.2 g/dL) lower intraoperative transfusion rate (66.7% vs. 100%, p = 0.008), lower postoperative transfusion rate (0% vs 28.6%, p = 0.03), and exposure to fewer unique units of packed red blood cells (0.7 ± 0.6 vs. 1.5 ± 0.9 units).

CONCLUSION

Our protocol resulted in decreased transfusion needs. These results add valuable information to the growing body of work on transfusion reduction in craniosynostosis surgery.

Quantification of Severity of Unilateral Coronal Synostosis

OBJECTIVES

Severity of unilateral coronal synostosis (UCS) can vary. Quantification is important for treatment, expectations of treatment and natural outcome, and education of the patient and parents.

DESIGN

Retrospective study.

SETTING

Primary craniofacial center.

PATIENTS, PARTICIPANTS

Twenty-three preoperative patients with unilateral coronal craniosynostosis (age < 2 years).

INTERVENTION

Utrecht Cranial Shape Quantifier (UCSQ) was used to quantify severity using the variables: asymmetry ratio of frontal peak and ratio of frontal peak gradient.

MAIN OUTCOME MEASURES(S)

The UCSQ variables were combined and related to visual score using Pearson correlation coefficient; UCSQ and visual score were additionally compared to Di Rocco classification by one-way analysis of variance or Kruskal-Wallis test. All measurements were made on computed tomography scans.

RESULTS

Good correlation between UCSQ and visual score was found (r = 0.67). No statistically significant differences were found between group means of UCSQ in the 3 categories of Di Rocco classification (F _2,20 = 0.047; P > .05). Kruskal-Wallis test showed no significant differences between group means of visual score in the 3 categories of Di Rocco classification (Kruskal-Wallis H (2) = 0.871; P > .05).

CONCLUSIONS

Using UCSQ, we can quantify UCS according to severity using characteristics, it outperforms traditional methods and captures the whole skull shape. In future research, we can apply UCSQ to 3D-photogrammetry due to the utilization of external landmarks.

Cranioorbital Morphology Caused by Coronal Ring Suture Synostosis

BACKGROUND

Minor cranial sutural synostosis is currently regarded as a rare diagnosis. As clinical awareness grows, a greater number of cases are being documented. This study aims to describe the variants of unicoronal synostosis with regard to major and minor sutural involvement and secondary effects on cranial and orbital morphology. The information is aimed to improve clinical diagnosis and management.

METHODS

A retrospective study was conducted collecting preoperative computed tomographic scans of patients diagnosed with unicoronal synostosis and listed for surgical interventions, identified from a craniofacial database. Within these patients, different synostotic variants were identified based on which suture was affected. Scans of normal pediatric skulls (trauma) were used for a control group. Computed tomographic scans were analyzed for sutural involvement, cranial base deflection, and ipsilateral and contralateral orbital height and width. One-way analysis of variance was used to detect differences between synostotic variants and controls.

RESULTS

A total of 57 preoperative computed tomographic scans of patients with unicoronal synostosis were reviewed, in addition to 18 computed tomographic scans of normal skulls (control group). Four variants of unicoronal synostosis were identified: frontoparietal, frontosphenoidal, frontoparietal and frontosphenoidal, and frontosphenoidal and frontoparietal. The last two variants differ in their temporal involvement in the direction of sutural synostosis and ultimately cranial and orbital morphology. Three variants have been previously identified, but the fourth is presented for the first time.

CONCLUSIONS

An understanding of the variants of unicoronal synostosis and their temporal relationships is integral for accurate clinical diagnosis and surgical correction. Recommendations for treatment are based on discrete changes in orbital morphology.

Extraocular muscle positions in anterior plagiocephaly: V-pattern strabismus explained using geometric mophometrics

INTRODUCTION

Ophthalmological involvement in anterior plagiocephaly (AP) due to unicoronal synostosis (UCS) raises management challenges. Two abnormalities of the extraocular muscles (EOM) are commonly reported in UCS without objective quantification: (1) excyclorotation of the eye and (2) malposition of the trochlea of the superior oblique muscle. Here we aimed to assess the positions of the EOM in AP, using geometric morphometrics based on MRI data.

MATERIALS AND METHODS

Patient files were listed using Dr WareHouse, a dedicated big data search engine. We included all patients with AP managed between 2013 and 2018, with an available digital preoperative MRI. MRIs from age-matched controls without craniofacial conditions were also included. We defined 13 orbital and skull base landmarks in order to model the 3D position of the EOM. Cephalometric analyses and geometric morphometrics with Procrustes superimposition and principal component analysis were used with the aim of defining specific EOM anomalies in UCS.

RESULTS

We included 15 preoperative and 7 postoperative MRIs from patients with UCS and 24 MRIs from age-matched controls. Cephalometric analyses, Procrustes superimposition and distance computations showed a significant shape difference for the position of the trochlea of the superior oblique muscle and an excyclorotation of the EOM.

CONCLUSIONS

Our results confirm that UCS-associated anomalies of the superior oblique muscle function are associated with malposition of its trochlea in the roof of the orbit. This clinical anomaly supports the importance of MRI imaging in the surgical management of strabismus in patients with UCS.

Imaging in craniosynostosis: when and what?

PURPOSE

Currently, the interest on craniosynostosis in the clinical practice is raised by their increased frequency and their genetic implications other than by the still existing search of less invasive surgical techniques. These reasons, together with the problem of legal issues, make the need of a definite diagnosis for a crucial problem, even in single-suture craniosynostosis (SSC). Although the diagnosis of craniosynostosis is primarily the result of physical examination, craniometrics measuring, and observation of the skull deformity, the radiological assessment currently plays an important role in the confirmation of the diagnosis, the surgical planning, and even the postoperative follow-up. On the other hand, in infants, the use of radiation or the need of sedation/anesthesia raises the problem to reduce them to minimum to preserve such a delicate category of patient from their adverse effects.

METHODS, RESULTS AND CONCLUSIONS

This review aims at summarizing the state of the art of the role of radiology in craniosynostosis, mainly focusing on indications and techniques, to provide an update not only to pediatric neurosurgeons or maxillofacial surgeons but also to all the other specialists involved in their management, like neonatologists, pediatricians, clinical geneticists, and pediatric neurologists.

Quantitative analysis of cranial-orbital changes in infants with anterior synostotic plagiocephaly

PURPOSE

The effects of premature fusion of one coronal suture cause skull and orbital alterations in term of side-to-side asymmetry. This study aimed to quantify the cranio-orbital complex changes related to the severity of skull base dysmorphology in patients with unicoronal synostosis.

METHODS

Twenty-four infants affected by unicoronal synostosis were subdivided in three subgroups according to the severity of skull base deformity and their high-resolution CT images were quantitatively analyzed (groups IIa, IIb, III). Dimensions of cranial fossae, intracranial volume (ICV), ICV synostotic and ICV non synostotic side, whole brain volume (WBV), orbital volumes (OV), ICV/WBV, ICV_synostotic/ICV_{non-synostotic}, and OV_synostotic/OV_{non-synostotic} were evaluated.

RESULTS

Asymmetry and reduction in the growth of the anterior and middle fossae were found in all groups while asymmetry of the posterior cranial fossa was found only in IIb and III groups. In all groups, ICV, WBV, and ICV/WBV were not significantly different while ICV_synostotic/ICV_{non-synostotic} and OV_synostotic/OV_{non-synostotic} resulted significant difference (p < 0.05). ICV_{synostotic side} resulted reduction only in group III. OV on the synostotic side was not significantly reduced although a trend in progressively reducing volumes was noted according to the severity of the group.

CONCLUSION

Skull and orbital changes revealed a side-to-side asymmetry but the effects of the premature synostosis were more severe in group III suggesting an earlier timing of premature unicoronal synostosis in group III with respect to the other groups. The assessment of the skull base deformity might be an indirect parameter of severity of skull orbital changes and it might be useful for surgical planning.

3D morphological change of skull base and fronto-temporal soft-tissue in the patients with unicoronal craniosynostosis after fronto-orbital advancement

PURPOSE

This study aims to comprehensively evaluate the deformation of the skull base and fronto-temporal soft tissue in the patients with anterior plagiocephaly over 1 year of age by three-dimensional (3D) imaging after fronto-orbital advancement (FOA).

METHODS

We quantitatively analyzed the surgical results and outcome of FOA performed in 10 patients with anterior plagiocephaly. The measurements of the skull base and fronto-temporal soft tissue were performed based on 3D computed tomography (CT) scan. We assessed symmetry of the skull base and fronto-temporal soft tissue change.

RESULTS

The mean age of patients at FOA was 38.9 months. A significant asymmetry of the skull base was found in all the patients. The growth of the anterior and middle fossae was restricted and the deformation of the fronto-temporal region was marked by soft tissue measurements in different grades. On the follow-up CT images 23.6 months after surgery, there was prominent change (p < 0.05) between the two hemibases (CSO^ ratio) and between the lengths and angles of the anterior and middle cranial hemi-fossae (CX, CSX^, XSM^, XM ratio), especially in grade IIA. Anterior cranial vault asymmetry index obviously decreased to - 1.2 from 12% after surgery (p < 0.05). What's more, ACA^ was also proved to be less after surgical correction (19.91° versus 8.29°, p < 0.01) in grade IIA. The change of fronto-temporal soft tissue was significant such as the frontal angle, the angle of the frontal plane, the fontal-temporal angle, and the angle of the temporal plane in different grades.

CONCLUSIONS

The asymmetry of the skull base and the deformation of the fronto-temporal region can be presented by intracranial view at over 1 year of age in different grades. FOA can correct the skeletal malformation of the fronto-temporal region as well as soft tissue and the asymmetry of the skull base was improved after surgical treatment.

[3D printing in neurosurgery: a specific model for patients with craniosynostosis]

INTRODUCTION

Craniosynostosis is a rare condition and requires a personalised surgical approach, which is why we consider the use of 3D printed models beneficial in the surgical planning of this procedure.

MATERIAL AND METHODS

Acrylonitrile butadiene styrene plastic skull models were designed and printed from CT images of patients between 3 and 6 months of age with craniosynostosis of different sutures. The models were used to simulate surgical procedures.

RESULTS

Four models of four patients with craniosynostosis were produced: two with closure of the metopic suture and two with sagittal suture closure. The mean age of the patients was 5 months (3-6m) and the mean duration of the surgery was 286min (127-380min). The acrylonitrile butadiene styrene plastic models printed for the project proved to be optimal for the simulation of craniosynostosis surgeries, both anatomically and in terms of mechanical properties and reaction to surgical instruments.

CONCLUSIONS

3D printers have a wide range of medical applications and they offer an easy and affordable way to produce skull models. The acrylonitrile butadiene styrene material is suitable for the production of operable bone models as it faithfully reproduces the mechanical characteristics of bone tissue.

Quantitative analysis of craniofacial dysmorphology in infants with anterior synostotic plagiocephaly

PURPOSE

The study aimed to identify premature synostosis of "major" and "minor" sutures of the coronal sutural arch and splanchnocranium sutures to evaluate the relationship between craniofacial dysmorphology and the sutural pattern in children with anterior plagiocephaly.

METHODS

A quantitative analysis of the skull base and facial changes was performed on preoperative high-resolution CT images in 18 children with anterior synostotic plagiocephaly and compared with imaging findings in 18 age-matched healthy subjects.

RESULTS

All patients had patent splanchnocranium sutures. Fifteen out of 18 children showed early and isolated synostosis of the unicoronal suture (the major suture of the coronal ring) and were classified in groups II and III according to the classification scheme of anterior synostotic plagiocephaly based on the severity of craniofacial dysmorphology. Premature fusion of the unilateral coronal suture in groups II and III caused a marked asymmetry and reduced growth of the anterior and middle fossae on the synostotic side and a secondary varying severity in terms of asymmetric growth of the facial complex. Although both groups showed anterior displacement of the mandibular articulation on the synostotic side, group II showed only maxillary asymmetry, while group III showed maxillary and mandibular asymmetry.

CONCLUSIONS

In anterior synostotic plagiocephaly, the severity of skull base changes and asymmetric growth of the facial complex is not caused by skull base sutural synostotic involvement but is probably related to the different timing of unilateral coronal suture closure.

Diagnosis of infant synostotic and nonsynostotic cranial deformities: a review for pediatricians

Objective:

To review the current comprehensive care for nonsyndromic craniosynostosis and nonsynostotic cranial deformity and to offer an overall view of these craniofacial conditions.

Data source:

The review was conducted in the PubMed, SciELO, and LILACS databases without time or language restrictions. Relevant articles were selected for the review.

Data synthesis:

We included the anatomy and physiology of normal skull development of children, discussing nuances related to nomenclature, epidemiology, etiology, and treatment of the most common forms of nonsyndromic craniosynostosis. The clinical criteria for the differential diagnosis between positional deformities and nonsyndromic craniosynostosis were also discussed, giving to the pediatrician subsidies for a quick and safe clinical diagnosis. If positional deformity is accurately diagnosed, it can be treated successfully with behavior modification. Diagnostic doubts and craniosynostosis patients should be referred straightaway to a multidisciplinary craniofacial center.

Conclusions:

Pediatricians are in the forefront of the diagnosis of patients with cranial deformities. Thus, it is of paramount importance that they recognize subtle cranial deformities as it may be related to premature fusion of cranial sutures.

Photometric evaluation of cranial and facial symmetry in hemicoronal single suture synostosis treated with surgical fronto-orbital remodeling

OBJECTIVE

Evaluation of frontal vault symmetry and progressive facial symmetrization in a cohort of patients with hemicoronal single suture synostosis treated with a standardized cranioplasty and rigid fixation.

PATIENTS AND METHODS

Fifty-four patients with hemicoronal synostosis operated between 1999 and 2014 were reviewed retrospectively. Pre, immediately postoperative and yearly photographs from the top of the skull and frontal views of the face were taken with the same head position and projection. A photogrammetric method was applied to quantify the pre and postoperative contour changes. The anterior skull hemispheres were traced, divided into two equal parts and the areas were compared. Angular measurements obtained by the intersection of the interpupillary line and the glabella perpendicular vertical line were calculated. The average photographic follow-up was 6.8 years. Range 1-14 years.

RESULTS

The average advancement on the affected side was 18 mm (range: 16-23 mm). The pre-surgical cranial area on the affected side was increased on average 14.6 + 2.4% (range: 10-18%). The angular measurements documented the frontal symmetry obtained and the progressive improvement of facial symmetry.

CONCLUSION

Cranioplasty with rigid fixation achieved a stable correction of anterior plagiocephaly leading to subsequent symmetrical facial growth. Photogrammetry allowed fora quantitative long-term validation.

Diagnosis of infant synostotic and nonsynostotic cranial deformities: a review for pediatricians

OBJECTIVE

To review the current comprehensive care for nonsyndromic craniosynostosis and nonsynostotic cranial deformity and to offer an overall view of these craniofacial conditions.

DATA SOURCE

The review was conducted in the PubMed, SciELO, and LILACS databases without time or language restrictions. Relevant articles were selected for the review.

DATA SYNTHESIS

We included the anatomy and physiology of normal skull development of children, discussing nuances related to nomenclature, epidemiology, etiology, and treatment of the most common forms of nonsyndromic craniosynostosis. The clinical criteria for the differential diagnosis between positional deformities and nonsyndromic craniosynostosis were also discussed, giving to the pediatrician subsidies for a quick and safe clinical diagnosis. If positional deformity is accurately diagnosed, it can be treated successfully with behavior modification. Diagnostic doubts and craniosynostosis patients should be referred straightaway to a multidisciplinary craniofacial center.

CONCLUSIONS

Pediatricians are in the forefront of the diagnosis of patients with cranial deformities. Thus, it is of paramount importance that they recognize subtle cranial deformities as it may be related to premature fusion of cranial sutures.

Unilateral coronal synostosis: can we trust the sagittal suture as a landmark for the underlying superior sagittal sinus?

OBJECTIVE The sagittal suture is usually considered an external anatomical landmark, indicating the location of the superior sagittal sinus (SSS) for surgical approaches. Children with unilateral coronal synostosis (UCS) often present with an important deviation of the sagittal suture. Because these patients usually undergo frontal reconstruction or even endoscope-assisted minimally invasive procedures, it is imperative to know the location of the SSS. The aim of this investigation was to study the anatomical relationship between the SSS and the sagittal suture in children with anterior plagiocephaly. METHODS The authors retrospectively studied the relationship between the sagittal sinus and the sagittal suture at 5 points: nasion, midpoint nasion-bregma, bregma, midpoint bregma-lambda, and lambda. The study analyzed CT scans of 50 children with UCS admitted to the craniofacial unit of Necker Enfants Malades Hospital between March 2006 and March 2013 and compared them with 50 control children with no evidence of craniosynostosis, bone disease, or genetic syndromes. The authors also analyzed the presence of extracerebral fluid collection and ventricular asymmetry in children with UCS. RESULTS Fifty-six percent of patients had anterior right UCS and 44% had left-sided UCS. Type I UCS was seen in 1 patient, Type IIA in 20 patients, Type IIB in 20 patients, and Type III in 9 patients. The authors found that the nasion is usually deviated to the ipsilateral side of the synostosis, the bregma contralaterally, and the lambda ipsilaterally. The gap distances between the reference point and the SSS were 0-7.3 mm (mean 1.4 mm) at the nasion; 0-16.7 mm (mean 3.8 mm) at the midpoint nasion-bregma; 0-12 mm (mean 5.8 mm) at the bregma; 0-9.5 mm (mean 3 mm) at the midpoint bregma-lambda; and 0-11.6 mm (mean 5.5 mm) at the lambda. Conversely, a discrepancy of more than 1 mm between the SSS and the position of the suture was found only in 7 control cases (14%). Of patients with UCS, 38% presented with an extracerebral fluid collection contralateral to the fused coronal suture. Fifty-two percent had a ventricular asymmetry, which was characterized by reduced ventricular volume ipsilateral to the synostosis in all but 1 patient. CONCLUSIONS In this study, the SSS was usually deviated contralaterally to the closed coronal suture. It tended to be in the midline of the cranial vault and could be projected virtually along an imaginary line passing through the midline of the cranial base. The authors recommend a distance of 37 mm from the sagittal suture as a safety margin during surgery.

Facial changes after early treatment of unilateral coronal synostosis question the necessity of primary nasal osteotomy

BACKGROUND

The premature fusion of unilateral coronal suture can cause a significant asymmetry of the craniofacial skeleton, with an oblique deviation of the cranial base that negatively impacts soft tissue facial symmetry. The purpose of this study was to assess facial symmetry obtained in patients with unilateral coronal synostosis (UCS) surgically treated by 2 different techniques. We hypothesized that nasal deviation should not be addressed in a primary surgical correction of UCS.

METHODS

Consecutive UCS patients were enrolled in a prospective study and randomly divided into 2 groups. In group 1, the patients underwent total frontal reconstruction and transferring of onlay bone grafts to the recessive superior orbital rim (n = 7), and in group 2, the patients underwent total frontal reconstruction and unilateral fronto-orbital advancement (n = 5). Computerized photogrammetric analysis measured vertical and horizontal axis of the nose and the orbital globe in the preoperative and postoperative periods. Intragroup and intergroup comparisons were performed.

RESULTS

Intragroup preoperative and postoperative comparisons showed a significant (all P < 0.05) reduction of the nasal axis and the orbital-globe axis in the postoperative period in the 2 groups. Intergroup comparisons showed no significant difference (all P > 0.05).

CONCLUSIONS

Facial symmetry was achieved in the patients with UCS who underwent surgery regardless of surgical approach evaluated here. Our data showed a significant improvement in nasal and orbital-globe deviation, leading us to question the necessity of primary nasal correction in these patients.

Anthropometry of craniosynostosis

BACKGROUND

Anthropometry is becoming a popular method for diagnostics of various diseases in pediatric clinical practice. The aim of this study was to assess the growth changes in craniofacial parameters in patients with craniosynostosis and positional plagiocephaly.

METHODS

Inclusion criteria for the study were presence of craniostenosis or positional plagiocephaly in a patient with at least three anthropometric evaluations at our department. Studied patients were aged from 1.0 month to 2.5 years with median age at the first and last anthropometric evaluation as 1.83 and 25.27 months, respectively. Further anthropometric results in patients older than 2.5 years were excluded from the study. Statistical significance was tested by the Mann-Whitney test.

RESULTS

The studied group consisted of 70.5% male patients. The type of craniosynostosis was represented by scaphocephaly in 44.1%, by trigonocephaly in 45.6% and by coronal craniosynostosis in 10.3% of the cases. Cranial index was proven as a suitable parameter for evaluating differences in the trend of growth in craniosynostosis (p<0.001) and also for evaluating post-operative results. Significance was found in width of the head (p=0.038) for scaphocephaly and in length of the head for trigonocephaly (p=0.001) in surgically treated patients. Trend of cranial growth in operated patients copied the curve of the norm but in higher or lower values which depends on the type of prematurely closed suture.

CONCLUSION

Longitudinal anthropometric follow-up is an objective and measurable method that can accurately non-invasively and non-expensively assess skull growth in pediatric patients with cranial deformity.

Unilateral coronal craniosynostosis and Down syndrome

There is no known correlation between Down syndrome and craniosynostosis. The authors report 2 infants with trisomy 21 and right unilateral coronal craniosynostosis. Both patients were clinically asymptomatic but displayed characteristic craniofacial features associated with each disorder. One patient underwent a bilateral fronto-orbital advancement and the other underwent an endoscopically assisted strip craniectomy with postoperative helmet therapy. Both patients demonstrated good cosmesis at follow-up.

The assessment of relationship between the skull base development and the severity of frontal plagiocephaly after bilateral fronto-orbital advancement in the early life

PURPOSE

The deformation of the skull base in patients with unilateral frontal plagiocephaly (UFP) is well known, but the mechanism is not still clear. We analyzed the skull base in the patients with UFP who underwent fronto-orbital advancement (FOA) in the early life during the last decade.

METHODS

We assessed the treatment results and outcome of FOA performed in six patients, four girls and two boys younger than 2 years, in the last decade. Also, the basal cranium's angles were measured by 3D reconstruction images on computed tomography (CT) scan.

RESULTS

The mean patients' age at FOAs was 11 months. Two cases were classified as grade 2A, two cases as grade 2B, and two cases as grade 3 (the classification of Di Rocco and Velardi). The ethmoidal axis was deviated a mean of 8.2° to the affected side. The mean angle between the petrosal pyramids and the midline (anterior-petrosal-sagittal angle, APSA) was 75.3° on the affected side and 66.2° on the normal side. The mean difference of APSA was 9.2°. On the follow-up CT images 5 years after surgery, the deviations of the ethmoidal axis clearly decreased, 5.7°, but the differences of APSA did not change, 8.8°.

CONCLUSIONS

The midline distortion of anterior skull base should be considered to be spontaneously corrected during the follow-up periods in patients with all types of UFP who underwent FOA, unlike posterior skull base in the patients with grades 2B and 3 classification.

Synostotic anterior plagiocephaly: a cause of familial congenital superior oblique muscle palsy

Anterior plagiocephaly due to unicoronal craniosynostosis is commonly associated with an ipsilateral hypertropia and a contralateral head tilt. The ipsilateral superior oblique weakness has been attributed to the shortening of the orbital roof with retroplacement of the trochlea, and to heterotopic positioning of the vertical rectus muscles within the orbit. These anatomical aberrations may alter ocular rotations to mimic a true congenital superior oblique palsy. This paper describes two siblings with synostotic plagiocephaly and simulated superior oblique palsy with ocular torticollis successfully managed by strabismus surgery. Synostotic plagiocephaly should be included in the differential diagnosis of familial congenital superior oblique palsy.