Nonsyndromic Craniosynostosis and Deformational Head Shape Disorders

Craniosynostosis: Quantifying Differences in Skull Architecture

Craniosynostosis, a condition marked by the premature fusion of one or more cranial sutures, exhibits diverse phenotypes. This study aims to advance the understanding of these phenotypes beyond the conventional 2-dimensional analysis by focusing on identifying indicators of increased intracranial pressure (ICP) such as bony thinning or irregularities in skull morphology.

A retrospective review was conducted for all pediatric patients with midline craniosynostosis who presented to our tertiary academic center for evaluation. Control patients were carefully selected to match for age, sex, and weight. All computed tomography data were segmented in 3-dimensional Slicer and then delineated along with suture lines into occipital, parietal, and frontal segments. Main outcome measures included general skull shape (assessed via measures of flatness and surface area to volume ratio) and skull topography (analyzed via measures of bone thickness, surface variance, and surface standard deviation).

Forty-one patients with midline craniosynostoses were identified (22 metopic and 19 sagittal). Patients with sagittal craniosynostosis had significantly angulated frontal and occipital bones, reflective of the frontal bossing and occipital bulleting commonly seen in this population, and significantly flatter parietal bones, reflective of limited growth along with the transverse axis. Interestingly, evaluation of bone topography revealed that patients with sagittal craniosynostosis had significantly higher parietal bone surface variance, reflective of gyral impressions secondary to increased ICP. In contrast, patients with metopic craniosynostosis had statistically flatter frontal bones-reflective of limited anterior brain growth caused by the fused metopic suture-with minimal impacts to parietal or occipital bones.

Predictive Value of Sonographic Parameters on the Effects of Cranial Molding Helmet Therapy in Infants with Positional Plagiocephaly

Positional plagiocephaly is a deformational cranial flattening frequently treated in pediatric neurosurgical practice. Positional maneuvers and orthotic helmet therapy are preferred therapeutic options for moderate-to-severe forms. Treatment response seems to be age-dependent. Nevertheless, predictive data are vague, and cost-efficiency might be a limiting factor for treatment. The purpose of this study was to investigate the early predictive value of sonographic parameters on the efficacy of orthotic helmet therapy through the assessment of changes in skull shape and correlation of the parameters with caliper cephalometry values and with age. A consecutive cohort of 49 patients < 10 months of age, undergoing orthotic helmet therapy for positional plagiocephaly, was recruited prospectively. The authors routinely assessed the patency of the lambdoid sutures by ultrasound and the following additional skull parameters were measured: suture width, adjacent full bone thickness, adjacent cortical bone thickness and occipital angle. Caliper cephalometric values, as well as demographic and clinical data were collected. Retrospective data analysis showed an inverse relation between both cortical and full skull bone thickness and early treatment efficacy, defined by a reduction in the occipital angle. The improvement of sonographic parameters correlated with the development of cranial caliper cephalometry values. In conclusion, the sonographic assessment of skull bone thickness is a safe and cost-effective tool to predict the early efficacy of orthotic helmet therapy in positional plagiocephaly and might, therefore, help the clinician to foresee the potential evolution of the deformity.

Comparison of Morphometric Outcomes following Open Posterior Expansion versus Endoscopic Strip Craniectomy for Sagittal Synostosis

BACKGROUND

Open middle and posterior cranial vault expansion (OPVE) or endoscopic (ES) strip craniectomy are two surgical techniques for normalization of head shape in isolated sagittal synostosis. This study aims to compare 2-year cranial morphometrics after these two approaches.

METHODS

The authors performed morphometric analysis on preoperative [time (T) 0], immediately postoperative (T1), and 2-year (T2) postoperative computed tomographic scans of patients who underwent OPVE or ES before 4 months of age. Perioperative data and morphometrics were compared between the two groups and age-matched controls.

RESULTS

Nineteen patients were included in the ES cohort, 19 age-matched patients were included in the OPVE cohort, and 57 were included as controls. Median surgery time and blood transfusion volume were less for the ES approach (118 minutes and 0 cc, respectively) compared with OPVE (204 minutes and 250 cc, respectively). Anthropometric measurements after OPVE were closer in normal controls at T1 compared with ES, but the skull shapes were comparable at T2. In the midsagittal plane, anterior vault was higher after OPVE at T2 compared with both ES and controls, but the posterior length was shorter and closer to controls than in the ES cohort. Cranial volumes were like controls for both cohorts at T2. There was no difference in complication rate.

CONCLUSIONS

Both OPVE and ES techniques result in normalization of cranial shape in patients with isolated sagittal synostosis after 2 years with minimal morphometric differences. Family decision-making between the two approaches should be based on age at presentation, avoidance of blood transfusion, scar pattern, and availability of helmet molding and not on expected outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Endoscopic Strip Craniectomy and Helmet Therapy for Sagittal Craniosynostosis: An Analysis of Cranial Growth Changes in the Early Postoperative Period

OBJECTIVE

The purpose of this study is to analyze cranial width and length growth curves in the early postoperative period of patients by undergoing endoscopic sagittal strip craniectomy (ESC) to determine the timing of the maximal growth curve change. By analyzing the complex interplay of cephalic length and width measurements, we hope to better understand the cephalic index (CI) growth curve during this early period. This is the first of a multistep process to elucidate the ideal cranial remolding orthosis (CRO) treatment duration.

DESIGN

Retrospective review.

SETTING

Tertiary academic institution.

PATIENTS

Children with isolated sagittal craniosynostosis.

INTERVENTIONS

ESC and postoperative CRO treatment (2015-2019).

MAIN OUTCOME MEASURES

One cranial orthotist obtained preoperative and postoperative measurements. The maximal rate of change of width, length, and CI were compared against the postoperative week these occurred.

RESULTS

Thirteen children (mean age: 3.3 months, average preoperative CI: 73.4) underwent this intervention. CI reached its highest growth rate by 4.9 average weeks postoperatively, which correlated with the maximal width growth rate (5.2 weeks). Length curves reached their maximal growth rate by 15.5 weeks. CI peaked (81.3) by 22.7 weeks postoperatively, a significant increase from baseline.

CONCLUSIONS

Following ESC, in the early postoperative period, the CI growth curve has 4 phases: initial rapid expansion, early and late slowed expansion, and plateau, followed by possible regression phases. This highlights the importance of early postoperative CRO initiation, CRO compliance, and properly fitting CROs, especially in the first 2 phases. This data sets the stage for investigating the ideal treatment length.

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.

Surface Cranial Ultrasound: The Natural Heir to X-Ray for the Screening of Skull Deformities in Infants

PURPOSE

Volumetric tomography (3D-CT) is currently considered the gold standard for the diagnosis of craniosynostosis, but its use as the first-line examination for cranial deformities is a topic of debate, because of skull X-ray radiation and low sensitivity and specificity. Cranial ultrasound is an emerging noninvasive radiation-free alternative, but its diagnostic accuracy still needs confirmation.

MATERIALS AND METHODS

The present prospective study included 350 infants with skull deformities, who underwent cranial ultrasound as the first-line examination, followed by 3D-CT if the echography results was positive or unclear. If the results were negative, infants underwent physical treatment and follow-up. To evaluate ultrasound reliability, we focused on cases that underwent both the index test and the gold standard and performed a double-blind comparison of the echography and 3D-CT results.

RESULTS

Ultrasound documented patent sutures in 293 infants and 9 had inconclusive results. The 293 ultrasound-negative infants were followed clinically: all improved, except 28 that underwent 3D-CT. In all of these cases, 3D-CT confirmed the ultrasonography results (no false negatives). 48 infants showed premature suture closure and underwent 3D-CT: 47 were confirmed (true positive), 1 was false positive. The sensitivity was 100%, the specificity was 99.7%, the positive and negative predictive values were 97.9% and 100%, respectively, the accuracy was 99.7%, and the diagnostic test evaluation was conclusive.

CONCLUSION

The study documented the high sensitivity and specificity of echography for the diagnosis of craniosynostosis in a referral center, with better results being achieved before 6 months of age. Major limitations are the loss of diagnostic significance as the child grows and the learning curve needed. The advantages are avoidance of radiation and chance to evaluate the brain at the same time.

[Difficulties in differential diagnosis of sagittal synostosis (scaphocephaly)]

Craniosynostosis is characterized by congenital absence or premature closure of skull sutures. The most common form of craniosynostosis is synostosis of sagittal suture followed by scaphocephaly. There are some head deformities similar to scaphocephaly such as positional and constitutional dolichocephaly, etc. These patients have no sagittal suture synostosis. However, there are difficulties in differential diagnosis between these deformities and scaphocephaly.

OBJECTIVE

To develop differential diagnostic criteria between dolichocephalic head deformities and true scaphocephaly following sagittal synostosis.

MATERIAL AND METHODS

The study included 33 patients with dolichocephaly (25 (75.8%) boys and 8 (24.2%) girls) between December 2013 and August 2022. The inclusion criterion was available CT or ultrasound data confirming or excluding sagittal synostosis. Age of patients was 8.62±7.71 (1.77-36) months. We analyzed anamnestic, clinical and radiological data. Radiological data was compared with diagnostic findings in 20 patients with scaphocephaly. Both groups were comparable in age, gender and cranial index.

RESULTS

We present clinical and radiological signs, as well as algorithm for differential diagnosis between scaphocephaly and dolichocephaly.

CONCLUSION

There are objective difficulties in differential diagnosis between scaphocephaly following sagittal synostosis and dolichocephalic head deformities. In most cases, we cannot establish the cause of congenital forms of dolichocephaly. The most likely causes may be pre- and postnatal compressive and positional effects. Ultrasound of skull sutures is preferable for differential diagnosis between these abnormalities. Correction of dolichocephaly can be carried out according to aesthetic indications with individual cranial orthoses.

Quality of life and satisfaction in surgical versus conservative treatment of nonsyndromic children with craniosynostosis

OBJECTIVE

Craniosynostosis represents the second most common reason for referral to pediatric neurosurgery. However, the quality of life and neurodevelopmental impact of leaving this physical disorder uncorrected is poorly understood.

METHODS

This multicenter cross-sectional study identified previously managed nonsyndromic infants (< 24 months of age) with single-suture craniosynostosis at both pediatric neurosurgical centers in Alberta, Canada. The primary variable of interest was the allocated treatment (surgical vs conservative). The primary outcome was the Pediatric Quality of Life Inventory (PedsQL), a validated measure of quality of life examining physical, emotional, social, and school functioning. Treatment decision satisfaction and the reasons for selected management were quantified and collected directly from caregivers.

RESULTS

One hundred fourteen children met the inclusion criteria: 78% underwent surgery and 22% had conservative treatment. The most common suture affected was sagittal (54%), followed by metopic (33%), coronal (10%), and lambdoid (3%). Caregivers most commonly opted for surgery because of severe appearance (80%). Seventy-six percent and 72% of the caregivers of children with conservative management did so due to concerns of surgical risks and mild appearance, respectively. There was a statistically significant relationship between both the parents' (p < 0.001) and the surgeon's (p = 0.001) impression of a severe head shape and surgical management. Parental satisfaction with their child's appearance as well as satisfaction with their treatment decision did not differ between management types. Regarding quality of life, on univariate analysis, the conservative group had a statistically higher physical summary score (p = 0.01), psychosocial summary score (p = 0.004), and mean total scale score (p = 0.003) compared to the surgical group. However, after adjusting for severity and age at consult, no significant independent associations between management type and any of the PedsQL summary scores were found.

CONCLUSIONS

Alberta families have a high number of children with craniosynostosis treated with conservative management. Conservatively managed infants were largely minimally affected patients, particularly those with metopic synostosis. The study found no independent association between management type (surgery vs conservative) and quality of life when adjusted for important patient factors.

Anthropometric cranial measurements in metopic craniosynostosis/trigonocephaly: diagnostic criteria, classification of severity and indications for surgery

ABSTRACT

Metopic craniosynostosis is the second most frequent type of craniosynostosis. When the phenotypic presentation has been deemed severe the treatment is surgical in nature and is performed in infancy with fronto-orbital advancement and cranial vault remodeling. At the time of this writing, there is no consensus regarding an objective evaluation system for severity, diagnostic criteria, or indications for surgery. This study aims to review the anthropometric cranial measurements and the relative diagnostic criteria/classification of severity/surgical indications proposed so far for this skull malformation, and to investigate if there is any scientific support for their utility.

Quality of life in patients with craniosynostosis and deformational plagiocephaly: A Systematic Review

BACKGROUND

Craniosynostosis is a bony dysmorphism of the calvarium due to premature suture fusion and is classified as syndromic (part of congenital syndrome) or nonsyndromic (isolated). Deformational plagiocephaly (DP) is due to external positional forces on the skull after birth. This review aims to investigate the various quality of life (QoL) metrics across syndromic, nonsyndromic and DP patients.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search was done through EMBASE, MEDLINE, PubMed and Web of Science. After two stages of screening by two authors, seventeen articles met inclusion criteria; 11 on syndromic, 4 nonsyndromic, and 2 DP.

RESULTS

The literature suggests syndromic patients have more severe consequences on QoL, especially on psychological well-being, social functioning, and obstructive sleep apnea (OSA), leading to behavioral difficulties. Nonsyndromic patients show a less clear trend across QoL measures, but a majority stated QoL is comparable to the general population. DP patients noted motor development and QoL improvement as well as improved subjective aesthetic outcomes after orthotic helmet molding therapy (HMT).

CONCLUSIONS

While a majority of literature classifies QoL in syndromic craniosynostosis alone, this review highlights the importance of these factors in nonsyndromic craniosynostosis and plagiocephaly patients. Psychological well-being, social functioning, and secondary health impacts such as OSA are important to consider in comprehensive craniofacial care in all calvaria deformities.

Tranexamic Acid in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis

ABSTRACT

Blood loss is a potential cause of morbidity and mortality in craniosynostosis surgery. Recent reports have suggested that the use of tranexamic acid (TXA), an antifibrinolytic agent, mitigates this blood loss. A comprehensive systematic review and subsequent meta-analysis was undertaken, with the view to clarify the effectiveness of TXA in reducing blood loss and transfusion requirements in craniosynostosis surgery. Medline and PubMed databases were searched using the preferred reporting items for systematic reviews and meta-analyses technique, and 7003 articles were assessed based on predefined selection criteria. Seven trials were identified, of which 2 were randomized controlled trials and the remainder retrospective cohort studies. All trials were assessed using the Jadad and strengthening the reporting of observational studies in epidemiology scores. The meta-analysis found a clear statistical reduction in blood loss in those patients who received TXA perioperatively, with a combined blood loss reduction of 7.06 ml/kg (95% confidence interval -8.97 to -5.15, P < 0.00001). The blood loss reduction was found to extrapolate to a reduction in perioperative transfusion requirements by 8.47 ml/kg in this cohort (95% confidence interval -10.9 to -6.04, P < 00001). There were no TXA-related adverse outcomes recorded in the 258 patients who received TXA across all trials. The trials included in this meta-analysis were limited by underpowered population sizes and significant heterogeneity in blood loss recording techniques. Further, there was significant heterogeneity amongst operations performed. The current literature appears to support the use of TXA in craniosynostosis surgery, but further high quality randomized controlled trials are indicated, ideally including a subgroup analysis between the operations performed.

The utilisation of 3D printing in paediatric neurosurgery

3D printing technology has evolved over the years and there is a growing interest in its application in paediatric neurosurgery. Modern 3D printers have enabled the development of patient-specific 3D models that provide a realistic representation of complex anatomies and will aid in planning complex procedures. Paediatric neurosurgical operations are challenging and hands-on training is restricted. Surgical simulation training with biomodel has provided a new paradigm for trainees to master their surgical skills before encountering similar scenarios in real-life environment. This paper reviews the aspects of 3D printing for preoperative planning and simulation-based surgical training in paediatric neurosurgery.

Statistical shape modelling for the analysis of head shape variations

The aim of this study is, firstly, to create a population-based 3D head shape model for the 0 to 2-year-old subjects to describe head shape variability within a normal population and, secondly, to test a combined normal and sagittal craniosynostosis (SAG) population model, able to provide surgical outcome assessment. 3D head shapes of patients affected by non-cranial related pathologies and of SAG patients (pre- and post-op) were extracted either from head CTs or 3D stereophotography scans, and processed. Statistical shape modelling (SSM) was used to describe shape variability using two models - a normal population model (MODEL1) and a combined normal and SAG population model (MODEL2). Head shape variability was described via principal components analysis (PCA) which calculates shape modes describing specific shape features. MODEL1 (n = 65) mode 1 showed statistical correlation (p < 0.001) with width (125.8 ± 13.6 mm), length (151.3 ± 17.4 mm) and height (112.5 ± 11.1 mm) whilst mode 2 showed correlation with cranial index (83.5 mm ± 6.3 mm, p < 0.001). The remaining 9 modes showed more subtle head shape variability. MODEL2 (n = 159) revealed that post-operative head shape still did not achieve full shape normalization with either spring cranioplasty or total calvarial remodelling. This study proves that SSM has the potential to describe detailed anatomical variations in a paediatric population.

Impact of the Use of the Beanie on the Neurodevelopmental Outcomes of Preterm Infants With Plagiocephaly: A Pilot Study

Background

Deformational plagiocephaly (DP) is the abnormal flattening of the skull. Infants with DP have been found to have abnormal brain shape and asymmetry associated with worse neurodevelopmental outcomes on the Bayley Scales of Infant and Toddler Development-III (BSID-III) compared to those without DP. In 2009, the FDA approved a repositioning Beanie, the TortleTM (Tortle Products LLC, Greenwood Village, CO), for the prevention of flat head syndrome. 

Purpose

Our goal was to assess the impact of the use of the Beanie on the neurodevelopment of preterm infants with DP admitted in the neonatal intensive care unit (NICU) using the BSID-III.

Methods

Subjects were identified using a retrospective chart review of infants during January 2013-2017. Infants of less than 32 weeks of gestational age, under 1500 g birth weight, and attending the high-risk follow-up clinic were included in the study. Neurodevelopmental assessment of patients' cognition, language, motor development using the BSID-III was performed at the 12-month and 24-month follow-up visits. The BSID-III scores for patients who used the Beanie were compared to those who did not.

Results

A total of 207 patients met the inclusion criteria. The gestational age ranged from 22.5 to 31.5 weeks with a median and mean gestational age of 26.4 weeks and 26.5 weeks respectively. Of the patients, 105 were females and 102 males. The birth weight ranged between 460 g and 1460 g with a mean of 879 g and a median of 860 g. The Beanie was used in 32 patients; 31 patients were found to use the Beanie at 12 months and 16 patients at 24 months. Of note, 12-month Bayley cognition scores were found to be statistically improved in babies who used the Beanie versus those who did not (p: 0.02). The statistical significance was not appreciated at 24 months, which could be due to a decrease in the sample size.

Conclusion 

The Beanie is an inexpensive and simple way to help prevent DP in preterm infants, which in turn could improve the aforementioned outcomes.

Infectious Complications After Open Cranial Vault Remodeling for Craniosynostosis

BACKGROUND

Surgical site infection (SSI) after open cranial vault reconstruction (CVR), while relatively uncommon, has received little attention in the literature to date. Here, the authors report our institution's experience with the perioperative management of infectious complications following CVR for craniosynostosis and present the first systematic review of the literature on this topic.

METHODS

The authors performed a retrospective chart review for patients with syndromic and nonsyndromic craniosynostosis who underwent open CVR between 1990 and 2015 at a single institution to determine predictors of SSIs and a systematic review of studies that evaluated for SSI after CVR to ascertain the pooled incidence of SSI, common infectious organisms, and prophylactic antibiotic protocols.

RESULTS

Out of 548 primary and 163 secondary CVR cases at our institution, 6 primary reconstruction patients (1.09%) and 9 secondary reconstruction patients (5.52%) developed an SSI requiring extended hospital stay or readmission (P <0.001); overall infection rate was 2.11%. Streptococcus and Staphylococcus species were the most common organisms isolated. On multivariate analysis, syndromic status conferred more than 7 times greater odds of SSI (OR 7.7, P = 0.023). Pooled analysis of the literature yielded an overall SSI rate of 1.05% to 2.01%. In contrast to our institutional findings, the most common organisms reported were Candida species and Pseudomonas aeruginosa. The most common prophylactic antibiotic protocol was a first-generation cephalosporin for 24 to 72 hours post-operatively.

CONCLUSIONS

Patients undergoing secondary reconstruction have higher infection rates after CVR, and syndromic status is an important predictor of infection when controlling for other patient factors. Our literature review reveals nosocomial organisms to be the most commonly reported source of infection, though this is contrary to our institutional findings of skin flora being most common. Antibiotic prophylaxis varies institutionally.

The Craniosynostosis Puzzle: New Simulation Model for Neurosurgical Training

BACKGROUND

Neurosurgical training usually requires long hours for hands-on procedures, making it difficult for inexperienced surgeons to quickly learn in an error-proof environment. The objective of this study was to propose a puzzle-like new model for neurosurgical education that simulates craniosynostosis correction (scaphocephaly type) using Renier's H technique. A model of a 3-dimensional (3D) anatomic simulator for craniosynostosis training is presented and evaluated.

METHODS

The cranial model was created using 1-mm computed tomography scan images from patients with scaphocephaly in the Digital Imaging and Communications in Medicine format. This information was processed using an algorithm to generate a 3D biomodel in resin. The puzzle model and its variable training models were assessed qualitatively by a team of expert neurosurgeons. Next, the model was applied in trainees and was evaluated using specific questionnaires.

RESULTS

Experts and trainees evaluated the model. The mean number of attempts without errors was 2.3 ± 0.675, for 1 error was 2.2 ± 0.918, and for 2 errors was 1.3 ± 0.707. The mean score of the simulator was 9.2 ± 0.421. Twelve residents (second evaluation) answered the questionnaire with a positive assessment of diagnosis capabilities, appropriateness of the model, time commitment, adequate environment, reliable 3D reconstruction, and teaching method. Three participants had used a 3D simulator previously, and the simulator was evaluated obtaining a 9.9 final average (range, 0-10).

CONCLUSIONS

The puzzle may be a complementary tool for surgical training. It allows several degrees of immersion and realism, offering symbolic, geometric, and dynamic information with 3D visualization. It provides additional data to support the practice of complex surgical procedures without exposing real patients to undue risk.

Evaluation and Management of V pattern Strabismus in Craniosynostosis

V pattern strabismus is the most common ocular motor disorder reported in patients with craniosynostosis. Strabismus management may prove challenging, and few studies provide perspective on surgical approach. The purpose of this review is to discuss evaluation and surgical options for treating V pattern strabismus in patients with craniosynostosis. We provide a step-by-step approach to facilitate surgical planning.

Sagittal Craniosynostosis with Uncommon Anatomical Pathologies in a 56-Year-Old Male Cadaver

Sagittal craniosynostosis (CS) is a pathologic condition that results in premature fusion of the sagittal suture, restricting the transverse growth of the skull leading in some cases to elevated intracranial pressure and neurodevelopmental delay. There is still much to be learned about the etiology of CS. Here, we report a case of 56-year-old male cadaver that we describe as sagittal CS with torus palatinus being an additional anomaly. The craniotomy was unsuccessful (cephalic index, CI = 56) and resulted in abnormal vertical outgrowth of the craniotomized bone strip. The histological analysis of the latter revealed atypical, noncompensatory massive bone overproduction. Exome sequencing of DNA extracted from the cadaveric tissue specimen performed on the Next Generation Sequencing (NGS) platform yielded 81 genetic variants identified as pathologic. Nine of those variants could be directly linked to CS with five of them targeting RhoA GTPase signaling, with a potential to make it sustained in nature. The latter could trigger upregulated calvarial osteogenesis leading to premature suture fusion, skull bone thickening, and craniotomized bone strip outgrowth observed in the present case.

Current Trends in Management of Nonsyndromic Unilateral Coronal Craniosynostosis: A Cross-sectional Survey

Background

Although the natural history of nonsyndromic unilateral coronal craniosynostosis has been extensively described, optimal management remains controversial due to lack of Level 1 evidence. This study aims to assess the current state of practice among craniofacial surgeons.

Methods

Ninety-four craniofacial surgeons were approached to complete a survey consisting of 15 questions. Data were collected assessing surgeons' primary surgical indication, timing of intervention, preoperative imaging, and choice of technique for patients presenting with nonsyndromic unilateral coronal craniosynostosis. Choice of technique and timing of intervention in case of recurrence were also investigated.

Results

After 5 mailings, the response rate was 61%. The combination of both appearance and raised intracranial pressure was the primary indication for treatment for 73.2% of surgeons. Preoperative CT scan of the skull was "always" performed by 70.1% of respondents. Open surgical management was most commonly performed at 8-10 months of age (38.6%). Bilateral frontal craniectomy with remodeling of the supraorbital bandeau and frontal bone was the most common choice of procedure (84.2%). In case of mild to moderate and moderate to severe recurrences at 1 year of age, 89.5% and 47.4% of surgeons opted for conservative management, respectively. Optimal timing for repeat cranioplasty was after 4 years of age (65.5%). Overall, 43.4% quoted lack of evidence as the greatest obstacle to clinical decision-making when dealing with unilateral synostosis.

Conclusion

This survey exposes the lack of consensus and the disparity of opinion among craniofacial surgeons regarding the management of nonsyndromic coronal synostosis, particularly in the setting of recurrence.

Non-syndromic craniosynostosis in children: Scoping review

Background

Craniosynostosis (CS) is a complex condition consisting of the early fusion of one or more cranial sutures in the intrauterine stage. The affected infant exhibits abnormal head shape at time of birth or shortly thereafter. It can be observed in normal individuals (non-syndromic CS or NSCS) or as a part of a multisystem syndrome. The purposes of the present article were to carry out a scoping review on Non-Syndromic CS and to discuss the most important findings retrieved.

Material and Methods

The steps of this scoping review were as follows: first, to pose a research question; second, to identify relevant studies to answer the research question; third, to select and retrieve the studies; fourth, to chart the critical data, and finally, to collate, summarize, and report the results from the most important articles. Relevant articles published over a 20-year period were identified and retrieved from five Internet databases: PubMed; EMBASE; Cochrane Library; Google Scholar, and EBSCO.

Results

Fourteen articles were finally included in the present scoping review. The following four most important clinical issues are discussed: (i) normal cranial development, clinical manifestations, and pathogenesis of NCSC; (ii) clinical evaluation of NCSC; (iii) treatment and post-surgical follow-up; and (iv) additional considerations.

Conclusions

NSCS may be present with associated head shapes. Multiple early surgical reconstructive options are currently available for the disorder. Pediatric Dentistry practitioners must be familiarized with this condition and form part of a multi-approach health team as those responsible for the opportune oral health care of the affected child.

Key words:Craniosynostosis, cranial development, children, scoping review, dental management.

Statistical shape modelling to aid surgical planning: associations between surgical parameters and head shapes following spring-assisted cranioplasty

PURPOSE

Spring-assisted cranioplasty is performed to correct the long and narrow head shape of children with sagittal synostosis. Such corrective surgery involves osteotomies and the placement of spring-like distractors, which gradually expand to widen the skull until removal about 4 months later. Due to its dynamic nature, associations between surgical parameters and post-operative 3D head shape features are difficult to comprehend. The current study aimed at applying population-based statistical shape modelling to gain insight into how the choice of surgical parameters such as craniotomy size and spring positioning affects post-surgical head shape.

METHODS

Twenty consecutive patients with sagittal synostosis who underwent spring-assisted cranioplasty at Great Ormond Street Hospital for Children (London, UK) were prospectively recruited. Using a nonparametric statistical modelling technique based on mathematical currents, a 3D head shape template was computed from surface head scans of sagittal patients after spring removal. Partial least squares (PLS) regression was employed to quantify and visualise trends of localised head shape changes associated with the surgical parameters recorded during spring insertion: anterior-posterior and lateral craniotomy dimensions, anterior spring position and distance between anterior and posterior springs.

RESULTS

Bivariate correlations between surgical parameters and corresponding PLS shape vectors demonstrated that anterior-posterior (Pearson's [Formula: see text]) and lateral craniotomy dimensions (Spearman's [Formula: see text]), as well as the position of the anterior spring ([Formula: see text]) and the distance between both springs ([Formula: see text]) on average had significant effects on head shapes at the time of spring removal. Such effects were visualised on 3D models.

CONCLUSIONS

Population-based analysis of 3D post-operative medical images via computational statistical modelling tools allowed for detection of novel associations between surgical parameters and head shape features achieved following spring-assisted cranioplasty. The techniques described here could be extended to other cranio-maxillofacial procedures in order to assess post-operative outcomes and ultimately facilitate surgical decision making.

[Efficacy of sleep position correction for treating infants with positional plagiocephaly]

OBJECTIVE

To investigate the efficacy of 2-month course of sleeping position correction in the treatment of positional plagiocephaly in infants aged <8 months.

METHODS

A total of 73 infants with positional plagiocephaly between January 2015 and June 2016 were divided into treatment group (n=46) and control group (n=27) according to parents' wishes. The treatment group received sleeping position correction, while the control group received sleep curve mattress. The oblique diameters A and B in the two groups were measured and the cranial vault asymmetry (CVA) was calculated before and after treatment. The severity of positional plagiocephaly based on CVA was compared between the two groups before and after treatment. The Gesell Developmental Scale was used to determine the developmental quotients (DQs) in the motor, adaptive, language, and social domains in the two groups before and after treatment.

RESULTS

Before treatment, there were no significant differences in oblique diameters A and B, CVA, and DQs in the four specific domains between the two groups (P>0.05). After 2 months of treatment, the treatment group had a significantly greater oblique diameter B and a significantly smaller CVA than the control group (P<0.05); there were no significant differences in DQs in the four specific domains between the two groups (P>0.05). After treatment, both groups had significant improvements in oblique diameters A and B, CVA, and DQs in the motor and adaptive domains (P<0.01); moreover, the treatment group showed a significant improvement in the DQs in the social domain (P<0.01). There was no significant difference in the severity of positional plagiocephaly between the two groups before and after treatment (P>0.05).

CONCLUSIONS

For infants with positional plagiocephaly, sleeping position correction has better efficacy and is more convenient and economical than the sleep curve mattress, so it holds promise for clinical application.