Clinical findings precede objective diagnostic testing in the identification of increased ICP in syndromic craniosynostosis

Crouzon Syndrome: a Comprehensive Review

Crouzon syndrome is a rare genetic disorder with autosomal dominant inheritance. The underlying pathological process is premature synostosis of the cranial sutures with subsequent phenotypic alterations of the affected person. A review of the literature has been conducted in order to resume the overall characteristics of Crouzon syndrome such as craniomaxillofacial malformations, clinical features, dentoalveolar characteristics, aesthetic impairments, and psychological background, as well as, the different therapeutic procedures, which combine surgical and orthodontic interventions. Facial and functional malformations in individuals with Crouzon syndrome could be significantly improved after a series of surgical and orthodontic procedures in almost all cases. A multidisciplinary treatment approach would provide the best outcomes in affected patients.

Morphometric Analysis of the Posterior Cranial Fossa in Syndromic and Nonsyndromic Craniosynostosis

Posterior cranial fossa (PCF) anatomy can be abnormal in craniosynostosis, and hindbrain herniation may occur. This study analyzed PCF anatomy in single suture and complex craniosynostosis.Children with craniosynostosis and age-matched controls were identified. Cephalic index (CI) for cranial vault and PCF as well as tentorial (TA) and occipital angles (OA) were measured on preoperative imaging.Children with syndromic (N = 6), bicoronal (N = 4), sagittal (N = 12), and metopic synostosis (N = 4) as well as controls (N = 10) were enrolled. Mean CI for cranial vault was 0.89, 0.93, 0.65, 0.74, and 0.78, respectively. Corresponding CI for PCF was 0.81, 0.93, 0.62, 0.74, and 0.78. Mean TA and OA were 45.4° and 96.6° in syndromic, 39.7° and 87.0° in bicoronal, 34.0 and 75.0° in sagittal, 39.7° and 87.0° in metopic synostosis, and 42.9° and 88.3° in controls.While CI, TA, and OA in metopic synostosis were similar to controls, abnormalities were found in syndromic, bicoronal, and sagittal synostosis. Syndromic and bicoronal craniosynostosis patients had a higher CI for both cranial vault and PFC as well as larger TA and OA, indicating a brachycephalic skull with steep tentorium and narrow PCF. In sagittal synostosis, CI for cranial vault and PCF were lower and TA and OA smaller, reflecting scaphocephalic deformity also at PCF, with a flat tentorium. This study provides basic PCF morphometry in craniofacial conditions.

Osseous Convexity at the Anterior Fontanelle: A Presentation of Metopic Fusion?

BACKGROUND

Craniosynostosis, or a premature fusion of 1 or more cranial vault sutures, results in characteristic head shape deformities. In previous reports, an osseous prominence at the anterior fontanelle has been suggestive of adjacent suture fusion and local elevation in intracranial pressure (ICP). This prominence has been termed the "volcano" sign, and has been described in the anterior fusion of the sagittal suture and serves as an indication for surgery.

METHODS

Two patients presented for head shape evaluation with mild metopic ridging and anterior fontanellar osseous convexities consistent with the volcano sign. Low-dose computed tomography imaging was performed in both patients due to concern for underlying craniosynostosis with elevated locoregional ICP.

RESULTS

In both patients, imaging was significant for a localized, superior forehead metopic fusion, as well as a bony, convex prominence at the site of the ossified anterior fontanelle. There were no other clinical or radiologic signs or symptoms to suggest elevated ICP. Surgery was not indicated in either patient.

CONCLUSIONS

Here the authors present 2 patients with osseous convexities at the site of the closed anterior fontanelle without signs or symptoms of elevated ICP, or classic signs of metopic synostosis. The authors hypothesize that this pattern may be due to a form of mechanically induced premature fusion of a normal metopic suture that is focused superiorly at the bregma, with minimal resultant restriction of overall skull growth. This is in contrast to metopic synostosis, which primarily has a sutural pathology and leads to characteristic findings of hypotelorism and trigonocephaly.

Telemetric Intracranial Pressure Monitoring in Syndromic Craniosynostosis

Syndromic and nonsyndromic craniosynostosis can be associated with raised intracranial pressure (ICP). After corrective surgery, raised ICP persists or reoccurs in a subgroup of patients. The standard procedure for monitoring ICP is insertion of a percutaneous intraparenchymal probe for a limited time, usually 24 to 48 hours. However, in selected patients repeated ICP measurements might be useful in the clinical setting, and a noninvasive method for achieving this would be desirable. The authors present the use of a telemetric ICP monitoring system implanted during cranial vault expansion in a child with syndromic craniosynostosis. This system, once implanted, allows for noninvasive transdermal ICP readings and might represent a promising alternative to conventional ICP monitoring devices in selected patients with craniofacial conditions.

Crouzon syndrome: A case report and review of literature

Crouzon syndrome, also called craniofacial dysostosis is an autosomal dominant disorder characterized by premature closure of cranial sutures, midfacial hypoplasia and orbital defects. Herein we report a case of this rare entity who presented with brachycephaly, maxillary hypoplasia, wide parrot beaked nose, repaired bilateral cleft lip and cleft palate along with dental and orbital abnormalities.

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.

Difficulties of delayed treatment of craniosynostosis in a patient with Crouzon, increased intracranial pressure, and papilledema

Crouzon syndrome is an autosomal dominant disorder characterized by cranial synostosis, hypertelorism, orbital proptosis, parrot-beaked nose, short upper lip, hypoplastic maxilla, and a relative mandibular prognathism, without extremity involvement. Surgical intervention should occur at the onset of progressive craniosynostosis to treat or to prevent intracranial hypertension and visual impairment. Throughout developing countries, early treatment is often not a viable option. Often, the only option for treatment is through humanitarian missions. Appropriate preselection of surgical patients is essential, as is having a multidisciplinary team and a well-equipped hospital and staff to perform the operations and to care for the postsurgical patient. This type of humanitarian care benefits the patient selected to receive the intense logistical and financial effort when there is no possibility of timely care in their own countries. This clinical report describes a patient with Crouzon syndrome brought to the United States from a developing country through humanitarian efforts. She presented at 19 months of age with bicoronal and sagittal synostosis and advanced visual impairment and papilledema. Surgical intervention included cranial expansion and reconstruction with a multidisciplinary team. This case illustrates not only the difficulty of delayed treatment but also some of the issues arising from this type of humanitarian medical care.

Case report of optic atrophy in pansynostosis: an unusual presentation of scalp edema from hair braiding

Pansynostosis (fusion of all cranial sutures) and optic atrophy were found as incidental CT scan and ophthalmological findings in an 8-year-old who presented to the emergency room with scalp edema from tight 'cornrow' hair braiding. Cranial vault expansion was successfully performed. Ophthalmological problems have stabilized but have not reversed. Late presentation of craniosynostosis and the pathophysiology of secondary optic atrophy are discussed.

The effects of craniosynostosis on the brain with respect to intracranial pressure

Intracranial pressure (ICP) and skull volume are intricately related. Craniosynostosis alters skull volume, and the many forms of craniosynostosis complicate the relationship to ICP even further. Patients with single-suture synostosis are less likely to experience elevated ICP than patients in whom multiple sutures, craniofacial syndromes, or both are involved. Among patients with more than one suture involved, the multifactorial mechanisms underlying elevated ICP include cephalocranial disproportion and venous outflow obstruction. Direct monitoring of ICP for at least 24 hours can aid in the diagnosis and decision making process. The management of craniosynostotic patients is diverse and necessitates a long-term plan for follow-up.