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Makoshi Z, Hayek G, Aquino V, Arias A, Guido J, Radenovich V, Jimenez D, Yates D. Intraoperative Intracranial Pressure Changes in Children With Craniosynostosis Undergoing Endoscopic-Assisted Strip Craniectomy. Neurosurgery 2024:00006123-990000000-01312. [PMID: 39166852 DOI: 10.1227/neu.0000000000003141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/09/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Craniosynostosis can lead to progressive cranial and skull base deformities and can be associated with increased intracranial pressure (ICP), ophthalmological manifestations, behavioral changes, and developmental delay. Most published data on the incidence of elevated ICP include older children undergoing open surgical correction. Endoscopic-assisted release of fused sutures with postoperative helmet therapy is an established method for managing craniosynostosis presenting at an early age; however, the immediate effect of this approach on ICP in a young cohort has not been previously reported. METHODS Prospective data on 52 children undergoing endoscopic-assisted release of stenosed cranial sutures were included. Individuals were excluded if they underwent open correction or had previous cranial surgery. Individuals underwent a standardized endoscopic approach for each suture type. ICP was measured using an intraparenchymal sensor both before creation of the neosuture and after complete release of the stenosed suture. An ICP reading of >10 mm Hg was considered elevated. RESULTS The mean age was 5.3 months, range 1 to 32 months, and 94% was younger than 12 months. The mean opening pressure was 12.7 mm Hg, and the mean closing pressure was 2.9 mm Hg. Opening ICP ≥10 mm Hg was present in 58%, ≥15 mm Hg was present in 31%, and ≥20 mm Hg was present in 23%. No patient had an ICP above 10 mm Hg at closing. The mean percentage change in ICP among all craniosynostosis cases was a 64% decrease. Optic disk swelling was identified in 28 children preoperatively and improved in 22 children at follow-up. CONCLUSION Elevated ICP may occur in infants with craniosynostosis at higher rates than previously reported. Endoscopic-assisted craniectomy has an immediate effect on lowering ICP and improving postoperative ophthalmological findings.
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Affiliation(s)
- Ziyad Makoshi
- Neuroscience Department, El Paso Children's Hospital, El Paso, Texas, USA
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Gabriel Hayek
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
- Avon Oral and Maxillofacial Surgery, Avon, Connecticut, USA
| | | | | | - Julia Guido
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Violeta Radenovich
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
- Children's Eye Center of El Paso, El Paso, Texas, USA
| | - David Jimenez
- Neuroscience Department, El Paso Children's Hospital, El Paso, Texas, USA
| | - David Yates
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
- El Paso Children's Hospital, El Paso, Texas, USA
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Raposo-Amaral CE, Vincenzi-Lemes M, Medeiros ML, Raposo-Amaral CA, Ghizoni E. Apert syndrome: neurosurgical outcomes and complications following posterior vault distraction osteogenesis. Childs Nerv Syst 2024; 40:2557-2563. [PMID: 38700706 DOI: 10.1007/s00381-024-06436-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 04/27/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE Posterior vault distraction osteogenesis (PVDO) has been utilized during the past 15 years to treat a variety of clinical features commonly presented by patients with Apert syndrome. The objective of this study is to determine the efficacy of PVDO in addressing both elevated intracranial pressure (ICP) and ectopia of the cerebellar tonsils (ECT) in young Apert patients. In addition, we aimed to determine the prevalence of hydrocephalus in Apert syndrome patients who underwent PVDO. METHODS A retrospective study was made with a cohort of 40 consecutive patients with syndromic craniosynostosis (SC), previously diagnosed with Apert syndrome, who underwent PVDO between 2012 and 2022, and thereafter received at least 1 year of follow-up care. Demographic data and diagnosis, along with surgical and outcome data, were verified using medical records, clinical photographs, radiologic examination, and interviews with the parents of all cohort patients. RESULTS The average patient age when PVDO was performed was 12.91 ± 10 months. The average posterior advancement distance achieved per patient was 22.68 ± 5.26 mm. The average hospital stay per patient was 3.56 ± 2.44 days. The average absolute and relative blood transfusion volumes were 98.47 ml and 17.63 ml/kg, respectively. Although five patients (14%) presented ECT preoperatively, this condition was completely resolved by PVDO in three of these five patients. One of the three patients whose ECT had completely resolved presented syringomyelia postoperatively, requiring subsequent extra dural foramen magnum decompression. All of the remaining four patients were asymptomatic for ECT for at least 1 year of follow-up, and none of these four patients required any additional treatments to address ECT. Two patients presented hydrocephalus requiring ventriculoperitoneal shunt placement. CONCLUSIONS This study demonstrates that PVDO both reduces diagnosed elevated ICP symptoms and is partially effective in treating ECT in Apert syndrome patients. Hydrocephalus in Apert syndrome is an uncommon feature. The effectiveness of PVDO in addressing hydrocephalus is uncertain.
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Affiliation(s)
- Cassio Eduardo Raposo-Amaral
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil.
- Department of Neurology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil.
| | - Marcela Vincenzi-Lemes
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil
| | - Mateus L Medeiros
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil
| | - Cesar Augusto Raposo-Amaral
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil
| | - Enrico Ghizoni
- Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo, 13084-880, Brazil
- Department of Neurology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
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Braud SC, Treger D, Lizardi JJ, Boghosian T, El Abd R, Arakelians A, Jabori SK, Thaller SR. The Top 100 Most-Cited Publications in Clinical Craniofacial Research. J Craniofac Surg 2024; 35:1372-1378. [PMID: 38709050 DOI: 10.1097/scs.0000000000010185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/05/2024] [Indexed: 05/07/2024] Open
Abstract
INTRODUCTION Craniosynostosis is a birth defect defined as premature closure of sutures leading to possible neurological deficits and cosmetic deformities. Most of the current literature to date focuses on craniosynostosis etiology by analyzing genetics. This paper is a bibliometric analysis of the most influential works related to the clinical management of craniosynostosis to help guide clinicians in their decision-making. METHODS AND MATERIALS Clarivate Web of Science database was used to identify the top 100 most-cited articles addressing the clinical management of craniosynostosis. A bibliometric review was performed to analyze publication metrics and track research trends. RESULTS The 100 most-cited publications pertaining to craniosynostosis management were cited a cumulative 12,779 times. The highest cited article was Shillito and colleagues' "Craniosynostosis: A Review Of 519 Surgical Patients" with 352 citations. The oldest clinical craniosynostosis article dates back to 1948, and the most recent was published in 2016. The year with the most clinical-focused publications was 2011. The most prolific author was Renier, D. The United States produced 56 of the 100 articles. Most articles (n=52) were level 3 evidence. DISCUSSION This bibliometric evaluation of craniosynostosis provides insight into the most impactful literature on this topic. The highest cited articles retrospectively analyze large sample sizes, outline proper evaluation, discuss intervention timelines, and highlight specific treatment plans for this birth defect. By filtering through existing literature, this analysis can guide clinicians on the management of craniosynostosis to maximize patient outcomes.
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Affiliation(s)
- Savannah C Braud
- Florida Atlantic University Schmidt College of Medicine, Boca Raton, FL
| | - Dylan Treger
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Juan J Lizardi
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | | | - Rawan El Abd
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Aris Arakelians
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Sinan K Jabori
- Division of Plastic Surgery, University of Miami Hospital, Dewitt Daughtry Department of Surgery, Miami, FL
| | - Seth R Thaller
- Division of Plastic Surgery, University of Miami Hospital, Dewitt Daughtry Department of Surgery, Miami, FL
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Kalmar CL, Malphrus EL, Blum JD, Kosyk MS, Zapatero ZD, Heuer GG, Bartlett SP, Taylor JA, Lang SS, Swanson JW. Intracranial Pressure Patterns in Children with Sagittal Craniosynostosis. Plast Reconstr Surg 2024; 154:135e-145e. [PMID: 37285193 DOI: 10.1097/prs.0000000000010797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Elevated intracranial pressure (ICP) in sagittal craniosynostosis has a wide spectrum of reported incidence, and patterns are not well understood across infancy and childhood. Characterizing the natural history of ICP in this population may clarify risks for neurocognitive delay and inform treatment decisions. METHODS Infants and children with sagittal craniosynostosis and unaffected control subjects were prospectively evaluated with spectral-domain optical coherence tomography from 2014 to 2021. Elevated ICP was determined based on previously validated algorithms using retinal optical coherence tomography parameters. RESULTS Seventy-two patients with isolated sagittal craniosynostosis and 25 control subjects were evaluated. Overall, 31.9% ( n = 23) of patients with sagittal craniosynostosis had evidence of ICP greater than or equal to 15 mmHg, and 27.8% ( n = 20) of patients had ICP greater than or equal to 20 mmHg. Children with sagittal craniosynostosis younger than 6 months were more likely to have normal ICP (88.6% <15 mmHg; 91.4% <20 mmHg) than those aged between 6 and 12 months (54.5%, P = 0.013; 54.5%, P = 0.005) than those older than 12 months (46.2%, P < 0.001; 53.8%, P = 0.001). ICP was directly correlated with severity of scaphocephaly ( P = 0.009). No unaffected control subjects at any age exhibited retinal thickening suggestive of elevated ICP. CONCLUSION Elevated ICP is rare in isolated sagittal craniosynostosis younger than 6 months, but it becomes significantly more common after 6 months of age, and may correlate with severity of scaphocephaly. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
| | | | - Jessica D Blum
- From the Divisions of Plastic and Reconstructive Surgery
| | | | | | | | | | - Jesse A Taylor
- From the Divisions of Plastic and Reconstructive Surgery
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Svalina A, Serlo W, Sinikumpu JJ, Salokorpi N. Experiences of surgical complications and reoperations in nonsyndromic sagittal synostosis patients in Oulu. Childs Nerv Syst 2024:10.1007/s00381-024-06519-0. [PMID: 38940955 DOI: 10.1007/s00381-024-06519-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 06/21/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE The purpose of this study was to evaluate the surgical complications of patients treated for nonsyndromic sagittal craniosynostosis and the necessity for reoperations due to craniocerebral disproportion. MATERIALS AND METHODS The patient cohort of this study consisted of patients (N = 82) who were treated in the Oulu University Hospital using the open vault cranioplasty with a modified H-technique between the years 2008 to 2022. There were 69 males (84.1%) and 13 females (15.9%). The mean age at the primary operation was 6.1 months. Mean follow-up time was 9.0 years. RESULTS There were no major complications related to the procedures. Two patients (2.4%) had a minor dural lesion. There were no postoperative wound infections. Of the 82 patients, seven patients with primary craniosynostosis (13.0%) developed symptomatic craniocerebral disproportion requiring reoperation to increase intracranial volume. In all these patients, invasive intracranial pressure (ICP) monitoring was performed prior to decision-making. In the majority of cases, the aesthetical outcome was considered good or excellent. CONCLUSION The operative method used was feasible and safe. Thirteen percent of patients who were followed over 5 years required major surgery due to development of craniocerebral disproportion later in life.
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Affiliation(s)
- Anja Svalina
- Research Unit of Clinical Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland.
- Medical Research Center, Oulu University Hospital, Oulu, Finland.
- Department of Neurosurgery, NeurocenterOulu University Hospital, PO Box 21, 90029, Oulu, OYS, Finland.
| | - Willy Serlo
- Research Unit of Clinical Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
- Medical Research Center, Oulu University Hospital, Oulu, Finland
- Skills Center for Children and Women, Oulu University Hospital, Oulu, Finland
| | - Juha-Jaakko Sinikumpu
- Research Unit of Clinical Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
- Medical Research Center, Oulu University Hospital, Oulu, Finland
- Skills Center for Children and Women, Oulu University Hospital, Oulu, Finland
| | - Niina Salokorpi
- Research Unit of Clinical Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Neurosurgery, NeurocenterOulu University Hospital, PO Box 21, 90029, Oulu, OYS, Finland
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Liu J, Chaij J, Linguraru MG, French B, Keating R, Alexander AL, Porras AR. Cranial bone thickness and density anomalies quantified from CT images can identify chronic increased intracranial pressure. Neuroradiology 2024:10.1007/s00234-024-03393-0. [PMID: 38871879 DOI: 10.1007/s00234-024-03393-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Abstract
PURPOSE The diagnosis of chronic increased intracranial pressure (IIP)is often based on subjective evaluation or clinical metrics with low predictive value. We aimed to quantify cranial bone changes associated with pediatric IIP using CT images and to identify patients at risk. METHODS We retrospectively quantified local cranial bone thickness and mineral density from the CT images of children with chronic IIP and compared their statistical differences to normative children without IIP adjusting for age, sex and image resolution. Subsequently, we developed a classifier to identify IIP based on these measurements. Finally, we demonstrated our methods to explore signs of IIP in patients with non-syndromic sagittal craniosynostosis (NSSC). RESULTS We quantified a significant decrease of bone density in 48 patients with IIP compared to 1,018 normative subjects (P < .001), but no differences in bone thickness (P = .56 and P = .89 for age groups 0-2 and 2-10 years, respectively). Our classifier demonstrated 83.33% (95% CI: 69.24%, 92.03%) sensitivity and 87.13% (95% CI: 84.88%, 89.10%) specificity in identifying patients with IIP. Compared to normative subjects, 242 patients with NSSC presented significantly lower cranial bone density (P < .001), but no differences were found compared to patients with IIP (P = .57). Of patients with NSSC, 36.78% (95% CI: 30.76%, 43.22%) presented signs of IIP. CONCLUSION Cranial bone changes associated with pediatric IIP can be quantified from CT images to support earlier diagnoses of IIP, and to study the presence of IIP secondary to cranial pathology such as non-syndromic sagittal craniosynostosis.
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Affiliation(s)
- Jiawei Liu
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Jasmine Chaij
- Department of Pediatric Plastic & Reconstructive Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, USA
- Departments of Radiology and Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Brooke French
- Department of Pediatric Plastic & Reconstructive Surgery, Children's Hospital Colorado, Aurora, CO, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA
| | - Robert Keating
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Allyson L Alexander
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA
- Department of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Antonio R Porras
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Department of Pediatric Plastic & Reconstructive Surgery, Children's Hospital Colorado, Aurora, CO, USA.
- Department of Surgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA.
- Department of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, CO, USA.
- Departments of Pediatrics and Biomedical Informatics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Kai LC, Khaliddin N, Hassan MK, Hariri F. Skeletal expansion via craniofacial distraction osteogenesis technique in syndromic craniosynostosis: impact on ophthalmic parameters. Int Ophthalmol 2024; 44:147. [PMID: 38499845 DOI: 10.1007/s10792-024-03084-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 02/23/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND This study aims to compare the changes in ophthalmic parameters among syndromic craniosynostosis patients who underwent craniofacial skeletal expansion procedures via distraction osteogenesis (DO). METHOD A retrospective study was conducted involving syndromic craniosynostosis patients who underwent surgical expansion via the DO technique from the year 2012 to March 2022. Changes in six parameters which consist of visual acuity, refractive error, optic disc health, intraocular pressure, degree of proptosis and orbital volume were measured objectively pre and post-surgery. For categorical parameters, the Chi-square cross-tab test was done. Paired sample T-test was used for normally distributed variables. Wilcoxon signed-rank test was used for non-normally distributed data. RESULTS Visual impairment was present in 21.4% of eyes before surgery and increased to 28.5% post-surgery. Three patients had changes of refractive error post-surgery with one developed hypermetropia, another developed anisometropia and the last had improvement to no refractive error. Two patients had optic disc swelling which was resolved post-surgery. Intraocular pressure changes were inconsistent post-surgery. All patients achieved a significant reduction in the degree of proptosis post-surgery. Orbital volume calculation using computed tomography (CT) scans shows a significant increase in volume post-surgery for all patients. CONCLUSION Our study shows a significant increase in orbital volume post-surgery with a reduction in the degree of proptosis. Optic disc and nerve health improved after the surgery. Changes in terms of visual acuity, refractive error and IOP were inconsistent after the surgical intervention.
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Affiliation(s)
- Lim Chin Kai
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Nurliza Khaliddin
- Department of Ophthalmology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Muhammad Kamil Hassan
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Firdaus Hariri
- Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, Universiti Malaya, 50603, Kuala Lumpur, Malaysia.
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Chang YH, Staffa SJ, Yavuz Saricay L, Zurakowski D, Gise R, Dagi LR. Sensitivity, Specificity, and Cutoff Identifying Optic Atrophy by Macular Ganglion Cell Layer Volume in Syndromic Craniosynostosis. Ophthalmology 2024; 131:341-348. [PMID: 37742723 DOI: 10.1016/j.ophtha.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 09/26/2023] Open
Abstract
PURPOSE To determine the sensitivity, specificity, and cutoff of macular ganglion cell layer (GCL) volume consistent with optic atrophy in children with syndromic craniosynostosis and to investigate factors independently associated with reduction in GCL volume. DESIGN Retrospective cross-sectional study. PARTICIPANTS Patients with syndromic craniosynostosis evaluated at Boston Children's Hospital (2010-2022) with reliable macular OCT scans. METHODS The latest ophthalmic examination that included OCT macula scans was identified. Age at examination, sex, ethnicity, best-corrected logarithm of the minimum angle of resolution (logMAR) visual acuity, cycloplegic refraction, and funduscopic optic nerve appearance were recorded in addition to history of primary or recurrent elevation in intracranial pressure (ICP), Chiari malformation, and obstructive sleep apnea (OSA). Spectral-domain OCT software quantified segmentation of macula retinal layers and was checked manually. MAIN OUTCOME MEASURES The primary outcome was determining sensitivity, specificity, and optimal cutoff of GCL volume consistent with optic atrophy. The secondary outcome was determining whether previously elevated ICP, OSA, Chiari malformation, craniosynostosis diagnosis, logMAR visual acuity, age, or sex were independently associated with lower GCL volume. RESULTS Median age at examination was 11.9 years (interquartile range, 8.5-14.8 years). Fifty-eight of 61 patients (112 eyes) had reliable macula scans, 74% were female, and syndromes represented were Apert (n = 14), Crouzon (n = 17), Muenke (n = 6), Pfeiffer (n = 6), and Saethre-Chotzen (n = 15). Optimal cutoff identifying optic atrophy was a GCL volume < 1.02 mm3 with a sensitivity of 83% and specificity of 77%. Univariate analysis demonstrated that significantly lower macular GCL volume was associated with optic atrophy on fundus examination (P < 0.001), Apert syndrome (P < 0.001), history of elevated ICP (P = 0.015), Chiari malformation (P = 0.001), OSA (P < 0.001), male sex (P = 0.027), and worse logMAR visual acuity (P < 0.001). Multivariable median regression analysis confirmed that only OSA (P = 0.005), optic atrophy on fundus examination (P = 0.003), and worse logMAR visual acuity (P = 0.042) were independently associated with lower GCL volume. CONCLUSIONS Surveillance for optic atrophy by GCL volume may be useful in a population where cognitive skills can limit acquisition of other key ophthalmic measures. It is noteworthy that OSA is also associated with lower GLC volume in this population. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Yoon-Hee Chang
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leyla Yavuz Saricay
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ryan Gise
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Linda R Dagi
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Mitchell A, Baig AA, Kanj U, Rodrigues D, Painter S, Abbott J. Papilloedema: a highly specific predictor of raised intracranial pressure in a complex neurosurgical paediatric cohort. Childs Nerv Syst 2024; 40:463-469. [PMID: 37665341 DOI: 10.1007/s00381-023-06137-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/23/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE Papilloedema is recognised as an indicator of raised intracranial pressure, although there is a paucity of literature describing the utility of fundoscopy in screening for raised ICP in children with craniofacial synostosis, particularly young children. We sought to investigate the association of optic disc morphology with ICP in children, and to define the sensitivity and specificity of papilloedema as a clinical indicator of raised ICP and determine if age, or underlying conditions impact the findings. METHOD Retrospective analysis of all patients undergoing ICP monitoring at a designated paediatric neurosurgical and craniofacial unit in the United Kingdom between October 2009 and October 2018. The fundoscopy findings and ICP monitoring data were analysed for 31 children with craniosynostosis and 29 children without craniosynostosis. RESULTS All children who had papilloedema had raised ICP confirmed with monitoring. Across the 60-patient cohort, confirmed papilloedema on fundoscopy had Positive Predictive Value (PPV) of 1.00, Negative Predictive Value (NPV) of 0.64 with sensitivity 48% and specificity 100% for the presence of raised ICP (p = < 0.0001). In the craniosynostosis group, PPV was 1.00, NPV was 0.39, sensitivity 48% and specificity 100% (p = < 0.03). There is no correlation between severity of optic disc swelling using Frisen grading and elevation of ICP. Age did not affect the presence of papilloedema in those with raised ICP. CONCLUSION The presence of papilloedema is a strong indicator of raised ICP in a child, regardless of underlying aetiology. Detailed fundoscopy can prevent the need for further investigations including imaging-related radiation and invasive CSF pressure monitoring.
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Affiliation(s)
- Alexander Mitchell
- Department of Craniofacial Surgery, Birmingham Women and Children's Foundation NHS Trust, Birmingham, United Kingdom.
| | - Azam Ali Baig
- Department of Craniofacial Surgery, Birmingham Women and Children's Foundation NHS Trust, Birmingham, United Kingdom
| | - Usama Kanj
- Department of Craniofacial Surgery, Birmingham Women and Children's Foundation NHS Trust, Birmingham, United Kingdom
| | - Desiderio Rodrigues
- Department of Craniofacial Surgery, Birmingham Women and Children's Foundation NHS Trust, Birmingham, United Kingdom
| | - Sally Painter
- Department of Craniofacial Surgery, Birmingham Women and Children's Foundation NHS Trust, Birmingham, United Kingdom
| | - Joseph Abbott
- Department of Craniofacial Surgery, Birmingham Women and Children's Foundation NHS Trust, Birmingham, United Kingdom
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Estrela T, Dagi LR. Optic neuropathy in craniosynostosis. FRONTIERS IN OPHTHALMOLOGY 2024; 3:1303723. [PMID: 38983067 PMCID: PMC11182278 DOI: 10.3389/fopht.2023.1303723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/21/2023] [Indexed: 07/11/2024]
Abstract
Craniosynostosis (CS) or the premature fusion of one or more cranial sutures in utero, or during the first years of life, can present in isolation or as a multisystem clinical disorder with a particular impact on visual function. Among ophthalmic complications, optic neuropathy is a significant cause of irreversible vision loss in these patients. Children with CS are at higher risk of developing elevated intracranial pressure which can lead to papilledema and, ultimately, optic atrophy. In addition, sometimes associated obstructive sleep apnea, abnormalities in central nervous system venous development, and Chiari malformation may contribute to optic neuropathy. Ophthalmologists have an important role in managing a number of coexistent ophthalmologic complications such as strabismus, anisometropia, amblyopia, ptosis, and exposure keratopathy in addition to maintaining surveillance for early signs of optic neuropathy; they play a critical consultative role contributing to the decision for primary or repeat decompressive surgery. In this article, we aim to review the etiology, diagnostic approach, and management of optic neuropathies in patients with craniosynostosis.
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Affiliation(s)
- Tais Estrela
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Linda R Dagi
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
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Kerscher SR, Tellermann J, Zipfel J, Bevot A, Haas-Lude K, Schuhmann MU. Influence of sex and disease etiology on the development of papilledema and optic nerve sheath extension in the setting of intracranial pressure elevation in children. BRAIN & SPINE 2023; 4:102729. [PMID: 38510611 PMCID: PMC10951694 DOI: 10.1016/j.bas.2023.102729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 12/03/2023] [Accepted: 12/08/2023] [Indexed: 03/22/2024]
Abstract
Introduction Dilatation of the optic nerve sheath diameter and swelling of the optic disc are known phenomena associated with intracranial pressure elevation. Research question Do sex and disease etiology have an impact on the development of optic disc elevation and optic nerve sheath extension in children in the setting of ICP elevation? Fundoscopic papilledema and point-of-care-ultrasound techniques-optic nerve sheath diameter (US-ONSD) and optic disc elevation (US-ODE) - were compared in this regard. Material and methods 72 children were included in this prospective study; 50 with proven pathology (e.g. pseudotumor cerebri, tumor), 22 with pathology excluded. Bilateral US-ONSD and US-ODE were quantified by US using a 12-MHz-linear-array-transducer. This was compared with fundoscopic optic disc findings and in 28 patients with invasive ICP values, stratified for sex and etiology. Results In patients with proven disease, significant more girls (69%) had fundoscopic papilledema compared with boys (37%, p < 0.05). Girls had also larger US-ODE values (0.86 ± 0.36 mm vs. 0.65 ± 0.40 mm in boys). 80% of tumor patients had initial papilledema (100% girls, 79% boys), compared with 50% in pseudotumor cerebri (PTC) (83% girls, 30% boys). US-ONSD had no sex- and no etiology-specificity. Discussion and conclusion Presence of papilledema appears to be influenced by sex and etiology, whereas US-ONSD is not. Girls seem more likely to develop papilledema under similar conditions. Male sex and PTC appear as risk factors for being undetected by fundoscopic findings. US-ONSD and US-ODE seem useful tools to identify pathologies with potentially increased ICP requiring treatment in children regardless of sex and etiology.
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Affiliation(s)
- Susanne Regina Kerscher
- Department of Neurosurgery and Neurotechnology, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Germany
| | - Jonas Tellermann
- Department of Neurosurgery and Neurotechnology, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, Germany
| | - Julian Zipfel
- Department of Neurosurgery and Neurotechnology, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, Germany
| | - Andrea Bevot
- Department of Pediatric Neurology and Developmental Medicine, University Children’ s Hospital of Tuebingen, Germany
| | - Karin Haas-Lude
- Department of Pediatric Neurology and Developmental Medicine, University Children’ s Hospital of Tuebingen, Germany
| | - Martin Ulrich Schuhmann
- Department of Neurosurgery and Neurotechnology, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, Germany
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Kurzbuch AR, Cooper B, Duncan C, Ellenbogen J, Richardson D, Sinha A, Weber A, Sithambaram S, Hennedige A, Parks C. Patient Tailored Surgery in Saethre-Chotzen Syndrome: Analysis of Reoperation for Intracranial Hypertension. J Craniofac Surg 2023; 34:2099-2103. [PMID: 37226293 DOI: 10.1097/scs.0000000000009429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/08/2023] [Indexed: 05/26/2023] Open
Abstract
Saethre-Chotzen syndrome (SCS) is a syndromic craniosynostosis with pathogenic variants in the TWIST1 gene showing a broad phenotypic spectrum. Controversies exist in the literature regarding surgical management with single one-stage versus patient-tailored surgery and the related reoperation rate for intracranial hypertension of up to 42%. At our center, SCS patients are offered patient-tailored surgery with single-stage fronto-orbital advancement and remodeling or fronto-orbital advancement and remodeling and posterior distraction in an individually determined order. The authors' database identified 35 confirmed SCS patients between 1999 and 2022. Involved sutures in craniosynostosis were left unicoronal (22.9%), bicoronal (22.9%), sagittal (8.6%), bicoronal and sagittal (5.7%), right unicoronal (2.9%), bicoronal and metopic (2.9%), bicoronal, sagittal and metopic (2.9%), and bilateral lambdoid (2.9%). There was pansynostosis in 8.6% and no craniosynostosis in 14.3% of the patients. Twenty-six patients, 10 females, and 16 males were operated on. Mean age at the first surgery was 1.70 years, and 3.86 years at the second surgery. Eleven of 26 patients had invasive intracranial pressure monitoring. Three patients presented with papilledema before the first surgery and 4 afterward. Four of the 26 operated patients were operated initially elsewhere. The other 22 patients were initially referred to our unit and underwent patient-tailored surgery. Nine of these patients (41%) had a second surgery, and 3 (14%) of them were because of raised intracranial pressure. Seven (27%) of all operated patients had a complication. Median follow-up was 13.98 years (range, 1.85-18.08). Patient-tailored surgery in a specialized center and long-term follow-up allow for a low reoperation rate for intracranial hypertension.
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Affiliation(s)
- Arthur R Kurzbuch
- Department of Neurosurgery, Craniofacial Unit, Alder Hey Children's NHS Foundation Trust
| | - Ben Cooper
- Department of Neurosurgery, Craniofacial Unit, Alder Hey Children's NHS Foundation Trust
| | - Christian Duncan
- Department of Maxillofacial and Craniofacial Surgery, Alder Hey Children's NHS Foundation Trust
| | - Jonathan Ellenbogen
- Department of Neurosurgery, Craniofacial Unit, Alder Hey Children's NHS Foundation Trust
| | - David Richardson
- Department of Maxillofacial and Craniofacial Surgery, Alder Hey Children's NHS Foundation Trust
| | - Ajay Sinha
- Department of Neurosurgery, Craniofacial Unit, Alder Hey Children's NHS Foundation Trust
| | - Astrid Weber
- Liverpool Centre for Genomic Medicine, Liverpool Women's NHS Foundation Trust
| | | | - Anusha Hennedige
- Department of Maxillofacial and Craniofacial Surgery, Alder Hey Children's NHS Foundation Trust
| | - Chris Parks
- Department of Neurosurgery, Craniofacial Unit, Alder Hey Children's NHS Foundation Trust
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Doerga PN, Goederen RD, van Veelen MLC, Joosten KFM, Tasker RC, Mathijssen IMJ. What We Know About Intracranial Hypertension in Children With Syndromic Craniosynostosis. J Craniofac Surg 2023; 34:1903-1914. [PMID: 37487059 DOI: 10.1097/scs.0000000000009517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/17/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVE A scoping review of literature about mechanisms leading to intracranial hypertension (ICH) in syndromic craniosynostosis (sCS) patients, followed by a narrative synopsis of whether cognitive and behavioral outcome in sCS is more related to genetic origins, rather than the result of ICH. METHODS The scoping review comprised of a search of keywords in EMBASE, MEDLINE, Web of science, Cochrane Central Register of Trials, and Google scholar databases. Abstracts were read and clinical articles were selected for full-text review and data were extracted using a structured template. A priori, the authors planned to analyze mechanistic questions about ICH in sCS by focusing on 2 key aspects, including (1) the criteria for determining ICH and (2) the role of component factors in the Monro-Kellie hypothesis/doctrine leading to ICH, that is, cerebral blood volume, cerebrospinal fluid (CSF), and the intracranial volume. RESULTS Of 1893 search results, 90 full-text articles met criteria for further analysis. (1) Invasive intracranial pressure measurements are the gold standard for determining ICH. Of noninvasive alternatives to determine ICH, ophthalmologic ones like fundoscopy and retinal thickness scans are the most researched. (2) The narrative review shows how the findings relate to ICH using the Monro-Kellie doctrine. CONCLUSIONS Development of ICH is influenced by different aspects of sCS: deflection of skull growth, obstructive sleep apnea, venous hypertension, obstruction of CSF flow, and possibly reduced CSF absorption. Problems in cognition and behavior are more likely because of genetic origin. Cortical thinning and problems in visual function are likely the result of ICH.
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Affiliation(s)
- Priya N Doerga
- Sophia Children's Hospital, Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus MC, University Medical Center
| | - Robbin de Goederen
- Sophia Children's Hospital, Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus MC, University Medical Center
| | - Marie-Lise C van Veelen
- Sophia Children's Hospital, Department of Neurosurgery, Erasmus MC, University Medical Center
| | - Koen F M Joosten
- Sophia Children's Hospital Pediatric Intensive Care Unit, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Robert C Tasker
- Department of Anaesthesia (Pediatrics) and Division of Critical Care Medicine, Harvard Medical School and Boston Children's Hospital, Boston, MA
| | - Irene M J Mathijssen
- Sophia Children's Hospital, Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus MC, University Medical Center
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14
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Pandey SK, Kalmar CL, Bonfield CM, Golinko MS. Frontal sinus hypoplasia in unoperated older patients with craniosynostosis: a pilot study. Childs Nerv Syst 2023; 39:2139-2146. [PMID: 37133486 DOI: 10.1007/s00381-023-05927-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 03/17/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE The purpose of this study is to determine whether patients with unoperated craniosynostosis have different frontal sinus pneumatization than unaffected controls. METHODS Retrospective review was performed between 2009 and 2020 of previously unoperated patients with craniosynostosis older than 5 years old at first presentation to our institution. Total frontal sinus volume (FSV) was calculated using 3D volume rendering tool in Sectra IDS7 PACS system. Age-matched normative FSV data was collected from 100 normal CT scans for the control group. The two groups were statistically compared using Fisher's exact test and T-test. RESULTS Study group included nine patients, 5-39 years old, median age 7 years. Frontal sinus pneumatization was absent in 12% of the normal 7-year-old controls, while frontal sinus pneumatization was absent in 89% of the studied craniosynostosis patients (p < .001). Mean FSV of the study group (113 ± 340 mm3) was significantly different from that of age matched control mean FSV (2016 ± 2529 mm3) (p = .027). CONCLUSIONS Frontal sinus pneumatization is suppressed in unreleased craniosynostosis and may be an intracranial space conservation phenomenon. This absent frontal sinus can have implications in future frontal region trauma and frontal osteotomies.
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Affiliation(s)
- Sonia K Pandey
- Department of Plastic Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA
| | - Christopher L Kalmar
- Department of Plastic Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA.
| | | | - Michael S Golinko
- Department of Plastic Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA
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15
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The Paediatric Vault Score (PVS)-A Novel Scoring Tool for Prioritisation of Surgical Management of Craniosynostosis Patients. J Craniofac Surg 2023; 34:e283-e287. [PMID: 36928030 DOI: 10.1097/scs.0000000000009250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 03/18/2023] Open
Abstract
Craniosynostosis is the premature fusion of the skull sutures, resulting in abnormal skull shape and volume. Timely management is a priority in avoiding raised intracranial pressure which can result in blindness and neurodevelopmental delay. Due to the COVID-19 pandemic, theater access was reduced. A risk stratification scoring system was thus devised to score patients attending surgery and aid in prioritization according to surgical need. The authors present the Paediatric Vault Score (PVS), which can also be customized to each unit's individual protocols. Ten patients on the waiting list were randomly selected and their clinical information was summarized in uniform anonymized reports. Six craniofacial consultants were selected as assessors and given 1 week to independently rank the patients from 1 to 10. Each scorer's ranking was verified against the PVS template and concordance was analyzed using the Kendall tau correlation coefficient (KT). Three cycles of the scoring process were carried out. Improvements were made to the scoring tool following cycle 1. Cycle 1 revealed 2 clinicians to be concordant with the PVS system and 4 to be discordant. Cycle 2 revealed all 6 clinicians to be concordant, with a mean KT score of 0.61. The final cycle revealed all 6 clinicians to be concordant, with a mean KT score of 0.70. Four scorers increased their concordance once the scoring sheet was introduced. Kendall's correlation of concordance calculated the interrater reliability to be 0.81. The PVS is the first known vault scoring system to aid in risk stratification and waiting list prioritization.
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16
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Riazi A, Aminmansoor B, Mahdkhah A. Bone Increment: a novel technique in correction of fronto-orbital deformity in patients with craniosynostosis. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
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17
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Grosser JA, Kogan S, Layton RG, Pontier JF, Bins GP, Runyan CM. The Need for Additional Surgery after Passive versus Active Approaches to Syndromic Craniosynostosis: A Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4891. [PMID: 36936458 PMCID: PMC10017396 DOI: 10.1097/gox.0000000000004891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/02/2023] [Indexed: 03/17/2023]
Abstract
Endoscopically assisted craniofacial surgery (EACS) has numerous advantages over traditional, open approaches, such as fronto-orbital advancement in treating nonsyndromic craniosynostosis. However, several articles report high reoperation rates in syndromic patients treated with EACS. This meta-analysis and review examines undesirable outcome rates (UORs), defined as reoperation or Whitaker category III/IV, in syndromic patients undergoing primary EACS compared with procedures that actively expand the cranial vault. Methods PubMed and Embase were searched in June 2022 to identify all articles reporting primary reoperation or Whitaker outcomes for syndromic patients undergoing cranial vault expanding surgery or suturectomy. A meta-analysis of proportions was performed comparing UORs, and a trim-and-fill adjustment method was used to validate sensitivity and assess publication bias. Results A total of 721 articles were screened. Five EACS articles (83 patients) and 22 active approach articles (478 patients) met inclusion criteria. Average UORs for EACS and active approaches were 26% (14%-38%) and 20% (13%-28%), respectively (P = 0.18). Reoperation occurred earlier in EACS patients (13.7 months postprimary surgery versus 37.1 months for active approaches, P = 0.003). Relapse presentations and reason for reoperation were also reviewed. Subjectively, EACS UORs were higher in all syndromes except Apert, and Saethre-Chotzen patients had the highest UOR for both approaches. Conclusions There was no statistically significant increase in UORs among syndromic patients treated with EACS compared with traditional approaches, although EACS patients required revision significantly sooner. Uncertainties regarding the long-term efficacy of EACS in children with syndromic craniosynostosis should be revisited as more data become available.
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Affiliation(s)
- Joshua A. Grosser
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
| | - Samuel Kogan
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
| | - Ryan G. Layton
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
| | - Joshua F. Pontier
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
| | - Griffin P. Bins
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
| | - Christopher M. Runyan
- From the Department of Plastic and Reconstructive Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, N.C
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18
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R M, Bansal A. Multimodal Neuromonitoring in Pediatric Neurocritical Care: Current Perspectives. Indian J Pediatr 2023; 90:261-271. [PMID: 36607512 DOI: 10.1007/s12098-022-04415-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/28/2022] [Indexed: 01/07/2023]
Abstract
Children with neurological illness in the critical care unit are always at higher risk of developing secondary brain injury (SBI). Brain insult can lead to changes in cerebral autoregulation, intracranial pressure (ICP), cerebral oxygenation, and metabolism. This can cause a raised ICP, cerebral ischemia, hypoxia, excitotoxicity, cellular energy failure, and nonconvulsive status epilepticus. Simultaneous and continuous assessment of these parameters will help to improve patient care and neurological outcomes. Even though clinical examination and neuroimaging can help in the initial diagnosis of the neurological illness, they may not be helpful in continuous monitoring of cerebral pathophysiological changes. The ideal single neuromonitoring device to detect these real-time changes is currently unavailable. However, a range of invasive and noninvasive monitors are available to monitor these cerebral functional parameters. Invasive monitoring techniques include invasive ICP monitoring, cerebral autoregulation monitoring, brain tissue partial oxygen pressure, and cerebral microdialysis. Noninvasive-monitoring techniques include pupillometry, brain and ocular ultrasonography, near-infrared spectroscopy, and electrophysiological monitoring. Multimodal (MM) neuromonitoring involves incorporating these techniques and tools for the early identification and treatment of primary and secondary brain insults. The utility and feasibility of most of these techniques are well described in adult neurocritical care. Even though the evidence on their usage in children is primarily available in pediatric traumatic brain injury, the emerging data help to further expand their utility in pediatric nontraumatic coma. MM neuromonitoring aims to provide clinical and pathophysiological information to the intensivists to improve their understanding of the child's neurological status and to formulate patient-specific treatment approaches.
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Affiliation(s)
- Muthuvel R
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Arun Bansal
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
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van de Beeten SDC, Kurniawan MSIC, Kamst NW, Loudon SE, Mathijssen IMJ, van Veelen MLC. Early and long-term skull growth after surgical correction for sagittal synostosis in relation to the occurrence of papilledema. Childs Nerv Syst 2023; 39:211-220. [PMID: 36053310 PMCID: PMC9968680 DOI: 10.1007/s00381-022-05629-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/19/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Stagnation of skull growth is correlated with papilledema in craniosynostosis. In this retrospective cohort study, we describe the postoperative skull growth after surgical correction for sagittal synostosis and its relation to the development of papilledema. METHODS Patients with isolated sagittal synostosis at our center between 2005 and 2012 were included. Occipitofrontal circumference (OFC) was analyzed, at 3 time points (preoperative, 2 years postoperative, and last OFC measurement) and 3 phases (initial postoperative growth, long-term growth, and overall growth), and related to papilledema on fundoscopy. RESULTS In total, 163 patients were included. The first time interval showed a decline in skull growth, with subsequent stabilization at long term. Papilledema occurred postoperatively in 10 patients. In these patients, the OFC at 2 years and at last follow-up (T3) were significantly smaller than in patients without papilledema. A larger OFC resulted in a decreased odds of developing papilledema at both postoperative time points (at T2 (OR = 0.40, p = 0.01) and at T3 (OR 0.29, p < 0.001)). Sensitivity and specificity analysis indicated that an OFC below 0.25 SD at T2 (sensitivity 90%, specificity 65%) and below 0.49 at T3 (sensitivity 100%, specificity 60%) are related to the occurrence of papilledema. CONCLUSION A small OFC is correlated with the occurrence of papilledema. A decline in OFC within 2 years postoperatively is common in sagittal synostosis and is acceptable up to a value of 0.25SD. Patients with an OFC at last follow-up of less than 0.5SD are at risk for developing papilledema.
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Affiliation(s)
- Stephanie D C van de Beeten
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus Medical Center, Room Ee15.91, 2040, 3000 CA, Rotterdam, the Netherlands
| | - Melissa S I C Kurniawan
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus Medical Center, Room Ee15.91, 2040, 3000 CA, Rotterdam, the Netherlands.
| | - Nathalie W Kamst
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus Medical Center, Room Ee15.91, 2040, 3000 CA, Rotterdam, the Netherlands
| | - Sjoukje E Loudon
- Department of Ophthalmology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Irene M J Mathijssen
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus Medical Center, Room Ee15.91, 2040, 3000 CA, Rotterdam, the Netherlands
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Rufai SR, Marmoy OR, Thompson DA, van de Lande LS, Breakey RW, Bunce C, Panteli V, Schwiebert K, Mohamed S, Proudlock FA, Gottlob I, Dunaway DJ, Hayward R, Bowman R, Jeelani NUO. Electrophysiological and fundoscopic detection of intracranial hypertension in craniosynostosis. Eye (Lond) 2023; 37:139-145. [PMID: 34974540 PMCID: PMC9829653 DOI: 10.1038/s41433-021-01839-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 10/08/2021] [Accepted: 11/02/2021] [Indexed: 01/17/2023] Open
Abstract
AIMS To assess the diagnostic accuracy of fundoscopy and visual evoked potentials (VEPs) in detecting intracranial hypertension (IH) in patients with craniosynostosis undergoing spring-assisted posterior vault expansion (sPVE). METHODS Children with craniosynostosis undergoing sPVE and 48-hour intracranial pressure (ICP) monitoring were included in this single-centre, retrospective, diagnostic accuracy study. Data for ICP, fundoscopy and VEPs were analysed. Primary outcome measures were papilloedema on fundoscopy, VEP assessments and IH, defined as mean ICP > 20 mmHg. Diagnostic indices were calculated for fundoscopy and VEPs against IH. Secondary outcome measures included final visual outcomes. RESULTS Fundoscopic examinations were available for 35 children and isolated VEPs for 30 children, 22 of whom had at least three serial VEPs. Sensitivity was 32.1% for fundoscopy (95% confidence intervals [CI]: 15.9-52.4) and 58.3% for isolated VEPs (95% CI 36.6-77.9). Specificity for IH was 100% for fundoscopy (95% CI: 59.0-100) and 83.3% for isolated VEPs (95% CI: 35.9-99.6). Where longitudinal deterioration was suspected from some prVEPs but not corroborated by all, sensitivity increased to 70.6% (95% CI: 44.0-89.7), while specificity decreased to 60% (95% CI: 14.7-94.7). Where longitudinal deterioration was clinically significant, sensitivity decreased to 47.1% (23.0-72.2) and specificity increased to 100% (47.8-100). Median final BCVA was 0.24 logMAR (n = 36). UK driving standard BCVA was achieved by 26 patients (72.2%), defined as ≥0.30 logMAR in the better eye. CONCLUSION Papilloedema present on fundoscopy reliably indicated IH, but its absence did not exclude IH. VEP testing boosted sensitivity at the expense of specificity, depending on method of analysis.
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Affiliation(s)
- Sohaib R. Rufai
- grid.424537.30000 0004 5902 9895Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK ,grid.83440.3b0000000121901201UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK ,grid.419248.20000 0004 0400 6485The University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Robert Kilpatrick Clinical Sciences Building, PO Box 65, Leicester, LE2 7LX UK ,grid.424537.30000 0004 5902 9895Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK
| | - Oliver R. Marmoy
- grid.424537.30000 0004 5902 9895Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK ,grid.83440.3b0000000121901201UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK
| | - Dorothy A. Thompson
- grid.424537.30000 0004 5902 9895Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK ,grid.83440.3b0000000121901201UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK
| | - Lara S. van de Lande
- grid.83440.3b0000000121901201UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK ,grid.424537.30000 0004 5902 9895Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK
| | - R. William Breakey
- grid.83440.3b0000000121901201UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK ,grid.424537.30000 0004 5902 9895Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK
| | - Catey Bunce
- grid.5072.00000 0001 0304 893XClinical Trials Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ UK
| | - Vasiliki Panteli
- grid.424537.30000 0004 5902 9895Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK
| | - Kemmy Schwiebert
- grid.424537.30000 0004 5902 9895Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK
| | - Shafquet Mohamed
- grid.424537.30000 0004 5902 9895Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK
| | - Frank A. Proudlock
- grid.419248.20000 0004 0400 6485The University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Robert Kilpatrick Clinical Sciences Building, PO Box 65, Leicester, LE2 7LX UK
| | - Irene Gottlob
- grid.419248.20000 0004 0400 6485The University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Robert Kilpatrick Clinical Sciences Building, PO Box 65, Leicester, LE2 7LX UK
| | - David J. Dunaway
- grid.83440.3b0000000121901201UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK ,grid.424537.30000 0004 5902 9895Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK
| | - Richard Hayward
- grid.83440.3b0000000121901201UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK ,grid.424537.30000 0004 5902 9895Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK
| | - Richard Bowman
- grid.424537.30000 0004 5902 9895Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK ,grid.83440.3b0000000121901201UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK
| | - Noor ul Owase Jeelani
- grid.83440.3b0000000121901201UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH UK ,grid.424537.30000 0004 5902 9895Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH UK
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Clinical and Genetic Studies of the First Monozygotic Twins with Pfeiffer Syndrome. Genes (Basel) 2022; 13:genes13101850. [PMID: 36292735 PMCID: PMC9601734 DOI: 10.3390/genes13101850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
Objective: To report the clinical and radiographic findings and molecular etiology of the first monozygotic twins affected with Pfeiffer syndrome. Methods: Clinical and radiographic examination and whole exome sequencing were performed on two monozygotic twins with Pfeiffer syndrome. Results: An acceptor splice site mutation in FGFR2 (c.940-2A>G) was detected in both twins. The father and both twins shared the same haplotype, indicating that the mutant allele was from their father’s chromosome who suffered severe upper airway obstruction and subsequent obstructive sleep apnea. Hypertrophy of nasal turbinates appears to be a newly recognized finding of Pfeiffer syndrome. Increased intracranial pressure in both twins were corrected early by fronto-orbital advancement with skull expansion and open osteotomy, in order to prevent the more severe consequences of increased intracranial pressure, including hydrocephalus, the bulging of the anterior fontanelle, and the diastasis of suture. Conclusions: Both twins carried a FGFR2 mutation and were discordant for lambdoid synostosis. Midface hypoplasia, narrow nasal cavities, and hypertrophic nasal turbinates resulted in severe upper airway obstruction and subsequent obstructive sleep apnea in both twins. Hypertrophy of the nasal turbinates appears to be a newly recognized finding of Pfeiffer syndrome. Fronto-orbital advancement with skull expansion and open osteotomy was performed to treat increased intracranial pressure in both twins. This is the first report of monozygotic twins with Pfeiffer syndrome.
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22
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Deopujari CE, Samantray SK. Intracranial pressure monitoring in craniosynostosis. J Neurosci Rural Pract 2022; 13:583-584. [PMID: 36743759 PMCID: PMC9894321 DOI: 10.25259/jnrp-2022-6-41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/20/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Saurav Kumar Samantray
- Department of Paediatric Neurosurgery, NH SRCC Children’s Hospital, Mumbai, Maharashtra, India
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Manrique M, Mantilla-Rivas E, Rana MS, Crowder H, Oh N, Oh AK, Keating RF, Rogers GF. Normocephalic sagittal craniosynostosis in young children is common and unrecognized. Childs Nerv Syst 2022; 38:1549-1556. [PMID: 35716184 DOI: 10.1007/s00381-022-05533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 04/16/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Sagittal craniosynostosis (SC) is usually diagnosed during early childhood by the presence of scaphocephaly. Recently, our group found 3.3% of children under 5 years of age with normocephalic sagittal craniosynostosis (NSC) using computed tomography (CT) scans. This paper aims to validate our preliminary findings using a larger cohort of patients, and analyze factors associated with incidental NSC. METHODS A retrospective review of head CT scans in patients aged 0 to 71 months who presented to the emergency department of our tertiary care institution between 2008 and 2020 was completed. Patients with syndromes associated with craniosynostosis (CS), history of hydrocephalus, or other brain/cranial abnormalities were excluded. Two craniofacial surgeons reviewed the CT scans to evaluate the presence and extent of CS. Demographic information, gestational age, past medical and family history, medications, and chief complaint were recorded as covariates, and differences between patients with and without CS were analyzed. Furthermore, comparison of the prevalence of CS across age groups was studied. Additional analysis exploring association between independent covariates and the presence of CS was performed in two sub-cohorts: patients ≤ 24 months of age and patients > 24 months of age. RESULTS A total of 870 scans were reviewed. SC was observed in 41 patients (4.71% - 25 complete, 16 incomplete), all with a normal cranial index (width/length > 0.7). The prevalence of SC increased up to 36 months of age, then plateaued through 72 months of age. Patients under 2 years of age with family history of neurodevelopmental disease had 49.32 (95% CI [4.28, 567.2]) times higher odds of developing CS. Sub-cohort of patients above 24 months of age showed no variable independently predicted developing CS. CONCLUSION NSC in young children is common. While the impact of this condition is unknown, the correlation with family history of neurodevelopmental disease is concerning.
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Affiliation(s)
- M Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - E Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - M S Rana
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, USA
| | - H Crowder
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - N Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - A K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - R F Keating
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - G F Rogers
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA.
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Shakir S, Birgfeld CB. Syndromic Craniosynostosis: Cranial Vault Expansion in Infancy. Oral Maxillofac Surg Clin North Am 2022; 34:443-458. [PMID: 35787825 DOI: 10.1016/j.coms.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Syndromic craniosynostosis (CS) represents a relatively uncommon disease process that poses significant reconstructive challenges for the craniofacial surgeon. Although there is considerable overlap in clinical features associated with various forms of syndromic CS, key extracranial features and close examination of the extremities help to distinguish the subtypes. While Virchow's law can easily guide the diagnosis of single suture, nonsyndromic CS, syndromic CS traditionally results in atypical presentations inherent to multiple suture fusion. Coronal ring involvement in isolation or associated with additional suture fusion is the most common pattern in syndromic CS often resulting in turribrachycephaly.
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Affiliation(s)
- Sameer Shakir
- University of Washington, Seattle Children's Hospital, M/S OB.9.532, PO Box 5371, 4800 Sand Point Way, Seattle, WA 98105, USA
| | - Craig B Birgfeld
- University of Washington, Seattle Children's Hospital, M/S OB.9.532, PO Box 5371, 4800 Sand Point Way, Seattle, WA 98105, USA.
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Optic Nerve Atrophy in Syndromic Craniosynostosis. Plast Reconstr Surg 2022; 150:381e-386e. [PMID: 35671456 DOI: 10.1097/prs.0000000000009367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numerous children born with syndromic craniosynostosis will develop visual impairments. Based on the hypothesis that elevations in intracranial pressure might have greater impacts on vision than development, this review sought to ascertain the prevalence of optic nerve atrophy in syndromic craniosynostosis and to look for potential predictive factors. METHODS A retrospective chart review of all children with syndromic craniosynostosis treated at a single center. RESULTS Of 442 patients with syndromic craniosynostosis, complete ophthalmologic records were available for 253. Although no instances of optic nerve atrophy were noted among those with Saethre-Chotzen or Muenke syndromes, an overall 14.7% prevalence was noted among those with Apert (7.8%), Crouzon (27.9%), and Pfeiffer syndromes (23.1%), with initial diagnoses occurring at a mean age of 10 years. The presence of a Chiari malformation was found to significantly correlate with the subsequent diagnosis of optic nerve atrophy (Odds ratio 3.544, p = 0.002); however, the timing of the first cranial vault procedure, presence of a venticuloperitoneal shunt, degree of brachycephaly, number of vault expansions, and diagnosis of sleep apnea, did not show significant associations. CONCLUSIONS A substantial percentage of children with Apert, Crouzon, and Pfeiffer syndrome were found to develop optic nerve atrophy, with a prevalence likely to trend higher with longer follow up. Chiari malformations were the only significant potential predictor for optic nerve atrophy. With the goal of preventing visual losses, more frequent monitoring for raised intracranial pressure with ophthalmologic evaluations and MRI measurements of optic nerve sheath diameters should be considered.
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26
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Secondary Surgery in Metopic Craniosynostosis: Outcomes in a Tertiary Care Craniofacial Center in Australia. J Craniofac Surg 2022; 33:539-542. [DOI: 10.1097/scs.0000000000008333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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27
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Rostamzad P, Arslan ZF, Mathijssen IMJ, Koudstaal MJ, Pleumeekers MM, Versnel SL, Loudon SE. Prevalence of Ocular Anomalies in Craniosynostosis: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11041060. [PMID: 35207332 PMCID: PMC8877705 DOI: 10.3390/jcm11041060] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/12/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The aim of this study was to describe the ophthalmic abnormalities and their prevalence in craniosynostosis prior to craniofacial surgery. Methods: A systematic search was conducted on Medline OVID, Embase, Cochrane, Google Scholar, Web of Science Core Collection. Inclusion criteria were English papers, children aged <18 years with non-syndromic and syndromic craniosynostosis, case reports, case series, and case-control studies. A system of domains was established consisting of an anatomic and functional ophthalmic domain. A meta-analysis of single proportions was carried out using random effects model and pooled mean proportions with 95% confidence intervals (CI) were calculated. Results: Thirty-two papers analyzing 2027 patients were included. Strabismus was the most common anomaly in non-syndromic craniosynostosis: Horizontal strabismus was highest prevalent in unicoronal craniosynostosis (UCS) 19% (95% CI 9–32), followed by vertical strabismus 17% (95% CI 5–33). In syndromic craniosynostosis, horizontal strabismus was most prevalent in Crouzon syndrome 52% (95 CI 26–76), followed by Apert syndrome 50% (95% CI 42–58). Vertical strabismus was most prevalent in Saethre-Chotzen 60% followed by Muenke’s syndrome 36%. Furthermore, astigmatism was the second most reported outcome in non-syndromic craniosynostosis and highest prevalent in UCS 35% (95% CI 21–51). In syndromic craniosynostosis, astigmatism was most frequently seen in Crouzon syndrome 43% (95% CI 22–65), followed by Apert syndrome 34% (95% CI 14–58). Moreover, in syndromic craniosynostosis, 5–40% had a decrease in visual acuity (VA) ≤ 0.3 LogMAR in the better eye and 11–65% had a VA ≤ 0.3 LogMAR in at least one eye. Discussion: This review demonstrates the high prevalence of ocular anomalies in non-syndromic and syndromic craniosynostosis. A multidisciplinary and systematic approach is needed for the screening and optimal treatment of these conditions in a timely manner.
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Affiliation(s)
- Parinaz Rostamzad
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
- Correspondence:
| | - Zehra F. Arslan
- Department of Ophthalmology, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Irene M. J. Mathijssen
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Maarten J. Koudstaal
- Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Mieke M. Pleumeekers
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Sarah L. Versnel
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Sjoukje E. Loudon
- Department of Ophthalmology, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
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28
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Elevated Intracranial Pressure in Patients with Craniosynostosis by Optical Coherence Tomography. Plast Reconstr Surg 2022; 149:677-690. [PMID: 35041630 DOI: 10.1097/prs.0000000000008821] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Craniosynostosis may lead to elevated intracranial pressure, which may be implicated with impaired neurocognitive development. However, accurately measuring intracranial pressure is challenging, and patterns in craniosynostosis patients are poorly characterized. Spectral-domain optical coherence tomography may enable noninvasive assessment of intracranial pressure in pediatric patients with craniosynostosis. METHODS Pediatric patients with craniosynostosis undergoing surgical intervention between 2014 and 2019 prospectively underwent optical coherence tomographic evaluation. Intracranial pressure was directly measured intraoperatively in a subset of cases. Optical coherence tomographic parameters were compared to directly measured intracranial pressure and used for pattern assessment. RESULTS Optical coherence tomography was performed in 158 subjects, among which 42 underwent direct intracranial pressure measurement during an initial cranial procedure. Maximal retinal nerve fiber layer thickness, maximal retinal thickness, and maximal anterior projection optical coherence tomographic parameters were positively correlated with intracranial pressure (p ≤ 0.001), with all parameters showing significantly higher values in patients with intracranial pressure thresholds of 15 mmHg (p < 0.001) and 20 mmHg (p ≤ 0.007). Patients with maximal retinal nerve fiber layer thickness and maximal anterior projection exceeding set thresholds in optical coherence tomography of either eye demonstrated 77.3 percent sensitivity and 95.0 percent specificity for detecting intracranial pressure above 15 mmHg, and 90.0 percent sensitivity and 81.3 percent specificity for detecting intracranial pressure above 20 mmHg. Patients with associated syndromes or multiple suture involvement and patients aged 9 months or older were significantly more likely to have elevated intracranial pressure above 15 mmHg (p ≤ 0.030) and above 20 mmHg (p ≤ 0.035). CONCLUSIONS Spectral-domain optical coherence tomography can noninvasively detect elevated intracranial pressure in patients with craniosynostosis with reliable sensitivity and specificity. This technology may help guide decisions about the appropriate type and timing of surgical treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, I.
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29
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Rufai SR, Jeelani NUO, Bowman R, Bunce C, Proudlock FA, Gottlob I. Recognition of intracranial hypertension using handheld optical coherence tomography in children (RIO Study): a diagnostic accuracy study protocol. BMJ Open 2022; 12:e048745. [PMID: 35017232 PMCID: PMC8753392 DOI: 10.1136/bmjopen-2021-048745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Paediatric intracranial hypertension (IH) is a rare but serious condition that can pose deleterious effects on the brain and vision. Estimating intracranial pressure (ICP) in children is difficult. Gold standard direct ICP measurement is invasive and carries risk. It is impractical to routinely perform direct ICP measurements over time for all children at risk of IH. This study proposes to assess the diagnostic accuracy of handheld optical coherence tomography (OCT), a non-invasive ocular imaging method, to detect IH in children. METHODS AND ANALYSIS This is a prospective study evaluating the diagnostic accuracy of handheld OCT for IH in at risk children. Inclusion criteria include clinical and/or genetic diagnosis of craniosynostosis, idiopathic intracranial hypertension, space occupying lesion or other conditions association with IH and age 0-18 years old. Exclusion criteria include patients older than 18 years of age and/or absence of condition placing the child at risk of IH. The primary outcome measures are handheld OCT and 48-hour ICP assessments, which will be used for diagnostic accuracy testing (sensitivity, specificity, positive predictive value, negative predictive value and accuracy). Main secondary outcome measures include visual acuity, fundoscopic examination, contrast sensitivity, visual field testing and visual evoked potentials, wherever possible. ETHICS AND DISSEMINATION Ethical approval was granted for this study by the East Midlands Nottingham 2 Research Ethics committee (UOL0348/IRAS 105137). Our findings will be disseminated through presentation at relevant meetings, peer-reviewed publication and via the popular media. TRIAL REGISTRATION NUMBER ISRCTN52858719.
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Affiliation(s)
- Sohaib R Rufai
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
- Ulverscroft Eye Unit, University of Leicester, Leicester, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Noor Ul Owase Jeelani
- UCL Great Ormond Street Institute of Child Health, London, UK
- Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Richard Bowman
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Catey Bunce
- Clinical Trials Unit, Royal Marsden Hospital NHS Trust, London, UK
| | | | - Irene Gottlob
- Ulverscroft Eye Unit, University of Leicester, Leicester, UK
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30
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Bansal S, Konar S, Shukla D, Srinivas D, Pandey V, Jayan M, Sadashiva N, Devi BI. Intraoperative Measurement of Intracranial Pressure During Cranial Vault Remodeling in Children with Craniosynostosis. J Neurosci Rural Pract 2022; 13:80-86. [PMID: 35110924 PMCID: PMC8803524 DOI: 10.1055/s-0041-1741564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Purpose
In this study, we analyzed the utility of intracranial pressure (ICP) monitoring intraoperatively for deciding height reduction and need for cerebrospinal fluid (CSF) diversion during cranial vault remodeling in children with multisutural craniosynostosis (CS).
Methods
This is a retrospective observational study of children who underwent surgery for CS and ICP monitoring during surgery. The ICP was monitored using an external ventricular drainage catheter. The ICP monitoring was continued during the entire procedure.
Results
A total of 28 (19 boys) children with the involvement of two or more sutures underwent ICP monitoring during surgery. The commonest pattern of suture involvement was bicoronal seen in 16 (57.1%) children followed by pancraniosynostoses in eight (28.6%) cases. The mean opening ICP was 23 mm Hg, which dropped to 10.9 mm Hg after craniotomy. The ICP increased transiently to 19.5 mm Hg after height reduction, and the mean ICP at closure was 16.2 mm Hg. The ICP recordings helped in undoing the height reduction in two children and ventriculoperitoneal shunt after surgery in two children.
Conclusions
Intraoperative monitoring of ICP helps in deciding the type of cranial vault remodeling and the need for CSF diversion after surgery.
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Affiliation(s)
- Sonia Bansal
- Department of Neuroanesthesiology and Critical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dwarakanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Vishram Pandey
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Mini Jayan
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Bhagavatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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31
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van de Beeten SDC, Ramdas WD, Yang S, Loudon SE, den Ottelander BK, Rizopoulos D, van Veelen MLC, Mathijssen IMJ. The use of OCT to detect signs of intracranial hypertension in patients with sagittal suture synostosis: Reference values and correlations. Childs Nerv Syst 2022; 38:1937-1947. [PMID: 35972534 PMCID: PMC9522733 DOI: 10.1007/s00381-022-05598-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/01/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To obtain pediatric normative reference values and determine whether optical coherence tomography (OCT) corresponds better with clinical signs of intracranial hypertension (ICH) compared to the traditional screening method fundoscopy in a large cohort of one type of single suture craniosynostosis. METHODS Control subjects without optic nerve diseases and isolated sagittal synostosis patients aged 3-10 years who underwent fundoscopy and OCT were included in this prospective cohort study. Normative reference values were obtained through bootstrap analysis. Main outcome was the association between peripapillary total retinal thickness (TRT) and total retinal volume (TRV) and appearance on fundoscopy. Signs and symptoms suggestive of ICH, including skull growth arrest, fingerprinting, and headache, were scored. RESULTS Sixty-four healthy controls and 93 isolated sagittal synostosis patients were included. Normative cut-off values for mean TRT are < 256 μm and > 504 μm and for mean TRV < 0.21 mm3 and > 0.39 mm3. TRT was increased in 16 (17%) and TRV in 15 (16%) of 93 patients, compared to only 4 patients with papilledema on fundoscopy (4%). Both parameters were associated with papilledema on fundoscopy (OR = 16.7, p = 0.02, and OR = 18.2, p = 0.01). Skull growth arrest was significantly associated with abnormal OCT parameters (OR = 13.65, p < 0.01). CONCLUSIONS The established cut-off points can be applied to screen for ICH in pediatrics. The present study detected abnormalities with OCT more frequent than with fundoscopy, which were associated with skull growth arrest. Therefore, a combination of OCT, fundoscopy, and skull growth arrest can improve clinical decision-making in craniosynostosis.
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Affiliation(s)
- Stephanie D C van de Beeten
- Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Room EE-1591, Postbus 2040, 3000 CA, Wytemaweg 80, 2015 CN, Rotterdam, The Netherlands.
| | - Wishal D Ramdas
- Department of Ophthalmology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sumin Yang
- Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Room EE-1591, Postbus 2040, 3000 CA, Wytemaweg 80, 2015 CN, Rotterdam, The Netherlands
| | - Sjoukje E Loudon
- Department of Ophthalmology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Bianca K den Ottelander
- Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Room EE-1591, Postbus 2040, 3000 CA, Wytemaweg 80, 2015 CN, Rotterdam, The Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Marie-Lise C van Veelen
- Department of Neurosurgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Room SK-1204, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Irene M J Mathijssen
- Dutch Craniofacial Center, Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Room EE-1591, Postbus 2040, 3000 CA, Wytemaweg 80, 2015 CN, Rotterdam, The Netherlands
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Kronig ODM, Kronig SAJ, Van Adrichem LNA. Intracranial Volume Measured and Correlated to Cephalic Index in Syndromic and Nonsyndromic Anterior Brachycephaly. Ann Plast Surg 2021; 87:575-579. [PMID: 33587462 DOI: 10.1097/sap.0000000000002750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Premature fusion of both coronal sutures (anterior brachycephaly) alters skull shape and potentially affects intracranial volume (ICV). Currently little is known about preoperative ICV in anterior brachycephaly. Aim is to measure preoperative ICV and compare this with normative data. Additionally, ICV will be correlated to most used clinical method of quantification: cephalic index (CI). METHODS Preoperative patients with anterior brachycephaly (age, ≤12 months) were included and categorized by syndrome (when present). Computed tomography scans were used for ICV measurement by manual segmentation (OsiriX (Fondation OsiriX, Geneva, Switzerland)). Intracranial volume of each subgroup was compared with Lichtenberg normative cranial volume growth curves for controls. Cephalic index was calculated and correlated to ICV using Pearson correlation coefficient. RESULTS Thirty-four patients with both syndromic and nonsyndromic anterior brachycephaly were included: 17 with Apert syndrome, 6 with Muenke syndrome, 5 with Saethre Chotzen syndrome, 3 with Crouzon, 1 with craniofrontonasal dysplasia, and 2 nonsyndromal. Mean age at preoperative computed tomography scan was 4 months (1-10 months). Mean ICV was 847.31 cm3 (473.91-1459.22 cm3). Nineteen of 34 patients had skull volumes between ±2 SD curves of Lichtenberg, none of the patients had an ICV smaller than -2 SD and 15 of 34 had an ICV larger than +2 SD. Mean ICV in Apert syndrome was 829.85 cm3 (473.91-1061.53 cm3), in Muenke syndrome 942.06 cm3 (768.02-1136.75 cm3), in Saethre Chotzen syndrome 779.72 cm3 (609.21-1002.95 cm3), in Crouzon syndrome 700.57 cm3 (652.31-784.32 cm3), in craniofrontonasal dysplasia 738.97 cm3, and in the nonsyndromal group 1154.64 cm3 (850.07-1459.22 cm3). Apert had a mean greater than +2SD above the mean, the other subgroups had a mean within normal ranges (±2 SD). Correlation between severity of brachycephaly and overall ICV was low (r = 0.42). CONCLUSIONS Mean preoperative ICV in both syndromic and nonsyndromic anterior brachycephaly was 847.31 cm3. Intracranial volume in anterior brachycephaly is in 55.9% between normal ranges (±2 SD). In 44.1% ICV was greater than +2 SD, especially in Apert syndrome (11/16 Apert patients). None of the included patients had a deviant small ICV of less than -2 SD. Additionally, low correlation between ICV and CI (r = 0.42) was found and therefore CI is not suitable for estimating ICV in anterior brachycephaly.
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Affiliation(s)
- Otto D M Kronig
- From the Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, The Netherlands
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33
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Severity of Unilateral Coronal Synostosis Linked to Intracranial Volume. J Craniofac Surg 2021; 32:2388-2392. [PMID: 34705384 DOI: 10.1097/scs.0000000000007842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Severity of unilateral coronal synostosis (UCS) varies and can affect intracranial volume (ICV), and intracranial pressure. Correlation between ICV and severity according to Utrecht Cranial Shape Quantifier and presence of papilledema as sign of raised intracranial pressure is determined. The authors included patients with UCS (≤18 months). Intracranial volume was calculated on preoperative CT scans by manual segmentation (OsiriX [Fondation OsiriX, Geneva, Switzerland]). Calculated ICV was compared to Lichtenberg normative data for control patients. When present, papilledema was noted. Utrecht Cranial Shape Quantifier was used to quantify severity using the variables: asymmetry ratio of frontal peak and ratio of frontal peak gradient. Severity of UCS was correlated to ICV using Pearson correlation coefficient. Mean age at CT scan of patients with UCS was 7 months (1-18 months). Mean calculated ICV was 870.96 mL (617.31-1264.46 mL). All patients had ICV between ± 2 SD curves of Lichtenberg; 10 had an ICV between -1 SD and +1 SD. Majority of ICV in girls was at or larger than normative mean, in boys ICV was mostly lower than normative mean. Pearson correlation coefficient between severity of UCS and ICV was negligible (r = -0.28). Preoperative papilledema during fundoscopy was found in 4.5% (1/22; ICV 1003.88 mL; severe UCS). Therefore, severity of UCS does not correlate to ICV. Despite varying severity of UCS, ICV remains within normal ranges.
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Premature Fusion of the Sagittal Suture as an Incidental Radiographic Finding in Young Children. Plast Reconstr Surg 2021; 148:829-837. [PMID: 34398865 DOI: 10.1097/prs.0000000000008332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Craniosynostosis typically develops prenatally and creates characteristic changes in craniofacial form. Nevertheless, postnatal forms of craniosynostosis have been described. The purpose of this study was to determine the prevalence of incidentally identified, but temporally premature, cranial suture fusion in normocephalic children. METHODS Computed tomographic scans obtained from children aged 1 to 5 years evaluated in the authors' emergency department between 2005 and 2016 were reviewed for evidence of craniosynostosis. Patients with prior ventriculoperitoneal shunt, brain or cranial abnormality, or known syndromes were excluded. The presence of craniosynostosis and cranial index was assessed by a panel of three craniofacial surgeons and one pediatric neurosurgeon. Demographic information, fusion type, reason for the computed tomographic scan, and medical history were recorded as covariates. Cranial shape and intracranial volume were calculated using previously validated automated system. RESULTS Three hundred thirty-one patients met the inclusion criteria. The mean age was 2.4 ± 1.3 years. Eleven patients (3.3 percent) were found to have a complete (n = 9) or partial (n = 2) fusion of the sagittal suture. All patients had a normal cranial index (0.80; range, 0.72 to 0.87) and a grossly normal head shape. Only two fusions (18.2 percent) were documented by the radiologist. Cranial shape analysis performed in five of the 11 patients showed subtle phenotypic changes along the scaphocephaly spectrum in four patients, with a normal shape in the remaining case. CONCLUSIONS Sagittal fusion is present in 3.3 percent of otherwise phenotypically normal children aged 1 to 5 years. The clinical significance of this result is unclear, but routine screening of affected patients is paramount. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, IV.
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Rufai SR, Hisaund M, Jeelani NUO, McLean RJ. Detection of intracranial hypertension in children using optical coherence tomography: a systematic review. BMJ Open 2021; 11:e046935. [PMID: 34380720 PMCID: PMC8359522 DOI: 10.1136/bmjopen-2020-046935] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To evaluate the diagnostic capability of optical coherence tomography (OCT) in children aged under 18 years old with intracranial hypertension (IH). DESIGN Systematic review. METHODS We conducted a systematic review using the following platforms to search the keywords 'optical coherence tomography' and 'intracranial hypertension' from inception to 2 April 2020: Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PubMed and Web of Science, without language restrictions. Our search returned 2729 records, screened by two independent screeners. Studies were graded according to the Oxford Centre for Evidence-Based Medicine and National Institutes of Health Quality Assessment Tool for observational studies. RESULTS Twenty-one studies were included. Conditions included craniosynostosis (n=354 patients), idiopathic IH (IIH; n=102), space-occupying lesion (SOL; n=42) and other pathology (n=29). OCT measures included optic nerve parameters, rim parameters (notably retinal nerve fibre layer thickness) and retinal parameters. Levels of evidence included 2b (n=13 studies), 3b (n=4) and 4 (n=4). Quality of 10 studies was fair and 11 poor. There was inconsistency in OCT parameters and reference measures studied, although OCT did demonstrate good diagnostic capability for IH in craniosynostosis, IIH and SOL. CONCLUSIONS This systematic review identified various studies involving OCT to assist diagnosis and management of IH in children with craniosynostosis, IIH, SOL and other pathology, in conjunction with established clinical measures of intracranial pressure. However, no level 1 evidence was identified. Validating prospective studies are, therefore, required to determine optimal OCT parameters in this role and to develop formal clinical guidelines. PROSPERO REGISTRATION NUMBER CRD42019154254.
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Affiliation(s)
- Sohaib R Rufai
- University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Leicester, UK
- UCL Great Ormond Street Institute of Child Health and Craniofacial Unit, Great Ormond Street Hospital for Children, London, UK
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children, London, UK
| | - Michael Hisaund
- University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Leicester, UK
| | - Noor Ul Owase Jeelani
- UCL Great Ormond Street Institute of Child Health and Craniofacial Unit, Great Ormond Street Hospital for Children, London, UK
| | - Rebecca J McLean
- University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Leicester, UK
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Dibbs RP, Beh HZ, Donoho DA, Davies LW, Ferry AM, Bauer DF, Buchanan EP. Late Presenting Multi-Suture Craniosynostosis. J Craniofac Surg 2021; 33:e34-e37. [PMID: 34292251 DOI: 10.1097/scs.0000000000007888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The authors provide the case of a 6-year-old male who presented late with multi-suture craniosynostosis and chronically elevated intracranial pressures (ICPs). He was surgically managed with frontal orbital advancement. This particular case illustrates the significant bleeding and unique bony pathology that can occur in patients with high ICP with concomitant venous collateralization. At 1-month follow-up, he demonstrated significant improvement with maintained expansion and no signs of elevated ICP despite delayed intervention. Frontal orbital advancement serves as an effective method for cranial vault expansion and correction of frontal deformities caused by craniosynostosis.
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Affiliation(s)
- Rami P Dibbs
- Division of Plastic Surgery, Texas Children's Hospital Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine Department of Neurosurgery, Texas Children's Hospital, Houston, TX
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Marmoy OR, Hodson-Tole E, Thompson DA. Photopic negative response (PhNR) in the diagnosis and monitoring of raised intracranial pressure in children: a prospective cross-sectional and longitudinal protocol. BMJ Open 2021; 11:e047299. [PMID: 34285008 PMCID: PMC8292810 DOI: 10.1136/bmjopen-2020-047299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Raised intracranial pressure (rICP) can be a consequence of a variety of neurological disorders. A significant complication of rICP is visual impairment, due to retinal ganglion cell (RGC) dysfunction. In children, subjective measurements to monitor this, such as visual field examination, are challenging. Therefore, objective measurements offer promising alternatives for monitoring these effects. The photopic negative response (PhNR) is a component of the flash electroretinogram produced by RGCs; the cells directly affected in rICP-related vision loss. This project aims to assess the clinical feasibility and diagnostic efficacy of the PhNR in detecting and monitoring paediatric rICP. METHODS AND ANALYSIS Section 1 is a cross-sectional study; group 1 young persons with disorders associated with rICP and a comparator group 2 of age-matched children without rICP. Both groups will undergo a PhNR recording alongside a series of structural and functional ophthalmic investigations, with the rICP group also having measurement of intracranial pressure.Section 2 is a longitudinal study of the relationship between the PhNR and directly recorded intracranial pressure measurements, through repeated measures. PhNR amplitudes and peak times will be assessed against optical coherence tomography parameters, mean deviation of visual fields, other electrophysiology and ICP measurement through regression analyses.Group differences between PhNR measurements in the rICP and control groups will be performed to determine clinically relevant cut-off values and calculation of diagnostic accuracy. Longitudinal analysis will assess PhNR amplitude against ICP measurements through regression analysis. Feasibility and efficacy will be measured through acceptability, practicality and sensitivity outcomes. ETHICS AND DISSEMINATION Favourable opinion from a research ethics committee has been received and the study approved by Manchester Metropolitan University, the Health Research Authority and the Great Ormond Street Institute of Child Health (GOS-ICH) Research and Development office. This project is being undertaken as a doctoral award (ORM) with findings written for academic thesis submission, peer-reviewed journal and conference publications.
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Affiliation(s)
- Oliver Rajesh Marmoy
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
- GOS-ICH, University College London, London, UK
| | - Emma Hodson-Tole
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - Dorothy Ann Thompson
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
- GOS-ICH, University College London, London, UK
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Secondary Raised Intracranial Pressure After Cranial Vault Remodeling for Isolated Sagittal Craniosynostosis. J Craniofac Surg 2021; 32:2651-2655. [PMID: 34238873 DOI: 10.1097/scs.0000000000007886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The management of sagittal craniosynostosis has evolved over the decades as teams seek to refine their surgical approaches to idealize head shape with the least possible morbidity. Here, the authors identify the incidence of raised intracranial pressure (ICP) and its risk factors, requiring secondary surgical intervention after cranial vault remodeling (CVR) procedure at a single tertiary referral craniofacial unit. A retrospective case-control study was performed on the patients with isolated non-syndromic sagittal craniosynostosis. All patients who underwent CVR in our unit and had a minimum of 1.5 years follow-up were included. One hundred and eighty-four patients (134 male and 50 female) who underwent primary CVR surgery for isolated sagittal craniosynostosis were included. Thirteen patients (7.07%) had clinical evidence of late raised ICP resulting in repeat CVR procedures. Higher incidence of raised ICP in patients who had primary surgery before 6 months than after or at 6 months of age (P = 0.001). There were 23.5%, 5.6%, 3.2%, and 1.9% of secondary raised ICP patients who underwent the primary surgery between 1999-2004, 2005-2010, 2011-2015 and 2016-2018, respectively (P = 0.024). The risk of secondary raised ICP was higher in patients with isolated sagittal craniosynostosis whose primary surgery occurred before the age of 6 months (two times more likely). More extensive CVR can be performed safely in sagittal synostosis with promising outcomes. The late presentation with raised ICP reinforces the importance of long-term multidisciplinary protocol-based follow-up.
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Rufai SR, Bowman R, Bunce C, Panteli V, McLean RJ, Teli S, Gottlob I, Thomas MG, Jeelani NUO, Proudlock FA. Feasibility and Repeatability of Handheld Optical Coherence Tomography in Children With Craniosynostosis. Transl Vis Sci Technol 2021; 10:24. [PMID: 34313724 PMCID: PMC8322722 DOI: 10.1167/tvst.10.8.24] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/11/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose To determine whether handheld optical coherence tomography (OCT) is feasible and repeatable in children with craniosynostosis. Methods This was a prospective cross-sectional study. Children with syndromic and non-syndromic craniosynostosis 0 to 18 years of age were recruited between February 13, 2020, and October 1, 2020. Main outcome measures included feasibility (patient recruitment and handheld OCT success rates) and repeatability, which were assessed using intraclass correlation coefficients (ICCs) where repeated images of the optic nerve head (ONH) within the same visit were available. ONH parameters used for repeatability analysis included cup depth, width, and area; disc width; rim height; retinal thickness; retinal nerve fiber layer thickness; and Bruch's membrane opening minimum rim width. Results Fifty children were approached, and all 50 (100%) were successfully recruited. Median age was 51.1 months (range, 1.9-156.9; interquartile range, 37.0-74.2), and 33 of the children (66%) were male. At least one ONH image was obtained in 43 children (86%), and bilateral ONH imaging was successful in 38 children (76%). Factors boosting the likelihood of success included good understanding and cooperation of the child and parent/guardian and availability of an assistant. Repeatability analysis was performed in 20 children, demonstrating good repeatability (ICC range, 0.77-0.99; the majority exceeded 0.90). OCT correctly identified two cases of intracranial hypertension, one of which was undetected by prior fundoscopy. Conclusions Handheld OCT is feasible and repeatable in children with syndromic and non-syndromic forms of craniosynostosis. Translational Relevance Our handheld OCT approach could be used for the clinical surveillance of children with craniosynostosis.
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Affiliation(s)
- Sohaib R. Rufai
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
- The University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Leicester, UK
- Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Richard Bowman
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Catey Bunce
- Clinical Trials Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Vasiliki Panteli
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Rebecca J. McLean
- The University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Leicester, UK
| | - Seema Teli
- The University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Leicester, UK
| | - Irene Gottlob
- The University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Leicester, UK
| | - Mervyn G. Thomas
- The University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Leicester, UK
| | - Noor ul Owase Jeelani
- UCL Great Ormond Street Institute of Child Health, London, UK
- Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Frank A. Proudlock
- The University of Leicester Ulverscroft Eye Unit, Leicester Royal Infirmary, Leicester, UK
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Frič R, Langvatn EA, Due-Tønnessen BJ, Eide PK. The role of pulsatile and static intracranial pressure measurements in the management of children with craniosynostosis-an institutional experience from 49 patients. Acta Neurochir (Wien) 2021; 163:2015-2023. [PMID: 33389123 DOI: 10.1007/s00701-020-04680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although measurement of intracranial pressure (ICP) has occasionally been utilized in children with craniosynostosis (CSS), data on parameters of pulsatile ICP in CSS are still lacking, and the role of pulsatile ICP measurements in the management of CSS is not well established. METHODS From our department's database, we retrieved the data from children in whom the measurement of static and pulsatile ICP was a part of the diagnostic work-up in different clinical situations related to CSS. Both clinical and ICP data were retrospectively reviewed and analyzed. RESULTS We identified 49 children with CSS, median age 4.4 years (range 0.2-18.9), in whom a total of 67 diagnostic ICP measurements were undertaken between 2002 and 2014. The CSS was syndromal in 23 cases. The rationale for ICP measurement was a question of indication for cranial vault expansion surgery (CVES) in 12 patients (Group 1), of its timing in 10 patients (Group 2), of suspected abnormally elevated ICP or hydrocephalus in 11 patients (Group 3), of indication for repeated CVES in 13 patients (Group 4), or shunt dysfunction in three patients (Group 5). The average mean ICP for the whole cohort was 15.1 ± 5.5 mmHg and mean wave amplitude (MWA) 5.3 ± 2.2 mmHg. There was no significant difference in ICP parameters when compared between Groups 1-5. Fundoscopy revealed papilledema in five out of 32 children (15.6%). There were significantly higher parameters of pulsatile ICP (MWA) in patients with papilledema, but no statistically significant difference in parameters of static ICP. CONCLUSIONS In this cohort of pediatric patients with CSS presenting with various diagnostic challenges, we found the diagnostic measurement of static and pulsatile ICP useful in selecting the optimal treatment modality and timing of surgery. Papilledema was associated with elevated pulsatile ICP, a parameter that in previous studies has been shown to correlate with impaired intracranial compliance.
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Kronig ODM, Kronig SAJ, Van Adrichem LNA. Intracranial Volume Not Correlated With Severity in Trigonocephaly. Cleft Palate Craniofac J 2021; 59:794-799. [PMID: 34137298 PMCID: PMC9121522 DOI: 10.1177/10556656211025185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives: Severity of trigonocephaly varies and potentially affects intracranial volume
(ICV) and intracranial pressure (ICP). The aim of this study is to measure
ICV in trigonocephaly patients and compare it to normative data and
correlate ICV with the severity of the skull deformity according to UCSQ
(Utrecht Cranial Shape Quantifier). Design: Retrospective study. Setting: Primary craniofacial center. Patients, Participants: Nineteen preoperative patients with nonsyndromic trigonocephaly (age ≤12
months). Intervention: Intracranial volume was measured on preoperative computed tomography (CT)
scans by manual segmentation (OsiriX Fondation). Utrecht Cranial Shape
Quantifier was used to quantify the severity of the skull deformity. When
present, papilledema as sign of elevated ICP was noted. Main Outcome Measures(s): Measured ICV was compared to Lichtenberg normative cranial volume growth
curves, and Pearson correlation coefficient was used to correlate UCSQ with
the ICV. Results: Mean age at CT scan was 6 months (2-11). Mean measured ICV was 842 mL
(579-1124). Thirteen of h19 patients (11/15 boys and 2/4 girls) had an ICV
between ±2 SD curves of Lichtenberg, 2 of 19 (1/15 boys and 1/4 girls) had
an ICV less than −2 SD and 4 of 19 (3/15 boys and 1/4 girls) had an ICV
greater than +2 SD. Mean UCSQ severity of trigonocephaly was 2.40 (−622.65
to 1279.75). Correlation between severity and ICV was negligible (r =
−0.11). No papilledema was reported. Conclusions: Measured ICV was within normal ranges for trigonocephaly patients, in both
mild and severe cases. No correlation was found between severity of
trigonocephaly and ICV.
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Affiliation(s)
- Otto D M Kronig
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, the Netherlands
| | - Sophia A J Kronig
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, the Netherlands
| | - Léon N A Van Adrichem
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, the Netherlands
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Ntoula E, Nowinski D, Holmstrom G, Larsson E. Ophthalmological findings in children with non-syndromic craniosynostosis: preoperatively and postoperatively up to 12 months after surgery. BMJ Open Ophthalmol 2021; 6:e000677. [PMID: 33981856 PMCID: PMC8076926 DOI: 10.1136/bmjophth-2020-000677] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/29/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022] Open
Abstract
Aims Craniosynostosis is a congenital condition characterised by premature fusion of one or more cranial sutures. The aim of this study was to analyse ophthalmic function before and after cranial surgery, in children with various types of non-syndromic craniosynostosis. Methods Children referred to Uppsala University Hospital for surgery of non-syndromic craniosynostosis were examined preoperatively. Visual acuity was measured with Preferential Looking tests or observation of fixation and following. Strabismus and eye motility were noted. Refraction was measured in cycloplegia and funduscopy was performed. Follow-up examinations were performed 6–12 months postoperatively at the children’s local hospitals. Results One hundred twenty-two children with mean age 6.2 months were examined preoperatively. Refractive values were similar between the different subtypes of craniosynostosis, except for astigmatism anisometropia which was more common in unicoronal craniosynostosis. Strabismus was found in seven children, of which four had unicoronal craniosynostosis. Postoperatively, 113 children were examined, at mean age 15.9 months. The refractive values decreased, except for astigmatism and anisometropia in unicoronal craniosynostosis. Strabismus remained in unicoronal craniosynostosis. Two new cases with strabismus developed in unicoronal craniosynostosis and one in metopic, all operated with fronto-orbital techniques. No child had disc oedema or pale discs preoperatively or postoperatively. Conclusion Ophthalmic dysfunctions were not frequent in children with sagittal craniosynostosis and preoperative ophthalmological evaluation may not be imperative. Children with unicoronal craniosynostosis had the highest prevalence of strabismus and anisometropia. Fronto-orbital techniques used to address skull deformity may be related to a higher prevalence of strabismus postoperatively.
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Affiliation(s)
- Evangelia Ntoula
- Department of Neuroscience/Ophthalmology, Uppsala University, Uppsala, Sweden
| | - Daniel Nowinski
- Department of Surgical Sciences/Plastic Surgery, Uppsala University, Uppsala, Sweden
| | - Gerd Holmstrom
- Department of Neuroscience/Ophthalmology, Uppsala University, Uppsala, Sweden
| | - Eva Larsson
- Department of Neuroscience/Ophthalmology, Uppsala University, Uppsala, Sweden
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Ferry AM, Dibbs RP, Sarrami SM, Abu-Ghname A, Beh HZ, Maricevich RS, Buchanan EP. Pediatric Fronto-Orbital Skull Reconstruction. Facial Plast Surg 2021; 37:771-780. [PMID: 33525031 DOI: 10.1055/s-0041-1722920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Craniofacial surgery in children is a highly challenging discipline that requires extensive knowledge of craniofacial anatomy and pathology. Insults to the fronto-orbital skeleton have the potential to inflict significant morbidity and even mortality in patients due to its proximity to the central nervous system. In addition, significant aesthetic and ophthalmologic disturbances frequently accompany these insults. Craniosynostosis, facial trauma, and craniofacial tumors are all pathologies that frequently affect the fronto-orbital region of the craniofacial skeleton in children. While the mechanisms of these pathologies vary greatly, the underlying principles of reconstruction remain the same. Despite the limited data in certain areas of fronto-orbital reconstruction in children, significant innovations have greatly improved its safety and efficacy. It is imperative that further investigations of fronto-orbital reconstruction are undertaken so that craniofacial surgeons may provide optimal care for these patients.
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Affiliation(s)
- Andrew M Ferry
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Rami P Dibbs
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Shayan M Sarrami
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Han Zhuang Beh
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Renata S Maricevich
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Edward P Buchanan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
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Duan M, Skoch J, Pan BS, Shah V. Neuro-Ophthalmological Manifestations of Craniosynostosis: Current Perspectives. Eye Brain 2021; 13:29-40. [PMID: 33542671 PMCID: PMC7853409 DOI: 10.2147/eb.s234075] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/12/2020] [Indexed: 12/20/2022] Open
Abstract
Craniosynostosis, a premature fusion of cranial sutures that can be isolated or syndromic, is a congenital defect with a broad, multisystem clinical spectrum. The visual pathway is prone to derangements in patients with craniosynostosis, particularly in syndromic cases, and there is a risk for permanent vision loss when ocular disease complications are not identified and properly treated early in life. Extensive advancements have been made in our understanding of the etiologies underlying vision loss in craniosynostosis over the last 20 years. Children with craniosynostosis are susceptible to interruptions in visual input arising from strabismus, refractive errors, and corneal damage; any of these aberrations can result in understimulation of the visual cortex during childhood neurodevelopment and permanent amblyopia. Elevated intracranial pressure resulting from abnormal cranial shape or volume can lead to papilledema and, ultimately, optic atrophy and vision loss. A pediatric ophthalmologist is a crucial component of the multidisciplinary care team that should be involved in the care of craniosynostosis patients and consistent ophthalmologic follow-up can help minimize the risk to vision posed by such entities as papilledema and amblyopia. This article aims to review the current understanding of neuro-ophthalmological manifestations in craniosynostosis and explore diagnostic and management considerations for the ophthalmologist taking care of these patients.
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Affiliation(s)
- Michael Duan
- Baylor College of Medicine, School of Medicine, Houton, TX, USA
| | - Jesse Skoch
- Cincinnati Children’s Hospital Medical Center, Division of Pediatric Neurosurgery, Cinicinnati, OH, USA
| | - Brian S Pan
- Cincinnati Children’s Hospital Medical Center, Division of Plastic Surgery, Cinicinnati, OH, USA
| | - Veeral Shah
- Cincinnati Children’s Hospital Medical Center, Division of Pediatric Ophthalmology, Cinicinnati, OH, USA
- University of Cincinnati, Department of Ophthalmology, Cincinnati, OH, USA
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Chiari Malformation Type 1 and Syringomyelia in a Patient With Prior Surgically-Treated Sagittal Synostosis Effectively Treated With Posterior Cranial Vault Distraction Osteogenesis. J Craniofac Surg 2021; 32:2110-2113. [PMID: 33405455 DOI: 10.1097/scs.0000000000007401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT The presenting report describes the use of a posterior cranial vault distraction procedure in resolving a Chiari malformation with associated syringomyelia following a surgically-treated nonsyndromic craniosynostosis. Chiari malformations are typically treated with posterior fossa decompression with or without expansion duraplasty. The objective of this report is to describe the effectiveness in resolving both Chiari malformation and secondary syringomyelia with posterior cranial vault distraction osteogenesis. A 5-year-old male, with a history of surgery for sagittal synostosis during infancy, presented with daily severe headaches and dysesthesias in the hands and feet. Imaging demonstrated a copper-beaten calvarium and a Chiari 1 malformation with a 7 mm diameter C4-T1 syrinx. He underwent posterior cranial vault distraction osteogenesis over 3 months to increase his intracranial volume. The patients' headaches improved significantly, and his dysesthesias resolved postoperatively. A magnetic resonance imaging performed 7 months after completion of distraction demonstrated resolution of the Chiari malformation and decompression of his syrinx. A computed tomography scan at 9 months postdistraction showed resolution of the copper-beaten calvarium. Patients with a history of craniosynostosis can develop inadequate cranial volume over time due to abnormal skull growth, leading to secondary Chiari malformation with or without syringomyelia. Posterior vault distraction is an effective strategy to address these conditions and can be employed later in childhood to treat the underlying pathology. The mechanism potentially expands both calvarium and dura, which in turn addresses both the Chiari malformation and secondary syringomyelia.
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Rufai SR, Jeelani NUO, McLean RJ. Early Recognition of Raised Intracranial Pressure in Craniosynostosis Using Optical Coherence Tomography. J Craniofac Surg 2021; 32:201-205. [PMID: 33185414 PMCID: PMC7769183 DOI: 10.1097/scs.0000000000006771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/14/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Craniosynostosis can be associated with raised intracranial pressure (ICP), which can pose deleterious effects on the brain and vision if untreated. Estimating ICP in children is challenging, whilst gold standard direct intracranial measurement of ICP is invasive and carries risk. This systematic review aims to evaluate the role of optical coherence tomography (OCT), a noninvasive imaging technique, for detecting raised ICP in children with craniosynostosis. METHODS The authors conducted a systematic review of the literature published from inception until 19 August, 2019 in the Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and EMBASE. Eligible studies evaluated the role of OCT in detecting raised ICP in children aged 0 to 16 years with craniosynostosis. Main outcome measures were sensitivity and specificity of OCT parameters for raised ICP. Quality assessment was performed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-sectional Studies. RESULTS Out of 318 records identified, data meeting the inclusion criteria were obtained from 3 studies. The quality of 2 studies was poor whilst 1 was fair. Optical coherence tomography demonstrated higher sensitivity and specificity for detecting raised ICP compared to fundus examination, clinical history, radiological testing, and visual field testing. CONCLUSIONS This systematic review demonstrated a lack of quality evidence for OCT as a screening tool for children with craniosynostosis. Further research is required to clarify the strength of OCT in this role and to determine which OCT parameters are most appropriate.
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Affiliation(s)
- Sohaib R. Rufai
- University of Leicester Ulverscroft Eye Unit, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester
- Clinical and Academic Department of Ophthalmology
| | - Noor ul Owase Jeelani
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London
- Developmental Biology & Cancer Department, UCL GOS Institute of Child Health, Faculty of Population Health Sciences, UCL, London, UK
| | - Rebecca J. McLean
- University of Leicester Ulverscroft Eye Unit, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester
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Shpanskaya K, Quon JL, Lober RM, Nair S, Johnson E, Cheshier SH, Edwards MSB, Grant GA, Yeom KW. Diffusion tensor magnetic resonance imaging of the optic nerves in pediatric hydrocephalus. Neurosurg Focus 2020; 47:E16. [PMID: 31786546 DOI: 10.3171/2019.9.focus19619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While conventional imaging can readily identify ventricular enlargement in hydrocephalus, structural changes that underlie microscopic tissue injury might be more difficult to capture. MRI-based diffusion tensor imaging (DTI) uses properties of water motion to uncover changes in the tissue microenvironment. The authors hypothesized that DTI can identify alterations in optic nerve microstructure in children with hydrocephalus. METHODS The authors retrospectively reviewed 21 children (< 18 years old) who underwent DTI before and after neurosurgical intervention for acute obstructive hydrocephalus from posterior fossa tumors. Their optic nerve quantitative DTI metrics of mean diffusivity (MD) and fractional anisotropy (FA) were compared to those of 21 age-matched healthy controls. RESULTS Patients with hydrocephalus had increased MD and decreased FA in bilateral optic nerves, compared to controls (p < 0.001). Normalization of bilateral optic nerve MD and FA on short-term follow-up (median 1 day) after neurosurgical intervention was observed, as was near-complete recovery of MD on long-term follow-up (median 1.8 years). CONCLUSIONS DTI was used to demonstrate reversible alterations of optic nerve microstructure in children presenting acutely with obstructive hydrocephalus. Alterations in optic nerve MD and FA returned to near-normal levels on short- and long-term follow-up, suggesting that surgical intervention can restore optic nerve tissue microstructure. This technique is a safe, noninvasive imaging tool that quantifies alterations of neural tissue, with a potential role for evaluation of pediatric hydrocephalus.
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Affiliation(s)
| | - Jennifer L Quon
- 2Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Robert M Lober
- 3Department of Neurosurgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Sid Nair
- 4Division of Pediatric Neuroradiology, Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California
| | - Eli Johnson
- 1Stanford University School of Medicine, Stanford
| | - Samuel H Cheshier
- 5Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, Salt Lake City, Utah; and
| | - Michael S B Edwards
- 6Division of Pediatric Neurosurgery, Department of Neurosurgery, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California
| | - Gerald A Grant
- 6Division of Pediatric Neurosurgery, Department of Neurosurgery, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California
| | - Kristen W Yeom
- 4Division of Pediatric Neuroradiology, Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California
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Quantifying the Severity of Metopic Craniosynostosis: A Pilot Study Application of Machine Learning in Craniofacial Surgery. J Craniofac Surg 2020; 31:697-701. [PMID: 32011542 DOI: 10.1097/scs.0000000000006215] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The standard for diagnosing metopic craniosynostosis (CS) utilizes computed tomography (CT) imaging and physical exam, but there is no standardized method for determining disease severity. Previous studies using interfrontal angles have evaluated differences in specific skull landmarks; however, these measurements are difficult to readily ascertain in clinical practice and fail to assess the complete skull contour. This pilot project employs machine learning algorithms to combine statistical shape information with expert ratings to generate a novel objective method of measuring the severity of metopic CS.Expert ratings of normal and metopic skull CT images were collected. Skull-shape analysis was conducted using ShapeWorks software. Machine-learning was used to combine the expert ratings with our shape analysis model to predict the severity of metopic CS using CT images. Our model was then compared to the gold standard using interfrontal angles.Seventeen metopic skull CT images of patients 5 to 15 months old were assigned a severity by 18 craniofacial surgeons, and 65 nonaffected controls were included with a 0 severity. Our model accurately correlated the level of skull deformity with severity (P < 0.10) and predicted the severity of metopic CS more often than models using interfrontal angles (χ = 5.46, P = 0.019).This is the first study that combines shape information with expert ratings to generate an objective measure of severity for metopic CS. This method may help clinicians easily quantify the severity and perform robust longitudinal assessments of the condition.
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Wilson AT, Den Ottelander BK, De Goederen R, Van Veelen MLC, Dremmen MHG, Persing JA, Vrooman HA, Mathijssen IMJ. Intracranial hypertension and cortical thickness in syndromic craniosynostosis. Dev Med Child Neurol 2020; 62:799-805. [PMID: 32060907 DOI: 10.1111/dmcn.14487] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2020] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the impact of risk factors for intracranial hypertension (ICH) on cerebral cortex thickness in syndromic craniosynostosis. METHOD ICH risk factors including papilloedema, hydrocephalus, obstructive sleep apnea (OSA), cerebellar tonsillar position, occipitofrontal circumference (OFC) curve deflection, age, and sex were collected from the records of patients with syndromic craniosynostosis (Apert, Crouzon, Pfeiffer, Muenke, Saethre-Chotzen syndromes) and imaging. Magnetic resonance images were analysed and exported for statistical analysis. A linear mixed model was developed to determine correlations with cerebral cortex thickness changes. RESULTS In total, 171 scans from 107 patients (83 males, 88 females [including repeated scans], mean age 8y 10mo, range 1y 1mo-34y, SD 5y 9mo) were evaluated. Mean cortical thickness in this cohort was 2.78mm (SD 0.17). Previous findings of papilloedema (p=0.036) and of hydrocephalus (p=0.007) were independently associated with cortical thinning. Cortical thickness did not vary significantly by sex (p=0.534), syndrome (p=0.896), OSA (p=0.464), OFC (p=0.375), or tonsillar position (p=0.682). INTERPRETATION Detection of papilloedema or hydrocephalus in syndromic craniosynostosis is associated with significant changes in cortical thickness, supporting the need for preventative rather than reactive treatment strategies. WHAT THIS PAPER ADDS Papilloedema is associated with thinning of the cerebral cortex in syndromic craniosynostosis, independently of hydrocephalus.
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Affiliation(s)
- Alexander T Wilson
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Surgery, Section of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Bianca K Den Ottelander
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Robbin De Goederen
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | | | - John A Persing
- Department of Surgery, Section of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Henri A Vrooman
- Department of Radiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Medical Informatics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Irene M J Mathijssen
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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Yoon SB, Ji SH, Jang YE, Lee JH, Kim EH, Kim JT, Kim HS. Effects of prone positioning with neck extension on intracranial pressure according to optic nerve sheath diameter measured using ultrasound in children. Childs Nerv Syst 2020; 36:1001-1007. [PMID: 31797072 DOI: 10.1007/s00381-019-04442-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/13/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE Optic nerve sheath diameter has been used for measure of intracranial pressure. The aim of this study was to evaluate the effect of prone positioning with neck extension on intracranial pressure in infants undergoing craniosynostosis surgery and to determine precautions using optic nerve sheath diameter measurement. METHODS We enrolled 30 infants who were scheduled for correction of craniosynostosis in which planning included the prone position with neck extension. Optic nerve sheath diameter (anterior/lateral transbulbar approach) was measured 5 times in each eyeball at the following time points: 15 min after intubation in supine position as the baseline value (supine 1); 10 min after final surgical position before skin incision (prone); and 10 min after returning to supine position at the conclusion of surgery (supine 2). Hemodynamic parameters, airway peak pressure, oxygen saturation, and ETCO2 were monitored. Data were analyzed using repeated-measures multivariate analysis of variance to evaluate the effect of different positions under anesthesia on changes in using optic nerve sheath diameter and P < 0.05 was considered to be statistically significant. RESULTS There was no difference in optic nerve sheath diameter after prone position with neck extension in all the measure. After surgery, optic nerve sheath diameter was decreased compared with the preoperative baseline values (Rt anterior/lateral 5.6/5.5: 5.4/5.2; Lt anterior/lateral 5.6/5.5: 5.4/5.3, P < 0.05, respectively). CONCLUSIONS In conclusion, prone positioning with head extension did not further increase intracranial pressure, although the surgical procedure could reduce intracranial pressure in the immediate postoperative period in infants undergoing craniosynostosis surgery.
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Affiliation(s)
- Soo-Bin Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, #101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, #101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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