Assessment of Epidemiological Trends in Craniosynostosis: Limitations of the Current Classification System

Clinical-Epidemiological Study of a Cohort of 35 Patients with Craniosynostosis

Introduction:Craniosynostosis is a congenital anomaly defined as early ossification of the cranial sutures. It is a rare pathology worldwide, implicitly also in our country, with a prevalence of 1:2100-1:2500. However, it represents a condition with potentially severe complications in terms of patient functionality. At the same time, not much research has been done in this field. Thus, it was considered useful to conduct a study on the epidemiology of craniosynostosis in Bihor county. Objectives: The present study had the following objectives: updating epidemiological data; analysis of the clinical data of the study group; identification of risk factors in the occurrence of the disease; evaluating the prospects for a genetic approach to the disease, including genetic testing and genetic counseling. Materials and method: This is a retrospective cross-sectional study. Data from a cohort of 35 patients were collected using the database which were made available by the Bihor Regional Center for Medical Genetics. Only patients with imaging-confirmed craniosynostosis in the last three decades were included in the study. Outcomes:Most patients were diagnosed in the age range of one month - one year, the mean being 197 days. The most frequently affected suture was the sagittal suture (60%) and the least affected one the metopic suture (5%). Combined lesions were present in three cases. The majority (75%) of cases were isolated craniosynostosis, with the remaining 25% being diagnosed in the context of a genetic syndrome (most frequently Apert syndrome). Throughout the three explored decades, a significant increase in the number of cases was observed. Conclusion:The most commonly affected groups included male patients, those from rural areas, those born after year 2000, especially from 2011 to the present. Most cases were isolated craniosynostosis. Heredo-collateral antecedents were insignificant. Three risk factors were present, including male sex, maternal smoking during pregnancy and advanced parents' ages. Complications of the disease were rare and a minority of patients benefited from surgical treatment. Genetic counseling is an important component of disease prevention and should be offered as soon as possible.

Tranexamic Acid Dosing in Craniosynostosis Surgery: A Systematic Review with Meta-analysis

This study aimed to compare operative time, blood loss, and transfusion requirement in patients receiving a high tranexamic acid (TXA) dose of greater than 10 mg/kg versus those receiving a low dose of 10 mg/kg or less.

Methods

PubMed, Cochrane Central, and Embase were queried to perform a systematic review with meta-analysis. Studies reporting outcomes of TXA use in craniosynostosis surgery were included. TXA dosing, operative time, blood loss, and transfusion requirement were the primary outcomes studied. Other variables studied included age and types of craniosynostosis.

Results

In total, 398 individuals in the included articles received TXA for craniosynostosis surgery. TXA loading doses ranged from 10 mg/kg to 50 mg/kg. Overall, administration of TXA was not associated with changes in operative time, but was associated with decreased blood loss and transfusion requirement on meta-analysis. Comparison of high dose TXA (>10 mg/kg) versus low dose (10 mg/kg or less) showed no statistical differences in changes in operative time, blood loss, or transfusion requirement.

Conclusions

Overall, TXA reduced blood loss and transfusion requirement in patients undergoing surgery for craniosynostosis. There was no difference in outcomes between high dose and low dose regimens amongst those receiving TXA. Low dose TXA appears adequate to achieve clinical efficacy with a low adverse event rate.

Imaging in craniofacial disorders with special emphasis on gradient echo Black-Bone and Zero Time Echo MRI sequences

Context:

The well-known effects of ionizing radiation on brain cells have been a major driving force toward the use of non-ionizing methods of imaging in both elective and emergency settings. Pediatric neurosurgery has certainly leveraged on this shift in clinical practice, however patients with craniofacial disorders could not fully benefit from the adoption of magnetic resonance imaging (MRI) because computed tomography (CT) scans still retain superior imaging power on bone tissue.

Aims:

To explore the knowledge available on the use of MRI as surrogate for CT scan in the assessment of craniosynostosis.

Settings and Design:

A scoping review was designed to identify landmark studies and ongoing clinical trials exploring the accuracy of MRI-based bone imaging in the preoperative planning of pediatric patients with craniosynostosis.

Materials and Methods:

A total of 492 records were screened from Pubmed, Ovid Medline, Scopus, and Cochrane Library databases; while 55 records were retrieved from ClinicalTrials.gov register. Only clinical studies revolving around the use of Gradient Echo Black-Bone (BB) and Zero Time Echo (ZTE) MRI sequences for the preoperative planning of pediatric craniosynostosis were retained for inclusion.

Results and Conclusions:

This review identified only five clinical studies reporting a high accuracy of MRI-based 3D bone reconstruction in 47 pediatric candidates to surgical correction of craniosynostosis. Although promising, limited evidence (Level IV) exist that BB and ZTE MRI could help in the surgical planning for craniosynostosis management. The results of two ongoing randomized clinical trials, which are actively enrolling patients, will hopefully help answering this research question.

Comparison of safety outcomes between bi-coronal and direct approaches for device removal in patients treated with distraction osteogenesis for craniosynostosis

The study aimed at comparing the safety outcomes between conventional bicoronal and direct method in device removal after cranial distraction in the treatment of craniosynostosis. This was a retrospective cohort study of patients treated with distraction osteogenesis to expand intracranial volume in the anteroposterior direction. Preoperative patient demographics, distraction protocols, and perioperative outcomes (operative time, estimated blood loss, intraoperative fluid volume, lowest hematocrit during surgery, transfusion, hospital stay, drain, postoperative complication) were collected and analyzed with the independent samples t-test. Twenty-four patients were included in the study (15 in the conventional and 9 in the direct approach group). The mean duration of surgery and intraoperative fluid volume were significantly shorter (114.56 ± 36.91 min vs. 177.20 ± 47.00 min, p = 0.003) and less (241.88 ± 194.07 ml vs. 624.00 ± 524.92 ml, p = 0.026), respectively in the direct group than in the conventional. No patients were transfused intraoperatively and admitted to the intensive care unit (ICU) postoperatively in the direct group. The mean intraoperative and total transfusion volumes were significantly greater in the conventional group (p = 0.004, 0.045, respectively). There were no significant differences in other safety outcomes. No postoperative wound complications were reported. The findings of this study indicated that the direct approach for distraction device removal in children with craniosynostosis appears to be safer than the conventional approach owing to the reduced operation time, intraoperative transfusion requirements, and ICU stay.

Craniosynostosis: Neonatal Perspectives

Craniosynostosis is the premature fusion of 1 or more sutures that normally separate the bony plates of an infant's skull and occurs in about 1 in 2,000 to 2,500 live births. Primary or congenital craniosynostoses represent the majority of cases and consist of single-suture and multisuture synostoses. Multisuture synostoses are typically associated with distinct craniofacial syndromes, including Muenke syndrome, Apert syndrome, Crouzon syndrome, and Pfeiffer syndrome, and are thus categorized under syndromic craniosynostoses. Secondary causes of craniosynostoses include metabolic or hematologic disorders that affect bone metabolism and typically present much later than primary synostoses. The severity of the deformity and the presence of increased intracranial pressure dictate the need for early surgical intervention, prompting the importance of early recognition and timely referral. Infants with craniosynostosis are also at increased risk for neurodevelopmental impairment and thus require close follow-up and monitoring. The early recognition and referral of craniosynostosis is imperative for the optimization of management and minimization of potential neurologic impairments that may develop.