Evaluation of the infant with an abnormal skull shape

Quantitative morphological analysis framework of infant cranial sutures and fontanelles based on CT images

Characterizing the suture morphological variation is a crucial step to investigate the influence of sutures on infant head biomechanics. This study aimed to establish a comprehensive quantitative framework for accurately capturing the cranial suture and fontanelle morphologies in infants. A total of 69 CT scans of 2-4 month-old infant heads were segmented to identify semilandmarks at the borders of cranial sutures and fontanelles. Morphological characteristics, including length, width, sinuosity index (SI), and surface area, were measured. For this, an automatic method was developed to determine the junction points between sutures and fontanelles, and thin-plate-spline (TPS) was utilized for area calculation. Different dimensionality reduction methods were compared, including nonlinear and linear principal component analysis (PCA), as well as deep-learning-based variational autoencoder (VAE). Finally, the significance of various covariates was analyzed, and regression analysis was performed to establish a statistical model relating morphological parameters with global parameters. This study successfully developed a quantitative morphological framework and demonstrate its application in quantifying morphologies of infant sutures and fontanelles, which were shown to significantly relate to global parameters of cranial size, suture SI, and surface area for infants aged 2-4 months. The developed framework proved to be reliable and applicable in extracting infant suture morphology features from CT scans. The demonstrated application highlighted its potential to provide valuable insights into the morphologies of infant cranial sutures and fontanelles, aiding in the diagnosis of suture-related skull fractures. Infant suture, Infant fontanelle, Morphological variation, Morphology analysis framework, Statistical model.

Three-Dimensional Quantification of Facial Asymmetry in Children with Positional Cranial Deformity

BACKGROUND

The extent of facial involvement in positional plagiocephaly is only little investigated so far. Investigation methods that take into account the challenging anatomical conditions and growth of infants' faces are desirable. In this study, the authors established a new three-dimensional photogrammetry quantification method evaluating pretherapeutic and posttherapeutic facial asymmetry in positional plagiocephaly. Furthermore, a facial asymmetry index was established and evaluated.

METHODS

Three-dimensional photographs of 100 children undergoing treatment with head orthoses were analyzed by constructing a standardized interindividual coordinate system. Defining landmarks, section planes, and point coordinates with a computer-aided design software, both sides of the faces were compared. Facial asymmetry was quantified by measuring differences between left and right sides and pretherapeutic and posttherapeutic changes in each patient. The facial asymmetry index was calculated by putting the absolute differences in relation with the coordinates of the nonaffected side.

RESULTS

Present results indicate that positional plagiocephaly results in a distinct facial asymmetry (range, -3.8 to 9.6 mm) in nearly all spatial directions and facial regions. Helmet therapy led to a significant reduction (p < 0.05) of intraindividual facial asymmetry (median change in facial asymmetry index, -1.9 to 3.1 percent). However, no correlation of the Cranial Vault Asymmetry Index and facial asymmetry (Spearman rank correlation coefficient, ρ = -0.09 to 0.47) has been seen. According to these results, severe occipital deformation does not necessarily provoke distinct facial asymmetry.

CONCLUSIONS

Present three-dimensional photogrammetry method allows the longitudinal quantification of facial involvement in positional plagiocephaly. Asymmetry has been determined in all facial regions. The facial asymmetry decreased through helmet therapy but was not eliminated completely.

The Effect of Using In Vitro Fertilization (IVF) on Increasing the Prevalence of Craniosynostosis

BACKGROUND

Craniosynostosis, a malformation caused by premature closure of one or more cranial sutures, is a rare congenital disability usually of unknown cause; however, it is often associated with assisted reproductive technology. Given the increasing prevalence of craniosynostosis and the use of the in vitro fertilization (IVF) method, the authors evaluated the association between IVF and the prevalence of craniosynostosis.

METHODS

This retrospective study reviewed records of patients with nonsyndromic craniosynostosis who underwent surgery in Mofid Hospital, a tertiary children's hospital affiliated to Shahid Beheshti University of Medical Sciences, between 2010 and 2019.

RESULTS

A total of 200 patients aged one month to 7 years old, were evaluated. Out of 200 patients, 43% were plagiocephalic, 39% trigonocephalic, 8.5% scaphocephalic, 8% brachiocephalic, and 1.5% were mixed. Nine (4.5%) patients had received clomiphene citrate. Eight (4%) mothers had become pregnant under IVF, and they all had used clomiphene citrate for ovulation stimulation. No use of artificial insemination was reported. Of the eight patients whose mother had become pregnant through IVF, three were trigonocephalic, and five were plagiocephalic.

CONCLUSIONS

Without a control group, we are not able report the statistical results confirming or denying a link between craniosynostosis and infertility treatment. However, 4% prevalence of IVF use among craniosynostosis patients is significant. Further studies with a broader statistical community are suggested in this regard.

Diagnosis and Management of Suture-Related Concerns of the Infant Skull

The cranial fontanelles and sutures have several benign variations, including most cases of "early" or "late" closure of the anterior fontanelle, bathrocephaly, overriding sutures, and benign metopic ridging. However, recognizing true craniosynostosis and referring the patient to a craniofacial specialist in a timely fashion are imperative, as minimally invasive options can be offered to most patients younger than 6 months of age. Gaining comfort with the physical examination of an infant with an abnormal head shape is best achieved through experience and pattern recognition and will frequently facilitate an accurate diagnosis without the need for ionizing radiation.

Using Sensitivity Analysis to Develop a Validated Computational Model of Post-operative Calvarial Growth in Sagittal Craniosynostosis

Craniosynostosis is the premature fusion of one or more sutures across the calvaria, resulting in morphological and health complications that require invasive corrective surgery. Finite element (FE) method is a powerful tool that can aid with preoperative planning and post-operative predictions of craniosynostosis outcomes. However, input factors can influence the prediction of skull growth and the pressure on the growing brain using this approach. Therefore, the aim of this study was to carry out a series of sensitivity studies to understand the effect of various input parameters on predicting the skull morphology of a sagittal synostosis patient post-operatively. Preoperative CT images of a 4-month old patient were used to develop a 3D model of the skull, in which calvarial bones, sutures, cerebrospinal fluid (CSF), and brain were segmented. Calvarial reconstructive surgery was virtually modeled and two intracranial content scenarios labeled “CSF present” and “CSF absent,” were then developed. FE method was used to predict the calvarial morphology up to 76 months of age with intracranial volume-bone contact parameters being established across the models. Sensitivity tests with regards to the choice of material properties, methods of simulating bone formation and the rate of bone formation across the sutures were undertaken. Results were compared to the in vivo data from the same patient. Sensitivity tests to the choice of various material properties highlighted that the defined elastic modulus for the craniotomies appears to have the greatest influence on the predicted overall skull morphology. The bone formation modeling approach across the sutures/craniotomies had a considerable impact on the level of contact pressure across the brain with minimum impact on the overall predicated morphology of the skull. Including the effect of CSF (based on the approach adopted here) displayed only a slight reduction in brain pressure outcomes. The sensitivity tests performed in this study set the foundation for future comparative studies using FE method to compare outcomes of different reconstruction techniques for the management of craniosynostosis.

Subjective perception of craniofacial growth asymmetries in patients with deformational plagiocephaly

OBJECTIVES

The present investigation aimed to evaluate the subjective perception of deformational cranial asymmetries by different observer groups and to compare these subjective perceptions with objective parameters.

MATERIALS AND METHODS

The 3D datasets of ten infants with different severities of deformational plagiocephaly (DP) were presented to 203 observers, who had been subdivided into five different groups (specialists, pediatricians, medical doctors (not pediatricians), parents of infants with DP, and laypersons). The observers rated their subjective perception of the infants' cranial asymmetries using a 4-point Likert-type scale. The ratings from the observer groups were compared with one another using a multilevel modelling linear regression analysis and were correlated with four commonly used parameters to objectively quantify the cranial asymmetries.

RESULTS

No significant differences were found between the ratings of the specialists and those of the parents of infants with DP, but both groups provided significantly more asymmetric ratings than did pediatricians, medical doctors, or laypersons. Moreover, the subjective perception of cranial asymmetries correlated significantly with commonly used parameters for objectively quantifying cranial asymmetries.

CONCLUSIONS

Our results demonstrate that different observer groups perceive the severity of cranial asymmetries differently. Pediatricians' more moderate perception of cranial asymmetries may reduce the likelihood of parents to seek therapeutic interventions for their infants. Moreover, we identified some objective symmetry-related parameters that correlated strongly with the observers' subjective perceptions.

CLINICAL RELEVANCE

Knowledge about these findings is important for clinicians when educating parents of infants with DP about the deformity.

Analysis of cranial type characteristics in term infants: a multi-center study

Background

Positional head deformity (PHD) is defined as a change in the shape of an infant’s skull due to an external force. In certain cases, it can lead to cosmetic deformities or even neurological issues due to its impact on the developing nervous system. Therefore, we conducted this study to investigate the incidence and characteristics of PHD in term infants in China and preliminarily establish a localized diagnostic reference standard.

Methods

Overall, 4456 term infants from three medical institutions in Chongqing were and divided and analyzed according to their age. Cranial vault asymmetry (CVA) and cephalic index (CI) were calculated in all infants. The current international diagnostic criteria were used to understand PHD incidence and analyze the CVA and CI distribution.

Results

According to the current international standards, the total detection rate of PHD in Chongqing’s term infants was 81.5%, with brachycephaly alone being the most frequent (39.4%), followed by brachycephaly with plagiocephaly (34.8%) and plagiocephaly alone (6.2%). The detection rates of dolichocephaly were low: alone, 0.9% and combined with plagiocephaly, 0.2%. According to age, plagiocephaly (44.5%) and brachycephaly (82.0%) were the most frequent in the 2-3-month group. The 75th/90th/97th and 3rd/10th/25th/75th/90th/97th percentiles of CVA and CIs were 0.4/0.7/1.0 and 76.4/78.8/82.3/91.1/94.6/99.2%, respectively.

Conclusions

According to the current international standards, the PHD detection rate among term infants in Chongqing was high. Therefore, a new diagnostic standard for Chinese infants was proposed where CVA ≥ 0.4 cm indicates plagiocephaly, CI ≥ 91% indicates brachycephaly, and CI ≤ 82% indicates dolichocephaly.

Combining deep learning with 3D stereophotogrammetry for craniosynostosis diagnosis

Craniosynostosis is a condition in which cranial sutures fuse prematurely, causing problems in normal brain and skull growth in infants. To limit the extent of cosmetic and functional problems, swift diagnosis is needed. The goal of this study is to investigate if a deep learning algorithm is capable of correctly classifying the head shape of infants as either healthy controls, or as one of the following three craniosynostosis subtypes; scaphocephaly, trigonocephaly or anterior plagiocephaly. In order to acquire cranial shape data, 3D stereophotographs were made during routine pre-operative appointments of scaphocephaly (n = 76), trigonocephaly (n = 40) and anterior plagiocephaly (n = 27) patients. 3D Stereophotographs of healthy infants (n = 53) were made between the age of 3-6 months. The cranial shape data was sampled and a deep learning network was used to classify the cranial shape data as either: healthy control, scaphocephaly patient, trigonocephaly patient or anterior plagiocephaly patient. For the training and testing of the deep learning network, a stratified tenfold cross validation was used. During testing 195 out of 196 3D stereophotographs (99.5%) were correctly classified. This study shows that trained deep learning algorithms, based on 3D stereophotographs, can discriminate between craniosynostosis subtypes and healthy controls with high accuracy.

An Investigation of Brain Functional Connectivity by Form of Craniosynostosis

PURPOSE

Long-term neurocognitive sequelae of nonsyndromic craniosynostosis (NSC) patients are just beginning to be clarified. This study uses functional MRI (fMRI) to determine if there is evidence of altered brain functional connectivity in NSC, and whether these aberrations vary by form of synostosis.

METHODS

Twenty adolescent participants with surgically treated NSC (10 sagittal synostosis, 5 right unilateral coronal synostosis [UCS], 5 metopic synostosis [MSO]) were individually matched to controls by age, gender, and handedness. A subgroup of MSO was classified as severe metopic synostosis (SMS) based on the endocranial bifrontal angle. Resting state fMRI was acquired in a 3T Siemens TIM Trio scanner (Erlangen, Germany), and data were motion corrected and then analyzed with BioImage Suite (Yale School of Medicine). Resulting group-level t-maps were cluster corrected with nonparametric permutation tests. A region of interest analysis was performed based on the left Brodmann's Areas 7, 39, and 40.

RESULTS

Sagittal synostosis had decreased whole-brain intrinsic connectivity compared to controls in the superior parietal lobules and the angular gyrus (P = 0.071). Unilateral coronal synostosis had decreased intrinsic connectivity throughout the prefrontal cortex (P = 0.031). The MSO cohort did not have significant findings on intrinsic connectivity, but the SMS subgroup had significantly decreased connectivity among multiple subcortical structures.

CONCLUSION

Sagittal synostosis had decreased connectivity in regions associated with visuomotor integration and attention, while UCS had decreased connectivity in circuits crucial in executive function and cognition. Finally, severity of metopic synostosis may influence the degree of neurocognitive aberration. This study provides data suggestive of long-term sequelae of NSC that varies by suture type, which may underlie different phenotypes of neurocognitive impairment.

Parents' Experiences of Their Child's Craniosynostosis and the Initial Care Process

Craniosynostosis is usually diagnosed in early infancy. Treatment almost always involves surgery and care is optimally organized around an interdisciplinary team of specialists at a craniofacial center. This study aimed to investigate Swedish parents' experiences of having a child with craniosynostosis and their perceptions of the initial care process. Semistructured telephone interviews were conducted with 20 parents (10 fathers and 10 mothers) of children with nonsyndromic craniosynostosis who were undergoing surgery at the Uppsala Craniofacial Center. A thematic data analysis revealed 6 themes presented in a timeline following the parents' journey from detection of their child's abnormal skull shape to waiting for surgery: Detection of the abnormal skull shape, thoughts, and feelings before the appointment with the craniofacial team, an appointment with the craniofacial team, searching the Internet and social media, waiting for surgery, and suggestions for improvement. Although meeting with the craniofacial team was considered informative, parents expressed concerns about surgery and their infant's long-term prognosis were evident. Most parents had no previous knowledge about craniosynostosis and craniofacial syndromes and wished for more information already at the time of its detection. The Internet was used both at the time of suspicion that something was wrong with the child and later to learn about risks and consequences, alternative treatments and prognosis.

Medical devices and the pediatric population - a head-to-toe approach

Introduction: This review uses a head-to-toe approach, a standardized approach similar to the format used by clinicians during the physical examination, to highlight important differences between children, adolescents and adults. The assessment of a pediatric patient is significantly different from an adult and the heterogeneity of the pediatric population requires knowledge of the inter- and intra-subpopulation differences in growth and development for all organ systems. Areas covered: A search of the English medical literature (PubMed and EMBASE) resulted in identification and review of articles that reported medical device use in the pediatric population based on specific organ systems. The review highlights unique considerations for the pediatric population with respect to growth and development as well as important physiologic and maturational differences between children and adults pertaining to the use of medical devices. Expert opinion: Children have unique medical device needs; adult devices are often adapted or configured to address these unmet needs. It is important that clinicians, and those who manufacture and design medical devices for the pediatric population, have a heightened awareness of the varied pediatric subpopulations (neonates to adolescents) with respect to growth and development, and the adjustments needed to ensure safe and effective use of devices for their unique needs.

Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy

BACKGROUND

Congenital muscular torticollis (CMT) is a postural deformity evident shortly after birth, typically characterized by lateral flexion/side bending of the head to one side and cervical rotation/head turning to the opposite side due to unilateral shortening of the sternocleidomastoid muscle; it may be accompanied by other neurological or musculoskeletal conditions. Infants with CMT should be referred to physical therapists to treat these postural asymmetries as soon as they are identified.

PURPOSE

This update of the 2013 CMT clinical practice guideline (CPG) informs clinicians and families as to whom to monitor, treat, and/or refer and when and what to treat. It links 17 action statements with explicit levels of critically appraised evidence and expert opinion with recommendations on implementation of the CMT CPG into practice.

RESULTS/CONCLUSIONS

The CPG addresses the following: education for prevention; referral; screening; examination and evaluation; prognosis; first-choice and supplemental interventions; consultation; discontinuation from direct intervention; reassessment and discharge; implementation and compliance audits; and research recommendations. Flow sheets for referral paths and classification of CMT severity have been updated.

Isolated Post-Shunt Metopic Synostosis and Neural Tube Defects

BACKGROUND

Craniosynostosis is an uncommon complication after shunting procedures for congenital hydrocephalus. We report a case of a child with myelomeningocele and normocephaly at the time of birth. She underwent ventricular shunting for Chiari malformation and hydrocephalus at 3 days of age. An immediate postoperative CT scan confirmed all sutures were open. Serial CT scans document an open metopic suture at 2 months, closed metopic suture at 5 months, and trigonocephaly at 11 months with concomitant slit ventricle syndrome, and collapsed lateral and third ventricles.

METHODS

An Ovid MEDLINE search within the dates of 1948 through 2017, using the keywords "synostosis AND shunt" was carried out. A tabulation of all patients and their respective synostosis patterns were recorded.

RESULTS

We identified 8 case series and 2 case reports during 43 years (1966-2017). Seventy-eight patients with 79 suture synostosis patterns were identified (one patient underwent a second cranial reconstruction for identification of a separate, newly formed synostosis). Eighteen (30.5%) cases were associated with a neural tube defect (NTD). Patients with NTD and secondary craniosynostosis had on average earlier age of shunt placement (P = 0.001), craniosynostosis presentation (P = 0.146), and cranioplasty (P = 0.325) than secondary craniosynostosis patients without NTD.

CONCLUSIONS

Ventricular shunt drainage in treating hydrocephalus rarely may lead to early synostosis and cranial deformity, especially in patients with NTDs. Early shunt placement poses significant risk in patients with NTD. Close follow-up may be necessary to evaluate overdrainage and cranial deformity after shunting procedures.

A Neonatal Bimodal MR-CT Head Template

Neonatal MR templates are appropriate for brain structural analysis and spatial normalization. However, they do not provide the essential accurate details of cranial bones and fontanels-sutures. Distinctly, CT images provide the best contrast for bone definition and fontanels-sutures. In this paper, we present, for the first time, an approach to create a fully registered bimodal MR-CT head template for neonates with a gestational age of 39 to 42 weeks. Such a template is essential for structural and functional brain studies, which require precise geometry of the head including cranial bones and fontanels-sutures. Due to the special characteristics of the problem (which requires inter-subject inter-modality registration), a two-step intensity-based registration method is proposed to globally and locally align CT images with an available MR template. By applying groupwise registration, the new neonatal CT template is then created in full alignment with the MR template to build a bimodal MR-CT template. The mutual information value between the CT and the MR template is 1.17 which shows their perfect correspondence in the bimodal template. Moreover, the average mutual information value between normalized images and the CT template proposed in this study is 1.24±0.07. Comparing this value with the one reported in a previously published approach (0.63±0.07) demonstrates the better generalization properties of the new created template and the superiority of the proposed method for the creation of CT template in the standard space provided by MR neonatal head template. The neonatal bimodal MR-CT head template is freely downloadable from https://www.u-picardie.fr/labo/GRAMFC.

Transcriptional analysis of human cranial compartments with different embryonic origins

OBJECTIVE

Previous investigations suggest that the embryonic origins of the calvarial tissues (neural crest or mesoderm) may account for the molecular mechanisms underlying sutural development. The aim of this study was to evaluate the differences in the gene expression of human cranial tissues and assess the presence of an expression signature reflecting their embryonic origins.

METHODS

Using microarray technology, we investigated global gene expression of cells from the frontal and parietal bones and the metopic and sagittal intrasutural mesenchyme (ISM) of four human foetal calvaria. qRT-PCR of a selected group of genes was done to validate the microarray analysis. Paired comparison and correlation analyses were performed on microarray results.

RESULTS

Of six paired comparisons, frontal and parietal compartments (distinct tissue types of calvaria, either bone or intrasutural mesenchyme) had the most different gene expression profiles despite being composed of the same tissue type (bone). Correlation analysis revealed two distinct gene expression profiles that separate frontal and metopic compartments from parietal and sagittal compartments. TFAP2A, TFAP2B, ICAM1, SULF1, TNC and FOXF2 were among differentially expressed genes.

CONCLUSION

Transcriptional profiles of two groups of tissues, frontal and metopic compartments vs. parietal and sagittal compartments, suggest differences in proliferation, differentiation and extracellular matrix production. Our data suggest that in the second trimester of human foetal development, a gene expression signature of neural crest origin still exists in frontal and metopic compartments while gene expression of parietal and sagittal compartments is more similar to mesoderm.

Osteoblast differentiation profiles define sex specific gene expression patterns in craniosynostosis

Single suture craniosynostosis (SSC) is the premature fusion of one calvarial suture and occurs in 1-1700-2500 live births. Congenital fusion of either the sagittal, metopic, or coronal sutures represents 95% of all cases of SSC. Sagittal and metopic synostosis have a male preponderance (3:1) while premature fusion of the coronal suture has a female preponderance (2:1). Although environmental and genetic factors contribute to SSC, the etiology of the majority of SSC cases remains unclear. In this study, 227 primary calvarial osteoblast cell lines from patients with coronal, metopic, or sagittal synostosis and unaffected controls were established and assayed for ALP activity and BrdU incorporation (n = 226) as respective measures of early stage osteoblast differentiation and proliferation. Primary osteoblast cell lines from individuals with sagittal synostosis demonstrated higher levels of ALP activity and reduced proliferation when compared to control lines. In order to address the sex differences in SSC types, the data was further stratified by sex. Osteoblasts from males and females with sagittal synostosis as well as males with metopic synostosis demonstrated higher levels of ALP activity when compared to sex matched controls, and males with sagittal or metopic synostosis demonstrated reduced levels of proliferation. In order to elucidate genes and pathways involved in these observed phenotypes, correlation analyses comparing ALP activity and proliferation to global gene expression was performed. Transcripts related to osteoblast differentiation were identified both differentially up and downregulated, correlated with ALP activity when compared to controls, and demonstrated a striking sex specific gene expression pattern. These data support that the dysregulation of osteoblast differentiation plays a role in the development of SSC and that genetic factors contribute to the observed sex related differences.

Craniofacial Surgery and Adverse Outcomes

Objective:

This study aimed to evaluate factors contributing to medical negligence relevant to craniofacial surgery.

Methods:

Retrospective analysis of verdict and settlement reports on the Westlaw legal database for outcome, awards, physician defendants, and other specific factors raised in malpractice litigation.

Results:

Of 42 verdicts and settlement reports included, 52.4% were resolved with either an out-of-court settlement or plaintiff verdict, with aggregate payments totaling $50.1M (in 2013 dollars). Median settlements and jury-awarded damages were $988 000 and $555 000, respectively. Payments in pediatric cases ($1.2M) were significantly higher. Plastic surgeons, oral surgeons, and otolaryngologists were the most commonly named defendants. The most common alleged factors included intraoperative negligence (69.0%), permanent deficits (54.8%), requiring additional surgery (52.4%), missed/delayed diagnosis of a complication (42.9%), disfigurement/scarring (28.6%), postoperative negligence (28.6%), and inadequate informed consent (20.6% of surgical cases). Failure to diagnose a fracture (19.0%) and cleft-reparative procedures (14.3%) were the most frequently litigated entities.

Conclusion:

Medical negligence related to craniofacial surgery involves plaintiffs in a wide age range as well as physician defendants in numerous specialties, and proceedings resolved with settlement and plaintiff verdict involve substantial payments. Cases with death, allegedly permanent injuries, and pediatric plaintiffs had significantly higher payments.

Molecular basis of cranial suture biology and disease: Osteoblastic and osteoclastic perspectives

The normal growth and development of the skull is a tightly regulated process that occurs along the osteogenic interfaces of the cranial sutures. Here, the borders of the calvarial bones and neighboring tissues above and below, function as a complex. Through coordinated remodeling efforts of bone deposition and resorption, the cranial sutures maintain a state of patency from infancy through early adulthood as the skull continues to grow and accommodate the developing brain's demands for expansion. However, when this delicate balance is disturbed, a number of pathologic conditions ensue; and if left uncorrected, may result in visual and neurocognitive impairments. A prime example includes craniosynostosis, or premature fusion of one or more cranial and/or facial suture(s). At the present time, the only therapeutic measure for craniosynostosis is surgical correction by cranial vault reconstruction. However, elegant studies performed over the past decade have identified several genes critical for the maintenance of suture patency and induction of suture fusion. Such deeper understandings of the pathogenesis and molecular mechanisms that regulate suture biology may provide necessary insights toward the development of non-surgical therapeutic alternatives for patients with cranial suture defects. In this review, we discuss the intricate cellular and molecular interplay that exists within the suture among its three major components: dura mater, osteoblastic related molecular pathways and osteoclastic related molecular pathways.

Craniosynostosis: caring for infants and their families

Craniosynostosis is a developmental anomaly with premature closure of the cranial sutures causing an abnormally shaped skull in an infant. Recommended surgical treatment involves cranial vault reconstruction to open the closed suture, increase intracranial volume, and allow the brain to grow normally. Parents work with a multidisciplinary team during the evaluation process and face various preoperative and postoperative stressors. Critical care nurses can improve the care of the infants and their families by being knowledgeable about the anatomy, assessment, and surgical and nursing management of infants with this anomaly and its impact on the patients' families. This article discusses the definitions, diagnosis, and treatment of craniosynostosis and support for parents of infants with this malformation.

Clinical classification of infant nonsynostotic cranial deformity

OBJECTIVE

Based on a pilot study including >400 children and a comprehensive database analysis of >2500 children, we sought to define the craniofacial norm and to objectify the categorization of positional head deformity.

STUDY DESIGN

A database was created containing clinical information on children assessed for nonsynostotic cranial deformity. The findings of standardized anthropometric measurements were compared with data from a group of 401 healthy children with a normal head shape collected in terms of a prospective pilot study. Using a statistical analysis of all anthropometric craniofacial measurements, cut-off percentiles for discriminating different groups of deformation and severity classes were generated.

RESULTS

Normative percentiles for all dimensions in cranial vault anthropometric measurements during the first year of life were calculated. Children with definite nonsynostotic head deformity could be clearly allocated into 3 different groups: positional plagiocephaly (abnormal Cranial Vault Asymmetry Index), positional brachycephaly (abnormal Cranial Index), and combined positional plagiocephaly and brachycephaly (abnormal Cranial Vault Asymmetry Index and Cranial Index). Additionally, a reliable 3-level severity categorization (mild, moderate, and severe) for each group of cranial deformation could be obtained according to age and sex.

CONCLUSIONS

Our results allow a meaningful and reliable classification of nonsynostotic early childhood cranial deformity.

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

INTRODUCTION

Anterior plagiocephaly due to the early unilateral fusion of the coronal suture is associated to a clinical phenotype characterized by the unilateral flattening of the frontal bone and the orbit and by the distortion and maldevelopment of adjacent cranial and facial bones. Homolateral anterior displacement of the ear and contralateral deviation of the nasal pyramid and mandible are other prominent clinical features. The differential diagnosis includes a variety of conditions characterized by facial asymmetry, namely, due to muscular alterations, anomalies of the visual function, congenital anomalies of the cervical spine and craniovertebral junction, abnormal pregnancy, and birth injuries. Anterior plagiocephaly is the direct cause of oculomotor anomalies, with a characteristic strabismus, and of progressive asymmetrical maldevelopment of the face, craniovertebral junction, and cervical spine.

METHODS

The medical literature was reviewed in regard to the epidemiology, clinical features, and radiological findings. Different categorization of the affected infants in specific subtypes according to the severity of the condition was analyzed. The aim was to contribute to a practical clinical classification to be utilized for the surgical indication and for predicting the prognosis according to the severity of the condition at presentation.

CONCLUSIONS

Anterior plagiocephaly represents the most challenging simple suture craniosynostosis. The clinical differential diagnosis with other forms of cranial asymmetry is possible on the grounds of mere clinical findings. A classification system is necessary not only for the establishment of surgical planning but also to predict the late cosmetic and functional outcomes.

Craniosynostosis and 3-dimensional computed tomography

Craniosynostosis is when cranial sutures fuse prematurely. It causes cosmetic deformity and may limit brain growth with more serious consequences, such as hydrocephalus. It may involve one or more sutures, may be syndromic, and is thought most likely to result from genetic causes. Specific sutural closures result in reproducible cranial appearances and head shapes. Three-dimensional computed tomography has become the standard for preoperative diagnosis to allow surgical planning as well as postsurgical assessment. Early diagnosis allows early surgical management, which improves outcome. Nonsyndromic and syndromic craniosynostoses are illustrated in this pictorial review.

Analysis of the alternative splicing of an FGFR2 transcript due to a novel 5' splice site mutation (1084+1G>A): case report

Craniosynostosis is characterized by premature fusion of one or more cranial sutures and is associated with mutations in fibroblast growth factor receptor (FGFR) genes. Here we describe a novel mutation (1084+1G>A) in the FGFR2 gene of a patient with isolated bicoronal synostosis. We detected two isoforms that result from the mutation and are characterized, respectively, by exon skipping and the use of a cryptic splice site. Interestingly, the alternatively spliced forms of FGFR2 appear to induce fusion of the cranial sutures suggesting that the mutation acts via a gain-of-function mechanism rather than a loss of protein functionality.

Occlusal alterations in unilateral coronal craniosynostosis

There are few studies on maxillomandibular skeletal alterations. Twenty-one patients with unilateral coronal craniosynostosis were analysed and compared with controls. Landmarks analysed were: sella-nasion-point A and B angles, point A-nasion-point B angle, interincisal angle, angle of superior incisor axis on the sella-nasion plane, lower incisor to mandibular plane angle, Frankfort mandibular plane angle, zygomatic-frontal suture (Z), point on the most concave part of pyramidal apophysis of the upper maxilla (Mx), antegonial incisure (AG), upper (UMT) and lower (LMT) molar teeth. Differences were significant for class II dentoskeletal occlusion (p<0.0001), mandibular hyperdivergence (p<0.0001), lingualization of superior incisor (p<0.005), deviation of inferior interincisal contralateral line to the synostosis (p<0.0001) in the plagiocephalic population. Compared with contralateral counterpoints, Z (p<0.05), Mx (p<0.005) and UMT (p<0.0005) on the affected side were closer to the midline; AG (p<0.0005) and LMT (p<0.05) were further from it. On the frontal plane, Z, Mx, UMT, LMT and AG on the affected side were higher. Vertical and transversal contraction of the jaw of the synostotic side and laterodeviation of the mandibular interincisal line of the contralateral synostotic were clear. The altered position of the glenoid cavity, anteriorized in unilateral coronal craniosynostosis, could be the cause of mandibular dentoskeletal asymmetry.

Topics in pediatric head and neck imaging: self-assessment module

OBJECTIVE

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of radiology in pediatric congenital sensorineural hearing loss, posterior plagiocephaly, and midline nasofrontal mass.

CONCLUSION

The activities in these articles guide the participant to understanding the key concepts of radiology in pediatric congenital sensorineural hearing loss, posterior plagiocephaly, and midline nasofrontal mass.

Diagnosis and management of deformational plagiocephaly

OBJECT

The increase in the prevalence of nonsynostotic occipital deformational plagiocephaly in infants, which resulted from the American Academy of Pediatrics' 1992 recommendation to have healthy infants sleep supine, has been accompanied by significant controversy in diagnosis and management. The controversy was exacerbated by the 1998 FDA classification of cranial orthotic devices as Class II devices requiring premarket notification, and the subsequent increase in treatment-associated costs.

METHODS

Two independent reviews of the literature were conducted to clarify the objective evidence available within the context of pediatric craniofacial knowledge.

RESULTS

Although deformational plagiocephaly is not a life-threatening problem, it is a source of disfigurement for children that may be detrimental to their well-being. Current methods for quantifying the degree of disfigurement have limited interrater reliability, and no prospective randomized controlled trials comparing the efficacy of cranial orthoses to repositioning and physical therapy protocols have been published. Despite this lack of Class I evidence, cranial orthoses are routinely and effectively used to treat persistent severe deformational plagiocephaly. The need for the current FDA regulations has not been supported by clinical experience and reported complications.

CONCLUSIONS

This review resulted in the following recommendations: 1) more parental education is needed to minimize the development and progression of deformational plagiocephaly; 2) mild deformity can be treated with repositioning and physical therapy protocols; and 3) severe deformity is likely to be corrected more quickly and effectively with cranial orthosis (when used during the appropriate period of infancy) than with repositioning and physical therapy. The available data do not support the need for FDA classification for cranial orthoses as Class II devices requiring premarket notification. Removal of the regulations, which centralized production of the orthoses to larger companies and markedly increased charges, will probably eliminate much of the controversy and parental anxiety generated by marketing strategies.