Update in Management of Craniosynostosis

Pediatric Cranial Vault Pathology

A wide variety of diagnoses can be approached with a common framework for diagnosis, extirpation, and reconstruction of pediatric cranial vault pathologies. Durability of reconstruction is critical for the range of pediatric patients from infancy to adolescence. Rigid reconstruction, preferably with autologous tissue when possible, promotes brain protection and satisfactory aesthetic outcome. Careful planning can allow for immediate definitive reconstruction of defects without need for further surgical intervention.

Genetic Heterogeneity, Craniofacial Surgical Burden, and Surgical Techniques in Patients With Saethre-Chotzen Syndrome

OBJECTIVE

While genotype correlates with phenotype in patients with many forms of syndromic craniosynostosis, the relationship between molecular diagnosis and craniofacial surgical history in patients with Saethre-Chotzen syndrome (SCS) is more variable. This manuscript characterizes that relationship and evaluates operative trends in these patients over the past 3 decades.

METHODS

Demographic information, molecular diagnosis, and craniofacial surgical history in patients born with SCS between 1989 and 2023 were compared with appropriate statistics, including t tests and analysis of variance.

RESULTS

Thirty-five patients with SCS were included, and there was no difference in total craniofacial procedures among those with TWIST1 substitutions (2.1 ± 1.6), duplications (3.0 ± 4.2), insertions (3.5 ± 0.7), or deletions (2.4 ± 1.9; P = 0.97). Cranial expansion rates were also similar across all genetic diagnoses (P>0.05), and surgical incidence was similar across patients with unicoronal, bicoronal, and multisuture involvement (P > 0.05). Those with an initial fronto-orbital advancement had a lower incidence of secondary cranial vault procedures compared with those with an initial posterior vault distraction osteogenesis (29% versus 71%, P < 0.05), though this did not control for phenotypic severity. On average, total cranial vault surgical burden (1.35 ± 0.67 versus 1.75 ± 0.46) and cranial expansion surgical burden (1.40 ± 0.68 versus 1.88 ± 0.64) between the fronto-orbital advancement-first and posterior vault distraction osteogenesis-first cohorts were similar (P = 0.11, P = 0.17, respectively).

CONCLUSION

While SCS is molecularly and phenotypically heterogeneous, genetic diagnosis does not appear associated with rates of craniofacial surgery. Additional prospective study of correlations between genotype, severity of craniofacial manifestations, and treatment algorithms is warranted; but, in the end, it may be that this highly variable form of syndromic craniosynostosis warrants tailored, expectant management.

Emphasis on Early Prenatal Diagnosis and Perinatal Outcomes Analysis of Apert Syndrome

Apert syndrome is an inherited condition with autosomal dominant transmission. It is also known as acrocephalosyndactyly type I, being characterized by a syndrome of craniosynostosis with abnormal head shape, facial anomalies (median hypoplasia), and limb deformities (syndactyly, rhizomelic shortening). The association can suspect the prenatal diagnosis of these types of anomalies. The methodology consisted of revising the literature, by searching the PubMed/Medline database in which 27 articles were selected and analyzed, comprising 32 cases regarding the prenatal diagnosis of Apert syndrome. A series of ultrasound parameters, the anatomopathological abnormalities found, the obstetric results, and the genetic tests were followed. The distribution of imaging results (US, MRI) identified in the analyzed cases was as follows: skull-shaped abnormalities were evident in 96.8% of cases, facial abnormalities (hypertelorism 43.7%, midface hypoplasia 25%, proptosis 21.8%), syndactyly in 87.5%, and cardiovascular abnormalities in 9.3%. The anomalies detected by the ultrasound examination of the fetus were confirmed postnatally by clinical or gross evaluation or imaging. The management of these cases requires an early diagnosis, an evaluation of the severity of the cases, and appropriate parental counseling.

Sociodemographic Disparities in Craniosynostosis: A Systematic Review

OBJECTIVE

Given the consequences of delayed treatment and diagnosis of craniosynostosis, this study reviews the literature on sociodemographic risk factors and disparities associated with delayed craniosynostosis treatment.

DESIGN

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search of PubMed/Medline and Embase was performed by two independent reviewers. Included studies discussed craniosynostosis health disparities. Demographic characteristics and outcomes were analyzed.

SETTING

Not applicable.

PATIENTS

Patients with craniosynostosis.

INTERVENTIONS

Standard surgical intervention for craniosynostosis.

RESULTS

Our literature search yielded 273 studies, of which 18 were included for analysis. Included studies represented data from 31 256 U.S. patients with craniosynostosis. Sixty percent of patients (n = 16 510) were White, 13.8% were Hispanic/Latino, 6.2% were Black/African American, 1.3% were Asian, 0.3% were American Indian or Alaska Native, and 0.1% were Native Hawaiian or Pacific Islander. Average age at surgery was 6.36 months for White patients, 10.63 months for Black patients, and 9.18 months for Hispanic patients. Minority racial and/or ethnic status was a risk factor for delayed presentation, and increased incidence of open surgery, complication rates, hospital charges, operative time, anesthesia duration, and hospital length of stay. Government-funded health insurance was associated with delayed intervention and increased complications.

CONCLUSIONS

Minority craniosynostosis patients experience delays in intervention and increased complication rates. Our findings highlight the importance of expedited and equitable referrals, screenings, and treatment, and the need for a standardized approach to investigating longitudinal demographic and outcomes data in this population.

A novel pathogenic variant of DNMT3A associated with craniosynostosis: a case report of Heyn-Sproul-Jackson syndrome

Pathogenic variants of DNMT3A have been implicated in Tatton-Brown-Rahman syndrome, an overgrowth disorder with macrocephaly and intellectual disability. However, there are recent reports of variants in the same gene giving rise to an opposing clinical phenotype presenting with microcephaly, growth failure, and impaired development-named Heyn-Sproul-Jackson syndrome (HESJAS). Here, we present a case of HESJAS caused by a novel pathogenic variant of DNMT3A. A five-year-old girl presented with severe developmental delay. Perinatal and family history were non-contributory. Physical exam showed microcephaly and facial dysmorphic features, and neurodevelopmental assessments revealed profound global developmental delay. Brain magnetic resonance imaging findings were normal; however, brain 3D computed tomography revealed craniosynostosis. Next generation sequencing revealed a novel heterozygous variant in DNMT3A (NM_175629.2: c.1012_1014 + 3del). The patient's parents did not carry the variant. In this report, a novel feature associated with HESJAS (craniosynostosis) is described, along with a more detailed account of clinical manifestations than those in the original report.

Smartphone Integration of Artificial Intelligence for Automated Plagiocephaly Diagnosis

Positional plagiocephaly is a pediatric condition with important cosmetic implications affecting ∼40% of infants under 12 months of age. Early diagnosis and treatment initiation is imperative in achieving satisfactory outcomes; improved diagnostic modalities are needed to support this goal. This study aimed to determine whether a smartphone-based artificial intelligence tool could diagnose positional plagiocephaly.

Methods

A prospective validation study was conducted at a large tertiary care center with two recruitment sites: (1) newborn nursery, (2) pediatric craniofacial surgery clinic. Eligible children were aged 0-12 months with no history of hydrocephalus, intracranial tumors, intracranial hemorrhage, intracranial hardware, or prior craniofacial surgery. Successful artificial intelligence diagnosis required identification of the presence and severity of positional plagiocephaly.

Results

A total of 89 infants were prospectively enrolled from the craniofacial surgery clinic (n = 25, 17 male infants [68%], eight female infants [32%], mean age 8.44 months) and newborn nursery (n = 64, 29 male infants [45%], 25 female infants [39%], mean age 0 months). The model obtained a diagnostic accuracy of 85.39% compared with a standard clinical examination with a disease prevalence of 48%. Sensitivity was 87.50% [95% CI, 75.94-98.42] with a specificity of 83.67% [95% CI, 72.35-94.99]. Precision was 81.40%, while likelihood ratios (positive and negative) were 5.36 and 0.15, respectively. The F1-score was 84.34%.

Conclusions

The smartphone-based artificial intelligence algorithm accurately diagnosed positional plagiocephaly in a clinical environment. This technology may provide value by helping guide specialist consultation and enabling longitudinal quantitative monitoring of cranial shape.

Multisuture craniosynostosis: a case report of unusual presentation of chromosome 14q32 deletion

Multisuture craniosynostosis is associated with a number of syndromes and underlying gene mutations. It is rarely caused by chromosome disorders. For the management, multisuture craniosynostosis raises concerns about abnormal head shape and risks of increased intracranial pressure in affected patients. Calvarial reconstruction to reshape the skull shape and expand the intracranial volume plays an essential role in correcting particular problems. Here, we report a 2-month-old female infant presenting with low birth weight, abnormal head shape, dysmorphic facies and pinnae, hypotonia, and feeding difficulty. Three-dimensional computed tomographic scans revealed left unicoronal and sagittal synostoses. Chromosome microarray analysis revealed de novo chromosome 14q32.12-q32.31 deletion. Among the deleted genes, YY1 and BCL11B are the most likely candidate genes causing craniosynostosis. Some clinical features of the patient are similar to Temple syndrome indicating that the deleted region is paternal in origin. In summary, this is a rare case of chromosome 14q32 deletion with multisuture craniosynostosis. We also report the multidisciplinary management and clinical outcomes after early cranial vault remodelling procedures.