Normocephalic Pancraniosynostosis: A Report of a Surgical Technique

Long-term sequelae of normocephalic pansynostosis: a rare but insidious entity

OBJECTIVE

Patients with normocephalic pansynostosis, who have a grossly normal head shape, are often overlooked early in life and present late with elevated intracranial pressure (ICP) requiring timely cranial vault expansion. This study evaluates the long-term clinical outcomes of patients with normocephalic pansynostosis.

METHODS

We retrospectively reviewed patients with a clinical and radiographic diagnosis of primary pansynostosis who underwent vault reconstruction between 2000 and 2023. Clinical and treatment course after craniofacial interventions was followed in patients with normocephaly to assess outcomes.

RESULTS

Thirty-five patients with primary pansynostosis were identified, of which eight (23.5%) had normocephaly and underwent initial vault expansion at a mean age of 5.0 ± 2.4 years. All eight patients (50.0% male) presented with symptoms of elevated ICP including headaches (50.0%), nausea and vomiting (50.0%), and developmental delay (62.5%) and/or signs of elevated ICP including papilledema (75.0%) and radiologic thumbprinting on head computed tomography scan (87.5%). Three of the four normocephalic patients who had over 7 years of postoperative follow-up developed subjective headaches, vision changes, or learning and behavioral issues in the long-term despite successful vault reconstruction.

CONCLUSIONS

Our longitudinal experience with this rare but insidious entity demonstrates the importance of timely intervention and frequent postoperative monitoring, which are critical to limiting long-term neurological sequelae. Multidisciplinary care by craniofacial surgery, neurosurgery, ophthalmology, and neuropsychology with follow-up into adolescence are recommended to assess for possible recurrence of elevated ICP secondary to cranio-cerebral disproportion.

Undiagnosed Normocephalic Pancraniosynostosis Presenting as Bilateral Abducens Nerve Palsy

ABSTRACT

Primary pancraniosynostosis is a rare variant of craniosynostosis in which the major cranial sutures prematurely fuse. Single-suture craniosynostosis is often recognized early in life due to an abnormal head shape. In contrast, primary pancraniosynostosis may be diagnosed later in life due to a grossly normal head shape and size. As such, these children can present with symptoms related to chronically elevated intracranial pressure (eg, vision loss or cognitive impairment). This report highlights a patient with primary pancraniosynostosis associated with unique neurologic sequelae-namely, bilateral abducens nerve palsy. A 9-year-old boy presented to the ophthalmologist with a 1-month history of double vision, drifting of his right eye toward the nasal bridge, and intracranial hypertension evident with papilledema. Physical examination was notable for mild bitemporal narrowing. A computed tomography study demonstrated radiologic thumbprinting, diffuse osseous sclerosis, and fusion of the bilateral coronal, sagittal, metopic, and lambdoid sutures. The patient underwent emergent cranial vault expansion with fronto-orbital advancement. Papilledema had resolved 4 months following surgery. At 2-year follow-up, abducens nerve palsy and head shape were significantly improved. This study brings attention to an unreported presenting symptom of pancraniosynostosis (bilateral abducens nerve palsy). This information may lead to quicker diagnosis and treatment of pancraniosynostosis-induced intracranial hypertension, which is critical to prevent long-term sequelae.

Primary normocephalic pancraniosynostosis detected incidentally after an accidental head injury: a case report and review of the literature

OBJECTIVE

Majority of multi-suture craniosynostosis are related to single-gene disorders or chromosomal abnormalities. Children with craniosynostosis usually present at an early age due to the presence of an abnormal head shape, with the exception of a unique entity termed primary normocephalic pancraniosynostosis. The objective of this article is to describe an unusual case of primary normocephalic pancraniosynostosis, detected incidentally following an accidental head injury. A comprehensive review of the literature will also be included. To the best of our knowledge, only eight cases of primary normocephalic pancraniosynostosis have been reported thus far.

CASE DESCRIPTION

A 3-year 2-month-old child presented to the emergency department after a fall with severe scalp swelling. The child was noted to have mild frontal bossing and bilateral exophthalmos. Head size was normal but bilateral mild papilloedema was noted. CT scan was performed and demonstrated pancraniosynostosis and diffuse subgaleal hematoma. Patient underwent fronto-orbital advancement and total cranial vault reconstruction with favorable outcome.

CONCLUSION

Our reported case adds to the current limited knowledge of this rare entity and emphasized the importance of a high index of suspicion in children with apparently normal head size and shape but show subtle evidence of raised intracranial pressure.