Preoperative craniofacial dysmorphology in isolated sagittal synostosis: a comprehensive anthropometric evaluation

Isolated Sagittal Craniosynostosis: A Comprehensive Review

Sagittal craniosynostosis, a rare but fascinating craniofacial anomaly, presents a unique challenge for both diagnosis and treatment. This condition involves premature fusion of the sagittal suture, which alters the normal growth pattern of the skull and can affect neurological development. Sagittal craniosynostosis is characterised by a pronounced head shape, often referred to as scaphocephaly. Asymmetry of the face and head, protrusion of the fontanel, and increased intracranial pressure are common clinical manifestations. Early recognition of these features is crucial for early intervention, and understanding the aetiology is, therefore, essential. Although the exact cause remains unclear, genetic factors are thought to play an important role. Mutations in genes such as FGFR2 and FGFR3, which disrupt the normal development of the skull, are suspected. Environmental factors and various insults during pregnancy can also contribute to the occurrence of the disease. An accurate diagnosis is crucial for treatment. Imaging studies such as ultrasound, computed tomography, magnetic resonance imaging, and three-dimensional reconstructions play a crucial role in visualising the prematurely fused sagittal suture. Clinicians also rely on a physical examination and medical history to confirm the diagnosis. Early detection allows for quick intervention and better treatment outcomes. The treatment of sagittal craniosynostosis requires a multidisciplinary approach that includes neurosurgery, craniofacial surgery, and paediatric care. Traditional treatment consists of an open reconstruction of the cranial vault, where the fused suture is surgically released to allow normal growth of the skull. However, advances in minimally invasive techniques, such as endoscopic strip craniectomy, are becoming increasingly popular due to their lower morbidity and shorter recovery times. This review aims to provide a comprehensive overview of sagittal craniosynostosis, highlighting the aetiology, clinical presentation, diagnostic methods, and current treatment options.

Three-Dimensional Assessment of Frontal Bossing and Temporal Pinching in Patients with Sagittal Craniosynostosis Using Curvature Analysis

BACKGROUND

Sagittal craniosynostosis results in varying degrees of frontal bossing and bilateral temporal pinching. This study assessed the three-dimensional changes in these regions using curvature analysis and volumetric analysis before and 1 year after extended sagittal strip craniectomy (ESC) with postoperative helmet therapy.

METHODS

A retrospective review of three-dimensional photographs of 50 subjects treated with ESC with postoperative helmet therapy and 50 age-matched controls was performed. Images were collected preoperatively and 1 year postoperatively. Forehead convexity and temple concavity were quantified. Computed tomographic scans of subjects with and without sagittal synostosis were analyzed to assess the percentage of total intracranial volume (ICV) in the anterior cranial fossa before and after ESC with postoperative helmet therapy.

RESULTS

Forehead convexity in the ESC with postoperative helmet therapy group preoperatively (24.49 ± 3.16 m -1 ) was significantly greater than controls (22.48 ± 3.84 m -1 ; P = 0.005). Forehead convexity significantly decreased after ESC with postoperative helmet therapy (18.79 ± 2.43 m -1 ; P < 0.001) and did not differ from controls (19.67 ± 3.08 m -1 ; P = 0.115). The ESC group had more concave temples preoperatively (-10.27 ± 4.37 m -1 ) as compared with controls (-6.99 ± 3.55 m -1 ; P < 0.001). Temple concavity significantly decreased after ESC (-4.82 ± 3.17 m -1 ; P < 0.001) and did not differ from controls (-5.64 ± 3.27 m -1 ; P = 0.075). In the ESC group, the percentage ICV in the anterior cranial fossa decreased from 22.03% to 18.99% after surgery, whereas the anterior volume in controls was stable (17.74% to 16.81%).

CONCLUSIONS

The ESC group had significantly greater forehead convexity, temple concavity and anterior cranial fossa volume compared with controls. One year after ESC with postoperative helmet therapy, forehead convexity, temple concavity, and percentage ICV in the anterior fossa were comparable to controls.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Making the Diagnosis in Sagittal Craniosynostosis-It's Height, Not Length, That Matters

INTRODUCTION

This study assesses the diagnostic reliability of a novel photogrammetric measurement to distinguish sagittal craniosynostosis (SS) from control and false positive cases (SNS).

METHODS

Head CTs from 2014-2020 were reviewed for patients with sagittal synostosis (SS, n = 177), presumed sagittal synostosis with normal imaging (SNS, n = 30), and controls (n = 100). Using preoperative clinical photographs and CTs, a measurement reflecting the anterior-posterior location of the vertex was measured using an angle drawn between the cranial vertex, nasion, and opisthocranion (VNO) in profile view, with the head in a neutral position.

RESULTS

Mean age at pre-operative head CT was 9.5 months for the SS cohort, 4.2 months for the SNS cohort, and 8.9 months for controls (p = .327). Mean age at pre-operative clinical photograph was 9.5 months for the SS cohort and 4.2 months for the SNS cohort (p = .149). Pearson correlations revealed no significant association between age and VNO angle. The average VNO angle measured on clinical photographs was 54.7° ± 3.8° for the SS group, 43.1° ± 2.2° for the SNS group, and 41.1° ± 3.7° for controls (p < .001). Receiver operating characteristic (ROC) analysis yielded a cut-off of ≥ 50° to identify SS. Diagnostic sensitivity and specificity were 96.6% and 99.2%, respectively. Three-rater analysis yielded an average ICC of 0.742 (p = .004).

CONCLUSIONS

Measurement of the VNO angle is a reliable screening tool to diagnose sagittal craniosynostosis, with an angle of 50° or more suggesting suture synostosis. This method relies on the relationship between the anterior displacement of the vertex and occipital bulleting to approach the diagnostic accuracy of CT imaging.

CT-based radiomics modeling for skull dysmorphology severity and surgical outcome prediction in children with isolated sagittal synostosis: a hypothesis-generating study

PURPOSE

To investigate the potentialities of radiomic analysis and develop radiomic models to predict the skull dysmorphology severity and post-surgical outcome in children with isolated sagittal synostosis (ISS).

MATERIALS AND METHODS

Preoperative high-resolution CT scans of infants with ISS treated with surgical correction were retrospectively reviewed. The sagittal suture (ROI_entire) and its sections (ROI_anterior/central/posterior) were segmented. Radiomic features extracted from ROI_entire were correlated to the scaphocephalic severity, while radiomic features extracted from ROI_anterior/central/posterior were correlated to the post-surgical outcome. Logistic regression models were built from selected radiomic features and validated to predict the scaphocephalic severity and post-surgical outcome.

RESULTS

A total of 105 patients were enrolled in this study. The kurtosis was obtained from the feature selection process for both scaphocephalic severity and post-surgical outcome prediction. The model predicting the scaphocephalic severity had an area under the curve (AUC) of the receiver operating characteristic of 0.71 and a positive predictive value of 0.83 for the testing set. The model built for the post-surgical outcome showed an AUC (95% CI) of 0.75 (0.61;0.88) and a negative predictive value (95% CI) of 0.95 (0.84;0.99).

CONCLUSION

Our results suggest that radiomics could be useful in quantifying tissue microarchitecture along the mid-suture space and potentially provide relevant biological information about the sutural ossification processes to predict the onset of skull deformities and stratify post-surgical outcome.

Delayed Presentation of Sagittal Suture Craniosynostosis

BACKGROUND

Sagittal craniosynostosis typically presents as dolichocephaly or less frequently as clinocephaly, a "saddle-shaped" phenotype. This project aimed to characterize clinically relevant differences between sagittal synostosis phenotypes and examine the etiology of the delay in presentation.

METHODS

An institutional review board-approved retrospective review was performed from January 1999 to November 2018 at a single institution. Analyses examined correlations between subphenotype, time of presentation, minor suture fusion, developmental delay, and operative technique.

RESULTS

One hundred sixty patients diagnosed with single-suture sagittal craniosynostosis were identified. A total of 30.6% had a saddle phenotype (n = 49) and 69.4% had dolichocephaly (n = 111). Patients with the saddle phenotype were more likely to present with a developmental delay and to have at least 1 minor suture fused than patients with dolichocephaly were. Patients with the saddle phenotype presented for surgery at an older age and were more likely to undergo open cranial vault repair, with increased blood loss, higher transfusion volume, and longer time.

CONCLUSIONS

This study highlights clinical differences in sagittal craniosynostosis phenotypes and shows that developmental delay is an initial presentation of the saddle phenotype. The saddle phenotype also correlated with fusion of the minor squamous and sphenoid sutures. The link between developmental delay and minor suture fusion was notable and should be explored with a larger sample size. Patients with saddle synostosis present for surgery at an older age than patients with dolichocephaly and therefore are more likely to receive open cranial vault repair, with a taxing intraoperative experience characterized by increased blood loss, increased transfusions, and longer operation time.

Comparisons of Intracranial Volume and Cephalic Index After Correction of Sagittal Craniosynostosis With Either Two or Three Springs

ABSTRACT

In this retrospective study, the authors determined changes in intracranial volume (ICV) and cephalic index (CI) in patients with sagittal craniosynostosis and operated with craniotomy combined with either 2 or 3 springs. The authors included patients (n = 112) with complete follow-up that had undergone surgical correction for isolated sagittal craniosynostosis with craniotomy combined with springs between 2008 and 2017. All patients underwent computed tomography examination preoperative, at the time of spring extraction, and at 3 years of age. Intracranial volume was measured using a semiautomatic MATLAB program, and CI was calculated as the width/length of the skull. The authors found that craniotomy combined with 2 springs increased the ICV from a preoperative value of 792 ± 113 mL (mean ± standard deviation) to 1298 ± 181 mL at 3 years of age and increased the CI from 72.1 ± 4.1 to 74.6 ± 4.3, whereas craniotomy combined with 3 springs increased the ICV from 779 ± 128 mL to 1283 ± 136 mL and the CI from 70.7 ± 4.3 to 74.8 ± 3.7. The relative increase in ICV was 65 ± 21% in the two-spring group and 68 ± 34% in the three-spring group (P value = 0.559), and the relative increase in CI was 3.6 ± 3.3% in the two-spring group as compared with 6.0 ± 5.0% in the three-spring group (P = 0.004). These findings demonstrated that use of 3 springs resulted in additional absolute and relative CI-specific effects as compared with 2 springs during the time when the springs were in place, with this effect maintained at 3 years of age.

Evaluating Surgical Decision-making in Nonsyndromic Sagittal Craniosynostosis Using a Digital 3D Model

Surgical correction of craniosynostosis addresses potentially elevated intracranial pressure and the cranial deformity. In nonsyndromic sagittal synostosis, approximately 15% of patients have elevated intracranial pressure. The decision to operate therefore likely reflects a combination of aesthetic goals, prevention of brain growth restriction over time, surgeon training and experience, and parental expectations. This study examines clinical factors that influence surgical decision-making in nonsyndromic sagittal synostosis.

Methods

An online survey sent to craniofacial and neurosurgeons presented 5 theoretical patients with varying severities of sagittal synostosis. For each cephalic index, 4 separate clinical scenarios were presented to assess influences of parental concern and developmental delay on the decision to operate.

Results

Fifty-six surveys were completed (response rate = 28%). Participants were predominantly from North America (57%), had over 10 years of experience (75%), and performed over 20 craniosynostosis procedures annually (50%). Thirty percent of respondents indicated they would operate regardless of head shape and without clinical and/or parental concern. Head shape was the greatest predictor of decision to operate (P < 0.001). Parental concern and developmental delay were independently associated with decision to operate (P < 0.001). Surgeons with more experience were also more likely to operate across all phenotypes (OR: 2.69, P < 0.004).

Conclusions

Surgeons responding to this survey were more strongly compelled to operate on children with nonsyndromic sagittal craniosynostosis when head shape was more severe. Additional factors, including parental concern and developmental delay, also influence the decision to operate, especially for moderate phenotypes. Geographic and subspecialty variations were not significant.

Visualization of skull remodeling and re-ossification after reconstructive surgery and mosaic-like cranioplasty in sagittal synostosis and deformational brachycephaly1

INTRODUCTION

Extended vertex craniectomy in sagittal synostosis (SS) and transposition craniectomy in severe deformational brachycephaly (DB) combined with mosaic-like cranioplasty (M-LC) have been performed in 17 and 24 infants from 2001 to 2003. The hitherto not well-known mechanisms of remodeling and effectiveness of M-LC is assessed by X-ray and anthropometry.

METHODS

Follow-ups included skull radiograms preoperatively and 3 and 15 months postoperatively, which were analyzed by craniometry according to Haas, long-term anthropometry, and clinical follow-up till mean age of 7.6 and 7.4 years. Analysis included the following: time course of cephalic indexes (CI), sizes of distances (breadth, length, height) and modulus, and mean deviation of distances and modulus from the normal age- and sex-dependent values; evaluation of re-ossification of the operative defects covered by M-L C.

RESULTS

CI in SS is normalized in early follow-up with stabilization thereafter; CI of DB is gradually normalized till late follow-up. Remodeling occurs in both disorders by active and passive mechanisms: increased growth of distances with preoperative minus and decreased growth of distances with surplus. The latter mechanism adds more to the postoperative remodeling. M-LC leads to concentric and final complete re-ossification of the defects.

DISCUSSION

Significant remodeling of the skull vault is observed in both disorders by the demonstrated time course and mechanisms. M-LC does not hinder early remodeling and guarantees re-ossification of the defects.

3D stereophotogrammetry versus traditional craniofacial anthropometry: Comparing measurements from the 3D facial norms database to Farkas's North American norms

INTRODUCTION

Datasets of soft-tissue craniofacial anthropometric norms collected with the use of different methods are available, but there is little understanding of how the measurements compare. Here we compare a set of standard facial measurements between 2 large datasets: the 3D Facial Norms (3DFN) dataset collected with the use of 3D stereophotogrammetry (n = 2454), and the Farkas craniofacial norms collected with the use of direct anthropometry (n = 2326).

METHODS

A common set of 24 craniofacial linear distances were compared by computing standardized effect sizes (Cohen d) for each measurement to describe the overall direction and magnitude of the difference between the 2 datasets.

RESULTS

Variables with higher mean d values (suggesting greater discrepancy across datasets) included measurements involving the ear landmark tragion, the landmark nasion, the width of nasolabial structures, the vermilion portion of the lips, and palpebral fissure length. Variables with lower mean d values included smaller midline measurements involving the lips and lower face and horizontal distance measures between the eyes. Eight measurements showed a significant negative correlation (P < 0.05) between Cohen d and age, indicating greater similarity across the 2 datasets as age increased.

CONCLUSIONS

There are considerable differences between the 3DFN and Farkas norms. In addition to the measurement methods, other factors accounting for discrepancies may include secular trends in craniofacial morphology or differences in ethnic composition.

Comparing Cephalic Index and Midsagittal Vector Analysis in Assessing Morphology in Sagittal Synostosis: A CT-Based Morphometric Analysis

INTRODUCTION

Assessment of cranial dysmorphism in sagittal synostosis is often subjective but objective measures can be applied. These include cephalic index (CI) and midsagittal vector analysis (MSVA).

OBJECTIVE

To assess discriminant validity, construct validity, and responsiveness of CI and MSVA measured from computed tomography (CT) in patients with sagittal synostosis.

METHODS

Patients with nonsyndromic isolated sagittal synostosis with complete preoperative (n = 30) and postoperative (n = 13) CT data were included. Age-matched control group (n = 24) comprised of normocephalic patients who underwent CT for reasons related to trauma.

OUTCOME MEASURES

Retrospective CT evaluation of CI and MSVA was conducted and correlated with a dysmorphism numeric rating scale (D-NRS) that measured surgeon-rated severity of sagittal synostosis. Responsiveness of CI and MSVA was evaluated using dysmorphism global rating of change (D-GRC).

RESULTS

Thirty patients with sagittal synostosis were demographically similar to 24 normocephalic patients. The difference in CI and MSVA was statistically significant between normocephalic and scaphocephalic patients. Cephalic index had a good correlation with D-NRS (r = -0.665, ρ = -0.667), but not with MSVA (r = 0.250, ρ = 0.203). Change in CI (r = 0.738, ρ = 0.657) was well correlated with D-GRC, but not with MSVA (r = -0.409, ρ = -0.301).

CONCLUSION

Cephalic index appears to quantify the severity of sagittal synostosis better than MSVA. Cephalic index also has better responsiveness than MSVA to measure a reduction in severity of disease; however, MSVA is a better descriptive craniometric measurement. Midsagittal vector analysis was able to quantify the shift in morphology in sagittal synostosis following surgical treatment.

The value of three-dimensional photogrammetry in isolated sagittal synostosis: Impact of age and surgical technique on intracranial volume and cephalic index─a retrospective cohort study

PURPOSE

The aim of this study was to compare the outcome of intracranial volume (ICV) and cephalic index (CI) between two different techniques for surgical therapy of sagittal synostosis.

MATERIAL AND METHODS

Between 2011 and 2015, all patients scheduled for surgical therapy of sagittal synostosis were consecutively enrolled. All patients younger than 6 months underwent early extended strip craniectomy (ESC group), and patients older than 6 months underwent late modified pi-procedure (MPP group). To measure ICV and CI, data acquisition was performed via three-dimensional photogrammetry, 1 day before (T0) and between 10 and 12 weeks after surgery (T1). Results were compared with an age-matched reference group of healthy children. Perioperative parameters, as duration of surgery and the amount of blood loss of both surgical procedures were analyzed.

RESULTS

A total of 85 patients were enrolled. Of the patients, 48 underwent an extended strip craniotomy with parietal osteotomies and biparietal widening and 37 patients underwent a late modified pi-procedure. There was no significant difference between the ESC group and the MPP group regarding the efficacy of improving CI (p > 0.05). Both techniques were able to normalize CI and to improve head shape. ICV was normal compared to age-matched norm-groups with both techniques, pre- and postoperatively. However, duration of the surgical procedure and calculated blood loss were significantly lower in the ESC group (p < 0.05).

CONCLUSION

ESC and MPP were effective techniques to normalize cephalic index (CI) and improve head shape at their recommended time of surgery. Measurement of ICV and CI with 3D photogrammetry is a valid method to objectively evaluate patients before and after surgery without exposing pediatric patients to ionizing radiation.

Multidisciplinary care of craniosynostosis

The management of craniosynostosis, especially in the setting of craniofacial syndromes, is ideally done in a multidisciplinary clinic with a team focused toward comprehensive care. Craniosynostosis is a congenital disorder of the cranium, caused by the premature fusion of one or more cranial sutures. This fusion results in abnormal cranial growth due to the inability of the involved sutures to accommodate the growing brain. Skull growth occurs only at the patent sutures, resulting in an abnormal head shape. If cranial growth is severely restricted, as seen in multisuture craniosynostosis, elevation in intracranial pressure can occur. Whereas most patients treated in a multidisciplinary craniofacial clinic have non-syndromic or isolated craniosynostosis, the most challenging patients are those with syndromic craniosynostosis. The purpose of this article was to discuss the multidisciplinary team care required to treat both syndromic and non-syndromic craniosynostosis.

Comparison Between Two Different Isolated Craniosynostosis Techniques: Does It Affect Cranial Bone Growth?

INTRODUCTION

Craniosynostosis is a premature closure of a cranial suture. Cranioplasty is indicated to correct skull deformity, relieve increased intracranial pressure, and promote homogenous cranial growth. Different techniques have been adopted to achieve optimal outcomes. Although surgical benefits are widely accepted, this intervention might also affect cranial skeletal growth.

METHODS

The authors conducted a retrospective case-control study including patients operated for isolated metopic or sagittal synostosis. These patients had undergone a computed tomography (CT) scan before surgery and/or at 3 years of age postoperatively. These were operated between 2002 and 2012. Intracranial volume was measured using a MATLAB application. The control group was age and sex-matched individuals who had CT scans for trauma or neurological indications. All results with P value <0.05 were considered statistically significant.

RESULTS

A total of 185 patients were included in the study with a preoperative CT scan (143 sagittal synostosis and 42 metopic synostosis). Postoperatively 160 patients were identified including 103 sagittal synostosis and 57 metopic synostosis. These patients were compared to 414 controls. There was a statistically significant reduction in intracranial volume (ICV) in patients operated for metopic synostosis with both techniques. It also demonstrated a statistically significant difference in ICV in patients with sagittal synostosis operated with Pi-plasty and a nonsignificant difference in ICV in patients operated with strip craniotomy and springs.

CONCLUSION

In conclusion, these measurements of ICV have revealed that extensive cranioplasties for premature craniosynostosis can lead to minor but significant growth restriction and reduced ICV at long-term follow-up.

Intracranial volume (ICV) in isolated sagittal craniosynostosis measured by 3D photocephalometry: A new perspective on a controversial issue

BACKGROUND

There are still controversies regarding the intracranial volumes in patients with isolated sagittal craniosynostosis compared to a healthy population. This study aimed to compare the intracranial volume of children with sagittal synostosis and scaphocephaly to an age- and gender-matched control cohort using three-dimensional (3D) photogrammetry.

METHODS

62 boys and nine girls with sagittal craniosynostosis were included in this study. The intracranial volume was measured at the first clinical presentation. However, 3D photogrammetry was performed at children not younger than 3 months. The 3D photogrammetric data of 547 healthy boys and 287 healthy girls between the ages of 3-10 month was analyzed to establish an age- and gender-matched control group.

RESULTS

Male patients with sagittal synostosis showed a significantly reduced intracranial volume compared to the reference group. For female patients, the intracranial volume was slightly lower compared to the norm group, but not significantly.

CONCLUSIONS

Male children with sagittal synostosis showed significantly decreased intracranial volume between the age of 3 and 10 months compared to an age- and gender-matched control group. Female patients in the same age group presented a lower intracranial volume compared to the norm group. Measuring intracranial volume using 3D photogrammetry is a comparable and valuable alternative to CT scans that leads to a significant reduction of radiation exposure to the growing brain.

The 3D Facial Norms Database: Part 1. A Web-Based Craniofacial Anthropometric and Image Repository for the Clinical and Research Community

With the current widespread use of three-dimensional (3D) facial surface imaging in clinical and research environments, there is a growing demand for high-quality craniofacial norms based on 3D imaging technology. The principal goal of the 3D Facial Norms (3DFN) project was to create an interactive, Web-based repository of 3D facial images and measurements. Unlike other repositories, users can gain access to both summary-level statistics and individual-level data, including 3D facial landmark coordinates, 3D-derived anthropometric measurements, 3D facial surface images, and genotypes from every individual in the dataset. The 3DFN database currently consists of 2454 male and female participants ranging in age from 3 to 40 years. The subjects were recruited at four US sites and screened for a history of craniofacial conditions. The goal of this article is to introduce readers to the 3DFN repository by providing a general overview of the project, explaining the rationale behind the creation of the database, and describing the methods used to collect the data. Sex- and age-specific summary statistics (means and standard deviations) and growth curves for every anthropometric measurement in the 3DFN dataset are provided as a supplement available online. These summary statistics and growth curves can aid clinicians in the assessment of craniofacial dysmorphology.

Application of digital anthropometry for craniofacial assessment

Craniofacial anthropometry is an objective technique based on a series of measurements and proportions, which facilitate the characterization of phenotypic variation and quantification of dysmorphology. With the introduction of stereophotography, it is possible to acquire a lifelike three-dimensional (3D) image of the face with natural color and texture. Most of the traditional anthropometric landmarks can be identified on these 3D photographs using specialized software. Therefore, it has become possible to compute new digital measurements, which were not feasible with traditional instruments. The term "digital anthropometry" has been used by researchers based on such systems to separate their methods from conventional manual measurements. Anthropometry has been traditionally used as a research tool. With the advent of digital anthropometry, this technique can be employed in several disciplines as a noninvasive tool for quantifying facial morphology. The aim of this review is to provide a broad overview of digital anthropometry and discuss its clinical applications.

Validity of the 3D VECTRA photogrammetric surface imaging system for cranio-maxillofacial anthropometric measurements

PURPOSE

The use of three-dimensional (3D) photography for anthropometric measurements is of increasing interest, especially in the cranio-maxillofacial field. Before standard implementation, accurate determination of the precision and accuracy of each system is mandatory.

METHODS

A mannequin head was labelled with 52 landmarks, and 28 three-dimensional images were taken using a commercially available five-pod 3D photosystem (3D VECTRA; Canfield, Fairfield, NJ) in different head positions. Distances between the landmarks were measured manually using a conventional calliper and compared with the digitally calculated distances acquired from labelling by two independent observers. The experimental set-up accounted for clinical circumstances by varying the positioning (vertical, horizontal, sagittal) of the phantom.

RESULTS

In the entire calliper measurement data set (n = 410), a significant difference (p = 0.02) between the directly measured and corresponding virtually calculated distances was found. The mean aberration between both modalities covering all data was 7.96 mm. No differences (p = 0.94) between the two groups were found using a cut-off of 10 % (leaving n = 369 distances) due to considerable errors in direct measurements and the necessary manual data translation. The mean diversity of both measurement modalities after cut-off was 1.33 mm (maximum, 6.70 mm). Inter-observer analysis of all 1,326 distances showed no difference (p = 0.99; maximal difference, 0.58 mm) in the digital measurements.

CONCLUSION

The precision and accuracy of this five-pod 3D photosystem suggests its suitability for clinical applications, particularly anthropometric studies. Three-hundred-and-sixty degree surface-contour mapping of the craniofacial region within milliseconds is particularly useful in paediatric patients. Proper patient positioning is essential for high-quality imaging.

Isolated sagittal craniosynostosis: definition, classification, and surgical indications

Sagittal craniosynostosis (SC) remains the most common type of synostosis, accounting for about a half of all forms. It would result from a mesenchymal disorder involving the intramembranous ossification of the sagittal suture and leading to its early fusion. No specific data on the etiologic factors are currently available. The premature ossification of the sagittal suture can result in three main types of SC, according to the different segment prevalently involved: anterior, posterior, and complete SC. The diagnosis is easily obtained by clinical examination. However, a radiological work up (3D CT scan) may be necessary to rule out hidden venous or cranial anomalies possibly associated with most severe cases, or for the surgical planning. The most common indication for surgery is the improvement of the cosmetic appearance of the skull, since a cranial deformation may have a significant psychological impact on affected subjects. To relieve from raised intracranial pressure is a further indication to surgery. Although an increased intracranial pressure can be demonstrated in a minority of affected children at diagnosis, indeed, it can present later (usually after the second/third year of life) with chronic symptoms. The role of surgery in the preservation of cognitive functions in scaphocephalic patients does not seem to be relevant, since minor anomalies of the cerebral development associated with SC would occur independently from the cranial shape. On the other hand, the surgical correction may show a protective effect on some visual skills, like the ability to fix and follow, and the fixation shift.

Need for standard outcome reporting systems in craniosynostosis

Craniosynostosis is the premature fusion of one or more cranial sutures. When a cranial suture fuses prematurely, skull growth is altered and the head takes on a characteristic pathological shape determined by the suture(s) that fuses. Numerous treatment options have been proposed, but until recently there were no parameters or guidelines of care. Establishing such parameters was an important step forward in the treatment of patients with craniosynostosis, but results are still assessed using radiographic measurements, complication rates, and ad hoc reporting scales. Therefore, clinical outcome reporting in the treatment of craniosynostosis is inconsistent and lacks methodological rigor.

Today, most reported evidence in the treatment of craniosynostosis is level 5 (expert opinion) or level 4 (case series) data. Challenges in obtaining higher quality level 1 or level 2 data include randomizing patients in a clinical trial as well as selecting the appropriate outcome measure for the trial. Therefore, determining core outcome sets that are important to both patients and health care professionals is an essential step in the evolution of caring for patients with craniosynostosis.

Traditional clinical outcomes will remain important, but patient-reported outcomes, such as satisfaction, body image, functional results, and aesthetic outcomes, must also be incorporated if the selected outcomes are to be valuable to patients and families making decisions about treatment. In this article, the authors review the most commonly used tools to assess craniosynostosis outcomes and propose a list of longitudinal parameters of care that should be considered in the evaluation, diagnosis, and treatment evaluation of a patient with craniosynostosis.