An Epidemiological Study of Nonsyndromal Craniosynostoses

Optimal untwisting of the orbital bandeau in unicoronal craniosynostosis correction: A finite element analysis

BACKGROUND

Surgical correction of unicoronal craniosynostosis (UCS) is highly complex due to its asymmetric appearance. Although fronto-orbital advancement (FOA) is a versatile technique for craniosynostosis correction, harmonization of the orbital bandeau in UCS is difficult to predict. This study evaluates the biomechanics of the orbital bandeau using different patterns and varying characteristics of inner cortical bone layer osteotomies in a finite element (FE) analysis.

METHOD

An FE model was created using the computed tomography (CT) scan of a 6.5-month-old male infant with a right-sided UCS. The unaffected side of the orbital bandeau was virtually mirrored, and anatomical correction of the orbital bandeau was simulated. Different combinations of osteotomy patterns, numbers, depths, and widths were examined (n = 48) and compared to an uncut model.

RESULTS

Reaction forces and maximum stress values differed significantly (p < 0.01) among osteotomy patterns and between each osteotomy characteristic. Regardless of the osteotomy pattern, higher numbers of osteotomies significantly (p < 0.05) correlated with reductions in reaction force and maximum stress. An X-shaped configuration with three osteotomies deep and wide to the bone was biomechanically the most favorable model.

CONCLUSION

Inner cortical bone layer osteotomy might be an effective modification to the conventional FOA approach in terms of predictable shaping of the orbital bandeau.

The Top 100 Most-Cited Publications in Clinical Craniofacial Research

INTRODUCTION

Craniosynostosis is a birth defect defined as premature closure of sutures leading to possible neurological deficits and cosmetic deformities. Most of the current literature to date focuses on craniosynostosis etiology by analyzing genetics. This paper is a bibliometric analysis of the most influential works related to the clinical management of craniosynostosis to help guide clinicians in their decision-making.

METHODS AND MATERIALS

Clarivate Web of Science database was used to identify the top 100 most-cited articles addressing the clinical management of craniosynostosis. A bibliometric review was performed to analyze publication metrics and track research trends.

RESULTS

The 100 most-cited publications pertaining to craniosynostosis management were cited a cumulative 12,779 times. The highest cited article was Shillito and colleagues' "Craniosynostosis: A Review Of 519 Surgical Patients" with 352 citations. The oldest clinical craniosynostosis article dates back to 1948, and the most recent was published in 2016. The year with the most clinical-focused publications was 2011. The most prolific author was Renier, D. The United States produced 56 of the 100 articles. Most articles (n=52) were level 3 evidence.

DISCUSSION

This bibliometric evaluation of craniosynostosis provides insight into the most impactful literature on this topic. The highest cited articles retrospectively analyze large sample sizes, outline proper evaluation, discuss intervention timelines, and highlight specific treatment plans for this birth defect. By filtering through existing literature, this analysis can guide clinicians on the management of craniosynostosis to maximize patient outcomes.

A Transfusion Regimen With Same-donor Packed Red Blood Cells Reduces Exposure to Multiple Blood Donors in Craniosynostosis Surgery

In major craniosynostosis surgery with moderate to severe blood loss, patients may be exposed to multiple donors. We have previously reported a method for reducing donor exposure using mixed pediatric units including plasma. To further reduce donor exposure, we used plasma-free divided pediatric units. The study aimed to investigate the feasibility of the new strategy for reducing donor exposure. This prospective observational study recruited children younger than 1 year who were scheduled for nonsyndromic craniosynostosis surgery. One adult red blood cell unit was divided into 4 equal units on the day before the operation for use intra- or postoperatively. Number of donor exposures, estimated blood loss, crystalloid, colloid, and blood product volumes, and coagulation parameters were evaluated. Nineteen infants were included. The mean estimated blood loss was 19 (3) mL/kg and the transfusion volume was 17 (7) mL/kg. The median donor exposure per patient was 1 (range, 1-3). During surgery, all infants received at least one DPU. Two infants received transfusions from more than one donor during the intraoperative period. In the first 24 hours postoperatively, 14 infants received transfusion; 10 received only DPUs, whereas 4 received from multiple donors. In all, multiple donor exposure was prevented in 14 of 19 infants. Postoperative Pk-INR was 1.33 (0.16); no plasma or platelets were transfused. The plasma-free DPU transfusion protocol may be useful to reduce donor exposure in open craniosynostosis surgery in infants.

Comparison of emotional and behavioral regulation between metopic and sagittal synostosis

PURPOSE

Children with surgically corrected nonsyndromic craniosynostosis have been previously found to have neurocognitive and behavioral difficulties. Children with metopic synostosis have been described to have more difficulties than children with sagittal synostosis. This study aims to characterize the behavioral differences between children with metopic and sagittal synostosis.

METHODS

Children with metopic and sagittal synostosis were recruited at school age. Parents completed four separated behavioral assessments: Conners-3 (evaluation of ADHD), Social Responsiveness Scale-2 (SRS-2: evaluation of autism), Behavior Rating Inventory of Executive Function-2 (BRIEF-2: evaluation of executive function), and Child Behavior Checklist (CBCL: evaluation of overall behavioral problems). Children underwent intelligence quotient (IQ) testing using the Wechsler Abbreviated Scale of Intelligence (WASI-II).

RESULTS

There were 91 children (45 with metopic and 46 with sagittal synostosis). More children with metopic synostosis reported requiring supportive services (57.7% vs 34.7%, p = 0.02) and more reached or exceeded borderline clinical levels of two executive function subscales of the BRIEF-2 (emotion regulation index: 33.3% vs 17.4%, p = 0.05; global executive composite: 33.3% vs 17.4%, p = 0.05). Children with sagittal synostosis had higher scores on the rule-breaking and externalizing problem subscales of the CBCL. Increasing age at surgery was associated with worse executive function scores.

CONCLUSIONS

A relationship between suture subtype and behavioral outcomes exists at school age. More children with metopic synostosis required social services indicating more overall difficulties. Children with metopic synostosis have more specific problems with executive function, while children with sagittal synostosis had more difficulties with externalizing behaviors.

Exploring Different Management Modalities of Nonsyndromic Craniosynostosis

Craniosynostosis is an atypical skull shape characterized by the premature fusion of cranial sutures. It is one of the most common congenital anomalies encountered by craniofacial surgeons, with a prevalence of one in every 2000-2500 births. It is classified into two main types: syndromic and nonsyndromic. In syndromic, the patient presents with other abnormalities involving the trunk, face, or extremities. While in nonsyndromic the only anomy is the premature fusion, which usually involves one suture; the most common subtypes are unicoronal, sagittal, bicoronal, metopic, and lambdoid. As a consequence, premature fusion before its natural time restricts the space for the brain to grow, increases intracranial pressure, causes damage to the brain tissue, and affects the development of the child. This review comprehensively provides a detailed overview of nonsyndromic craniosynostosis and aims to highlight the importance of early and accurate diagnosis, and determining the most suitable intervention, whether surgical or conservative modalities. The optimal treatment approach produces the most favorable aesthetic and functional outcomes.

Prevalence of craniosynostosis in Finland, 1987-2010: A population-based study

BACKGROUND

Craniosynostosis is a prevalent craniofacial malformation in Finland; however, comprehensive population-based epidemiological data are limited. This study aimed to estimate the total and birth prevalence of craniosynostosis in Finland from 1987 to 2010 and examine temporal trends.

METHODS

We collected the data from nationwide registers maintained by the Finnish Institute for Health and Welfare and Statistics Finland, as well as treating hospitals, encompassing live births, stillbirths, terminations for fetal anomalies, and infant deaths with suspected or diagnosed craniosynostosis or skull deformation. A craniofacial surgeon and a clinical geneticist reviewed 1878 medical records for diagnostic confirmation.

RESULTS

Out of 877 craniosynostosis cases, 83% were single-suture synostoses (all live births), 10% craniosynostosis syndromes, and 7% multisutural non-syndromic synostoses. Live birth prevalence from 1987 to 2010 was 6.0/10,000 live births, ranging from 5.0/10,000 in 1987 to 7.5/10,000 in 2010. Total prevalence, including live births, stillbirths, and terminations, varied from 5.0/10,000 in 1987 to 8.0/10,000 in 2010. Sagittal synostosis was the most common synostosis, with a prevalence of 3.9/10,000 live births, followed by metopic (0.6/10,000), unicoronal (0.4/10,000), and unilambdoid (0.1/10,000) synostoses.

CONCLUSIONS

The total combined prevalence of all craniosynostosis types significantly increased driven by a nonsignificant rise across all subgroups and a significant increase in the syndrome group. In live births increase was significant only within the syndrome subgroup, primarily due to an increase in Muenke syndrome patients. The rising prevalence of syndromes necessitates further investigation. Contrasting with trends in Europe, Australia, and the USA, Finland showed no significant increase in metopic craniosynostosis.

Optimizing Blood Loss and Management in Craniosynostosis Surgery: A Systematic Review of Outcomes Over the Last 40 Years

Surgical correction of craniosynostosis can involve significant blood loss. Rates of allogenic blood transfusion have been reported to approach 100%. Multiple interventions have been described to reduce blood loss and transfusion requirements. The aim of this study was to analyze various approaches over the last 4 decades to optimize blood loss and management during craniosynostosis surgery.

PRISMA guidelines for systematic reviews were followed. PubMed and Cochrane database searches identified studies analyzing approaches to minimizing blood loss or transfusion rate in craniosynostosis surgery.

Primary outcomes included rate or amount of allogenic or autologous blood transfusion, estimated blood loss (EBL), postoperative hemoglobin (Hg), or hematocrit (Hct) levels. Secondary outcomes were examined when reported.

Fifty-two studies met inclusion criteria. There was marked heterogeneity regarding design, inclusion criteria, surgical intervention, and endpoints. The majority of the studies were nonrandomized and noncomparative. Four studies analyzed erythropoietin (EPO), 6 analyzed various cell-saver (CS) technologies, 18 analyzed antifibrinolytics (tranexamic acid [TXA], aminocaproic acid [ACA], and aprotinin [APO]), 8 analyzed various alternatives, and 16 analyzed multimodal pathways & protocols. Some studies analyzed multiple approaches.

Although the majority of studies reviewed represent level III/IV evidence, several high-quality level I studies were identified and included. Level I evidence supported an improvement in blood outcomes by utilizing EPO, CS, and TXA, individually or in concert with one another. Thus, this review suggests that a multi-prong approach may be the most effective means to optimize blood loss and transfusion outcomes in craniosynostosis surgery.

Craniosynostosis in Isfahan, Iran: A Cross-Sectional Study

Background

Craniosynostosis is the premature closure of cranial sutures. According to the literature, several factors are related to this disorder. Due to the relatively high prevalence in Iran and a lack of related studies in this region, this study was designed to determine the characteristics of a group of these patients in this region.

Methods

This cross-sectional study was performed from 2016 to 2019 at two tertiary referral hospitals for children in Isfahan, Iran. Studied variables included: age, sex, birth weight, type of craniosynostosis, concurrent anomalies, parents' age, father's job, fetus position, maternal parity, history of maternal smoking during the pregnancy, use of fertility assistant treatments, and history of maternal endocrine disorders.

Results

We had 125 infants, including 82 (65.6%) males and 43 (34.4%) females. The most common type was metopic (29%). The most common concurrent disorder was congenital heart defects (43.2% of patients). The mean age of infants was 0.62SD0.59 years. Gender distribution showed a significant difference (p value = 0.006). While the metopic (n = 31) type was significantly more common in boys, the coronal type was female predominant (n = 14). The mean age of fathers was 33.08SD5.66 and mothers, was 29.02SD5.70 with no significant difference (p value = 0.669 and 0.149, respectively). Other evaluated factors also didn't show a significant difference.

Conclusion

Craniosynostosis is more prevalent in boys, especially the metopic type. Coronal type has a female predilection. The most common subtype is metopic. The most common concurrent congenital disorder is congenital heart defects.

Clomiphene Citrate and Enclomiphene Hydrochloride Exposure Is Associated With Interfrontal Suture Fusion in Zebrafish

Background: The last several decades have witnessed an increase in metopic craniosynostosis incidence. Population-based studies suggest that pharmacological exposure in utero may be responsible. This study examined effects of the fertility drug clomiphene citrate (CC) on calvarial development in an established model for craniofacial development, the zebrafish Danio rerio. Results: Zebrafish larvae were exposed to clomiphene citrate or its isomer enclomiphene for five days at key points during calvarial development. Larvae were then raised to adulthood in normal rearing water. Zebrafish were analyzed using whole-mount skeletal staining. We observed differential effects on survivability, growth and suture formation depending on the treatment. Treatments with CC or enclomiphene at 5.5 mm SL led to increased fusion of the interfrontal suture (p < .01) compared to controls. Conclusions: Exposure to fertility drugs appears to affect development of the cranial vault, specifically the interfrontal suture, in zebrafish. Further research is required to identify the signaling mechanisms at play. This work suggests that fertility drug treatment may contribute to the increased incidence of metopic craniosynostosis observed globally.

Craniometric and Aesthetic Outcomes in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review the published comparative aesthetic outcomes, and its determinants, for craniosynostoses surgically treated by minimally-invasive cranial procedures and open cranial vault remodeling (CVR).

DESIGN

PRISMA-compliant systematic review.

SETTING

Not-applicable.

PATIENTS/PARTICIPANTS

Articles were included if they compared spring cranioplasty, strip minimally-invasive craniectomy or CVR for outcomes related to aesthetics or head shape. Forty-two studies were included, comprising 2402 patients.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

The craniometric and PROM used to determine surgical outcomes.

RESULTS

Twenty-five studies (59%) evaluated sagittal craniosynostosis, with metopic (7;17%) and unicoronal (4;10%) the next most prevalent. Thirty-eight studies (90%) included CVR, 24 (57%) included strip craniectomy with helmeting, 9 (22%) included strip craniectomy without helmeting, 11 (26%) included spring cranioplasty, and 3 (7%) included vault distraction. A majority of studies only used 1 (43%) or 2 (14%) craniometric measures to compare techniques. In sagittal synostosis, 13 (59%) studies showed no difference in craniometric outcomes, 5 (23%) showed better results with CVR, 3 (14%) with strip craniectomy, and 1 (5%) with springs. In studies describing other synostoses, 10/14 (71%) were equivocal. Subjective outcome measures followed similar trends. Meta-analysis shows no significant difference in cranial index (CI) outcomes between CVR and less invasive procedures in patients with sagittal synostosis.

CONCLUSIONS

There is no difference in CI outcomes between CVR and less invasive procedures. The majority of literature comparing craniometric and aesthetic outcomes between CVR and less invasive procedures shows equivocal results for sagittal synostosis. However, the heterogeneity of data for other craniosynostoses did not allow meta-analysis.

Ophthalmic Manifestations of Unilateral Coronal Synostosis

PURPOSE

To summarize the ophthalmic manifestations of unilateral coronal synostosis patients.

METHODS

We performed a literature search in the electronic database of PubMed, CENTRAL, Cochrane, and Ovid Medline guided by Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement for studies evaluating ophthalmic manifestations of unilateral coronal synostosis.

RESULTS

Unilateral coronal synostosis, also called unicoronal synostosis, may be mistaken for deformational plagiocephaly, an asymmetric skull flattening common in newborns. Characteristic facial features, however, distinguish the two. Ophthalmic manifestations of unilateral coronal synostosis include a "harlequin deformity", anisometropic astigmatism, strabismus, amblyopia, and significant orbital asymmetry. The astigmatism is greater on the side opposite the fused coronal suture. Optic neuropathy is uncommon unless unilateral coronal synostosis accompanies more complex multi-suture craniosynostosis. In many cases, surgical intervention is recommended; without intervention, skull asymmetry and ophthalmic disorders tend to worsen with time. Unilateral coronal synostosis can be managed by early endoscopic stripping of the fused suture and helmeting through a year of age or by fronto-orbital-advancement at approximately 1 year of age. Several studies have demonstrated that anisometropic astigmatism, amblyopia, and severity of strabismus are significantly lower after earlier intervention with endoscopic strip craniectomy and helmeting compared to treatment by fronto-orbital-advancement. It remains unknown whether the earlier timing or the nature of the procedure is responsible for the improved outcomes. As endoscopic strip craniectomy can only be performed in the first few months of life, early recognition of the facial, orbital, eyelid, and ophthalmic characteristics by consultant ophthalmologists enables expeditious referral and optimized ophthalmic outcomes.

CONCLUSION

Timely identification of craniofacial and ophthalmic manifestations of infants with unilateral coronal synostosis is important. Early recognition and prompt endoscopic treatment appears to optimize ocular outcomes.

A Subdural Hygroma Necessitating a Subdural-Peritoneal Shunt in a Pediatric Patient Following Total Cranial Vault Remodeling Surgery

Sagittal synostosis is a common non-syndromic synostosis treated with open or endoscopic cranial vault remodeling. Early intervention is recommended to avoid restricted brain growth, increased intracranial pressure, and resultant developmental delay. Common complications such as failure or reconstruction, cerebrospinal fluid leak, blood loss, and stroke are well-reported in the literature. Here, we present a rare case of the development of a subdural hygroma following cranial vault remodeling in a seven-month-old male, necessitating the insertion of a subdural-peritoneal shunt.

An Esthetic Scoring System for Scaphocephaly Assessment and Outcomes: A Pilot Study

Scaphocephaly is the commonest form of craniosynostosis with a varied presentation consisting of many morphological components and a range of possible surgical interventions. However, with regard to esthetic assessment, there is no universally applied assessment system. The aim was to develop a simple assessment tool encompassing multiple phenotypic components of scaphocephaly. This was done by piloting a red/amber/green (RAG) scoring system to judge esthetic outcomes following scaphocephaly surgery using photographs and experienced observers. Standard photographic views of 20 patients who had undergone either passive or anterior 2/3 vault remodelling were scored by 5 experienced assessors. Using a RAG scoring system before and after scaphocephaly correction according to 6 morphological characteristics: visual impression of cephalic index, calvarial height, bitemporal pinching, frontal bossing, posterior bullet, and displacement of the vertex. All 5 assessors were asked to score the preoperative and postoperative views independently. The RAG scores were each assigned a number (1-3) and added to give a composite score (range 6-18) and these were averaged between the 5 assessors. There was a highly statistically significant difference between both preoperative and postoperative composite scores ( P <0.0001). A subgroup analysis of the postoperative composite score between the 2 surgical techniques showed no significant difference ( P =0.759). The RAG scoring system can be used to assess esthetic change following scaphocephaly correction and it provides both a visual analogue and a numerical indicator of change. This assessment method needs further validation but is a potentially reproducible way to score and compare esthetic outcomes in scaphocephaly correction.

Early bone reformation after cranial vault remodelling for sagittal craniosynostosis: A retrospective 3D analysis

This study aims to measure postoperative bone reformation percentage, rates and patterns after cranial vault remodelling (CVR) in isolated non-syndromic sagittal craniosynostosis. Volumetric bone measurements were performed starting from the DICOM files of previously available postoperative CT scans. The 3D images were then resampled into the master box, and 'Skull 3D models' were derived. The percentage of bone reformation was investigated using automated 3D analysis software. The intra-rater reliability analysis revealed high reliability (Intraclass correlation coefficient = 0.99, p < 0.001). The median bone reformation volume and rate were 11.2 ml and 1.98 ml/week, respectively. The median percentage of bone reformation was 56.7% when the median postoperative CT timing was 6.1 weeks. As a statistic model, the linear plateau showed the highest Pseudo R² in both volume and percentage of bone reformation predicting patterns. By using the calculated model at 9 weeks postoperatively, the re-osteogenesis reaches 80% of the total cranial defect. After CVR, the early bone reformation pattern was demonstrated as a linear plateau model rather than logarithmic. This study gives a better understanding of the pattern and quantity of re-osteogenesis at cranial defects after CVR. The statistic model can facilitate healthcare practitioners to predict bone reformation and improve postoperative care protocol in sagittal craniosynostosis management.

"Validation of Artificial Intelligence Severity Assessment in Metopic Craniosynostosis"

OBJECTIVE

Several severity metrics have been developed for metopic craniosynostosis, including a recent machine learning-derived algorithm. This study assessed the diagnostic concordance between machine learning and previously published severity indices.

DESIGN

Preoperative computed tomography (CT) scans of patients who underwent surgical correction of metopic craniosynostosis were quantitatively analyzed for severity. Each scan was manually measured to derive manual severity scores and also received a scaled metopic severity score (MSS) assigned by the machine learning algorithm. Regression analysis was used to correlate manually captured measurements to MSS. ROC analysis was performed for each severity metric and were compared to how accurately they distinguished cases of metopic synostosis from controls.

RESULTS

In total, 194 CT scans were analyzed, 167 with metopic synostosis and 27 controls. The mean scaled MSS for the patients with metopic was 6.18 ± 2.53 compared to 0.60 ± 1.25 for controls. Multivariable regression analyses yielded an R-square of 0.66, with significant manual measurements of endocranial bifrontal angle (EBA) (P = 0.023), posterior angle of the anterior cranial fossa (p < 0.001), temporal depression angle (P = 0.042), age (P < 0.001), biparietal distance (P < 0.001), interdacryon distance (P = 0.033), and orbital width (P < 0.001). ROC analysis demonstrated a high diagnostic value of the MSS (AUC = 0.96, P < 0.001), which was comparable to other validated indices including the adjusted EBA (AUC = 0.98), EBA (AUC = 0.97), and biparietal/bitemporal ratio (AUC = 0.95).

CONCLUSIONS

The machine learning algorithm offers an objective assessment of morphologic severity that provides a reliable composite impression of severity. The generated score is comparable to other severity indices in ability to distinguish cases of metopic synostosis from controls.

Occlusal characteristics and oral health-related quality of life in adults operated due to sagittal synostosis in childhood: a case-control study with 26 years of follow-up

PURPOSE

The aim of this case-control study was to investigate occlusal characteristics, received orthodontic treatment, oral health-related quality of life (OHRQoL), and satisfaction with dental esthetics in adults operated due to sagittal synostosis.

METHODS

The study group consisted of 40 adults (25 males, 15 females, mean age 27.4 years, range 18-41) who were operated due to isolated sagittal synostosis in childhood. The control group comprised 40 age and gender-matched adults. Occlusal characteristics were evaluated clinically during study visits. Information on the previous orthodontic treatment was collected from dental records. OHRQoL was measured using the 14-item Oral Health Impact Profile (OHIP-14), and satisfaction with dental esthetics was evaluated using a visual analogue scale.

RESULTS

No statistically significant differences were found between the patient group and the controls in malocclusion traits (overjet, overbite, molar relationships, crossbite, scissor bite), previous orthodontic treatment, pre-treatment malocclusion diagnoses, OHIP variables, or satisfaction with dental esthetics. However, there was a tendency toward increased overjet and overbite in scaphocephalic patients.

CONCLUSION

It seems that adults with scaphocephaly operated in childhood do not differ from the average population in terms of occlusion, received orthodontic treatment, or oral health-related well-being.

3-Dimensional Morphometric Outcomes After Endoscopic Strip Craniectomy for Unicoronal Synostosis

BACKGROUND

Endoscopic strip craniectomy with postoperative helmeting (ESCH) for unicoronal synostosis has shown to be a less morbid procedure when compared with fronto-orbital remodeling (FOR). We aim in this pilot study to report objective methods and quantitative morphologic outcomes of endoscopically treated unicoronal synostosis using 3-dimensional surface scans.

METHODS

Our electronic records were reviewed for ophthalmological, neurodevelopmental outcomes, and helmet-related complications. For morphologic outcomes, the following parameters were used: Cranial Index, Cranial Vault Asymmetry Index, Anterior Symmetry Ratio (ASR), and Root Mean Square between the normal and synostotic sides of the head. Three-dimensional stereophotogrammetry scans were evaluated at 3 time points preoperative, 6 months post-op, and at the end of the treatment, which was compared with age-matched scans of normal controls and FOR patients. Nonparametric tests were used for statistical analysis.

RESULTS

None of the ESCH cases developed strabismus, major neurodevelopmental delay, or helmet complications. All morphologic parameters improved significantly at 6 months post-op except for the Cranial Vault Asymmetry Index. The ASR was the only parameter to change significantly between 6 months post-op and final scans. At end of helmet treatment, ASR and Root Mean Square differed significantly between the ESCH and both FOR and control groups.

CONCLUSIONS

Endoscopic strip craniectomy with postoperative helmeting for single unicoronal synostosis had excellent clinical outcomes. Most of the improvement in head morphology occurred in the first 6 months of treatment. Despite the normalization of the overall head shape, there was residual asymmetry in the frontal and temporal regions of the head.

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.

Paediatric skull growth models: A systematic review of applications to normal skulls and craniosynostoses

INTRODUCTION

Craniosynostoses affect 1/2000 births and their incidence is currently increasing. Without surgery, craniosynostosis can lead to neurological issues due to restrained brain growth and social stigma due to abnormal head shapes. Understanding growth patterns is essential to develop surgical planning approaches and predict short- and long-term post-operative results. Here we provide a systematic review of normal and pathological cranial vault growth models.

MATERIAL AND METHODS

The systematic review of the literature identified descriptive and comprehensive skull growth models with the following criteria: full text articles dedicated to the skull vault of children under 2 years of age, without focus on molecular and cellular mechanisms. Models were analysed based on initial geometry, numerical method, age determination method and validation process.

RESULTS

A total of 14 articles including 17 models was reviewed. Four descriptive models were assessed, including 3 models using statistical analyses and 1 based on deformational methods. Thirteen comprehensive models were assessed including 7 finite element models and 6 diffusion models. Results from the current literature showed that successful models combined analyses of cranial vault shape and suture bone formation.

DISCUSSION

Growth modelling is central when assessing craniofacial architecture in young patients and will be a key factor in the development of future customized treatment strategies. Recurrent technical difficulties were encountered by most authors when generalizing a specific craniosynostosis model to all types of craniosynostoses, when assessing the role of the brain and when attempting to relate the age with different stages of growth.

Scaphocephaly and increased intra-cranial pressure in non-operated adults: A controlled anthropological study on 21 skulls

AIM AND SCOPE

The prevalence of increased intra-cranial pressure (ICP) in patients with scaphocephaly is controversial. Here, based on anthropological material, we aimed to determine whether adults with non-operated sagittal synostosis show indirect signs of increased ICP.

MATERIALS AND METHODS

Thirty-eight dry skulls (21 skulls with sagittal craniosynostosis and 17 controls) were selected from the collections of the National Museum of Natural History (Paris, France). All skulls registered as 'fused sagittal suture' or 'scaphocephaly' in the registry of the Museum were included. All had total fusion of the sagittal suture. Controls were selected within skulls of similar origin (France), without visible craniofacial anomalies. The 38 skulls were CT-scanned using a standard medical CT-scan with a protocol dedicated to dry bone imaging. Eight radiological signs associated with raised ICP were assessed: (1) calvaria and (2) skull base thinning, (3) dorsum sellae erosion, (4) sella turcica lengthening, (5) copper beaten skull, (6) suture diastasis, (7) persistent metopic suture, and (8) small frontal sinus. Scaphocephaly was assessed based on head circumference, cranial index, intra-cranial volume, fronto-nasal angle, and inter-zygomatic distance. Linear and non-linear logistic models were used to compare groups.

RESULTS

19/21 skulls with sagittal synostosis were significantly scaphocephalic. None of the criteria for ICP were significantly different in skulls with scaphocephaly relative to controls. Nevertheless, 5 individual skulls with scaphocephaly had ≥ 3 signs in favor of a history of raised ICP. We do not report the significant prevalence of indirect signs of raised ICP in adults with scaphocephaly. These results do not allow ruling out a history of early raised ICP or of minor prolonged raised ICP. Even though our findings support the fact that scaphocephaly is not significantly associated with prolonged raised ICP, individual cases (5/21) with clear signs in favor of a history of brain compression indicate that scaphocephaly correction should be considered as a functional procedure until the production of clear evidence. Cognitive assessments of non-operated adult patients with scaphocephaly could contribute to tackle this recurring question in craniofacial surgery.

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.

Bilateral Coronal Synostosis and Mega Cisterna Magna: A Case Report

Craniosynostosis is often associated with raised intracranial pressure (ICP), especially when multiple sutures are involved. In this report, we discuss an unusual association in a patient with craniosynostosis. We report a case of a two-year-old Caucasian male with bilateral coronal synostosis (BCS) who was found to have a concomitant mega cisterna magna (MCM). Although counterintuitive, even in the presence of craniosynostosis, patients with this finding can also have intracranial CSF fluid collections such as the MCM reported here. We hope this report will enhance our understanding of some similar cases that are equivocal regarding raised ICP.

Update in Management of Craniosynostosis

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the craniofacial dysmorphology of craniosynostosis, and the variation of each type. 2. Identify the functional concerns and learn the rationale behind timing of operative intervention. 3. Approach each dysmorphology critically and identify the operative intervention needed to improve form and function 4. Understand and address the specific issues related to syndromic craniosynostosis and be able to delineate management plan.

SUMMARY

Craniosynostosis is a condition in which premature fusion of one or more cranial sutures lead to abnormal head shape and growth restriction of the brain. Nonsyndromic craniosynostosis occurs in isolation, and usually involves a single suture, whereas syndromic craniosynostosis may involve multiple sutures and is associated with extracraniofacial findings. Although surgical management can be similar, the treatment plan must take into consideration issues specific to the syndromes. This article aims to provide a concise overview of the authors' current understanding regarding the presentation, treatment principle, surgical option, and debates in craniosynostosis.

Targeted Sequencing of Candidate Regions Associated with Sagittal and Metopic Nonsyndromic Craniosynostosis

Craniosynostosis (CS) is a major birth defect in which one or more skull sutures fuse prematurely. We previously performed a genome-wide association study (GWAS) for sagittal non-syndromic CS (sNCS), identifying associations downstream from BMP2 on 20p12.3 and intronic to BBS9 on 7p14.3; analyses of imputed variants in DLG1 on 3q29 were also genome-wide significant. We followed this work with a GWAS for metopic non-syndromic NCS (mNCS), discovering a significant association intronic to BMP7 on 20q13.31. In the current study, we sequenced the associated regions on 3q29, 7p14.3, and 20p12.3, including two candidate genes (BMP2 and BMPER) near some of these regions in 83 sNCS child-parent trios, and sequenced regions on 7p14.3 and 20q13.2-q13.32 in 80 mNCS child-parent trios. These child-parent trios were selected from the original GWAS cohorts if the probands carried at least one copy of the top associated GWAS variant (rs1884302 C allele for sNCS; rs6127972 T allele for mNCS). Many of the variants sequenced in these targeted regions are strongly predicted to be within binding sites for transcription factors involved in craniofacial development or bone morphogenesis. Variants enriched in more than one trio and predicted to be damaging to gene function are prioritized for functional studies.

Neurocognitive outcomes of children with non-syndromic single-suture craniosynostosis

While the focus of craniosynostosis surgery is to improve head shape, neurocognitive sequelae are common and are incompletely understood. Neurodevelopmental problems that children with craniosynostosis face include cognitive and language impairments, motor delays or deficits, learning disabilities, executive dysfunction, and behavioral problems. Studies have shown that children with multiple suture craniosynostosis have more impairment than children with single-suture craniosynostosis. Children with isolated single-suture subtypes of craniosynostosis such as sagittal, metopic, and unicoronal craniosynostosis can have distinct neurocognitive profiles. In this review, we discuss the unique neurodevelopmental profiles of children with single-suture subtypes of craniosynostosis.

The clinical manifestations, molecular mechanisms and treatment of craniosynostosis

Craniosynostosis is a major congenital craniofacial disorder characterized by the premature fusion of cranial suture(s). Patients with severe craniosynostosis often have impairments in hearing, vision, intracranial pressure and/or neurocognitive functions. Craniosynostosis can result from mutations, chromosomal abnormalities or adverse environmental effects, and can occur in isolation or in association with numerous syndromes. To date, surgical correction remains the primary treatment for craniosynostosis, but it is associated with complications and with the potential for re-synostosis. There is, therefore, a strong unmet need for new therapies. Here, we provide a comprehensive review of our current understanding of craniosynostosis, including typical craniosynostosis types, their clinical manifestations, cranial suture development, and genetic and environmental causes. Based on studies from animal models, we present a framework for understanding the pathogenesis of craniosynostosis, with an emphasis on the loss of postnatal suture mesenchymal stem cells as an emerging disease-driving mechanism. We evaluate emerging treatment options and highlight the potential of mesenchymal stem cell-based suture regeneration as a therapeutic approach for craniosynostosis.

Safety and efficacy of aprotinin versus tranexamic acid for reducing absolute blood loss and transfusion in pediatric patients undergoing craniosynostosis surgery: a randomized, double-blind, three-arm controlled trial

OBJECTIVE

Craniosynostosis surgery is associated with considerable blood loss and need for transfusion. Considering the lower estimated blood volume (EBV) of children compared to adults, excessive blood loss may quickly lead to hypovolemic shock. Therefore, reducing blood loss is important in craniosynostosis surgery. This study was conducted to evaluate the efficacy of aprotinin or tranexamic acid (TXA) in blood loss reduction in these patients.

METHODS

In the current randomized controlled trial, 90 eligible pediatric patients with craniosynostosis were randomly divided into three groups to receive either aprotinin, TXA, or no intervention. The absolute blood loss and transfusion amount were assessed for all patients both intraoperatively and 2 and 8 hours postoperatively.

RESULTS

Although crude values of estimated blood loss were not significantly different between groups (p = 0.162), when adjusted to the patient's weight or EBV, the values reached the significance level (p = 0.018), particularly when the aprotinin group was compared to the control group (p = 0.0154). The EBV losses 2 hours and 8 hours postoperatively significantly dropped in the TXA and aprotinin groups compared to the control group (p = 0.001 and p < 0.001, respectively). Rates of postoperative blood transfusion were significantly higher in the control group (p = 0.024). Hemoglobin and hematocrit 8 hours postoperatively were lower in the control group than in the TXA or aprotinin treatment groups (p < 0.002 and p < 0.001, respectively). There were no serious adverse events associated with the interventions in this study.

CONCLUSIONS

Aprotinin and TXA can reduce blood loss and blood transfusion without serious complications and adverse events in pediatric patients undergoing craniosynostosis surgery.

Disparities in Craniosynostosis Outcomes by Race and Insurance Status

ABSTRACT

Disparities in access to care for surgical intervention in craniosynostosis have been suggested as a cause in discrepancies between the surgical approach and consequently perioperative outcomes following surgery. This work aimed to investigate the influence of race, insurance status, and the presence of craniosynostosis-related conditions on the short-term outcomes after the surgical management of craniosynostosis. Using the National Inpatient Sample database for the years 2010 to 2012, sociodemographic predictors for 30-day postoperative complication rates and requirements for blood transfusion in craniosynostosis surgeries were identified. Medicaid patients were significantly more likely to experience complications (P = 0.013) and higher rates of blood transfusions (P = 0.011). Compared to those without any complications, patients who experienced postoperative complications and blood transfusions were older (191.5 versus 181.7 days old, P < 0.001), had a greater number of chronic diseases (P < 0.001), and had a longer average length of stay (P < 0.001). On multivariable regression, Medicaid patients were 1.7 times more likely to experience any postoperative complication compared to privately insured patients. White patients also experienced a 0.741 times lower likelihood of requiring a blood transfusion. At the hospital level, receiving surgery at government-operated hospitals was found to be a protective factor for postoperative complications compared to for-profit private (P = 0.016) and nonprofit private (P = 0.028). Healthcare providers and policy makers should be cognizant of these sociodemographic disparities and their potential causes to ensure equitable treatment for all patients regardless of insurance status and racial/ethnic background.

Treatment of Sagittal Craniosynostosis using Osteoplastic Parietal Craniotomy Flap with Distraction Osteogenesis: A Variation on Technique

ABSTRACT

Late presentation sagittal craniosynostosis presents a unique challenge due to the decreased ability of the skull to repair the bony defects created by standard of care techniques. Distraction osteogenesis is a viable strategy to correct this defect in late presenting cases. The authors describe a variation in technique in which the temporalis muscle origin is retained, creating an osteoplastic bone flap with retained vascularity through the temporalis muscle. This may improve postoperative bony healing of bony defects in this compromised population. The authors present two patients who presented to them late with sagittal synostosis who were treated with distraction osteogenesis in which vascular continuity to the parietal bones is preserved through the temporalis muscle.

Genetics of craniofacial malformations

The field of craniofacial malformations is comprehensive and does not allow to discuss all craniofacial malformations which have been described as single entities. Many of the syndromes with craniofacial malformations are ultrarare. In this review we have chosen craniofacial malformation syndromes which are of relevance for the pediatrician, especially neonatologist: different types of craniosynostoses, oculo-auriculo-vertebral spectrum, Pierre Robin sequence and Treacher Collins syndrome. These syndromes will be described in detail. Diagnostic and therapeutic options will be discussed.

Nonsyndromic craniosynostosis in Vietnam: initial surgical outcomes of subspecialty mentorship

OBJECTIVE

There is a global deficit of pediatric neurosurgical care, and the epidemiology and overall surgical care for craniosynostosis is not well characterized at the global level. This study serves to highlight the details and early surgical results of a neurosurgical educational partnership and subsequent local scale-up in craniosynostosis correction.

METHODS

A prospective case series was performed with inclusion of all patients undergoing correction of craniosynostosis by extensive cranial vault remodeling at Children's Hospital 2, Ho Chi Minh City, Vietnam, between January 1, 2015, and December 31, 2019.

RESULTS

A total of 76 patients were included in the study. The group was predominantly male, with a male-to-female ratio of 3.3:1. Sagittal synostosis was the most common diagnosis (50%, 38/76), followed by unilateral coronal (11.8%, 9/76), bicoronal (11.8%, 9/76), and metopic (7.9%, 6/76). The most common corrective technique was anterior cranial vault remodeling (30/76, 39.4%) followed by frontoorbital advancement (34.2%, 26/76). The overall mean operative time was 205.8 ± 38.6 minutes, and the estimated blood loss was 176 ± 89.4 mL. Eleven procedures were complicated by intraoperative durotomy (14.5%, 11/76) without any damage of dural venous sinuses or brain tissue. Postoperatively, 4 procedures were complicated by wound infection (5.3%, 4/76), all of which required operative wound debridement. There were no neurological complications or postoperative deaths. One patient required repeat reconstruction due to delayed intracranial hypertension. There was no loss to follow-up. All patients were followed at outpatient clinic, and the mean follow-up period was 32.3 ± 18.8 months postoperatively.

CONCLUSIONS

Surgical care for pediatric craniosynostosis can be taught and sustained in the setting of collegial educational partnerships with early capability for high surgical volume and safe outcomes. In the setting of the significant deficit in worldwide pediatric neurosurgical care, this study provides an example of the feasibility of such relationships in addressing this unmet need.

Premature Fusion of the Sagittal Suture as an Incidental Radiographic Finding in Young Children

BACKGROUND

Craniosynostosis typically develops prenatally and creates characteristic changes in craniofacial form. Nevertheless, postnatal forms of craniosynostosis have been described. The purpose of this study was to determine the prevalence of incidentally identified, but temporally premature, cranial suture fusion in normocephalic children.

METHODS

Computed tomographic scans obtained from children aged 1 to 5 years evaluated in the authors' emergency department between 2005 and 2016 were reviewed for evidence of craniosynostosis. Patients with prior ventriculoperitoneal shunt, brain or cranial abnormality, or known syndromes were excluded. The presence of craniosynostosis and cranial index was assessed by a panel of three craniofacial surgeons and one pediatric neurosurgeon. Demographic information, fusion type, reason for the computed tomographic scan, and medical history were recorded as covariates. Cranial shape and intracranial volume were calculated using previously validated automated system.

RESULTS

Three hundred thirty-one patients met the inclusion criteria. The mean age was 2.4 ± 1.3 years. Eleven patients (3.3 percent) were found to have a complete (n = 9) or partial (n = 2) fusion of the sagittal suture. All patients had a normal cranial index (0.80; range, 0.72 to 0.87) and a grossly normal head shape. Only two fusions (18.2 percent) were documented by the radiologist. Cranial shape analysis performed in five of the 11 patients showed subtle phenotypic changes along the scaphocephaly spectrum in four patients, with a normal shape in the remaining case.

CONCLUSIONS

Sagittal fusion is present in 3.3 percent of otherwise phenotypically normal children aged 1 to 5 years. The clinical significance of this result is unclear, but routine screening of affected patients is paramount.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Do standard surgical techniques lead to satisfying aesthetic results in nonsyndromic sagittal suture synostosis?

OBJECTIVE

Surgical correction of synostotic cranial sutures is typically performed early in an affected child's life. Depending on the severity of the cranial synostoses, different aspects of the surgical treatment may have varying degrees of importance. In this sense, the aesthetic appearance in children with normal neurological development in single-suture synostosis plays an important role in self-perception and social acceptance for both the patients themselves and their caregivers. Therefore, in this study, the authors aimed to evaluate the aesthetic outcome after surgical correction in a cohort of patients with nonsyndromic sagittal suture synostosis.

METHODS

Between December 2002 and December 2019, a total of 99 patients underwent surgical correction of a synostotic sagittal suture at the Medical University of Vienna. Depending on their age, patients underwent either an extended midline strip craniectomy (EMSC) (< 4 months) or a modified pi procedure (MPP) (≥ 4 months). After the surgical procedure, the outcome was evaluated by the treating neurosurgeon at 1- and 12-month follow-up visits, and after approximately 5 years, before the patient entered elementary school. In addition to that, the patients' caregivers were asked to evaluate the aesthetic outcome of the surgical procedure after 12 months. These results were then compared to evaluate potential differences in the perception of the surgical outcome.

RESULTS

After 12 months, the majority of the included patients were evaluated as having a good aesthetic outcome by the treating neurosurgeon (97%) and by their caregivers (89%). These differences did not show statistical significance (p = 0.11). Similarly, no differences in the aesthetic outcome depending on the surgical procedure performed could be found (p = 0.55). At the last follow-up visit, before entering elementary school, all available patients had an excellent or good surgical outcome. Moreover, the majority of caregivers (73%) reported that their child had a normal head shape appearance after surgical correction.

CONCLUSIONS

The results of this study have suggested that surgical correction of sagittal suture synostosis by simple operative techniques leads to a good aesthetic outcome and a normal head shape appearance in the majority of patients. An analysis of the evaluation of the surgical outcome by either the treating neurosurgeon or the patient caregivers showed comparable results and, thus, early intervention with simple surgical techniques can be recommended.

Modified Cephalic Index Measured at Superior Levels of the Cranium Revealed Improved Correction With Helmet Therapy for Patients With Sagittal Suture Craniosynostosis

OBJECTIVE

Historically, studies have shown that cranial remolding therapy improves surgical correction and protects against regression for patients with sagittal suture craniosynostosis. This study aimed to define the most responsive cranial height for measuring cephalic index (CI) following cranial remolding therapy for infants with sagittal suture craniosynostosis.

METHODS

The authors performed a retrospective analysis of data between January 2018 and August 2019. The outcomes measured were CI-3 (level of glabella) through CI-7 (superior to eurions), where each value was defined as the width at levels 3 through 7 divided by the length at level 3. Differences between baseline- and post-treatment measurements were assessed using a 5 × 2 repeated measures analysis of variance.

RESULTS

Data from thirty-four patients (19 males, 15 females, and mean age 2.79 months) were analyzed. Mean treatment duration was 4.59 ± 1.86 months. There was a significant increase between baseline and posttreatment measurements (baseline: 72.60% ± 0.70%, post: 76.30% ± 0.80%; F1,33 = 27.74, P < 0.001). The interaction effect for CI level * baseline-post was also significant (F1.43,47.16 = 6.75, P = 0.006). Post hoc analyses revealed the posttreatment measures were significantly greater than baseline measures at every CI level. The magnitude of the measured differences systematically decreased from CI-7 to CI-3, with a greater effect size at the most superior level (ie CI-7) of 0.961 compared to 0.778 at the traditional level (ie CI-3).

CONCLUSIONS

The CI measurement at level 7 demonstrated the greatest responsiveness to treatment, whereas the traditional CI measurement taken at level 3, the current standard, proved the least responsive.

Quantifying Orthotic Correction of Trigonocephaly Using Optical Surface Scanning

ABSTRACT

Numerous publications describe techniques to measure trigonocephaly caused by metopic synostosis, but they are potentially hazardous for use in acquiring longitudinal data. Optical surface scanning technology can safely yield craniometrics but has not established a practical means for measuring objective morphological changes to trigonocephaly during the practical time constraints of a clinical visit. The purpose of this preliminary study was to evaluate a method for safely and repeatedly measuring frontal angle (FA) using technology available at multiple centers providing treatment with cranial remolding orthoses.Optical scans of infants who underwent endoscopic-assisted minimally-invasive craniectomy for repair of metopic synostosis with cranial remolding were retrospectively analyzed. A novel FA measurement technique "FA30" was developed based on repeatable, geometrically-related surface landmarks approximating the glabella and frontotemporali. Results were compared to a control group and categories of non-synostotic deformity. Inter-rater reliability was assessed for pre- and post-treatment scan measurements among separate clinicians.All trigonocephalic subjects (n = 5) had initial FA30 significantly lower than the control group and other cohorts (P < 0.001). During the course of orthotic cranial remolding following surgical release mean FA30 increased from 121.5° to 138.5° (P < 0.001), approaching the control group mean of 144.4°. Intraclass coefficient calculation showed high reliability (intraclass correlation coefficient: 0.993, 95% confidence interval: 0.957-0.998, P < 0.001), which was supported with Bland-Altman analyses of agreement.Optical surface scanning may provide a safe, accurate, and repeatable means to measure FA. Increase in FA30 demonstrates correction of trigonocephaly. The method presented enables expeditious reporting of treatment progress to the infant's surgeon and parents, and has potential for use in optimizing treatment outcomes at multiple centers.

Comparison of aesthetic outcomes between open and endoscopically treated sagittal craniosynostosis

OBJECTIVE

In the last several decades, there has been much debate regarding the ideal treatment for sagittal synostosis. The purpose of this study was to compare perioperative, anthropometric, and subjective assessments of cosmetic outcomes between open and endoscopic management of isolated sagittal synostosis.

METHODS

At their routine postoperative follow-up, pediatric patients with sagittal craniosynostosis were recruited to undergo digital cranial measurement and standardized photography for objective and subjective assessments of perioperative outcomes. Age-normalized z-scores for cephalic index, head circumference, euryon-euryon diameter (Eu-Eu), and glabella-opisthocranion diameter (G-Op) were calculated for each patient. Faculty surgeons, surgical trainees, nurses, and laypersons were asked to rate the normalcy of craniofacial appearances using a 5-point Likert scale. Outcomes were compared between patients treated with endoscopic correction and those treated with open repair.

RESULTS

A total of 50 patients were included in the study. Thirty-one had undergone open surgical correction, and 19 had undergone endoscopic treatment. Endoscopic repair involved significantly lower operative time, blood loss, transfusion rate, and hospital length of stay than those with open repair (p < 0.001). There was no significant difference between groups in terms of z-scores for head circumference (p = 0.22), cephalic index (p = 0.25), or Eu-Eu (p = 0.38). Endoscopic treatment was associated with a significantly lower G-Op (p = 0.009). Additionally, the average subjective rating of head shape was higher for endoscopic treatment when corrected for age, gender, and ethnicity (p = 0.02).

CONCLUSIONS

The study findings suggest that patients who are treated endoscopically may have an overall more normal appearance in skull morphology and cosmesis, although these results are limited by poor reliability.

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.

Quantitative outcomes of endoscopic strip craniectomy for metopic craniosynostosis in children with severe trigonocephaly

PURPOSE

To assess intermediate-term (> 3 years) outcomes of endoscopic strip craniectomy with postoperative helmet therapy (ESC + HT) for the treatment of infants with severe trigonocephaly.

METHODS

This retrospective study examined cranial morphology of consecutive patients with severe trigonocephaly treated with minimally invasive ESC + HT. Preoperative and follow-up clinical parameters were collected from patient charts. Interfrontal divergence angle (IFDA), a validated and accurate measure of forehead narrowing, was measured on preoperative CT scans and on preoperative and postoperative 2D photographs.

RESULTS

Seven patients (4 male, 3 female) were included with a mean age at surgery of 2.76 months (range 1.8 to 4.1 months) and mean clinical follow-up of 3.71 years (photographic follow-up 2.73 years). The mean operative time was 91.4 min, with a mean estimated blood loss (EBL) of 57.1 ml and mean hospital length of stay of 1.14 days. IFDA improved from 118.8° to 135.9° (p < 0.01), with the mean final measurement falling within normal limits. The head circumference percentile was not significantly changed in follow-up. There was a statistically significant improvement in the inner-to-outer canthal distance ratio (p = 0.01) in follow-up, showing an improvement in hypotelorism. There were no dural tears, CSF leaks, infections, or other significant surgical morbidities, and there were no serious complications related to the use of helmet therapy. All patients achieved excellent aesthetic results judged by photographic comparison.

CONCLUSION

This study demonstrated that patients treated with ESC + HT for metopic craniosynostosis showed measurable and significant improvement in forehead shape. This technique is a safe and effective alternative to more invasive surgical interventions.

Distinguishing craniomorphometric characteristics and severity in metopic synostosis patients

The decision about which metopic synostosis patients should undergo surgery remains controversial. Multiple measures for radiographic severity have been developed in order to determine the optimal criteria for treatment. The aim of this study was to perform an extensive craniomorphometric analysis of patients who underwent surgery for metopic synostosis to validate and compare the various severity scales developed for this non-syndromic craniosynostosis. A comparative morphometric analysis was performed using computed tomography scans of preoperative metopic synostosis patients (n=167) and normal controls (n=44). Measurements included previous and newly developed metopic severity indices. Volumetric and area analyses were used to determine the degree of anterior cranial area and potential volume restrictions. Of the severity indices measured, the frontal angle, endocranial bifrontal angle (EBF), adjusted EBF (aEBF), anterior cranial fossa angle, horizontal cone angle, and bitemporal/biparietal distance ratio were significantly different in the metopic subjects relative to controls overall. However, metopic index, orbital rim angle, foramen ovale distance, and cranial volume exhibited no significant difference from controls. Only the frontal angle and aEBF correlated with the changes in anterior cranial dimensions observed in metopic synostosis. In conclusion, the frontal angle and aEBF provide the most accurate measures of severity in metopic synostosis.

A protocol of situation-dependent transfusion, erythropoietin and tranexamic acid reduces transfusion in fronto-orbital advancement for metopic and coronal craniosynostosis

PURPOSE

Assess the effect of a protocol of preoperative erythropoietin (EPO) and ferrous sulfate in addition to perioperative tranexamic acid (TXA) on blood transfusions in patients with coronal or metopic craniosynostosis undergoing cranial vault remodeling (CVR) with fronto-orbital advancement (FOA).

METHODS

Retrospective review of all coronal and metopic craniosynostosis patients undergoing CVR and FOA from March 2010 to June 2019 was performed. Before 2014 ("Control group"), all patients received blood transfusion at the start of surgery. In 2014, a protocol of preoperative EPO and ferrous sulfate with perioperative TXA and non-automatic transfusion was instituted ("Study group"). Patient demographics and anthropometrics, perioperative hemoglobin (Hb) levels, and transfusion details were collected and compared.

RESULTS

Thirty-six patients met inclusion criteria. Twenty-one patients were in the control group, and 15 in the Study group. Nineteen patients had metopic synostosis, 11 had unicoronal synostosis, and 6 had bicoronal synostosis. There were no significant differences between groups in demographics, operative time, intraoperative crystalloid volume, craniofacial syndromes, or sutures affected. The Study group had higher preoperative Hb (13.9 ± 1.0 vs. 12.6 ± 0.8 g/dL, p < 0.001), lower intraoperative Hb nadir (7.4 ± 1.8 vs. 9.2 ± 1.2 g/dL) lower intraoperative transfusion rate (66.7% vs. 100%, p = 0.008), lower postoperative transfusion rate (0% vs 28.6%, p = 0.03), and exposure to fewer unique units of packed red blood cells (0.7 ± 0.6 vs. 1.5 ± 0.9 units).

CONCLUSION

Our protocol resulted in decreased transfusion needs. These results add valuable information to the growing body of work on transfusion reduction in craniosynostosis surgery.

Combined unilateral coronal-lambdoid suture synostosis: surgical outcome of suturectomy and postoperative helmet therapy

INTRODUCTION

Nonsyndromic, multi-suture craniosynostosis is not common, especially those involving unilateral coronal and lambdoid sutures. Based on the experience on 6 cases, we analyzed the skull morphology of combined unilateral coronal-lambdoid suture synostosis and evaluated the surgical outcome of suturectomy.

METHODS

Patients who underwent an operation for craniosynostosis in Seoul National University Children's Hospital from 2010 to 2018 were reviewed. For qualitative analysis of the surgical outcome, five typical morphologic characteristics (ipsilateral superior orbital rim deviation, deviation of the nasal ridge, ipsilateral frontal flattening, contralateral parietal bulging, ipsilateral occipitomastoid bulging) in unilateral coronal-lambdoid suture synostosis were evaluated based on medical photos, plain skull radiographs, and CT scans. For quantitative analysis, three parameters (nasal root deviation, orbital asymmetry, posterior skull base deviation) were measured.

RESULTS

Among 316 patients with craniosynostosis, 41 patients had nonsyndromic, multi-suture synostosis. There were 6 unilateral coronal-lambdoid suture synostosis patients who were all treated with suturectomy. Qualitative evaluation of the postoperative outcome revealed that the nasal root and orbital rim deviations and the contralateral occipitomastoid bulging showed satisfactory improvements. However, ipsilateral frontal flattening and contralateral parietal bulging were improved but still present in most cases. Quantitative, craniometric analysis supported the qualitative outcomes. The nasal ridge deviation angle was corrected from 7.04 to 1.79 degrees. The posterior skull base deviation angle improved from 6.29 to 3.55 degrees.

CONCLUSION

Unilateral coronal-lambdoid suture synostosis suturectomy followed by helmet therapy resulted in favorable outcomes, although the correction of frontal flattening was less satisfactory than the other measures. Considering the minimal invasiveness of the treatment, suturectomy may be a viable option for these patients.

Neurological Functional Connectivity in Unilateral Coronal Synostosis: A Side-Based Comparison

PURPOSE

Unicoronal synostosis (UCS) has been associated with reading, language, and social dysfunction. Limited brain function connectivity studies exist for UCS with none devoted to comparing outcomes by side of synostosis (left versus right-sided UCS).

METHODS

Twelve patients with surgically treated UCS, 7 right-sided and 5 left-sided, were age matched to healthy controls. Resting state functional MRI was acquired in a 3T Siemens TIM Trio scanner (Erlangen, Germany). Data was collected with intrinsic connectivity distribution and seed-connectivity analysis using BioImage Suite (Yale School of Medicine). Region of interest analysis was performed based on Brodmann areas related to emotional, executive, language, motor, and visuo-spatial function. Significance was set at P < 0.05.

RESULTS

Compared to controls, all UCS patients demonstrated decreased connectivity in areas of the parietal and temporal cortices responsible for visuo-motor coordination and language function. Right UCS patients demonstrated decreased intrinsic connectivity in regions related to complex motor movement and proprioception relative to control subjects. Left UCS patients demonstrated decreased seed connectivity between regions of the parietal lobe and occipital lobe related to motor coordination, visual function, and language compared to right UCS patients.

CONCLUSION

Unicoronal synostosis had decreased functional connectivity in regions associated with memory, visual information processing, and motor function. Moreover, left-sided UCS had decreased connectivity in circuits for motor coordination and language when compared to right-sided UCS. This study provides data suggestive of long-term sequelae of UCS that varies by sidedness, which may be responsible for neurocognitive impairments found in previous cognitive analyses.

Risk factors and time trends for isolated craniosynostosis

BACKGROUND

We sought to investigate associations between maternal/infant characteristics and isolated craniosynostosis as well as its subtypes sagittal, metopic, and coronal synostosis, and assess trends in the prevalence of these conditions.

METHODS

We identified cases in the Texas Birth Defects Registry from 1999 to 2014. We used Poisson regression to identify associations between maternal/infant characteristics and craniosynostosis. We used joinpoint regression and unadjusted Poisson regression to evaluate temporal trends. Finally, we computed adjusted Poisson models to evaluate whether temporal trends were evident after accounting for changes in the population distributions of maternal/infant characteristics over time.

RESULTS

Relative to all live births in the general population, cases were more frequently male or preterm. Mothers of cases were more frequently non-Hispanic white and more frequently obese. Non-Hispanic black or Hispanic maternal race/ethnicity was associated with a lower prevalence of all craniosynostosis subtypes. Previous live births were associated with sagittal synostosis; residence on the U.S.-Mexico border was associated with sagittal and coronal synostosis. The prevalence of any isolated craniosynostosis increased (average annual percent change estimated from joinpoint regression [AAPC]: 2.9%), as did the prevalences of sagittal (AAPC: 3.3%) and metopic synostosis (AAPC: 5.4%). In crude Poisson models, the same temporal trends were observed, however these were attenuated after adjusting for maternal/infant characteristics.

CONCLUSIONS

Prevalence of isolated craniosynostosis increased from 1999 to 2014. The largest AAPC was observed for metopic synostosis. Changes in the population distribution of associated maternal/infant characteristics may explain these trends.

Quantification of Severity of Unilateral Coronal Synostosis

OBJECTIVES

Severity of unilateral coronal synostosis (UCS) can vary. Quantification is important for treatment, expectations of treatment and natural outcome, and education of the patient and parents.

DESIGN

Retrospective study.

SETTING

Primary craniofacial center.

PATIENTS, PARTICIPANTS

Twenty-three preoperative patients with unilateral coronal craniosynostosis (age < 2 years).

INTERVENTION

Utrecht Cranial Shape Quantifier (UCSQ) was used to quantify severity using the variables: asymmetry ratio of frontal peak and ratio of frontal peak gradient.

MAIN OUTCOME MEASURES(S)

The UCSQ variables were combined and related to visual score using Pearson correlation coefficient; UCSQ and visual score were additionally compared to Di Rocco classification by one-way analysis of variance or Kruskal-Wallis test. All measurements were made on computed tomography scans.

RESULTS

Good correlation between UCSQ and visual score was found (r = 0.67). No statistically significant differences were found between group means of UCSQ in the 3 categories of Di Rocco classification (F _2,20 = 0.047; P > .05). Kruskal-Wallis test showed no significant differences between group means of visual score in the 3 categories of Di Rocco classification (Kruskal-Wallis H (2) = 0.871; P > .05).

CONCLUSIONS

Using UCSQ, we can quantify UCS according to severity using characteristics, it outperforms traditional methods and captures the whole skull shape. In future research, we can apply UCSQ to 3D-photogrammetry due to the utilization of external landmarks.

Craniosynostosis: To Study the Spectrum and Outcome of Surgical Intervention at a Tertiary Referral Institute in India

Aims and Objectives:

This study aimed to analyze the spectrum and surgical outcome of cases of craniosynostosis operated at a tertiary referral institute in India

Design:

This was a cross-sectional study.

Materials and Methods:

We retrospectively examined 60 cases of craniosynostosis operated at our institute from 2008 to 2014 (with a minimum follow-up of 2 years). Data was collected including name, age, gender, involved sutures, other medical conditions, whether syndromic craniosynostosis or not, whether symptoms and signs of intracranial hypertension were present or not, associated findings on magnetic resonance imaging of brain and cervico-medullary junction, type of surgery performed, age at which surgery was performed, perioperative complications (if any), and findings on follow-up. To be able to analyze the surgical results, we used the seven category classification system used by Sloan et al.

Results:

Craniosynostosis affected more men than women. The incidence of syndromic craniosynostosis was 11.67%. Mean age at first surgery was 3.85 years. Chiari malformation was present in 80% of the Crouzon’s syndrome cases, 62.5% of the oxycephaly cases, and 4.44% of the non-syndromic, non-oxycephaly cases. Intracranial hypertension was present in 80% of the Crouzon’s syndrome cases, 75% of the oxycephaly cases, and 6.67% of the non-syndromic, non-oxycephaly cases. Perioperative complications were present in 42.86% of the syndromic craniosynostosis cases, 50% of the oxycephaly cases, and 15.56% of the non-syndromic, non-oxycephaly cases. Compromised overall correction was present in 4 of 7 cases of syndromic craniosynostosis, 3 of 8 cases of oxycephaly, and 2 of 45 cases of non-syndromic, non-oxycephaly group.

Conclusion:

The study highlights the importance of educating the masses so that cases of craniosynostosis present early. The incidence of Chiari malformation, intracranial hypertension, and perioperative complications was significantly higher in the syndromic craniosynostosis and oxycephaly groups than in single-suture craniosynostosis. The best surgical outcome and the least perioperative complications were seen in the trigonocephaly group. Compromised overall correction and reoperations were more common in the syndromic and complex craniosynostosis groups than in single-suture craniosynostosis.

Cognitive, behavioral and psychological functioning of children and adults with conservatively managed metopic synostosis

Children diagnosed with metopic synostosis (MS) commonly experience poor neuropsychological outcomes, with research suggesting that children whose MS is managed conservatively (without surgery) potentially having worse outcomes than their operated peers. However, studies of children whose MS was managed conservatively are scarce. This study therefore examined the cognitive, behavioral, and psychological functioning of children/adults with conservatively managed MS (N = 38) and compares their outcomes to individually matched healthy controls (N = 38) of the same age and sex (matched-pairs design) from the general community. Age-appropriate, validated assessments measuring general cognition, verbal and visuospatial ability, attention and working memory, executive functioning, behavior, depression, anxiety, and satisfaction with appearance were utilized. Group differences were estimated using linear regression for (a) the overall sample and (b) by broad developmental stages: 2&3 yrs; ≥6-≤17. Moderate to large negative effects (g = -0.38 to -1.30) were evident before controlling for socio-economic status (SES), with the MS group performing significantly worse on 8 out of the 10 cognitive domains (general cognition, visuospatial ability, working memory, information processing, executive functioning: semantic & initial letter verbal fluency, switching, inhibition+switching). However, only initial letter verbal fluency (g = -0.99) and switching (g = -1.19) remained significant after adjusting for SES. The MS group displayed more behavioral problems, although this was not significant. Depression, anxiety, and satisfaction with appearance did not differ between the groups. Regular monitoring of cognitive functioning, particularly executive functioning, should be undertaken for those with conservatively managed MS.

Assessment of the Outcome of Calvarial Vault Remodeling and Spring-Mediated Cranioplasty in the Correction of Isolated Sagittal Suture Synostosis

BACKGROUND

Sagittal synostosis is the commonest form of nonsyndromic isolated craniosynostosis. Calvarial vault remodeling (CVR) and spring-mediated cranioplasty (SMC) are the commonly used correction techniques.

AIM OF THE WORK

To study and compare clinical and radiographic outcomes of CVR and SMC in the correction of isolated sagittal suture synostosis.

METHODS

A prospective cohort with the patients were divided into group; I (SMC) and II (CVR), each 15 patients. They were observed to evaluate the outcome and detect complications.

RESULTS

Mean operative time was 59.2 minutes in SMC and 184 minutes in CVR. Mean intraoperative blood loss was 26 mL in SMC and 64.7 mL in CVR. Intraoperative complications in SMC were dural tear in 1 patient and superior sagittal sinus injury in another patient, while in CVR 2 patients with dural tears and a 3rd with superior sagittal sinus injury. Postoperative complications in SMC were exposed spring, gaped wound, and parietal eminence elevation, while in CVR 2 patients needed blood transfusion. The mean hospital stays was 1.4 days in SMC and 4.1 days in CVR. In SMC, the relative increase in cephalic index varied between 5.5% and 8.2%, while for CVR, it varied between 5.1% and 7.9%.

CONCLUSION

The SMC and CVR are safe procedures, with good long-term results and significant objective changes toward normalization of the skull morphology in isolated sagittal craniosynostosis. The SMC is less invasive and associated with reduced hospital stays, decreased blood loss, and can be performed at a younger age than CVR with a lower morbidity.

Identifying the Misshapen Head: Craniosynostosis and Related Disorders

Pediatric care providers, pediatricians, pediatric subspecialty physicians, and other health care providers should be able to recognize children with abnormal head shapes that occur as a result of both synostotic and deformational processes. The purpose of this clinical report is to review the characteristic head shape changes, as well as secondary craniofacial characteristics, that occur in the setting of the various primary craniosynostoses and deformations. As an introduction, the physiology and genetics of skull growth as well as the pathophysiology underlying craniosynostosis are reviewed. This is followed by a description of each type of primary craniosynostosis (metopic, unicoronal, bicoronal, sagittal, lambdoid, and frontosphenoidal) and their resultant head shape changes, with an emphasis on differentiating conditions that require surgical correction from those (bathrocephaly, deformational plagiocephaly/brachycephaly, and neonatal intensive care unit-associated skill deformation, known as NICUcephaly) that do not. The report ends with a brief discussion of microcephaly as it relates to craniosynostosis as well as fontanelle closure. The intent is to improve pediatric care providers' recognition and timely referral for craniosynostosis and their differentiation of synostotic from deformational and other nonoperative head shape changes.

Craniometric and Volumetric Analyses of Cranial Base and Cranial Vault Differences in Patients With Nonsyndromic Single-Suture Sagittal Craniosynostosis

PURPOSE

How different from "normal" are the cranial base and vault of infants with nonsyndromic, single-suture sagittal synostosis (NSSS)? This study quantitatively addresses this question utilizing computed tomography (CT) analytic technology.

METHOD

Head CT scans of infants with NSSS and normocephalic controls were analyzed using Mimics to calculate craniometric angles, distances, and segmented volumes. Craniometric measurements and asymmetry indices were compared between NSSS and control groups using linear regressions controlling for age. Ratios of anterior-, middle-, and posterior-to-total cranial vault volume were compared between groups using beta regressions controlling for age.

RESULTS

Seventeen patients with NSSS and 19 controls were identified. Cranial index and interoccipital angle were significantly smaller in NSSS compared with controls (P = 0.003 and <0.001, respectively). Right-but not left-external acoustic meatus angle and internal acoustic meatus-to-midline distance were significantly greater in NSSS than in controls (P = 0.021 and 0.016, respectively). NSSS patients and controls did not significantly differ in any asymmetry indices, except for the articular fossa angle asymmetry index (P = 0.016). Anterior vault volume proportion was greater in NSSS relative to controls (proportion ratio = 1.63, P < 0.001). NSSS trended toward a smaller posterior vault volume proportion (P = 0.068) yet did not differ in middle vault volume proportion compared with controls.

CONCLUSION

In this small study, patients with nonsyndromic, single-suture sagittal craniosynostosis had relatively similar cranial base measurements, and larger anterior vault volumes, when compared with controls. Further work is needed to confirm the possibility of rightward asymmetry of the anterior cranial base.

Radiographic Severity of Metopic Craniosynostosis Correlates with Long-Term Neurocognitive Outcomes

BACKGROUND

Reports of neurodevelopmental delays in adolescents with metopic craniosynostosis have ranged from 15 to 61 percent. Previously, event-related potentials have correlated preoperative radiographic severity with language deficiencies in infancy. This study sought to characterize neurocognitive testing at cranial maturity and correlate outcomes to preoperative radiographic severity.

METHODS

Patients diagnosed with metopic craniosynostosis who underwent surgical correction in infancy completed a neurodevelopmental battery evaluating age-normalized intelligence quotient, academic achievement, and visuomotor integration. Data were stratified by preoperative endocranial bifrontal angle (moderate, >124 degrees; severe, <124 degrees). Multiple variable regression was used to control measured intelligence and achievement for age at surgery, age at testing, parental education, and income. Significance was set at p < 0.05.

RESULTS

Twenty patients completed neurodevelopmental testing. Mean intelligence quotient was 111.7 ± 13 and academic achievement was similar to national averages (word reading, 53.4 percent; reading comprehension, 53.4 percent; reading composite, 53.5 percent; spelling, 44 percent; and math, 52.9 percent). Radiographic measurements revealed 36 percent of patients with moderate phenotype and 64 percent with severe. Patients with severe phenotypes had lower intelligence quotient measures and scored more poorly in every academic measure tested. Word reading (113 versus 95; p = 0.035) and reading composite (109 versus 98; p = 0.014) reached significance.

CONCLUSIONS

Overall, cranial mature patients with metopic craniosynostosis had above average intelligence quotient and academic achievement near the national mean. Long-term neurocognitive function was correlated to preoperative radiographic severity in metopic craniosynostosis, with more severe cases performing worse.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.