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Luo A, Gurses ME, Gecici NN, Kozel G, Lu VM, Komotar RJ, Ivan ME. Machine learning applications in craniosynostosis diagnosis and treatment prediction: a systematic review. Childs Nerv Syst 2024; 40:2535-2544. [PMID: 38647661 PMCID: PMC11269440 DOI: 10.1007/s00381-024-06409-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 04/13/2024] [Indexed: 04/25/2024]
Abstract
Craniosynostosis refers to the premature fusion of one or more of the fibrous cranial sutures connecting the bones of the skull. Machine learning (ML) is an emerging technology and its application to craniosynostosis detection and management is underexplored. This systematic review aims to evaluate the application of ML techniques in the diagnosis, severity assessment, and predictive modeling of craniosynostosis. A comprehensive search was conducted on the PubMed and Google Scholar databases using predefined keywords related to craniosynostosis and ML. Inclusion criteria encompassed peer-reviewed studies in English that investigated ML algorithms in craniosynostosis diagnosis, severity assessment, or treatment outcome prediction. Three independent reviewers screened the search results, performed full-text assessments, and extracted data from selected studies using a standardized form. Thirteen studies met the inclusion criteria and were included in the review. Of the thirteen papers examined on the application of ML to the identification and treatment of craniosynostosis, two papers were dedicated to sagittal craniosynostosis, five papers utilized several different types of craniosynostosis in the training and testing of their ML models, and six papers were dedicated to metopic craniosynostosis. ML models demonstrated high accuracy in identifying different types of craniosynostosis and objectively quantifying severity using innovative metrics such as metopic severity score and cranial morphology deviation. The findings highlight the significant strides made in utilizing ML techniques for craniosynostosis diagnosis, severity assessment, and predictive modeling. Predictive modeling of treatment outcomes following surgical interventions showed promising results, aiding in personalized treatment strategies. Despite methodological diversities among studies, the collective evidence underscores ML's transformative potential in revolutionizing craniosynostosis management.
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Affiliation(s)
- Angela Luo
- Department of Neurosurgery, Miller School of Medicine, University of Miami, 1475 NW 12th Ave, Miami, FL, 33136, USA
| | - Muhammet Enes Gurses
- Department of Neurosurgery, Miller School of Medicine, University of Miami, 1475 NW 12th Ave, Miami, FL, 33136, USA.
| | | | - Giovanni Kozel
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Victor M Lu
- Department of Neurosurgery, Miller School of Medicine, University of Miami, 1475 NW 12th Ave, Miami, FL, 33136, USA
| | - Ricardo J Komotar
- Department of Neurosurgery, Miller School of Medicine, University of Miami, 1475 NW 12th Ave, Miami, FL, 33136, USA
| | - Michael E Ivan
- Department of Neurosurgery, Miller School of Medicine, University of Miami, 1475 NW 12th Ave, Miami, FL, 33136, USA
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Zucchelli M, Ruggiero F, Babini M, Lefosse M, Borghi A, Rodriguez-Florez N, Tarsitano A, Nicolini F, Galassi E. Surgical strategy in treatment of metopic synostosis in a single centre experience: technical note and quantitative analysis of the outcomes. Childs Nerv Syst 2024:10.1007/s00381-024-06520-7. [PMID: 39001880 DOI: 10.1007/s00381-024-06520-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 06/21/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE Trigonocephaly is the most common craniosynostosis involving orbits. Although some degree of agreement has been reached regarding surgical timing and indications for treatment, there is no consensus regarding the ideal operative technique to guarantee an optimal morphological outcome. The purpose of this study is to describe both strategies and to compare morphological outcomes by means of morphological surface analysis obtained from three-dimensional (3D) stereophotogrammetry, with two different techniques. METHODS We retrospectively investigated 43 patients with metopic synostosis surgically treated between 2004 and 2020. Two different techniques were applied, addressed as technique A and B. Ten patients undergone postoperative 3d stereophotogrammetry were enrolled, and cephalometric measurements were taken and compared to a cohort of unaffected patients matched by age and gender. RESULTS Comparison of the groups demonstrated a hypercorrection of the metopic angle of the second technique, associated with a slightly lower correction of the interfrontoparietal diameter. The metopic angle showed to be significantly undercorrected with the first method. CONCLUSIONS Alternated barrel staving technique appears to be a quick and satisfactory method in cranial remodelling for metopic synostosis. It guarantees an optimal aesthetic result in the first years after surgery.
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Affiliation(s)
- Mino Zucchelli
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Pediatric Neurosurgery, Bologna, Italy
| | - Federica Ruggiero
- Oral and Maxillofacial Surgery Unit, AUSL Bologna, Bellaria Maggiore Hospital, Bologna, Italy.
- DIBINEM, Alma Mater Studiorum Unversity of Bologna, Bologna, Italy.
| | - Micol Babini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Pediatric Neurosurgery, Bologna, Italy
| | - Mariella Lefosse
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Pediatric Neurosurgery, Bologna, Italy
| | - Alessandro Borghi
- Department of Engineering, Durham University, Durham, UK
- Great Ormond Street Institute of Child Health, University College of London, London, UK
- Great Ormond Street Hospital for Children, Craniofacial Unit, London, UK
| | - Naiara Rodriguez-Florez
- Universidad de Navarra, TECNUN Escuela de Ingeneiros, San Sebastian, Spain
- Basque Foundation for Science, Bilbao, Spain
| | - Achille Tarsitano
- DIBINEM, Alma Mater Studiorum Unversity of Bologna, Bologna, Italy
- Oral and Maxillofacial Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Francesca Nicolini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Pediatric Neurosurgery, Bologna, Italy
| | - Ercole Galassi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Pediatric Neurosurgery, Bologna, Italy
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Barrero CE, Pontell ME, Naidu K, Wagner CS, Salinero LK, Swanson JW, Taylor JA, Bartlett SP. A critical eye on metopic craniosynostosis: A retrospective study assessing orbital dysmorphology as a marker of disease. J Craniomaxillofac Surg 2024; 52:865-871. [PMID: 38796332 DOI: 10.1016/j.jcms.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 02/27/2024] [Accepted: 04/27/2024] [Indexed: 05/28/2024] Open
Abstract
This investigation sought to ascertain whether orbital morphology could predict genuine metopic craniosynostosis (MCS). The study retrospectively analyzed preoperative three-dimensional computed tomography (3D-CT) scans of patients who underwent surgical correction for MCS. MCS severity was evaluated using the interfrontal angle (IFA). Orbital dysmorphology was assessed based on multiple angles, including supraorbital notches and nasion (SNS), infraorbital foramina and nasion (INI), zygomaticofrontal suture-supraorbital notch-dacryon (ZSD), and orbital long axis (OLA). Results were juxtaposed against age/gender-matched controls and individuals with non-synostotic metopic ridge (MR). The study included 177 patients: 68 MCS, 35 MR, and 74 control subjects. All orbital measurements exhibited significant differences across groups. IFA demonstrated a strong association with all orbital measurements, particularly SNS (B = 0.79, p < 0.001). SNS showed the highest area under the curve among orbital measurements (0.89). Using a 95% sensitivity threshold, the optimal diagnostic angle for SNS was 129.23° (specificity 54%, sensitivity 96%). These findings suggest a correlation between orbital dysmorphology and trigonocephaly severity. The observed dysmorphology manifested in a superomedially accentuated rotational pattern. Importantly, SNS angle predicted MCS, with an angle greater than 130° indicating <5% likelihood of MCS diagnosis. The simplicity of measuring SNS angle on any 3D-CT scan highlights its practical use for assisting with MCS diagnosis.
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Affiliation(s)
- Carlos E Barrero
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew E Pontell
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kirin Naidu
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Connor S Wagner
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lauren K Salinero
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott P Bartlett
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Romeo DJ, Becerra SL, Barrero CE, Massenburg BB, Du S, Ng JJ, Wu M, Swanson JW, Taylor JA, Bartlett SP. Validating the Supraorbital Notch-Nasion-Supraorbital Notch Angle as a Marker for Metopic Craniosynostosis Severity. J Craniofac Surg 2024; 35:1035-1039. [PMID: 38743289 DOI: 10.1097/scs.0000000000010302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/18/2024] [Indexed: 05/16/2024] Open
Abstract
OBJECTIVE Metopic craniosynostosis (MCS) can be difficult to differentiate from metopic ridge (MR) or normal frontal morphology. This study assess whether the supraorbital notch-nasion-supraorbital notch (SNS) angle can help identify MCS. METHODS Records of 212 patients with preoperative three-dimensional computed tomography scans were examined. The SNS angles, surgeon craniofacial dysmorphology rankings, and CranioRate metopic severity scores (MSSs) were compared with the Spearman rank correlation coefficient. Receiver operating characteristic (ROC) curves with Youden J-statistic and cross-validation of regression models assessed the ability of these measures to predict surgery. RESULTS A total of 212 patients were included, consisting of 78 MCS, 37 MR, and 97 controls. Both the mean SNS angle (MCS: 111.7 ± 10.7 degrees, MR: 126.0 ± 8.2 degrees, controls: 130.7 ± 8.8 degrees P < 0.001) and MSS (MCS: 5.9 ± 2.0, MR: 1.4 ± 1.9, controls: 0.2 ± 1.9, P < 0.001) were different among the cohorts. The mean SNS angle (111.5 ± 10.7 versus 129.1 ± 8.8, P < 0.001) was lower in those who had surgery and CranioRate score (5.9 ± 2.1 versus 0.8 ± 2.2, P < 0.001) was higher in those who underwent surgery. SNS angles were positively correlated with surgeon craniofacial dysmorphology rankings ( r = 0.41, P < 0.05) and CranioRate MSS ( r = 0.54, P < 0.05). The ROC curve requiring high sensitivity revealed an SNS angle of 124.8 degrees predicted surgery with a sensitivity of 88.7% and a specificity of 71.3%. A ROC curve using the CranioRate MCC values ≥3.19 predicted surgery with 88.7% sensitivity and 94.7% specificity. CONCLUSION Orbital dysmorphology in patients with MCS is well captured by the supraorbital-nasion angle. Both the SNS angle and CranioRate MSS scores accurately predict surgical intervention.
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Affiliation(s)
- Dominic J Romeo
- Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
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Bloch K, Geoffroy M, Taverne M, van de Lande L, O'Sullivan E, Liang C, Paternoster G, Moazen M, Laporte S, Khonsari RH. New diagnostic criteria for metopic ridges and trigonocephaly: a 3D geometric approach. Orphanet J Rare Dis 2024; 19:204. [PMID: 38762603 PMCID: PMC11102612 DOI: 10.1186/s13023-024-03197-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 04/29/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Trigonocephaly occurs due to the premature fusion of the metopic suture, leading to a triangular forehead and hypotelorism. This condition often requires surgical correction for morphological and functional indications. Metopic ridges also originate from premature metopic closure but are only associated with mid-frontal bulging; their surgical correction is rarely required. Differential diagnosis between these two conditions can be challenging, especially in minor trigonocephaly. METHODS Two hundred seven scans of patients with trigonocephaly (90), metopic rigdes (27), and controls (90) were collected. Geometric morphometrics were used to quantify skull and orbital morphology as well as the interfrontal angle and the cephalic index. An innovative method was developed to automatically compute the frontal curvature along the metopic suture. Different machine-learning algorithms were tested to assess the predictive power of morphological data in terms of classification. RESULTS We showed that control patients, trigonocephaly and metopic rigdes have distinctive skull and orbital shapes. The 3D frontal curvature enabled a clear discrimination between groups (sensitivity and specificity > 92%). Furthermore, we reached an accuracy of 100% in group discrimination when combining 6 univariate measures. CONCLUSION Two diagnostic tools were proposed and demonstrated to be successful in assisting differential diagnosis for patients with trigonocephaly or metopic ridges. Further clinical assessments are required to validate the practical clinical relevance of these tools.
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Affiliation(s)
- Kevin Bloch
- Service de chirurgie maxillofaciale et chirurgie plastique, Hôpital Necker - Enfants malades, Assistance Publique - Hôpitaux de Paris, CRMR CRANIOST, Faculté de Médecine, Université Paris Cité, Paris, France
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers Institute of Technology, Paris, France
| | - Maya Geoffroy
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers Institute of Technology, Paris, France
- Laboratoire 'Forme et Croissance du Crâne', Hôpital Necker - Enfants malades, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Maxime Taverne
- Laboratoire 'Forme et Croissance du Crâne', Hôpital Necker - Enfants malades, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Lara van de Lande
- Craniofacial Unit, Great Ormond Street Hospital for Children; UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Oral and Maxillofacial Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | | | - Ce Liang
- Department of Mechanical Engineering, University College London, London, UK
| | - Giovanna Paternoster
- Service de Neurochirurgie, Hôpital Necker - Enfants malades, Assistance Publique - Hôpitaux de Paris, CRMR CRANIOST, Paris, France
| | - Mehran Moazen
- Department of Mechanical Engineering, University College London, London, UK
| | - Sébastien Laporte
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers Institute of Technology, Paris, France
| | - Roman Hossein Khonsari
- Service de chirurgie maxillofaciale et chirurgie plastique, Hôpital Necker - Enfants malades, Assistance Publique - Hôpitaux de Paris, CRMR CRANIOST, Faculté de Médecine, Université Paris Cité, Paris, France.
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers Institute of Technology, Paris, France.
- Laboratoire 'Forme et Croissance du Crâne', Hôpital Necker - Enfants malades, Assistance Publique - Hôpitaux de Paris, Paris, France.
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Bianchi F, Agostini L, Frassanito P, Massimi L, Tamburrini G. Coexistence of Trigonocephaly and Sylvian Arachnoid Cysts: A Coincidence? Pediatr Neurosurg 2024; 59:115-120. [PMID: 38531328 DOI: 10.1159/000538559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/15/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION The association between trigonocephaly and Sylvian fissure arachnoid cysts (ACs) has been occasionally reported in the literature. However, the real incidence of this association and its clinical relevance remain unknown. METHODS The authors collected and retrospectively reviewed all clinical charts and CT scans of patients surgically treated for trigonocephaly at the Pediatric Neurosurgical Department of Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS from January 2014 to June 2023. RESULTS During the study period, 136 patients with trigonocephaly underwent surgery. Analysis of the clinical charts revealed that in 39.7% of the cases (54/136), preoperative CT scan depicted the presence of a Sylvian fissure AC. Of these, AC was bilateral in 23 cases and unilateral in the remaining 31. All unilateral ACs were on the left side. The ACs were classified as Galassi grade I in 52 cases (96.3%) and Galassi grade II in 2 cases (3.7%). Interestingly, in 1 case we reported a Galassi grade I AC enlargement during follow-up, thereby necessitating surgical fenestration. CONCLUSION ACs and trigonocephaly are well-known conditions for pediatric neurosurgeons; however, their association is poorly defined. Despite the lack of reports on the incidence and clinical significance of this association, it is worth knowing that radiological follow-up is essential in monitoring AC evolution.
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Affiliation(s)
- Federico Bianchi
- Pediatric Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Milan, Italy
| | | | - Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Milan, Italy
| | - Luca Massimi
- Pediatric Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Milan, Italy
- Università Cattolica del Sacro Cuore, Milan, Italy
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Gaillard L. A Suture-specific Photo Score for Metopic Synostosis. J Craniofac Surg 2024; 35:75-79. [PMID: 37815380 PMCID: PMC10749672 DOI: 10.1097/scs.0000000000009773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023] Open
Abstract
Head shape assessments in children with metopic synostosis are a relevant outcome measure in addition to functional measures, such as neurocognitive outcomes, behavioral outcomes, and visual functioning outcomes. However, consensus on head shape assessments in children with metopic synostosis is lacking. The aim of this study is to develop a reproducible and reliable suture-specific photo score that can be used for cross-center comparison of phenotypical severity of metopic synostosis and evaluation of esthetic outcome of treatment later in childhood. We conducted a retrospective study among nonsyndromic metopic synostosis patients aged <18 years. Preoperative and postoperative photosets of patients with metopic synostosis from 6 expert centers were included. The photo score was discussed in the group of expert craniofacial plastic surgeons and pediatric neurosurgeons. Interrater reliability was determined with modified weighted Fleiss' kappa and intraclass correlation coefficients. Correlation between individual photo score items with overall phenotype was assessed using Spearman correlation analyses. The metopic synostosis photo score contained the following items: "wedging of the forehead", "hypotelorism", "temporal hollowing", "biparietal widening,"and an assessment of "overall phenotype". Items were scored on a 4-point ordinal scale ranging from normal to severe. We found moderate interrater reliability for all items, but substantial agreement for the summed scores. Correlation with overall phenotype was lowest for biparietal widening. To conclude, although agreement on individual photo score items was suboptimal, the agreement on the summed score was substantial, which indicates there is consensus on the overall severity of the metopic synostosis phenotype.
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Beiriger JW, Tao W, Bruce MK, Anstadt E, Christensen C, Smetona J, Whitaker R, Goldstein JA. CranioRate: An Image-Based, Deep-Phenotyping Analysis Toolset and Online Clinician Interface for Metopic Craniosynostosis. Plast Reconstr Surg 2024; 153:112e-119e. [PMID: 36943708 DOI: 10.1097/prs.0000000000010452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND The diagnosis and management of metopic craniosynostosis involve subjective decision-making at the point of care. The purpose of this work was to describe a quantitative severity metric and point-of-care user interface to aid clinicians in the management of metopic craniosynostosis and to provide a platform for future research through deep phenotyping. METHODS Two machine-learning algorithms were developed that quantify the severity of craniosynostosis-a supervised model specific to metopic craniosynostosis [Metopic Severity Score (MSS)] and an unsupervised model used for cranial morphology in general [Cranial Morphology Deviation (CMD)]. Computed tomographic (CT) images from multiple institutions were compiled to establish the spectrum of severity, and a point-of-care tool was developed and validated. RESULTS Over the study period (2019 to 2021), 254 patients with metopic craniosynostosis and 92 control patients who underwent CT scanning between the ages of 6 and 18 months were included. CT scans were processed using an unsupervised machine-learning based dysmorphology quantification tool, CranioRate. The average MSS was 0.0 ± 1.0 for normal controls and 4.9 ± 2.3 ( P < 0.001) for those with metopic synostosis. The average CMD was 85.2 ± 19.2 for normal controls and 189.9 ± 43.4 ( P < 0.001) for those with metopic synostosis. A point-of-care user interface (craniorate.org) has processed 46 CT images from 10 institutions. CONCLUSIONS The resulting quantification of severity using MSS and CMD has shown an improved capacity, relative to conventional measures, to automatically classify normal controls versus patients with metopic synostosis. The authors have mathematically described, in an objective and quantifiable manner, the distribution of phenotypes in metopic craniosynostosis.
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Affiliation(s)
- Justin W Beiriger
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center
| | | | - Madeleine K Bruce
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center
| | - Erin Anstadt
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center
| | | | - John Smetona
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center
| | | | - Jesse A Goldstein
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center
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Bhalodia R, Elhabian S, Adams J, Tao W, Kavan L, Whitaker R. DeepSSM: A blueprint for image-to-shape deep learning models. Med Image Anal 2024; 91:103034. [PMID: 37984127 PMCID: PMC11087075 DOI: 10.1016/j.media.2023.103034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 10/06/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Abstract
Statistical shape modeling (SSM) characterizes anatomical variations in a population of shapes generated from medical images. Statistical analysis of shapes requires consistent shape representation across samples in shape cohort. Establishing this representation entails a processing pipeline that includes anatomy segmentation, image re-sampling, shape-based registration, and non-linear, iterative optimization. These shape representations are then used to extract low-dimensional shape descriptors that are anatomically relevant to facilitate subsequent statistical analyses in different applications. However, the current process of obtaining these shape descriptors from imaging data relies on human and computational resources, requiring domain expertise for segmenting anatomies of interest. Moreover, this same taxing pipeline needs to be repeated to infer shape descriptors for new image data using a pre-trained/existing shape model. Here, we propose DeepSSM, a deep learning-based framework for learning the functional mapping from images to low-dimensional shape descriptors and their associated shape representations, thereby inferring statistical representation of anatomy directly from 3D images. Once trained using an existing shape model, DeepSSM circumvents the heavy and manual pre-processing and segmentation required by classical models and significantly improves the computational time, making it a viable solution for fully end-to-end shape modeling applications. In addition, we introduce a model-based data-augmentation strategy to address data scarcity, a typical scenario in shape modeling applications. Finally, this paper presents and analyzes two different architectural variants of DeepSSM with different loss functions using three medical datasets and their downstream clinical application. Experiments showcase that DeepSSM performs comparably or better to the state-of-the-art SSM both quantitatively and on application-driven downstream tasks. Therefore, DeepSSM aims to provide a comprehensive blueprint for deep learning-based image-to-shape models.
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Affiliation(s)
- Riddhish Bhalodia
- Scientific Computing and Imaging Institute, 72 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA; School of Computing, 50 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA.
| | - Shireen Elhabian
- Scientific Computing and Imaging Institute, 72 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA; School of Computing, 50 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA
| | - Jadie Adams
- Scientific Computing and Imaging Institute, 72 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA; School of Computing, 50 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA
| | - Wenzheng Tao
- Scientific Computing and Imaging Institute, 72 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA; School of Computing, 50 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA
| | - Ladislav Kavan
- School of Computing, 50 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA
| | - Ross Whitaker
- Scientific Computing and Imaging Institute, 72 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA; School of Computing, 50 Central Campus Dr, University of Utah, Salt Lake City, UT 84112, USA
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Nguyen HT, Washington GN, Cepeda A, Littlefield T, Teichgraeber JF, Greives MR, Nguyen PD. Evaluation of Helmeting Therapy Duration After Endoscopic Strip Craniectomy for Metopic and Sagittal Craniosynostosis. J Craniofac Surg 2023:00001665-990000000-01219. [PMID: 37973053 DOI: 10.1097/scs.0000000000009887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/16/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Endoscopic strip craniectomy (ESC) is a minimally invasive option for early surgical treatment of metopic (MC) and sagittal craniosynostosis (SC). For ESC, however, the postoperative duration and compliance of helmet therapy are crucial to correct MC and SC asymmetry. The purpose of this study is to assess the period of postoperative band therapy and determine differences, if any, between MC and SC. METHODS A single-institution retrospective review was performed for patients with MC and SC who underwent ESC from November 2015 to 2019. Patients received preoperative, postoperative, and post-band 3-dimensional imaging. Factors recorded included patient sex, insurance type, number of helmets needed, age at surgery, time of first helmet, and at time of completion of helmet therapy, cephalic index, interfrontal angle, and cranial vault asymmetry index. RESULTS Patients with SC and MC had ESC surgery at 3.3 and 3.4 months of age, respectively.Patients with SC were found to have completed banding therapy at a younger age (7.88 versus 10.0 mo), with shorter duration (4.17 versus 6.00 mo), and less number of bands (1.54 versus 2.21) than patients with MC. After regression analysis, suture type was found to be a significant predictor of total time in band therapy (P=0.039) with MC requiring a longer duration of banding therapy when compared with SC. CONCLUSIONS Suture type directly correlates with duration of helmeting therapy for patients, with patients with MC requiring longer periods of postop helmeting and increased number of bands as compared with SC.
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Affiliation(s)
- Huan T Nguyen
- The University of Texas Health Science Center at Houston, McGovern Medical School
| | - George N Washington
- Division of Plastic Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School & Children's Memorial Hermann Hospital
| | - Alfredo Cepeda
- Department of Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | | | - John F Teichgraeber
- Division of Plastic Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School & Children's Memorial Hermann Hospital
| | - Matthew R Greives
- Division of Plastic Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School & Children's Memorial Hermann Hospital
| | - Phuong D Nguyen
- Division of Plastic Surgery, Department of Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School & Children's Memorial Hermann Hospital
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Elkhill C, Liu J, Linguraru MG, LeBeau S, Khechoyan D, French B, Porras AR. Geometric learning and statistical modeling for surgical outcomes evaluation in craniosynostosis using 3D photogrammetry. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 240:107689. [PMID: 37393741 PMCID: PMC10527531 DOI: 10.1016/j.cmpb.2023.107689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/11/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Accurate and repeatable detection of craniofacial landmarks is crucial for automated quantitative evaluation of head development anomalies. Since traditional imaging modalities are discouraged in pediatric patients, 3D photogrammetry has emerged as a popular and safe imaging alternative to evaluate craniofacial anomalies. However, traditional image analysis methods are not designed to operate on unstructured image data representations such as 3D photogrammetry. METHODS We present a fully automated pipeline to identify craniofacial landmarks in real time, and we use it to assess the head shape of patients with craniosynostosis using 3D photogrammetry. To detect craniofacial landmarks, we propose a novel geometric convolutional neural network based on Chebyshev polynomials to exploit the point connectivity information in 3D photogrammetry and quantify multi-resolution spatial features. We propose a landmark-specific trainable scheme that aggregates the multi-resolution geometric and texture features quantified at every vertex of a 3D photogram. Then, we embed a new probabilistic distance regressor module that leverages the integrated features at every point to predict landmark locations without assuming correspondences with specific vertices in the original 3D photogram. Finally, we use the detected landmarks to segment the calvaria from the 3D photograms of children with craniosynostosis, and we derive a new statistical index of head shape anomaly to quantify head shape improvements after surgical treatment. RESULTS We achieved an average error of 2.74 ± 2.70 mm identifying Bookstein Type I craniofacial landmarks, which is a significant improvement compared to other state-of-the-art methods. Our experiments also demonstrated a high robustness to spatial resolution variability in the 3D photograms. Finally, our head shape anomaly index quantified a significant reduction of head shape anomalies as a consequence of surgical treatment. CONCLUSION Our fully automated framework provides real-time craniofacial landmark detection from 3D photogrammetry with state-of-the-art accuracy. In addition, our new head shape anomaly index can quantify significant head phenotype changes and can be used to quantitatively evaluate surgical treatment in patients with craniosynostosis.
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Affiliation(s)
- Connor Elkhill
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Pediatric Plastic and Reconstructive Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA.
| | - Jiawei Liu
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, 7144 13th Pl NW, Washington, DC 20012, USA; Departments of Radiology and Pediatrics, George Washington University School of Medicine and Health Sciences, Ross Hall, 2300 Eye Street, NW, Washington, DC 20037, USA
| | - Scott LeBeau
- Department of Pediatric Plastic and Reconstructive Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA
| | - David Khechoyan
- Department of Pediatric Plastic and Reconstructive Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA
| | - Brooke French
- Department of Pediatric Plastic and Reconstructive Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA
| | - Antonio R Porras
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Pediatric Plastic and Reconstructive Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Biomedical Informatics, School of Medicine, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA; Department of Pediatrics and Department of Neurosurgery, School of Medicine, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO 80045, USA
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12
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Magnet R, Bloch K, Taverne M, Melzi S, Geoffroy M, Khonsari RH, Ovsjanikov M. Assessing craniofacial growth and form without landmarks: A new automatic approach based on spectral methods. J Morphol 2023; 284:e21609. [PMID: 37458086 DOI: 10.1002/jmor.21609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 05/19/2023] [Accepted: 05/29/2023] [Indexed: 07/18/2023]
Abstract
We present a novel method for the morphometric analysis of series of 3D shapes, and demonstrate its relevance for the detection and quantification of two craniofacial anomalies: trigonocephaly and metopic ridges, using CT-scans of young children. Our approach is fully automatic, and does not rely on manual landmark placement and annotations. Our approach furthermore allows to differentiate shape classes, enabling successful differential diagnosis between trigonocephaly and metopic ridges, two related conditions characterized by triangular foreheads. These results were obtained using recent developments in automatic nonrigid 3D shape correspondence methods and specifically spectral approaches based on the functional map framework. Our method can capture local changes in geometric structure, in contrast to methods based, for instance, on global shape descriptors. As such, our approach allows to perform automatic shape classification and provides visual feedback on shape regions associated with different classes of deformations. The flexibility and generality of our approach paves the way for the application of spectral methods in quantitative medicine.
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Affiliation(s)
- Robin Magnet
- LIX, École Polytechnique, IP Paris, Palaiseau, France
| | - Kevin Bloch
- Laboratoire "Forme et Croissance du Crâne", Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Université Paris Cité, Paris, France
| | - Maxime Taverne
- Laboratoire "Forme et Croissance du Crâne", Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Université Paris Cité, Paris, France
| | - Simone Melzi
- Department of Informatics, Systems and Communication, University of Milano-Bicocca, Milan, Italy
| | - Maya Geoffroy
- Laboratoire "Forme et Croissance du Crâne", Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Université Paris Cité, Paris, France
| | - Roman H Khonsari
- Laboratoire "Forme et Croissance du Crâne", Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Université Paris Cité, Paris, France
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13
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Junn A, Dinis J, Hauc SC, Bruce MK, Park KE, Tao W, Christensen C, Whitaker R, Goldstein JA, Alperovich M. "Validation of Artificial Intelligence Severity Assessment in Metopic Craniosynostosis". Cleft Palate Craniofac J 2023; 60:274-279. [PMID: 34787505 PMCID: PMC9250829 DOI: 10.1177/10556656211061021] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Alexandra Junn
- Department of Surgery, Division of Plastic Surgery, 12228Yale School of Medicine, New Haven, CT, USA
| | - Jacob Dinis
- Department of Surgery, Division of Plastic Surgery, 12228Yale School of Medicine, New Haven, CT, USA
| | - Sacha C Hauc
- Department of Surgery, Division of Plastic Surgery, 12228Yale School of Medicine, New Haven, CT, USA
| | - Madeleine K Bruce
- Department of Plastic Surgery, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kitae E Park
- Department of Plastic and Reconstructive Surgery, 1501Johns Hopkins Hospital; Baltimore, MD, USA
| | - Wenzheng Tao
- School of Computing, University of Utah, Salt Lake City, UT, USA
| | | | - Ross Whitaker
- School of Computing, University of Utah, Salt Lake City, UT, USA
| | - Jesse A Goldstein
- Department of Plastic Surgery, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Alperovich
- Department of Surgery, Division of Plastic Surgery, 12228Yale School of Medicine, New Haven, CT, USA
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14
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Anstadt EE, Tao W, Guo E, Dvoracek L, Bruce MK, Grosse PJ, Wang L, Kavan L, Whitaker R, Goldstein JA. Quantifying the Severity of Metopic Craniosynostosis Using Unsupervised Machine Learning. Plast Reconstr Surg 2023; 151:396-403. [PMID: 36696326 PMCID: PMC9881746 DOI: 10.1097/prs.0000000000009853] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Quantifying the severity of head shape deformity and establishing a threshold for operative intervention remains challenging in patients with metopic craniosynostosis (MCS). This study combines three-dimensional skull shape analysis with an unsupervised machine-learning algorithm to generate a quantitative shape severity score (cranial morphology deviation) and provide an operative threshold score. METHODS Head computed tomography scans from subjects with MCS and normal controls (5 to 15 months of age) were used for objective three-dimensional shape analysis using ShapeWorks software and in a survey for craniofacial surgeons to rate head-shape deformity and report whether they would offer surgical correction based on head shape alone. An unsupervised machine-learning algorithm was developed to quantify the degree of shape abnormality of MCS skulls compared to controls. RESULTS One hundred twenty-four computed tomography scans were used to develop the model; 50 (24% MCS, 76% controls) were rated by 36 craniofacial surgeons, with an average of 20.8 ratings per skull. The interrater reliability was high (intraclass correlation coefficient, 0.988). The algorithm performed accurately and correlates closely with the surgeons assigned severity ratings (Spearman correlation coefficient, r = 0.817). The median cranial morphology deviation for affected skulls was 155.0 (interquartile range, 136.4 to 194.6; maximum, 231.3). Skulls with ratings of 150.2 or higher were very likely to be offered surgery by the experts in this study. CONCLUSIONS This study describes a novel metric to quantify the head shape deformity associated with MCS and contextualizes the results using clinical assessments of head shapes by craniofacial experts. This metric may be useful in supporting clinical decision making around operative intervention and in describing outcomes and comparing patient population across centers.
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Affiliation(s)
- Erin E Anstadt
- From the University of Pittsburgh Medical Center, Department of Plastic Surgery
| | | | - Ejay Guo
- School of Computing, University of Utah
| | - Lucas Dvoracek
- From the University of Pittsburgh Medical Center, Department of Plastic Surgery
| | - Madeleine K Bruce
- Department of Plastic Surgery, UPMC Children's Hospital, University of Pittsburgh Medical Center
| | - Philip J Grosse
- Clinical and Translational Science Institute, University of Pittsburgh
| | - Li Wang
- Clinical and Translational Science Institute, University of Pittsburgh
| | | | | | - Jesse A Goldstein
- Department of Plastic Surgery, UPMC Children's Hospital, University of Pittsburgh Medical Center
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15
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Blum JD, Beiriger J, Villavisanis DF, Morales C, Cho DY, Tao W, Whitaker R, Bartlett SP, Taylor JA, Goldstein JA, Swanson JW. Machine Learning in Metopic Craniosynostosis: Does Phenotypic Severity Predict Long-Term Esthetic Outcome? J Craniofac Surg 2023; 34:58-64. [PMID: 35946829 PMCID: PMC9825625 DOI: 10.1097/scs.0000000000008868] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/23/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND There have been few longitudinal studies assessing the effect of preoperative phenotypic severity on long-term esthetic outcomes in metopic craniosynostosis. This study evaluates the relationship between metopic severity and long-term esthetic outcomes using interfrontal angle (IFA) and CranioRate, a novel metopic synostosis severity measure. METHODS Patients with metopic craniosynostosis who underwent bifrontal orbital advancement and remodeling between 2012 and 2017 were reviewed. Preoperative computed tomography head scans were analyzed for IFA and CranioRate, a machine learning algorithm which generates quantitative severity ratings including metopic severity score (MSS) and cranial morphology deviation (CMD). Long-term esthetic outcomes were assessed by craniofacial surgeons using blinded 3-rater esthetic grading of clinical photos. Raters assessed Whitaker score and the presence of temporal hollowing, lateral orbital retrusion, frontal bone irregularities and/or "any visible irregularities." RESULTS Preoperative scans were performed at a mean age of 7.7±3.4 months, with average MSS of 6/10, CMD of 200/300, and IFA of 116.8±13.8 degrees. Patients underwent bifrontal orbital advancement and remodeling at mean 9.9±3.1 months. The average time from operation to esthetic assessment was 5.4±1.0 years. Pearson correlation revealed a significant negative correlation between MSS and age at computed tomography ( r =-0.451, P =0.004) and IFA ( r =-0.371, P =0.034) and between IFA and age at surgery ( r =-0.383, P =0.018). In multinomial logistic regression, preoperative MSS was the only independent predictor of visible irregularities (odds ratio=2.18, B =0.780, P =0.024) and preoperative IFA alone significantly predicted Whitaker score, with more acute IFA predicting worse Whitaker score (odds ratio=0.928, B =-0.074, P =0.928). CONCLUSIONS More severe preoperative phenotypes of metopic craniosynostosis were associated with worse esthetic dysmorphology. Objective measures of preoperative metopic severity predicted long-term esthetic outcomes.
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Affiliation(s)
- Jessica D Blum
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Justin Beiriger
- Division of Plastic Surgery, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Dillan F Villavisanis
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Carrie Morales
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Daniel Y Cho
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Wenzheng Tao
- School of Computing, University of Utah, Salt Lake City, UT
| | - Ross Whitaker
- School of Computing, University of Utah, Salt Lake City, UT
| | - Scott P Bartlett
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Jesse A Taylor
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Jesse A Goldstein
- Division of Plastic Surgery, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jordan W Swanson
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia
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16
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Sakar M, Haidar H, Sönmez Ö, Erdoğan O, Saçak B, Bayri Y, Dağçınar A. A new method for quantification of frontal retrusion and complex skull shape in metopic craniosynostosis: a pilot study of a new outcome measure for endoscopic strip craniectomy. J Neurosurg Pediatr 2022:1-9. [PMID: 35276659 DOI: 10.3171/2022.1.peds21553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to propose a new skull outline-based method to objectively quantify complex 3D skull shapes and frontal and supraorbital retrusion in metopic craniosynostosis using 3D photogrammetry. METHODS A standard section from 3D photogrammetry, which represents the trigonocephalic shape, was used in this study. From the midpoint of the area of this section, half diagonals were calculated to the skull outline at 5° increments in the anterior half of the head. These half diagonals were used to create a sinusoidal curve, and the area under the sinusoidal curve (AUC) was used to represent the mathematical expression of the trigonocephalic head shape. The AUC from 0° to 180° (90° from the midline to each side) was calculated and is referred to as AUC0→180. The AUC from 60° to 120° (30° from the midline to each side) was also calculated and is referred to as AUC60→120. A total of 24 patients who underwent endoscopic strip craniectomy and 13 age- and sex-matched controls were included in the study. The AUC values obtained in patients at different time points and controls were analyzed. RESULTS The mean preoperative AUC60→120 and AUC0→180 in the patients were significantly lower than those in control individuals. The increase in both AUC60→120 and AUC0→180 values is statistically significant at the discontinuation of helmet therapy and at final follow-up. Receiver operating characteristic curve analysis indicated that AUC60→120 is a more accurate classifier than AUC0→180. CONCLUSIONS The proposed method objectively quantifies complex head shape and frontal retrusion in patients with metopic craniosynostosis and provides a quantitative measure for follow-up after surgical treatment. It avoids ionizing radiation exposure.
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Affiliation(s)
- Mustafa Sakar
- 1Marmara University, School of Medicine, Department of Neurosurgery, Istanbul, Turkey.,2Marmara University, Institute of Neurological Sciences, Istanbul, Turkey
| | - Hassan Haidar
- 3Marmara University, School of Medicine, Istanbul, Turkey; and
| | - Özcan Sönmez
- 1Marmara University, School of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | - Onur Erdoğan
- 1Marmara University, School of Medicine, Department of Neurosurgery, Istanbul, Turkey
| | - Bülent Saçak
- 4Marmara University, School of Medicine, Plastic and Reconstructive Surgery, Istanbul, Turkey
| | - Yaşar Bayri
- 1Marmara University, School of Medicine, Department of Neurosurgery, Istanbul, Turkey.,2Marmara University, Institute of Neurological Sciences, Istanbul, Turkey
| | - Adnan Dağçınar
- 1Marmara University, School of Medicine, Department of Neurosurgery, Istanbul, Turkey.,2Marmara University, Institute of Neurological Sciences, Istanbul, Turkey
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17
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Superior Long-term Appearance of Strip Craniectomy Compared with Cranial Vault Reconstruction in Metopic Craniosynostosis. Plast Reconstr Surg Glob Open 2022; 10:e4097. [PMID: 35169528 PMCID: PMC8830858 DOI: 10.1097/gox.0000000000004097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022]
Abstract
Background: Strip craniectomy with orthotic helmet therapy (SCOT) is an increasingly supported treatment for metopic craniosynostosis, although the long-term efficacy of deformity correction remains poorly defined. We compared the longterm outcomes of SCOT versus open cranial vault reconstruction (OCVR). Methods: Patients who underwent OCVR or SCOT for isolated metopic synostosis with at least 3 years of follow-up were identified at our institution. Anthropometric measurements were used to assess baseline severity and postoperative skull morphology. Independent laypersons and craniofacial surgeons rated the appearance of each patient’s 3D photographs, compared to normal controls. Results: Thirty-five patients were included (15 SCOT and 20 OCVR), with similar follow-up between groups (SCOT 7.9 ± 3.2 years, OCVR 9.2 ± 4.1 years). Baseline severity and postoperative anthropometric measurements were equivalent. Independent adolescent raters reported that the forehead, eye, and overall appearance of SCOT patients was better than OCVR patients (P < 0.05, all comparisons). Craniofacial surgeons assigned Whitaker class I to a greater proportion of SCOT patients with moderate-to-severe synostosis (72.2 ± 5.6%) compared with OCVR patients with the same severity (33.3 ± 9.2%, P = 0.02). Parents of children who underwent SCOT reported equivalent satisfaction with the results of surgery (100% versus 95%, P > 0.99), and were no more likely to report bullying (7% versus 15%, P = 0.82). Conclusions: SCOT was associated with superior long-term appearance and perioperative outcomes compared with OCVR. These findings suggest that SCOT should be the treatment of choice for patients with a timely diagnosis of metopic craniosynostosis.
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Consistency of Cranial Shape Measures Obtained From Laser Surface and Computed Tomography Imaging. J Craniofac Surg 2021; 32:2763-2767. [PMID: 34727475 DOI: 10.1097/scs.0000000000007885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Children with cranial shape abnormalities are often subjected to radiation from computed tomography (CT) for evaluation and clinical decision making. The STARscanner Laser Data Acquisition System (Orthomerica, Orlando, FL) may be a noninvasive alternate. The purpose of this study is to determine whether the STARscanner provides valid and accurate cranial measurements compared to CT. DESIGN We performed an institutional review board-approved retrospective review of a prospectively maintained database of patients with metopic suture abnormalities from 2013 to 2016. SETTING Plastic surgery clinic in an institutional tertiary care center. PATIENTS Eight patients were included that presented with metopic suture abnormalities, age less than 1 year, and CT and STARscanner imaging within 30 days of one another. MAIN OUTCOME MEASURES Cranial measurements were collected twice from 3 scan types: STARscanner, CT windowed for soft tissue, and CT windowed for bone. Measurements included: intracranial volume, height, base width, maximum antero-posterior length, maximum medio-lateral width, and oblique diameters. Nested analysis of variance were performed to determine the proportion of error attributable to: between-subject variance, scan type, and rater. RESULTS Measurements from STARscanner and both CT scans windows were highly consistent, with less than 1% of total error attributable to scan type for all measures. CONCLUSIONS Cranial shape measurements obtained from STARscanner images are highly consistent with those obtained from CT scans. The STARscanner has added benefits of speed of acquisition, minimal cost, and lack of radiation.
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García-Mato D, Porras AR, Ochandiano S, Rogers GF, García-Leal R, Salmerón JI, Pascau J, Linguraru MG. Effectiveness of Automatic Planning of Fronto-orbital Advancement for the Surgical Correction of Metopic Craniosynostosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3937. [PMID: 34786322 PMCID: PMC8589244 DOI: 10.1097/gox.0000000000003937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The surgical correction of metopic craniosynostosis usually relies on the subjective judgment of surgeons to determine the configuration of the cranial bone fragments and the degree of overcorrection. This study evaluates the effectiveness of a new approach for automatic planning of fronto-orbital advancement based on statistical shape models and including overcorrection. METHODS This study presents a planning software to automatically estimate osteotomies in the fronto-orbital region and calculate the optimal configuration of the bone fragments required to achieve an optimal postoperative shape. The optimal cranial shape is obtained using a statistical head shape model built from 201 healthy subjects (age 23 ± 20 months; 89 girls). Automatic virtual plans were computed for nine patients (age 10.68 ± 1.73 months; four girls) with different degrees of overcorrection, and compared with manual plans designed by experienced surgeons. RESULTS Postoperative cranial shapes generated by automatic interventional plans present accurate matching with normative morphology and enable to reduce the malformations in the fronto-orbital region by 82.01 ± 6.07%. The system took on average 19.22 seconds to provide the automatic plan, and allows for personalized levels of overcorrection. The automatic plans with an overcorrection of 7 mm in minimal frontal breadth provided the closest match (no significant difference) to the manual plans. CONCLUSIONS The automatic software technology effectively achieves correct cranial morphometrics and volumetrics with respect to normative cranial shapes. The automatic approach has the potential to reduce the duration of preoperative planning, reduce inter-surgeon variability, and provide consistent surgical outcomes.
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Affiliation(s)
- David García-Mato
- From the Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Antonio R. Porras
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, D.C
- Department of Biostatistics and Informatics – Colorado School of Public Health, Department of Pediatrics – School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Santiago Ochandiano
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Servicio de Cirugía Oral y Maxilofacial, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gary F. Rogers
- Division of Plastic and Reconstructive Surgery, Children’s National Hospital, Washington, D.C
| | - Roberto García-Leal
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José I. Salmerón
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Servicio de Cirugía Oral y Maxilofacial, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Pascau
- From the Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, D.C
- School of Medicine and Health Sciences, George Washington University, Washington, D.C
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20
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Anthropometric cranial measurements in metopic craniosynostosis/trigonocephaly: diagnostic criteria, classification of severity and indications for surgery. J Craniofac Surg 2021; 33:161-167. [PMID: 34690312 DOI: 10.1097/scs.0000000000008196] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Metopic craniosynostosis is the second most frequent type of craniosynostosis. When the phenotypic presentation has been deemed severe the treatment is surgical in nature and is performed in infancy with fronto-orbital advancement and cranial vault remodeling. At the time of this writing, there is no consensus regarding an objective evaluation system for severity, diagnostic criteria, or indications for surgery. This study aims to review the anthropometric cranial measurements and the relative diagnostic criteria/classification of severity/surgical indications proposed so far for this skull malformation, and to investigate if there is any scientific support for their utility.
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21
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Bhalodia R, Elhabian S, Kavan L, Whitaker R. Leveraging unsupervised image registration for discovery of landmark shape descriptor. Med Image Anal 2021; 73:102157. [PMID: 34293535 PMCID: PMC8489970 DOI: 10.1016/j.media.2021.102157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
In current biological and medical research, statistical shape modeling (SSM) provides an essential framework for the characterization of anatomy/morphology. Such analysis is often driven by the identification of a relatively small number of geometrically consistent features found across the samples of a population. These features can subsequently provide information about the population shape variation. Dense correspondence models can provide ease of computation and yield an interpretable low-dimensional shape descriptor when followed by dimensionality reduction. However, automatic methods for obtaining such correspondences usually require image segmentation followed by significant preprocessing, which is taxing in terms of both computation as well as human resources. In many cases, the segmentation and subsequent processing require manual guidance and anatomy specific domain expertise. This paper proposes a self-supervised deep learning approach for discovering landmarks from images that can directly be used as a shape descriptor for subsequent analysis. We use landmark-driven image registration as the primary task to force the neural network to discover landmarks that register the images well. We also propose a regularization term that allows for robust optimization of the neural network and ensures that the landmarks uniformly span the image domain. The proposed method circumvents segmentation and preprocessing and directly produces a usable shape descriptor using just 2D or 3D images. In addition, we also propose two variants on the training loss function that allows for prior shape information to be integrated into the model. We apply this framework on several 2D and 3D datasets to obtain their shape descriptors. We analyze these shape descriptors in their efficacy of capturing shape information by performing different shape-driven applications depending on the data ranging from shape clustering to severity prediction to outcome diagnosis.
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Affiliation(s)
- Riddhish Bhalodia
- Scientific Computing and Imaging Institute, 72 Central Campus Dr, University of Utah, Salt Lake City, Utah-84112, USA.
| | - Shireen Elhabian
- Scientific Computing and Imaging Institute, 72 Central Campus Dr, University of Utah, Salt Lake City, Utah-84112, USA; School of Computing, 50 Central Campus Dr, University of Utah, Salt Lake City, Utah-84112, USA
| | - Ladislav Kavan
- School of Computing, 50 Central Campus Dr, University of Utah, Salt Lake City, Utah-84112, USA
| | - Ross Whitaker
- Scientific Computing and Imaging Institute, 72 Central Campus Dr, University of Utah, Salt Lake City, Utah-84112, USA; School of Computing, 50 Central Campus Dr, University of Utah, Salt Lake City, Utah-84112, USA
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22
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Quantifying Orthotic Correction of Trigonocephaly Using Optical Surface Scanning. J Craniofac Surg 2021; 32:1727-1733. [PMID: 34319676 DOI: 10.1097/scs.0000000000007513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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23
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Kuehle R, Ewerbeck N, Rückschloß T, Ristow O, El Damaty A, Freudlsperger C, Hoffmann J, Engel M. Photogrammetric evaluation of corrective surgery for trigonocephaly. Int J Oral Maxillofac Surg 2021; 51:70-77. [PMID: 34229921 DOI: 10.1016/j.ijom.2021.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 05/30/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022]
Abstract
The aim of this study was to capture preoperative, postoperative, and follow-up head shapes of male trigonocephaly patients who underwent fronto-orbital remodelling (FOR), using three-dimensional (3D) photography. Fifty-seven male infants with metopic synostosis operated on using standardized FOR during a 5-year period were included. All measurements were compared with those of an age-matched healthy control cohort (n = 253 for early postoperative comparison, n = 43 for the 1-year follow-up comparison) to determine the effect of FOR at 14 days and at 1 year post-surgery. Intracranial volume, frontal angle, nasofrontal angle, interfrontoparietal-interparietal ratio, and inter-orbital distances were measured 1 day preoperatively, 14 days and 1 year postoperatively. Mean age at surgery was 9.7 ± 1.1 months. Prior to surgery, boys with metopic synostosis showed a reduced intracranial volume (-7.0%, P < 0.001), frontal angle (-10.2%, P < 0.001), interfrontoparietal-interparietal ratio (-4.9%, P < 0.01), and orbital distances (-6.5%, P < 0.001) compared to the reference group, but values did not differ significantly from the specific control group after surgery (all P> 0.05). This was consistent by the time of the follow-up examination. Corrective surgery should therefore aim to achieve volume expansion and correction of the deformity. Furthermore, 3D photogrammetry provides a valuable alternative to computed tomography scans in the diagnosis of metopic synostosis, significantly reducing the amount of radiation exposure to the brain.
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Affiliation(s)
- R Kuehle
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany.
| | - N Ewerbeck
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - T Rückschloß
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - O Ristow
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - A El Damaty
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - C Freudlsperger
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - J Hoffmann
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
| | - M Engel
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, Heidelberg, Germany
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24
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Yan Q, He J, Gao Z, Qiu D, Zheng L, Zhang X, Wang G. Evaluation of fronto-orbital reconstruction surgery for the treatment of metopic synostosis in Chinese population. Childs Nerv Syst 2021; 37:1167-1174. [PMID: 33404707 DOI: 10.1007/s00381-020-04977-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate the efficacy of fronto-orbit reconstruction surgery on pediatric metopic synostosis via an image-based 3D reconstruction in Chinese population. METHODS Thirty pediatric metopic synostosis patients who received fronto-orbital reconstruction surgery in the Children's Hospital of Nanjing Medical University, Department of Neurosurgery, from January 2007 to December 2018 were analyzed in the study. Here we use the Mimics 20.0 software to reconstruct patients' cranial thin-section CT scan images from pre- and post-operation and control groups. Then the data of intracranial volume, frontal volume, orbital hypertelorism, ECA, ZF, and ORA were analyzed using the paired t-test or Wilcoxon matched-pairs signed-ranks test. RESULTS The age of these patients was 15.83 ± 16.12 months. After surgery, the mean frontal volume was enlarged from 92.75 ± 26.97 to 138.62 ± 47.97 cm3 (P < 0.0001), and the intracranial volume was enhanced from 976.87 ± 230.83 to 1059.44 ± 217.98 cm3 (P < 0.0001). In the meantime, the ECA was changed from 108.02 ± 8.17 to 134 ± 5.59° (P < 0.0001). In line with the alteration of the parameters mentioned above, the head shapes in all patients were also significantly improved after the surgery with no obvious complications. CONCLUSION Fronto-orbit reconstruction surgery is a safe and effective treatment for pediatric metopic synostosis. Computer-aided 3D reconstruction could serve as a quantitative strategy to evaluate the efficacy of craniofacial surgery.
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Affiliation(s)
- Qing Yan
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Junping He
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhe Gao
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Dezhi Qiu
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Zheng
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xianli Zhang
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Wang
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, China.
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25
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Kronig ODM, Kronig SAJ, Vrooman HA, Veenland JF, Van Adrichem LNA. New method for quantification of the relative severity and (a)symmetry of isolated metopic synostosis. Int J Oral Maxillofac Surg 2021; 50:1477-1484. [PMID: 33744098 DOI: 10.1016/j.ijom.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/17/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022]
Abstract
Trigonocephaly is the result of premature fusion of the metopic suture and its severity can vary widely. However, there is no gold standard for quantification of the severity. This study was performed to quantify severity using the Utrecht Cranial Shape Quantifier (UCSQ) and to assess forehead symmetry. Nineteen preoperative non-syndromic trigonocephaly patients (age ≤1 year) were included for the analysis of severity and symmetry. Severity according to the UCSQ was based on the following combined variables: forehead width and relative skull elongation. The UCSQ was compared to the most established quantification methods. A high correlation was found between the UCSQ and visual score (r=0.71). Moderate to negligible correlation was found between the UCSQ and frontal angle, binocular distance, inter-ocular distance, and frontal stenosis. Additionally, correlation between the visual score and these established quantification methods was negligible. Assessment of the frontal peak (a)symmetry (ratio of right to left triangle area in the curve) showed a mean right versus left triangle area ratio of 1.4 (range 0.9-2.4). The results suggest that the UCSQ is appropriate for the quantification of severity based on the high correlation with clinical judgement. Furthermore, a larger triangle area right than left was unexpectedly found, indicating forehead asymmetry.
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Affiliation(s)
- O D M Kronig
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - S A J Kronig
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H A Vrooman
- Department of Radiology, Erasmus MC, Rotterdam, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Informatics, Erasmus MC, Rotterdam, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J F Veenland
- Department of Radiology, Erasmus MC, Rotterdam, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Medical Informatics, Erasmus MC, Rotterdam, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - L N A Van Adrichem
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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26
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García-Mato D, García-Sevilla M, Porras AR, Ochandiano S, Darriba-Allés JV, García-Leal R, Salmerón JI, Linguraru MG, Pascau J. Three-dimensional photography for intraoperative morphometric analysis in metopic craniosynostosis surgery. Int J Comput Assist Radiol Surg 2021; 16:277-287. [PMID: 33417161 DOI: 10.1007/s11548-020-02301-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/11/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Surgical correction of metopic craniosynostosis typically involves open cranial vault remodeling. Accurate translation of the virtual surgical plan into the operating room is challenging due to the lack of tools for intraoperative analysis of the surgical outcome. This study aimed to evaluate the feasibility of using a hand-held 3D photography device for intraoperative evaluation and guidance during cranial vault surgical reconstruction. METHODS A hand-held structured light scanner was used for intraoperative 3D photography during five craniosynostosis surgeries, obtaining 3D models of skin and bone surfaces before and after the remodeling. The accuracy of this device for 3D modeling and morphology quantification was evaluated using preoperative computed tomography imaging as gold-standard. In addition, the time required for intraoperative 3D photograph acquisition was measured. RESULTS The average error of intraoperative 3D photography was 0.30 mm. Moreover, the interfrontal angle and the transverse forehead width were accurately measured in the 3D photographs with an average error of 0.72 degrees and 0.62 mm. Surgeon's feedback indicates that this technology can be integrated into the surgical workflow without substantially increasing surgical time. CONCLUSION Hand-held 3D photography is an accurate technique for objective quantification of intraoperative cranial vault morphology and guidance during metopic craniosynostosis surgical reconstruction. This noninvasive technique does not substantially increase surgical time and does not require exposure to ionizing radiation, presenting a valuable alternative to computed tomography imaging. The proposed methodology can be integrated into the surgical workflow to assist during cranial vault remodeling and ensure optimal surgical outcomes.
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Affiliation(s)
- David García-Mato
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Avenida de la Universidad 30, 28911, Leganés, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Mónica García-Sevilla
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Avenida de la Universidad 30, 28911, Leganés, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Antonio R Porras
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, USA
| | - Santiago Ochandiano
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Servicio de Cirugía Oral y Maxilofacial, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan V Darriba-Allés
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Roberto García-Leal
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José I Salmerón
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Servicio de Cirugía Oral y Maxilofacial, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, USA
- School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Javier Pascau
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Avenida de la Universidad 30, 28911, Leganés, Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
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27
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Lajthia O, Rogers GF, Tsering D, Keating RF, Magge SN. Quantitative outcomes of endoscopic strip craniectomy for metopic craniosynostosis in children with severe trigonocephaly. Childs Nerv Syst 2021; 37:573-579. [PMID: 32812117 DOI: 10.1007/s00381-020-04849-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/30/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Orgest Lajthia
- Division of Neurosurgery, Children's National Hospital, 4th Floor, Suite 100, 111 Michigan Avenue NW, Washington, DC, 20010, USA.,Department of Neurosurgery, Georgetown University Medical Center, Washington, DC, USA
| | - Gary F Rogers
- Division of Plastic Surgery, Children's National Health System, Washington, DC, USA
| | - Deki Tsering
- Division of Neurosurgery, Children's National Hospital, 4th Floor, Suite 100, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Hospital, 4th Floor, Suite 100, 111 Michigan Avenue NW, Washington, DC, 20010, USA.,Department of Neurosurgery, George Washington University School of Medicine, Washington, DC, USA
| | - Suresh N Magge
- Division of Neurosurgery, Children's National Hospital, 4th Floor, Suite 100, 111 Michigan Avenue NW, Washington, DC, 20010, USA. .,Department of Neurosurgery, George Washington University School of Medicine, Washington, DC, USA.
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28
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Tandon D, Skolnick GB, Naidoo SD, Grames LM, Cradock MM, Smyth MD, Patel KB. Morphologic Severity of Craniosynostosis: Implications for Speech and Neurodevelopment. Cleft Palate Craniofac J 2021; 58:1361-1369. [PMID: 33467909 DOI: 10.1177/1055665620984643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Single-suture craniosynostosis (SSC) can be associated with neurodevelopmental deficits. We examined the correlation between morphologic severity and incidence of speech-language or psychological concerns. METHODS In 62 patients (33 sagittal, 17 metopic, and 12 unicoronal), morphologic severity was determined via preoperative computed tomography (CT). Severity metrics for sagittal, metopic, and unicoronal synostosis were adjusted cephalic index (aCI), interfrontal angle (IFA), and anterior cranial fossa area ratio (ACFR), respectively. Speech-language and psychological concerns were assessed at age ≥4.5 years and defined as recommendation for therapy or monitoring. RESULTS Mean assessment age was 5.7 years; 32% had a speech-language concern and 44% had a psychological concern; 44% had neither. Sagittal: Mean aCI of those with a speech-language concern (0.62) and those without (0.62) were equivalent (P = .580), as were mean aCI of those with a psychological concern (0.62) and those without (0.62; P = .572). Metopic: Mean IFA with (117.9) and without (125.2) a speech-language concern were equivalent (P = .326), as were mean IFA with (120.2) and without (123.2) a psychological concern (P = .711). Unicoronal: Mean ACFR with (0.65) and without (0.69) a psychological concern (P = .423) were equivalent. However, mean ACFR with (0.74) and without (0.63) a speech-language concern were not (P = .022*). Bivariate rank correlation showed significant association between morphologic severity and speech-language score only for unicoronal synostosis (ρ = .722; P = .008*). CONCLUSION A significant portion of patients with SSC had speech-language or psychological concerns. We found no correlation between morphologic severity and incidence of speech-language or psychological concerns for patients with sagittal or metopic synostosis. Morphological severity did correlate with speech concerns in patients with unicoronal synostosis.
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Affiliation(s)
- Damini Tandon
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, MO, USA
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, MO, USA
| | - Sybill D Naidoo
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, MO, USA
| | - Lynn Marty Grames
- Cleft Palate and Craniofacial Institute, St. Louis Children's Hospital, MO, USA
| | | | - Matthew D Smyth
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Kamlesh B Patel
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, MO, USA
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29
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A Comparison of Intracranial Volumes and Metopic Index in Patients With Isolated Metopic Ridge, Metopic Craniosynostosis, and Normal Healthy Children. J Craniofac Surg 2020; 32:108-112. [PMID: 33186289 DOI: 10.1097/scs.0000000000007044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Previous research has shown that patients with metopic craniosynostosis have significantly reduced intracranial volumes (ICVs) compared to normal healthy children. Furthermore, the metopic index (ratio of midfrontozygomatic diameter to maximal cranial width) has been described as an anthropometric cranial index for patients with metopic craniosynostosis. We aimed to determine whether patients with isolated metopic ridge have significantly different ICVs or metopic indices than normal children and patients with metopic craniosynostosis. METHODS A retrospective chart review of all patients with a diagnosis of a metopic ridge or metopic craniosynostosis was performed from 2000 to 2015 at Rady Children's Hospital. Patients were grouped based on computed tomographic scans consistent with metopic craniosynostosis versus metopic ridge. RESULTS Data were available for 15 metopic ridge patients, 74 metopic craniosynostosis patients, and 213 normal patients. Mean metopic ridge ICV was greater than mean metopic craniosynostosis ICV at 4 to 6 months and 7 to 12 months. Controlling for age and sex, the difference in ICV associated with metopic ridging was 197.484 cm3 and 137.770 cm3 at 4 to 6 and 7 to 12 months, respectively. Similarly, mean metopic index was significantly greater in metopic ridge patients compared to mean metopic craniosynostosis at 4 to 6 months and at 7 to 12 months. CONCLUSIONS Our study provides volumetric and anthropometric data to support the hypothesis that isolated metopic ridge is an intermediate phenotype between metopic craniosynostosis and normal cranial anatomy. We hope that characterizing the spectrum of disease involving premature closure of the metopic suture with regard to ICV and metopic index will aid physicians in their management of patients with isolated metopic ridge.
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30
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Pressler MP, Hallac RR, Geisler EL, Seaward JR, Kane AA. Comparison of Head Shape Outcomes in Metopic Synostosis Using Limited Strip Craniectomy and Open Vault Reconstruction Techniques. Cleft Palate Craniofac J 2020; 58:669-677. [PMID: 33153285 DOI: 10.1177/1055665620969294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM Metopic craniosynostosis (MCS), with its trigonocephalic head shape, is often treated with either limited incision strip craniectomy (LISC) followed by helmet orthotic treatment, or open cranial vault reconstruction techniques (OCVR). There is controversy regarding resultant shape outcomes among craniofacial surgeons. Those adverse to LISC claim normal head shape is never attained, while proponents believe there is gradual correction to an equivalent outcome. This study aims to quantitate, over time, the three-dimensional (3D) head shapes in patients who have undergone LISC or OCVR intervention for MCS. METHODS Sixty-three 3D images of 26 patients with MCS were analyzed retrospectively. Head shape analyses were performed at: (1) preoperative, (2) 1-month postoperative, (3) 10 to 14 months postoperative (1 year), and (4) 2 years postoperative. Composite 3D head shapes of patients were compared at each time point. Two-dimensional (2D) standardized cross sections of the forehead were also compared. RESULTS Composite head shapes for both groups were nested, to allow visual comparison as the child's forehead grows and expands. The difference between LISC and OCVR 2D cross sections was calculated; 108.26 mm preoperatively, 127.18 mm after 1-month postoperative, 51.05 mm after 10 to 14 months postoperative, and 27.03 mm after 2 years postoperative. CONCLUSIONS This study found excellent head shape outcomes for both the LISC and OCVR techniques at 2 years of age. It also corroborates the slow and progressive improvement in head shape with the LISC technique. This study highlights the advantages of 3D photography for measurement of contour outcomes, utilizing both 2D vector and 3D whole head analytical techniques.
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Affiliation(s)
- Mark Philip Pressler
- Department of Plastic Surgery, 89063UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, 2755Children's Medical Center, Dallas, TX, USA
| | - Rami R Hallac
- Department of Plastic Surgery, 89063UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, 2755Children's Medical Center, Dallas, TX, USA
| | - Emily L Geisler
- Department of Plastic Surgery, 89063UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, 2755Children's Medical Center, Dallas, TX, USA
| | - James R Seaward
- Department of Plastic Surgery, 89063UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, 2755Children's Medical Center, Dallas, TX, USA
| | - Alex A Kane
- Department of Plastic Surgery, 89063UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, 2755Children's Medical Center, Dallas, TX, USA
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31
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Quantifying the Severity of Metopic Craniosynostosis: A Pilot Study Application of Machine Learning in Craniofacial Surgery. J Craniofac Surg 2020; 31:697-701. [PMID: 32011542 DOI: 10.1097/scs.0000000000006215] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The standard for diagnosing metopic craniosynostosis (CS) utilizes computed tomography (CT) imaging and physical exam, but there is no standardized method for determining disease severity. Previous studies using interfrontal angles have evaluated differences in specific skull landmarks; however, these measurements are difficult to readily ascertain in clinical practice and fail to assess the complete skull contour. This pilot project employs machine learning algorithms to combine statistical shape information with expert ratings to generate a novel objective method of measuring the severity of metopic CS.Expert ratings of normal and metopic skull CT images were collected. Skull-shape analysis was conducted using ShapeWorks software. Machine-learning was used to combine the expert ratings with our shape analysis model to predict the severity of metopic CS using CT images. Our model was then compared to the gold standard using interfrontal angles.Seventeen metopic skull CT images of patients 5 to 15 months old were assigned a severity by 18 craniofacial surgeons, and 65 nonaffected controls were included with a 0 severity. Our model accurately correlated the level of skull deformity with severity (P < 0.10) and predicted the severity of metopic CS more often than models using interfrontal angles (χ = 5.46, P = 0.019).This is the first study that combines shape information with expert ratings to generate an objective measure of severity for metopic CS. This method may help clinicians easily quantify the severity and perform robust longitudinal assessments of the condition.
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Zubovic E, Skolnick GB, Naidoo SD, Bellanger M, Smyth MD, Patel KB. Endoscopic treatment of combined metopic-sagittal craniosynostosis. J Neurosurg Pediatr 2020; 26:113-121. [PMID: 32302979 DOI: 10.3171/2020.2.peds2029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Combined metopic-sagittal craniosynostosis is traditionally treated with open cranial vault remodeling and fronto-orbital advancement, sometimes in multiple operations. Endoscopic treatment of this multisuture synostosis presents a complex challenge for the surgeon and orthotist. METHODS The authors retrospectively analyzed the preoperative and 1-year postoperative CT scans of 3 patients with combined metopic-sagittal synostosis, all of whom were treated with simultaneous endoscope-assisted craniectomy of the metopic and sagittal sutures followed by helmet therapy. Established anthropometric measurements were applied to assess pre- and postoperative morphology, including cranial index and interfrontal divergence angle (IFDA). Patients' measurements were compared to those obtained in 18 normal controls. RESULTS Two boys and one girl underwent endoscope-assisted craniectomy at a mean age of 81 days. The mean preoperative cranial index was 0.70 (vs control mean of 0.82, p = 0.009), corrected postoperatively to a mean of 0.82 (vs control mean of 0.80, p = 0.606). The mean preoperative IFDA was 110.4° (vs control mean of 152.6°, p = 0.017), corrected postoperatively to a mean of 139.1° (vs control mean of 140.3°, p = 0.348). The mean blood loss was 100 mL and the mean length of stay was 1.7 days. No patient underwent reoperation. The mean clinical follow-up was 3.4 years. CONCLUSIONS Endoscope-assisted craniectomy with helmet therapy is a viable single-stage treatment option for combined metopic-sagittal synostosis, providing correction of the stigmata of trigonoscaphocephaly, with normalization of the cranial index and IFDA.
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Affiliation(s)
- Ema Zubovic
- 1Division of Plastic & Reconstructive Surgery, Department of Surgery, and
| | - Gary B Skolnick
- 1Division of Plastic & Reconstructive Surgery, Department of Surgery, and
| | - Sybill D Naidoo
- 1Division of Plastic & Reconstructive Surgery, Department of Surgery, and
| | | | - Matthew D Smyth
- 2Department of Neurosurgery, Washington University School of Medicine in St. Louis; and
| | - Kamlesh B Patel
- 1Division of Plastic & Reconstructive Surgery, Department of Surgery, and
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Pressler MP, Geisler EL, Hallac RR, Seaward JR, Kane AA. The Use of Eye Tracking to Discern the Threshold at Which Metopic Orbitofrontal Deformity Attracts Attention. Cleft Palate Craniofac J 2020; 57:1392-1401. [PMID: 32489115 DOI: 10.1177/1055665620926014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Surgical treatment for trigonocephaly aims to eliminate a stigmatizing deformity, yet the severity that captures unwanted attention is unknown. Surgeons intervene at different points of severity, eliciting controversy. This study used eye tracking to investigate when deformity is perceived. MATERIAL AND METHODS Three-dimensional photogrammetric images of a normal child and a child with trigonocephaly were mathematically deformed, in 10% increments, to create a spectrum of 11 images. These images were shown to participants using an eye tracker. Participants' gaze patterns were analyzed, and participants were asked if each image looked "normal" or "abnormal." RESULTS Sixty-six graduate students were recruited. Average dwell time toward pathologic areas of interest (AOIs) increased proportionally, from 0.77 ± 0.33 seconds at 0% deformity to 1.08 ± 0.75 seconds at 100% deformity (P < .0001). A majority of participants did not agree an image looked "abnormal" until 90% deformity from any angle. CONCLUSION Eye tracking can be used as a proxy for attention threshold toward orbitofrontal deformity. The amount of attention toward orbitofrontal AOIs increased proportionally with severity. Participants did not generally agree there was "abnormality" until deformity was severe. This study supports the assertion that surgical intervention may be best reserved for more severe deformity.
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Affiliation(s)
- Mark P Pressler
- Department of Plastic Surgery, 12334UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, Children's Medical Center, Dallas, TX, USA
| | - Emily L Geisler
- Department of Plastic Surgery, 12334UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, Children's Medical Center, Dallas, TX, USA
| | - Rami R Hallac
- Department of Plastic Surgery, 12334UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, Children's Medical Center, Dallas, TX, USA
| | - James R Seaward
- Department of Plastic Surgery, 12334UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, Children's Medical Center, Dallas, TX, USA
| | - Alex A Kane
- Department of Plastic Surgery, 12334UT Southwestern, Dallas, TX, USA.,Analytical Imaging and Modeling Center, Children's Medical Center, Dallas, TX, USA
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Orbito-facial dysmorphology in patients with different degrees of trigonocephaly severity: quantitative morpho-volumetric analysis in infants with non-syndromic metopic craniosynostosis. Childs Nerv Syst 2020; 36:1263-1273. [PMID: 31845029 DOI: 10.1007/s00381-019-04456-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 11/27/2019] [Indexed: 01/13/2023]
Abstract
PURPOSE Craniofacial dysmorphology varies significantly along a wide spectrum of severity in metopic cranial synostosis (MCS). This study aimed to quantify craniofacial changes, in MCS, to investigate their relationships with the severity of trigonocephaly. METHODS By combining the metopic ridge and interfrontal angles, we identified three groups of trigonocephaly severity (mild group n.14, moderate group n.19, severe group n.18). We perform a quantitative analysis using high-resolution CT images evaluating (1) cranial fossae dimensions; (2) vault indices and ratios: interparietal/ intercoronal (IPD/ICD), interparietal/intertemporal (IPD/ITD), cephalic index, vertico-longitudinal index; (3) orbito-facial distances (midfacial depth, maxillary height, upper facial index, orbital distances, globe protrusions), maxilla and orbital volumes; (4) supratentorial (ICV) and infratentorial (PCFV) cranial volumes and supratentorial (WBV) and infratentorial (PCFBV) brain volumes. RESULTS In all groups, middle skull base lengths and upper midface index were increased. In moderate and severe groups: anterior hemifossa lengths were reduced, IPD/ICD and vertico-longitudinal index were changed; midfacial depth, anterior, mild, and lateral interorbital distances were reduced; globe protrusions were increased. The comparison between moderate and severe groups showed an increase of both globe protrusions and IPD/ICD. Among all groups, ICV and WBV were reduced in the severe group. CONCLUSION This morpho-volumetric study provides new insights in understanding the craniofacial changes occurring in infants at different severity of trigonocephaly. The increase of globe protrusions and the reduction of supratentorial volumes found in the severe group reflect the severity of trigonocephaly; these findings might have a clinical and surgical relevance.
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Craniofacial Sutural Pattern and Surgical Management in Patients With Different Degrees of Trigonocephaly Severity. J Comput Assist Tomogr 2020; 44:374-379. [PMID: 32176157 DOI: 10.1097/rct.0000000000001002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The aim of this study was to identify quantitative tools to classify the severity of trigonocephaly to guide surgical management and predict outcome. METHODS We reviewed high-resolution computed tomography images of 59 patients with metopic synostosis. We assessed the craniofacial sutural pattern as well as interfrontal and metopic angles, and we related the frontal angulation degree with the sutural pattern, the surgical management, and clinical outcome. RESULTS We identified 3 groups according to the severity of trigonocephaly. No difference was found between the sutural pattern of nasion complex and severity, whereas the closure of zygomatic maxillary sutures increased with the severity degree (P < 0.05). The operative management was related to the severity degree (P < 0.001) and to the reduced age (P = 0.009). CONCLUSIONS Interfrontal and metopic angles are complementary measurements to evaluate with high accuracy the degree of frontal angulation. In preoperative assessment, they may guide surgery decision in particular when the choice is not straightforward.
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One-Piece Fronto-orbital Distraction With Midline Splitting But Without Bandeau for Metopic Craniosynostosis. Ann Plast Surg 2019; 83:285-292. [DOI: 10.1097/sap.0000000000001992] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Practical Computed Tomography Scan Findings for Distinguishing Metopic Craniosynostosis from Metopic Ridging. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e1944. [PMID: 31044100 PMCID: PMC6467624 DOI: 10.1097/gox.0000000000001944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/27/2018] [Indexed: 11/26/2022]
Abstract
Background: Premature fusion of the metopic suture (ie, metopic craniosynostosis) can be difficult to discriminate from physiological closure of the metopic suture with ridging (MR). Yet, MCS is treated surgically, whereas MR is treated nonsurgically. Often, the diagnosis can be made by physical examination alone, but in difficult cases, a computed tomography (CT) scan can add additional diagnostic information. Methods: We de-identified, randomized, and analyzed the CT scans of patients with MCS (n = 52), MR (n = 20) and age-matched normative controls (n = 52) to identify specific findings helpful in distinguishing between MCS and MR. Four expert clinicians were blinded to the clinical diagnosis and assessed each CT for features of the orbits, frontal bones, and inner table of calvaria. Results: Although no single feature was diagnostic of MCS, we identified several signs that were correlated with MCS, MR, or controls. Features such as “posteriorly displaced frontal bone” and “frontal bone tangent to mid-orbit or medial” demonstrated higher correlation with MCS than MR and the addition of other features improves the accuracy of diagnosis as did inclusion of the interfrontal divergence angle. Conclusion: The presence of a closed metopic suture in addition to other CT scan findings may improve the accuracy of diagnosing MCS, MR, and normocephaly.
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Jaskolka MS. Current Controversies in Metopic Suture Craniosynostosis. Oral Maxillofac Surg Clin North Am 2017; 29:447-463. [DOI: 10.1016/j.coms.2017.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Post-Surgical Relapse in Metopic Synostosis and Limitations of the Interfrontal Angle as an Outcome Measure. J Craniofac Surg 2017; 28:e494-e500. [DOI: 10.1097/scs.0000000000003800] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Quantifying the effect of corrective surgery for trigonocephaly: A non-invasive, non-ionizing method using three-dimensional handheld scanning and statistical shape modelling. J Craniomaxillofac Surg 2017; 45:387-394. [DOI: 10.1016/j.jcms.2017.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/30/2016] [Accepted: 01/03/2017] [Indexed: 11/19/2022] Open
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Objective Assessment of the Interfrontal Angle for Severity Grading and Operative Decision-Making in Metopic Synostosis. Plast Reconstr Surg 2016; 137:1548-1555. [PMID: 27119927 DOI: 10.1097/prs.0000000000002052] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the utility of a previously validated interfrontal angle for classification of severity of metopic synostosis and as an aid to operative decision-making. METHODS An expert panel was asked to study 30 cases ranging from minor to severe metopic synostosis. Based on computed tomographic images of the skull and clinical photographs, they classified the severity of trigonocephaly (1 = normal, 2 = mild, 3 = moderate, and 4 = severe) and management (0 = nonoperative and 1 = operative). The severity scores and management reported by experts were then pooled and matched with the interfrontal angle computed from each respective computed tomographic scan. A threshold was identified at which most experts agree on operative management. RESULTS Expert severity scores were higher for more acute interfrontal angles. There was a high concordance at the extremes of classifications, severe (4) and normal (1) (p < 0.0001); however, between interfrontal angles of 114.3 and 136.1 degrees, there exists a "gray zone," with severe discordance in expert rankings. An operative threshold of 118.2 degrees was identified, with the interfrontal angle able to predict the expert panel's decision to proceed with surgery 87.6 percent of the time. CONCLUSIONS The interfrontal angle has been previously validated as a simple, accurate, and reproducible means for diagnosing trigonocephaly, but must be obtained from computed tomographic data. In this article, the authors demonstrate that the interfrontal angle can be used to further characterize the severity of trigonocephaly. It also correlated with expert decision-making for operative versus nonoperative management. This tool may be used as an adjunct to clinical decision-making when the decision to proceed with surgery may not be straightforward. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, V.
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What’s in a Name? Accurately Diagnosing Metopic Craniosynostosis Using a Computational Approach. Plast Reconstr Surg 2016; 137:205-213. [DOI: 10.1097/prs.0000000000001938] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Are Endoscopic and Open Treatments of Metopic Synostosis Equivalent in Treating Trigonocephaly and Hypotelorism? J Craniofac Surg 2015; 26:129-34. [DOI: 10.1097/scs.0000000000001321] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Metzler P, Ezaldein HH, Persing JA, Steinbacher DM. Comparing two fronto-orbital advancement strategies to treat trigonocephaly in metopic synostosis. J Craniomaxillofac Surg 2014; 42:1437-41. [DOI: 10.1016/j.jcms.2014.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 04/11/2014] [Accepted: 04/15/2014] [Indexed: 11/27/2022] Open
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Wes AM, Paliga JT, Goldstein JA, Whitaker LA, Bartlett SP, Taylor JA. An evaluation of complications, revisions, and long-term aesthetic outcomes in nonsyndromic metopic craniosynostosis. Plast Reconstr Surg 2014; 133:1453-1464. [PMID: 24867728 DOI: 10.1097/prs.0000000000000223] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The authors evaluated the complications, revisions, and long-term aesthetic outcomes of patients with isolated metopic synostosis. METHODS A retrospective chart review was performed on consecutive metopic craniosynostosis patients treated from June of 1987 to June of 2012 at The Children's Hospital of Philadelphia. Patient demographics, operative details, and postoperative data were collected. Outcomes were reported as Whitaker classification and postoperative clinical characteristics assessed before additional interventions. Reoperation in patients with greater than 5 years of follow-up was noted. Appropriate statistical analyses were applied. RESULTS From 1987 to 2012, 178 patients underwent surgical correction of isolated metopic craniosynostosis, and 147 met inclusion criteria. Average age at surgery was 0.83 year (range, 0.3 to 4.7 years); average follow-up was 5.8 years (range, 1.0 to 17.8 years). There were 13 surgical complications (8.8 percent), three major (2.0 percent), and 10 minor (6.8 percent). At follow-up, 67 patients (56.8 percent) were classified as Whitaker class I, six (5.1 percent) as class II, 43 (36.4 percent) as class III, and two (1.7 percent) as class IV. Patients with greater than 5 years' follow-up (n = 57) were more likely to have temporal hollowing (OR, 2.9; 95 percent CI, 1.2 to 7.3; p = 0.021), lateral orbital retrusion (OR, 4.9; 95 percent CI, 1.9 to 12.7; p = 0.001), and Whitaker class III or IV classification (OR, 4.0; 95 percent CI, 1.5 to 10.6; p = 0.006) compared with those with less than 5 years' follow-up. CONCLUSION This study reports low complication and reoperation rates in the treatment of isolated metopic craniosynostosis, but demonstrates a clear trend toward worsening aesthetic outcomes over time. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Ari M Wes
- Philadelphia, Pa. From the Division of Plastic Surgery, the Perelman School of Medicine at the University of Pennsylvania, and The Children's Hospital of Philadelphia
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Ezaldein HH, Metzler P, Persing JA, Steinbacher DM. Three-dimensional orbital dysmorphology in metopic synostosis. J Plast Reconstr Aesthet Surg 2014; 67:900-5. [DOI: 10.1016/j.bjps.2014.03.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 03/08/2014] [Indexed: 10/25/2022]
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Forehead contour and hypotelorism in patients with metopic craniosynostosis: comparing minimally invasive and open treatments. EUROPEAN JOURNAL OF PLASTIC SURGERY 2013. [DOI: 10.1007/s00238-013-0912-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gociman B, Agko M, Blagg R, Garlick J, Kestle JR, Siddiqi F. Endoscopic-Assisted Correction of Metopic Synostosis. J Craniofac Surg 2013; 24:763-8. [DOI: 10.1097/scs.0b013e31828696a5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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