Craniosynostosis: diagnosis and management in the new millennium

Three-Dimensional Animated Videos Improve Caregiver Craniosynostosis Education

Background: Craniosynostosis management involves various surgical options early in a patient's life. Nevertheless, few three-dimensional (3D) tools exist to help caregivers comprehend craniosynostosis anatomy and surgical options. This study aims to assess the efficacy of 3D animated videos for enhancing craniosynostosis education in caregivers. Methods: We created 3D animated videos describing anatomy and surgical options (eg, fronto-orbital advancement, posterior vault reconstruction) for three craniosynostosis diagnoses: bicoronal, metopic, and sagittal. In a cross-sectional survey, caregivers rated their understanding of craniosynostosis on 10-point Likert-scales, labelled anatomic sutures, and answered true/false general (eg, "The sutures have fused too early") and diagnosis-specific (eg, "The distractors are not removed after surgery") craniosynostosis knowledge questions. Respondents were then shown an animated video and asked the same set of questions after watching the video. Results: A total of 69 craniosynostosis caregivers (mean age 35 years, 73% Caucasian, 64% female) completed the survey. After watching the video, caregivers self-rated their understanding of craniosynostosis as significantly higher (mean score difference: 2.62, P < .01). Caregivers also scored significantly higher on the general and diagnosis-specific knowledge questions (mean score difference: 1.27, P < .01). Conclusions: Our findings indicate that our animated videos improved caregiver craniosynostosis understanding and knowledge. These findings may inform how surgeons approach future caregiver craniosynostosis education.

A novel surgical rotation overlapping craniotomy technique for the management of non-syndromic anterior plagiocephaly

Background

Nonsyndromic anterior plagiocephaly is one of the most common types of craniosynostosis. Different surgical techniques to correct this deformity have been developed with dissatisfaction among many surgeons. In this study, we describe a novel surgical technique to manage this pathology. The inclusion criteria were patients presenting with non-syndromic anterior plagiocephaly below 1 year of age presenting to the Pediatric Hospital in the period between 2016 and 2019. Surgical time, blood loss, and complications were recorded. The follow-up period was at least 1 year postoperative, and cosmetic outcome satisfactory categories were reported.

Results

Seven patients were included in this study. No intraoperative complications were reported, and no blood replacement was needed in any of the patients. The parents of six patients were completely satisfied (85.7%) with the outcome and partially satisfied in 1 patient (14.3%).

Conclusion

The results of the described rotational overlapping flap technique are promising and can be considered one of the minimally invasive techniques for the correction of this pathology.

Planning and Osteotomy Designs in the Correction of Single-Suture Craniosynostosis

BACKGROUND

Craniosynostosis is among the abnormalities that are more commonly encountered by craniofacial surgeons. Although the overall concepts for cranial vault remodeling are relatively simple, osteotomy designs and methods for calvarial rearrangement are highly varied. In this work, we present a summary of the known designs for correction of single-suture craniosynostosis.

METHODS

A review of the literature was performed of the more frequently used osteotomy designs for single-suture craniosynostosis, as well as their reported results and outcomes. Also reviewed are some of the current available approaches for the diagnosis and surgical planning for single-suture craniosynostosis.

RESULTS

There remains a diversity of techniques available for the reconstruction of each fused cranial suture. Certain osteotomy designs are reported in the literature and are used by craniofacial surgeons more frequently. Each has its own benefits and disadvantages, and there is a growing body of outcome data available to guide surgical decision-making. Regarding diagnosis and surgical planning, computed tomography with 3-dimensional reconstruction remains the diagnostic standard of care, and efforts are ongoing to develop and implement new diagnostic modalities like Black Bone MRI to reduce radiation exposure.

CONCLUSIONS

There has been ongoing evolution of the surgical techniques available to reconstruct single-suture craniosynostosis, leading to ever-improving patient outcomes.

Prenatal ultrasonography of craniofacial abnormalities

Craniofacial abnormalities are common. It is important to examine the fetal face and skull Epub ahead of print during prenatal ultrasound examinations because abnormalities of these structures may indicate the presence of other, more subtle anomalies, syndromes, chromosomal abnormalities, or even rarer conditions, such as infections or metabolic disorders. The prenatal diagnosis of craniofacial abnormalities remains difficult, especially in the first trimester. A systematic approach to the fetal skull and face can increase the detection rate. When an abnormality is found, it is important to perform a detailed scan to determine its severity and search for additional abnormalities. The use of 3-/4-dimensional ultrasound may be useful in the assessment of cleft palate and craniosynostosis. Fetal magnetic resonance imaging can facilitate the evaluation of the palate, micrognathia, cranial sutures, brain, and other fetal structures. Invasive prenatal diagnostic techniques are indicated to exclude chromosomal abnormalities. Molecular analysis for some syndromes is feasible if the family history is suggestive.

Brain structure in sagittal craniosynostosis

Craniosynostosis, the premature fusion of one or more cranial sutures, leads to grossly abnormal head shapes and pressure elevations within the brain caused by these deformities. To date, accepted treatments for craniosynostosis involve improving surgical skull shape aesthetics. However, the relationship between improved head shape and brain structure after surgery has not been yet established. Typically, clinical standard care involves the collection of diagnostic medical computed tomography (CT) imaging to evaluate the fused sutures and plan the surgical treatment. CT is known to provide very good reconstructions of the hard tissues in the skull but it fails to acquire good soft brain tissue contrast. This study intends to use magnetic resonance imaging to evaluate brain structure in a small dataset of sagittal craniosynostosis patients and thus quantify the effects of surgical intervention in overall brain structure. Very importantly, these effects are to be contrasted with normative shape, volume and brain structure databases. The work presented here wants to address gaps in clinical knowledge in craniosynostosis focusing on understanding the changes in brain volume and shape secondary to surgery, and compare those with normally developing children. This initial pilot study has the potential to add significant quality to the surgical care of a vulnerable patient population in whom we currently have limited understanding of brain developmental outcomes.

Normally shaped heads with no sutures, normally shaped heads with abnormal sutures, and abnormally shaped heads with normal sutures

We present a series of children whose head shapes and suture status do not make sense. There were 3 patients with complete absence of sutures and normal head shapes. One patient was evaluated for microcephaly at 6 years of age. In the second, the absence of sutures was discovered on workup for headaches at 8 years of age. The third underwent x-ray imaging for parasagittal bony nodules at 1 month of age. The head circumferences fell at the 4th, 25th, and 50th percentiles, respectively. The 2 older children were in normal classes, and the youngest was meeting milestones appropriately. We encountered 3 patients with fusion of the sagittal suture and normal head shapes. One had a flattened occiput, the second patient was thought to be brachycephalic, and the third was macrocephalic. Head circumferences were at the fourth, 50th, and 75th percentiles. The patient with head circumference at the fourth percentile had fetal alcohol syndrome and speech delay. The other 2 were developing normally with follow-up of 14 months. Finally, 3 patients underwent surgery for characteristic craniosynostotic head shapes and were found to have patent sutures at surgery. One patient had classic unilateral coronal synostosis and a patent suture on the side of the defect. The second patient had Crouzon syndrome with characteristic head shape, but open coronal sutures. The third patient had the appearance of bicoronal synostosis, with a patent suture on one side. They have had good results from their craniofacial reconstructions at 24, 12, and 6 months' follow-up.

CONCLUSIONS

We have no explanation for these interesting findings.

Pitfalls for the pediatrician: positional molding or craniosynostosis?

Abnormal head morphology is common among infants and often leads parents to ask their pediatricians for guidance. While the vast majority of such children development and prevent adverse neurobehavioral sequelae secondary to increased intracranial pressure or impaired cerebral growth. The coordination of a multidisciplinary team in the setting of a center experienced in the management of craniosynostosis will assure the best possible results for each patient.

Prenatal diagnosis of cloverleaf skull: watch the hands!

Pfeiffer syndrome is an extremely rare autosomal-dominant condition whose prenatal diagnosis has only been reported 6 times, mainly on the basis of a fetal cloverleaf skull deformity. Three types have been described, each with a different prognosis. This case report stresses the need to thoroughly analyze the fetus and particularly the fetal hands in case of prenatal observation of a cloverleaf skull. The discovery of characteristic hand abnormalities allowed the early prenatal detection of type 2 Pfeiffer syndrome in our patient.

Demonstration of cranial sutures and fontanelles at 15 to 16 weeks of gestation: a comparison between two-dimensional and three-dimensional ultrasonography

OBJECTIVE

The purpose of this study was to evaluate the feasibility of obtaining good quality three-dimensional ultrasound pictures of the cranial sutures and fontanelles and to compare between two-dimensional and three-dimensional ultrasound in identifying the normal appearance of cranial sutures and fontanelles by the transvaginal approach at 15 to 16 weeks of gestation.

METHODS

Fifty fetuses were prospectively evaluated by two-dimensional and three-dimensional transvaginal sonography between 15 and 16 weeks of gestation. The sagittal, coronal, lambdoidal, and metopic sutures, as well as anterior and posterior fontanelles, were inspected.

RESULTS

Three-dimensional ultrasound enabled visualization of all sutures in 37 (74%) fetuses compared to 28 (56%) fetuses examined by two-dimensional ultrasonography (p = NS). The visualization of the sagittal suture was significantly superior by three-dimensional ultrasonography compared to two-dimensional ultrasonography (50 (100%) vs 35 (70%), p < 0.001). No significant difference between the two modalities was found in visualization of the fontanelles.

CONCLUSION

Sutures and fontanelles are usually satisfactorily demonstrated by two-dimensional and three-dimensional ultrasound at 15 to 16 weeks of gestation. The sagittal suture is difficult to visualize using two-dimensional ultrasound, and three-dimensional ultrasound appears to be the best method for its demonstration.

Prenatal ultrasound diagnosis of fetal craniosynostosis

OBJECTIVE

Craniosynostosis is defined as the premature closure of the calvarial sutures. The prevalence of this heterogeneous condition is 1 in 2000 and approximately 100 different forms have been described with an established genetic transmission in half of them. Prenatal diagnosis of craniosynostosis relies mainly on identification of associated anomalies and molecular analysis of fetal DNA, which is only feasible in some syndromic forms and in well-documented families. The objective of this study was to investigate the value of prenatal ultrasound examination of cranial sutures in fetuses at risk for craniosynostosis.

METHODS

Forty fetuses at risk for craniosynostosis on the basis of either a family history (Group 1, n = 16) or skull deformity suspected on a first-level fetal ultrasound examination (Group 2, n = 24) were retrospectively investigated. Craniosynostosis was suspected on the basis of skull deformities when present, however the diagnosis was only made in cases where there was a loss of hypoechogenicity of the normal sutures. All infants had both clinical and radiological investigations performed postnatally.

RESULTS

In Group 1, serial ultrasound examination from 12 weeks' gestation onwards led to accurate prenatal diagnosis in all 16 cases. Dysmorphism and skull deformity preceded closure of the sutures by 4 to 16 weeks. In Group 2, prenatal diagnosis was correct in 23/24 cases. There were no false-negative results in either group.

CONCLUSIONS

This series questions further the uncertain genetic determinism of craniosynostosis and seems to rule out the hypothesis of a deformation sequence following primary closure of the cranial sutures. It also suggests that ultrasound examination is useful to demonstrate closure of the sutures in the third trimester of pregnancy in most affected cases.