Can Craniosynostosis be Diagnosed on Physical Examination? A Retrospective Review

Craniosynostosis is a developmental craniofacial defect in which one or more sutures of the skull fuse together prematurely. Uncorrected craniosynostosis may have serious complications including elevated intracranial pressure, developmental delay, and blindness. Proper diagnosis of craniosynostosis requires a physical examination of the head with assessment for symmetry and palpation of sutures for prominence. Often, if craniosynostosis is suspected, computed tomography (CT) imaging will be obtained. Recent literature has posited that this is unnecessary. This study aims to address whether physical examination alone is sufficient for the diagnosis and treatment planning of single suture craniosynostosis. Between 2015 and 2022, the Divisions of Pediatric Neurosurgery and Pediatric Plastic Surgery at UTHealth Houston evaluated 140 children under 36 months of age with suspected craniosynostosis by physical examination and subsequently ordered CT imaging for preoperative planning. Twenty-three patients received a clinical diagnosis of multi-sutural or syndromic craniosynostosis that was confirmed by CT. One hundred seventeen patients were diagnosed with single suture craniosynostosis on clinical examination and follow-up CT confirmed suture fusion in 109 (93.2%) patients and identified intracranial anomalies in 7 (6.0%) patients. These patients underwent surgical correction. Eight (6.8%) patients showed no evidence of craniosynostosis on CT imaging. Treatment for patients without fused sutures included molding helmets and observation alone. This evidence suggests that physical examination alone may be inadequate to accurately diagnose single suture synostosis, and surgery without preoperative CT evaluation could lead to unindicated procedures.

A Systematic Review of Idiopathic Secondary Stenosis Following Index Surgery for Craniosynostosis

BACKGROUND

Primary craniosynostosis is a congenital craniofacial disorder in which cranial sutures prematurely close. Iatrogenic secondary stenosis is abnormal cranial suture closure caused by surgical manipulation of the suture. In contrast, idiopathic secondary stenosis develops in a suture that did not undergo surgical manipulation. The objective of this systematic review was to consolidate and characterize the incidence, classification, and management of idiopathic secondary stenosis in the literature.

METHODS

Literature from PubMed, Web Of Science, and EMBASE from 1970 to March 2022 was reviewed. The following information was extracted for individual patients: incidence of idiopathic secondary stenosis, index primary craniosynostosis, primary surgical correction, presenting signs of secondary stenosis, management, and further complications.

RESULTS

Seventeen articles detailing 1181 patients were included. Ninety-one developed idiopathic secondary stenosis (7.7%). Only 3 of these patients were syndromic. The most common index craniosynostosis was sagittal synostosis (83.5%). The most common suture undergoing idiopathic secondary stenosis was the coronal suture (91.2%). Patients presented at a median age of 24 months. The most common presenting sign was a radiologic finding (85.7%), although some patients presented with headache or head deformity. Only 2 patients, both syndromic, had complications following surgical correction of secondary stenosis.

CONCLUSIONS

Idiopathic secondary stenosis is a rare, long-term complication following index surgical repair of craniosynostosis. It can occur following any surgical technique. It most commonly affects the coronal suture but can affect any of the sutures, including pansynostosis. Surgical correction is curative in nonsyndromic patients.

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

AIM AND SCOPE

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

MATERIALS AND METHODS

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

RESULTS

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

Quantitative Morphologic Analysis of Cranial Vault in Twist1+/- Mice: Implications in Craniosynostosis

BACKGROUND

The haploinsufficiency in the TWIST1 gene encoding a basic helix-loop-helix transcription factor is a cause of one of the craniosynostosis syndromes, Saethre-Chotzen syndrome. Patients with craniosynostosis usually require operative release of affected sutures, which makes it difficult to observe the long-term consequence of suture fusion on craniofacial growth.

METHODS

In this study, we performed quantitative analysis of morphologic changes of the skull in Twist1 heterozygously-deleted mice (Twist1+/-) with micro-computed tomographic images.

RESULTS

In Twist1+/- mice, fusion of the coronal suture began before postnatal day 14 and progressed until postnatal day 56, during which morphologic changes occurred. The growth of the skull was not achieved by a constant increase in the measured distances in wild type mice; some distances in the top-basal axis were decreased during the observation period. In the Twist1+/- mouse, growth in the top-basal axis was accelerated and that of the frontal cranium was reduced. In the unicoronal suture fusion mouse, the length of the zygomatic arch of affected side was shorter in the Twist1+/- mouse. In one postnatal day 56 Twist1+/- mouse with bilateral coronal suture fusion, asymmetric zygomatic arch length was identified.

CONCLUSION

The authors'results suggest that measuring the length of the left and right zygomatic arches may be useful for early diagnosis of coronal suture fusion and for estimation of the timing of synostosis, and that more detailed study on the growth pattern of the normal and the synostosed skull could provide prediction of the risk of resynostosis.

CLINICAL RELEVANCE STATEMENT

The data from this study can be useful to better understand the cranial growth pattern in patients with craniosynostosis.

Sagittal Synostosis and Its Association With Cognitive, Behavioral, and Psychological Functioning: A Meta-analysis

IMPORTANCE

Findings on the cognitive, behavioral, and psychological functioning of individuals with sagittal synostosis (SS) are highly disparate, limiting their clinical utility.

OBJECTIVE

To identify and review research on individuals with SS and to determine whether, and to what extent, they experience cognitive, behavioral, and psychological difficulties compared with their healthy peers or normative data for each measure.

DATA SOURCES

PubMed, Scopus, Embase, and PsycINFO were searched through January 2021 with no date restrictions. Scopus citation searches and manual checks of the reference lists of included studies were conducted.

STUDY SELECTION

Studies included participants of any age who had received a diagnosis of single-suture (isolated or nonsyndromic) SS or scaphocephaly and who had been assessed on cognitive, behavioral, and psychological outcomes.

DATA EXTRACTION AND SYNTHESIS

Data were independently extracted by 2 reviewers. Case-control outcomes (individuals with SS vs healthy peers or normative data) were compared using random-effects models with 3 effect sizes calculated: weighted Hedges g (gw), odds ratios (ORs), and mean prevalence rates. This study follows the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines.

MAIN OUTCOMES AND MEASURES

Findings were categorized by surgical status (conservatively managed, presurgery, postsurgery, or combined); domain (eg, general cognition); type of cognitive, behavioral, or psychological measure (objective or subjective); and source of comparison data (peers or normative data).

RESULTS

Data from 32 studies, involving a pooled sample of 1422 children and adults with SS (mean [SD] age at assessment, 5.7 [6.6] years; median [interquartile range] age, 3.3 [0.5-10.3] years), were analyzed. Data on sex were available for 824 participants, and 642 (78%) were male. Individual study results varied substantially. Objective tests identified significant moderate group differences on 3 of 16 examined domains: presurgical motor functioning (3 studies; gw = -0.42; 95% CI, -0.67 to -0.18; P < .001), postsurgical short-term memory (2 studies; gw = -0.45; 95% CI, -0.72 to -0.17; P < .001), and postsurgical visuospatial ability (6 studies; gw = 0.31; 95% CI, 0.18 to 0.44; P < .001). Prevalence estimates and ORs varied widely, with 15 studies showing prevalence estimates ranging from 3% to 37%, and 3 studies showing ORs ranging from 0.31 (95% CI, 0.01 to 6.12) for processing speed in the conservatively managed sample to 4.55 (95% CI, 0.21 to 98.63) for postsurgical visuospatial abilities.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, findings for the functioning of participants with SS were highly disparate and often of low quality, with small samples sizes and control groups rarely recruited. Nonetheless, the findings suggest that some individuals with SS experience negative outcomes, necessitating routine assessment.

Syndromic Craniosynostosis

Management strategies for syndromic craniosynostosis patients require multidisciplinary subspecialty teams to provide optimal care for complex reconstructive approaches. The most common craniosynostosis syndromes include Apert (FGFR2), Crouzon (FGFR2), Muenke (FGFR3), Pfeiffer (FGFR1 and FGFR2), and Saethre-Chotzen (TWIST). Bicoronal craniosynostosis (turribrachycephaly) is most commonly associated with syndromic craniosynostosis. Disease presentation varies from mild sutural involvement to severe pansynostoses, with a spectrum of extracraniofacial dysmorphic manifestations. Understanding the multifaceted syndromic presentations while appreciating the panoply of variable presentations is central to delivering necessary individualized care. Cranial vault remodeling aims to relieve restriction of cranial development and elevated intracranial pressure and restore normal morphology.

Extreme proximal junctional kyphosis-a complication of delayed lambdoid suture closure in Hajdu-Cheney syndrome: a case report and literature review

PURPOSE

To describe the manifestations, surgical treatment, and potential complications of Hajdu-Cheney syndrome (HCS), and the management of these complications.

METHODS

The clinical presentation, management and outcome of HCS with severe osteoporosis and open skull sutures is presented, together with a literature review.

RESULTS

A 20-year-old female with HCS underwent posterior occipitocervical fusion for symptoms of progressive basilar invagination. Because of delayed lambdoid suture closure, the stiff fusion construct lead to increased suture distraction, most notably in the upright (suture-open) position, with relief in the supine (suture-closed) position. This was successfully remedied with extension of the fusion construct anteriorly over the skull vertex to the frontal bones.

CONCLUSIONS

In patients with HCS and other conditions with delayed suture closure, the surgeon must be cognizant of the presence of mobility at the suture lines, and consider extending the fusion construct anteriorly over the skull vertex up to the frontal bones. Because of significant osteoporosis in these syndromes, multiple fixation points and augmentation with bone graft are important principles.

[Original three-dimensional reconstruction of a case of metopism associated with a unilateral complete absence of the left frontal sinus: Clinical interest and review of the literature]

Metopism (complete persistence of the metopic suture in adults) is a rare but not exceptional variation of the calvaria. Hypoplasia or aplasia of the frontal sinus may be associated without evident correlation. Nevertheless, a misdiagnosis of these variations may have clinical consequences, especially in a traumatic context. The aim of this paper was to report a case of metopism associated with a unilateral aplasia of the left frontal sinus, originally illustrated with 3D image fusion volume rendering reconstructions.

[Skull fracture or accessory suture in a child?]

Differentiation between accessory sutures and fractures in the skull of an infant can be difficult. Apart from the regular sutures there is a multitude of variations that may be mistaken for a fracture line. Such variations include for instance the intraparietal suture between the two ossification centers of the parietal bone or the mendosal suture between the supraoccipital and interparietal bone of the occipital squama. The presented case refers to an approximately 20-month-old female child. During autopsy, a discontinuity in the right paramedian posterior cranial fossa parallel to the internal occipital crest with connection to the foramen magnum was observed. The macroscopic findings suggested a fracture line because of its course. However, neither a hemorrhage in the soft tissue nor callus formation was discernible. The discontinuity was preserved with the adjacent parts of the occipital bone for further histological examination. In the report of a cranial CT, which was carried out five days before the child's death, an accessory suture paramedially in the right posterior cranial fossa was described. When the clinical CT records were re-evaluated, a similar discontinuity at the corresponding position on the other side was detected, though of noticeably shorter length. Additionally, the preserved occipital bone fragment including the discontinuity was histologically processed. In the radiological literature, precise (radiological) criteria for differential diagnosis are indicated. A zigzag pattern with sclerotic borders and a bilateral and fairly symmetric occurrence indicate a suture, whereas a sharp lucency with non-sclerotic edges and a unilateral occurrence indicate a fracture. Taking all the findings into account, the depicted discontinuity was regarded as an accessory suture. This case demonstrates that differentiation between a fracture and an accessory suture may be difficult in the autopsy of a child and underlines the importance of a postmortem CT examination.

Therapeutic effect of nanogel-based delivery of soluble FGFR2 with S252W mutation on craniosynostosis

Apert syndrome is an autosomal dominantly inherited disorder caused by missense mutations in fibroblast growth factor receptor 2 (FGFR2). Surgical procedures are frequently required to reduce morphological and functional defects in patients with Apert syndrome; therefore, the development of noninvasive procedures to treat Apert syndrome is critical. Here we aimed to clarify the etiological mechanisms of craniosynostosis in mouse models of Apert syndrome and verify the effects of purified soluble FGFR2 harboring the S252W mutation (sFGFR2IIIc^S252W) on calvarial sutures in Apert syndrome mice in vitro. We observed increased expression of Fgf10, Esrp1, and Fgfr2IIIb, which are indispensable for epidermal development, in coronal sutures in Apert syndrome mice. Purified sFGFR2IIIc^S252W exhibited binding affinity for fibroblast growth factor (Fgf) 2 but also formed heterodimers with FGFR2IIIc, FGFR2IIIc^S252W, and FGFR2IIIb^S252W. Administration of sFGFR2IIIc^S252W also inhibited Fgf2-dependent proliferation, phosphorylation of intracellular signaling molecules, and mineralization of FGFR2^S252W-overexpressing MC3T3-E1 osteoblasts. sFGFR2IIIc^S252W complexed with nanogels maintained the patency of coronal sutures, whereas synostosis was observed where the nanogel without sFGFR2^S252W was applied. Thus, based on our current data, we suggest that increased Fgf10 and Fgfr2IIIb expression may induce the onset of craniosynostosis in patients with Apert syndrome and that the appropriate delivery of purified sFGFR2IIIc^S252W could be effective for treating this disorder.

Absence of the sagittal suture does not result in scaphocephaly

PURPOSE

Premature fusion or craniosynostosis of suture(s) of the calvaria is known to result in skull deformation. However, absence of sutures may be interpreted as premature closure of a suture of the calvaria. In the study, the authors investigated skull configuration in skulls found to have isolated absence of the sagittal suture.

METHODS

For this study, 400 adult and child skulls from all of the authors' osteological collections were analyzed.

RESULTS

Of these 400 skulls, three specimens were found to have isolated absence of the sagittal suture (one child and two adults). None of these three skulls were found to have scaphocephaly as a result of the suture absence. No other malformations were found on any specimen. One clinical case is also presented with radiologic findings on the absence of the sagittal suture that also did not have resultant skull malformation.

CONCLUSIONS

The authors found that the isolated absence of the sagittal suture does not produce a scaphocephalic skull shape.

Value of high-resolution ultrasound in the differential diagnosis of scaphocephaly and occipital plagiocephaly

Secondary to the increase in deformational plagiocephaly a growing number of infants with cranial deformity present to craniofacial teams. Computed tomography (CT) is diagnostic, but uses ionizing radiation. The purpose of this study was to evaluate ultrasound as a screening test for the patency of cranial sutures in scaphocephaly and occipital plagiocephaly. The cranial sutures of 54 infants with this cranial deformity were assessed by ultrasound. Sutures were read as patent or fused if a hypoechoic gap could or could not be demonstrated between the hyperechoic clavarial bones, respectively. Seven children suffered from true craniosynostosis of either the sagittal or the lambdoid suture. In five cases the ultrasound findings were diagnostic for a fused suture, in two cases the results were inconclusive. Forty-seven infants presented with deformational plagiocephaly. Ultrasound examination demonstrated patent sutures in 45 cases and was inconclusive in two cases. Sonography of the cranial sutures is a good screening tool to distinguish fused from patent cranial sutures in scaphocephaly and occipital plagiocephaly and avoids the radiation exposure associated with CT examinations.

Correlations between the abnormal development of the skull base and facial skeleton growth in anterior synostotic plagiocephaly: the predictive value of a classification based on CT scan examination

BACKGROUND

Anterior cranial plagiocephaly, depending on the early hemicoronal suture fusion, is the most relevant form of plagiocephaly in terms of clinical implications. Its estimated incidence ranges between 0.4 and 1 per 1,000 live births. In the present report, we aim at validating the classification of Di Rocco and Velardi, proposing a scheme based on basicranium analysis using CT scans and its predictive value by evaluating the developmental characteristics of a population of adult subjects affected by anterior plagiocephaly who had underwent the surgical correction in the first months of life.

MATERIALS AND METHODS

The group of patients here considered was retrieved from among all patients operated upon for craniostenosis in the pediatric neurosurgery unit of Policlinico Gemelli in Rome between January 1, 1980 and December 31, 1989. The study group consisted of 13 patients, seven females and six males, affected by anterior synostotic plagiocephaly ranging in age between 20 and 32 years (mean 25.54 years). We also formed a group of unaffected patients in order to control for normal variability in the population. The subjects of the study group were evaluated using CT scan exams and cephalometric analyses were performed using three-dimensional reconstruction.

DISCUSSION AND CONCLUSION

In this study, we were able to associate a facial phenotype to confirm the predictive value of the classification proposed. It is highly probable that the different outcomes depend on the different degrees of involvement in the synostotic process by the various skull base sutures which were essentially unaffected by the surgical procedures.

Metopism: as an indicator of cranial pathology; a good example from Iranian plateau

Metopism had been observed as a genetic trait. Recent studies have brought to light that it can get as an indicator of cranial pathology. An example of this pathology has been studied by this author on an Iranian skeletal sample. The purpose of this paper is to provide basic information on the subject and thereby to create awareness among Iranian anthropologists and archaeologists of this new line of evidence as well as to pathologists.

Palatal expansion in a patient with solitary median maxillary central incisor syndrome

The objective of this article was to report a clinical case of a patient with solitary median maxillary central incisor syndrome. He was treated with rapid maxillary expansion and evaluated with computed tomography. The boy, aged 6 years 7 months, had a single maxillary central incisor in the midline, posterior crossbite, prominent midpalatal ridge, indistinct philtrum, no incisive papilla, and no labial frenulum. No other systemic anomalies were found. Posteroanterior cephalometric radiography showed skeletal atresia of the maxilla that was corrected with rapid maxillary expansion. A Haas expander was used and activated twice per day (quarter turn per activation) for 15 days. The procedure was monitored with computed tomography to evaluate any effect on the intermaxillary suture and tooth. Although the crossbite was clinically corrected after the expansion, radiographs and tomographs showed no opening of the midpalatal suture. Rapid maxillary expansion resulted in neither midpalatal suture opening nor transverse increase of the maxillary skeletal base in this patient.

Characteristics, head shape measurements and developmental delay in 287 consecutive infants attending a plagiocephaly clinic

AIM

To describe the characteristics, developmental status and severity of head shape deformation in infants presenting to a plagiocephaly clinic.

METHODS

Head shape was measured and neck function assessed in 287 consecutive infants presenting to a plagiocephaly outpatient clinic. Information was obtained on demographic and obstetric factors, plagiocephaly history and current positioning strategies. Development was assessed by the Ages and Stages Questionnaire (ASQ).

RESULTS

After clinical examination, craniosynostosis was suspected in seven infants (2%) and a skull computed tomography (CT) scan was performed; five showed suture abnormalities. Fifty-eight percent of cases had a history of limitation of neck function; this was more likely in plagiocephalic infants than brachycephalic infants. Males, firstborn infants, instrument-delivered infants, supine sleep position and right-sided flattening were predominant. One or more delays on the ASQ were seen in 36% of infants.

CONCLUSION

Physical examination of infants with head shape deformities is essential in order to rule out craniosynostosis. Infants with deformational plagiocephaly frequently have neck muscle dysfunction. We postulate that the higher than expected number of developmental delays may be related to the effects of supine sleep position, low or variable tone, lower activity levels, male gender and neck muscle dysfunction.

Classification system for sagittal craniosynostosis

Scaphocephaly is an important but incompletely defined entity resulting from premature fusion of the sagittal suture. Our goal was to use the clarity afforded by three-dimensional computed tomographies (CTs) to discern what characteristics of this disease are most representative and singular. Furthermore, we sought to define a classification system wherein the dominant physical trait, as it results from varied sites of premature fusion, determines the type of scaphocephaly in a particular patient. All patients with CT-diagnosed isolated single-suture sagittal craniosynostosis seen by a single craniofacial surgeon and a single pediatric neurosurgeon over a 5-year period are included (N = 76). Patients were stratified into anterior, central, posterior, or complex subtypes dependent upon the presence of a single dominant characteristic as seen on CT scan. Anterior type features a transverse retrocoronal band; central type has a heaped sagittal ridge; posterior type has an especially prominent occiput; and complex type includes those patients in whom a single dominant feature is not present. Forty-eight patients fit into anterior, central, or posterior types. Thirteen percent (N = 7) lack a single dominant feature and are complex. Incidence and prevalence for each type in this population are the following: anterior, 13/24%; central, 16/29%; posterior, 19/35%; and complex, 7/13%. Heterogeneous points of initial fusion may be responsible for the differing representations. Clinical applications using this classification system are ongoing and may allow us to individualize surgical intervention to optimize clinical outcome.

Job syndrome masquerading as non-accidental injury

Awareness of the rare condition of Job syndrome is low among both paediatricians and geneticists. Consequently, observation of the recurrent fractures in the majority of such cases can result in misdiagnosis of non-accidental injury in young children who have the syndrome. The case we report here represents an example of this diagnostic pitfall, which deserves wide recognition due to the serious consequences for children, families and paediatricians acting as experts in legal actions in such circumstances.

Early treatment of anterior calvarial craniosynostosis using endoscopic-assisted minimally invasive techniques

BACKGROUND

A total of 100 patients who presented with synostosis of the metopic or coronal suture were consecutively treated during a 6-year period using minimally invasive endoscopic-assisted suturectomies. After surgery, all patients were fitted with custom-made cranial helmets for up to 12 months.

MATERIALS AND METHODS

The coronal group consisted of 50 patients, 26 females and 23 males with a mean age of 3.78 months. Surgery was done through a single 2-mm incision at the ipsilateral stephanion. After endoscopic-assisted dissection, a craniectomy of the involved suture was done (mean width, 6 mm, and mean length, 10 cm). The metopic group consisted of 50 patients, 35 males and 16 females with a mean age of 4.1 months. A single 2- to 3-cm incision was placed on the midline behind the hairline. A suturectomy of the suture from anterior fontanelle to nasofrontal suture was performed (mean width, 7 mm, and mean length, 9.8 cm).

RESULTS

For the entire cohort, the mean estimated blood loss was 34 cc (5-250 cc). The mean estimated percent of blood volume lost was 5.2% (1-26%). There were no intraoperative blood transfusions and five postoperative for a total transfusion rate of 6.7%. The mean surgical time was 56 min. All but one patient (99%) was discharged on the first postoperative day. Complications included two dural tears and four pseudomeningoceles. There were two cases of incomplete reossification of the craniectomy. There were no infections, mortalities, hematomas, or visual injuries. There were no complications related to helmet therapy except three superficial skin breakdowns that cleared immediately with helmet non-use for 3-4 days. Using anthropometric measurements and extensive photographic and physical assessments, excellent results were obtained in 84%, good results in 9%, and poor results in 7% of patients.

CONCLUSIONS

Early treatment of infants with coronal or metopic craniosynostosis using endoscopic assisted minimally invasive suturectomies is a safe and efficacious treatment alternative associated with excellent results in a large portion of these patients.

Distraction osteogenesis in the surgical treatment of craniostenosis: a comparison of internal and external craniofacial distractor devices

PURPOSE

To compare the practical difficulties of external and internal craniofacial distraction devices used in craniofacial advancement in terms of technical surgical limitations and patients' discomfort.

MATERIALS AND METHODS

This study involved analysis of the pertinent literature and personal experience on the treatment of patients affected with syndromic craniosynostoses treated with craniofacial distraction advancement.

RESULTS

One hundred patients who underwent internal craniofacial distraction were analyzed. This kind of distraction device was found to be adequately tolerated by the patients with regards to physical and psychological aspects. They had relatively little impact on day-life activities. However, a significant drawback of this type of device is represented by the difficulty in controlling the vectors of distraction. Thirty-eight patients were analyzed after having received the implantation of an external craniofacial distraction device. This type of instrumentation was found to have a significant psychological impact and important limitation on recreational activities. External devices, however, offered important advantages in the control of the vectors of distraction, which could be modified according to the patient's needs during the perioperative and early postoperative clinical course. There were no significant differences among the two types of devices with regard to osteogenesis and degree of facial advancement.

CONCLUSION

Both internal and external devices are effective in distraction craniofacial advancement. However, significant differences do exist concerning the surgical aspects and the practical difficulties experienced by the patients.

Frontosphenoidal synostosis: a rare cause of unilateral anterior plagiocephaly

INTRODUCTION

When a child walks in the clinic with a unilateral frontal flattening, it is usually associated in our minds with unilateral coronal synostosis. While the latter might be the most common cause of anterior plagiocephaly, it is not the only one. A patent coronal suture will force us to consider other etiologies, such as deformational plagiocephaly, or synostosis of another suture. To understand the mechanisms underlying this malformation, the development and growth of the skull base must be considered.

MATERIALS AND METHODS

There have been few reports in the literature of isolated frontosphenoidal suture fusion, and we would like to report a series of five cases, as the recognition of this entity is important for its treatment.

CONCLUSION

Frontosphenoidal synostosis must be searched in the absence of a coronal synostosis in a child with anterior unilateral plagiocephaly, and treated surgically.

Effectiveness of a limited invasive scalp approach in the correction of sagittal craniosynostosis

BACKGROUND

Several surgical techniques have been proposed for the correction of sagittal craniosynostosis. Extensive procedures seem to ensure the most stable long-term results and are more indicated in the older age group. Mini-invasive approaches are particularly useful in the very young infant as they are associated with a minor surgical risk. Furthermore, they are weighted by a minor cosmetic impact related to a less extended surgical scar.

MATERIALS AND METHODS

Data of the last 94 consecutively operated on scaphocephalic patients have been reviewed to verify the effectiveness of a personal limited-invasive approach based on four to six short linear scalp incisions vs the traditional bicoronal skin flap. The patients have been divided in two groups: (1) the control group (2000-2002): 45 children, operated on by means of a traditional bicoronal skin incision, and (2) the study group (2002-2004): 49 children, treated through four to six linear scalp incisions. The patients' variables were comparable. The results were evaluated in terms of duration of the surgical procedure, estimated blood loss (EBL), transfusion risk, postoperative complication rate, length of hospital stay, and postoperative cephalic index and cosmetic outcome as perceived by the patients' families.

RESULTS

No significant differences between the two groups were found about the early and the long-term surgical results; however, about one third of the subjects of the control group complained about the visibility of the surgical scar. In the study group, a significant reduction in the duration of the operation (p < 0.0001), postoperative hospital stay (p < 0.0001), EBL (p = 0.011), transfusion risk (p = 0.018), and complication rate (p = 0.016) was observed.

CONCLUSION

The current trend in the management of scaphocephaly is to favor simplified surgical procedures to be performed in the younger ages prevalently. The technique here presented allows achieving a stable long-term cranial reshaping, even when performed in the very young patient. The technique can be utilized also in older subjects with results comparable to those of more extensive surgical procedures. This less invasive technique is weighted by minor complication rates and minor impact of the surgical scar.

Fetuses with Down syndrome have an enlarged anterior fontanelle in the second trimester of pregnancy

OBJECTIVE

Neonates with Down syndrome are known to have an enlarged anterior fontanelle. The aim of this study was to assess whether fetuses diagnosed with Down syndrome in the second trimester have larger anterior fontanelles in comparison with normal euploid fetuses.

METHODS

The study population included 13 fetuses with trisomy 21 and 26 normal euploid fetuses analyzed between the 19(th) and the 23(rd) weeks of gestation. The anterior fontanelle was assessed by three-dimensional ultrasound, with the midsagittal plane of the fetal head being the reference view for acquisition of the volume. Anteroposterior and laterolateral diameters, perimeter and area of the fontanelle were then measured offline; the diameters were normalized for biparietal diameter and the perimeter and area were normalized for head circumference. Non-parametric statistical analysis was used to compare the mean values of all variables in the two groups of fetuses. Intra- and interobserver variability were also assessed.

RESULTS

All variables except the fontanelle laterolateral diameter were significantly greater in Down syndrome fetuses than in controls, with anterior fontanelle perimeter/head circumference and fontanelle area/head circumference ratios showing the highest sensitivity for the detection of Down syndrome. Using a cut-off of 2.1 for the fontanelle area/head circumference ratio, the sensitivity and specificity for the detection of Down syndrome were 77% and 96%, respectively.

CONCLUSION

During the mid-trimester the dimensions of the anterior fontanelle are significantly increased in fetuses with Down syndrome in comparison with normal euploid fetuses. This finding may be of help in the detection of trisomy 21 at the time of the anomaly scan.

Non-syndromic trigonocephaly: surgical decision making and long-term cosmetic results

BACKGROUND

Surgical correction is often required for cosmetic correction of trigonocephaly. The purpose of this paper was to report the long-term aesthetic outcome as appreciated by the parents/patients themselves. The self-evaluation of cosmetic outcome after trigonocephaly correction has not previously been reported. The management and different surgical techniques utilized over a 16-year period are discussed.

MATERIALS AND METHODS

An observational study was undertaken of the clinical outcome, operative data, complications and cosmetic satisfaction of these trigonocephaly patients. The parents/child were asked to rate their satisfaction with the cosmetic outcome both in terms of head shape and scar appearance, on a five-point scale (excellent-5, very good-4, good-3, fair-2 and poor-1).

RESULTS

Sixty-three patients presented with non-syndromic trigonocephaly over the 16 years. Nineteen of 63 had a mild form of trigonocephaly and were managed conservatively. The remainder underwent surgical correction. Forty-two of 44 (95%) underwent fronto-orbital advancement with either barrel staving (26/44) or frontal bone rotation/re-modelling (16/44), with 2 of 44 having burring of the metopic ridge. Head shape rating was regarded as excellent in 25 of 63 (40%), very good in 18 of 63 (28%), good in 18 of 63 (28%) and fair in 2 of 63 (4%). Of those that underwent surgery, the scar was zigzag in 32 of 44 and straight in 12 of 44. Scar was rated as being excellent in 21 of 44 (48%), very good in 12 of 44 (28%) good in 11 of 44 (24%).

CONCLUSIONS

Metopic synostosis can result in varying degrees of severity. Milder forms can be treated conservatively, with more severe forms requiring both frontal bone re-modelling and fronto-orbital advancement. Surgical correction results in a high level of patient/parent satisfaction.

[Skull plasty to correct congenital craniosynostosis]

OBJECTIVE

To investigate the technique of skull reconstruction for the congenital craniosynostosis.

METHODS

Many technique of skull plasty were adopted to correct the congenital craniosynostosis. We advanced fronto-orbital, reversal change of the frontal bone to correct the brachycephalic, hydrocephaly acrocephaly, which were supported by parietal bone. Plum-plasty of the calvaria was performed for sagittal synostosis; Fronto-orbital plasty correct the trigonocephaly; for single coronal synostosis, which result to frontal plagiocephaly,we reversed both frontal sides, advanced orbital strip and tilted the invalid side . The post plagiocephaly because of single Lambdoid synostosis, we performed of plum-plasty, reversal change of total occipital. Fronota-facial advancement cured the brachycephalic complicating with Apert or Crouzon which caused by coronal synostosis and cranial basal suture synostosis.

RESULTS

37 cases were recovery without complication. The figures were improved.

CONCLUSIONS

Big calvarial flap plasty is an optimal technique to correct the congenital craniosynostosis. But it is not substituted by bone lengthening and minimally invasive technique.

Persistent metopic suture can mimic the skull fractures in the emergency setting?

Metopism is partially or totally persisting suture extending from the nasion to the anterior angle of the bregma. The time of physiological closure of the metopic suture varies from birth to 8 years of age. Widely accepted closuring time is approximated at 2 years of age. Although formerly reported skull studies mentioned the persistent metopic suture, it is extremely rare in clinical practice. We presented a trauma case of 43 years of age who was demonstrated radiologically to have a persisting suture. Persistent metopic suture may be misdiagnosed as a vertical traumatic skull fracture extending in the mid-line in head trauma patients. Therefore the surgeon should be aware of this anatomical condition in the primary and secondary surveillance of the traumatized patient and during surgical intervention including especially frontal craniotomy. Reconstructed tomography scan demonstrating sutural closuring status may provide additional informative value in the diagnostic sequence superior to plain X-ray in the emergency setting.

'Z-Pattern' Craniosynostosis

The majority of infants with multiple sutural craniosynostosis have identifiable syndromes, which affect both coronal sutures (Apert, Crouzon, Pfeiffer, and so on), and multiple sutural fusions not involving both these sutures are exceeding rare. We report a highly unusual pattern of trisutural fusion, which to our knowledge has not been previously described. A retrospective clinical review was performed of all cases of craniosynostosis, which had presented to the Craniofacial Center in Dallas, over a 15-year period. Two patients were identified with a unique pattern of craniosynostosis involving the left coronal, sagittal, and right lambdoid sutures creating a "Z-pattern." Both patients were treated with staged cranial vault reconstructive procedures with an initial posterior remodeling (3 to 4 months) followed by an anterior repair (7 to 8 months). Both patients developed cerebellar tonsillar herniation, and one symptomatic patient required surgical decompression. With a follow up of greater than 2 years, normocephaly has been maintained with growth, and both children appear to have normal intellectual development. A unique pattern of trisutural "Z-patterned" craniosynostosis is presented. This distinctive pattern of craniosynostosis appears to be associated with cerebellar tonsillar herniation. In this small series, a two-staged procedure successfully normalized the calvarial dysmorphism, and early growth and development appear normal.

Strabismus in Unicoronal Synostosis

Unicoronal synostosis is a premature fusion of one of the coronal sutures and is thought to carry an increased prevalence for strabismus. Studies suggest the nature of the strabismus to be a hypertropia occurring ipsilateral to the fused coronal suture. The aim of this study is to investigate the laterality of strabismus in unicoronal synostosis and report on ocular motility and refractive findings in a large, unbiased sample group. A retrospective case study analysis was carried out on 59 patients with a confirmed diagnosis of unicoronal synostosis referred to the Oxford Craniofacial Unit over a 14 year period. Manifest strabismus in the primary position was found in 34 (57.6%) cases. In 19 (55.9%) cases, this occurred contralateral to the fused suture, and in 9 (26.5%) cases, strabismus was on the ipsilateral side. Six had alternating strabismus. These results are contrary with apparent findings in the literature but are not statistically significant (P = 0.0872) for strabismus occurring more frequently on the nonsynostotic side. Esotropia with a vertical component was most common, found in 61% of all cases with strabismus. Apparent inferior oblique overaction was found in 30 of the 59 (50.8%) cases, with this occurring bilaterally in 14 cases. Significant refractive error was found in 46% of all cases, most of which showed anisometropia and astigmatism that occurred more frequently on the contralateral, nonsynostotic side (P = 0.0106). All cases of unicoronal synostosis with a mutation of the FGFR2 or FGFR3 gene had manifest strabismus. Manifest strabismus was found in 57.6% of cases reviewed, but this was found to be no more likely to occur on the side contralateral or ipsilateral to the fused suture (P = 0.0872). Anisometropia and astigmatism were found more frequently in the eye contralateral to the fused suture.

Modeling of Scaphocephaly Using Superelastic Titanium-Nickel Rings: A Preliminary Report

As long as resection of sagittal suture eliminates craniostenosis it leads to desired cranium broadening and shortening solely in the case of children under six months of age. In the majority of cases, especially in older children, boat-shaped cranium remains rather unchanged and its effective modeling requires extensive dissection and osteotomy of the whole cranium vault (e.g., frontal, occipital and parietal bones). Lauritzen's method is an alternative solution. It consists of distraction of cranium vault bones with the aid of steel springs. In order to simplify and improve the efficacy of treatment since 2002, the authors originated the application of titanium-nickel rings to model the cranium. After the sparing excision of cranium vault sutures in the shape of letter "H" the compressed ring is given in the sagittal axis oval shape and in this form it is fixed to osseous margins. The ring's expansion at the same time broadens and shortens the cranium vault. Material was analyzed from 7 children (range, 9 months to 4 years of age), who were treated in the years 2002-2006 because of sagittal craniostenosis. Observations made so far and good treatment results indicate purposefulness of discussed treatment continuation.

Atypical midline cleft with duplication of the metopic suture

INTRODUCTION

In contrast to the common clefts of the lip, alveolus and palate, the atypical clefts of the face may come in myriad patterns of clinical expression and are often not easy to define.

PURPOSE

In this report, a case of median craniofacial dysraphia is described.

PATIENT

At presentation, the 3-month-old male patient had a bilateral complete cleft of the lip, alveolus and palate. The nose was wide and a horn was present on the nasal dorsum. 3-D CT AND MRI REVEALED: Duplication of the metopic suture ending at the wide anterior fontanel; orbital hypertelorism; midline cranial cleft ending just superior to the nasal dorsum; frontoethmoidal encephalocoele and holoprosencephaly. The presence of two metopic sutures was confirmed during surgery.

CONCLUSION

The presented case carries the characteristics of the median cleft face syndrome. However, it differs from similar cases in two respects. First, the patient had two metopic sutures, one on either side of the cranial extension of the median cleft. Second, the patient had a bilateral cleft lip in contrast to the expected median cleft lip deformity.

Impaired posterior frontal sutural fusion in the biglycan/decorin double deficient mice

Biglycan (Bgn) and decorin (Dcn) are highly expressed in numerous tissues in the craniofacial complex. However, their expression and function in the cranial sutures are unknown. In order to study this, we first examined the expression of biglycan and decorin in the posterior frontal suture (PFS), which predictably fuses between 21 and 45 days post-natal and in the non-fusing sagittal (S) suture from wild-type (Wt) mice. Our data showed that Bgn and Dcn were expressed in both cranial sutures. We then characterized the cranial suture phenotype in Bgn deficient, Dcn deficient, Bgn/Dcn double deficient, and Wt mice. At embryonic day 18.5, alizarin red/alcian blue staining showed that the Bgn/Dcn double deficient mice had hypomineralization of the frontal and parietal craniofacial bones. Histological analysis of adult mice (45-60 days post-natal) showed that the Bgn or Dcn deficient mice had no cranial suture abnormalities and immunohistochemistry staining showed increased production of Dcn in the PFS from Bgn deficient mice. To test possible compensation of Dcn in the Bgn deficient sutures, we examined the Bgn/Dcn double deficient mice and found that they had impaired fusion of the PFS. Semi-quantitative RT-PCR analysis of RNA from 35 day-old mice revealed increased expression of Bmp-4 and Dlx-5 in the PFS compared to their non-fusing S suture in Wt tissues and decreased expression of Dlx-5 in both PF and S sutures in the Bgn/Dcn double deficient mice compared to the Wt mice. Failure of PFS fusion and hypomineralization of the calvaria in the Bgn/Dcn double deficient mice demonstrates that these extracellular matrix proteoglycans could have a role in controlling the formation and growth of the cranial vault.

Neurodevelopment of children with single suture craniosynostosis: a review

INTRODUCTION

Rates of neurocognitive risk range from 35-50% of school-aged children with isolated single suture craniosynostosis (SSC). It has been hypothesized that early surgical intervention to release suture fusion reduces risk for increased intracranial pressure (ICP) and the corresponding risk to neurodevelopment. However, studies assessing children with SSC have been inconsistent in finding an association between neurocognitive development, age of surgery, and ICP.

REVIEW

SSC produces notable distortion of the cranial vault and underlying brain mass. Although a linear relationship between skull distortion, ICP, and neurocognitive deficits has generally been assumed, recent studies have postulated an interactive process between the skull and developing brain that results in neuroanatomical changes that are not limited to areas directly beneath the fused suture. The specific neuropsychological deficits identified in children with SSC including problems with attention and planning, processing speed, visual spatial skills, language, reading, and spelling may be related to the anatomic differences that persist after correction of suture fusion.

CONCLUSIONS

Available literature on neurocognitive development of children with SSC is suggestive of mild but persistent neuropsychological deficits, which become more significant as cognitive demands increase at school age. Anatomical studies of children without SSC are beginning to identify particular groups of brain structures that if disrupted or malformed, may be associated with specific cognitive deficits. Controlled research investigating the relationship between persistent anatomical changes and neurocognitive functioning of school-aged children with SSC is needed.

Age dependence of fusion of primary occipital sutures: a radiographic study

PURPOSE

When linear lucency is present in the occipital bone on radiographs throughout childhood, differential diagnosis becomes important because some primary sutures are similar to fractures. The authors here chronicled the normal development of ossification centers, sutures, and synchondroses in the chondrocranium by radiographic examination.

METHODS

One hundred and twenty-seven children, aged from newborns to 6 years and without any skull base deformities, were referred to for radiographs of Towne's projection.

RESULTS

In the occipital bone at birth, three primary sutures could be identified. At the age of 0-3 years, occipital and innominate sutures started to fuse, this being complete by 4 years, whereas mendosal sutures persisted until 6 years of age, after which no primary sutures could be seen.

CONCLUSION

The complex process of skull base development features a step-wise process sutural closure for which radiographic standards allow differential diagnosis from fractures with judgment of the timing.

Trigonocephaly: surgical considerations and long term evaluation

Trigonocephaly accounts for approximately 10% of all craniosynostosis. Severe trigonocephaly results in a triangular-shaped forehead, superior-lateral orbital depression, hypotelorism, and compensatory occipital-parietal calvarial changes. Radiographic findings include ovoid orbits with parallel medial borders, thickened keel-shaped frontal bone, small ethmoid sinuses, and a short anterior cranial fossa with pitched sphenoid wings. Our experience with 50 infantile cases of severe nonsyndromic trigonocephaly patients treated from 1987 to 2005 is clinically reviewed to assess long-term growth based on a standardized operative technique. The average age of the patients at surgery was 6 months and the mean follow-up was 12 years. Our complication rate was 2%; the reoperative rate was 12%. The use of resorbable rigid plate fixation combined with alloplastic augmentation has improved the cosmetic outcome in patients treated since 1996 and reduced the reoperative rate.

[Total calvarial reconstruction for sagittal synostosis]

OBJECTIVE

To study the technique of total calvaria reconstruction for sagittal synostosis.

METHODS

11 children with sagittal synostosis were treated. The David II procedure was used to reconstruct the calvarial gap in 6 cases; Osteotomies with reversal change was performed on 2 cases; Plum-plasty of the calvaria was performed on 3 cases.

RESULTS

The 11 cases were cured with satisfactory head shape.

CONCLUSIONS

The David II procedure is applicable for patient of 1 approximately 3 months. The technique of floating skull flap plasty and plum-plasty of the calvaria can be performed on patients older than 3 months.

Normal skull suture variant mimicking intentional injury

A presumed skull fracture might be a variant of a normal skull suture, especially when bilateral

Changes in Anthropometric Values of Paired Craniofacial Measurements of Patients With Right Coronal Synostosis

Quantitative changes of the 5 paired (right and left) projective linear measurements of the craniofacial complex were analyzed by anthropometric methods in 26 patients (9 males and 17 females) with right coronal synostosis, 16 in infancy (0-5 and 6-12 months) and 10 in early childhood (1-10 years). Measurements were taken from 3 regions: the supraorbital rim length of the head (t-g), the length (en-ex) and height (ps-pi) of the eye fissures in orbits, and the width (pra-pa) and length (sa-sba) of the ears. None of the patients had undergone corrective surgery.Anthropometric analysis of patients in infancy showed a large percentage of subnormal supraorbital rim lengths (t-g) on the right side of the head, with a higher frequency in females (90.9%) than in males (80.0%). Eye fissure lengths (en-ex) were subnormal more often in males than in females on both sides, while heights were generally normal bilaterally in both sexes (72.7-100% of cases). Ears of normal width (pra-pa) and length (sa-sba) were more frequent in females. In males, the frequency of subnormal ear widths and lengths surpassed those in females. The most remarkable changes between infancy and early childhood were noted in the orbital region, in which subnormal eye fissure lengths became bilaterally normal in both sexes.

Metopic suture in fetuses with trisomy 21 at 11 + 0 to 13 + 6 weeks of gestation

OBJECTIVE

To investigate the development of the frontal bones and metopic suture in fetuses with trisomy 21 at 11 + 0 to 13 + 6 weeks of gestation.

METHODS

Three-dimensional (3D) ultrasound was used to measure the height of and gap between the frontal bones in 75 fetuses with trisomy 21 and these were compared to the measurements in 200 normal fetuses at 11 + 0 to 13 + 6 (median, 12 + 6) weeks of gestation.

RESULTS

In the fetuses with trisomy 21, compared to the normal fetuses, there was no significant difference in either the height of the frontal bones (mean difference 0.16 SD, range -1.78 to 2.17 SD; P = 0.369) or the gap between them (mean difference 0.012, 95% CI -0.073 to 0.097; P = 0.780). Additionally, within the group of trisomy 21 fetuses there were no significant differences in the development of the frontal bones and metopic suture between those with absent (n = 46) and those with present (n = 29) nasal bone.

CONCLUSIONS

In trisomy 21 the development of the frontal bones and metopic suture is as normal and is independent from the development of the nasal bones.

[Clinical and roentgenological characteristics of synostosis frontal plagiocephaly, induced by early synostosis of cranio-cerebral sutures]

In this study authors demonstrate description and analysis of clinical and roentgenological presentations of early synostosis of cranio-cerebral sutures in children. Roentgenological description of cranio-cerebral sutures in infants showed up their significant narrowing and the increase in shadow density, early appearance of ossifications zones in the peripheral parts of the sutures, diffuse increase of cranial bones thickness because of apposition osteogenesis disorder. Results of the study show that many alterations in the cerebral cranium are accompanied with malformations of facial skeleton.

Metopic suture in fetuses with holoprosencephaly at 11 + 0 to 13 + 6 weeks of gestation

OBJECTIVE

To investigate the development of the metopic suture in fetuses with holoprosencephaly at 11 + 0 to 13 + 6 weeks of gestation.

METHODS

Three-dimensional (3D) ultrasound was used to measure the height and gap between the frontal bones in 200 normal fetuses and in nine fetuses with holoprosencephaly at 11 + 0 to 13 + 6 (median, 12) weeks of gestation.

RESULTS

In the 200 normal fetuses, the height of the frontal bones increased significantly with gestation from a mean of 2.5 mm (5(th) and 95(th) centiles: 1.9 mm and 3.3 mm) at 11 weeks to 6.1 mm (5(th) and 95(th) centiles: 4.6 mm and 8.1 mm) at 13 + 6 weeks. The gap between the two frontal bones did not change significantly with gestation (mean: 1.5 mm; 5(th) centile: 1.0 mm; 95(th) centile: 2.0 mm). In fetuses with holoprosencephaly, the height of the frontal bones was significantly larger (mean difference, 5.6 SDs; range, 3.9-7.7 SDs; P < 0.0001) and the gap was significantly smaller (mean 0.2 mm, range 0-0.8 mm; P < 0.0001) than those in normal fetuses.

CONCLUSIONS

Holoprosencephaly is associated with an accelerated development of the frontal bones and premature closure of the metopic suture.

Pseudoclosure of anterior fontanelle by wormian bone in isolated sagittal craniosynostosis

AIMS AND OBJECTIVES

Although syndromic craniosynostosis is one of the causes for early closure of the anterior fontanelle, there is no literature on the incidence and causes of fontanelle closure in isolated single-suture craniosynostosis. The objective of this study was to review the incidence of fontanelle closure by a wormian bone in isolated, nonsyndromic sagittal craniosynostosis.

MATERIALS AND METHODS

Intraoperative records of 100 consecutive children under 1 year of age, operated for isolated sagittal synostosis over a 14-year period (1987- 2000), were reviewed to identify the presence of a wormian bone closing the anterior fontanelle.

RESULTS

The median age at surgery was 4.2 months with a range of 1.9-11.7 months. Intraoperatively, a wormian bone was seen replacing the anterior fontanelle in 4 cases giving an incidence of 4%.

CONCLUSIONS

A wormian bone can occupy the anterior fontanelle in children with isolated sagittal craniosynostosis giving the appearance of a 'closed fontanelle'.

Metopic suture in fetuses with Apert syndrome at 22-27 weeks of gestation

OBJECTIVES

To examine the possible association of skull deformity and the development of the cranial sutures in fetuses with Apert syndrome.

METHODS

Three-dimensional (3D) ultrasound was used to examine the metopic and coronal sutures in seven fetuses with Apert syndrome at 22-27 weeks of gestation. The gap between the frontal bones in the transverse plane of the head at the level of the cavum septi pellucidi was measured and compared to findings in 120 anatomically normal fetuses undergoing routine ultrasound examination at 16-32 weeks.

RESULTS

In the normal group, the gap between the frontal bones in the metopic suture at the level of the cavum septi pellucidi, decreased significantly with gestation from a mean of 2.2 mm (5th and 95th centiles: 1.5 mm and 2.9 mm) at 16 weeks to 0.9 mm (5th and 95th centiles: 0.3 mm and 1.6 mm) at 32 weeks. In the seven cases with Apert syndrome, two-dimensional ultrasound examination demonstrated the characteristic features of frontal bossing, depressed nasal bridge and bilateral syndactyly. On 3D examination there was complete closure of the coronal suture and a wide gap in the metopic suture (15-23 mm).

CONCLUSION

In normal fetuses, cranial bones are believed to grow in response to the centrifugal pressure from the expanding brain and proximity of the dura to the suture is critical in maintaining its patency. In Apert syndrome, the frontal bossing may be a mere consequence of a genetically predetermined premature closure of the coronal suture. Alternatively, there is a genetically predetermined deformation of the brain, which in turn, through differential stretch of the dura in the temporal and frontal regions, causes premature closure of the coronal suture and impaired closure of the metopic suture.

Three-dimensional sonographic description of abnormal metopic suture in second- and third-trimester fetuses

OBJECTIVE

To describe patterns of abnormal development of the metopic suture in association with fetal malformations during the second and third trimesters of pregnancy.

METHODS

This was a cross-sectional study of the frontal bones and metopic suture in 11 fetuses at 17-32 weeks of gestation. Cases were selected because there were obvious abnormalities in the metopic sutures. In each case, a malformation was detected by two-dimensional (2D) ultrasound and the abnormality of the metopic suture was detected and evaluated on three-dimensional (3D) ultrasound, using transparent maximum mode.

RESULTS

There were essentially four patterns of abnormality in the metopic suture: firstly, delayed development with a V- or Y-shaped open suture, which is found in normal fetuses at 12-16 weeks; secondly, a U-shaped open suture, presumably due to upward growth of the frontal bones with delayed closure; thirdly, premature closure of the suture, which is normally observed after 32 weeks; fourthly, the presence of additional bone between the frontal bones. Premature closure of the suture or additional bone between the frontal bones was observed in fetuses with holoprosencephaly and abnormalities of the corpus callosum, whereas the V-, Y- and U-shaped metopic sutures were observed in fetuses with facial defects involving the orbits, nasal bones, lip, palate and mandible, in the absence of holoprosencephaly and abnormal corpus callosum.

CONCLUSIONS

This preliminary study describes the pattern of possible abnormalities of the metopic suture and should stimulate further investigation to establish the prevalence and evolution of abnormal sutures as well as the incidence and pattern of other associated defects.

Nonsynostotic scaphocephaly: the so-called sticky sagittal suture

OBJECT

Scaphocephaly is a common craniofacial abnormality that results from craniosynostosis of the sagittal suture. The authors have treated a group of infants who presented with nonsynostotic scaphocephaly, or a so-called sticky sagittal suture. The purpose of this study was to describe these patients with nonsynostotic scaphocephaly, the natural history of the disease, and its treatment.

METHODS

At the University of Texas-Houston Medical School between 1996 and 2002, nine patients presented with nonsynostotic scaphocephaly. When the abnormality in patients was diagnosed prior to 12 months of age, the majority (seven of eight) were successfully managed by molding helmet therapy. The only child in this group in whom this therapy failed to correct the deformity was noted on repeated computerized tomography scanning to have true sagittal synostosis, which required surgical correction. One child with nonsynostotic scaphocephaly, who presented after 1 year of age, required surgical correction followed by postoperative molding helmet therapy.

CONCLUSIONS

Patients with nonsynostotic scaphocephaly appear to have sagittal synostosis. If treated early (at < 12 months of age), head shape in these patients can be normalized by molding helmet therapy. Surgery is reserved for older patients (> 12 months of age) or those with sagittal synostosis.

Intracranial pressure monitoring in children with single suture and complex craniosynostosis: a review

INTRODUCTION

One third of patients with craniofacial dysostosis syndromes and about 15-20% of children with single suture craniostenosis have a documented increase in intracranial pressure (ICP). The early detection of intracranial hypertension is important in order to reduce the risks for brain development and visual function. However, in children with craniosynostosis, the clinical manifestations of abnormally increased ICP are difficult to detect, as the majority of patients may have neither warning signs nor symptoms for a long period of time.

REVIEW

Moreover, data from the literature suggest that neither fundoscopic nor radiological findings are necessarily related to intracranial pressure recordings in this type of pathology. In this context prolonged ICP monitoring seems actually to be the most valuable diagnostic tool. Extradural, subdural, and intraparenchymal devices have been used, and different softwares have been employed for PC storage and analysis of the data obtained. Most recent series consider mean ICP combined with plateaux waves as the most sensitive indicators in the final evaluation of the results.

CONCLUSIONS

The analysis of the literature demonstrates a significant difference in the prevalence of raised ICP preoperatively between non-syndromic and syndromic patients. Among the non-syndromic children, a direct relation between the number of sutures involved and raised ICP is documented. The analysis of plateaux waves seems to be particularly important in children with borderline mean ICP values. Persistent postoperative raised ICP has been described in 6-15% of patients with craniofacial dysostosis. It must be related to the multifactorial etiology of increased ICP in these patients, which includes cerebral venous congestion, upper airway obstruction, and hydrocephalus.