Cranial Vault Asymmetry Index Research Articles

Jugular foramen stenosis in external hydrocephalus in infants.

To measure the size of jugular foramina in infants affected by external hydrocephalus (EH) and in a control group, to support the hypothesis that a jugular foramen (JF) stenosis may determine dural venous sinus alterations and increased venous outflow resistance as main pathophysiological factor. Minimum, maximum, and mean values of JF areas were measured in a series of phase-contrast magnetic resonance venous angiography (angio MRV PCA3D) performed on 81 infants affected by EH. Results were compared with a group of 54 controls. Smaller JF area was significantly smaller in patients versus controls (43.1 ± 14.6 vs. 52.7 ± 17.8; p < 0.001) resulting in a significantly smaller mean JF areas in patients vs. controls (51.6 ± 15.8 vs. 57.0 ± 18.3; p = 0.043). In patients, smaller JF areas were significantly associated with higher venous obstruction grading score (VOGS) both on the right (p = 0.018) and on the left side (p = 0.005). Positional plagiocephaly (cranial vault asymmetry index > 3.5%) was more frequent among EH patients than controls (38/17) but the difference was not significant (p = 0.07). In the 38 plagiocephalic patients, JF area was smaller on the flattened side than the contralateral in a significant number of cases both in right (21/7) and left (9/1) plagiocephaly (p < 0.0005) as well as the mean area (48.2 + 16.4 mm2 vs. 57.5 + 20.7 mm2, p = 0.002) and VOGS was significantly higher on the plagiocephalic side than on the contralateral side (1.6 ± 1.1 vs. 1.1 ± 0.9, p = 0.019). In this series of infants affected by EH, the mean size of the ostium of both JF resulted significantly smaller than controls. JF stenosis was significantly associated with higher degrees of venous obstruction on both sides, suggesting a direct extrinsic effect of JF size on dural sinus lumen and possible consequent effect on venous outflow resistance. Positional plagiocephaly, when present, was associated with a decreased JF area and increased VOGS on the flattened side.

A Study on the Effectiveness of Helmet Therapy for Cranial Deformations According to Cranial Shape.

To investigate the effects of helmet therapy on plagiocephaly, according to head circumference, cephalic index (CI), and skull height. Plagiocephaly is a condition in which the skull is congenitally asymmetrical or affected by acquired factors such as compression in the womb or the habit of sleeping on one side. Although there are numerous studies on the effectiveness of helmet therapy for plagiocephaly, research on its effectiveness on skull shape is lacking. We conducted a prospective study on 400 patients who underwent helmet therapy. The infants were enrolled and the therapy was explained to the caregiver when the child had positional plagiocephaly and had a cranial vault asymmetry (CVA) exceeding 10 mm or a CVA index (CVAI) exceeding 3.5%. The CVA and CVAI changes were compared to investigate the effectiveness of helmet therapy according to head circumference, CI, and skull height. A significant treatment effect was observed for CI values between 90 and 103. The treatment effect was found to increase with greater skull height. However, no significant difference was observed in the effectiveness of helmet therapy according to head circumference. According to the findings, the effectiveness of helmet therapy in children with positional plagiocephaly is greater for children with higher skulls and for those with CI values between 90 and 103; it is unrelated to head circumference. Based on these results, we can provide predictions of the effectiveness of helmet therapy to caregivers of children with positional plagiocephaly.

Efficacy of Cranial Orthosis for Plagiocephaly Based on 2D and 3D Evaluation.

Background With the advent of cranial orthoses as therapeutic medical devices for the treatment of severe positional head deformities in Japan, an increasing number of patients are being treated with them. However, assessing the effectiveness of a treatment is often difficult due to the use of different metrics. This study aimed to evaluate the effectiveness of cranial orthoses for deformational plagiocephaly using two- (2D) and three-dimensional (3D) evaluation metrics. Methods We conducted a retrospective study of infant patients with deformational plagiocephaly who underwent cranial orthosis treatment. We evaluated the severity of deformational plagiocephaly using cranial asymmetry (CA) and the cranial vault asymmetry index (CVAI) as 2D metrics, and anterior and posterior symmetry ratios as 3D metrics. The patients were divided into 24 subgroups based on the initial severity of each outcome and their age at the start of treatment. We analyzed the changes in outcomes and correlations within improvements across the age and severity categories. Results Overall, 1,038 infants were included in this study. The mean CA, CVAI, and anterior and posterior symmetry ratios improved significantly after cranial orthosis treatment. The improvement in each score was greater in patients with more severe initial deformities and in those who underwent treatment at a younger age. Conclusion Cranial orthosis treatment was effective in correcting deformational plagiocephaly in infants, as demonstrated by improvements in both 2D and 3D metrics. Patients with more severe initial deformities and those who underwent treatment at a younger age showed greater improvement.

Prevalence and Severity of Positional Posterior Plagiocephaly and Positional Posterior Brachycephaly in Children and Adolescents in Japan.

This study aimed to assess the prevalence, severity, and natural history of positional posterior plagiocephaly (PPP) and positional posterior brachycephaly in Japan. We conducted a cross-sectional study of pediatric patients, ranging from 0 to 15 years old, evaluated for head trauma with negative computed tomography (CT) findings. The cranial vault asymmetry index (CVAI) was calculated using CT images at the superior orbital rim. Asymmetry according to CVAI values was subcategorized as follows: mild (3.5%-7%), moderate (7%-12%), and severe (>12%). The results were analyzed according to different age groups: group 1, 2-23 months (54 patients); group 2, 2-6 years (123 patients); and group 3, 7-15 years (123 patients). Overall, 300 patients were included (109 [36.3%] girls and 191 [63.7%] boys). The overall prevalence of PPP in the 300 patients was 46.7% (140 patients). PPP prevalence decreased consistently with age group: group 1, 57.4%; group 2, 47.2%; and group 3, 41.5%. Severe asymmetry was seen in all age groups. The overall mean cephalic index (CI) was 85.2. Cephalic index scores decreased consistently with age: group 1, 87.4; group 2, 85.1; and group 3, 84.3. The prevalence of PPP in Japan was higher than that reported in other countries. Although there was an overall decrease in the prevalence and severity of PPP with increasing patient age, PPP does not necessarily resolve spontaneously in all children. Furthermore, severe asymmetry was seen across all age groups.

Effectiveness of Helmet therapy for infants with moderate to severe positional plagiocephaly.

The use of helmet treatment for positional plagiocephaly has increased recently; however, its effect is unknown in Korea. This study aimed to investigate the effectiveness of helmet therapy and identify its influencing factors. Ninety pediatric patients diagnosed with moderate to severe positional plagiocephaly received helmet therapy. Severity of moderate to severe positional plagiocephaly was defined as cranial vault asymmetry (CVA) >10 mm or CVA index (CVAI) >6%. Patients were categorized by age, severity, and daily helmet wear. Multiple regression analysis controlled for factors like sex and prematurity. Treatment success was assessed by comparing pre/post-helmet theray CVA and CVAI, considering normalization or decrease to mild plagiocephaly (CVA ≤10 mm or CVAI ≤6%). A total of 90 participants were enrolled (mean age, 5.6±1.6 months; male, 53 [58.9%]). The mean helmet therapy duration was 6.4±2.7 months, while the mean daily wear time was 18.4±2.7 hours. Among the 90 patients, 66 (73.3%) had moderate disease and 24 (26.7%) had severe disease. The mean CVA and CVAI decreased by 6.3±2.7 mm and 4.3%±1.8% after versus before treatment (P<0.001). Treatment was successful in 76 infants (84.4%). The most effective changes in CVA and CVAI were noted in those who began treatment before 9 months of age (6.2±2.5 mm and 5.0%±1.9%, P<0.001), had high compliance (6.2±2.4 mm and 4.9%±1.9%, P<0.001), and had high severity (8.0±2.3 mm and 6.6%±1.7%, P<0.001). Starting helmet treatment before 9 months and wearing it over 15 hours daily yielded better outcomes.

Bilateral fronto-orbital advancement combined with cranial vault release using a free-floating bone flap technique for nonsyndromic unilateral coronal synostosis.

The goals of operative treatment for unilateral coronal synostosis (UCS) are to improve appearance and allow unrestricted brain growth. However, for severe unilateral premature closure of the coronal suture, existing methods do not address the compression of the brain or expand the volume of the skull cavity. We report our retrospective experience with bilateral fronto-orbital advancement combined with cranial vault release using a free-floating bone flap (CVR + FFBF) technique and the resulting changes in the anterior cranial vault asymmetry index (ACVAI) and intracranial volume. Twenty patients with UCS who underwent bilateral fronto-orbital advancement combined with CVR + FFBF technique from April 2014 to May 2019 were included. Surgical efficacy was evaluated by the ACVAI and intracranial volume before the operation, 1 week after the operation, and at the last follow-up (average 19.8 months; range, 12 to 40 months). The measurement data are presented as the mean ± standard deviation and were statistically analyzed by t-test. The ACVAI was 9.07%±3.55% before the operation, 3.56%±3.42% 1 week after the operation, and 3.13%±2.41% at the last follow-up. The ACVAI 1 week after the operation was significantly lower than that before the operation (t=4.827, P<0.001). There was no significant difference between the ACVAI 1 week after the operation and at the last follow-up (t=0.660, P=0.517). The intracranial volume was 1,027.85±112.25 mL in patients before the operation and 1,131.92±161.71 mL in the normal control group, which was a statistically significant difference (t=2.364, P=0.023). The intracranial volume significantly increased 1 week after surgery: 1,081.62±111.10 mL (t=8.703, P<0.001), and this trend continued at the last follow-up (1,386.90±119.30 mL) similarly to the normal control group (1,438.22±89.28 mL). At the last follow-up, there was no significant difference between the two groups (t=1.540, P=0.132). For the treatment of UCS, bilateral fronto-orbital advancement combined with CVR + FFBF technique offers functional and cosmetic outcomes in terms of intracranial volume expansion and fronto-orbital symmetry.

Image processing and machine learning for diagnosis and screening of craniosynostosis in children

Objectivecraniosynostosis (CSO) is a congenital disorder resulting from early closure of cranial sutures in newborns, while could cause significant cosmetic and neurodevelopmental problems. As a standard method, different craniometric indices are measured directly from child head or from their 3D CT scan of skull for diagnosis or in post-operative follow-up period. We propose a novel telehealth-compatible deep learning neural network-based method for identifying different craniometric indices in non-syndromic CSO patients 2D photographic data. Methods624 pre-operative and post-operative top-down cranial digital images of 145 craniosynostotic infants (59 sagittal, 55 metopic and 31 unicoronal synostosis) who had surgery at Mofid Children’s Hospital, Tehran, Iran were used in a deep learning neural network algorithm. Head boundary was defined by a faster region-based convolutional neural network (Faster R-CNN) and then different cranial indices (cranial index (CI), cranial vault asymmetry index (CVAI), anterior-posterior width ratio (APWR), anterior-midline width ratio (AMWR) and left–right height ratio (LRHR)) were calculated from segmented images. Accuracy, sensitivity and specificity were calculated for software versus specialist data association between cranial indices were evaluated with inter-class correlation coefficients. ResultsThe head border was segmented in the proposed images with accuracy of 88.67 ± 1.94 in comparison with standard hand made procedure with a sensitivity of 86.91 ± 3.75 and specificity of 88.60 ± 4.81. Among calculated cranial indices, significant decrease in CI value is most useful for diagnosis of sagittal synostosis (CIsagittal = 71.97 ± 4.33), significant increase in CVAI value and significant decrease in LRHR value is most appropriate for unicoronal suture synostosis diagnosis (CVAIunicoronal=6.79±3.80 and LRHRunicoronal = 0.91 ± 0.05) and significant decrease in APWR and AMWR values could be indicator of metopic synostosis (AMWRmetopic= 0.77 ± 0.04 and APWRmatopic = 0.83 ± 0.05). ConclusionDeep learning neural network algorithms could have high levels of capability in calculating cranial indices from routine 2D digital images of non-syndromic craniosynostotic children and act as a substitute for optical scanner or 3D CT-based craniometrics. This method could act as a corner stone for developing a software for a mobile platform that that would allow for screening by tele-medicine or in a primary care setting.

Evaluation of Helmeting Therapy Duration After Endoscopic Strip Craniectomy for Metopic and Sagittal Craniosynostosis

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.

Impact of the lateral skeletal stability following bilateral sagittal split ramus osteotomy for mandibular asymmetry

This study evaluated the stability of bilateral sagittal split ramus osteotomy (BSSRO) associated with positional plagiocephaly and temporal and masseter muscles using posteroanterior cephalogram analysis and three-dimensional computed tomography (3D-CT). This retrospective cohort study included 31 patients who underwent BSSRO for mandibular asymmetry. The cranial vault asymmetry index (CVAI) and the cephalic index were used as indicators of positional plagiocephaly. The distance from the vertical reference line to the menton (Me) was measured on posteroanterior cephalograms immediately and 1 year after surgery, and postoperative stability was assessed. Temporal and masseter muscles were constructed from 3D-CT data and their volumes were measured. Simple regression analysis showed a significant correlation between postoperative changes in the vertical reference line to the Me and the CVAI (R=0.56, p=0.001), the amount of surgical movement in the vertical reference line to the Me (R=0.41, p=0.023), and the variable temporal muscle volume (R=0.27, p=0.028). There was no significant correlation between postoperative changes in the vertical reference line to the Me and the cephalic index (R=0.093, p=0.62) and variable masseter muscle volume (R=0.16, p=0.38). According to multivariate analysis, CVAI (p=0.003) and amount of surgical movement in the vertical reference line to the Me (p=0.014) were significant predictors of postoperative change in the vertical reference line to the Me. Positional plagiocephaly and amount of surgical movement influence lateral skeletal stability following BSSRO for mandibular asymmetry.

Ophthalmic Features 5 Years after Cranioplasty in Children with Unilateral Coronal Craniosynostosis

Purpose: To investigate ocular asymmetry status 5 years after cranioplasty in children with unilateral coronal craniosynostosis.Methods: The medical records of 41 children who underwent cranioplasty at a mean age of 11.7 months were retrospectively reviewed. The cranial vault asymmetry index (CVAI) and the amount of head tilt were measured on images obtained before cranioplasty. Presence of anisometropia, aniso-astigmatism, amblyopia, and strabismus was evaluated at a mean age of 6.8 years. Correlations among the CVAI, direction of synostotic suture and ocular asymmetries were analyzed.Results: Before cranioplasty, the CVAI was 4.5%; 31 of 41 patients (75.6%) exhibited head tilting, which was contralateral to the synostotic suture site in 29 of these patients. At a mean of 5.6 years after cranioplasty, anisometropia of ≥ 1.00 diopters on the spherical equivalent was present in 9 patients (22.0%) and aniso-astigmatism of ≥ 1.00 diopters in 10 patients (24.4%). Amblyopia was in 15 patients (36.6%); the eye contralateral to the synostotic suture was more frequently affected, and anisometropic amblyopia was the most common subtype. Strabismus was present in 28 patients (68.3%); exodeviation and vertical deviation were the most common subtypes. The non-dominant eye was the eye ipsilateral to the synostotic suture in 12 of 13 patients (92.3%) with simulated superior oblique palsy and in 7 of 10 patients (70.0%) with dissociated vertical deviation. In children with CVAI of ≥ 5%, anisometropia was significantly more common than in other children (p = 0.04), but we found no relationship between any other type of ocular asymmetry and a high CVAI.Conclusions: Ocular asymmetries including anisometropia, aniso-astigmatism, amblyopia, and strabismus were observed even 5 years after successful cranioplasty treatment for unilateral coronal craniosynostosis, emphasizing the need for continuous ophthalmic follow-up.

Positional cranial deformities in preterm infants and their association with health indicators.

To describe positional cranial deformities and peri/postnatal pathologies in preterm infants and to analyze the association between gestational age, birth weight, length of hospitalization, and severity of cranial deformities measured by the Cranial Vault Asymmetry Index (CVAI) and the Cephalic Index (CI). Analytic, cross-sectional study. 103 preterm infants aged under 4 months of corrected age admitted during 2017 to an Early Intervention Program (EIP) were included. Participants were classified according to gestational age as follows: extremely preterm (< 28 weeks), very preterm (28-32 weeks), and moderate-to-late preterm (32-37 weeks). Head circumference, anteroposterior diameter, width, and head diagonals were measured, and the CVAI and CI were calculated. Peri- and postnatal history was obtained from clinical records. 103 preterm infants were evaluated (17 extremely preterm, 78 very preterm, and 8 moderate-to-late preterm). 99 (96.1%) of the preterm infants had positional cranial deformity and, regardless of the degree of prematurity, presented similar cranial anthropometric measurements. Mild plagiocephaly was the most frequent cranial deformity in all groups. We observed a positive association between the days of hospitalization and the CVAI and there was no relationship between the degree of prematurity and the severity of the positional cranial deformation. Most of the patients admitted to the EIP presented positional cranial deformities, mainly mild plagiocephaly, regardless of the degree of prematurity. The presence of plagiocephaly was positively associated with prolonged periods of hospitalization. No relationship was confirmed between the degree of prematurity and the severity of the positional cranial deformity.

Comparison of molding helmet therapy versus natural course in twins with nonsynostotic head deformation

This observational study aims to compare the effectiveness of helmet therapy versus natural course in twin siblings suffering from nonsynostotic head deformations.A retrospective analysis of all twin couples treated with helmet therapy between March 2009 and May 2017 at an orthopedic hospital was conducted. Inclusion criteria were me if only one twin received helmet therapy. The other twin acted as control. A classification for different head shapes was used.A total of 61 twin couples was included. Change in outcome parameters of helmet therapy and natural course differed significantly: cranial vault asymmetry (CVA) −0.66 cm vs. −0.04 cm, cranial vault asymmetry index (CVAI) −5.35% vs. −0.51% (both p < 0.001), cephalic index (CI) −3.10% vs. −1.91% (p = 0.006). Helmet therapy showed a success rate (CI < 90% and CVAI ≤7% or better) of 63.6% vs. 21.1% in children with natural course (p = 0.002).Within the limitations of the study it seems that the results of this retrospective, single-center study confirm that helmet therapy to be a reliable treatment for mild to severe positional head deformation.

Changes in Cranial Shape and Developmental Quotient at 6 Months of Age in Preterm Infants.

The purpose of this study was to investigate changes in cranial shape among preterm neonates aged 1-6 months and the relationship between developmental quotient (DQ) and cranial shape at 6 months of age. Preterm infants who were hospitalized in our hospital were prospectively followed for 6 months. The cephalic index (CI) and cranial vault asymmetry index (CVAI) were evaluated at 1 (T1), 3 (T2), and 6 months (T3) of age and compared with those of the full-term infants. The relationship between CI or CVAI and DQ at T3 was analyzed using the Enjoji Scale of Infant Analytical Development. A total of 26 participants born at 34.7 ± 1.9 weeks of gestation were included. The CI increased with age (T1: 77.2%, T2: 82.9%, T3: 85.4%, p < 0.01). The prevalence of dolichocephaly at T3 did not significantly differ from that in full-term infants (15.4% vs. 4.5%, p = 0.08). CVAI did not significantly differ between preterm and full-term infants. The DQ showed no significant correlation with either the CI or CVAI (correlation coefficients: 0.23 for CI, -0.01; CVAI). Dolichocephaly improved over time in preterm infants and no relationship between cranial shape and development was observed in preterm infants at 6 months of age.

Direct Anthropometry Overestimates Cranial Asymmetry-3D Digital Photography Proves to Be a Reliable Alternative.

This study compared manual and digital measurements of plagiocephaly and brachycephaly in infants and evaluated whether three-dimensional (3D) digital photography measurements can be used as a superior alternative in everyday clinical practice. A total of 111 infants (103 with plagiocephalus and 8 with brachycephalus) were included in this study. Head circumference, length and width, bilateral diagonal head length, and bilateral distance from the glabella to the tragus were assessed by manual assessment (tape measure and anthropometric head calipers) and 3D photographs. Subsequently, the cranial index (CI) and cranial vault asymmetry index (CVAI) were calculated. Measured cranial parameters and CVAI were significantly more precise using 3D digital photography. Manually acquired cranial vault symmetry parameters were at least 5 mm lower than digital measurements. Differences in CI between the two measuring methods did not reach significance, whereas the calculated CVAI showed a 0.74-fold decrease using 3D digital photography and was highly significant (p < 0.001). Using the manual method, CVAI calculations overestimated asymmetry, and cranial vault symmetry parameters were measured too low, contributing to a misrepresentation of the actual anatomical situation. Considering consequential errors in therapy choices, we suggest implementing 3D photography as the primary tool for diagnosing deformational plagiocephaly and positional head deformations.

Research into the correlation between positional skull deformation and motor performance of infants aged under 4 months

ObjectiveTo investigate the correlation between positional skull deformation (PD) and motor performance of infants under 4 months of age.MethodsInfants aged under 4 months were enrolled in the children’s healthcare and the premature infants follow-up Clinic of the Second Affiliated Hospital of Army Military Medical University. The cranial vault asymmetry (CVA) and cephalic index (CI) were calculated in all infants, and the infant motor performance test (TIMP) was used to evaluate the infant motor performance. The motor performances of infants with different types and degrees of PD were compared, so were the incidences of PD in infants with different motor performance levels.ResultsOverall, 2118 infants were recruited and divided according to the types of PD and TIMP scores. The comparison of TIMP scores within different types of PD at different months of age showed that, regardless of the types of PD, TIMP scores of infants with PD were lower than those of normal infants. In particular, the difference in TIMP scores was statistically significant (P < 0.05) in infants with dolichocephaly, plagiocephaly,dolicho-plagiocephaly and brachy-plagiocephy. In addition, the comparison of CVA values of infants with different TIMP score levels at different months of age showed that the CVA values of the extremely low-level group were significantly higher than those of the medium-level and high-level group, especially in the 3-month-old and 4-month-old groups, which showed significant statistical differences (P < 0.05).ConclusionsPD and motor performance of infants aged under 4 months seem to interact and influenc each other. The more serious the severity of PD were,the worse the motor performance of infants. Conversely, the incidence of PD increased in infants with poor motor performance.

Minimally invasive craniectomy and postoperative cranial remolding orthotic treatment in infants with craniosynostosis: A multicenter prospective study

ObjectiveTo investigate the effectiveness of minimally invasive suturectomy (MIS) with cranial remolding orthosis (CRO) for treatment of patients with single-suture craniosynostosis. MethodsIn this multicenter prospective study, all patients included underwent MIS followed by postoperative CRO. The values of the cephalic index (CI) and cranial vault asymmetry index (CVAI) were measured and recorded before the surgery, at initiation of CRO, and at the cessation of CRO. The total cranial volume (TV), anterior hemisphere cranial volume (AV), and AV to TV were also acquired with a non-contact optical scanner. All patients were followed up at least until the end of the twelfth month of age. ResultsA total of 38 patients were included. The average operative time including anesthesia was 95.38 minutes. The average length of hospital admission was 2.5 days. There was a statistically significant difference in CI values for the patients with sagittal craniosynostosis (p < 0.05). The improvement in CVAI values were statistically significant in all three groups of participants (p < 0.001). The AV and TV from initiation to cessation of CRO treatment were statistically significant in all three groups of participants (p < 0.001). Regarding the AV to TV ratio, there was a significant difference from initiation to the cessation of CRO treatment in sagittal and metopic groups of participants (p < 0.05). The average daily hours of CRO wearing was 18.54 hours. ConclusionsThe findings of this investigation complement those of earlier studies and showed that MIS with CRO treatment is a good strategy with satisfactory results for patients with single-suture craniosynostosis.

Three-Dimensional Composite Heatmaps of Unilateral Lambdoid Synostosis and Deformational Plagiocephaly

Background: The differentiation of unilateral lambdoid synostosis (ULS) and deformational plagiocephaly (DP) is vital to provide appropriate treatment intervention. Three-dimensional (3D) photo grammetry provides rapid, reproducible image capture without radiation exposure. Advanced analytical methods can help identify distinctive features to differentiate the two craniofacial conditions. This study uses 3D photogrammetry of ULS and DP patients to analyze the global cranial morphology for diagnostic differentiation. Methods: A retrospective review of 3D photogrammetry of 19 ULS and 25 DP patients were analyzed. Cranial vault asymmetry index, oblique cranial length ratio, and diagonal difference were measured. 3D photogrammetry-based composites were created and overlaid on age and gender-matched controls to generate heat maps representing morphologic differences in contour. Results: Cranial vault asymmetry index and oblique cranial length ratio were significantly different between ULS and DP (0.019; 0.022). 3D photogrammetry ULS composite showed retrusion in the ipsilateral occipitoparietal area, contralateral posterior parietal projection, contralateral frontal projection, relative ipsilateral mastoid bulge, and facial projection. DP composite showed unilateral occipital projection and contralateral anterior projection. The contralateral occipital regions in the occipital and anterior areas remained equivocal to control patients. Conclusions: Diagnostic differentiation of ULS and DP has previously relied on observation and linear measurements of cranial asymmetry in a single plane. 3D photogrammetry composites provide a global contour evaluation for diagnosis and longitudinal outcome analysis.

Denominator of Cranial Vault Asymmetry Index: Choosing Between Longer and Shorter Diagonal Lengths.

Since it was proposed in this journal in 2001, the cranial vault asymmetry index (CVAI) has been an important parameter for assessing cranial shape. However, different publications currently use different variables in the denominator of the CVAI formula. We thus investigated the use of long and short diagonal lengths as variables in the denominator of the CVAI formula. We searched the databases of PubMed, Google Scholar, and Scopus for articles published between 2016 and 2022 that cited the original work article of CVAI. Articles were included if they were written in English and if the denominator of the CVAI formula was specified. For multiple articles by the same author, only the most recent article was included. In total, 30 articles were included; 10 articles used the longer diagonal length as the denominator and 20 articles used the shorter diagonal length. No uniform trend was observed by a country or journal of publication. Application of the CVAI formula using different denominators yielded interchangeable results, and the resulting values had only negligible differences clinically. However, it would be necessary to create a standard formula for using the CVAI as a parameter for reporting cranial shape assessments consistently.

Cranial Shape Changes in Nonsyndromic Unilateral Lambdoid Synostosis after Open Posterior Vault Remodeling.

The purpose of this study was to quantify change in cranial morphology in patients with nonsyndromic unilateral lambdoid craniosynostosis (ULC) from presentation (t0), after open posterior switch-cranioplasty (t1), and at 2-year follow-up (t2). Volumetric, linear, and angular analysis were performed on computed tomographic scans at the three time points and against normal control subjects. Significance was set at P < 0.05. Twenty-two patients were included. ULC cranial vault asymmetry index was higher than in control subjects before surgery (6.22 ± 3.55) but decreased after surgery (3.00 ± 2.53) to become comparable with the normal asymmetry range present in the controls. After surgery, both diagonals increased, but more on the fused side. In the 2 years after surgery, both diagonals in patients with ULC grew proportionately, but the fused diagonal remained slightly shorter than the patent side. Total cranial volume was higher in patients with ULC than in control subjects after surgery but became comparable at t2. Cranial base angulation improved by t2 but did not approach normal, and ear position remained unchanged. The facial twist was higher than in controls at t0 and t1 but was comparable at t2. Coronal asymmetry improved with surgery but remained undercorrected at t2, with the greatest residual asymmetry at opisthion. Open-switch cranioplasty normalizes cranial vault asymmetry index by increasing the fused cranial diagonal more than the patent side and is stable at 2 years. Skull base twist does not normalize, but facial twist approaches normal. Technique improvement should focus on residual coronal asymmetry present at opisthion. Therapeutic, IV.

Orthotic Helmet Therapy for Deformational Plagiocephaly: Stratifying Outcomes by Insurance.

Deformational Plagiocephaly (DP) is commonly treated with cranial orthosis, or helmet therapy. A large, national study on the impact of insurance status on helmet outcomes is lacking. We assessed treatment outcomes for helmet therapy based on insurance status. This was a retrospective data analysis of patients referred to Cranial Technologies, Inc for helmet therapy between 2014-2020 across 21 states. There were a total of 211,417 patients referred for helmeting, of whom 141,513 received helmet therapy. Multivariate regression was used to assess the relationship of insurance status with post-treatment residual flattening, measured by cephalic index (CI) and cranial vault asymmetry index (CVAI), and treating provider rating of success. Patients with Medicaid were more likely to complete treatment with residual flattening measured by CI and CVAI when compared to patients with private insurance (OR: 1.58, CI: 1.51-1.65, p < 0.001 and OR: 1.21, CI: 1.15-1.28, p < 0.001, respectively). Providers of patients with Medicaid were more likely to give a low rating of success following treatment (OR: 3.25, CI: 2.70-3.92, p < 0.001). Our study investigating the impact of insurance status on helmet therapy across 21 states found that patients with Medicaid were more likely to experience residual flattening and have lower provider-rated outcomes compared to those with commercial insurance. Given significant caregiver burden posed by helmet therapy, which requires frequent visits and consistent helmet use, caregivers of patients with Medicaid may require greater support to reduce outcome disparities observed here.