Metopic Research Articles

Metopic Suture Synostosis ( Trigonocephaly ) : A Case Report

Craniosynostosis is a premature fusion of single or multiple cranial sutures. It occurs in one of 2000–2500 live births (1, 2). Trigonocephaly is a form of craniosynostosis arising from the premature fusion and ossification of the metopic suture, which separates the two frontal bones and physiologically closes at 3–8 months of age (3, 4). Described first by Welcker in 1862, trigonocephaly is a Greek term meaning triangular forehead. Metopic synostosis occurs in between 1/700 and 1/15.000 newborns (5, 6). This results in a skull with a triangular forehead and deficient lateral orbital rims add to the supraorbital retrusion and bitemporal indentations. The growth restriction results in decreased intracranial volume. Thus, a surgical intervention is indicated to restore the volume of the skull along with appearance (7). This study aimed to present the case of a child born with trigonocephaly who was operated at 6 months of age with bifrontal craniotomy and fronto-orbital advancement.

Children with Metopic Ridge.

The premature closure of the metopic suture results in metopic synostosis, also known as trigonocephaly. However, there is a group of children who have only a frontal metopic ridge, obvious with inspection and fingertip palpation, without the clinical features of trigonocephaly. This study aims to report a group of children with metopic ridge with a special emphasis on the definition and the diagnostic features. Thirty-eight children with a diagnosis of metopic ridge were followed up with clinical examinations and photographs in the pediatric neurosurgery outpatient clinic between January 2010 and November 2015. Children were between 3 and 30 (mean=14) months of age at diagnosis. Twenty-five (65.8%) of the children were boys and 13 (34.2%) were girls. A midline metopic ridge without fronto-orbital trigonocephalic deformity was the only diagnostic criterion. The parents" concern about the metopic deformity at initial diagnosis was a common feature in every case. Seven (18.4%) of the children had a sibling with either metopic ridge (n=4) or trigonocephaly (n=3). None of the children had worsened or had received surgery in the follow-up period. The metopic ridge is a pathology of the metopic suture and is a concern for parents in the context of craniosynostosis. Radiological investigation and craniosynostosis surgery are unnecessary in children with a metopic ridge.This clinical entity may be considered the mildest form of metopic synostosis.

Metopic synostosis: our surgical experience

Background: Trigonocephaly is nowadays considered the second in incidence between single suture synostosis. Early closure of the metopic suture leads to skull malformations with a triangular forehead showing a midline ridge, hypotelorism, deformation of the orbital roofs and bitemporal indentations.

Morphology of cranial sutures and radiologic evaluation of the variations of intersutural bones

As far as our literature searches showed us, morphological characteristics of cranium such as sutures, sutural bones and fontanelles had been examined in the skulls in the museums and dry specimens until now. As a modern method, three-dimensional virtual reconstruction of cranial bones by using multidetector computed tomography-computed tomography angiography (MDCT-CTA) can display in vivo morphological characteristics. In our study, we aimed to determine the presence and incidence of these morphological characteristics that can be clinically significant in our population, by using radiologic methods. We examined head and neck regions of 185 patients via MDCT-CTA. We evaluated radiologically detectable variations of the metopic sutures, lambda, bregma, asterion and pterion, which can be very easily confused with fractures. Additionally, the differences between the genders and incidence of coexistence of these variations were evaluated. According to our study, the incidence of persistent metopic suture was 8.1% and the incidence of lambda variations was 5.9%. Variations were most commonly encountered on the left asterion, and least commonly on the bregma and left pterion. In the evaluation of the coexistence of the parameters and combinations, the Wormian bones located at the right and left asterions were detected. There were no statistically significant differences between genders. Variations of the sutures and sutural bones can be easily misdiagnosed with the fractures of related bony regions in unconscious patients with multiple traumas. During surgical interventions in these patients, surgeons must take this fact into consideration in order to make differential diagnosis of fractures and intersutural bone variations.

Rare morphological variants of the bones: epicondylar processes, metopic suture and Wormian bones in XVIII century skeleton.

Analysis of the female skeleton from the 18th century revealed a collection of morphological changes. Anthropological evaluation and dental X-ray techniques allowed the age to be determined at 12-13 years. The distal parts of the both humerus bones had distinct, supracondylar processes of about 5 mm at the medial-lateral surface. The frontal bone had a well-preserved metopic suture along the entire length of the squama. There were also two Wormian bones (Inca bones), asymmetrical mastoid foramen, and only left non-obliterated condylar canal. The skull measurements allowed the cranial index to be determined - 93.5 (brachycephalia) and height-length index - 98.6 (akrocephalus). Moreover, X-ray analysis of incomplete dentition was made.

Objective classification system for sagittal craniosynostosis based on suture segmentation.

Spring-assisted surgery is an effective and minimally invasive treatment for sagittal craniosynostosis (CSO). The principal barrier to the advancement of spring-assisted surgery is the patient-specific spring selection. The selection of spring force depends on the suture involved, subtypes of sagittal CSO, and age of the infant, among other factors. Clinically, physicians manually judge the subtype of sagittal CSO patients based on their CT image data, which may cause bias from different clinicians. An objective system would be helpful to stratify the sagittal CSO patients and make spring choice less subjective. The authors developed a novel informatics system to automatically segment and characterize sutures and classify sagittal CSO. The proposed system is composed of three phases: preprocessing, sutures segmentation, and classification. First, the three-dimensional (3D) skull was extracted from the CT images and aligned with the symmetry of the cranial vault. Second, a "hemispherical projection" algorithm was developed to transform 3D surface of the skull to a polar two-dimensional plane. Through the transformation, an "effective" projected region can be obtained to enable easy segmentation of sutures. Then, the different types of sutures, such as coronal sutures, lambdoid sutures, sagittal suture, and metopic suture, obtained from the segmented sutures were further identified by a dual-projection technique of the midline of the sutures. Finally, 108 quantified features of sutures were extracted and selected by a proposed multiclass feature scoring system. The sagittal CSO patients were classified into four subtypes: anterior, central, posterior, and complex with the support vector machine approach. Fivefold cross validation (CV) was employed to evaluate the capability of selected features in discriminating the four subtypes in 33 sagittal CSO patients. Receiver operating characteristics (ROC) curves were used to assess the robustness of the developed system. The segmentation results of the proposed method were clinically acceptable for the qualitative evaluation. For the quantitative evaluation, the fivefold CV accuracy of the classification for the four subtypes was 72.7%. This classification system was reliable with the area under curve (in ROC analysis) being greater than 0.8 for four two-class problems. The proposed hemispherical projection algorithm based on backtracking search can successfully segment sutures of the cranial vault. The classification system can also offer a desirable performance. As a result, the proposed segmentation and classification system is expected to bring insights into clinic research and the selection of the spring force to facilitate widespread application of this minimally invasive treatment.

Clinical and genetic characteristics of craniosynostosis in Hungary

Craniosynostosis, the premature closure of cranial sutures, is a common craniofacial disorder with heterogeneous etiology and appearance. The purpose of this study was to investigate the clinical and molecular characteristics of craniosynostoses in Hungary, including the classification of patients and the genetic analysis of the syndromic forms. Between 2006 and 2012, 200 patients with craniosynostosis were studied. Classification was based on the suture(s) involved and the associated clinical features. In syndromic cases, genetic analyses, including mutational screening of the hotspot regions of the FGFR1, FGFR2, FGFR3, and TWIST1 genes, karyotyping and FISH study of TWIST1, were performed. The majority (88%) of all patients with craniosynostosis were nonsyndromic. The sagittal suture was most commonly involved, followed by the coronal, metopic, and lambdoid sutures. Male, twin gestation, and very low birth weight were risk factors for craniosynostosis. Syndromic craniosynostosis was detected in 24 patients. In 17 of these patients, Apert, Crouzon, Pfeiffer, Muenke, or Saethre-Chotzen syndromes were identified. In one patient, multiple-suture craniosynostosis was associated with achondroplasia. Clinical signs were not typical for any particular syndrome in six patients. Genetic abnormalities were detected in 18 syndromic patients and in 8 relatives. In addition to 10 different, known mutations in FGFR1,FGFR2 or FGFR3, one novel missense mutation, c.528C>G(p.Ser176Arg), was detected in the TWIST1 gene of a patient with Saethre-Chotzen syndrome. Our results indicate that detailed clinical assessment is of paramount importance in the classification of patients and allows indication of targeted molecular testing with the highest possible diagnostic yield.

Evaluation of the effect of a laparoscopic robotized needle holder on ergonomics and skills.

Laparoscopy generates technical and ergonomics difficulties due to limited degrees of freedom (DOF) of forceps. To reduce this limitation, a new 5-mm robotized needle holder with two intracorporeal DOF, Jaimy(®), has been developed. The aim of this study was to evaluate its effects on ergonomics and skills. Fourteen surgeons including eight senior and six residents were crossover randomized and stratified based on experience. Three suturing tasks were performed with both Jaimy(®) and a classic needle holder (NH): task 1: Peg-Board; task 2: hexagonal suture; task 3: frontal suture. Postural ergonomics of the dominant arm were evaluated with an ergonomics score (RULA score) thanks to motion capture, and muscular ergonomics with electromyography of six muscular groups (flexor and extensor carpis, biceps, triceps, deltoid, trapeze). Performance outcomes are a quantitative and qualitative score, and skills outcomes are the measurement of the number of movements and the path length travelled by the instrument. The RULA score showed a statistically improved posture with Jaimy(®) (p < 0.001). The cumulative muscular workload (CMW) of four muscles was not different. However, the CMW was in favor of the NH for the flexor carpi ulnaris (p < 0.001) and the triceps (p = 0.027). The number of movements was not different (p = 0.39) although the path length was shorter with Jaimy(®) (p = 0.012). The score for task 1 was in favor of the NH (p = 0.006) with a higher quantity score. Task 2 score was not different (p = 0.086): The quality part of the score was in favor of Jaimy(®) (p = 0.009) and the quantity part was higher with the NH (p = 0.04). The score for task 3 was higher with Jaimy(®) (p = 0.001). This study suggests that the use of a robotized needle holder improves both posture and the quality of laparoscopic sutures.

A new operative open-wings technique to correct the frontoforehead unit in metopic synostosis.

The technology adoption and creation of a multidisciplinary team have helped to overcome the complexity associated. Craniofacial surgery has thus emerged from the valuable contributions of neurosurgery, maxillofacial surgery, plastic surgery, eyes, nose, and throat as well as head and neck surgery. A patient with trigonocephaly may present a prominent "keel" forehead, accompanied by recession of the lateral orbit rims, hypotelorism, and constriction of the anterior frontal fossa when the metopic suture fuses before 6 months of age. In a period between 2007 and 2011, in the Salesi Children's Hospital, were treated for nonsyndromic variety of metopic synostosis 11 infants; their ages ranged from 6 months to 9 months, and 7 were males and 4 females. The most important aims of our new surgical technique are the achievement of symmetry as well as normal proportion and reconstruction of the frontoforehead unit but remaining in a very conservative treatment. The morphology and position of the supraorbital ridge-lateral orbital rim region are key elements of upper facial esthetics. This new "open-wings" technique for the reconfiguration of the bilateral emisupraorbital bar requires a midline incomplete osteotomy that involves only the internal cortex of the frontonasal region. Hence, both lateral orbital walls are bent inwardly and tilting forward, as in computed tomographic scan planning, with a greenstick fracture pivoting on the preserved medial frontonasal region. This open-wings conservative technique allows the avoidance of the most important complication that may result in the traditional way such as dead space in the anterior cranial fossa, infections, and blood loss but with an achievement of satisfactory craniofacial form and aesthetic result.

A new genus of Iassinae (Hemiptera: Cicadellidae) from Peru and a new species of Daveyoungana Blocker & Webb.

The new iassine leafhopper genus Linnavuoria is described and illustrated based on L. tingomariaensis sp. nov., from Peru, and placed in the previously monobasic tribe Selenomorphini (based on Selenomorphus Evans from New Caledonia), along with two other New World genera, Pachyopsis Uhler and Scaroidana Osborn (new placements). The new genus is similar to Pachyopsis in overall structure, but differs as follows: head with crown flat and forming distinct angle with face in profile; face coarsely punctate, without distinct transverse striations or rugae; lateral frontal sutures extended from antennal ledge to midline and joining with distinct coronal suture; forewing with numerous dark pigment spots corresponding to setal sockets; hind femur with macrosetal formula 2+1+1+1. A revised diagnosis and key to genera are given for Selenomorphini. The previously monotypic leafhopper genus Daveyoungana Blocker & Webb (Iassinae: Hyalojassini) recorded from Brazil is also reviewed and the detailed morphology of the genus is redescribed and illustrated, including the first description of the female. A new species, D. maniforma sp. nov. from Ecuador is described and illustrated and a key to the species in this genus is given.

Two new species of Emersonella (Hymenoptera: Eulophidae: Entedoninae) from the Brazilian Atlantic Forest

Emersonella Girault, 1916 is a wasp genus including species that parasitize Chrysomelidae (Coleoptera) eggs, mainly Cassidinae. It occurs only in the Americas, and is primarily distributed in the Neotropical Region. In this paper two new species of Emersonella from the Atlantic Forest of southeastern Brazil are described and compared to similar species. Emersonella appendigastersp. nov. is characterized by an elongate last gastral tergite in female, thoracic dorsum flat, femora and tibiae yellowish in female, malar sulcus absent, frontal suture slightly down-curved laterally, eyes with scattered hairs, frons and vertex smooth, and propodeum smooth with small anteromedian foveae. Emersonella frieirocostaisp. nov. is characterized by an elongate gaster in the female, at most 1.3 times as long as mesosoma and pointed at apex, propodeum with two large anterolateral foveae, pronotum hardly visible in dorsal view, with posterior part smooth, transverse pronotal carina present and malar sulcus absent. Both species are egg parasitoids of Metriona elatior (Klug, 1820) (Chrysomelidae) which feeds on Solanum viarum Dunal (Solanaceae).

Osteoblast differentiation profiles define sex specific gene expression patterns in craniosynostosis

Single suture craniosynostosis (SSC) is the premature fusion of one calvarial suture and occurs in 1–1700–2500 live births. Congenital fusion of either the sagittal, metopic, or coronal sutures represents 95% of all cases of SSC. Sagittal and metopic synostosis have a male preponderance (3:1) while premature fusion of the coronal suture has a female preponderance (2:1). Although environmental and genetic factors contribute to SSC, the etiology of the majority of SSC cases remains unclear. In this study, 227 primary calvarial osteoblast cell lines from patients with coronal, metopic, or sagittal synostosis and unaffected controls were established and assayed for ALP activity and BrdU incorporation (n=226) as respective measures of early stage osteoblast differentiation and proliferation. Primary osteoblast cell lines from individuals with sagittal synostosis demonstrated higher levels of ALP activity and reduced proliferation when compared to control lines. In order to address the sex differences in SSC types, the data was further stratified by sex. Osteoblasts from males and females with sagittal synostosis as well as males with metopic synostosis demonstrated higher levels of ALP activity when compared to sex matched controls, and males with sagittal or metopic synostosis demonstrated reduced levels of proliferation. In order to elucidate genes and pathways involved in these observed phenotypes, correlation analyses comparing ALP activity and proliferation to global gene expression was performed. Transcripts related to osteoblast differentiation were identified both differentially up and downregulated, correlated with ALP activity when compared to controls, and demonstrated a striking sex specific gene expression pattern. These data support that the dysregulation of osteoblast differentiation plays a role in the development of SSC and that genetic factors contribute to the observed sex related differences.

Phenobarbitone for the Management of Neonatal Seizures - A Single Center Study

Introduction: Metopic suture which is placed between frontal bone and usually disappear during infancy and childhood, may persist from nasion to anterior angle of bregma, this is called metopism. Objective: To find the incidence of metopism in western Rajasthan and to compare it with other study in other parts of India and Abroad. Methodology: Present study was autopsy done on 200 dead bodies of all age group who were brought to J L N Medical college, Ajmer for autopsy during the period of 6 months. Vault was observed morphological for presence of metopism on both outer and inner side after removal of periosteum. Results: The incidence of metopism was 6.5% in all observed skull in this study. The incidence of metopism was observed more in child age group i.e. 100% in 0-5 years & 80% in 6-10 years as compare to the adults and old age groups i.e. 3.4% in 41-50 years. Conclusion: The presence of metopic suture simulates the fracture of frontal bone, therefore it should be properly ruled out in x-rays by radiologists and neurosurgeons.

Frontal cranial modeling using endocranial resorbable plate fixation in 27 consecutive plagiocephaly and trigonocephaly patients.

Premature ossification of coronal and metopic sutures is treated by fronto-orbital remodeling. Such operations require stable fixation of the reshaped cranial bones. Currently, biodegradable plating systems are used to provide sufficient stability over the time that takes for the osteotomies to ossify. Plates that are placed traditionally on the outer surface of the cranium are often palpable and even visible through the thin overlying skin, compromising the cosmetic results of these operations. Improved aesthetics could be achieved by placing the plates endocranially. This study aimed to evaluate endocranial resorbable plate fixation and its clinical and radiographic results in frontal remodeling cranioplasty for plagiocephaly and trigonocephaly patients with follow-up sufficiently long for the plates to have been completely resorbed. A poly(lactide-co-glycolide) (PLGA) resorbable plating system was used on the inner aspect of frontal bone in 27 patients treated for coronal and metopic craniosynostoses. The outcome was evaluated at follow-up visits. The mean follow-up was 79.2months. Three patients had complications that required reoperations. None of these complications were related to the endocranial location of the plates. There were no problems with ossification of the osteotomy sites. All but one patient's outcome was judged as good or excellent. Placement of resorbable fixation on the endocranial surface of the calvarial bones is safe, stable, and results in satisfactory aesthetics without interfering with the ossification of the cranial bones.

Metopic suture and RUNX2, a key transcription factor in osseous morphogenesis with possible important implications for human brain evolution.

Overall, the comparative data available on the timing of metopic suture closure in present-day and fossil members of human lineage, as well as great apes, seem to indicate that human brain evolution occurred within a complex network of fetopelvic constraints, which required modification of frontal neurocranial ossification patterns, involving delayed fusion of the metopic suture. It is very interesting that the recent sequencing of the Neanderthal genome has revealed signs of positive selection in the modern human variant of the RUNX2 gene, which is known to affect metopic suture fusion in addition to being essential for osteoblast development and proper bone formation. It is possible that an evolutionary change in RUNX2, affecting aspects of the morphology of the upper body and cranium, was of importance in the origin of modern humans. Thus, to contribute to a better understanding of the molecular evolution of this gene probably implicated in human evolution, we performed a comparative bioinformatic analysis of the coding sequences of RUNX2 in Homo sapiens and other non-human Primates. We found amino-acid sequence differences between RUNX2 protein isoforms of Homo sapiens and the other Primates examined, that might have important implications for the timing of metopic suture closure. Further studies are needed to clear the potential distinct developmental roles of different species-specific RUNX2 N-terminal isoforms. Meantime, our bioinformatic analysis, regarding expression of the RUNX2 gene in Homo sapiens and other non-human Primates, has provided a contribution to this important issue of human evolution.

Anesthetic management of a rare case of craniosynostosis

Craniosynostosis is a condition of premature intrauterine fusion of sutures causing abnormal skull shape, neurological abnormalities and increased intracranial pressure. It can occur as an isolated condition or may be part of a syndrome. The key to treating an infant with craniosynostosis is early diagnosis and accurate treatment as untreated craniosynostosis can affect mental development and visual abnormalities which are linked to raised intracranial pressure. In this case, we describe the anesthetic management of a 13-month-old baby, a case of nonsyndromic craniosynostosis involving sagittal, metopic and coronal sutures posted for strip craniectomies.

Paramastoid apophysis: case report

AbstractThe aim of this study was to report a case of a paramastoid apophysis of a human skull, identified during routine lessons at the Laboratory of Human Anatomy, Federal University of Pernambuco and Recife-PE, Brazil. The skull used in this study showed a morphological variation present only on the right side of the occipital bone, which had a height of 18.10 mm and had a facet joint with the transverse process of the atlas, being identified as paramastoid apophysis. Other anatomical variations in skull were found as: presence of sutural bone along the lambdoidal suture and persistent metopic suture. Thus, this study will be important for the health sciences and those who keep interest in pathologies associated with atlanto-occipital joint, because the description of the structures that deviate from the normal organogenesis resulting from disorders: hereditary basis or not, has a practical interest that prints the modification to the arrangement of the constituent elements of the region and possible functional alterations resulting therefrom.

An assessment of sexual dimorphism in relation to facial asymmetry in esthetically pleasing faces.

Objective:The aim of the study is to detect gender-wise difference in the skeletal asymmetry in the esthetically pleasing faces.Materials and methods:a cross sectional study was conducted on 25 females and 25 males of age 18 -25 years using the posterior-anterior cephalograms. The selected part of grummon’s frontal analysis for analyzing the vertical skeletal asymmetries, mandibular morphology, transverse asymmetry and mandibular deviation was used. The obtained data was subjected to independent student’s‘t’ test for comparing the difference between males and females.Results:there was statistically significant difference between the males and females for the measurements like Gonion-Menton length for the mandibular morphology and for the transverse parameters like zygomatico frontal suture length, jular length and antegonial notch length. There was no significant difference for the sidedness of asymmetry for the males and females.Conclusion:frontal facial asymmetry showed sexual dimorphism with males showing greater asymmetric values than the females. The asymmetry showed right sided prominence for both the males and females. This knowledge can be utilized for planning facial reconstruction and remodeling surgeries.

Analysis of pre- and post-operative symptoms of patients with mild trigonocephaly using several developmental and psychological tests.

Over the past decade, we collected the cases where patients underwent decompressive cranioplasty for the treatment of mild metopic suture synostosis (mild trigonocephaly) with developmental delays. To evaluate the effectiveness of this surgery, we administered several developmental and psychological examinations to children with this condition who underwent decompressive cranioplasty. Thirty-four children (32 boys and 2 girls) who had developmental disorders with mild trigonocephaly underwent four different tests at three different time points (pre-operation, 3 and 6months after surgery) including the: (a) Kyoto form developmental test (2001) to calculate the developmental quotient (DQ), (b) National Rehabilitation Center Sign-Significance Test (NRC S-S test) to evaluate the patients' language use and acquisition, (c) Pervasive Developmental Disorders Autism Society Japan Rating Scale (PARS) to identify autistic tendencies, and (d) Japanese Child Behavior Checklist (J-CBCL) to evaluate behavioral problems. The scores were initially analyzed using analyses of variance. When significant results were observed, Tukey-Kramer multiple comparison tests were applied for further statistical evaluation. Significant DQ improvements were observed, as assessed by the Kyoto form developmental test. Additionally, significant improvement in the expression of words (measured with the NRC S-S test), the scores on PARS, and some behavioral factors (measured with the J-CBCL) were observed. The results in this cohort suggest that decompressive cranioplasty may play an important role in supporting the improvement of developmental delays in these patients.

Morphometric Study of Metopic suture in Adult North Indian skulls

Background: A suture is a type of fibrous joint which only occurs in the skull or cranium. They are bound together by sharpey”s fibre. A tiny amount of movement is permitted at sutures, which contributes to the compliance and elasticity of the skull. Sutures are junctions or line of articulation between adjacent bones of skull.Methods: The present study was carried out in the department of anatomy on Adult North Indian 100 Skulls of unknown age and sex which were obtained from the osteology section of Integral Institute of Medical Sciences and Research & King George medical university. 20 damaged and diseased skulls were excluded from the study and 80 skulls were observed.Results: In our study we observed 66 (82.50%) skulls who had neither complete nor incomplete metopic suture. 14 skulls (17.5%) had metopic suture either in the form of complete or incomplete. Complete metopic suture was found in two skulls (2.50%) and incomplete suture was observed in twelve skulls (15%). Among the incomplete metopic sutures, the incidence of linear incomplete metopic suture was 9/80 (11.25%), inverted 'U' shaped incomplete metopic suture was 1/80 (1.25%) and 'V' shaped incomplete suture was 2/80 (2.5%).Conclusions: Knowledge regarding persistent metopic suture is essential in studying the radiographs to avoid misinterpretation as fractures. It is also useful in evaluating various medico legal cases.