Sagittal Suture Research Articles

Efficacy of Molding Helmet Therapy following Suturectomy for Craniosynostosis: A Single-center, Retrospective Analysis in Japan

Craniosynostosis limits normal cranial growth, significantly affecting the growth and development of children. This increase in intracranial pressure results in significant cosmetic and functional losses. This study investigated the efficacy of combining molding helmets with suturectomy for craniosynostosis. Patients who underwent suturectomy and molding helmet therapy for craniosynostosis at a single institution between 2017 and 2024 were included. Changes in cephalic index (CI) and cranial vault asymmetry index (CVAI) were analyzed. A total of 14 patients (12 males, 2 females) were included, with a median age of 4.5 months (2–6 mo). The affected sutures were as follows: sagittal (n=8), bilateral coronal (n=4), unilateral coronal (n=1), and lambdoid (n=1) sutures. The median duration of postoperative molding helmet therapy was 44.5 weeks. For the sagittal suture group, the median preoperative CI, median postoperative CI, and rate of change were 72.0 (68.3–85.8), 77.0 (72.1–86.4), and 0.0646, respectively. For the bilateral coronal suture group, measurements for the same parameters were 104.0 (99.3–110.0), 92.5 (89.1–94.5), and 0.1114, respectively. For the unilateral coronal group, the measured parameters were 89.0 (87.7–91.2), 84.0 (81.2–87.1), and 0.059, respectively. Although all suture types showed improvement in cranial shape, with sagittal synostosis showing the most significant change, our findings did not support the added benefit of molding helmet therapy. Overall, the study suggests that suturectomy is a crucial first step in craniosynostosis treatment, leading to improvements in cranial morphology and growth.

Comparing cranial suture interdigitation in humans and non-human primates: unearthing links to osteopathic cranial concept.

Since William Garner Sutherland's inception of osteopathic cranial manipulative medicine (OCMM), osteopathic physicians have practiced with the knowledge that cranial sutures exhibit motion. We hypothesize that the complexity of suture interdigitation in humans may provide clues to elucidate the concept of OCMM. We compared the interdigitation of sagittal, coronal (left and right), and lambdoid (left and right) sutures in computed tomography (CT) scans of humans and five nonhuman primate species (Gorilla gorilla, Pongo pygmaeus, Pan troglodytes, Hylobates lar, and Nasalis larvatus). Human ages are evenly distributed between 10 and 65 years of age, with an equal number of males (n=16) and females (n=16) in the sample. Nonhuman primates are all females, and the sample includes juveniles (n=6) and adults (n=34). Sutures were evaluated on a scale ranging from 0 to 3 (0: fused sutures; 1: no interdigitation; 2: low complexity; and 3: representing the highest degree of interdigitation and complexity). Based on ordinary least squares linear regression, we found no significant relationship between suture interdigitation and age in humans. Chi-square tests were utilized to assess sex differences within humans, species-level differences, and differences between humans and nonhuman primates across all five sutures. Humans exhibited a statistically significant greater degree of suture complexity than all five nonhuman species across all five sutures. These findings indicate that human suture interdigitation is more complex than their closest living relatives (African apes) and other primates (Asian monkeys and apes). We theorize that this would enable subtle movement and serve to transmit forces at the cranial sutures from dietary or ethological behaviors, similar to the pattern observed in other mammals. While humans have a softer diet compared to other living primates, the uniqueness of human craniofacial growth and extended developmental period could contribute to the necessity for complex cranial sutures. More studies are needed to understand variation in human and nonhuman sutural complexity and its relationship to cranial motion.

Exploring the effects of extracranial injections of botulinum toxin type A on activation and sensitization of central trigeminovascular neurons by cortical spreading depression in male and female rats.

OnabotulinumtoxinA (onabotA), is assumed to achieve its therapeutic effect in migraine through blocking activation of unmyelinated meningeal nociceptors and their downstream communications with central dura-sensitive trigeminovascular neurons in the spinal trigeminal nucleus (SPV). The present study investigated the mechanism of action of onabotA by assessing its effect on activation and sensitization of dura-sensitive neurons in the SPV by cortical spreading depression (CSD). It is a follow up to our recent study on onabotA effects on activation and sensitization of peripheral trigeminovascular neurons. In anesthetized male and female rats, single-unit recordings were used to assess effects of extracranial injections of onabotA (five injections, one unit each, diluted in 5 μl of saline were made along the lambdoid (two injection sites) and sagittal (two injection sites) suture) vs. vehicle on CSD-induced activation and sensitization of high-threshold (HT) and wide-dynamic range (WDR) dura-sensitive neurons in the SPV. Single cell analysis of onabotA pretreatment effects on CSD-induced activation and sensitization of central trigeminovascular neurons in the SPV revealed the ability of this neurotoxin to prevent activation and sensitization of WDR neurons (13/20 (65%) vs. 4/16 (25%) activated neurons in the control vs. treated groups, p = 0.022, Fisher's exact). By contrast, onabotA pretreatment effects on CSD-induced activation and sensitization of HT neurons had no effect on their activation (12/18 (67%) vs. 4/7 (36%) activated neurons in the control vs. treated groups, p = 0.14, Fisher's exact). Regarding sensitization, we found that onabotA pretreatment prevented the enhanced responses to mechanical stimulation of the skin (i.e. responses reflecting central sensitization) in both WDR and HT neurons. In control but not treated WDR neurons, responses to brush (p = 0.004 vs. p = 0.007), pressure (p = 0.002 vs. p = 0.79) and pinch (p = 0.007 vs. 0.79) increased significantly two hours after CSD. Similarly, in control but not treated HT neurons, responses to brush (p = 0.002 vs. p = 0.79), pressure (p = 0.002 vs. p = 0.72) and pinch (p = 0.0006 vs. p = 0.28) increased significantly two hours after CSD. Unexpectedly, onabotA pretreatment prevented the enhanced responses of both WDR and HT neurons to mechanical stimulation of the dura (commonly reflecting peripheral sensitization). In control vs. treated WDR and HT neurons, responses to dural stimulation were enhanced in 70 vs. 25% (p = 0.017) and 78 vs. 27% (p = 0.017), respectively. The ability of onabotA to prevent activation and sensitization of WDR neurons is attributed to its preferential inhibitory effects on unmyelinated C-fibers. The inability of onabotA to prevent activation of HT neurons is attributed to its less extensive inhibitory effects on the thinly myelinated Aδ-fibers. These findings provide further pre-clinical evidence about differences and potentially complementary mechanisms of action of onabotA and calcitonin gene-related peptide-signaling neutralizing drugs.

Biparietal expansion with partial suturectomy of the sagittal suture and linear frontal osteotomies for the scaphocephaly correction in children over 12 months of age

Introduction: Sagittal craniosynostosis (SC) has a prevalence of 1: 2500 live births and represents 40-60% of all craniosynostosis. The objective of this work is to share the preliminary results, with the use of the surgical technique mentioned above for the treatment of SC in children older than 12 months. Methods: A retrospective study from April 2019 to September 2023. Four patients with a diagnosis of non-syndromic scaphocephaly were evaluated, who met the following inclusion criteria: (i) age over 12 months, (ii) CT scan with 3D reconstruction, (iii) scaphocephaly due to postoperative restenosis and (iv) patients operated on with this surgical technique. Results: There were 2 females (50%) and 2 males (50%), with an average age of 39.25 months. All four patients had complete closure of the sagittal suture; there was no evidence of entrapment of the superior sagittal sinus by the stenosed suture. Papilledema was evaluated with the modified Frisén scale. All four patients had grade 2 bilateral papilledema preoperatively and this reversed 6 months postoperatively. The cranial index (CI) preoperatively was 64 (range 58-72) and postoperatively 72.25 (range 66-83). There was no need to reoperate on any patient and we had no complications Conclusion: This surgical technique is presented as an option for the treatment of scaphocephaly in children older than 12 months, and in scaphocephaly due to postoperative restenosis, proving to be a reproducible and effective procedure to achieve adequate brain decompression and reach satisfactory aesthetic results.

Intraoperative Ultrasound in Endoscopic Sagittal Suture Synostosis to Optimize Incision Planning and Avoid Misdiagnosis.

Endoscopy-assisted craniectomy with lateral osteotomies and postoperative helmet molding therapy is a widely used approach in managing sagittal suture craniosynostosis. Generally, the incisions are placed just posterior to the anterior fontanel and just anterior to the posterior fontanel and lambdoid sutures, and accurate incision placement optimizes the safe separation of the superior sagittal sinus. The authors present their 10 year experience with an ultrasound-assisted approach to identify the lambdoid sutures and precisely place the skin incisions. The authors included all patients in care at their institution between 2010 and 2023 who operated for sagittal suture craniosynostosis with endoscopy-assisted craniectomy with lateral osteotomies and postoperative helmet molding therapy. A retrospective review of clinical parameters, surgical data, as well as outcomes, and imaging studies was performed. One hundred patients were operated during the observation period. The mean age was 3.9 ± 3.5 (range: 2.7-6.4) months. Intraoperative ultrasound was documented in 61% of cases (n = 61). In 100% of cases, the incisions were placed behind the anterior and in front of the posterior fontanel, as planned with ultrasound. In 2 additional cases, intraoperative sonography identified a patent sagittal suture in the operating room. A histopathological review showed suture ossification in 100% of operated cases with available reports. Using this technique of ultrasound-guided identification of the lambdoid suture/posterior fontanel, as well as coronal suture/anterior fontanel, may aid in the adequate placement of skin incisions. Patent sutures can be identified in clinically misdiagnosed patients. This study reaffirms the overall utility of ultrasound in pediatric operative neurosurgery.

A coddling of the sagittal suture: inequality in spring-assisted expansion.

We examined differences in long-term morphometric outcomes of spring-mediated cranioplasty (SMC) for various forms of isolated nonsyndromic sagittal craniosynostosis. A retrospective review was performed of children who underwent SMC from 2011 to 2020 at the Children's Hospital of Philadelphia. Cephalic indices (CI), Whitaker grades, parietal bone thickness, and degree of suture fusion were assessed. Frontal bossing and vertex-nasion-opisthocranion (VNO) angles were compared to a normal control group. Fifty-four subjects underwent surgery at age 3.6 ± 1.0 months with follow-up of 6.3 ± 1.8 years. Mean CI was 75.2 ± 4.1 at 5.9 ± 2.0 years postoperatively. Mean CI were 75.8 ± 4.1 (n = 32), 76.4 ± 4.0 (n = 22), and 77.1 ± 4.8 (n = 11) at 5, 7, and 9+ years postoperatively, respectively. Three (5.6%) required reoperation for persistent scaphocephalic cranial deformity. Fifty-one (94.4%) were Whitaker Grade I. On physical examination, 12 (22.2%) demonstrated craniofacial abnormalities. At long-term follow-up, there were no differences in frontal bossing angle (102.7 ± 5.2 degrees versus 100.7 ± 5.6 degrees, p = .052) and VNO angle (44.9 ± 3.3 degrees versus 43.9 ± 2.2 degrees, p = .063) between study and control groups. Younger age at surgery predicted a lower Whitaker grade, more normalized VNO angle, and greater change in CI during active expansion. Increased percentage fused of the posterior sagittal suture predicted a higher Whitaker grade, while decreased anterior fusion was associated with frontal bossing and temporal hollowing. Overall, children undergoing spring-mediated cranioplasty for sagittal craniosynostosis demonstrated maintenance of CI, favorable cosmetic outcomes, and a low reoperation rate at mid-term follow-up. Early intervention is associated with improved aesthetic outcomes, and regional fusion patterns may influence long-term craniofacial dysmorphology.

Estimating infant age from skull X-ray images using deep learning

This study constructed deep learning models using plain skull radiograph images to predict the accurate postnatal age of infants under 12 months. Utilizing the results of the trained deep learning models, it aimed to evaluate the feasibility of employing major changes visible in skull X-ray images for assessing postnatal cranial development through gradient-weighted class activation mapping. We developed DenseNet-121 and EfficientNet-v2-M convolutional neural network models to analyze 4933 skull X-ray images collected from 1343 infants. Notably, allowing for a ± 1 month error margin, DenseNet-121 reached a maximum corrected accuracy of 79.4% for anteroposterior (AP) views (average: 78.0 ± 1.5%) and 84.2% for lateral views (average: 81.1 ± 2.9%). EfficientNet-v2-M reached a maximum corrected accuracy 79.1% for AP views (average: 77.0 ± 2.3%) and 87.3% for lateral views (average: 85.1 ± 2.5%). Saliency maps identified critical discriminative areas in skull radiographs, including the coronal, sagittal, and metopic sutures in AP skull X-ray images, and the lambdoid suture and cortical bone density in lateral images, marking them as indicators for evaluating cranial development. These findings highlight the precision of deep learning in estimating infant age through non-invasive methods, offering the progress for clinical diagnostics and developmental assessment tools.

Mercedes Benz pattern craniosynostosis associated with Chiari malformation type 1: A case report of a rare condition

Introduction: Craniosynostosis results from the premature fusion of cranial sutures and is classified as complex when it affects multiple sutures. The abnormal and rare fusion of the sagittal and bilateral lambdoid sutures is known as the Mercedes-Benz (CMB) pattern responsible for up to 0.7% of craniosynostoses. It's characterized by flattening of the occipital bone and sub-lambdoid depression. Additionally, the Arnold-Chiari malformation, one of the anomalies associated, occurs due to the junction of deformities in the posterior fossa and rhombencephalon. Type 1 (CM1) is the most incident and less severe, represented by the pointed shape of the cerebellar tonsils. Objective: The objective of this article is to report a rare case presentation of Mercedes Benz pattern Craniosynostosis associated with Arnold Chiari malformation Case presentation: Male patient, 11 months old, diagnosed with CMB associated with CM1, presenting with anterior turribrachycephaly and occipital brachycephaly. The diagnosis was made after the 10th month of life, with typical findings on computed tomography and cerebellar tonsil herniation (CTH) on magnetic resonance imaging (MRI). No signs of neurodevelopmental delay were observed, and there is no history of cranial malformations in the family. At 11 months, the patient underwent neurosurgery involving cranial parietal remodeling to correct craniosynostosis, along with posterior fossa decompression to address CM1. Conclusion: Neurosurgical techniques like parietal remodeling and posterior decompression, despite their complexity, play a central role in addressing CMB. It's crucial to discuss this rare condition to ensure early diagnosis and treatment, facilitating an efficient approach and preventing potential later consequences.

RhoA/ROCK-TAZ Axis regulates bone formation within calvarial trans-sutural distraction osteogenesis

BackgroundCraniofacial skeletal deformities can be addressed by applying tensile force to sutures to prompt sutural bone formation. The intricate process of mechanical modulation in craniofacial sutures involves complex biomechanical signal transduction. The small GTPase Ras homolog gene family member A (RhoA) functions as a key mechanotransduction protein, orchestrating the dynamic assembly of the cytoskeleton by activating the Rho-associated coiled-coil containing protein kinase (ROCK). Transcriptional coactivator with PDZ-binding motif (TAZ) serves as a crucial mediator in the regulation of genes and the orchestration of biological functions within the mechanotransduction signaling pathway. However, the role of RhoA/ROCK-TAZ in trans-sutural distraction osteogenesis has not been reported. MethodsWe utilized pre-osteoblast-specific RhoA deletion mice to establish an in vivo calvarial trans-sutural distraction model and an in vitro mechanical stretch model for pre-osteoblasts isolated from neonatal mice. Micro-CT and histological staining were utilized to detect the formation of new bone in the sagittal suture of the skull as well as the activation of RhoA, Osterix and TAZ. The activation of ROCK-limk-cofilin and the nuclear translocation of TAZ in pre-osteoblasts under mechanical tension were detected through Western blot, qRT-PCR, and immunofluorescence. ResultsThe osteogenic differentiation of pre-osteoblasts was facilitated by mechanical tension through the activation of RhoA and Rho-associated kinase (ROCK), while ablation of RhoA impaired osteogenesis by inhibiting pre-osteoblast differentiation after suture expansion. Furthermore, inhibiting RhoA expression could block tensile-stimulated nuclear translocation of TAZ by preventing F-actin assembly through ROCK-LIM-domain kinase (LIMK)-cofilin pathway. In addition, the TAZ agonist TM-25659 could attenuate impaired osteogenesis caused by ablation of RhoA in pre-osteoblasts by increasing TAZ nuclear accumulation. ConclusionsThis study demonstrates that mechanical stretching promotes the osteogenic differentiation of pre-osteoblasts in trans-sutural distraction osteogenesis, and this process is mediated by the RhoA/ROCK-TAZ signaling axis. Overall, our results may provide an insight for potential treatment strategies for craniosynostosis patients through trans-sutural distraction osteogenesis.

Persistent Depression of the Lambda Site with Progressive Skull Deformity May Be a Sign of Suture Closure: Case Series and Pathologic Consideration

Back groundFlat head syndrome (FHS) sometimes occurs when a baby maintains the same head position during the first several months of life causing a skull deformity. FHS usually improves with time and natural growth, however, some shows aggravation against conservative treatment. We reviewed pathologically proved early closure of skull suture that may have seen secondary to FHS. MethodsThe clinical and radiological findings of the patients who showed progressive skull deformity resembling FHS were retrospectively reviewed. All the patients underwent surgical treatment and pathological specimens were obtained. ResultsThe detected patients included two 5-month-old infants and one 1-year-old infant. The formers were conservatively treated without any obvious premature suture closure on computed tomography (CT), and later developed progressive tower-like skull deformities. The infants were diagnosed with possible premature fusion of Lambda site and underwent removal around lambda depression (LD). The latter showed evident sagittal suture closure on CT with digital markings, and was diagnosed with increased intracranial pressure and underwent cranioplasty of posterior expansion. Histopathological specimens obtained from the patients’ resected sutures showed irregularly narrowed suture structure with ossification and fibrous tissue proliferation within them, supporting the diagnosis of premature closure of the sagittal sutures. Their postoperative courses were uneventful, and their skull deformities subsequently improved. ConclusionsConservative therapy-resistant progressive occipital skull deformity with LD may be a sign of early suture closure, even if CT does not show obvious suture closure. The findings are helpful for early diagnosis and might lead to minimal invasive surgery if needed.

Distraction Osteogenesis and Endoscopic Suturectomy in the Treatment of Rachitic Craniosynostosis: A Case Series and Updated Literature Review With Discussion of Cephalometrics

Background: Individuals with genetic or nutritional rickets frequently suffer from craniosynostosis. While cranial vault remodeling is most often performed, other approaches, such as distraction osteogenesis and endoscopic suturectomy, are infrequently reported. Here, we discuss the status of the current literature and describe 2 patients with rachitic craniosynostosis, one of whom had previously undergone endoscopic suturectomy, who both successfully underwent distraction osteogenesis. Case description: Two male patients with rickets-associated craniosynostosis, 1 genetic and 1 nutritional, underwent posterior-vault distraction osteogenesis (PVDO). The patient with genetic rickets previously underwent endoscopic-assisted cranial suturectomy of the sagittal suture with barrel-staving at an outside hospital and subsequently re-fused all cranial sutures 19 months postoperatively necessitating reintervention. Complete distraction was confirmed by X-ray and both patients recovered without complication and without re-synostosis at 18 month follow-up. The patient with nutritional rickets required subsequent fronto-facial advancement because of poor midface growth. Conclusion: PVDO effectively treats rachitic craniosynostosis associated with both genetic and nutritional etiologies. Long-term follow up is warranted to monitor for skull-base involvement and associated midface retrusion in these patients.

Nonsyndromic Craniosynostosis Correlation Between Ethnicity, Race, and Pattern of Affected Suture Type: Meta-Analysis.

Previous studies have sought to analyze risk factors associated with craniosynostosis and while syndromic craniosynostosis is often linked to genetic mutations, the factors impacting nonsyndromic cases are less investigated. The aim of current meta-analysis is to evaluate the relationship between ethnicity and suture type in nonsyndromic craniosynostosis patients. The search term "craniosynostosis [Title/Abstract] AND (race [Title/Abstract] OR ethnicity [Title/Abstract])) NOT (syndrome [Title/Abstract])" was used to search the PubMed, Cochrane, and MEDLINE databases. Analyses were conducted separately for each racial and ethnic group for each suture type cohort. Odds ratios were conducted for each suture cohort and confounders were adjusted using linear mixed-effect models. Because of the homogeneity of the populations and categorical nature of the classification, binary logistic regression was run on aggregate data. The literature search yielded 165 articles. After reviewing titles, abstracts, and manuscript contents of these articles, 5 studies were ultimately included in a meta-analysis. Studies with missing data for a particular cohort or variable were excluded from the respective analysis. Hispanic children had higher odds of sagittal suture involvement (OR: 1.53, P <0.001), whereas Asian had coronal suture (OR: 2.47, P <0.001). Both Asian and African American children had significantly lower odds of sagittal suture involvement (OR: 0.50, P <0.001 and OR: 0.7, P =0.04, respectively). The relationship between ethnicity and craniosynostosis has been suggested as a risk factor, but without definitive conclusion. Present meta-analysis findings demonstrated association between ethnicity and suture type, however further research with larger scale and geographically varied data is warranted.

Influence of immunodeficiency on spring-assisted cranioplasty: A study in mice

BackgroundSpring-assisted cranioplasty has been widely used in craniomaxillofacial surgery in recent years, but the molecular mechanisms that regulate the process of spring-assisted distraction osteogenesis are still unclear. The study aimed to investigate the influence of immunodeficiency on spring-assisted distraction osteogenesis. MethodsThe experimental group consisted of Thirty-six 6-week-old male scid-beige mice and the control group consisted of Thirty-six wild-type mice. All mice conducted spring-assisted cranioplasty with a distraction force of 10 g. The sagittal suture tissue of mice was obtained at 6 time points: Immediately after surgery, 1, 3, 7, 14, and 28 days after surgery. The width of the sagittal suture was measured and osteogenesis was observed through HE staining and Masson staining. The expression levels of OPG, RANKL, and IL-6 were detected through immunohistochemistry and RT-PCR. ResultsThe control group had the widest sagittal suture gap on the 3rd postoperative day, and then the gap narrowed to exceed the preoperative level. The experimental group had the widest sagittal suture gap on the 7th postoperative day, and then the gap narrowed and reached the preoperative level. Histological staining showed that the experimental group showed slower growth of skull tissue. Immunohistochemistry showed that the percentage of positive cells for OPG, RANKL, and IL-6 in the experimental group increased and decreased later than that of the control group, and the magnitude of change was smaller. RT-PCR showed that the mRNA expression levels of OPG, RANKL, and IL-6 in the experimental group exhibited a smaller increase, lower peak levels, and a delayed time to reach peak expression. These differences were statistically significant (P<0.05). ConclusionsDuring the process of spring-assisted cranioplasty, immunodeficient mice had lagging bone reconstruction responses and poor osteogenic ability. Immunologic factors, especially lymphocytes, may play an important regulatory role in the distraction osteogenesis process.

Research on electrical capacitance tomography (ECT) detection of cerebral hemorrhage based on symmetrical cancellation method

Currently, there is an urgent need for a fast and portable intracerebral hemorrhage (ICH) detection technology for pre-hospital emergency scenarios. Owing to the disproportionately elevated permittivity of blood compared to other brain tissues, Electrical Capacitance Tomography (ECT) offers a viable modality for mapping the spatial distribution of permittivity within the brain, thus facilitating the imaging-based identification of ICH. Currently, ECT is confined to time-differential imaging due to limited sensitivity, and this methodology requires non-hemorrhagic measurements for comparison, data that are frequently inaccessible in clinical contexts. To overcome this limitation, in accordance with the natural bilateral symmetry of the cerebral hemispheres, a symmetrical cancellation scheme is introduced. In this method, electrodes are uniformly arrayed around the cranial periphery and strategically positioned in a symmetrical manner relative to the sagittal suture. Subsequently, the measured capacitances for each electrode pair are subtracted from those of their symmetrical counterparts aligned with the sagittal suture. As a result, this process isolates the capacitance attributable solely to hemorrhagic events within a given hemisphere, permitting the absolute imaging of ICH. To assess the feasibility of this method, simulation and empirical imaging were conducted respectively on a numerical hemorrhage model and three physical models (a water-wrapped hemorrhage model, an isolated porcine fat-wrapped hemorrhage model, and an isolated porcine brain tissue-wrapped hemorrhage model). Traditional absolute imaging, time-differential imaging and symmetrical cancellation imaging were performed on all models. The results substantiate that the proposed imaging modality is capable of obtaining absolute imaging of ICH. But a mirrored artifact, symmetrical to the site of the actual hemorrhage image appeared in each of the imaging results. This mirror artifact was characterized by identical dimensions and an inverted pixel-value schema, an intrinsic consequence of the symmetrical cancellation imaging algorithm. The real image of hemorrhage can be ascertained through pre-judgment with the symptoms of the patient. Additionally, the quality of this imaging is seriously dependent on the precise alignment between the electrodes and the sagittal suture of the brain; even a minor deviation in symmetry could introduce excessive noises. Thus, the complicated operational procedures remain as challenges for practical application.

What to do with an incidental finding of a fused sagittal suture: a modified Delphi study.

As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition. A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose. Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment. Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.

Concordance factors in craniosynostosis twins: a meta-analysis and case report

Introductions: Craniosynostosis is a condition where the cranial sutures close prematurely. It is influenced by both genetics and environment. This paper focuses on craniosynostosis in twins, which is an understudied area. It presents a case report of male identical twins and conducts a meta-analysis based on 34 articles to understand the factors affecting concordance in twins who have craniosynostosis. The study considers factors such as zygosity, gender, genetic syndromes, and the type of synostosis. Material and methods: A meta-analysis was conducted on 105 twin pairs (210 patients) identified from studies carried out between 1963 to 2023. The eligible studies, based on PICO criteria, included case reports and case series focusing on twins with craniosynostosis. A systematic literature search was conducted on PUBMED and Mendeley platforms to gather data on gestational age, zygosity, genetic syndromes, affected sutures, and concordance. Results: The report is about two identical twin brothers who had sagittal and metopic suture synostosis. They were treated successfully with cranial remodeling surgery. In a meta-analysis of 105 twin pairs (210 patients) , a total of 25.9% showed concordance. The study found a significant difference in concordance between monozygotic (45.3%) and dizygotic (7.3%) twins. The analysis also revealed that twins with scaphocephaly had a higher degree of concordance than those with trigonocephaly (46.7% vs. 18.9%, respectively). The study did not find any significant correlation between gender, the presence of genetic syndromes, and concordance. Conclusion: This investigation highlights the complex interplay of genetic and environmental factors in craniosynostosis in twins. The higher concordance in monozygotic twins emphasizes the genetic basis. These findings validate existing literature and provide new insights.

The surgical management of scaphocephaly in a seven-month-old infant

Introduction: Scaphocephaly is a cranial malformation resulting from premature closure of the sagittal suture. In some cases, the diagnosis is made late, leading to delayed corrective surgery. Due to the necessity of early surgical intervention, we present this condition to facilitate understanding by any physician and improve the quality of life for patients. Observation: A seven-month-old female infant presented with worsening cranial vault deformity present since birth. Morphologically, the patient exhibited a narrow and elongated head, accompanied by a median frontal bulge, with a cranial circumference of 49 cm. Standard frontal and lateral radiographs revealed an elongated skull with closure of the sagittal suture. CT scan revealed complete fusion of the sagittal suture with the classic appearance of "boat-shaped" skull. We employed the standard H-type craniectomy method. The surgical outcome, assessed 8 months post-intervention, was satisfactory both neurologically and in terms of psychomotor and aesthetic development. Conclusion: Without intervention, scaphocephaly can lead to aesthetic discomfort and contribute to low self-esteem, as well as difficulties in social, academic, and professional integration.

Age Estimation by Machine Learning and CT-Multiplanar Reformation of Cranial Sutures in Northern Chinese Han Adults.

To establish age estimation models of northern Chinese Han adults using cranial suture images obtained by CT and multiplanar reformation (MPR), and to explore the applicability of cranial suture closure rule in age estimation of northern Chinese Han population. The head CT samples of 132 northern Chinese Han adults aged 29-80 years were retrospectively collected. Volume reconstruction (VR) and MPR were performed on the skull, and 160 cranial suture tomography images were generated for each sample. Then the MPR images of cranial sutures were scored according to the closure grading criteria, and the mean closure grades of sagittal suture, coronal sutures (both left and right) and lambdoid sutures (both left and right) were calculated respectively. Finally taking the above grades as independent variables, the linear regression model and four machine learning models for age estimation (gradient boosting regression, support vector regression, decision tree regression and Bayesian ridge regression) were established for northern Chinese Han adults age estimation. The accuracy of each model was evaluated. Each cranial suture closure grade was positively correlated with age and the correlation of sagittal suture was the highest. All four machine learning models had higher age estimation accuracy than linear regression model. The support vector regression model had the highest accuracy among the machine learning models with a mean absolute error of 9.542 years. The combination of skull CT-MPR and machine learning model can be used for age estimation in northern Chinese Han adults, but it is still necessary to combine with other adult age estimation indicators in forensic practice.

Genetic and Protein Expression Comparison of Tissues of Differing Embryonic Origin.

Non-syndromic Craniosynostosis (CS) has an unknown etiology. The overproduction of thyroid hormones (THs) during pregnancy known as maternal hyperthyroidism has been cited by the CDC as a potential cause of CS. Elucidation of the mechanism for TH induced CS may allow for the creation of a novel more suitable treatment option. There are several signaling pathways involved in the differentiation and development of the tissues of the skull such as, BMP, Ihh, and Wnt. Wnt signaling has been linked to the differentiation of both embryonic mesoderm as well as neural crest cells, from which the relevant tissues of the skull originate. The goal of this study is to quantify and compare genetic and protein expression of relevant Wnt signaling molecules and their target genes within the Sagittal and Coronal sutures. Beta-Catenin is a Wnt signaling molecule that acts as a transcription factor modulating the expression of genes such as Runx2 and Twist1. These genes were selected as they are known to be involved in cranial development. Sutures were collected from an avian model of induced thyrotoxicosis and analyzed using qRT-PCR and western blotting. Results of the qRT-PCR showed a significant downregulation in Runx2 and Twist1 expression in the coronal sutures with no change in Twist1 and a significant upregulation of Runx2 expression in the sagittal sutures. Western blot results are still pending. While further investigation into these pathways is necessary, our findings conclude that these key pathways react differently to modulation by thyroid hormones in tissues of differing embryonic origin.

Understanding the influence of surgical parameters on craniofacial surgery outcomes: a computational study.

Sagittal craniosynostosis (SC) is a congenital condition whereby the newborn skull develops abnormally owing to the premature ossification of the sagittal suture. Spring-assisted cranioplasty (SAC) is a minimally invasive surgical technique to treat SC, where metallic distractors are used to reshape the newborn's head. Although safe and effective, SAC outcomes remain uncertain owing to the limited understanding of skull-distractor interaction and the limited information provided by the analysis of single surgical cases. In this work, an SC population-averaged skull model was created and used to simulate spring insertion by means of the finite-element analysis using a previously developed modelling framework. Surgical parameters were varied to assess the effect of osteotomy and spring positioning, as well as distractor combinations, on the final skull dimensions. Simulation trends were compared with retrospective measurements from clinical imaging (X-ray and three-dimensional photogrammetry scans). It was found that the on-table post-implantation head shape change is more sensitive to spring stiffness than to the other surgical parameters. However, the overall end-of-treatment head shape is more sensitive to spring positioning and osteotomy size parameters. The results of this work suggest that SAC surgical planning should be performed in view of long-term results, rather than immediate on-table reshaping outcomes.