Craniosynostosis with associated cranial base anomalies: a morphologic and histologic study of affected like-sexed twins

Coronal Clival Cleft in CHARGE Syndrome: Fetal MRI Series

BACKGROUND AND PURPOSE

CHARGE is a syndrome that affects the brain, eyes, ears, heart, face, and genitourinary system. Prenatal diagnosis could optimize counseling, delivery planning, and therapeutic interventions; however, reports of associated fetal neuroimaging features are scarce. While some findings are nonspecific, olfactory, inner ear, and skull base anomalies are commonly present and may be observable at the time of fetal imaging. We sought to determine the scope of prenatal CNS MRI findings in CHARGE syndrome with emphasis on findings not included in the diagnostic criteria for CHARGE syndrome, such as coronal clival cleft.

MATERIALS AND METHODS

Retrospective review of fetal +/- postnatal neuroimaging from patients with genetic diagnosis of CHARGE syndrome was conducted. Brain, ear, eye, face, and skull base bone abnormalities were documented. Descriptive statistics were employed to characterize the findings.

RESULTS

Eighteen fetal-maternal dyads were included. Median gestational age at time of prenatal MRI was 26.25 weeks. Thirteen (72%) subjects were born alive, of which 10 (55.6%) were males. One died on the first day of life (5.6%) and 4/18 (22.2%) underwent termination of pregnancy. Twelve (66.7%) had postnatal brain MRI and/or temporal bone CT. On prenatal MRI, coronal clival cleft was seen in 72% of the cases and confirmed in all patients with postnatal imaging. Inner ear dysplasia was universally seen in all prenatal MRI, except for 1 case, in which this was not evaluable, and confirmed in all cases postnatally. On prenatal imaging, olfactory apparatus hypoplasia/absence was detected in 83% of the cases, followed by globe dysmorphia and/or colobomas in 44% of the cases, atresia of choanae (39%), facial clefts (22%), and cerebellar malformation (16.7%). Of the 10 cases with postnatal brain MRI available, 4 (40%) demonstrated cerebellar gray matter heterotopia.

CONCLUSIONS

The most common fetal neuroimaging findings supporting the diagnosis of CHARGE syndrome are olfactory deficiency and inner ear dysplasia. Coronal clival clefts are often present and are frequently visible on prenatal MR imaging. The presence of a clival coronal cleft should raise the possibility of CHARGE syndrome, particularly when associated with other known cardinal findings, such as cerebellar dysgenesis, olfactory apparatus deficiency, and inner ear dysplasia.

Another TWIST on Baller-Gerold syndrome

Baller-Gerold syndrome is characterized by craniosynostosis and preaxial upper limb malformations. Wide heterogeneity exists with regard to the presence of additional anomalies. Most of the 31 reported cases involve other malformations, including cardiac, Central Nervous System (CNS), and urogenital anomalies. Baller-Gerold syndrome is thought to have autosomal recessive inheritance. However, Gripp et al. [1999: Am. J. Med. Genet. 82:170-176] recently provided the first evidence for autosomal dominant inheritance with variable expressivity and severity. A nonsense mutation was found in TWIST, a gene associated with Saethre-Chotzen syndrome (SCS). Here we report on a male Caucasian patient of nonconsanguineous parents, with synostosis of the coronal, metopic, and sagittal sutures, and bilateral radial ray hypoplasia. The patient's small, round ears with prominent crus helices, and cervical anomalies are common features of SCS. The father had very mild features of SCS. We identify direct paternal transmission of a novel missense TWIST mutation in the highly conserved Helix II domain of this bHLH-family gene. This report lends further support to the recent findings by Gripp et al. [1999]. Future TWIST mutational analysis on patients with craniosynostosis and radial ray involvement will shed light on whether Baller-Gerold syndrome should be a distinct entity or some cases should be reclassified as a heterogeneous form of SCS.

Baller-Gerold syndrome associated with congenital portal venous malformation

We report a 4 year old boy in whom the clinical features of craniosynostosis and bilateral absent radii led to a diagnosis of Baller-Gerold syndrome. Additional congenital abnormalities included midface hypoplasia, atrial and ventricular septal defects, right hydronephrosis, partial sacral agenesis, and anterior ectopic anus. Evidence of portal venous hypertension was present from 8 months and a congenital portal venous malformation was discovered at 2 years. This is the first reported case of Baller-Gerold syndrome associated with a congenital portal venous malformation. We discuss the diagnostic confusion between this syndrome and other overlapping malformation syndromes and propose optimal evaluation strategies aimed at clarifying the nosology of these syndromes.

Craniosynostosis, microcephaly, hydrancephaly, humero-radial synostosis, and thumb aplasia: a new syndrome?

We describe a growth-retarded newborn infant with craniosynostosis, microcephaly, hydrancephaly, oligodactyly, humero-radial synostosis, and normal chromosomes. The combination of anomalies has hitherto been unreported and we consider this to be a "new" syndrome.

Phenotypic variability in the Baller-Gerold syndrome: report of a mildly affected patient and review of the literature

We report a patient with a mild form of the Baller-Gerold syndrome (craniosynostosis-radial aplasia syndrome). The patient, a 3-year 3 month-old boy, has trigonocephaly with bilateral absent radii and thumbs. His growth parameters and psychomotor development have been normal. No visceral anomalies were found. This patient represents a new case of the rare mild form of the syndrome.

Multiple pterygium syndrome with body asymmetry

We report on a fetus with multiple pterygia in the popliteal, antecubital, intercrural, axillary, and nuchal region, arthrogryposis, camptodactyly, anal atresia, hypospadias, ambiguous genitalia, and neonatal death. Arthrogryposis was much more pronounced at the left than at the right side. Moreover, there was gross body asymmetry with hypoplasia of the left arm, leg, pelvis, and kidney. As this spectrum of anomalies does not fit any of the known multiple pterygium syndromes, this patient adds another clinical entity to the already wide spectrum of multiple pterygium syndromes.

Magnetic resonance imaging to visualize the internal anatomy in the Baller-Gerold syndrome

The Baller-Gerold syndrome is identified by radial aplasia with craniosynostosis. Only 12 cases have been reported previously in the literature; none of the reports describe surgical treatment for the radial aplasia. We report the case of a 10-month-old female infant with this syndrome, including severe bilateral radial clubhands. A radial anlage, which was tethering growth of the ulna, was suspected on physical examination and confirmed with magnetic resonance imaging. Resection of the anlage resulted in dramatic improvement in elbow extension, but additional follow-up will be necessary to determine the complete functional effect of the procedure.

Further delineation of the Baller-Gerold syndrome

Three new patients with the Baller-Gerold syndrome bring the number of reported cases to 20. In addition to craniosynostosis involving various sutures and preaxial reduction defects of variable severity, affected patients may have anal, urogenital, cardiac, central nervous system, and vertebral defects. Autosomal recessive inheritance is supported by the presence of affected sibs and parental consanguinity.

The Baller-Gerold syndrome

A case of severe craniosynostosis-radial aplasia (Baller-Gerold) syndrome is described in a newborn male, following a pregnancy complicated by polyhydramnios and intrauterine growth retardation. Death occurred after two hours owing to a prolonged apnoeic spell. Extensive agenesis of the frontal and parietal bones, resulting in a very large fontanelle, in addition to coronal bilateral craniosynostosis was observed at necropsy. There was also bilateral radial agenesis, oligodactyly of the hands and feet, a midline facial angioma, and a scrotally positioned anus, all of which have been described in some of the 10 previously reported cases. Microcephaly, erythroblastosis of the liver, and pancreatic islet cell hypertrophy were also noted.

Baller-Gerold syndrome: case report and clinical and radiological review

The major manifestations of the Baller-Gerold syndrome (BGS) are craniosynostosis and preaxial limb anomaly involving the radius and/or the thumb. We report on a new patient with coronal and sagittal suture involvement, mild unilateral radial and thumb hypoplasia, imperforate anus, rectovaginal fistula, prenatal onset growth deficiency, and mental retardation. This patient also had some minor oral-facial anomalies, severe nonfamilial myopia, bilateral conductive hearing loss, ureteric reflux, and skeletal anomalies other than those noted in the skull and upper limbs. This patient confirms the clinical variability among the patients and the wide pleiotropic effects of the BGS gene.

Baller-Gerold syndrome associated with congenital hydrocephalus

We present a new case of the Baller-Gerold syndrome (BGS) in an infant with prenatally apparent severe hydrocephalus, growth retardation, and cardiac and limb abnormalities detected by ultrasound at 26 weeks of gestational age. Subsequent survival to term and neonatal examination confirmed an unsuspected diagnosis of BGS.

Baller-Gerold syndrome: an 11th case of craniosynostosis and radial aplasia

We report on a patient with craniosynostosis, left radius aplasia, right radius hypoplasia, and other congenital anomalies. This is the 11th reported case of the Baller-Gerold syndrome. Autosomal recessive inheritance of this syndrome is suggested by evidence of probable parental consanguinity.

Normal growth and development in a child with Baller-Gerold syndrome (craniosynostosis and radial aplasia)

The cardinal features of the Baller-Gerold syndrome (MIM *21860) are craniosynostosis and radial aplasia. Only 12 cases have been published and these are roughly divisible into two groups: cases without any additional abnormalities and cases with a broad range of additional features. We describe a boy with craniosynostosis and radial aplasia alone and highlight genetic counselling difficulties presented by a sporadic case of this rare syndrome.

The effects of long-term fetal constraint in vitro on the cranial base and other skeletal components

Recently it was suggested that some cases of premature closure of the sagittal suture in humans may be due to fetal head constraint. Using various modifications of the procedure for long-term shell-less cultivation of chick embryos, we sought to test the hypothesis that fetal head constraint may result in abnormalities of the cranial base and other skeletal structures of the head. Our experiments with various sized containers demonstrate that fetal constraint is associated with both deformation and malformation of the craniofacial skeleton, including the cranial base, squamosal, columella (stapes), and mandible. The severity of both deformation and malformation appears to be a function of the degree of fetal constraint. If, as some suggest, abnormality of the cranial base is the primary anomaly in craniosynostosis, then our results tend to support the fetal constraint hypothesis as one explanation of simple craniostenosis.