Craniosynostosis

Regional variability in craniofacial stiffness: a study in normal and Crouzon mice during postnatal development

Craniosynostosis (CS) is the premature closure of craniofacial joints known as sutures. Typically, this condition is treated by numerous invasive surgical interventions. Previously we investigated the level of mechanical strain induced due to frontal bone loading on a mouse model of this condition in light of a minimally invasive cyclic bone loading, showing success in retaining coronal suture patency in the Crouzon mouse model. Here we expanded on the previous investigations and characterised the response to external loading on the anterior part of the parietal bone, posterior part of the parietal bone and interparietal bone in addition to the previously investigated frontal bone loading. The results highlighted the significantly higher deformation of the skull and cranial joints during loading of the posterior skull compared to anterior skull loading. These results suggest that loading-based treatment requires different loading regimes depending on location. Additionally, the response of the coronal suture was investigated directly at postnatal day 7 (P7) in both mutant and wild-type animals. The wild-type mice exhibited significant deformation of the coronal suture across all loading locations, whereas no significant deformation was observed in the mutants. Finally, the experimental results were utilised to develop and analyse computational models of WT mice at three ages: P7, P14, and P21. This underscored the challenges in accurately capturing the highly variable response of the mouse craniofacial system to external loading. In summary, this work provided more details on the mechanics of the mouse craniofacial system and its variable overall stiffness across the different anatomical regions of the skull.

Functional analyses of splice site variants in TCF12

Pre-mRNA splicing is a fundamental step in protein synthesis within a cell. Malfunctions during this process can lead to dysfunctional proteins and thus, to a variety of different human diseases. Mis-splicing can be caused by genetic variants influencing many different molecular processes, e.g. splice donor and splice acceptor site variants. Today, the consequences of these variants can be calculated via different in-silico programs. Due to the complexity of the splicing process, however, these predictions are not always correct and should not be used as stand-alone criteria for the classification of potentially disease-causing variants. Therefore, in case RNA from an appropriate tissue is not available additional in-vitro studies, such as a minigene splice assay, which allows functional analyses of potentially disease-causing variants, are necessary to demonstrate an effect on splicing. One example of a human developmental disorder occasionally caused by mis-splicing of transcripts is craniosynostosis. This congenital disorder is defined by the premature fusion of one or multiple cranial sutures in the neurocranium. To date, numerous mutation types in more than 50 genes which are involved in a broad range of different cellular functions and pathways have been associated with craniosynostosis. For instance, the TCF12 gene encoding the bHLH (basic helix-loop-helix) protein TCF12 (transcription factor 12) is linked to Craniosynostosis 3 (OMIM: 615314) which exhibits a Saethre-Chotzen (OMIM:101400) like phenotype. In this study, we report a pipeline for functional validation of potential splice site altering variants. First, we describe the identification of two novel genetic variants and revalidation of one previously described genetic variant in patients with craniosynostosis. According to in-silico predictions, the splicing of the corresponding transcripts is altered, and the variants are potentially disease causing. We subsequently classify the consequences of alterations in TCF12 experimentally. The suspected aberrant splicing was investigated via an in-vitro minigene splice assay. In two out of three variants, the in-silico prediction and in-vitro experiments were consistent. In all variants a significantly reduced transcriptional activity was demonstrated. In summary, the combination of in-silico prediction and functional assays allowed us to classify the variants as likely pathogenic without the need for additional patient material.

Ephrin-B1 regulates cell surface residency of heparan sulfate proteoglycans (HSPGs) and complexes with the HSPG CD44V3-10 and fibroblast growth factor receptors

The ephrin family of membrane proteins mediate intracellular signalling as ligands of transmembrane Eph tyrosine kinase receptors during cell-cell interactions. Ephrin/Eph signalling regulates processes like cell migration and angiogenesis and is of particular importance during embryonic development. Ephrins-A3 and -B3 can also bind to cell surface-associated and soluble heparan sulfate proteoglycans (HSPGs) that also play important roles during early development. Here we show that ephrins-B1, -B2, and -B3 all can bind in cis to cell surface HSPGs, while only ephrin-B1 interacts with cell surface HSPGs in a way that retards HSPG endocytosis. Expressing ephrin-B1 in HEK293T cells, using polyethyleneimine (PEI) as transfection agent, increased cell surface levels of HSPGs which were detected by an anti-heparan sulfate (HS) antibody or by ephrin-B3-Fc binding. Ephrin-B1 in the plasma membrane seemed to retard PEI-induced HSPG internalisation and degradation. Binding of HSPGs by ephrin-B1 was observed for the human, mouse, xenopus, and zebrafish homologs, and did not require the cytoplasmic tail of ephrin-B1 that contains tyrosines shown to be involved in intracellular signalling. Furthermore, ephrin-B1 could bind the HSPG variant of CD44 (CD44V3-10), a complex that could further associate with fibroblast growth factor receptors (1 and 4) after co-expression with one of these receptors. In summary, our data indicate that ephrin-B1 can regulate cellular HSPG turnover and is able to form complexes of potential biological importance with CD44V3-10 and fibroblast growth factor receptors.

Diagnostic and Surgical Experiences of Australian Parents Navigating Their Child's Craniosynostosis: A Reflexive Thematic Analysis

Nonsyndromic craniosynostosis is a congenital condition causing abnormal skull shape and growth, that is typically surgically treated in the first year of life. Parents of children diagnosed with craniosynostosis endure parental stress and complex emotional responses to their child's diagnosis and treatment. This study examines the psychosocial experiences of parents and their support needs across the diagnostic and perioperative period. Semi-structured interviews with 17 Australian families who had a child diagnosed with nonsyndromic craniosynostosis were undertaken. Reflexive thematic analysis, conducted with an inductive and social-constructionist epistemological approach, generated 5 themes. These themes were: (1) the journey begins; (2) the advocate; (3) waiting for surgery; (4) traveling on the "right" path; and (5) the "different" child. Challenges faced by parents across their journey were multi-faceted and disproportionately impacted mothers. Health care professionals must be responsive to parent support needs and attend to the provision of psychological support for families affected by appearance-altering surgery. Findings highlighted the value of interinstitutional collaboration between Australian craniofacial units, and the importance of family-oriented approaches to care.

Current Understanding of Crouzon Syndrome Pathophysiology and New Therapeutic Approaches

Crouzon syndrome (CS) is a rare genetic disorder characterized by the premature fusion of cranial sutures, leading to craniofacial abnormalities and potential neurological complications. CS is caused primarily by gain-of-function mutations in the FGFR2 gene and, less commonly, by mutations in the FGFR3 gene (specifically associated with CS with acanthosis nigricans). Managing CS requires a multidisciplinary approach, combining early and later surgical interventions to prevent intracranial hypertension and correct craniofacial deformities, along with ongoing care to address associated complications. Recent advancements in CS classification on the basis of cranial suture involvement have refined phenotype-genotype correlations, improving personalized therapeutic strategies. This review aims to provide a comprehensive and updated overview of CS, including detailed insights into molecular genetics and biological mechanisms underlying its pathophysiology, and a depiction of the clinical features, diagnosis, and surgical aspects of CS. In addition, we delve into innovative theranostic views, where molecular genetic testing allows the design of personalized noninvasive therapeutic approaches based on innovative biotechnologies, including RNA-interference molecules, pharmacological modulation of FGFR signaling pathways, and recombinant proteins. These advancements underscore the importance of integrating molecular studies into diagnostic and therapeutic protocols to increase the precision and effectiveness of nonsurgical treatments for CS.

Do Race and Socioeconomic Status Affect Date of Initial Presentation and Repair of Patients with Cleft lip ± Palate and Head Shape Conditions?

ObjectiveTo evaluate regarding the effect of race and socioeconomic status (SES) on the timing of cleft lip and/or palate (CL ± P), craniosynostosis, and plagiocephaly presentation to clinic and possible repair.Design/MethodsA retrospective review of patients with CL ± P and head shape conditions from Jan 2001 to Feb 2022 were included. Age at first plastic surgery clinic appointment, age at repair if applicable, gender, race, and zip code were collected. The Validated Child Opportunity Index (COI) scale was calculated based on zip code as a measure of SES. Kruskal-Wallis tests and Dunn's procedures were used for continuous variables and post hoc pairwise comparisons.Results2733 patients with CL ± P, 9974 with plagiocephaly/brachycephaly, and 59 patients with craniosynostosis were included. Among patients with CL ± P, Black and Hispanic patients presented significantly later to both first plastic surgery clinic appointment and age at repair than White patients (P < .001). White patients and higher SES were associated with a significantly earlier date of initial presentation to plastic surgery clinic for head shape conditions (P < .001).ConclusionsRace and SES may play an important role in the delay of first presentation to plastic surgery clinic and subsequent repair for these patient populations. Further educational efforts must be provided to ensure equitable care. This single institutional study may serve to encourage other academic centers to analyze the timing of care for our pediatric patients.

A head start: The relationship of placental factors to craniofacial and brain development

In recent years, the importance of placental function for fetal neurodevelopment has become increasingly studied. This field, known as neuroplacentology, has greatly expanded possible etiologies of neurodevelopmental disorders by exploring the influence of placental function on brain development. It is also well-established that brain development is influenced by craniofacial morphogenesis. However, there is less focus on the impact of the placenta on craniofacial development. Recent research suggests the functional influence of placental nutrients and hormones on craniofacial skeletal growth, such as prolactin, growth hormone, insulin-like growth factor 1, vitamin D, sulfate, and calcium, impacting both craniofacial and brain development. Therefore, interactions between the placenta and both fetal neurodevelopment and craniofacial development likely influence the growth and morphology of the head as a whole. This review discusses the role of placental hormone production and nutrient delivery in the development of the fetal head-defined as craniofacial and brain tissue together-expanding on the more established focus on brain development to also include the skull (or cranium) and face.

ERF-Related Craniosynostosis in a Patient With Hypochondroplasia: A Case Report

We report a case of multiple suture craniosynostosis in a patient with hypochondroplasia. The patient presented with short stature marked by a relatively long trunk and short extremities. The clinical and radiological findings were suggestive of hypochondroplasia. Additionally, craniosynostosis was identified during the evaluation, which is an unusual finding in hypochondroplasia. To further investigate, exome sequencing was performed, revealing previously reported pathogenic heterozygous variants in FGFR3 and ERF genes. Exome sequencing not only enhances the accuracy of diagnosing individual cases of genetic skeletal disorders but also contributes to the collective knowledge base, advancing future research in the field.

Craniosynostosis in Africa: Insights from 8 Countries-A Systematic Review and Meta-Analysis

OBJECTIVE

Craniosynostosis is a congenital skull deformity that impacts development and quality of life of children if left untreated. This study aimed to evaluate literature regarding presentation, treatment, and outcomes of craniosynostosis in Africa.

METHODS

A systematic review of the literature using PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Fourteen retrospective/prospective studies with 620 patients and 14 case reports involving 27 cases (8 countries) were included. In 12 articles, 56.6% of patients (317/560) were males, with a mean age of 2.4 years (confidence interval [CI]: 1.1-3.7). Abnormal head shape was the most reported presentation in 77.8% of cases (332/427, 8 articles). Syndromic craniosynostosis was seen in 25.2% (CI: 13.7%-36.6%). Common phenotypes were trigonocephaly in 31.5% (CI: 3.6%-59.4%), anterior plagiocephaly in 23.2% (CI: 5.1%-41.3%), and scaphocephaly in 22.1% (CI: 13.5%-30.8%). Five hundred seventy eight patients, 99.5% (CI: 99.0%-100.0%), underwent surgical treatment. Vault remodeling was performed in 72.9% patients (CI: 47.4%-98.6%). Postoperative complications included cerebrospinal fluid leaks 5.4% (CI: 0.0%-11.6%) and surgical site infections 4.5% (CI: 0.0%-10.8%). Follow-up ranged between 0.2 and 40.9 months; 95.6% of cases (CI: 90.1%-100.0%) exhibited improved deformity and neurological deficits at last follow-up. The mortality rate was 3.1% (CI: 0.0%-6.9%, 2 articles).

CONCLUSIONS

Few studies on craniosynostosis in Africa highlight the need for more research. Treatment with open techniques yields few complications and a low mortality rate. Early diagnosis and collaborative data reporting will enhance understanding of its burden and variations across Africa.

Surgical Outcomes in Unicoronal Synostosis-A 23-Year Experience From a Single Supraregional Craniofacial Unit

Unicoronal synostosis is a rare condition leading to anterior plagiocephaly with facial scoliosis and deformation of the anterior cranial fossa. Fronto-orbital advancement and remodelling (FOAR) is the standard of care for management, aiming to normalise the brow shape and position while ameliorating the risk of raised intracranial pressure (ICP) throughout childhood. Published long-term surgical outcome data for unicoronal synostosis is lacking. The authors present our series of 151 cases of FOAR for unicoronal synostosis between January 2000 and January 2023. The average age at surgery was 22.7 months, with an average follow-up of 87 months. Ninety-six patients (66.2%) had no comorbidity. Nineteen (13.1%) had named genetic or chromosomal disorders. There was a 33.1% dural tear rate with no related postoperative CSF leak. Ninety-three patients (67.8%) had a blood transfusion with average donor exposure <1. The total early complication rate was 8.6% most commonly infection and wound dehiscence at 3.4% and 2.8%, respectively. The most common late complication was temporal recession in 30 (20.1%) patients and 3 of these patients required revision surgery. None of our patients required investigation for, or treatment of, raised ICP after the primary surgery. There were no life-threatening complications or mortalities. The authors compare our results to a previous publication on trigonocephaly patients and other available published data. The authors present our recommendations, which include support for a supraregionalized service that encompasses high-volume workload and multidisciplinary care.

Craniosynostosis: Quantifying Differences in Skull Architecture

Craniosynostosis, a condition marked by the premature fusion of one or more cranial sutures, exhibits diverse phenotypes. This study aims to advance the understanding of these phenotypes beyond the conventional 2-dimensional analysis by focusing on identifying indicators of increased intracranial pressure (ICP) such as bony thinning or irregularities in skull morphology.

A retrospective review was conducted for all pediatric patients with midline craniosynostosis who presented to our tertiary academic center for evaluation. Control patients were carefully selected to match for age, sex, and weight. All computed tomography data were segmented in 3-dimensional Slicer and then delineated along with suture lines into occipital, parietal, and frontal segments. Main outcome measures included general skull shape (assessed via measures of flatness and surface area to volume ratio) and skull topography (analyzed via measures of bone thickness, surface variance, and surface standard deviation).

Forty-one patients with midline craniosynostoses were identified (22 metopic and 19 sagittal). Patients with sagittal craniosynostosis had significantly angulated frontal and occipital bones, reflective of the frontal bossing and occipital bulleting commonly seen in this population, and significantly flatter parietal bones, reflective of limited growth along with the transverse axis. Interestingly, evaluation of bone topography revealed that patients with sagittal craniosynostosis had significantly higher parietal bone surface variance, reflective of gyral impressions secondary to increased ICP. In contrast, patients with metopic craniosynostosis had statistically flatter frontal bones-reflective of limited anterior brain growth caused by the fused metopic suture-with minimal impacts to parietal or occipital bones.

Optic Nerve Head Morphological Variation in Craniosynostosis: A Cohort Study

OBJECTIVE

To evaluate optic nerve head (ONH) morphology in children with craniosynostosis versus healthy controls.

DESIGN

Single-center, prospective cohort study.

METHODS

Handheld optical coherence tomography (OCT) was performed in 110 eyes of 58 children (aged 0-13 years) with craniosynostosis. Inclusion criteria were as follows: normal intracranial pressure on invasive overnight monitoring, or clinically stable intracranial pressure. The latter was defined as stable VA within 1 logMAR line and no papilledema on fundoscopy for at least 4 months following OCT, and normal/stable visual evoked potentials. Control data for 218 eyes of 218 children were obtained from a published normative dataset. The main outcome measures were disc width, cup width, rim width, and retinal nerve layer thickness (nasal and temporal). Outcome measures were compared using three-way linear mixed model regression analysis (fibroblast growth factor receptor [FGFR] 1/2-associated craniosynostosis, non-FGFR 1/2-associated craniosynostosis, and controls).

RESULTS

Out of 63 eligible children with craniosynostosis, handheld OCT imaging was successful in 110 eyes of 58 children (92%). Of these, 22 (38%) were female. Median subject age at OCT examination was 53 months (range: 2-157; IQR: 39-73). Twelve children (21%) had FGFR1/2-associated syndromes (Crouzon, n = 6; Apert, n = 4; Pfeiffer, n = 2). Control data were available for 218 eyes of 218 healthy children. 122 controls (56%) were female. Median control age at OCT examination was 20 months (range: 0-163; IQR: 6-59). When comparing ONH morphology in craniosynostosis (n = 58) versus controls (n = 218), disc width was 6% greater (P = .001), temporal cup width was 13% smaller (P = .027), rim width was 16% greater (P < .001) and temporal retinal nerve fiber layer was 11% smaller (P = .027). When comparing FGFR1/2-associated syndromes (Crouzon, Apert, and Pfeiffer syndromes, n = 12) to the rest of the craniosynostosis group (n = 46), disc width was 10% smaller (P = .014) and temporal cup width was 38% smaller (P = .044).

CONCLUSIONS

This cohort demonstrated morphological differences of the ONH in craniosynostosis, most markedly in Crouzon, Apert, and Pfeiffer syndromes. These findings could help improve ophthalmological monitoring and surgical decision-making in children with craniosynostosis. Further work on longitudinal ONH changes in syndromic and nonsyndromic craniosynostosis would be valuable.

Evaluating the Learning Curve and Patient Outcomes in Endoscopically Assisted Craniosynostosis Surgery: A 20-Year Analysis

OBJECTIVES

To analyze the learning curve associated with endoscopic-assisted craniosynostosis surgery (EACS) at a single institution over a period of 2 decades.

MATERIAL AND METHODS

Patients who underwent EACS between 2004 and 2023 were included in this retrospective study. The impact of surgical experience was assessed by analyzing the duration of surgery and anesthesia, blood loss, need for blood transfusion, postoperative complications, and length of hospital stay, in relation to the number of surgeries performed.

RESULTS

On the basis of 310 patients, the overall complication rate was low, with only 23 patients (7.4%) experiencing postoperative complications and 33 patients (10.6%) requiring a blood transfusion. The median length of hospital stay was 3 days (range 1-7 days). The results showed a statistically significant learning curve associated with EACS, with each additional surgery reducing the odds of postoperative complications by 0.7% ( P <0.001) and the odds of blood transfusion by 0.8% ( P <0.001). In addition, there were significant reductions in the duration of anesthesia, duration of surgery, and length of hospital stay over time ( P <0.001).

CONCLUSION

EACS is a safe and effective technique for treating craniosynostosis with low complication rates and a significant learning curve over time. Surgeons can expect to achieve better outcomes with greater surgical experience.

Three contrasts in 3 min: Rapid, high-resolution, and bone-selective UTE MRI for craniofacial imaging with automated deep-learning skull segmentation

PURPOSE

Ultrashort echo time (UTE) MRI can be a radiation-free alternative to CT for craniofacial imaging of pediatric patients. However, unlike CT, bone-specific MR imaging is limited by long scan times, relatively low spatial resolution, and a time-consuming bone segmentation workflow.

METHODS

A rapid, high-resolution UTE technique for brain and skull imaging in conjunction with an automatic segmentation pipeline was developed. A dual-RF, dual-echo UTE sequence was optimized for rapid scan time (3 min) and smaller voxel size (0.65 mm3). A weighted least-squares conjugate gradient method for computing the bone-selective image improves bone specificity while retaining bone sensitivity. Additionally, a deep-learning U-Net model was trained to automatically segment the skull from the bone-selective images. Ten healthy adult volunteers (six male, age 31.5 ± 10 years) and three pediatric patients (two male, ages 12 to 15 years) were scanned at 3 T. Clinical CT for the three patients were obtained for validation. Similarities in 3D skull reconstructions relative to clinical standard CT were evaluated based on the Dice similarity coefficient and Hausdorff distance. Craniometric measurements were used to assess geometric accuracy of the 3D skull renderings.

RESULTS

The weighted least-squares method produces images with enhanced bone specificity, suppression of soft tissue, and separation from air at the sinuses when validated against CT in pediatric patients. Dice similarity coefficient overlap was 0.86 ± 0.05, and the 95th percentile Hausdorff distance was 1.77 ± 0.49 mm between the full-skull binary masks of the optimized UTE and CT in the testing dataset.

CONCLUSION

An optimized MRI acquisition, reconstruction, and segmentation workflow for craniofacial imaging was developed.

Utility of zero echo time (ZTE) sequence for assessing bony lesions of skull base and calvarium

BACKGROUND

The emergence of zero echo time (ZTE) imaging has transformed bone imaging, overcoming historical limitations in capturing detailed bone structures. By minimizing the time gap between radiofrequency excitation and data acquisition, ZTE generates CT-like images. While ZTE has shown promise in various applications, its potential in assessing skull base and calvarium lesions remains unexplored. Hence we aim to introduce a novel perspective by investigating the utility of inverted ZTE images (iZTE) and pseudoCT (pCT) images for studying lesions in the skull base and calvarium.

MATERIALS AND METHODS

A total of 35 eligible patients, with an average age of 42 years and a male/female ratio of 1:4, underwent ZTE MRI and images are processed to generate iZTE and pCT images were generated through a series of steps including intensity equalization, thresholding, and deep learning-based pCT generation. These images were then compared to CT scans using a rating scale; inter-rater kappa coefficient evaluated observer consensus while statistical metrics like sensitivity and specificity assessed their performance in capturing bone-related characteristics.

RESULTS

The study revealed excellent interobserver agreement for lesion assessment using both pCT and iZTE imaging modalities, with kappa coefficient of 0.91 (P < 0.0001) and 0.92 respectively (P < 0.0001). Also, pCT and iZTE accurately predicted various lesion characteristics with sensitivity ranging from 84.3% to 95.1% and 82.6%-94.2% (95% CI) with a diagnostic accuracy of 95.56% and 94.44% respectively. Although both of them encountered challenges with ground glassing, hyperostosis, and intralesional bony fragments, they showed good performance in other bony lesion assessments.

CONCLUSIONS

The pilot study suggests strong potential for integrating the ZTE imaging into standard care for skull base and calvarial bony lesions assessment. Additionally, larger-scale studies are needed for comprehensive assessment of its efficacy.

TWIST1 Gene Variants Cause Craniosynostosis with Limb Abnormalities in Asian Patients

The TWIST1 gene codes for a highly conserved transcription factor in a basic helix-loop-helix transcription factors family. The pattern of inheritance is autosomal dominant in Saethre-Chotzen syndrome, Robinow-Sorauf syndrome, and Sweeney-Cox syndrome. Major features of these syndromes include coronal synostosis, vision problems, and deafness, and facial features include hypertelorism, low-set ears, arched eyebrows, beaked nose, maxillary hypoplasia, and other dysmorphisms including broad great toes, clinodactyly, brachydactyly, and cutaneous syndactyly. TWIST1 (bHLH) transcription factor regulates the formation of head and limbs in the embryo. We describe three families affected with craniosynostosis in whom a sporadic TWIST1 variant was identified on whole exome sequencing, chromosomal microarray, and Sanger sequencing.

Dura-based automated vault expansion remodelling (DAVE-R): automated planning of volume expansion in fronto-orbital advancement for trigonocephaly

Cranial vault remodelling for craniosynostosis aims to increase intracranial volume to facilitate brain growth, avoid the development of raised intracranial pressure and address cosmesis. The extent of vault expansion is predominantly limited by scalp closure and reconstruction technique. Virtual surgical planning tools have been developed to predict post-operative changes and guide expansion. We present a validation study of a novel 'Dura-based Automated Vault Expansion-Remodeling' (DAVE-R) model to guide pre-operative planning for fronto-orbital advancement and remodelling (FOAR).

METHODS

Patients with trigonocephaly who underwent FOAR with pre- and post-operative imaging from 2018 to 2020 were identified from a prospectively maintained database. Post-operative scans, normative atlas and whole brain parcellation were registered to the pre-operative images to quantify the change in intracranial volume and morphology (utilising measurement of fronto-orbital advancement and bifrontozygomatic distance) compared to that predicted by the DAVE-R model.

RESULTS

Ten patients were included. The DAVE-R model predicted bifrontozygomatic distances of 92.0 + / - 5.14 mm (mean + /SD), which closely matched the post-operative results of 92.7 + / - 6.02 mm (mean + / - SD); (t(d.f. 9) = -0.306, p = 0.77). The fronto-orbital advancement predicted by the DAVE-R method was 11.5 + / - 1.96 mm (mean + / - SD) which was significantly greater than 8.6 + / - 2.94 mm (mean ± SD); (t(d.f. 9) = 3.137, p = 0.01) achieved post-operatively.

CONCLUSIONS

We demonstrate that the DAVE-R model provides an objective means of extracting realistic surgical goals in patients undergoing FOAR for trigonocephaly that closely correlates with post-operative outcomes. The normative dural model warrants further study and validation for other forms of craniosynostosis correction.

Experiences of surgical complications and reoperations in nonsyndromic sagittal synostosis patients in Oulu

OBJECTIVE

The purpose of this study was to evaluate the surgical complications of patients treated for nonsyndromic sagittal craniosynostosis and the necessity for reoperations due to craniocerebral disproportion.

MATERIALS AND METHODS

The patient cohort of this study consisted of patients (N = 82) who were treated in the Oulu University Hospital using the open vault cranioplasty with a modified H-technique between the years 2008 to 2022. There were 69 males (84.1%) and 13 females (15.9%). The mean age at the primary operation was 6.1 months. Mean follow-up time was 9.0 years.

RESULTS

There were no major complications related to the procedures. Two patients (2.4%) had a minor dural lesion. There were no postoperative wound infections. Of the 82 patients, seven patients with primary craniosynostosis (13.0%) developed symptomatic craniocerebral disproportion requiring reoperation to increase intracranial volume. In all these patients, invasive intracranial pressure (ICP) monitoring was performed prior to decision-making. In the majority of cases, the aesthetical outcome was considered good or excellent.

CONCLUSION

The operative method used was feasible and safe. Thirteen percent of patients who were followed over 5 years required major surgery due to development of craniocerebral disproportion later in life.

Craniosynostosis in Siblings, an Extremely Rare Occurrence: A Case Report

Craniosynostosis (CS) is the premature fusion of skull sutures, with all sutures except the metopic suture typically fusing in adulthood. Premature fusion constrains brain growth, leading to abnormal skull shape and potential neurocognitive or neurological issues, along with syndromic features in some cases. While CS is rare, its occurrence in siblings is exceptionally uncommon and holds significant academic importance. We report a case of CS in siblings: a 13-month-old boy and his five-and-a-half-year-old sister. Neither parent exhibits craniofacial dysmorphism or signs of increased intracranial pressure (ICP). The younger sibling presents with dolichocephaly and normal neurological, cognitive, and motor development, while the elder sibling exhibits proptosis, midface hypoplasia, and normal developmental milestones. Neither sibling displays limb or systemic anomalies. Imaging studies, including multislice plain CT brain with 3D skull reconstruction and MRI, revealed multiple suture closures. The younger sibling has complete sagittal suture closure with partial closure of other sutures, while the elder sibling shows multisutural CS. Ophthalmologic evaluations and developmental assessments excluded increased ICP and systemic issues. Most CS cases follow an autosomal dominant inheritance pattern, making this case particularly significant. CT with 3D skull reconstruction remains the diagnostic gold standard. Management aims to preserve cosmetic appearance and prevent complications from increased ICP. Treatment options range from conservative follow-up to surgical interventions, including endoscopic suturectomy, open craniotomy, and distraction osteogenesis, depending on the presence of neurocognitive issues or elevated ICP. Both siblings currently show normal neurological, cognitive, and motor development without increased ICP, emphasizing the need for ongoing monitoring to identify new developments or recurrence after treatment. Differential diagnoses, such as deformational plagiocephaly, must also be considered in such cases.

Latent disentanglement in mesh variational autoencoders improves the diagnosis of craniofacial syndromes and aids surgical planning

BACKGROUND AND OBJECTIVE

The use of deep learning to undertake shape analysis of the complexities of the human head holds great promise. However, there have traditionally been a number of barriers to accurate modelling, especially when operating on both a global and local level.

METHODS

In this work, we will discuss the application of the Swap Disentangled Variational Autoencoder (SD-VAE) with relevance to Crouzon, Apert and Muenke syndromes. The model is trained on a dataset of 3D meshes of healthy and syndromic patients which was increased in size with a novel data augmentation technique based on spectral interpolation. Thanks to its semantically meaningful and disentangled latent representation, SD-VAE is used to analyse and generate head shapes while considering the influence of different anatomical sub-units.

RESULTS

Although syndrome classification is performed on the entire mesh, it is also possible, for the first time, to analyse the influence of each region of the head on the syndromic phenotype. By manipulating specific parameters of the generative model, and producing procedure-specific new shapes, it is also possible to approximate the outcome of a range of craniofacial surgical procedures.

CONCLUSION

This work opens new avenues to advance diagnosis, aids surgical planning and allows for the objective evaluation of surgical outcomes. Our code is available at github.com/simofoti/CraniofacialSD-VAE.

New CRISPR/Cas9-based Fgfr2C361Y/+ mouse model of Crouzon syndrome exhibits skull and behavioral abnormalities

Crouzon syndrome (CS), a syndromic craniosynostosis, is a craniofacial developmental deformity caused by mutations in fibroblast growth factor receptor 2 (FGFR2). Previous CS mouse models constructed using traditional gene editing techniques faced issues such as low targeting efficiency, extended lineage cycles, and inconsistent and unstable phenotypes. In this study, a CRISPR/Cas9-mediated strategy was employed to induce a functional augmentation of the Fgfr2 point mutation in mice. Various techniques, including bone staining, micro-CT, histological methods, and behavioral experiments, were employed to systematically examine and corroborate phenotypic disparities between mutant mice (Fgfr2C361Y/+) and their wild-type littermates. Confirmed via PCR-Sanger sequencing, we successfully induced the p.Cys361Tyr missense mutation in the Fgfr2 IIIc isoform of the extracellular domain (corresponding to the p.Cys342Tyr mutation in humans) based on Fgfr2-215 transcript (ENSMUST00000122054.8). Fgfr2C361Y/+ mice exhibited characteristics consistent with the phenotypic features associated with CS, including skull-vault craniosynostosis, skull deformity, shallow orbits accompanied by exophthalmos, midface hypoplasia with malocclusion, and shortened skull base, notably without any apparent limb defects. Furthermore, mutant mice displayed behavioral abnormalities encompassing deficits in learning and memory, social interaction, and motor dysfunction, without anxiety-related disorders. Histopathological examination of the hippocampal region revealed structural abnormalities, suggesting possible brain development impairment secondary to craniosynostosis. In conclusion, we constructed a novel gene-edited Fgfr2C361Y/+ mice strain based on CRISPR/Cas9, which displayed skull and behavioral abnormalities, serving as a new model for studying genetic molecular mechanisms and exploring treatments for CS. KEY MESSAGES: CRISPR/Cas9 crafted a Crouzon model by enhancing Fgfr2-C361Y in mice. Fgfr2C361Y/+ mice replicate CS phenotypes-craniosynostosis and midface anomalies. Mutant mice show diverse behavioral abnormalities, impacting learning and memory. Fgfr2C361Y/+ mice offer a novel model for cranial suture studies and therapeutic exploration.

A physico-mechanical model of postnatal craniofacial growth in human

Our fundamental understanding of the physico-mechanical forces that drive the size and shape changes of the cranium during ontogeny are limited. Biomechanical models based on finite element method present a huge opportunity to address this critical gap in our knowledge. Here, we describe a validated computational framework to predict normal craniofacial growth. Our results demonstrated that this approach is capable of predicting the growth of calvaria, face, and skull base. We highlighted the crucial role of skull base in antero-posterior growth of the face and also demonstrated the contribution of the maxillary expansion to the dorsoventral growth of the face and its interplay with the orbits. These findings highlight the importance of physical interactions of different components of the craniofacial system. The computational framework described here serves as a powerful tool to study fundamental questions in developmental biology and to advance treatment of conditions affecting the craniofacial system such as craniosynostosis.

Assessing the Evidence for Nonobstetric Risk Factors for Deformational Plagiocephaly: Systematic Review and Meta-Analysis

BACKGROUND

Plagiocephaly is defined as an asymmetrical distortion of the skull, resulting in an oblique trapezoid or parallelogram head shape. Deformational plagiocephaly (DP) is caused by forces acting on one side of the back of the head, distorting normal skull symmetry.

OBJECTIVE

The aims of this systematic review and meta-analysis were to critically assess the evidence for nonobstetric risk factors for DP and to make evidence-based recommendations for reducing the prevalence of DP.

METHODS

The selection criterion was studies reporting risk factors for DP. Case reviews, case series, expert opinions, and systematic reviews were excluded. PubMed and Web of Science were searched from August 21, 2010, to August 21, 2022. Publication bias was assessed using funnel plots. Meta-analyses were presented using forest plots.

RESULTS

A total of 19 studies (cohort studies: n=13, 68%; case-control studies: n=5, 26%; and cross-sectional studies: n=1, 5%) with a total of 14,808 participants were included. Of the 43 investigated potential nonobstetric factors, 16 (37%) were associated with DP. Of these 16 factors, 12 (75%) had odds ratios (ORs) with 95% CIs not crossing 1: insufficient vitamin D intake (OR 7.15, 95% CI 3.77-13.54), head position preference (OR 4.75, 95% CI 3.36-6.73), bottle-only feeding (OR 4.65, 95% CI 2.70-8.00), reduced tummy time (OR 3.51, 95% CI 1.71-7.21), sleeping position (OR 3.12, 95% CI 2.21-4.39), fewer motor milestones reached by the age of 6 months (OR 2.56, 95% CI 1.66-3.96), obesity (OR 2.45, 95% CI 1.02-5.90), maternal education level (OR 1.66, 95% CI 1.17-2.37), male sex (OR 1.51, 95% CI 1.07-2.12), formula feeding (OR 1.51, 95% CI 1.00-2.27), head circumference (OR 1.22, 95% CI 1.06-1.40), and mechanical ventilation (OR 1.10, 95% CI 1.00-1.14). No evidence of publication bias was detected.

CONCLUSIONS

This study provides a comprehensive assessment of the nonobstetric factors associated with DP and presents 11 evidence-based recommendations for reducing its prevalence. The primary limitation is that only publication bias was assessed.

TRIAL REGISTRATION

PROSPERO CRD42020204979; https://www.crd.york.ac.uk/prospero/display_record.php? ID=CRD42020204979.

The Current State of Non-Invasive Measurement of Intracranial Pressure in Patients with Craniosynostosis: A Systematic Review

Introduction:

Despite being invasive, direct measurements remain the gold standard to measure intra-cranial pressure (ICP) in patients with craniosynostosis. However, there has been persistent effort to develop non-invasive modalities to measure ICP, possibly avoiding some of the risks of direct measurements. Here, we conduct a systematic review of the evidence behind various non-invasive modalities to monitor ICP in patients with craniosynostosis.

Methods:

A systematic review was conducted using PubMed, Cochrane, and Web of Science databases to identify studies describing the use of non-invasive ICP measurements in patients with craniosynostosis. Studies were included if they assessed a non-invasive method of ICP monitoring against a direct/invasive ICP monitoring technique in patients with craniosynostosis. Non-English and non-human studies were excluded.

Results:

A total of 735 studies were screened, of which 52 were included in the study. Nine methods of non-invasive ICP measurement were identified, with varying sensitivities and specificities in detecting elevated ICP. Specifically, optical coherence tomography (OCT), and ocular ultrasonography demonstrated ability to accurately measure ICP when compared to direct measurements.

Conclusion:

Here, we present the first systemic-review of the current literature surrounding non-invasive modalities to measure ICP in patients with craniosynostosis. While direct measurement remains the gold-standard, multiple reviewed modalities have shown promise in accurately measuring ICP. Of these, OCT has the most rigorous evidence supporting its use. Ocular sonography has also shown promise, albeit without as robust evidence supporting its use. Regardless, further investigation is required before any modality is able to obviate the need for invasive, direct measurements.

Multiple cranial pathologies in spotted hyaenas, Crocuta crocuta

Spotted hyaenas are generally considered to have resilience against injuries and pathogens, and the incidence of pathologies is scarcely reported. However, it is important for ecological studies and conservation efforts to have a clear overview of the physical threats that can occur in the life of a species. The present paper describes and interprets several osteopathologies in the crania of the spotted hyaena, Crocuta crocuta, in the collections of the Royal Museum for Central Africa (RMCA) in Tervuren, Belgium. Of the fifty-two specimens from central Africa examined, twenty-three (i.e., 44 %) of them showed evidence of pathologies, including injuries, congenital pathologies, and disease. Selected specimens were scanned using Computed Tomography and their internal cranial structures were studied. Here we describe and discuss the different types of pathologies evident in the crania of these hyaenas: craniosynostosis, microtia, osteomyelitis and periodontitis, as well as a trauma indicated by cranial fractures, dental fractures, and bite puncture marks. Some pathologies reported herein are novel for hyaenas, and there are some instances of multiple pathologies in the same individual. Implications of these pathologies, including the social interactions of hyenas, conservational threats, as well as biased data sampling, are highlighted. This study improves our knowledge of disease and trauma experienced by hyaenids, and provides a better understanding of their biology, and the potential threats faced by these iconic animals. This case study offers a comparative base for similar studies in other carnivorans, to clarify the pathological background of apex predators.

Neuroimaging in Nonsyndromic Craniosynostosis: Key Concepts to Unlock Innovation

Craniosynostoses (CRS) are caused by the premature fusion of one or more cranial sutures, with isolated nonsyndromic CRS accounting for most of the clinical manifestations. Such premature suture fusion impacts both skull and brain morphology and involves regions far beyond the immediate area of fusion. The combined use of different neuroimaging tools allows for an accurate depiction of the most prominent clinical-radiological features in nonsyndromic CRS but can also contribute to a deeper investigation of more subtle alterations in the underlying nervous tissue organization that may impact normal brain development. This review paper aims to provide a comprehensive framework for a better understanding of the present and future potential applications of neuroimaging techniques for evaluating nonsyndromic CRS, highlighting strategies for optimizing their use in clinical practice and offering an overview of the most relevant technological advancements in terms of diagnostic performance, radiation exposure, and cost-effectiveness.

Genetic Testing in Craniofacial Care: Development of Algorithms for Testing Patients with Orofacial Clefting, Branchial Arch Anomalies, and Craniosynostosis

OBJECTIVE

To develop consensus-based algorithms for genetic testing in patients with common craniofacial conditions.

DESIGN

An online collaborative consisting of online meetings, independent work, and feedback across groups. Setting/Participants: A collaborative of genetics and pediatrics providers from three regional craniofacial centers (four institutions).

METHODS

Collaborative participants agreed upon a shared initial framework, developed algorithms independently, and presented/tested the algorithms with a national audience. Algorithms were modified based on consensus feedback.

RESULTS

The collaborative group developed final algorithms for genetic testing in patients with orofacial cleft, branchial arch conditions, and craniosynostosis.

CONCLUSIONS

Timely and accurate diagnosis of genetic conditions can support medical management recommendations that result in safer surgical interventions. Algorithms can help guide best-practices for testing, particularly in institutions without easy access to genetics providers.

Application of Computerized Surgical Planning in Craniosynostosis Surgery

Craniosynostosis, a medical condition characterized by premature fusion of one or multiple cranial sutures, has historically been treated through surgical correction. Computerized Surgical Planning (CSP) and three-dimensional (3D) modeling have gained significant popularity across craniofacial surgery. Through a collaborative effort between surgeons and engineers, it is now possible to virtually execute a surgical plan based on preoperative imaging using computed tomography scans. The CSP workflow involves several elements including virtual 3D modeling, CSP computer-aided surgical guide design, manufacturing of guides and templates, and intraoperative implementation. Through the gradual optimization of this workflow, it has been possible to achieve significant progress in the surgical process including improvements in the preoperative planning of complex craniosynostosis cases and reduction of intraoperative time. Furthermore, CSP and 3D modeling have had a positive impact on surgical simulation and residency training, along with patient education and counseling. This article summarizes the CSP workflow in the treatment of craniosynostosis and the implications of this treatment modality on medical trainee education and patient management.

Medical Malpractice Litigations Involving Infant Craniosynostosis and Deformational Plagiocephaly in the United States

OBJECTIVE

To identify characteristics of malpractice litigations involving skull deformity in infants (craniosynostosis and deformational plagiocephaly).

DESIGN

Retrospective review of all lawsuits with jury verdicts or settlements involving infant skull deformity as the primary diagnosis using the Westlaw Legal Database.

SETTING

United States.

PATIENTS, PARTICIPANTS

Plaintiffs with skull deformity as the primary diagnosis.

MAIN OUTCOME MEASURES

Litigation outcome and indemnity payment amount.

RESULTS

From 1990 to 2019, 9 cases involving infant skull deformity met our inclusion/exclusion criteria. Among these cases, 8 (88.9%) cases resulted in indemnity payments to plaintiffs, totaling $30,430,000. Failure to diagnose (n = 4, 44.4%) and surgical negligence (n = 3, 33.3%) were the most common reasons for litigations.

CONCLUSIONS

There were a small number of malpractice lawsuits involving infant skull deformity over three decades. When cases go to court, physicians and hospitals have a high likelihood of judgment against them, frequently resulting in high indemnity payments.

Emphasis on Early Prenatal Diagnosis and Perinatal Outcomes Analysis of Apert Syndrome

Apert syndrome is an inherited condition with autosomal dominant transmission. It is also known as acrocephalosyndactyly type I, being characterized by a syndrome of craniosynostosis with abnormal head shape, facial anomalies (median hypoplasia), and limb deformities (syndactyly, rhizomelic shortening). The association can suspect the prenatal diagnosis of these types of anomalies. The methodology consisted of revising the literature, by searching the PubMed/Medline database in which 27 articles were selected and analyzed, comprising 32 cases regarding the prenatal diagnosis of Apert syndrome. A series of ultrasound parameters, the anatomopathological abnormalities found, the obstetric results, and the genetic tests were followed. The distribution of imaging results (US, MRI) identified in the analyzed cases was as follows: skull-shaped abnormalities were evident in 96.8% of cases, facial abnormalities (hypertelorism 43.7%, midface hypoplasia 25%, proptosis 21.8%), syndactyly in 87.5%, and cardiovascular abnormalities in 9.3%. The anomalies detected by the ultrasound examination of the fetus were confirmed postnatally by clinical or gross evaluation or imaging. The management of these cases requires an early diagnosis, an evaluation of the severity of the cases, and appropriate parental counseling.

Craniosynostosis: orofacial and oral health perspectives with masticatory insights

BACKGROUND

Craniosynostosis (CS), premature fusion of one or more cranial sutures, leads to abnormal skull development, impacting both facial esthetics and oral function. This study aimed to evaluate the specific orofacial and oral health characteristics, including masticatory performance, in Thai patients with CS.

METHODS

A comparative study was conducted with Thai CS patients aged 6-17 years and a control group of healthy individuals with similar age distribution. Assessments included craniofacial morphology, oral health status, and masticatory performance. Intergroup comparisons utilized appropriate statistical tests.

RESULTS

The study included 24 CS patients with a mean age of 10.11 ± 2.98 years and 30 controls. CS patients exhibited a significantly higher prevalence of various oral conditions compared to controls: cleft palate (20.8%), anterior open bite (41.7%), anterior crossbite (54.2%), posterior crossbite (50%), combined anterior-posterior crossbite (45.8%), dental crowding in both maxilla and mandible (50% and 45.8% respectively), congenitally missing teeth (50%), supernumerary teeth (12.5%), and eruption failure (54.2%). Furthermore, CS patients exhibited significantly higher caries prevalence and susceptibility, alongside poorer oral hygiene, compared to controls. Regarding jaw relationships, CS patients exhibited a significantly higher proportion of Angle's Class III malocclusion (50%) compared to the control group, where Class I malocclusion was predominant (50%). Masticatory performance, assessed using the two-color gum mixing ability test, showed significantly higher hue variance in CS patients (0.12 ± 0.07) compared to the control group, indicating reduced chewing performance.

CONCLUSION

This study underscores the significant orofacial and oral health challenges faced by children with CS, including a high prevalence of malocclusions, dental anomalies, elevated caries experience, and compromised masticatory function. These findings emphasize the importance of tailored interventions and comprehensive oral healthcare strategies to address the unique needs of this population and improve their overall quality of life.

Geospatial and Socioeconomic Disparities Influencing the Management and Outcomes of Nonsyndromic Craniosynostosis: A Systematic Review

Geospatial and socioeconomic health disparities are potential barriers to timely diagnosis and treatment of nonsyndromic craniosynostosis. This systematic review aims to assess published literature describing disparities in craniosynostosis care and to summarize the findings surrounding patient proximity to care centers and familial socioeconomic status as predictors of surgical management and outcomes. The data sources used include PubMed, MEDLINE, and Google Scholar. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used for appraisal of the quality of the studies included. Generally, the literature reviewed suggested that socioeconomic variables including race, insurance payor, and median zip code income quartile are predictors of suboptimal craniosynostosis surgical management outcomes including older age at time of surgery and more invasive surgical approach performed. The only geospatial data element assessed was the general region of the hospital where the patient was treated. The review highlighted various knowledge gaps within published literature describing health-related disparities in patients with craniosynostosis. There is a paucity of research assessing geospatial access to craniosynostosis care centers, suggesting that further research should be performed to evaluate this potential disparity. In addition, previous studies lack granularity when assessing socioeconomic factors and only one study accounted for suture fused, which is a potential confounding variable across the other published work. These considerations should be addressed in future studies addressing this topic. The limitations of this review include potential publication bias given that unpublished work was not included. An element of reviewer bias also exists considering only one reviewer screened the articles and extracted the data.

The Top 100 Most-Cited Publications in Clinical Craniofacial Research

INTRODUCTION

Craniosynostosis is a birth defect defined as premature closure of sutures leading to possible neurological deficits and cosmetic deformities. Most of the current literature to date focuses on craniosynostosis etiology by analyzing genetics. This paper is a bibliometric analysis of the most influential works related to the clinical management of craniosynostosis to help guide clinicians in their decision-making.

METHODS AND MATERIALS

Clarivate Web of Science database was used to identify the top 100 most-cited articles addressing the clinical management of craniosynostosis. A bibliometric review was performed to analyze publication metrics and track research trends.

RESULTS

The 100 most-cited publications pertaining to craniosynostosis management were cited a cumulative 12,779 times. The highest cited article was Shillito and colleagues' "Craniosynostosis: A Review Of 519 Surgical Patients" with 352 citations. The oldest clinical craniosynostosis article dates back to 1948, and the most recent was published in 2016. The year with the most clinical-focused publications was 2011. The most prolific author was Renier, D. The United States produced 56 of the 100 articles. Most articles (n=52) were level 3 evidence.

DISCUSSION

This bibliometric evaluation of craniosynostosis provides insight into the most impactful literature on this topic. The highest cited articles retrospectively analyze large sample sizes, outline proper evaluation, discuss intervention timelines, and highlight specific treatment plans for this birth defect. By filtering through existing literature, this analysis can guide clinicians on the management of craniosynostosis to maximize patient outcomes.

Adenoidectomy in a child with Crouzon syndrome complicated with severe obstructive sleep apnea: Case report and review of literature

RATIONALE

Crouzon syndrome is an extremely rare craniofacial dysplasia, which is mainly caused by the early ossification and closure of the coronal suture of the skull. Craniofacial deformities can cause stenosis of the nasal cavity and posterior nasal meatus, resulting in sleep apnea.

PATIENT CONCERNS

A 9-year-old boy with sleep snoring for 6 years, progressive aggravation in the past 1 month and accompanied by apnea during sleep.

DIAGNOSES

This case was diagnosed with Crouzon syndrome complicated with severe obstructive sleep apnea and severe hypoxemia.

INTERVENTIONS

After adenoidectomy, he was admitted to the pediatric intensive care unit with ventilator-assisted respiration. During this period, the blood oxygen saturation fluctuated greatly. After trying to extubate, the blood oxygen was difficult to maintain and had to be intubated again. After active treatment, extubation was successful.

OUTCOMES

The wound of nasopharynx recovered well and the sleep state was significantly improved 3 months postoperation.

LESSONS

It is suggested that the time of ventilator-assisted breathing should be prolonged and the perioperative airway management should be strengthened in order to reduce the risk of postoperative complications.

From Bedside to Bench and Back: Advancing Our Understanding of the Pathophysiology of Cleft Palate and Implications for the Future

OBJECTIVE

To provide a comprehensive understanding of the pathophysiology of cleft palate (CP) and future perspectives.

DESIGN

Literature review.

SETTING

Setting varied across studies by level of care and geographical locations.

INTERVENTIONS

No interventions were performed.

MAIN OUTCOME MEASURE(S)

Primary outcome measures were to summarize our current understanding of palatogenesis in humans and animal models, the pathophysiology of CP, and potential future treatment modalities.

RESULTS

Animal research has provided considerable insight into the pathophysiology, molecular and cellular mechanisms of CP that have allowed for the development of novel treatment strategies. However, much work has yet to be done to connect our mouse model investigations and discoveries to CP in humans. The success of innovative strategies for tissue regeneration in mice provides promise for an exciting new avenue for improved and more targeted management of cleft care with precision medicine in patients. However, significant barriers to clinical translation remain. Among the most notable challenges include the differences in some aspects of palatogenesis and tissue repair between mice and humans, suggesting that potential therapies that have worked in animal models may not provide similar benefits to humans.

CONCLUSIONS

Increased translation of pathophysiological and tissue regeneration studies to clinical trials will bridge a wide gap in knowledge between animal models and human disease. By enhancing interaction between basic scientists and clinicians, and employing our animal model findings of disease mechanisms in concert with what we glean in the clinic, we can generate a more targeted and improved treatment algorithm for patients with CP.

Oral Infections in Ancient Human Skulls in 2000 BC/Iron Age, Iran

Background

Oral infections have been seen in humans since ancient times. Excessive penetration of this infection can cause human death. Most of these infections are gum cysts and abscesses. The cyst creates large hard lumps in the gums, which is causes loose, and protruding teeth and abscesses, causing cavities in the jawbone and teeth. In this article, we have discussed for this infectious disease in 4000 - year - old ancient humans from Qazvin Province, Iran. The bone remains of our research are related to Sagezabad ancient cemetery in Qazvin plain.

Methods

We tried to use reliable international atlases to get detailed information about ancient oral infections. The bones were extracted from the 2019 excavation of the Ghara Tappe area of Sagezabad for the Iron Age 2nd and 3rd Qazvin plains of Iran. This cemetery belongs to the period of the Medes Kingdom (pre - Achaemenian kingdom) in Iran.

Results

We have discussed one of the ancient cemeteries with a large number of ancient populations. In this cemetery, there are signs of war and infectious diseases on the bones, which can be clearly seen. We have specially mentioned the abscess as the cause of oral infection from Sagezabad cemetery.

Conclusion

Oral infection existed in Iran since 2000 BC. Of course, this infection was common in ancient times and even Paleolithic period, like Homo Heidelbergensis.

Geospatial and Socioeconomic Disparities Influencing the Management of Craniosynostosis

BACKGROUND

Various social determinants of health have been described as predictors of clinical outcomes for the craniosynostosis population. However, literature lacks a granular depiction of socioeconomic factors that impact these outcomes, and little is known about the relationship between patients' proximity to the care center and management of the condition.

METHODS/DESIGN

This study retrospectively evaluated patients with craniosynostosis who presented to a tertiary children's hospital between 2000 and 2019. Outcomes of interest included age at presentation for surgery, incidence of reoperation, and length of follow-up. Patient addresses were geocoded and plotted on two separate shapefiles containing block group information within San Diego County. The shapefiles included percent parental educational attainment (bachelor's degree or higher) and median household income from 2010. The year 2010 was chosen for the shapefiles because it is the median year of data collection for this study. Multivariate linear, logistic, and polynomial regression models were used to analyze the relationship between geospatial and socioeconomic predictors and clinical outcomes.

RESULTS

There were 574 patients with craniosynostosis included in this study. The mean ± SD Haversine distance from the patient's home coordinates to the hospital coordinates was 107.2 ± 321.2 miles. After adjusting for the suture fused and insurance coverage, there was a significant positive correlation between distance to the hospital and age at index surgery (P = 0.018). There was no correlation between distance and incidence of reoperation (P = 0.266) or distance and duration of follow-up (P = 0.369). Using the same statistical adjustments, lower parental percent educational attainment and lower median household income correlated with older age at index surgery (P = 0.008 and P = 0.0066, respectively) but were not correlated with reoperation (P = 0.986 and P = 0.813, respectively) or duration of follow-up (P = 0.107 and P = 0.984, respectively).

CONCLUSIONS

The results offer evidence that living a greater distance from the hospital and socioeconomic disparities including parental education and median household income may serve as barriers to prompt recognition of diagnosis and timely care in this population. However, the geospatial and socioeconomic factors studied do not seem to hinder incidence of reoperation or length of follow-up, suggesting that, once care has been initiated, longitudinal outcomes may be less impacted.

Exploring Different Management Modalities of Nonsyndromic Craniosynostosis

Craniosynostosis is an atypical skull shape characterized by the premature fusion of cranial sutures. It is one of the most common congenital anomalies encountered by craniofacial surgeons, with a prevalence of one in every 2000-2500 births. It is classified into two main types: syndromic and nonsyndromic. In syndromic, the patient presents with other abnormalities involving the trunk, face, or extremities. While in nonsyndromic the only anomy is the premature fusion, which usually involves one suture; the most common subtypes are unicoronal, sagittal, bicoronal, metopic, and lambdoid. As a consequence, premature fusion before its natural time restricts the space for the brain to grow, increases intracranial pressure, causes damage to the brain tissue, and affects the development of the child. This review comprehensively provides a detailed overview of nonsyndromic craniosynostosis and aims to highlight the importance of early and accurate diagnosis, and determining the most suitable intervention, whether surgical or conservative modalities. The optimal treatment approach produces the most favorable aesthetic and functional outcomes.

Midface hypoplasia in syndromic craniosynostosis: predicting craniofacial growth via a novel regression model from anatomical morphometric analysis

Midface hypoplasia in syndromic craniosynostosis (SC) may lead to serious respiratory issues. The aim of this study was to analyse the morphometric correlation between midface and cranial base parameters in paediatric SC patients in order to formulate predictive regression models. The computed tomography scans of 18 SC patients and 20 control were imported into Materialise Mimics Medical version 21.0 software for the measurement of multiple craniofacial landmarks and correlation analysis. The results showed a strong correlation of anterior cranial base (SN), posterior cranial base (SBa), and total cranial base (NBa) (r = 0.935) to maxilla length and width (ZMR-ZML) (r = 0.864). The model of NBa = - 1.554 + 1.021(SN) + 0.753(SBa) with R2 = 0.875 is proposed to demonstrate the development of the cranial base that causes a certain degree of midface hypoplasia in SC patients. The formula is supported using a prediction model of ZMR-ZML = 5.762 + 0.920(NBa), with R2 = 0.746. The mean absolute difference and standard deviation between the predicted and true NBa and ZMR-ZML were 2.08 ± 1.50 mm and 3.11 ± 2.32 mm, respectively. The skeletal growth estimation models provide valuable foundation for further analysis and potential clinical application.

Multiscale mechanical characterisation of the craniofacial system under external forces

Premature fusion of craniofacial joints, i.e. sutures, is a major clinical condition. This condition affects children and often requires numerous invasive surgeries to correct. Minimally invasive external loading of the skull has shown some success in achieving therapeutic effects in a mouse model of this condition, promising a new non-invasive treatment approach. However, our fundamental understanding of the level of deformation that such loading has induced across the sutures, leading to the effects observed is severely limited, yet crucial for its scalability. We carried out a series of multiscale characterisations of the loading effects on normal and craniosynostotic mice, in a series of in vivo and ex vivo studies. This involved developing a custom loading setup as well as software for its control and a novel in situ CT strain estimation approach following the principles of digital volume correlation. Our findings highlight that this treatment may disrupt bone formation across the sutures through plastic deformation of the treated suture. The level of permanent deformations observed across the coronal suture after loading corresponded well with the apparent strain that was estimated. This work provides invaluable insight into the level of mechanical forces that may prevent early fusion of cranial joints during the minimally invasive treatment cycle and will help the clinical translation of the treatment approach to humans.

Prenatal diagnostic approaches diagnosed craniosynostosis and identified a novel nonsense variant in SMAD6 in a Chinese fetus

Craniosynostosis is one of the most common congenital craniofacial birth defects. The genetic etiology is complex, involving syndromic developmental diseases, chromosomal abnormalities, and monogenic non-syndromic diseases. Herein, we presented a proband of craniosynostosis, who firstly displayed structural abnormalities. This research conducted dynamic ultrasound monitoring a fetus with gradually developing intrauterine growth retardation (IUGR). A novel de novo variant c.41G > A: p.W14* in SMAD6 was identified by pedigree analysis and genetic examination approaches. Recombinant plasmid carrying wild-type sequence and mutant that carries c.41G > A in SMAD6 were constructed and transfected into HEK293T cells. mRNA and protein expression of SMAD6 were reduced in SMAD6 mutants compared to the wild type. Cycloheximide (CHX) treatment and si-UPF1 transfection rescued the SMAD6 mRNA expression in the mutant construct, indicating that c.41G > A: p.W14* in SMAD6 triggered nonsense-mediated mRNA degradation (NMD) process and thus led to haploinsufficiency of the protein product. Our study demonstrated that whole-exome sequencing (WES) was a powerful tool for further diagnosis and etiological identification once fetal malformation was detected by ultrasound. Novel de novo c.41G > A: p.W14* in SMAD6 is pathogenic and potentially leads to craniosynostosis via NMD process.

Yoda1 opens the lymphatic path for craniosynostosis therapy

The rediscovery of meningeal lymphatic vessels (MLVs) has sparked research interest in their function in numerous neurological pathologies. Craniosynostosis (CS) is caused by a premature fusion of cranial sutures during development. In this issue of the JCI, Matrongolo and colleagues show that Twist1-haploinsufficient mice that develop CS exhibit raised intracranial pressure, diminished cerebrospinal fluid (CSF) outflow, and impaired paravascular CSF-brain flow; all features that were associated with MLV defects and exacerbated pathology in mouse models of Alzheimer's disease. Activation of the mechanosensor Piezo1 with Yoda1 restored MLV function and CSF perfusion in CS models and in aged mice, opening an avenue for further development of therapeutics.

Transforming growth factor beta signaling and craniofacial development: modeling human diseases in zebrafish

Humans and other jawed vertebrates rely heavily on their craniofacial skeleton for eating, breathing, and communicating. As such, it is vital that the elements of the craniofacial skeleton develop properly during embryogenesis to ensure a high quality of life and evolutionary fitness. Indeed, craniofacial abnormalities, including cleft palate and craniosynostosis, represent some of the most common congenital abnormalities in newborns. Like many other organ systems, the development of the craniofacial skeleton is complex, relying on specification and migration of the neural crest, patterning of the pharyngeal arches, and morphogenesis of each skeletal element into its final form. These processes must be carefully coordinated and integrated. One way this is achieved is through the spatial and temporal deployment of cell signaling pathways. Recent studies conducted using the zebrafish model underscore the importance of the Transforming Growth Factor Beta (TGF-β) and Bone Morphogenetic Protein (BMP) pathways in craniofacial development. Although both pathways contain similar components, each pathway results in unique outcomes on a cellular level. In this review, we will cover studies conducted using zebrafish that show the necessity of these pathways in each stage of craniofacial development, starting with the induction of the neural crest, and ending with the morphogenesis of craniofacial elements. We will also cover human skeletal and craniofacial diseases and malformations caused by mutations in the components of these pathways (e.g., cleft palate, craniosynostosis, etc.) and the potential utility of zebrafish in studying the etiology of these diseases. We will also briefly cover the utility of the zebrafish model in joint development and biology and discuss the role of TGF-β/BMP signaling in these processes and the diseases that result from aberrancies in these pathways, including osteoarthritis and multiple synostoses syndrome. Overall, this review will demonstrate the critical roles of TGF-β/BMP signaling in craniofacial development and show the utility of the zebrafish model in development and disease.

Prenatal and infantile diagnosis of craniosynostosis in individuals with RASopathies

Fetuses with RASopathies can have a wide variety of anomalies including increased nuchal translucency, hydrops fetalis, and structural anomalies (typically cardiac and renal). There are few reports that describe prenatal-onset craniosynostosis in association with a RASopathy diagnosis. We present clinical and molecular characteristics of five individuals with RASopathy and craniosynostosis. Two were diagnosed with craniosynostosis prenatally, 1 was diagnosed as a neonate, and 2 had evidence of craniosynostosis noted as neonates without formal diagnosis until later. Two of these individuals have Noonan syndrome (PTPN11 and KRAS variants) and three individuals have Cardiofaciocutaneous syndrome (KRAS variants). Three individuals had single suture synostosis and two had multiple suture involvement. The most common sutures involved were sagittal (n = 3), followed by coronal (n = 3), and lambdoid (n = 2) sutures. This case series confirms craniosynostosis as one of the prenatal findings in individuals with RASopathies and emphasizes the importance of considering a RASopathy diagnosis in fetuses with multiple anomalies in combination with craniosynostosis.

Cranial bone imaging using ultrashort echo-time bone-selective MRI as an alternative to gradient-echo based "black-bone" techniques

OBJECTIVES

CT is the clinical standard for surgical planning of craniofacial abnormalities in pediatric patients. This study evaluated three MRI cranial bone imaging techniques for their strengths and limitations as a radiation-free alternative to CT.

METHODS

Ten healthy adults were scanned at 3 T with three MRI sequences: dual-radiofrequency and dual-echo ultrashort echo time sequence (DURANDE), zero echo time (ZTE), and gradient-echo (GRE). DURANDE bright-bone images were generated by exploiting bone signal intensity dependence on RF pulse duration and echo time, while ZTE bright-bone images were obtained via logarithmic inversion. Three skull segmentations were derived, and the overlap of the binary masks was quantified using dice similarity coefficient. Craniometric distances were measured, and their agreement was quantified.

RESULTS

There was good overlap of the three masks and excellent agreement among craniometric distances. DURANDE and ZTE showed superior air-bone contrast (i.e., sinuses) and soft-tissue suppression compared to GRE.

DISCUSSIONS

ZTE has low levels of acoustic noise, however, ZTE images had lower contrast near facial bones (e.g., zygomatic) and require effective bias-field correction to separate bone from air and soft-tissue. DURANDE utilizes a dual-echo subtraction post-processing approach to yield bone-specific images, but the sequence is not currently manufacturer-supported and requires scanner-specific gradient-delay corrections.

Fractality of Cranial Sutures

It has long been known that skull suture has a typical fractal structure. Although the fractal dimension has been utilized to assess morphology, the mechanism of the fractal structure formation remains to be elucidated. Recent advances in the mathematical modeling of biological pattern formation provided useful frameworks for understanding this mechanism. This chapter describes how various proposed mechanisms tried to explain the formation of fractal structures in cranial sutures.

DeepSSM: A blueprint for image-to-shape deep learning models

Statistical shape modeling (SSM) characterizes anatomical variations in a population of shapes generated from medical images. Statistical analysis of shapes requires consistent shape representation across samples in shape cohort. Establishing this representation entails a processing pipeline that includes anatomy segmentation, image re-sampling, shape-based registration, and non-linear, iterative optimization. These shape representations are then used to extract low-dimensional shape descriptors that are anatomically relevant to facilitate subsequent statistical analyses in different applications. However, the current process of obtaining these shape descriptors from imaging data relies on human and computational resources, requiring domain expertise for segmenting anatomies of interest. Moreover, this same taxing pipeline needs to be repeated to infer shape descriptors for new image data using a pre-trained/existing shape model. Here, we propose DeepSSM, a deep learning-based framework for learning the functional mapping from images to low-dimensional shape descriptors and their associated shape representations, thereby inferring statistical representation of anatomy directly from 3D images. Once trained using an existing shape model, DeepSSM circumvents the heavy and manual pre-processing and segmentation required by classical models and significantly improves the computational time, making it a viable solution for fully end-to-end shape modeling applications. In addition, we introduce a model-based data-augmentation strategy to address data scarcity, a typical scenario in shape modeling applications. Finally, this paper presents and analyzes two different architectural variants of DeepSSM with different loss functions using three medical datasets and their downstream clinical application. Experiments showcase that DeepSSM performs comparably or better to the state-of-the-art SSM both quantitatively and on application-driven downstream tasks. Therefore, DeepSSM aims to provide a comprehensive blueprint for deep learning-based image-to-shape models.

A unique presentation of Crouzon-like syndrome: Complex craniosynostosis in the absence of genetic mutations or familial predisposition - A case report

Background

Crouzon syndrome is a rare genetic disorder characterized by premature fusion of skull sutures during skull development, resulting in various craniofacial abnormalities and complex craniosynostosis is a condition in which more than one such sutures of the skull fuse prematurely.

Case Description

Herein, we present a case of a 5-year-old male diagnosed with Crouzon-like syndrome and complex craniosynostosis involving multiple cranial sutures, including metopic, sagittal, coronal (right and left), and lambdoid sutures, and without any identifiable mutations on karyotyping. The patient underwent successful surgical intervention with a satisfactory outcome, highlighting the importance of early diagnosis and intervention to prevent or minimize associated neurological manifestations and craniofacial abnormalities.

Conclusion

Our case report underscores the involvement of multiple cranial sutures in complex craniosynostosis and the absence of identifiable mutations or family history of similar craniofacial abnormalities, providing important insights into the diagnosis and management of this condition.

Spring-assisted posterior vault expansion: a parametric study to improve the intracranial volume increase prediction

Spring-assisted posterior vault expansion has been adopted at the London Great Ormond Street Hospital for Children to treat raised intracranial pressure in patients affected by syndromic craniosynostosis, a congenital calvarial anomaly causing the premature fusion of skull sutures. This procedure involves elastic distractors used to dynamically reshape the skull and increase the intracranial volume (ICV). In this study, we developed and validated a patient-specific model able to predict the ICV increase and carried out a parametric study to investigate the effect of surgical parameters on that final volume. Pre- and post-operative computed tomography data relative to 18 patients were processed to extract simplified patient-specific skull shape, replicate surgical cuts, and simulate spring expansion. A parametric study was performed to quantify each parameter's impact on the surgical outcome: for each patient, the osteotomy location was varied in a pre-defined range; local sensitivity of the predicted ICV to each parameter was analysed and compared. Results showed that the finite element model performed well in terms of post-operative ICV prediction and allowed for parametric optimization of surgical cuts. The study indicates how to optimize the ICV increase according to the type of procedure and provides indication on the most robust surgical strategy.