Are hyperostosis frontalis interna and leptin linked? a hypothetical approach about hormonal influence on human microevolution

Frequency of hyperostosis frontalis interna in patients with active acromegaly: is there a possible role of GH excess or hyperprolactinemia in its etiopathogenesis?

PURPOSE

Acromegaly is characterized by bone changes due to excessive growth hormone (GH) secretion. Hyperostosis frontalis interna (HFI) is described as an overgrowth in the inner plate of the frontal bone. An increased incidence of HFI has been reported in patients with acromegaly. Since the etiology of HFI is poorly understood, we have analyzed whether there is a relationship between the hormonal and metabolic status of patients with acromegaly (with or without hyperprolactinemia) and the pathogenesis of HFI.

METHODS

Forty-five patients with acromegaly and two control groups consisting of 25 patients with prolactinoma (group 1) and 47 healthy subjects (group 2) were included in this retrospective study. Baseline hormonal data and cranial imaging were obtained from medical records and analyzed.

RESULTS

Mean frontal bone thickness was 6.75 mm in acromegaly, 4.85 mm in group 1, and 5.1 mm in group 2 of controls (p < 0.001). The frequency of HFI was higher in acromegalic patients than in the controls (22%, 0%, and 2.2%, respectively). There was no difference between the HFI positive and negative acromegalic patients in basal GH, IGF-1, and PRL levels, IGF-1 index, diagnosis lag time, and insulin resistance. There was no difference between groups regarding parietal and occipital bone thickness.

CONCLUSION

Although the frequency of HFI is 22% in patients with acromegaly, neither excess GH nor hyperprolactinemia plays a role in its etiopathogenesis. Various genetic or epigenetic factors may contribute to its etiology.

Morpho-radiological and brain endocast analysis in the study of Hyperostosis Frontalis Interna (HFI): A combined approach

The purpose of this study is to anatomically evaluate the impact on the patient intra vitam of an endocranial condition on a late 20th century skull housed in the Section of Legal Medicine of the University of Foggia (Foggia, Apulia, Italy). After performing a retrospective diagnosis, the condition is framed in the broader context of studies on this pathology. An anthropological and radiological analysis (X-ray and CT scan imaging) made it possible to confirm the preliminary information and to detail the osteological diagnosis of HFI. In order to assess the impact on the cerebral surface of the endocranial growth a 3D endocast was obtained using the Software OrtogOnBlender. The skull is demonstrated to have belonged to a female senile individual known, from limited documentary evidence, to have suffered from a psychiatric condition during her life. The final diagnosis is hyperostosis frontalis interna (HFI), Type D. Although a direct correlation between the demonstrated intracranial bony growth and the onset of the patient's psychiatric condition is difficult to retrospectively ascertain, the pressure exerted on this female individual's frontal lobe may have contributed to further degenerative behavioural changes in the last years of her life. This case adds to previous knowledge, especially from the palaeopathological literature, on this condition and, for the first time, presents a neuroanatomical approach to assess the global impact of the disease.

Anatomical variations and evolution: re-evaluating their importance for surgeons

For several decades, anatomists and biological anthropologists have made an intensive study in anatomical variations in ancestral and living humans. While many anatomical variants do not require clinical attention, some may present diagnostic problems or augur adverse symptoms. It is only in the last few decades that a plausible argument has been made that anatomical changes in human individuals and lineages demonstrate ongoing microevolution. Since the mid-19th century, there has been a reduction in differential mortality. Increased variation of heritable traits is a consequential outcome of relaxation of natural selection. Consequently, this has contributed to various anatomical variations in musculo-skeletal anatomy, vascular anatomy as well as congenital disorders such as spina bifida occulta. The authors argue that surgeons and anatomists should improve their knowledge of evolution and its continuing influence on human morphology. Simply repeating the old mantra that anatomical variations are important because knowledge of them minimizes surgical complications, albeit important, is inadequate.

Micro-computed Tomography Study of Frontal Bones in Males and Females with Hyperostosis Frontalis Interna

Hyperostosis frontalis interna (HFI) represents irregular thickening of the endocranial surface of the frontal bone, mostly seen in postmenopausal females. The microarchitecture of this condition is poorly studied. The aim of this cross-sectional autopsy study was to investigate and compare microarchitectural structure of the frontal bone affected with HFI in both sexes and to test whether HFI severity could be distinguished at the microarchitectural level. The sample was taken from human donor cadavers, 19 males (61 ± 15 years old) and 17 females (75 ± 15 years old). After classification of HFI severity (type A, B, C or D), samples of the frontal bone were taken and scanned using micro-computed tomography. Bone volume fraction was higher and total porosity lower only in the outer table of males with HFI, compared to females with HFI. Mean total sample thickness differed only between males with HFI type A and D. Bone microarchitecture between males and females with corresponding HFI types (e.g., male with type A versus female with type A) differed only in HFI type C regarding the fractal dimension of diploe. The degree of anisotropy differed between HFI subtypes in males, but the post hoc analysis revealed no significant differences between individual groups. Other microarchitectural parameters did not differ among males with different HFI subtypes, as well in females, in any part of the frontal bone. There is no difference in microarchitectural structure of the frontal bone between males and females with HFI, in general aspect and within corresponding HFI subtypes. HFI severity could not be distinguished at the microarchitectural level, neither in males nor in females.

Finding of Hyperostosis Frontalis Interna During the Autopsy Procedure: Forensic Issues

Hyperostosis frontalis interna is a common phenomenon, which may have been overrated in its significance in the past, and may, currently be underrated in its significance. We present three cases of hyperostosis frontalis interna found during medicolegal autopsies and discuss their forensic considerations. The patients were all middle-aged women with metabolic and endocrine manifestations and psychiatric ailments; thickening of the inner table of the frontal bone of the skull was found during each autopsy. We describe the relationship between hyperostosis frontalis interna, metabolic manifestations, and neuropsychiatric symptoms as part of Morgagni-Stewart-Morel syndrome. There is still considerable disagreement in the scientific community as to whether this syndrome is a clinical entity. Nonetheless, awareness of Morgagni-Stewart-Morel syndrome can be of help in understanding the circumstances surrounding death. In some other cases, hyperostosis frontalis interna could be used by forensic pathologists as criteria for sexing and aging a skeleton.

Hyperostosis frontalis interna in ancient populations from the Carpathian Basin - A possible relationship between lifestyle and risk of development

OBJECTIVE

The prevalence of hyperostosis frontalis interna (HFI) was examined in different periods of the Carpathian Basin from 4900 BCE to 17th century AD. The study seeks to evaluate temporal changes in HFI and the possible impact of lifestyle on it.

MATERIALS

The studied material consisted of 4668 crania from Hungary and Serbia.

METHODS

The crania were analyzed employing macroscopic and endoscopic examination.

RESULTS

In historic periods, sex and age played a pivotal role in HFI development. Among predominantly pastoralist populations of the 5th-8th and 10th centuries, prevalence of HFI was considerably higher than in the medieval populations of the 9th-17th centuries.

CONCLUSIONS

In addition to age and sex, other factors could be implicated in HFI development. The physiological effects of the pastoralist lifestyle and diet on insulin regulation could explain the increased risk of developing HFI in the 5th-8th and 10th-century populations.

SIGNIFICANCE

The study provides the first comprehensive dataset of HFI from different archaeological periods from the Carpathian Basin. It has implications for lifestyle and risk of HFI development in past populations.

LIMITATIONS

The archaeological periods are not equally represented.

SUGGESTIONS FOR FURTHER RESEARCH

In order to better understand the etiology of HFI, lifestyle factors can be used to elucidate the risk of developing HFI in ancient populations.

Evolutionary Medicine: The Ongoing Evolution of Human Physiology and Metabolism

The field of evolutionary medicine uses evolutionary principles to understand changes in human anatomy and physiology that have occurred over time in response to environmental changes. Through this evolutionary-based approach, we can understand disease as a consequence of anatomical and physiological "trade-offs" that develop to facilitate survival and reproduction. We demonstrate how diachronic study of human anatomy and physiology is fundamental for an increased understanding of human health and disease.

What do cranial bones of LB1 tell us about Homo floresiensis?

Cranial vault thickness (CVT) of Liang Bua 1, the specimen that is proposed to be the holotype of Homo floresiensis, has not yet been described in detail and compared with samples of fossil hominins, anatomically modern humans or microcephalic skulls. In addition, a complete description from a forensic and pathological point of view has not yet been carried out. It is important to evaluate scientifically if features related to CVT bring new information concerning the possible pathological status of LB1, and if it helps to recognize affinities with any hominin species and particularly if the specimen could belong to the species Homo sapiens. Medical examination of the skull based on a micro-CT examination clearly brings to light the presence of a sincipital T (a non-metrical variant of normal anatomy), a scar from an old frontal trauma without any evident functional consequence, and a severe bilateral hyperostosis frontalis interna that may have modified the anterior morphology of the endocranium of LB1. We also show that LB1 displays characteristics, related to the distribution of bone thickness and arrangements of cranial structures, that are plesiomorphic traits for hominins, at least for Homo erectus s.l. relative to Homo neanderthalensis and H. sapiens. All the microcephalic skulls analyzed here share the derived condition of anatomically modern H. sapiens. Cranial vault thickness does not help to clarify the definition of the species H. floresiensis but it also does not support an attribution of LB1 to H. sapiens. We conclude that there is no support for the attribution of LB1 to H. sapiens as there is no evidence of systemic pathology and because it does not have any of the apomorphic traits of our species.

CT Examination of Nose and Paranasal Sinuses of Egyptian Mummies and Three Distinct Human Population Groups: Anthropological and Clinical Implications

The interaction of nasal morphology and climatic conditions has resulted in diverse hard- and soft-tissue configurations across human population groups. While the processes of skull pneumatization are not fully understood, the invasions of the paranasal sinuses [PNS] into the cranium have contributed to assorted morphologies. Human migratory patterns and the strong association with climatic variables through time and space may explain this diversity. This study examined four multiregional populations of which two are from Egypt but of widely divergent eras. Three Egyptian mummies [EG-M] from the middle kingdom were CT scanned providing a unique opportunity to investigate the status of PNS anatomy within a time frame from 1567 BCE to 600 CE and compare it to a contemporary Egyptian [EG] (n = 12) population. Dry skulls of Inuit [IT] (n = 10) and East African [EA] (n = 8) provide out-group comparisons, as one group represents an isolated geographic environment far different from that of Egypt and the other group inhabiting distinct environmental conditions albeit located within the same continent. Results showed EG-M and EG frontal sinus volumes were diminutive in size with no statistically significant difference between them. Maxillary sinus size values of EG-M and EG clustered together while IT and EA significantly differed from each other (P = 0.002). The multiregional groups exhibited population specific morphologies in their PNS anatomy. Ecogeographic localities revealed anatomical differences among IT and EA, while the potential time span of about 3,500 years produced only a negligible difference between the Egyptian groups. The small sample sizes incorporated into this research requires confirmation of the results by analyses of larger samples from each geographic region and with the integration of a larger group of Egyptian mummified remains.

Neuropsychological profile of a male psychiatric patient with a Morgagni-Stewart-Morel syndrome

In 1765 Giovanni Morgagni described a syndrome consisting of hyperostosis frontalis interna (HFI), obesity and hirsutism. In 1928 Stewart and in 1930 Morel added neuropsychiatric symptoms, e.g. depression and dementia, which led to the definition of the Morgagni-Stewart-Morel Syndrome (MSM). Although mostly women were characterized in literature no gender specifity is demanded. This case report presents the rare case of a 66 year old male psychiatric patient with Morgagni-Stewart-Morel Syndrome. The patient complained of loss of concentration and difficulties with activities of daily living. Admission diagnosis was an opioid misuse on the basis of a chronic pain syndrome. In this case report we are describing clinical features, the patient history and technical (MRI) and neuropsychological tests. Although severe psychiatric symptoms and neuropsychological deficits are commonly seen in these patients, our patient showed only mild symptoms. This case reports shows the possibility of a male patient with MSM. If MSM is a separate entity or just an epiphenomena of hormone dysregulation should be investigated in further studies.

Benign hyperostotic mass of the frontal bone

Diagnosis of a slow-growing mass of the cranium can be challenging. We present a rare clinical report of a 19-year-old woman with a unilateral mass of the frontal bone. Pathological diagnosis was hyperostosis, which is extremely rare in this age group. A comprehensive review of literature with recommendations for diagnostic modalities and treatment options is reported. Specifically, hyperostosis frontalis interna can be evaluated with computed tomography imaging of the cranium and treated with resection and reconstruction with split calvarial bone grafts. Annual radiographic imaging is recommended to ensure remission.

Frontal cortex dysfunction due to extensive hyperostosis frontalis interna

An 87-year-old patient was found to have an unusually protrusive hyperostosis frontalis interna, discovered on MRI examination during an assessment of cognitive decline. Neuropsychological evaluation suggested direct repercussions of the frontal lobe compression on executive functions, as well as psychiatric disorders and possibly memory loss.

Identifying and classifying hyperostosis frontalis interna via computerized tomography

The aim of this study was to recognize the radiological characteristics of hyperostosis frontalis interna (HFI) and to establish a valid and reliable method for its identification and classification. A reliability test was carried out on 27 individuals who had undergone a head computerized tomography (CT) scan. Intra-observer reliability was obtained by examining the images three times, by the same researcher, with a 2-week interval between each sample ranking. The inter-observer test was performed by three independent researchers. A validity test was carried out using two methods for identifying and classifying HFI: 46 cadaver skullcaps were ranked twice via computerized tomography scans and then by direct observation. Reliability and validity were calculated using Kappa test (SPSS 15.0). Reliability tests of ranking HFI via CT scans demonstrated good results (K > 0.7). As for validity, a very good consensus was obtained between the CT and direct observation, when moderate and advanced types of HFI were present (K = 0.82). The suggested classification method for HFI, using CT, demonstrated a sensitivity of 84%, specificity of 90.5%, and positive predictive value of 91.3%. In conclusion, volume rendering is a reliable and valid tool for identifying HFI. The suggested three-scale classification is most suitable for radiological diagnosis of the phenomena. Considering the increasing awareness of HFI as an early indicator of a developing malady, this study may assist radiologists in identifying and classifying the phenomena.

Hyperostosis frontalis interna: what does it tell us about our health?

OBJECTIVES

To examine whether the prevalence and severity of hyperostosis frontalis interna (HFI) has significantly changed during the past 100 years.

METHODS

Two female populations, 100 years apart, were studied; 992 historic and 568 present day females. Detection of HFI was carried out via direct observation or CT images (Brilliance 64, Philips Medical Systems, Cleveland, Ohio). HFI was graded according to Hershkovitz et al.’s (1999) 4-scale definition and according May et al.’s (2010c) 3-scale definition.

RESULTS

Following correction for age, present day females manifested a significantly higher HFI prevalence compared with historic females (P < 0.05). The risk of developing HFI was found to be approximately 2.5 times greater in present day females compared with females living 100 years ago (P < 0.05). In the young age cohort, present day females manifested a significantly higher prevalence of HFI type B (P < 0.05), whereas in the old age cohort, a significant difference in the prevalence of HFI types C and D was noted between the two groups (P < 0.05). HFI tended to appear at a younger age in the present population. The last two decades has witnessed an increase in HFI prevalence(from 55.6% to 75%).

CONCLUSIONS

HFI prevalence has increased during the last century, especially among young individuals, possibly indicating a profound change in human fertility patterns, together with the introduction of various hormonal treatments) and new dietary habits.

Hyperostosis frontalis interna, a genetic disease?: Two medieval cases from Southern Poland

Two cases of thickening of the internal tables of the frontal bones (hyperostosis frontalis interna, (HFI)) have been examined. These were two female skeletons from the 16th century Dominican Church in Raciborz (Southwest Poland). The similarity of their morphological and metrical traits indicates that they could be related, and suggests that HFI is likely to have a genetic base. These two skeletons are the subject of an analysis which may possibly throw some new light on the controversial and continually disputed nature of this illness.

Brief communication: Unusual finding at Pueblo Bonito: Multiple cases of hyperostosis frontalis interna

Hyperostosis frontalis interna (HFI) is a disease characterized by excess bone growth on the internal lamina of the frontal bone and, occasionally, other cranial bones. Although the disease is fairly common in modern populations, its etiology is poorly understood. Hyperostosis frontalis interna has been identified in antiquity, primarily in the Old World, but with a much lower frequency than in modern groups. The purpose of the present study is to report multiple cases of HFI at Pueblo Bonito (Chaco Canyon, New Mexico). Twelve out of 37 adults with observable frontal bones exhibited HFI, ranging from mild to severe, including 11 females and one male. This is the first published case report of HFI in archaeological remains from the New World having a frequency comparable with modern groups. Most archaeological cases of HFI are isolated, so comparative data for multiple cases at one site are rare. The results of this study emphasize the importance of looking for HFI in archaeological remains, although it is rarely observed. Possible genetic and environmental factors for the high frequency of HFI at Chaco Canyon are considered, but additional research is needed to discover the etiology and to better understand why HFI sometimes occurs at modern frequencies in ancient populations.

Evidence of a Genetic Basis of Morgagni-Stewart-Morel Syndrome

We report two 71-year-old female monozygotic twins presenting with advanced hyperostosis frontalis interna, obesity, shortness and cognitive impairment. They both have suffered from generalized seizures since their early adulthood. Moreover, the patients showed some additional conditions only occurring in one individual or the other such as migraine, marked recurrent depressive disorder or polyarthrosis. The symptoms common to both twins appear to correspond to the Morgagni-Stewart-Morel syndrome and indicate a genetic basis of this disorder as these features occur in genetically identical patients.

Hyperostosis frontalis interna: archaeological evidence of possible microevolution of human sex steroids?

Hyperostosis frontalis interna is a restricted bilateral thickening of the frontal endocranial surface, which is frequently found in postmenopausal females today. Surprisingly, this condition had a higher male prevalence in its rare archaeological records. This is again highlighted by the oldest known male European hyperostosis frontalis interna case in an adult Celtic from 100 BC presented here. This unique specimen supports earlier suggestions of the possible microevolution of human endocrine regulation, e.g. by sex steroids, and its pathoanatomical impact.