Behavioral, developmental, and educational problems in children with nonsyndromic trigonocephaly

The Craniofacial Collaboration UK: Developmental Outcomes in 7- and 10-Year-Old Children With Metopic Synostosis

The Craniofacial Collaboration (CC-UK) is a shared initiative across the Psychology teams attached to 4 highly specialized craniofacial centers in the United Kingdom. The CC-UK aims to address key limitations in the existing craniofacial literature by analyzing data for homogenous samples of children with craniosynostosis. This article presents the fifth wave of CC-UK data collection, focused on 7- and 10-year olds who have undergone primary corrective surgery for metopic synostosis (MS). Data for children with sagittal synostosis and MS have previously been presented at 3 and 5 years. This paper continues to build on this with consideration to older age groups, presenting the first CC-UK analysis of cognitive assessment data using the Wechsler Abbreviated Scale of Intelligence-Second Edition. Results show that the majority of children with MS fall within the average ranges across behavioral and neurodevelopmental domains. However, several domains indicated a trend of heightened concern when compared with normative data, particularly for parent-reported outcomes, suggesting that there may be some subtle difficulties for children with MS. Consideration of how these findings compare with that of previous CC-UK analyses is explored. Further, implications for clinical practice and future research are considered, with the need for longitudinal analyses, as well as data from multiple perspectives (eg, school, parents, and self) at older age points to establish patterns over time. Through collaboration across the highly specialized craniofacial centers, the CC-UK hopes to work toward this goal moving forward.

Academic Achievement in School-Aged Children with Single Suture Craniosynostosis Over Time

Introduction: Children with single suture craniosynostosis (SSC) are at risk for neurocognitive problems. The reported magnitude of differences between children with SSC and their normative peers on standardized tests of academic and intellectual ability are small. Evaluation of real-world academic outcomes of these children and its impact on educational resources have not been conducted. Methods: A retrospective cohort study of academic outcomes of children with SSC was conducted using the data from Ontario's Education Quality and Accountability Office (EQAO) standardized provincial reading, writing and mathematics tests. The need for special education was identified by documentation of the child's need for an Identification, Placement, and Review Committee (IPRC). Results: Of 296 eligible children, 42 participated in the study. Half of the children had sagittal synostosis, while the remaining were 10 (24%) unicoronal, 9 (21%) metopic, and 2 (5%) lambdoid synostosis. Thirty-six (86%) underwent operative management. The EQAO scores of operated children with SSC met the provincial academic standards on the Grade 3 and 6 EQAO scores across the 3 academic subjects. Converted grade-matched EQAO scores decreased in reading and writing over time, while math improved. Of the 21 patients with special education data, one child required an IPRC in Grade 3, while an additional four (24%) required an IPRC in Grade 6. Conclusions: Operated children with SSC had average academic performance, however, their needs appeared to change over time. Future studies are needed to evaluate academic difficulties and special education needs as these children progress through grade school.

The Craniofacial Collaboration UK: Developmental Outcomes in 5-Year-Old Children With Metopic Synostosis

The Craniofacial Collaboration (CC-UK) was setup in 2015 as a joint initiative between the Psychology teams attached to the 4 highly specialized craniofacial centers in the United Kingdom. The CC-UK aims to address key limitations in the existing craniofacial literature by applying strict exclusion criteria and collating clinical data on a homogenous sample of children. This article reports the fourth wave of data collection from the CC-UK, with the analysis of developmental and behavioral outcomes for children with metopic synostosis at 5 years old. Previous data for sagittal synostosis at 3 and 5 years, and metopic synostosis at 3 years, have been presented. This paper offers the first analysis of developmental and behavioral parent-report measures at school age for metopic synostosis. All children in the current data set had primary corrective surgery. Findings highlight similar patterns to that of previous research among children with single-suture craniosynostosis, as well as earlier CC-UK analyses, with the majority falling within 1 standard deviation of the normative mean. However, differences across key behavioral and emotional domains, with some areas reporting heightened concerns compared with those detected among sagittal groups, may suggest that subtle differences between individual diagnostic groups are present. This further highlights the importance of utilizing homogenous samples within the field of craniofacial research. To further build upon this work, and to provide a greater understanding of how these difficulties and concerns may develop, or diminish, over time, further consideration to longitudinal outcomes is needed for individual diagnostic groups. Through this collaboration, the authors seek to achieve this goal in their future work.

Trigonocephaly: Quantitative Comparison of the Complete Vault Reconstruction and Minimally Invasive Suturectomy

OBJECTIVE

The objective of the study was to present and compare outcomes and complications of conventional open reconstruction and minimally invasive correction of metopic synostosis in patients who underwent treatment of trigonocephaly in our center between 2015 and 2019.

METHODS

The hospital database was searched for hospitalization and surgical information, as well as imaging of individuals with trigonocephaly. Postoperative evaluation of the patients was performed during the follow-up sessions. The radiological evaluation was based on brain computed tomography scans taken 2 years following the operation.

RESULTS

Sixty-four patients (19 females and 45 males) had their trigonocephaly corrected surgically. Thirty-five patients (9 females and 26 males) had complete vault reconstruction surgery, while 29 patients (10 females and 19 males) had minimally invasive suturectomy (MIS). The postoperative cephalic width/intercoronal distance ratio and interpupillary distance/interfrontozygomatic distance ratio assessment showed no differences in the outcome of both groups (P value > 0.05). Minimally invasive techniques resulted in less intraoperative bleeding, a shorter stay in the intensive care unit and hospital, and a shorter surgery and anesthesia duration (P value < 0.05).

CONCLUSIONS

Surgical treatment of trigonocephaly can result in a satisfactory correction of the deformity. MIS delivers a comparable result to complete vault reconstruction with less invasiveness and hospitalization and can be considered a reasonable option for patients in their early months of life. Patients must, however, undergo long-term cosmetic, behavioral, and developmental evaluations.

Assessing Long-Term Neurodevelopment among Children with Non-Syndromic Single Suture Craniosynostosis

Background:

Single suture craniosynostosis (SSC) is a disorder, affecting brain growth. Reviewing literature reveals controversialists of papers in this field.

Methods:

This prospective study was conducted from 2014 to 2016. All the individuals, aged 2 to 16 years, whose medical records files were complete, with SSC from 1999 to 2013 were included. All patients had undergone cranial vault remodeling at Mofid Hospital, Tehran, Iran. Wechsler questionnaires, WPPSI-III and WISC-IV, were completed for each child based on his/her age.

Results:

Seventy children were included, with the mean age of 6.7 (±2.9) years. Forty-six (65.7%) children were boys while 24 (34.3%) were girls. Mean FSIQ for all of children was 95.5 (±13.2). Mean verbal IQ, performance IQ, verbal comprehension, perceptual reasoning, processing speed, and working memory are 93.4 (±14.1), 96.1 (±13.3), 97.5 (±13.9), 102.2 (±12.5), 94.5 (±9.8), and 97.5 (±12.9), respectively. There was statistically significant difference between FSIQ of children with SSC and that of unaffected children (P-value<0.05). There was significant difference between verbal IQ of children with SSC and that of unaffected ones (P-value< 0.007). There was significant difference between in processing speed between affected children and unaffected children (P-value<0.012).

Conclusion:

Children, aged 2 to 6 years, with SSC had a significantly lower Verbal IQ, and children, aged 6 to 16 years, with SSC had a significantly lower processing speed than their healthy counterparts. Though FSIQ of children with SSC falls within normal range, it is a little lower than healthy peers.

A Diffusion Tensor Imaging Analysis of Frontal Lobe White Matter Microstructure in Trigonocephaly Patients

BACKGROUND

Children with trigonocephaly are at risk for neurodevelopmental disorders. The aim of this study is to investigate white matter properties of the frontal lobes in young, unoperated patients with metopic synostosis as compared to healthy controls using diffusion tension imaging (DTI).

METHODS

Preoperative DTI data sets of 46 patients with trigonocephaly with a median age of 0.49 (interquartile range: 0.38) years were compared with 21 controls with a median age of 1.44 (0.98) years. White matter metrics of the tracts in the frontal lobe were calculated using FMRIB Software Library (FSL). The mean value of tract-specific fractional anisotropy (FA) and mean diffusivity (MD) were estimated for each subject and compared to healthy controls. By linear regression, FA and MD values per tract were assessed by trigonocephaly, sex, and age.

RESULTS

The mean FA and MD values in the frontal lobe tracts of untreated trigonocephaly patients, younger than 3 years, were not significantly different in comparison to controls, where age showed to be a significant associated factor.

CONCLUSIONS

Microstructural parameters of white matter tracts of the frontal lobe of patients with trigonocephaly are comparable to those of controls aged 0-3 years.

Craniometric Measurements and Surgical Outcomes in Trigonocephaly Patients Who Underwent Surgical Treatment

Objective

The aim of this study was to discuss the results of craniometric measurements and surgical treatments in patients operated for isolated trigonocephaly (TC) in light of the current literature.

Methods

A total of 18 cases who underwent surgery for isolated TC were included in the study. Age, gender, family history, follow-up time, complications, duration of surgery, surgical blood loss, and amount of blood replacement in these patients were recorded. Craniometric measurements such as metopic angle (MA), cephalic index (CI), interparietal distance (IPD), intercoronal distance (ICD), and their ratio to each other were evaluated according to pre-and postoperative parameters. Photographs of the patients were taken before and after the operation. The Whitaker classification and Kampf "aesthetic outcome staging" were used in the evaluations.

Results

The mean MA values after the operation increased to reach above 147 degrees in all cases. The average CI did not change. ICD measurement averages increased significantly. The average IPD/ICD ratio decreased due to the increase in ICD and the enlargement of the anterior fossa after the operation. According to the Whitaker classification and Kampf “aesthetic outcome staging” scale, 17 of our cases were at stage I, rated as perfect, and one was at stage II, rated as good.

Conclusion

Surgery performed at the appropriate time for TC yields cosmetically satisfactory results. Since potential neurological and cognitive morbidities occur mostly in school-age patients, long-term follow-up of the cases is required. Performing craniometric measurements enables patients to be evaluated with objective and measurable numerical data.

Postsurgical Size-Changing Temporal Lobe Arachnoid Cysts in Patients with Trigonocephaly Who Underwent Reconstructive Surgery: A Two-Case Report

INTRODUCTION

Trigonocephaly (TC), the tapering of the metopic suture toward the anterior, lateral inadequacy of supraorbital bar, hypoplasia of the ethmoid bone, and hypotelorism due to orbital medialization leads to a triangular shape in the head together with frontotemporal stenosis and widening of the biparietal diameter. Arachnoid cysts (ACs) are benign cysts, which are formed by cerebrospinal-fluid entrapment into the arachnoid membrane due to duplication or separation of the arachnoid membrane layers. ACs are typically located in the middle cranial fossa and Sylvian fissure region. They are mostly detected incidentally through neuroimaging. The coexistence of TC and AC is considerably rare; hence, its actual incidence is unknown. To our knowledge, the coexistence of nonsyndromic TC and AC has been revealed in only 2 publications in the literature. In this case study, 2 patients, one of whom were with unilateral and the other with bilateral temporally localized ACs, sizes of which increased following the reconstructive surgeries, and who underwent reconstructive surgery for TC, were presented.

CASE REPORT

Both of the 2 patients that we have presented in our study are 7 months old and male. Fronto-orbital advancement and calvarial remodeling operations were performed on both. ACs of the patients were not intervened. However, in the post-op follow-ups, the left temporal cyst of the 1st case and the right cyst of the 2nd case grew radiologically, and the left cyst became very small.

DISCUSSION/CONCLUSION

TC must be treated surgically. ACs may show changes in size secondary to the increase in intracranial volume following reconstructive surgery for TC. However, if it does not give rise to any complaints, it can be followed-up clinically and radiologically. Patients should be followed-up for many years, given that neurodevelopmental and behavioral problems may occur later in both pathologies.

Single-suture craniosynostosis: is there a correlation between preoperative ophthalmological, neuroradiological, and neurocognitive findings?

BACKGROUND

In spite of literature data stating that children with single-suture craniosynostosis have an increased risk for neuropsychological deficits, no data are present clarifying the potential risk factors.

METHODS

All children with non-syndromic single-suture craniosynostosis operated on from January 2014 to January 2017 were enrolled. A comprehensive neurocognitive and neuro-ophthalmological evaluation was performed before surgery and 6 months after surgery. A further neurocognitive evaluation was performed 12 months after surgery. All children had a preoperative CT/MR study.

RESULTS

One hundred forty-two patients were enrolled; 87 are affected by sagittal craniosynostosis, 38 by trigonocephaly, and 17 by plagiocephaly. A global neurocognitive impairment was documented in 22/87 children with scaphocephaly, 5/38 children with trigonocephaly, and 6/17 children with anterior plagiocephaly. There was a significant relationship between results of the ophthalmological evaluation, global IQ, and CT findings at diagnosis (r = 0.296, p < 0.001; r =0.187, p 0.05). Though a significant recovery was documented after surgery, a persistence of eye coordination deficits was present at 6 months in 1 out of 3 children with abnormal preoperative exams. A significant correlation was found between pathological CT findings and persistence of below average neuro-ophthalmological and neurocognitive findings 6 months after surgery, as well as between CT findings and neurocognitive scores at the 1 year follow-up (r = 0.411; p < 0.01).

CONCLUSION

The presence of neuroradiological abnormalities appears to be related to both ophthalmological and neurocognitive deficits at diagnosis. This relationship is maintained in spite of the surgical treatment in children who show the persistence of ophthalmological and neurocognitive deficits during the follow-up.

Cleft and Craniofacial Multidisciplinary Team Clinic: A Look at Attrition Rates for Patients With Complete Cleft Lip and Palate and Nonsyndromic Single-Suture Craniosynostosis

OBJECTIVE

To evaluate attrition rates prior to expected completion of team care for children with complete cleft lip and palate (cleft) or nonsyndromic single-suture craniosynostosis (synostosis).

DESIGN

A single-institution retrospective review of attendance data from 2002 to 2016.

SETTING

Single cleft and craniofacial center in the United States.

PATIENTS/PARTICIPANTS

A sample of 983 patients with either cleft or synostosis. Patients who were more than 2 to 3 years from their last visit were considered lost to follow-up. Patients with cleft older than 16 years or synostosis over 11 years were considered graduated from team care.

RESULTS

Survival analysis shows that in our patients with cleft, 25% leave before age 8 and over 60% are lost from team by age 16. In patients with synostosis, 25% leave before age 6 and 45% are lost by age 11. Cox regression showed underrepresented minorities being 1.7 times more likely to become lost in the cleft group (hazard ratio: 1.66, 95% confidence interval [CI]: 1.01-2.74).

CONCLUSIONS

Overall, attrition rates were high at our institution. Many patients are lost to follow-up prior to receiving key medical interventions. Improved family education and personalized care are needed to help ensure continuity of care.

GWAS reveals loci associated with velopharyngeal dysfunction

Velopharyngeal dysfunction (VPD) occurs when the muscular soft palate (velum) and lateral pharyngeal walls are physically unable to separate the oral and nasal cavities during speech production leading to hypernasality and abnormal speech reduction. Because VPD is often associated with overt or submucous cleft palate, it could be present as a subclinical phenotype in families with a history of orofacial clefting. A key assumption to this model is that the overt and subclinical manifestations of the orofacial cleft phenotype exist on a continuum and therefore share common etiological factors. We performed a genome-wide association study in 976 unaffected relatives of isolated CP probands, 54 of whom had VPD. Five loci were significantly (p < 5 × 10^-8) associated with VPD: 3q29, 9p21.1, 12q21.31, 16p12.3 and 16p13.3. An additional 15 loci showing suggestive evidence of association with VPD were observed. Several genes known to be involved in orofacial clefting and craniofacial development are located in these regions, such as TFRC, PCYT1A, BNC2 and FREM1. Although further research is necessary, this could be an indication for a potential shared genetic architecture between VPD and cleft palate, and supporting the hypothesis that VPD is a subclinical phenotype of orofacial clefting.

Genetic advances in craniosynostosis

Craniosynostosis, the premature ossification of one or more skull sutures, is a clinically and genetically heterogeneous congenital anomaly affecting approximately one in 2,500 live births. In most cases, it occurs as an isolated congenital anomaly, that is, nonsyndromic craniosynostosis (NCS), the genetic, and environmental causes of which remain largely unknown. Recent data suggest that, at least some of the midline NCS cases may be explained by two loci inheritance. In approximately 25-30% of patients, craniosynostosis presents as a feature of a genetic syndrome due to chromosomal defects or mutations in genes within interconnected signaling pathways. The aim of this review is to provide a detailed and comprehensive update on the genetic and environmental factors associated with NCS, integrating the scientific findings achieved during the last decade. Focus on the neurodevelopmental, imaging, and treatment aspects of NCS is also provided.

Psychological adjustment to craniofacial conditions (excluding oral clefts): A review of the literature

OBJECTIVE

A congenital craniofacial anomaly (CFA) is expected to impact upon several domains of psychological, emotional and social functioning, yet no recent reviews have comprehensively summarised the available literature. Further, existing reviews tend to draw upon literature in the field of cleft lip and palate, and do not give substantive attention to other types of CFAs.

DESIGN

A review of 41 papers published between January 2000 and March 2016 pertaining to psychological adjustment to CFAs.

MAIN OUTCOME MEASURES

Findings are presented according to key psychological domains: General Psychological Well-being, Quality of Life, Behaviour, Emotional Well-being, Social Experiences, Appearance, and Treatment-Related Experiences.

RESULTS

Current literature offers a contradictory picture of adjustment to CFAs. Psychological adjustment appeared to be comparable to norms and reference groups in approximately half of the papers related to non-syndromic CFAs, while more variation was found across domains among samples with syndromic CFAs. Associations were found between adjustment, physical health and cognitive function in several papers. The review identified a number of gaps in the literature, such as the inclusion of a wide range of diagnoses within research samples.

CONCLUSIONS

This review demonstrates the complexity of findings, both within and across domains, and highlights a number of methodological challenges.

Seasonal Pattern of Preterm Births in Korea for 2000-2012

The aim of this study was to investigate a seasonal pattern of preterm births in Korea. Data were obtained from the national birth registry of the Korean Statistics Office and included all births in Korea during the period 2000-2012 (n = 6,310,800). Delivery dates were grouped by month of the year or by season (winter [December, January, February], spring [March, April, May], summer [June, July, August], and autumn [September, October, November]). The seasonal patterns of prevalence of preterm births were assessed. The rates of preterm births at 37 weeks were highest twice a year (once in winter and again in summer). The rates of preterm births increased by 13.9% in summer and 7.5% in winter, respectively, than in spring (OR, 1.139; 95% CI, 1.127-1.152, and OR, 1.075; 95% 1.064-1.087, respectively) after controlling for age, the educational level of the parents, maternal parity, and neonatal gender. The pattern for spontaneous preterm births < 34 weeks was similar. In Korea, a seasonal pattern of preterm births was observed, with peak prevalence in summer and winter. A seasonal pattern of preterm births may provide new insights for the pathophysiology of preterm births.

Analysis of individualized education programs to quantify long-term educational needs following surgical intervention for single-suture craniosynostosis

BACKGROUND

Single-suture craniosynostosis (SSC) is a common craniofacial condition with potential neurocognitive sequelae.

OBJECTIVE

To quantify any long-term functional academic and behavioural difficulties of children with SSC as indicated by the need for individualized education programs (IEPs), despite having undergone surgical treatment.

METHODS

Records of all school-age patients from 1992 to 2011 who underwent operative intervention for SSC were identified. Fifty-nine patients' guardians were contacted by telephone to provide informed consent for completion of a mailed standardized questionnaire querying demographic information as well as information regarding the patient's health, family and educational history; specifically whether the patient had ever been provided educational support as delineated in an IEP. The primary outcome measure was the history of the patient being assigned educational support as delineated in an IEP.

RESULTS

Thirty-seven consenting guardians completed and returned the standardized questionnaire (response rate 62.7%). Twenty-one patients were male and 16 were female, with an age range of five to 14 years (mean age 10.2 years). Eleven (29.7%) patients had a previous history of or currently were receiving educational support delineated in an IEP.

CONCLUSIONS

A higher proportion of school-age patients with a history of SSC (status postsurgical intervention) in the present study received educational support delineated in an IEP than the proportion of IEPs in the general student population of the United States (11.3%).

Intellectual and academic functioning of school-age children with single-suture craniosynostosis

OBJECTIVE

We compared the developmental status of school-age children with single-suture craniosynostosis (case group) and unaffected children (control group). Within the case group we compared the performance of children distinguished by location of suture fusion (sagittal, metopic, unicoronal, lambdoid).

METHODS

We administered standardized tests of intelligence, reading, spelling, and math to 182 case participants and 183 control participants. This sample represented 70% of those tested during infancy before case participants had corrective surgery.

RESULTS

After adjustment for demographics, case participants' average scores were lower than those of control participants on all measures. The largest observed differences were in Full-Scale IQ and math computation, where case participants' adjusted mean scores were 2.5 to 4 points lower than those of control participants (Ps ranged from .002 to .09). Adjusted mean case-control differences on other measures of achievement were modest, although case deficits became more pronounced after adjustment for participation in developmental interventions. Among case participants, 58% had no discernible learning problem (score <25th percentile on a standardized achievement test). Children with metopic, unicoronal, and lambdoid synostosis tended to score lower on most measures than did children with sagittal fusions (Ps ranged from <.001 to .82).

CONCLUSIONS

The developmental delays observed among infants with single-suture craniosynostosis are partially evident at school age, as manifested by lower average scores than those of control participants on measures of IQ and math. However, case participants' average scores were only slightly lower than those of control participants on reading and spelling measures, and the frequency of specific learning problems was comparable. Among case participants, those with unicoronal and lambdoid fusions appear to be the most neurodevelopmentally vulnerable.

Psychosocial outcomes in children with and without non-syndromic craniosynostosis: findings from two studies

Objective : To evaluate the hypothesis that children with craniosynostosis and their parents have differences in psychosocial outcomes, as compared with an unaffected control group. Design : Two studies were conducted, both which followed children born with and without craniosynostosis. Study 1 ascertained affected children from clinics, and study 2 ascertained affected children from a population-based study of birth defects. Participants : Study 1 included 22 children with single-suture craniosynostosis and 18 controls, ages 4 to 5 years. Study 2 included 24 children with nonsyndromic craniosynostosis and 124 unaffected controls, ages 5 to 9 years. Main Outcome Measures : Outcome measures included the Child Behavior Checklist, Social Competence Scale, Pediatric Quality of Life Inventory, and Parenting Stress Index. Results : We observed lower scores on measures of health-related quality of life in cases versus controls, with adjusted effect sizes ranging from -0.72 to -0.44 (p < .05) on summary measures. Small but statistically nonsignificant increases in behavioral problems were observed in cases versus controls, with no apparent differences in social competence or parenting stress. Conclusions : Results provide preliminary evidence suggesting that children with nonsyndromic craniosynostosis may have elevated risk for psychosocial difficulties, particularly health-related quality of life. Continued follow-up through preadolescence and adolescence is warranted.

Nonsyndromic craniosynostosis

Nonsyndromic craniosynostosis is more commonly encountered than syndromic cases in pediatric craniofacial surgery. Affected children display characteristic phenotypes according to the suture or sutures involved. Restricted normal growth of the skull can lead to increased intracranial pressure and changes in brain morphology, which in turn may contribute to neurocognitive deficiency. Management has primarily focused on surgical correction of fused sutures prior to 12 months of age to optimize correction of the deformity and to ameliorate the effects of increased intracranial pressure. However, emphasis has recently shifted to better understanding the pathogenesis of neurocognitive impairment observed in these children, along with genetic mutations that contribute to premature suture fusion. Such understanding will provide opportunities for earlier and more specific neurocognitive interventions and for the development of targeted genetic therapy to prevent pathologic suture fusion. The authors review the common types of nonsyndromic craniosynostosis and the epidemiological, genetic, and neurodevelopmental details that are currently known from the literature. In addition, they present the rationale for surgical correction, offer suggestions for timing of intervention, and present some nuances of techniques that they find important in producing consistent results.