Benign Radiographic Coronal Synostosis After Sagittal Synostosis Repair

Abstract

Whether cranial vault remodeling surgery for nonsyndromic, isolated sagittal suture synostosis affects the patency of initially normal, unaffected sutures is unknown. The influence of coronal and lambdoidal suture patency after cranial vault remodeling on the trajectory of subsequent cranial growth is also unknown. Disruption of normal sutural anatomy during cranial vault reconstruction could influence the incidence of secondary craniosynostosis and need for reoperation in a small proportion of these patients.We performed a retrospective review of patients younger than 1 year with nonsyndromic sagittal synostosis treated at a single tertiary referral pediatric hospital from September 2005 to January 2010 by an interdisciplinary team. Computed tomographic images obtained preoperatively, immediately postoperatively, and 2 years postoperatively were evaluated for the occurrence of secondary synostosis of initially nonsynostotic sutures. Craniofacial disorders clinic and ophthalmologic follow-up records were also analyzed for the occurrence of radiographic cranial restenosis, clinical or ophthalmologic signs of intracranial hypertension (ICH), and reoperation.Fifty-one patients younger than 1 year underwent primary surgical repair of isolated, nonsyndromic sagittal suture synostosis during the study period. Thirty-seven of these patients (71%) had completed 2-year clinical and radiographic follow-up by the time of analysis, constituting the study population. The average age at surgery was 5.4 months (range, 3.1-11.5 months). Thirty-three (89%) of the 37 study patients showed radiographic evidence of bilateral secondary coronal synostosis (SCS). Five patients (15%) additionally showed partial lambdoid synostosis. One patient with radiographic SCS (3%) required reoperation for radiographic cranial restenosis, clinical signs and symptoms of ICH, and papilledema first noted 1 year after primary cranial vault reconstruction.There is a high incidence of secondary coronal suture synostosis following cranial vault remodeling for isolated, nonsyndromic sagittal synostosis. Postoperative SCS was only rarely associated with secondary radiographic cranial stenosis, clinical or ophthalmologic signs of ICH, and the need for reoperation.

Delayed intracranial hypertension after cranial vault remodeling for nonsyndromic single-suture synostosis

“…In contrast, skull scalloping and synostosis were common in all patients and not predictive of intracranial hypertension. 14 Of the various presenting clinical signs and symptoms of delayed intracranial hypertension, only recurrent relative microcephaly and crowding on CT were present in all 5 patients. Because patients do not routinely undergo ICP monitoring during follow-up for primary cranial vault reconstruction, it is possible that additional cases of delayed intracranial hypertension were not detected.…”

Secondary Cranial Vault Remodeling for Restenosis after Primary Sagittal Synostosis Repair

“…Various other findings may support the diagnosis of restenosis and intracranial hypertension, including headaches and the identification of papilledema during dilated funduscopy. Although copper-beaten changes of the skull inner table and closure of the coronal sutures are generally benign in asymptomatic patients, in combination with headaches or papilledema they may suggest the presence of cranial restenosis and a risk of intracranial hypertension [5,9]. …”

“…CT demonstrated minimal extra-axial space, generalized copper-beaten pattern to the inner table, volcano sign [11] and partial closure of the coronal sutures bilaterally (fig. 1a, b) [5,9]. The patient also developed headaches during this evaluation.…”

“…Various clinical and radiographic criteria have been used to screen for the occurrence of cranial stenosis and intracranial hypertension after primary cranial vault reconstruction surgery [3,4,5,6,7,8,9,10]. We report the case of a child who presented with decelerating head growth, headaches, papilledema and findings suggestive of cranial restenosis on computed tomographic (CT) imaging 2 years after primary sagittal synostosis repair.…”

“…Secondary cranial stenosis with intracranial hypertension leading to reoperation for cranial vault expansion has been reported in 0-25% of patients with isolated sagittal synostosis [3,4,5,6,7,8]. …”