Spring-assisted cranioplasty is an established technique for the correction of isolated sagittal craniosynostosis, yet data on long-term clinical durability and patient-perceived outcomes remain limited. The purpose of this study was to evaluate long-term surgical, aesthetic, and patient-reported outcomes following spring-assisted cranioplasty, with a particular focus on the need for secondary cranial surgery and concordance between surgeon- and parent-reported assessments. A single-centre cohort study was performed, including consecutive patients with isolated, nonsyndromic sagittal synostosis treated with spring-assisted cranioplasty between April 2010 and September 2015. Patients were followed within a standardized multidisciplinary craniofacial pathway extending into late childhood and adolescence. Long-term outcomes were assessed using reoperation rates, Kaplan–Meier reoperation-free survival analysis, surgeon-reported Whitaker classification, and structured parent-reported satisfaction measures. Ninety-one of the original 100 patients had complete long-term follow-up and were included, with a mean follow-up duration of 10.0 years (range 5–15 years). Nine patients (9.9

Background:. Sagittal craniosynostosis (SC) is the most common type of isolated craniosynostosis, resulting in premature fusion of the sagittal suture and a scaphocephalic head shape. Surgical interventions, such as spring-assisted cranioplasty (SAC) and open calvarial vault remodeling (CVR), are often required to normalize skull morphology and improve functional outcomes. The Swap Disentangled Variational Autoencoder (SD-VAE) was used for the objective assessment of the SC phenotype and quantification of surgical outcomes after SAC and CVR, focusing on global and regional head shape relative to a healthy population. Methods:. A dataset of computed tomography, magnetic resonance imaging, and 3-dimensional photographs was used to train the SD-VAE on preoperative SC patients and healthy controls. Paired pre- and postoperative scans were analyzed to evaluate surgical outcomes. Data augmentation addressed class imbalance, and linear and quadratic discriminant analyses were used to visualize, classify, and quantify head shape morphology relative to the healthy norm. Results:. For training, scans of 108 healthy children and 239 preoperative SC patients were included, with 21 CVR and 37 SAC pre- and postoperative pairs for evaluating surgical outcomes. The SD-VAE accurately distinguished SC patients from healthy controls based on global and regional morphology. Both SAC and CVR resulted in head shape normalization, with region-specific differences in effectiveness. Conclusions:. By providing objective, global, and region-specific analysis of head shape and surgical outcomes, the SD-VAE enhances understanding of the SC phenotype and supports standardized outcome assessment. Future work will explore predictive applications and integration into clinical workflows for patient counseling and surgical planning.

Congenital syndromes with subtle changes in maxillofacial morphology can pose significant diagnostic challenges, wherein artificial intelligence holds great promise in aiding diagnosis through shape analysis. The authors applied the recently proposed Swap Disentangled Variational Autoencoder (SD-VAE) in diagnosis of Beckwith-Wiedemann syndrome (BWS). The SD-VAE model was trained on a data set primarily comprised of surface 3D head scans [stereophotogrammetry (3D SPG)], gathered using a 3dMD Head System (3dMD LLC). It was also trained on CT scans when available. A total of 72 syndromic scans were used belonging to 56 different BWS patients. Scans of head shapes were pre-processed and annotated with 68 anatomic landmarks. This aided in achieving uniformity between the scans and a template mesh, making a better comparison possible. The SD-VAE model outputs were then visualized in a 2-dimensional space and classified as 'BWS-patient' or 'control'. For each anatomic facial region, the performance of the classification model was evaluated. This allowed us to understand the classification accuracy for each anatomic region as well as calculate the sensitivity and specificity for each region. The model demonstrated perfect diagnostic accuracy for BWS on the test set, with the most characteristic regions being the chin, cheeks, zygoma, eyes, jaw, and supraorbital region. This paper demonstrates how SD-VAE can be applied to 3D head meshes, to quantify the characteristic features of BWS. The authors distinguished BWS-specific features from those of the general population with high diagnostic accuracy. This makes SD-VAE a promising tool for aiding the referral and diagnosis of BWS in the future.

PURPOSE:Spring-assisted cranioplasty is an established technique for the correction of isolated sagittal craniosynostosis, yet data on long-term clinical durability and patient-perceived outcomes remain limited. The purpose of this study was to evaluate long-term surgical, aesthetic, and patient-reported outcomes following spring-assisted cranioplasty, with a particular focus on the need for secondary cranial surgery and concordance between surgeon- and parent-reported assessments. METHODS:A single-centre cohort study was performed, including consecutive patients with isolated, nonsyndromic sagittal synostosis treated with spring-assisted cranioplasty between April 2010 and September 2015. Patients were followed within a standardized multidisciplinary craniofacial pathway extending into late childhood and adolescence. Long-term outcomes were assessed using reoperation rates, Kaplan-Meier reoperation-free survival analysis, surgeon-reported Whitaker classification, and structured parent-reported satisfaction measures. RESULTS:Ninety-one of the original 100 patients had complete long-term follow-up and were included, with a mean follow-up duration of 10.0 years (range 5-15 years). Nine patients (9.9%) required secondary cranial surgery during follow-up, including four for raised intracranial pressure and five for aesthetic indications. Reoperation-free survival was 90.1% at 10 years, with the median survival not reached. Surgeon-reported outcomes were excellent, with 87.9% classified as Whitaker Class I. Parent-reported satisfaction was high, with 82.4% completely satisfied and unwilling to consider further surgery. CONCLUSION:Spring-assisted cranioplasty for isolated sagittal synostosis provides durable long-term functional and aesthetic outcomes, with a low incidence of secondary cranial surgery and high patient and parent satisfaction when combined with structured multidisciplinary follow-up.

BACKGROUND AND OBJECTIVE:Endoscopic strip craniectomy is a minimally invasive surgical technique offered to infants for craniosynostosis repair. We examine our institution's experience with infants undergoing this surgery with respect to perioperative physiological parameters, transfusion rates, complications, and length of hospital stay. METHODS:We performed an observational retrospective review of all infants undergoing endoscopic strip craniectomy at Great Ormond Street Hospital, UK from 2019 to 2024. Data were collected via the digital health record system EPIC (Epic Systems Corporation [2023], USA) and analyzed in Microsoft Excel. RESULTS:One hundred and eleven patients were included in the study undergoing single or multicranial suture repair: metopic (n = 67), unicoronal (n = 27), sagittal (n = 9), frontosphenoidal (n = 2), bicoronal (n = 4), and multisuture (n = 2). We present a mean age of 4.4 months (±1.05 SD), weight 6.95 kg (±1.05 SD), male (n = 66) population predominance, and ASA score from 1 to 3. Surgical procedure time was 73 min (±23 SD) across all sutures, with multisuture repair requiring a longer operative time of 96 min (±15 SD). The overall red cell transfusion rate was 1 in 5 children, with a higher incidence in those undergoing metopic suture repair (18/67, 26%). Mean preoperative and postoperative hemoglobin in the single suture repair group was 114 g/L (±11 g/L SD) and 87 g/L (±13 g/L SD) resulting in a mean reduction in hemoglobin of 26 g/L (±15 g/L SD). Mean preoperative and postoperative hemoglobin in the bilateral or multisuture repair group was 118 g/L (±7.17 g/L SD) and 85.5 g/L (±14.29 g/L SD) resulting in a mean reduction in hemoglobin of 35 g/L (±15 g/L SD). One hundred and six infants (95%) were discharged on Day 1 postoperatively, and no children required high dependency care. Complications reported were inadvertent extubation on positioning (n = 2), laryngospasm (n = 1), and a minor transfusion reaction (n = 1). CONCLUSION:Endoscopic strip craniectomy is a well-established minimally invasive surgical technique. Anesthesia for this procedure is typically performed in young infants who may be at greater risk of perioperative anesthetic complications and clinically significant blood loss and blood transfusion. We report a > 20% transfusion rate in our infant cohort mostly with metopic repairs.

To evaluate outcomes of three posterior vault expansion (PVE) techniques in children with craniosynostosis and confirmed raised intracranial pressure (ICP) and propose a practical framework to guide surgical technique selection based on patient-specific characteristics. We retrospectively analyzed 116 pediatric patients who underwent their first PVE for confirmed raised ICP between January 2018 and January 2024 at a tertiary craniofacial center. Patients underwent one of three surgical techniques: static remodeling (PVE-S), spring-assisted posterior vault expansion-classic (SAPVE-C), or spring-assisted posterior vault expansion-vertical vector (SAPVE-VV). Outcomes included functional improvement (fundoscopy, VEPs, symptoms, Chiari I), volumetric change in intracranial volume (ICV), operative time, transfusion rates, complications, and reoperation-free survival. Analyses were stratified by age and syndromic diagnosis. All techniques significantly improved functional markers, with complete resolution of papilledema and normalized VEPs in over 80

Craniosynostosis is a medical condition that affects the growth of babies' heads, caused by an early fusion of cranial sutures. In recent decades, surgical treatments for craniosynostosis have significantly improved, leading to reduced invasiveness, faster recovery, and less blood loss. At Great Ormond Street Hospital (GOSH), the main surgical treatment for patients diagnosed with sagittal craniosynostosis (SC) is spring assisted cranioplasty (SAC). This procedure involves a 15x15 mm2 osteotomy, where two springs are inserted to induce distraction. Despite the numerous advantages of this surgical technique for patients, the outcome remains unpredictable due to the lack of efficient preoperative planning tools. The surgeon's experience and the baby's age are currently relied upon to determine the osteotomy location and spring selection. Previous tools for predicting the surgical outcome of SC relied on finite element modeling (FEM), which involved computed tomography (CT) imaging and required engineering expertise and lengthy calculations. The main goal of this research is to develop a real-time prediction tool for the surgical outcome of patients, eliminating the need for CT scans to minimise radiation exposure during preoperative planning. The proposed methodology involves creating personalised synthetic skulls based on three-dimensional (3D) photographs, incorporating population average values of suture location, skull thickness, and soft tissue properties. A machine learning (ML) surrogate model is employed to achieve the desired surgical outcome. The resulting multi-output support vector regressor model achieves a R2 metric of 0.95 and MSE and MAE below 0.13. Furthermore, in the future, this model could not only simulate various surgical scenarios but also provide optimal parameters for achieving a maximum cranial index (CI).

To our knowledge, there has not been a review article summarizing the current evidence with regard to perinatal risk factors, and our aim is to perform a systematic review and meta-analysis of the evidence of perinatal risk factors in single suture craniosynostosis to inform our practice and identify any need for further research in this area. Our target population was pediatric single-suture craniosynostosis patients, and the intervention was perinatal risk factors. The comparison group was an age and sex-matched control group without craniosynostosis and the outcome we investigated was presence of single suture craniosynostosis. The literature search was done using OVID MEDLINE, Pubmed, and Embase databases from 1946 to 2023. A PRISMA flowchart was created, and statistical analysis was performed using RevMan pooled odds ratios, and 95% CIs were used to combine results from individual studies. Our initial search identified 625 abstracts and these were narrowed down to 16 articles, which were included in the final selection for the review. Out of these, 13 were used for the quantitative meta-analysis. Our meta-analysis showed a possible association between craniosynostosis and the following perinatal risk factors; presence of maternal thyroid disease, maternal age greater than 29, paternal age greater than 29, maternal smoking, gestational age above 37 weeks, and maternal underweight (BMI<18.5). Further prospective studies are warranted to investigate definite associations. The next step is to set up a multicenter prospective study among a craniofacial unit network.

Apert (AS), Crouzon (CS), Muenke (MS), Pfeiffer (PS), and Saethre Chotzen (SCS) are among the most frequently diagnosed syndromic craniosynostoses. The aims of this study were (1) to train an innovative model using artificial intelligence (AI)-based methods on two-dimensional facial frontal, lateral, and external ear photographs to assist diagnosis for syndromic craniosynostoses vs controls, and (2) to screen for genotype/phenotype correlations in AS, CS, and PS. We included retrospectively and prospectively, from 1979 to 2023, all frontal and lateral pictures of patients genetically diagnosed with AS, CS, MS, PS and SCS syndromes. After a deep learning-based preprocessing, we extracted geometric and textural features and used XGboost (eXtreme Gradient Boosting) to classify patients. The model was tested on an independent international validation set of genetically confirmed patients and non-syndromic controls. Between 1979 and 2023, we included 2228 frontal and lateral facial photographs corresponding to 541 patients. In all, 70.2% [0.593-0.797] (p < 0.001) of patients in the validation set were correctly diagnosed. Genotypes linked to a splice donor site of FGFR2 in Crouzon-Pfeiffer syndrome (CPS) caused a milder phenotype in CPS. Here we report a new method for the automatic detection of syndromic craniosynostoses using AI.

BACKGROUND:Endoscopic strip craniectomy followed by helmet therapy (ESCH) is a minimally invasive approach for correcting sagittal craniosynostosis. The treatment involves a patient-specific helmet designed to facilitate lateral growth while constraining sagittal expansion. In this study, finite element modelling was used to predict post-treatment head reshaping, improving our comprehension of the necessary helmet therapy duration. METHOD:Six patients (aged 11 weeks to 9 months) who underwent ESCH at Connecticut Children's Hospital were enrolled in this study. Day-1 post-operative 3D scans were used to create skin, skull, and intracranial volume models. Patient-specific helmet models, incorporating areas for growth, were designed based on post-operative imaging. Brain growth was simulated through thermal expansion, and treatments were modelled according to post-operative Imaging available. Mechanical testing and finite element modelling were combined to determine patient-specific mechanical properties from bone samples collected from surgery. Validation compared simulated end-of-treatment skin surfaces with optical scans in terms of shape matching and cranial index estimation. RESULTS:Comparison between the simulated post-treatment head shape and optical scans showed that on average 97.3 ± 2.1 % of surface data points were within a distance range of -3 to 3 mm. The cranial index was also accurately predicted (r = 0.91). CONCLUSIONS:In conclusion, finite element models effectively predicted the ESCH cranial remodeling outcomes up to 8 months postoperatively. This computational tool offers valuable insights to guide and refine helmet treatment duration. This study also incorporated patient-specific material properties, enhancing the accuracy of the modeling approach.

OBJECTIVE: Outcomes of surgical repair of trigonocephaly are well reported in the literature, but there is a paucity of information on the natural history of unoperated children. The authors evaluated a group of unoperated children with metopic synostosis to describe the natural change in head shape over time. METHODS: A database was screened for scans of children with unoperated trigonocephaly (2010-2021). Multisuture cases and those with a metopic ridge were excluded. Three-dimensional surface scans (3D stereophotogrammetry/CT) were used for morphological analysis. Nine previously published parameters were used: frontal angle (FA(30 degrees)), anteroposterior (AP) volume ratio (APVR), AP area ratio (APAR), AP width ratios 1 and 2 (APWR1 and APWR2), and 4 AP diagonal ratios (30 degrees right APDR( )[rAPDR(30)], 30 degrees left APDR [lAPDR(30)], 60 degrees right APDR [rAPDR(60)], and 60 degrees left APDR [lAPDR(60)]). RESULTS: Ninety-seven scans were identified from a cohort of 316 patients with a single metopic suture, in which the male-to-female ratio was 2.7:1. Ages at the time of the scan ranged from 9 days to 11 years and were stratified into 4 groups: group 1, < 6 months; group 2, 6-12 months; group 3, 1-3 years; and group 4, > 3 years. Significant improvements were detected in 5 parameters (APVR, APAR, APWR1, rAPDR(30), and lAPDR(30)) over time, whereas no significant differences were found in FA(30), APWR2, rAPDR(60), and lAPDR(60) between age groups. CONCLUSIONS: Forehead shape (surface area and volume), as well as narrowing and anterolateral contour at the frontal points, differed significantly over time without surgery. However, forehead angulation, narrowing, and anterolateral contour at temporal points did not show significant differences. This knowledge will aid in surgical and parental decision-making.

BackgroundPlagiocephaly 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. ObjectiveThe 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. MethodsThe 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. ResultsA 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. ConclusionsThis 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 RegistrationPROSPERO CRD42020204979; https://www.crd.york.ac.uk/prospero/display_record.php? ID=CRD42020204979

Background:Advancements in artificial intelligence and the development of shape models that quantify normal head shape and facial morphology provide frameworks by which the outcomes of craniofacial surgery can be compared. In this work, the authors demonstrate the use of the swap disentangled variational autoencoder to assess changes after midfacial surgery objectively.Methods:The model is trained on a data set of 1405 3-dimensional meshes of healthy individuals and syndromic patients, which was augmented using a technique based on spectral interpolation. Patients with a diagnosis of Apert or Crouzon syndrome who had undergone sub- or transcranial midfacial procedures using rigid external distraction had their results interpreted using this model as the point of comparison.Results:A total of 56 patients met the inclusion criteria: 20 with Apert syndrome and 36 with Crouzon syndrome. By using linear discriminant analysis to project the high-dimensional vectors derived by swap disentangled variational autoencoder onto a 2-dimensional space, the shape properties of Apert syndrome and Crouzon syndrome can be visualized in relation to the healthy population. In this way, the authors were able to show how surgery elicits global shape changes in each patient. To assess the regional movements achieved during surgery, the authors used a novel metric derived from the Mahalanobis distance to quantify movements through the latent space.Conclusions:Objective outcome evaluation, which encourages in-depth analysis and enhances decision-making, is essential for the progression of surgical practice. The authors demonstrate how artificial intelligence has the ability to improve our understanding of surgery and its effect on craniofacial morphology.

Plagiocephaly is defined as asymmetrical distortion of the skull resulting in an oblique trapezoid or parallelogram head shape. In the absence of skull growth restriction due to craniosynostosis, deformational plagiocephaly (DP) is caused by deformational forces acting on one side of the back of the head which distorts the normal symmetry of the skull. The aims of this systematic review and meta-analysis were to critically assess the evidence for non-obstetric risk factors for DP and to make evidence-based recommendations for reducing the prevalence of DP. A search of PubMed and Web of Science was performed covering 21 August 2010 to 21 August 2022. The searches yielded 159 articles, of which 18 articles were eligible for inclusion in this study. 43 non-obstetric factors were identified. Of these, a total of 17 factors were associated with DP. With the notable exceptions of maternal age, mechanical ventilation and tummy time, these associations were either supported by non-conflicting evidence or a meta-analysis that resolved conflicting evidence into a significant association. Thirteen factors had significant odds ratios that ranged from 1.10 (mechanical ventilation) to 7.15 (insufficient vitamin D intake). Of the five factors assessed by meta-analysis (male gender, reaching fewer motor milestones by six months of age, maternal education level, head position preference, sleeping position), only one (male gender) was associated with significant inter-study heterogeneity. No evidence of publication bias was detected. In summary, this study provides the most comprehensive meta-analytic assessment of non-obstetric factors associated with DP published to date. It provides 13 evidence-based recommendations which can be adopted by healthcare systems globally, to reduce the prevalence of DP and its impact on child development.

Objective Endoscopic suturectomy for craniosynostosis with helmet therapy (ESCH) has emerged as a successful treatment for craniosynostosis initially in North America. We present early outcomes from the first cohort of ESCH patients treated in the United Kingdom. Methods Retrospective cohort study with review of electronic records. Results 18 consecutive patients from the first procedure in the UK (May 2017) until January 2020 were identified. Our cohort consisted of 12 male and 6 female infants with craniosynostosis, with mean age of 4.6 months (range: 2.5–7.8 months) and weight of 6.8 kg (range 4.8–9.8 kg). The most commonly operated diagnosis was metopic synostosis (n=8) followed by unicoronal (n=7), sagittal (n=2) and multi-sutural (n=1) synostoses. Median length of skin incision was 3 cm (range 2–10 cm), with 15 patients having a single skin incision. 16/18 received no blood products with 2 requiring transfusion (1 donor exposure). Mean operative time (including anaesthesia) was 96 mins (range 40–127 mins). The median length of hospital stay was 1 night with no patients staying more than 2 nights (n=3). Only 1 surgical complication was noted (a suture abscess requiring oral antibiotics). All patients are currently undergoing helmet orthosis with 100% compliance so far. No patients have required revisional surgery. Conclusion Early peri-operative experience from the first UK cohort of ESCH patients suggests this is a safe and well tolerated technique with low morbidity, need for transfusion and short hospital stay. We hope the success of these results leads to developing discussions to facilitate funding of the helmet orthotic therapy as part of NHS highly specialised commissioning services at Great Ormond Street.

BackgroundThe four different local therapy strategies used for head and neck rhabdomyosarcoma (HNRMS) include proton therapy (PT), photon therapy (RT), surgery with radiotherapy (Paris-method), and surgery with brachytherapy (AMORE). Local control and survival is comparable; however, the impact of these different treatments on facial deformation is still poorly understood. This study aims to quantify facial deformation and investigates the differences in facial deformation between treatment modalities. MethodsAcross four European and North American institutions, HNRMS survivors treated between 1990 and 2017, more than 2 years post treatment, had a 3D photograph taken. Using dense surface modeling, we computed facial signatures for each survivor to show facial deformation relative to 35 age-sex-ethnicity-matched controls. Additionally, we computed individual facial asymmetry. FindingsA total of 173 HNRMS survivors were included, survivors showed significantly reduced facial growth (p < .001) compared to healthy controls. Partitioned by tumor site, there was reduced facial growth in survivors with nonparameningeal primaries (p = .002), and parameningeal primaries (p <=.001), but not for orbital primaries (p = .080) All patients were significantly more asymmetric than healthy controls, independent of treatment modality (p <= .001). There was significantly more facial deformation in orbital patients when comparing RT to AMORE (p = .046). In survivors with a parameningeal tumor, there was significantly less facial deformation in PT when compared to RT (p = .009) and Paris-method (p = .007). InterpretationWhen selecting optimal treatment, musculoskeletal facial outcomes are an expected difference between treatment options. These anticipated differences are currently based on clinicians' bias, expertise, and experience. These data supplement clinician judgment with an objective analysis highlighting the impact of patient age and tumor site between existing treatment options.

Background: Endoscopic strip craniectomy with postoperative helmeting (ESCH) for unicoronal synostosis has shown to be a less morbid procedure when compared with fronto-orbital remodeling (FOR). We aim in this pilot study to report objective methods and quantitative morphologic outcomes of endoscopically treated unicoronal synostosis using 3-dimensional surface scans. Methods: Our electronic records were reviewed for ophthalmological, neurodevelopmental outcomes, and helmet-related complications. For morphologic outcomes, the following parameters were used: Cranial Index, Cranial Vault Asymmetry Index, Anterior Symmetry Ratio (ASR), and Root Mean Square between the normal and synostotic sides of the head. Three-dimensional stereophotogrammetry scans were evaluated at 3 time points preoperative, 6 months post-op, and at the end of the treatment, which was compared with age-matched scans of normal controls and FOR patients. Nonparametric tests were used for statistical analysis. Results: None of the ESCH cases developed strabismus, major neurodevelopmental delay, or helmet complications. All morphologic parameters improved significantly at 6 months post-op except for the Cranial Vault Asymmetry Index. The ASR was the only parameter to change significantly between 6 months post-op and final scans. At end of helmet treatment, ASR and Root Mean Square differed significantly between the ESCH and both FOR and control groups. Conclusions: Endoscopic strip craniectomy with postoperative helmeting for single unicoronal synostosis had excellent clinical outcomes. Most of the improvement in head morphology occurred in the first 6 months of treatment. Despite the normalization of the overall head shape, there was residual asymmetry in the frontal and temporal regions of the head.

Introduction Poor sleep hygiene negatively impacts cognitive and physical abilities in students and is common among students of higher education.1 Moreover, a wide-range of literature explores the detrimental effect of poor sleep quality on learning. Methods An anonymous, self-administered questionnaire was made available to a cohort of medical students at Imperial College London (n=113; 60 female). Demographic information was collected to determine existing sleep quality. Questions regarding understanding of, and desire for sleep hygiene interventions to improve their experience of medical education were created on a 5-point Likert scale, ranging from 5 (strongly agree) to 1 (strongly disagree). Students were also asked to rank, the aspects in their lifestyle that warranted the most attention for improvement. Results Students from across all years strongly agreed that their sleeping habits could be improved (4.13±0.86). Equipping students with the time and energy management tools needed to maintain consistent sleep of adequate duration would be well received (3.73±0.97). Students agree that a concerted intervention effort, such as having sleep promotion activities across campus would be beneficial for their education (3.65±0.90). This study identified the main factors influencing sleep quality as the latency to fall asleep, sleep duration and frequency of dreams, together accounting for 29.0% (r2) of the variation in sleep. The presence of a bed partner, pain, temperature, breathing problems and waking up at night did not significantly influence sleep quality. Discussion University students would benefit from a comprehensive sleep education drive. Efforts in improving sleep quality could be directed to decreasing the latency to sleep onset and to increasing sleep duration via naps.

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.

OBJECTIVE:Sagittal craniosynostosis (SC) is the most commonly encountered form of craniosynostosis. Despite its relative frequency, there remains significant heterogeneity in both operative management and follow-up between centers and a relative paucity of long-term outcome data in the literature. At the authors' institution, families of children presenting with SC are offered the following options: 1) conservative management with ophthalmic surveillance, 2) minimally invasive surgery at < 6 months of age (spring-assisted cranioplasty [SAC]) or 3) calvarial vault remodeling at any age (CVR). The authors reviewed outcomes for all children presenting with SC during a 5-year period, regardless of the treatment received. METHODS:Consecutive children born between January 1, 2008, and December 31, 2012, presenting with SC were identified, and detailed chart reviews were undertaken. Demographic, surgical, perioperative, head shape, scar, and neurodevelopmental (behavioral, education, speech, and language) data were analyzed. The cohort was divided by type of surgery (none, SAC, or CVR) and by age at surgery (early, defined as ≤ 6 months; or late, defined as > 6 months) for comparison purposes. RESULTS:A total of 167 children were identified, 129 boys and 38 girls, with a median age at presentation of 5.0 (range 0.4-135) months. Three families opted for conservative management. Of the 164 children who underwent surgery, 83 underwent SAC, 76 underwent CVR, and 5 underwent a "hybrid" procedure (CVR with springs). At a median age of 7.0 (range 0.5-12.3) years, there was no significant difference in concerns regarding head shape, scar, or neurodevelopmental outcomes between the early and late intervention groups over all procedures performed, or between the early or late SAC and CVR cohorts. There were more head shape concerns in the SAC group than in the CVR group overall (25.7% vs 11.8%, respectively; p = 0.026), although most of these concerns were minor and did not require revision. CONCLUSIONS:In this cohort, regardless of operative intervention and timing of intervention, infants achieved similar neurodevelopmental outcomes. Minimally invasive surgery (SAC) appears to result in less complete correction of head shape than CVR, but this may be balanced by advantages in reduced operative time, hospitalization, and blood loss. SAC was equal to CVR in neuropsychological outcomes.