To shunt or not to shunt when closing myelomeningocele? A systematic review and meta-analysis of simultaneous versus delayed ventriculoperitoneal shunt placement in neonates undergoing myelomeningocele closure.

OBJECTIVE: Approximately 70%-80% of children born with myelomeningocele develop hydrocephalus and need CSF diversion, commonly a ventriculoperitoneal shunt (VPS) placement. The optimal timing of surgery is not known, but many centers delay VPS placement and perform it in a separate surgery to avoid shunt complications, mainly shunt contamination and infection. This systematic review and meta-analysis aimed to compare shunt-related complications between populations with VPS surgery performed either simultaneously with myelomeningocele closure or with delay. METHODS: The authors searched MEDLINE (PubMed), Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews databases on December 15, 2022, and November 11, 2023, using a predefined search strategy. Randomized and nonrandomized trials of neonates undergoing postnatal myelomeningocele closure and VPS placement before the age of 29 days were included. Cases with prenatal myelomeningocele closure and hydrocephalus treatment other than a VPS were excluded. All studies were screened and assessed by two independent reviewers. The authors performed a meta-analysis pooling risk ratios (RRs) with a 95% CI using the random-effects model. The quality of studies was assessed using the Newcastle-Ottawa Scale. RESULTS: After screening and a full-text review of 2099 database search results, 12 studies with a total number of 4894 patients were included. All studies were nonrandomized studies. Only 2 studies were ranked as good quality on the Newcastle-Ottawa Scale. No statistically significant differences were found between simultaneous and delayed shunt insertion in terms of shunt infection (RR 0.77, 95% CI 0.41-1.42); shunt revision (RR 0.49, 95% CI 0.19-1.30); overall mortality (RR 0.87, 95% CI 0.09-8.57); wound CSF leak (RR 0.20, 95% CI 0.03-1.23); or myelomeningocele wound dehiscence (RR 0.52, 95% CI 0.07-3.71). In the subgroup analysis of studies conducted in high-income countries, simultaneous shunting was superior to delayed shunting concerning shunt infection (RR 0.49, 95% CI 0.31-0.78) and shunt revision (RR 0.30, 95% CI 0.09-0.95). CONCLUSIONS: This systematic review and meta-analysis found no statistically significant differences in shunt-related complications between simultaneous and delayed VPS surgery in myelomeningocele-related hydrocephalus in neonates. The current literature does not support the common practice of delayed shunting or its alternative, simultaneous shunting.

Caffeine, Alcohol, and Drug Use as Work Adjuncts Among Neurosurgeons. Prevalence, Contributing Factors, and Proposed Strategies.

BACKGROUND: Neurosurgeons may resort to caffeine, alcohol, and various drugs to maintain peak performance as they grapple with work demands and escalated stress. The prevalence of this controversial strategy remains largely unexplored. METHODS: An anonymous survey of 23 questions formulated by our research group was distributed through personal contacts and neurosurgical societies. Inquiries revolved around the use of medications and other substances for job-related reasons. Data were analyzed via regression and descriptive statistics in python. RESULTS: In total, 215 neurosurgeons (43 residents) were included, with 213 disclosing their gender (94 females). Out of all, 9.3% were <30, 38.1% were 30-39, 44.6% were 40-59, and 7.9% were >60 years old. Most (70.7%) practiced in Europe, 18.6% in Asia, 6.5% in North and South America, and the rest in Africa or Australia. While 132 participants stated they consume caffeine to manage challenging schedules, drugs for cognitive and mood enhancement were utilized by 18 and 35 respectively. Alcohol was employed for stress relief by 28 with 4 reporting as heavy drinkers. Drugs posed a solution to sleep disorders for 82, and helped 8 others in strengthening their hand dexterity. Notably, 12 of those claiming drug use initiated it in medical school. Exercise, self-care activities, and relational support were the main alternatives sought. Ultimately, most responders recommended extending mental health assistance and raising awareness about drug use. CONCLUSIONS: Reflecting on our results on job-associated drug use by neurosurgeons, we propose the judicious use of pharmacological or nonpharmacological adjuncts, alongside the prioritization of neurosurgeons' well-being.

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

OBJECTIVE: The purpose of this study was to evaluate the surgical complications of patients treated for nonsyndromic sagittal craniosynostosis and the necessity for reoperations due to craniocerebral disproportion. MATERIALS AND METHODS: The patient cohort of this study consisted of patients (N = 82) who were treated in the Oulu University Hospital using the open vault cranioplasty with a modified H-technique between the years 2008 to 2022. There were 69 males (84.1%) and 13 females (15.9%). The mean age at the primary operation was 6.1 months. Mean follow-up time was 9.0 years. RESULTS: There were no major complications related to the procedures. Two patients (2.4%) had a minor dural lesion. There were no postoperative wound infections. Of the 82 patients, seven patients with primary craniosynostosis (13.0%) developed symptomatic craniocerebral disproportion requiring reoperation to increase intracranial volume. In all these patients, invasive intracranial pressure (ICP) monitoring was performed prior to decision-making. In the majority of cases, the aesthetical outcome was considered good or excellent. CONCLUSION: The operative method used was feasible and safe. Thirteen percent of patients who were followed over 5 years required major surgery due to development of craniocerebral disproportion later in life.

European Medical Students' Views on Neurosurgery, with Emphasis on South-East Europe (Albania, Greece, Serbia, and Turkey).

BACKGROUND: Neurosurgery, an intricate and dynamic surgical specialty, faces challenges in attracting medical graduates. Despite its potential appeal, a decreasing trend in medical students opting for surgical specialties, including neurosurgery, is noted. This study aims to assess European medical students' perceptions of neurosurgery, focusing on South-East Europe, and address concerns about the declining interest in this field. METHODS: A comprehensive digital survey, comprising 33 questions, was distributed to 1115 medical students across 17 European countries. The survey, conducted over 9 months, gathered responses through European neurosurgical societies, the European Association of Neurosurgical Societies (EANS), and university channels. Statistical analysis utilized IBM Statistical Package for the Social Sciences, presenting data through counts, proportions, and χ2 tests. RESULTS: The study reveals that, over the survey period, 834 medical students completed the questionnaire, with a predominant representation from South-East Europe. While 43.2% of participants were considering a surgical career, neurosurgery emerged as the most preferred specialty (26.37%). Despite this interest, 80.2% reported insufficient knowledge about pursuing a neurosurgical career, with limited exposure during medical education. Concerns about work-life balance, heavy workload, and hierarchical structures were prominent among respondents. CONCLUSIONS: The findings underscore the need for targeted interventions to address concerns influencing medical students' decisions regarding neurosurgery. Improving neurosurgical education, dispelling misconceptions, and creating a supportive work environment are crucial steps to attract and retain diverse talented individuals in neurosurgery. These efforts will be vital in narrowing the gap between the demand for neurosurgeons and the number of medical graduates entering the field, ensuring a sustainable future for this essential surgical specialty.

Occlusal characteristics and oral health-related quality of life in adults operated due to sagittal synostosis in childhood: a case-control study with 26 years of follow-up.

PURPOSE: The aim of this case-control study was to investigate occlusal characteristics, received orthodontic treatment, oral health-related quality of life (OHRQoL), and satisfaction with dental esthetics in adults operated due to sagittal synostosis. METHODS: The study group consisted of 40 adults (25 males, 15 females, mean age 27.4 years, range 18-41) who were operated due to isolated sagittal synostosis in childhood. The control group comprised 40 age and gender-matched adults. Occlusal characteristics were evaluated clinically during study visits. Information on the previous orthodontic treatment was collected from dental records. OHRQoL was measured using the 14-item Oral Health Impact Profile (OHIP-14), and satisfaction with dental esthetics was evaluated using a visual analogue scale. RESULTS: No statistically significant differences were found between the patient group and the controls in malocclusion traits (overjet, overbite, molar relationships, crossbite, scissor bite), previous orthodontic treatment, pre-treatment malocclusion diagnoses, OHIP variables, or satisfaction with dental esthetics. However, there was a tendency toward increased overjet and overbite in scaphocephalic patients. CONCLUSION: It seems that adults with scaphocephaly operated in childhood do not differ from the average population in terms of occlusion, received orthodontic treatment, or oral health-related well-being.

Abusive head trauma in small children - a single-centre experience in Finland.

Shaken baby syndrome (SBS) is a challenging condition from both a medical and legal perspective. The path of the patients differs significantly from those with noninflicted traumas. While treating these cases, it is essential that all history, information and treatment are comprehensively documented. This article describes the investigations and interventions necessary as soon as SBS is suspected. The Oulu University Hospital protocol for suspected child abuse is described. Authors also give an overview of the SBS path in Finland from the police and prosecution's point of view.

Gender differences in work-life balance of European neurosurgeons.

Introduction: Neurosurgery is one of the most demanding medical specialties. For neurosurgeons, balancing professional activity with personal life can be challenging. Research question: To evaluate gender differences in contribution of neurosurgeons in the household and child-rearing, as well as their impact on personal life and career. Material and methods: An anonymous, electronic, 59-item web-based survey was administered to National Neurosurgical Societies of Europe, and European Member Societies of the European Association of Neurosurgical Societies (June-October 2021). Results: A total of 205 European neurosurgeons (87 females and 118 males, mean age 40.7) are included in our survey. In neurosurgery, females are significantly more likely to be alone (37.9%), while males are significantly more likely to have children (66.9%). In terms of household efforts, females spend more time than males on the same tasks. Most participants (71.2%) view gender issues as a disadvantage in career pursuing. Women feel less accepted (54.3%) and having fewer opportunities (58.6%), while men believe that pregnancy/child-rearing (65.8%) and having many roles (51.3%) are the main obstacles. Both genders (77.6%) favor more convenient working conditions for young parents.Discussion and Conclusion. In our study we found that, women neurosurgeons take more responsibilities at home, especially in the child-rearing years. Female neurosurgeons are more likely to live alone or stay childless more often compared to their male colleagues. Supportive facilities, flexible programs, universal life policies and presumably curbing of the social stereotypes are of importance to overcome gender inequities that women are still facing in neurosurgery.

Appearance or attitude: what matters to craniosynostosis patients? Association of self-esteem, depressive symptoms, and facial aesthetics in patients with sagittal and metopic synostosis.

PURPOSE: The aim of this study was to investigate the presence of depressive symptoms and self-esteem, and their association with facial asymmetry in adults who were operated on in early childhood due to metopic and sagittal craniosynostosis. METHODS: The study population consisted of 49 non-syndromic patients of whom 41 had premature fusion of the sagittal and 8 of metopic suture. There were 64 controls from the Finnish National Register. Self-esteem, depressive symptoms, and subjective satisfaction with one's appearance were evaluated by using the Rosenberg self-esteem questionnaire (RSE), the short form of Beck Depression Inventory (R-BDI), and a purpose-designed questionnaire on satisfaction with facial and overall appearance. Aesthetic evaluation was done from standard photographs using panels. The facial symmetry was calculated by using 3D photogrammetric methods. RESULTS: Patients did not have a lower self-esteem or experience significantly more moderate or severe depressive symptoms. However, 20% of the patients and 6% of the controls (p = 0.041) experienced mild depressive symptoms. There was no difference between self-assessed evaluation of appearance between the groups. Only weak correlation was found between facial asymmetry and RSE or R-BDI results (cc = 0.27-0.42, p < 0.05). The self-assessed evaluation of facial and overall appearance correlated strongly with the R-BDI results. CONCLUSION: Non-syndromic craniosynostosis patients are as satisfied with their appearance in adulthood as the control group and do not experience a lower self-esteem or more depressive symptoms. Facial asymmetry does not correlate with low self-esteem or clinically significant depressive symptoms in adulthood. Subjective evaluation of one's appearance correlated with depressive symptoms. Age and gender do not influence the former results. Overall, patients are satisfied with their appearance.

Favourable long-term recovery after decompressive craniectomy: the Northern Finland experience with a predominantly adolescent patient cohort.

PURPOSE: Decompressive craniectomy (DC) is an effective treatment of intracranial hypertension. Correspondingly, the procedure is increasingly utilised worldwide. The number of patients rendered vegetative following surgery has been a concern-a matter especially important in children, due to long anticipated lifetime. Here, we report the long-term outcomes of all paediatric DC patients from an 11-year period in a tertiary-level centre that geographically serves half of Finland. METHODS: We identified all patients younger than 18 years who underwent DC in the Oulu University Hospital between the years 2009 and 2019. Outcomes and clinicoradiological variables were extracted from the patient records. RESULTS: Mean yearly prevalence of brain injury requiring DC was 1.34/100 000 children-twenty-four patients underwent DC during the study period and 21 (88%) survived. The median age of the patients was 16.0 years, and the median preoperative GCS was 5.0 (IQR 5.0). Fifteen patients (63%) had made a good recovery (Extended Glasgow Outcome Scale ≥ 7). Of the surviving patients, two (9.5%) had not returned to school. After traumatic brain injury (n = 20), the Rotterdam CT score (mean 3.0, range 1 to 5) was not associated with mortality, poor recovery or inability to continue school (p = 0.13, p = 0.41, p = 0.43, respectively). Absent basal cisterns were associated with mortality (p = 0.005), but not with poor recovery if the patient survived DC (p = 0.81). Hydrocephalus was associated with poor recovery and inability to continue school (p = 0.01 and p = 0.03, respectively). CONCLUSION: Most of our patients made a favourable recovery and were able to continue school. No late mortality was observed. Thus, even in clinically and radiologically severely brain-injured children, decompressive craniectomy appears to yield favourable outcomes.

Two-center validation of the Oulu resorption score for bone flap resorption after autologous cranioplasty.

OBJECTIVE: Autologous bone has been the gold standard of cranioplasty materials for decades. Unique to autologous cranioplasty, bone flap resorption is a poorly understood and unclearly defined complication. Even further, it has been unclear, whether the resorption process eventually stabilizes over time. Thus, the sufficient follow-up period after autologous cranioplasty is unknown. The Oulu Resorption Score (ORS) is a straight-forward classification system for the radiological interpretation of bone flap resorption. The aims of the present study were to evaluate the reliability of the ORS using intra-class correlation coefficient (ICC) and to assess the temporal progression of the resorption process. METHODS: We identified 108 consecutive autologous cranioplasty patients treated between 2005 and 2018 in two tertiary referral centers. All 365 head CT scans the patients had undergone were evaluated using the ORS in a blinded, independent two-center setting. Intra- and inter-observer reliabilities were calculated. The ORS was applied to study the temporal progression of the resorption process. RESULTS: The intra-observer reliability of the ORS was excellent (ICC 0.94, 95%CI 0.93-0.95). Inter-observer reliability was good-to-excellent (ICCs 0.87 and 0.89, 95%CIs 0.84-0.89 and 0.87-0.91, respectively). In scatterplot smoothing analyses, the progression of bone flap resorption appeared to stabilize 12-24 months after cranioplasty. CONCLUSIONS: ORS is the only validated radiological tool for the standardized analysis of bone flap resorption after autologous cranioplasty. Evaluated using the ORS, the resorption process seemed to stabilize during the first two postoperative years after cranioplasty, suggesting that the sufficient follow-up time after autologous cranioplasty is two years.

Craniofacial characteristics and cosmetic satisfaction of patients with sagittal and metopic synostosis: a case-control study using 3D photogrammetric imaging.

PURPOSE: The aim of this study was to investigate the craniofacial and aesthetic characteristics of adult metopic and sagittal craniosynostosis patients operated on in early childhood compared to controls. The goal was to find objective measurements that would correlate with the patient's subjective self-evaluation of their own cosmetic appearance. METHODS: The study population consisted of 49 patients from whom 41 had premature fusion of the sagittal and in 8 of metopic suture. There were 65 age and gender matching controls from The Finish National Register. The 3D photogrammetric models were created from all patients and controls. The images were analysed using Rapidform 2006. Facial landmarks were set by the standard Farkas points. Facial symmetry parameters were calculated by using the landmarks and the mirror shell of the face. Aesthetic evaluation was done from standard photographs using panels. Subjective satisfaction with one's own appearance was evaluated using questionnaires. RESULTS: Patients had the greatest asymmetry in the forehead area when compared to controls (symmetry percentage 59% versus 66%, p = 0.013). In the control group, the gap between the eyes was smaller than in the case group, resulting in an absolute 2 mm difference (p = 0.003). The area of the chin and the landmarks were more located on the left side in the patient group, resulting in up to a 1.1 mm difference between the groups (p = 0.003). Only a weak association was found between craniofacial symmetry and appearance evaluations. CONCLUSION: Patients operated on because of sagittal and metopic synostoses were found to have facial asymmetry at long follow-up. However, the differences were < 3 mm and not clinically important. The long-term aesthetical outcome of the surgery performed because of sagittal or metopic craniosynostosis based on the 3D image evaluation was good.

Preoperative measurements on MRI in Chiari 1 patients fail to predict outcome after decompressive surgery.

BACKGROUND: The purpose of our study was to research the parameters of magnetic resonance imaging (MRI) that would predict the outcome of surgery in patients with Chiari 1 malformation (CM1) and to evaluate changes in MRI parameters after surgery. METHODS: Fifty-one patients (19 children, 13 adolescents, and 19 adults) operated on due to CM1 in Oulu University Hospital between 2004 and 2018 were evaluated. Seventeen parameters were measured from the preoperative MRI and 11 from the postoperative MRI. The correlations between the MRI parameters and the clinical variables before and after surgery were analyzed. RESULTS: The majority (88.2%) of the patients had favorable surgical outcomes. Postoperatively, subjective symptoms improved in 88.6% of the patients and syringomyelia in 81.8%. The location of the cerebellar tonsils, when measured in relation to the C2 synchondrosis or the end plate, postoperatively moved cranially in 51.0% (n = 26), did not change in 27.4% (n = 14), and moved caudally in 21.6% (n = 11) of the patients. However, neither the location of the tonsils nor any other parameters measured from pre- or postoperative MRI correlated with the patients' symptoms or surgical outcomes. CONCLUSIONS: No specific parameters on preoperative MRI evaluation were predictive of the outcome of surgery, emphasizing clinical examination in surgical decision-making. Furthermore, the postoperative MRI parameters did not correlate with the surgical outcomes. Thus, routine postoperative imaging is suggested only for patients with preoperatively diagnosed syringomyelia or worsening of symptoms.

Posterior vault distraction technique: how I do it.

Posterior cranial vault distraction is an effective technique when a significant increase in the intracranial volume is required in patients with craniosynostoses. This technique has been proven to be safe and time saving and usually is associated with low perioperative morbidity as well as low intraoperative bleeding. Herein a technique is presented starting from the preoperative planning, describing the surgical steps of the operation and the postoperative distraction protocol used by the authors. The authors present important tips and tricks aiming to minimise complications and undesired events.

Intracranial bullet removal using O-arm navigation guidance.

PURPOSE: The purpose of this study is to report a new mini-invasive technique to remove an intracranial bullet in a child by using O-arm for intraoperative neuronavigation. CASE REPORT: A 14-year-old refugee boy had suffered a shooting injury 4 years earlier. O-arm imaging-assisted neuronavigation during craniotomy was performed in order to remove a bullet from the intracranial space in a paediatric patient. CONCLUSION: Navigation using O-arm is a feasible method in removing a foreign material in a child and gave an accurate location of the bullet in the adopted surgical operation position without significant imaging artefacts.

A comparison of indirect and direct targeted STN DBS in the treatment of Parkinson's disease-surgical method and clinical outcome over 15-year timespan.

BACKGROUND: Deep brain stimulation (DBS) in the subthalamic nucleus (STN) is used in advanced Parkinson's disease (PD) for reducing motor fluctuations and the side effects of antiparkinsonian medication (APM). The development of neuroimaging has enabled the direct targeting of the STN. The aim of this study is to evaluate the outcome in patients with PD using STN DBS when changing from atlas-based indirect targeting method (iTM) to direct MRI-based targeting (dTM) assuming dTM is superior. METHODS: Twenty-five consecutive PD patients underwent dTM STN DBS surgery from 2014 to 2017 with follow-up for 1 year. The neuroimaging, surgical method, outcome in Unified Parkinson's Disease Rating Scale (UPDRS) scores, and reduction of APM are described and compared with the results of an earlier iTM STN DBS study. RESULTS: Twelve months after a dTM STN DBS, significant improvement (p < 0.001) was seen in six out of seven parameters of UPDRS when patients had medication (medON) and stimulation (stimON). The activities of daily living (UPDRSII) and motor scores (UPDRSIII) improved by 41% and 62%, respectively. Dyskinesias and fluctuations were both reduced by 81%. In dTM STN DBS group, the levodopa equivalent dose (LED) and the total daily levodopa equivalent dose (LEDD) were significantly decreased by 62% and 55%, respectively, compared with the baseline (p < 0.001). Five patients (20%) were without levodopa medication 12 months after the operation. CONCLUSIONS: The development of surgical technique based on advanced neuroimaging has improved the outcome of PD STN DBS.

Interventional magnetic resonance imaging as a diagnostic and therapeutic method in treating acute pediatric atlantoaxial rotatory subluxation.

Atlantoaxial rotatory subluxation or fixation (AARF) is a rare condition, usually occurring in pediatric patients. It mimics benign torticollis but may result in permanent disability or death. The condition requires prompt diagnosis by thorough examination to avoid any treatment delays. Spiral computed tomography (CT) with three-dimensional reconstruction CT is recommended for identifying incongruence between C1 and C2 vertebrae, and magnetic resonance imaging (MRI) may be performed to exclude ligamentous injuries. In addition to static imaging, dynamic CT involves the reduction between C1 and C2 being confirmed using CT with the head turned maximally to the left and right. The present report (level of evidence, III) provides a method for treating AARF that has similar advantages as dynamic CT but avoids ionizing radiation by replacing CT with interventional MRI. The new method comprised simultaneous axial traction and manual closed reduction, performed under general anesthesia, and the use of interventional MRI to ensure that reduction was achieved and held. The head is turned maximally to the right and left during the manual reduction. A rigid cervical collar was used following reduction. Dynamic CT was not required but prior diagnostic static CT was performed in preparation. No further CT was required. There appears to be no previous studies on interventional MRI in AARF care. Being superior in its diagnostic soft-tissue visualization performance and lacking ionizing radiation, interventional MRI is a potential option for investigating and treating acute AARF in non-syndromic patients with no trauma history.

Experience with resorbable sonic pins for the attachment of distraction devices in posterior cranial vault distraction operations.

BACKGROUND: Distraction techniques are effective methods for the treatment of craniosynostoses when a significant gain of an intracranial volume is required. However, this technique raises some challenges at different stages of the treatment. While installing the distractors in patients with thin calvarial bone, there is a risk of dural damage from the titanium screws. The need for wide exposure of the devices and the screws during removal causes soft tissue damage and bleeding. OBJECTIVE: This study aimed to evaluate sonic pin use in the distraction procedures. METHODS: Resorbable sonic pins were used in 11 consecutive posterior cranial vault distraction procedures to attach distraction devices to the calvarial bone. RESULTS: This method allowed for a less traumatic and faster removal of the devices without the risk of leaving foreign bodies in the wound. In three out of 11 cases on follow-up, displacement of proximal distractor footplate and partial relapse of distraction were detected. Though there was a smaller volume increase in these patients, all of them benefited clinically from the PCVD and did not require reoperations. CONCLUSIONS: This method allows a strong and stable attachment of the distractor devices to the cranial vault bones with a reduced risk of dural tears due to the screws. It also allows for easier and less traumatic device removal.

Classification of bone flap resorption after cranioplasty: a proposal for a computed tomography-based scoring system.

BACKGROUND: Bone flap resorption (BFR) is the most prevalent complication resulting in autologous cranioplasty failure, but no consensus on the definition of BFR or between the radiological signs and relevance of BFR has been established. We set out to develop an easy-to-use scoring system intended to standardize the interpretation of radiological BFR findings. METHODS: All 45 autologous cranioplasty patients operated on at Oulu University Hospital from 2004 to 2014 were identified, and the bone flap status of all the available patients was evaluated using the new scoring system. Derived from previous literature, a three-variable score for the detection of BFR changes is proposed. The variables "Extent" (estimated remaining bone volume), "Severity" (possible perforations and their measured diameter), and "Focus" (the number of BFR foci within the flap) are scored from 0 to 3 individually. Using the sum of these scores, a score of 0-9 is assigned to describe the degree of BFR. Additionally, independent neurosurgeons assessed the presence and relevance of BFR from the same data set. These assessments were compared to the BFR scores in order to find a score limit for relevant BFR. RESULTS: BFR was considered relevant by the neurosurgeons in 11 (26.8%) cases. The agreement on the relevance of BFR demonstrated substantial strength (κ 0.64, 95%CI 0.36 to 0.91). The minimum resorption score in cases of relevant BFR was 5. Thus, BFR with a resorption score ≥ 5 was defined relevant (grades II and III). With this definition, grade II or III BFR was found in 15 (36.6%) of our patients. No risk factors were found to predict relevant BFR. CONCLUSIONS: The score was proven to be easy to use and we recommend that only cases with grades II and III BFR undergo neurosurgical consultation. However, general applicability can only be claimed after validation in independent cohorts.

Outcomes of 40 Nonsyndromic Sagittal Craniosynostosis Patients as Adults: A Case-Control Study With 26 Years of Postoperative Follow-up.

BACKGROUND: While sagittal synostosis is the most common craniosynostosis, long-term follow-up of these patients is lacking. OBJECTIVE: To evaluate the results of surgical management of those patients with sagittal synostosis who attain adulthood. METHODS: An outcome study of surgically treated isolated sagittal synostosis patients operated between 1977 and 1998 was conducted at the Craniofacial Center of Oulu University Hospital, Oulu, Finland with an average follow-up time of 26.5 yr. Patients' socioeconomic situation, satisfaction with their own facial appearance and attractiveness as rated by 2 independent panels was evaluated and compared to controls. RESULTS: The self-satisfaction with the patients' own appearance scored a mean of 75 mm on a visual analog scale of 100 mm between the patients and 76 mm with the control group. The subjective satisfaction of the patients with their own appearance failed to correlate with the rating of their appearance by the panels. The panels rated the patients' appearance to be on average 6 to 7 mm out of 100 mm visual analog scale less attractive than the controls. Data on socioeconomic situation, including marital status, housing, education, employment of the patients, and controls are presented. CONCLUSION: Isolated sagittal synostosis patients treated surgically were as happy with their facial appearance as were individuals in an age and gender-matched control group. Two independent panels found the patients' appearance to be only somewhat less attractive. Analysis of the socioeconomic situation and general health revealed that patients equaled that of controls.

Quantitative and qualitative analysis of bone flap resorption in patients undergoing cranioplasty after decompressive craniectomy.

OBJECTIVE: Autologous bone cranioplasty after decompressive craniectomy entails a notable burden of difficult postoperative complications, such as infection and bone flap resorption (BFR), leading to mechanical failure. The prevalence and significance of asymptomatic BFR is currently unclear. The aim of this study was to radiologically monitor the long-term bone flap survival and bone quality change in patients undergoing autologous cranioplasty. METHODS: The authors identified all 45 patients who underwent autologous cranioplasty at Oulu University Hospital, Finland, between January 2004 and December 2014. Using perioperative and follow-up CT scans, the volumes and radiodensities of the intact bone flap prior to surgery and at follow-up were calculated. Relative changes in bone flap volume and radiodensity were then determined to assess cranioplasty survival. Sufficient CT scans were obtainable from 41 (91.1%) of the 45 patients. RESULTS: The 41 patients were followed up for a median duration of 3.79 years (25th and 75th percentiles = 1.55 and 6.66). Thirty-seven (90.2%) of the 41 patients had some degree of BFR and 13 (31.7%) had a remaining bone flap volume of less than 80%. Patients younger than 30 years of age had a mean decrease of 15.8% in bone flap volume compared with the rest of the cohort. Bone flap volume was not found to decrease linearly with the passing of time, however. The effects of lifestyle factors and comorbidities on BFR were nonsignificant. CONCLUSIONS: In this study BFR was a very common phenomenon, occurring at least to some degree in 90% of the patients. Decreases in bone volume were especially prominent in patients younger than 30 years of age. Because the progression of resorption during follow-up was nonlinear, routine follow-up CT scans appear unnecessary in monitoring the progression of BFR; instead, clinical follow-up with mechanical stability assessment is advised. Partial resorption is most likely a normal physiological phenomenon during the bone revitalization process.