Craniosynostosis: orofacial and oral health perspectives with masticatory insights.

BACKGROUND: Craniosynostosis (CS), premature fusion of one or more cranial sutures, leads to abnormal skull development, impacting both facial esthetics and oral function. This study aimed to evaluate the specific orofacial and oral health characteristics, including masticatory performance, in Thai patients with CS. METHODS: A comparative study was conducted with Thai CS patients aged 6-17 years and a control group of healthy individuals with similar age distribution. Assessments included craniofacial morphology, oral health status, and masticatory performance. Intergroup comparisons utilized appropriate statistical tests. RESULTS: The study included 24 CS patients with a mean age of 10.11 ± 2.98 years and 30 controls. CS patients exhibited a significantly higher prevalence of various oral conditions compared to controls: cleft palate (20.8%), anterior open bite (41.7%), anterior crossbite (54.2%), posterior crossbite (50%), combined anterior-posterior crossbite (45.8%), dental crowding in both maxilla and mandible (50% and 45.8% respectively), congenitally missing teeth (50%), supernumerary teeth (12.5%), and eruption failure (54.2%). Furthermore, CS patients exhibited significantly higher caries prevalence and susceptibility, alongside poorer oral hygiene, compared to controls. Regarding jaw relationships, CS patients exhibited a significantly higher proportion of Angle's Class III malocclusion (50%) compared to the control group, where Class I malocclusion was predominant (50%). Masticatory performance, assessed using the two-color gum mixing ability test, showed significantly higher hue variance in CS patients (0.12 ± 0.07) compared to the control group, indicating reduced chewing performance. CONCLUSION: This study underscores the significant orofacial and oral health challenges faced by children with CS, including a high prevalence of malocclusions, dental anomalies, elevated caries experience, and compromised masticatory function. These findings emphasize the importance of tailored interventions and comprehensive oral healthcare strategies to address the unique needs of this population and improve their overall quality of life.

Heart rate variability and vasovagal tone index in brachycephalic dogs.

Brachycephalic breeds of dogs, most of which show signs of the brachycephalic syndrome may have greater parasympathetic stimulation than other breeds, leading to higher values of heart rate variability and vagal tone index. The aim of this study was to establish a computerized electrocardiographic study and an assessment of the vagus sympathetic balance through heart rate variability and vagal tone index of five brachycephalic breeds compared to mesocephalic dogs. Sixty dogs were used, divided into groups made up of Boxers, English Bulldogs, French Bulldogs, Pugs, Shih-Tzu and no defined breed mesocephalic dogs. Statistical analysis was carried out using the Shapiro-Wilk test, Kruskal-Wallis and Dunn's test or ANOVA and Bonferroni (p<0.05). In the evaluation of vagal sympathetic balance among all the dogs, there was a negative correlation between heart rate and HRV 10RR (r = - 0.7678; p < 0.0001), HRV 20RR (r = - 0.8548, p < 0.0001) and VVTI (r = - 0.2770; p = 0.0321). It can therefore be concluded that the dog's breed and morphology did not alter its electrocardiographic parameters or heart rate variability. The vagal tone index, which in other studies differed in brachycephalic dogs, showed no difference when compared separately in brachycephalic breeds.

Strabismus and refraction in non-syndromic craniosynostosis - A longitudinal study up to 5 years of age.

PURPOSE: To evaluate the refractive outcome and strabismus at 5 years of age, in children operated for various types of non-syndromic craniosynostosis, and further analyse the refractive and strabismic development over time. METHODS: Eighty-nine children, who had undergone operations for non-syndromic craniosynostosis, were examined at 5 years of age. These children also underwent ophthalmological examination preoperatively and up to 1 year after the operation. An age-matched control group including 32 healthy children was also recruited. Strabismus and eye motility were registered. Refraction was measured in cycloplegia. RESULTS: There was a difference regarding the refractive outcome between the different types of craniosynostosis. Higher values of hypermetropia were found in the metopic craniosynostosis group on both eyes. In the unicoronal craniosynostosis group, high values of hypermetropia and a higher degree of astigmatism were found on the side contralateral to the craniosynostosis. Strabismus was found in 11/88 children of whom 10/11 had unicoronal craniosynostosis. A vertical deviation on the side ipsilateral to the fused suture was highly prevalent (6/10 cases). Ophthalmological dysfunctions were rare in children operated for sagittal craniosynostosis. CONCLUSION: Ocular manifestations such as strabismus, astigmatism and anisometropia were highly prevalent in children operated for unilateral coronal craniosynostosis. Children operated for metopic craniosynostosis had higher rates of hypermetropia. The screening and follow-up protocols need to be tailored with regard to the type of craniosynostosis.

Evaluation of VEGF-A and CCL2 in dogs with brachycephalic obstructive airway syndrome or canine idiopathic pulmonary fibrosis and in normocephalic dogs.

Brachycephalic obstructive airway syndrome (BOAS) and canine idiopathic pulmonary fibrosis (CIPF) of West Highland White Terriers (WHWTs) often cause intermittent or chronic hypoxemia. Our objective was to evaluate serum and bronchoalveolar lavage fluid (BALF) concentrations of hypoxemia-related proinflammatory mediators vascular endothelial growth factor A (VEGF-A) and chemokine (CC motif) ligand 2 (CCL2) in brachycephalic dogs (BDs) and WHWTs with and without CIPF. Additionally, effects of BOAS severity and ageing on these mediators were assessed. 114 BDs (28 English Bulldogs (EBs), 37 French Bulldogs, 49 Pugs), 16 WHWTs with CIPF, 26 healthy WHWTs, and 39 normocephalic control dogs were included. Fifty-four BDs were re-examined after two to three years. Bead-based immunoassay was used for proinflammatory mediator measurements. Compared with controls, significantly higher serum concentrations of VEGF-A were seen in EBs (P = 0.009) and of CCL2 in CIPF and healthy WHWTs (P < 0.001; P = 0.002). BALF samples were available from controls, EBs, and WHWTs. VEGF-A was significantly lower in EBs (P < 0.001) and in CIPF and healthy WHWTs (P = 0.006; P = 0.007) and CCL2 was higher in CIPF WHWTs (P = 0.01) compared with controls. Between visits, only serum VEGF-A significantly decreased in BDs (P < 0.001), but breed, BOAS severity, or its change had no significant effect. In conclusion, in EBs with BOAS proinflammatory changes in VEGF-A were detected in both serum and BALF. Ageing reduced serum VEGF-A in BDs. In WHWTs, our results confirmed earlier findings of CCL2 as an important biomarker for CIPF.

The 27 Facial Sutures: Timing and Clinical Consequences of Closure.

SUMMARY: Facial sutures contribute significantly to postnatal facial development, but their potential role in craniofacial disease is understudied. Since interest in their development and physiology peaked in the mid-twentieth century, facial sutures have not garnered nearly the same clinical research interest as calvarial sutures or cranial base endochondral articulations. In addition to reinforcing the complex structure of the facial skeleton, facial sutures absorb mechanical stress and generally remain patent into and beyond adolescence, as they mediate growth and refine the shape of facial bones. However, premature closure of these sites of postnatal osteogenesis leads to disrupted growth vectors and consequent dysmorphologies. Although abnormality in individual sutures results in isolated facial deformities, we posit that generalized abnormality across multiple sutures may be involved in complex craniofacial conditions such as syndromic craniosynostosis. In this work, the authors comprehensively review 27 key facial sutures, including physiologic maturation and closure, contributions to postnatal facial development, and clinical consequences of premature closure.

Complex Airway Management in Patients with Tracheal Cartilaginous Sleeves.

OBJECTIVES/HYPOTHESIS: A tracheal cartilaginous sleeve (TCS) is a rare anomaly characterized by anterior fusion of tracheal cartilages. TCS is associated with syndromic craniosynostoses including Apert, Crouzon and Pfeiffer syndromes and FGFR2, FGFR3, and TWIST1 variants. This study presents a 30-year review of patients with syndromic craniosynostosis and TCS and describes diagnostic methods, genetic variants, surgical interventions, and long-term outcomes. STUDY DESIGN: Retrospective, single-institution review. METHODS: This review included patients with syndromic craniosynostosis and TCS treated at Seattle Children's Hospital from 1990 to 2020. Tracheostomy, genetic variants, and additional surgery were primary measures. Fisher's exact test compared need for tracheostomy in patients with proposed high-risk (FGFR2 p.W290 or FGFR2 p.C342) versus low-risk genetic variants. RESULTS: Thirty patients with TCS were identified. Average age at diagnosis was 12 months (range 2-weeks to 7.9-years; standard deviation 19.8 months). Syndromes included Pfeiffer (37%), Apert (37%), and Crouzon (26%). Severe obstructive sleep apnea was present in 76% of patients. Tracheostomy was performed in 17 patients (57%); five were successfully decannulated. Additional interventions included adenotonsillectomy (57%), nasal (20%), laryngeal (17%), and craniofacial skeletal surgery (87%). All patients with Pfeiffer syndrome and FGFR2 p.W290C variants and 83% of patients with FGFR2 p.C342 variants required tracheostomy, differing from other variants (P = .02, odds ratio 33, 95% confidence interval 1.56-697.96). One patient (3%) died. CONCLUSION: TCS contributes to multilevel airway obstruction in patients with syndromic craniosynostosis. Genetic testing in patients with FGFR2-related syndromic craniosynostoses may identify those at risk of TCS and facilitate early intervention. A better understanding of this patient population may foster individualized airway management strategies and improve outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:215-221, 2022.

Análise do retorno venoso intra e extracraniano em pacientes com craniossinostoses complexas e sindrômicas / Analysis of intra and extracranial venous return in patients with complex and syndromic craniosynostosis

Introdução. Retorno venoso extracraniano anormal é um importante fator relacionado às craniossinostoses complexas, sendo responsável por alta morbimortalidade. Associa-se a essa circulação, a estenose ou atresia do forame jugular, existindo dúvida na literatura se a presença de circulação colateral venosa é causa da estenose de forame, gerando hipertensão venosa; se o desenvolvimento da circulação venosa acontece como consequência da hipertensão intracraniana ou se existem componentes intrínsecos levando à formação de veias anômalas. Objetivo. Analisar o retorno venoso completo (intra e extracraniano) pré-operatório de pacientes com craniossinostoses complexas e sindrômicas e avaliar a sua relação com a: morfologia da base do crânio, funcionalidade dos forames e seios durais, hipertensão intracraniana e diagnostico sindrômico e molecular. Método. Estudo Retrospectivo e prospectivo de pacientes com craniossinostose complexa ou sindrômica submetidos à angiotomografia com fase venosa no Instituto Fernandes Figueira a partir de 2014. Para avaliação da gravidade do retorno venoso extracraniano foi elaborada uma classificação vascular, categorizando os pacientes em leves, moderados e graves. Essa classificação consistiu em uma pontuação em cada região de circulação colateral estudada, variando de 0 a 3. Desta forma, sendo 9 regiões de interesse (frontais, parietais, mastoides, condilares esquerda e direita e circulação transoccipital), a classificação variou entre 0 quando ausência completa de circulação colateral até 27, considerado a possibilidade mais grave apresentada. De acordo com o Cluster Hierárquico, os pacientes foram classificados em 3 categorias de circulação venosa extracraniana: Leve ­ pontuação vascular entre 0 e 9; Moderada ­ pontuação vascular entre 10 e 18; Grave ­ pontuação vascular entre 19 e 27. Os 3 grupos Moderada ­ pontuação vascular entre 10 e 18; Grave ­ pontuação vascular entre 19 e 27. Os 3 grupos foram comparados quanto à morfologia da base do crânio (áreas, medidas anteroposteriores e volumes do forame jugular, forame magno e fossa posterior), quanto ao retorno venoso intracraniano (seios venosos durais, funcionalidade do forame jugular), quanto à hipertensão intracraniana (número de suturas acometidas, presença de malformação de Chiari I, hidrocefalia, ventriculomegalia) e quanto às síndromes apresentadas (manifestações fenotípicas e estudo molecular). Resultados. Dentre o total de 45 pacientes, 44,4% (n= 20) pertenciam ao grupo leve, 37,8% (n= 17) ao grupo moderado e 17,8% (n= 8) ao grupo grave. A circulação venosa extracraniana não se correlacionou com as medidas anteroposteriores, transversas, de área e de volume dos forames jugulares, forame magno ou da fossa posterior, com o número de suturas acometidas, com a classificação dos seios venosos intracranianos e da fossa posterior, com a hidrocefalia ou ventriculomegalia. A malformação de Chiari I é mais frequente em pacientes mais graves (p valor <0,001). As mutações identificadas se correlacionaram com a gravidade da circulação venosa extracraniana (pvalor <0,001). Conclusões. A estratificação de pacientes em uma classificação vascular permite a avaliação mais adequada dos fatores que historicamente são relacionados à circulação venosa colateral em Craniossinostoses complexas e sindrômicas. As alterações venosas extracranianas não se correlacionaram diretamente com as alterações morfológicas da base do crânio, com a funcionalidade dos seios durais ou com sinais de hipertensão intracraniana. Essas alterações parecem ser resultado de manifestações intrínsecas relacionadas ao genótipo, sendo as mutações no gene FGFR2 mais gravemente relacionadas à circulação venosa extracraniana. Pacientes com síndrome de Pfeiffer apresentaram a classificação venosa extracraniana mais grave, seguido pelas síndromes de Crouzon, Apert, Jackson-Weiss, Saerthre-Chotzen e craniossinostoses complexas negativas. As veias emissárias mais frequentemente encontradas foram as condilares e mastóides, seguidas da circulação transóssea occipital. Atresia funcional do forame jugular se correlaciona com a gravidade da circulação venosa extracraniana e pode ser consequência da atividade molecular intrínseca no endotélio durante a formação do sistema venoso.

Introduction. Abnormal extracranial venous outflow is an important factor related to complex craniosynostosis, that can lead to high morbidity and mortality. It has been associated with stenosis or atresia of the jugular foramen. In fact, there is doubt in the literature if the collateral venous circulation is caused by Jugular foramen stenosis, generating venous hypertension or if the development of the venous circulation happens as a consequence of intracranial hypertension or whether if there are intrinsic components leading to the formation of anomalous veins. Objective. To analyze the preoperative complete venous outflow (intra and extracranial) of patients with complex and syndromic craniosynostosis and to evaluate its relationship with: morphology of the skull base, functionality of the jugular foramina and dural sinuses, intracranial hypertension and syndromic and molecular diagnosis. Method. A retrospective and prospective study of patients with complex or syndromic craniosynostosis on CT angiography with venous phase at Instituto Fernandes Figueira from 2014 to 2022. To assess the severity of extracranial venous drainage, a vascular classification was developed, categorizing patients into mild, moderate and severe. The classification consisted of a score in each region of collateral circulation studied, ranging from 0 to 3. Thus, with 9 regions of interest (frontal, parietal, mastoid, left and right condylar and transoccipital circulation), the classification ranged from 0 when absence collateral circulation up to 27, considered the most serious possibility presented. According to the Hierarchical Cluster, patients were in 3 extracranial circulation categories: Mild ­ vascular assessment between 0 and 9; Moderate ­ vascular assessment between 10 and 18; Severe ­ vascular assessment between 19 and 27. The 3 groups were compared regarding skull base morphology (areas, measurements of jugular foramen and foramen magnum, and posterior fossa volumes), intracranial venous outflow (dural venous sinuses, jugular foramen functionality), and intracranial hypertension (number of affected sutures, presence of Chiari I malformation, hydrocephalus, ventriculomegaly) and the syndromes presented (phenotypic manifestations and molecular study). Results. Among the 45 patients, 44.4% (n=20) belonged to the mild group, 37.8% (n=17) to the moderate group and 17.8% (n=8) to the severe group. The extracranial venous circulation does not correlate with the anteroposterior, transverse, area and volume measurements of the jugular foramen, foramen magnum or posterior fossa, with the number of affected sutures, with the intracranial venous sinuses and the posterior fossa, with the hydrocephalus or ventriculomegaly. Chiari I malformation correlates with the most severe patients (p value <0.001). The mutations identified correlate with the severity of the extracranial venous circulation (p-value <0.001). Conclusions. The stratification of patients in a vascular classification allows a more adequate evaluation of the factors that are historically related to the collateral venous circulation in complex and syndromic craniosynostosis. Extracranial venous changes did not directly correlate with morphological changes in the skull base, functionality of the dural sinuses, or with signs of intracranial hypertension. These alterations seem to be the result of intrinsic manifestations related to the genotype, with mutations in the FGFR2 gene most severely related to extracranial venous circulation. Patients with Pfeiffer syndrome had the most severe extracranial venous classification, followed by Crouzon, Apert, Jackson-Weiss, Saerthre-Chotzen and complex negative craniosynostosis. The emissary veins most frequently found were the condylar and mastoid veins, followed by the occipital transosseous circulation. Functional atresia of the jugular foramen correlates with the severity of extracranial venous circulation and may be a consequence of intrinsic molecular activity in the endothelium during formation of the venous system.

Comparison of intraocular pressure in healthy brachycephalic and nonbrachycephalic cats using the Icare® TONOVET Plus rebound tonometer.

OBJECTIVE: To compare intraocular pressure using the Icare® TONOVET Plus rebound tonometer in healthy brachycephalic and nonbrachycephalic cats. ANIMALS STUDIED: Both eyes of 78 healthy cats were investigated in this study. Cats were divided into two groups: brachycephalic (n = 39) and nonbrachycephalic (n = 39). PROCEDURES: Nose position and muzzle ratio were photographically recorded and analyzed. Physical and ophthalmic examinations were performed. Intraocular pressure was measured using the Icare® TONOVET Plus rebound tonometry instrument. Quantitative mean values were statistically compared using an unpaired t-test at a significance level of p < .05. RESULTS: Mean values of the nose position and muzzle ratio were significantly lower in the brachycephalic group (20.14 ± 5.43%, 9.61 ± 3.29%) compared with the nonbrachycephalic group (29.21 ± 4.30%, 13.97 ± 6.01%). The mean intraocular pressure for brachycephalic cats (15.76 ± 0.50 mmHg) was significantly lower (p < .001) than for nonbrachycephalic cats (18.77 ± 0.49 mmHg). CONCLUSIONS: Intraocular pressure was significantly lower in brachycephalic cats using the Icare® TONOVET Plus rebound tonometer. Intraocular pressure values obtained in this study could be used as a guideline for measurements obtained using this tonometry device in healthy brachycephalic and nonbrachycephalic cats.

Ciliary Signalling and Mechanotransduction in the Pathophysiology of Craniosynostosis.

Craniosynostosis (CS) is the second most prevalent inborn craniofacial malformation; it results from the premature fusion of cranial sutures and leads to dimorphisms of variable severity. CS is clinically heterogeneous, as it can be either a sporadic isolated defect, more frequently, or part of a syndromic phenotype with mendelian inheritance. The genetic basis of CS is also extremely heterogeneous, with nearly a hundred genes associated so far, mostly mutated in syndromic forms. Several genes can be categorised within partially overlapping pathways, including those causing defects of the primary cilium. The primary cilium is a cellular antenna serving as a signalling hub implicated in mechanotransduction, housing key molecular signals expressed on the ciliary membrane and in the cilioplasm. This mechanical property mediated by the primary cilium may also represent a cue to understand the pathophysiology of non-syndromic CS. In this review, we aimed to highlight the implication of the primary cilium components and active signalling in CS pathophysiology, dissecting their biological functions in craniofacial development and in suture biomechanics. Through an in-depth revision of the literature and computational annotation of disease-associated genes we categorised 18 ciliary genes involved in CS aetiology. Interestingly, a prevalent implication of midline sutures is observed in CS ciliopathies, possibly explained by the specific neural crest origin of the frontal bone.

Cranial Suture Regeneration Mitigates Skull and Neurocognitive Defects in Craniosynostosis.

Craniosynostosis results from premature fusion of the cranial suture(s), which contain mesenchymal stem cells (MSCs) that are crucial for calvarial expansion in coordination with brain growth. Infants with craniosynostosis have skull dysmorphology, increased intracranial pressure, and complications such as neurocognitive impairment that compromise quality of life. Animal models recapitulating these phenotypes are lacking, hampering development of urgently needed innovative therapies. Here, we show that Twist1+/- mice with craniosynostosis have increased intracranial pressure and neurocognitive behavioral abnormalities, recapitulating features of human Saethre-Chotzen syndrome. Using a biodegradable material combined with MSCs, we successfully regenerated a functional cranial suture that corrects skull deformity, normalizes intracranial pressure, and rescues neurocognitive behavior deficits. The regenerated suture creates a niche into which endogenous MSCs migrated, sustaining calvarial bone homeostasis and repair. MSC-based cranial suture regeneration offers a paradigm shift in treatment to reverse skull and neurocognitive abnormalities in this devastating disease.

Molecular basis of ciliary defects caused by compound heterozygous IFT144/WDR19 mutations found in cranioectodermal dysplasia.

Primary cilia contain specific proteins to achieve their functions as cellular antennae. Ciliary protein trafficking is mediated by the intraflagellar transport (IFT) machinery containing the IFT-A and IFT-B complexes. Mutations in genes encoding the IFT-A subunits (IFT43, IFT121/WDR35, IFT122, IFT139/TTC21B, IFT140 and IFT144/WDR19) often result in skeletal ciliopathies, including cranioectodermal dysplasia (CED). We here characterized the molecular and cellular defects of CED caused by compound heterozygous mutations in IFT144 [the missense variant IFT144(L710S) and the nonsense variant IFT144(R1103*)]. These two variants were distinct with regard to their interactions with other IFT-A subunits and with the IFT-B complex. When exogenously expressed in IFT144-knockout (KO) cells, IFT144(L710S) as well as IFT144(WT) rescued both moderately compromised ciliogenesis and the abnormal localization of ciliary proteins. As the homozygous IFT144(L710S) mutation was found to cause autosomal recessive retinitis pigmentosa, IFT144(L710S) is likely to be hypomorphic at the cellular level. In striking contrast, the exogenous expression of IFT144(R1103*) in IFT144-KO cells exacerbated the ciliogenesis defects. The expression of IFT144(R1103*) together with IFT144(WT) restored the abnormal phenotypes of IFT144-KO cells. However, the coexpression of IFT144(R1103*) with the hypomorphic IFT144(L710S) variant in IFT144-KO cells, which mimics the genotype of compound heterozygous CED patients, resulted in severe ciliogenesis defects. Taken together, these observations demonstrate that compound heterozygous mutations in IFT144 cause severe ciliary defects via a complicated mechanism, where one allele can cause severe ciliary defects when combined with a hypomorphic allele.

Do Infant Motor Skills Mediate the Association Between Positional Plagiocephaly/Brachycephaly and Cognition in School-Aged Children?

OBJECTIVE: Positional plagiocephaly/brachycephaly (PPB) is associated with lower cognitive scores in school-aged children. This study tested the hypothesis that infant motor skills mediate this association. METHODS: Children with a history of PPB (cases, n = 187) and without PPB (controls, n = 149) were followed from infancy through approximately 9 years of age. Infant motor skills were assessed using the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-3), and cognition was assessed using the Differential Ability Scales, 2nd edition (DAS-2). The Bayley-3 motor composite was examined as a mediator of the association between PPB and DAS-2 general cognitive ability (GCA) scores. In secondary analyses, mediation models were examined for the DAS-2 verbal ability, nonverbal ability, and working memory scores; models using the Bayley-3 fine versus gross motor scores also were examined. RESULTS: Cases scored lower than controls on the DAS-GCA (ß = -4.6; 95% CI = -7.2 to -2.0), with an indirect (mediated) effect of ß = -1.5 (95% CI = -2.6 to -0.4) and direct effect of ß = -3.1 (95% CI = -5.7 to -0.5). Infant motor skills accounted for approximately 33% of the case-control difference in DAS-2 GCA scores. Results were similar for other DAS-2 outcomes. Evidence of mediation was greater for Bayley-3 gross motor versus fine motor scores. CONCLUSION: Infant motor skills partially mediate the association between PPB and cognition in school-aged children. Monitoring motor development and providing intervention as needed may help offset associated developmental concerns for children with PPB. IMPACT: To our knowledge, this study is the first longitudinal investigation of the development of children with and without PPB from infancy through the early school years and the first to examine motor skills as a mediator of cognitive outcomes in this population. The findings highlight the importance of early motor skills for other developmental outcomes. LAY SUMMARY: Infants' motor skills are related to the development of PPB and its association with later cognition. If your child has PPB, physical therapists may have an important role in assessing and providing treatment to promote motor development.

Craniosynostosis: Clinical Presentation, Genetics, and Prenatal Diagnosis.

IMPORTANCE: Craniosynostosis is a fetal condition caused by premature closure of the cranial sutures. Through provider awareness, we can raise suspicion in high-risk individuals, increase prenatal detection, optimize genetic testing, perform appropriate antenatal surveillance and delivery planning, and allow for a comprehensive, multidisciplinary approach to treatment. OBJECTIVE: The aim of this study was to review what is currently known regarding the genetics, pathophysiology, diagnosis, and treatment of craniosynostosis for the obstetric care provider. EVIDENCE ACQUISITION: A comprehensive literature review was performed using the PubMed database with the search term "craniosynostosis." The search was limited to the English language. RESULTS: A total of 220 articles were identified, and a total of 53 were used in completion of this article. The results highlight the multiple factors involved with abnormal suture formation, including various genetic factors. Although rare at this time, prenatal detection can allow families to prepare and practitioners to provide appropriate clinical treatment. Both 3-dimensional sonography and magnetic resonance imaging have been identified as modalities to aid in detection for high-risk individuals. Early referral allows for less-invasive surgical outcomes with lower complication rates. RESULTS: Familiarity with craniosynostosis among obstetric providers can improve patient counseling, prenatal detection rates, and appropriate antepartum, intrapartum, and postpartum counseling.

Comparison of Neurocognitive Outcomes in Postoperative Adolescents with Unilateral Coronal Synostosis.

Unilateral coronal nonsyndromic craniosynostosis is associated with asymmetric skull growth, which may influence cerebral long-term function. Twenty affected adolescents who underwent cranial vault remodeling at a mean age of 8.2 months (12 from the Yale Craniofacial Clinic and eight from the Children's Hospital of Philadelphia) all completed a double-blinded neurodevelopmental assessment at an average age of 12.1 years. The study cohort included 55 percent female and 50 percent right-sided craniosynostosis. Mean verbal intelligence quotient was highest at 117.3, and mean performance intelligence quotient was 106.4, for a mean full-scale intelligence quotient of 112.5. Patients performed above the national average on all academic achievements except for numerical operations, which was significantly lower than word reading (p = 0.022). Patients performed below average on all Beery-Buktenica visual motor tests; motor-coordination was poorer than both visual motor integration and visual perception (p = 0.027 and p = 0.005). Significant positive correlations existed between paternal education/visual perception (r = 0.450; p = 0.046) and household income/verbal intelligence quotient (r = 0.628; p = 0.004). Patients with right unilateral coronal nonsyndromic craniosynostosis had improved spelling compared with left-sided patients on multivariate regression (p = 0.033). Female patients had higher motor coordination (p = 0.024). Breast-fed patients had better performance intelligence quotient (p = 0.024), visual motor integration (p = 0.014), and visual perception (p = 0.031). Adolescents who underwent cranial vault remodeling at two institutions had above average intelligence quotient scores, but worse mathematical and visual motor achievement compared with control subjects. Left-side craniosynostosis patients performed worse in spelling than right-side patients. Breast-feeding was an independent predictor for improved performance intelligence quotient, visual motor achievement, and visual perception performance. Study findings are limited by the cohort size. A larger population study is required, which could validate or modify the study conclusions.

Expanding the phenotypic spectrum of IFT81: Associated ciliopathy syndrome.

Short-rib polydactyly syndromes are a heterogeneous group of disorders characterized by narrow thorax with short ribs, polydactyly and often other visceral and skeletal malformations. To date there have only been six reported patients with homozygous and compound heterozygous variants in IFT81, causing a short-rib thoracic dysplasia, with, or without, polydactyly (SRTD19: OMIM 617895). IFT81 is a protein integral to the core of the intraflagellar transport complex B (IFT-B), which is involved in anterograde transport in the cilium. We describe the case of a male infant with compound heterozygous variants in IFT81, who presented with short long bones, a narrow thorax, polydactyly, and multiple malformations. Three novel clinical features are reported including complete situs inversus, micropenis, and rectal atresia, which have not previously been associated with variants in IFT81. We reviewed the literature and identified the most consistent clinical features associated with this rare ciliopathy syndrome. We postulate that dolichocephaly and sagittal craniosynostosis may be associated with this condition, and provide a clue to considering IFT81 as the causative gene when deciphering complex ciliopathies.

Motor Function in School-Aged Children With Positional Plagiocephaly or Brachycephaly.

OBJECTIVE: To determine whether children with a history of positional plagiocephaly/brachycephaly (PPB) show persistent deficits in motor development. METHODS: In a longitudinal cohort study, we completed follow-up assessments with 187 school-aged children with PPB and 149 participants without PPB who were originally enrolled in infancy. Primary outcomes were the Bruininks-Oseretsky Test of Motor Proficiency-Second Edition (BOT-2) composite scores. RESULTS: Children with PPB scored lower than controls on the BOT-2. Stratified analyses indicated that differences were restricted to children who had moderate-severe PPB. No consistent differences were observed in children who had mild PPB. CONCLUSION: Children who had moderate-severe PPB in infancy show persistent differences in motor function. We suggest close developmental monitoring and early intervention to address motor deficits.

Further delineation of CDC45-related Meier-Gorlin syndrome with craniosynostosis and review of literature.

Meier-Gorlin syndrome (MGS) is a rare autosomal recessive disorder characterized by the triad of short stature, microtia and absent or small patellae. We report on a patient with MGS secondary to biallelic mutations in CDC45 detected on whole exome sequencing (WES). Patients with MGS caused by mutations in CDC45 display a distinct phenotype characterized by craniosynostosis and anorectal malformation. Our patient had craniosynostosis, anorectal malformation and short stature, but did not have the microtia or patella hypoplasia. Our report also highlights the value of WES in aiding diagnosis of patients with rare genetic diseases. In conclusion, our case report and review of the literature illustrates the unique features of CDC45-related MGS as well as the benefits of WES in reducing the diagnostic odyssey for patients with rare genetic disorders.

Exploring the potential association among sleep disturbances, cognitive impairments, and immune activation in 22q11.2 deletion syndrome.

22q11.2 deletion syndrome (22q11.DS) is a neurogenetic disorder caused by a microdeletion in chromosome 22. Its phenotype includes high rates of psychiatric disorders, immune system abnormalities, and cognitive impairments. We assessed the quality of sleep in 22q11.2DS and its potential link to inflammatory markers and cognitive deficits. Thirty-three 22q11.2DS individuals and 24 healthy controls were studied. Sleep parameters were assessed by the Pittsburgh sleep quality index (PSQI) questionnaire and correlated with serum cytokine levels and cognitive functioning, measured using the Penn computerized neurocognitive battery (CNB). The 22q11.2DS individuals had significantly worse sleep quality scores than the controls, unrelated to the psychiatric or physical comorbidities common to 22q11.2DS. Interleukin 6 levels were correlated with the overall score of the PSQI questionnaire for nonpsychotic 22q11.2DS participants only. Several domains of the CNB were associated with poorer sleep quality, suggesting that cognitive impairments in 22q11.2DS may be at least partially explained by poor sleep quality. Our findings confirm sleep impairments in individuals with 22q11.2DS, which might negatively affect their cognitive functioning, and corroborate a potential role of immunological pathways in the 22q11.2DS neuro-phenotype.

A de novo truncating mutation in ASXL1 associated with segmental overgrowth.

Mutations in genes involved in chromatin remodelling have been implicated in broad phenotypes of congenital abnormalities and neurodevelopment. However, limited genotype-phenotype correlations are available for some of the rarest genetic disorders that affect chromatin regulation. We hereby describe a 12-year-old girl presented at birth with severe hypotonia, developmental delay, a mid-line capillary malformation and distinctive craniofacial features. During the natural history of her disease, the girl developed severe spasticity and drug-resistant seizures, leading to a diagnosis of Bohring-Opitz syndrome (BOS). We performed whole-exome sequencing (WES) and identified a de novo mutation in ASXL1 (c.2033dupG) which results in the introduction of a premature stop codon (p.R678fs*6). ASXL1 encodes a polycomb repressive complex protein implicated in chromatin regulation and de novo mutations are a known cause of BOS. Phenotypes with segmental craniofacial overgrowth associated to midline capillary malformations enlarge the clinical spectrum of BOS at onset and further expand the differential diagnosis in ASXL1 mutation carriers.

Use of computational fluid dynamics to compare upper airway pressures and airflow resistance in brachycephalic, mesocephalic, and dolichocephalic dogs.

Brachycephalic dog breeds are prone to breathing difficulties because of their upper airway anatomy. Several surgical techniques exist to correct anatomical pathologies and common surgical approaches aim to correct functional abnormalities in the nares and/or the soft palate. However, further research is needed to improve clinical outcomes. This study evaluated air pressure and airflow resistance in the upper airways and trachea in nine sedated, sternally recumbent dogs of different skull types (dolichocephalic, n=3; mesocephalic, n=3; brachycephalic, n=3). CT images were acquired from the nostrils to the caudal border of the lungs and geometrical reconstruction of the upper airway and trachea was performed. Analysis of computational fluid dynamics was performed using inspiratory flow adapted to bodyweight for each dog. Flow (L/min) and pressure (cmH2O) were computed for the entire upper airway and trachea. Resistance (cmH2O/L/min) was calculated using pressure differences between the nose, larynx, and trachea. In this pilot study, statistical comparisons were not performed. Pressure maps, airflow, and resistance were similar in dolichocephalic and mesocephalic breeds. Median pressure difference (3.76cmH2O) and resistance (0.154cmH2O/L/min) between the nose and larynx were numerically higher in brachycephalic dogs than in other breeds (0.45cmH2O and 0.016cmH2O/L/min, respectively). Median pressure difference (0.205cmH2O) and resistance (0.009cmH2O/L/min) between the larynx and trachea was numerically similar in all dogs, except for the English bulldog. The methodology used in this preliminary study to quantify airflow characteristics such as pressure and resistance could improve the understanding of brachycephalic obstruction airway syndrome.