Surgical Management of a Traumatic Brain Herniation Through the Bregmatic Fontanelle in a Dog.

A 1 yr old female Chihuahua was presented for traumatic skull injury. Computed tomography revealed brain herniation through the bregmatic fontanelle. The hernia was manually reduced, and the defect was repaired using a polypropylene mesh. To the authors' knowledge, this is the first reported case of brain herniation through the bregmatic fontanelle in a dog.

Determination of Anterior Fontanelle Size among Apparently Healthy Term Newborns in North Central Nigeria.

BACKGROUND: Anterior fontanelles (AFs) of healthy newborn infants vary widely in size, this being a function of race, geographical location, gender, birth weight, mode of delivery and gestation. Abnormal variations in AF size portend a serious pathology of the cranium or intracranial structures. The established reference value for normal AF size is, therefore, an essential diagnostic tool. This study was conducted to determine the mean AF size and factors that are associated with its variability among apparently healthy term neonates in Lokoja, North Central Nigeria. METHODS: AF size was measured in 200 healthy inborn term neonates between 24 and 48 h post-delivery using a modified version of Mattur's method. Other parameters measured were head circumference, birth weight and length. Relevant statistical methods were used for data analysis, and P < 0.05 at a confidence interval of 95% was considered statistically significant. RESULTS: Eighty-six (43%) of the babies were males, and the mean birth weight and gestation were 3.09 (0.37) kg and 38.8 (1.2) weeks, respectively. Majority (72%) were delivered spontaneously per vagina. The mean (± SD) AF size of the study neonates was 2.62 (0.72) cm (2.53 [0.61] cm in males and 2.69 [0.79] cm in females). Neither gender nor mode of delivery affected AF size significantly. There was no significant correlation between AF size and occipitofrontal circumference. CONCLUSION: AF size for term babies in our hospital differs from AF sizes reported from other parts of the world, further reiterating the utility of local/regional neonatal AF reference values.

Adelola Adeyole (1935-2021): Early descriptor of congenital dermoid or epidermoid inclusion cyst over the anterior fontanelle and below the galea aponeurotica.

The author wished to detail the life and contributions of Dr. Adelola Adeloye, MBBS, MS, FWCS, FRCS, FACS, FRCP, in hope to pay homage to this giant in Global Neurosurgery. Dr. Adelola Adeloye was born on July 18, 1935 in Illesa, Osun State, present-day South-West Nigeria. The Adeloye-Odeku disease is an eponym for a congenital dermoid or epidermoid inclusion cyst (CDIC/CEDIC) over the anterior fontanelle and below the galea aponeurotica. In 1971, Adeloye and Odeku first described these cysts in 18 Nigerian patients. While overall rare and predominantly noted in children, the Adeloye-Odeku disease has been found to impact adults too. In terms of rarity, CDICs make up 0.1-0.5% of cranial tumors and 0.2% of inclusion cysts. CDICs can be distinguished from CEDICs through histopathology as dermoid cysts may contain hair follicles, sweat, sebaceous glands, and teeth, whereas CEDICs usually are only composed of keratinized debris and epidermal tissue. Assumed first to be an African cyst, cases of the Adeloye-Odeku disease were subsequently reported in other ethnic populations: Turkish, Czechs, Slovaks, Chinese, Japanese, Canadians, Saudi Arabians, Indians, Caucasians, Bangladeshis, Spaniards, and Brazilians.

Case series of infants presenting to the emergency department with fever, bulging anterior fontanelle and COVID-19 infection.

We present a three patient case series of infants who presented to the pediatric emergency department with fever, bulging anterior fontanelle (BAF), and an omicron variant COVID-19 infection. All patients had a benign course, none developed meningitis, and all had symptom resolution after two days. Considerations for neuroimaging and lumbar puncture are discussed. This case series adds to the previously published case reports of infants with COVID-19, fever and BAF and further describes a variant in the presenting symptomology of COVID-19 infection in infants under 12 months. Acute and primary care providers who treat infants should consider COVID-19 testing in patients who are well appearing, with fever and BAF.

Quantitative morphological analysis framework of infant cranial sutures and fontanelles based on CT images.

Characterizing the suture morphological variation is a crucial step to investigate the influence of sutures on infant head biomechanics. This study aimed to establish a comprehensive quantitative framework for accurately capturing the cranial suture and fontanelle morphologies in infants. A total of 69 CT scans of 2-4 month-old infant heads were segmented to identify semilandmarks at the borders of cranial sutures and fontanelles. Morphological characteristics, including length, width, sinuosity index (SI), and surface area, were measured. For this, an automatic method was developed to determine the junction points between sutures and fontanelles, and thin-plate-spline (TPS) was utilized for area calculation. Different dimensionality reduction methods were compared, including nonlinear and linear principal component analysis (PCA), as well as deep-learning-based variational autoencoder (VAE). Finally, the significance of various covariates was analyzed, and regression analysis was performed to establish a statistical model relating morphological parameters with global parameters. This study successfully developed a quantitative morphological framework and demonstrate its application in quantifying morphologies of infant sutures and fontanelles, which were shown to significantly relate to global parameters of cranial size, suture SI, and surface area for infants aged 2-4 months. The developed framework proved to be reliable and applicable in extracting infant suture morphology features from CT scans. The demonstrated application highlighted its potential to provide valuable insights into the morphologies of infant cranial sutures and fontanelles, aiding in the diagnosis of suture-related skull fractures. Infant suture, Infant fontanelle, Morphological variation, Morphology analysis framework, Statistical model.

Ommaya reservoir placement using ultrasound guidance via anterior fontanelle combined with frameless electromagnetic neuronavigation in patients with mucopolysaccharidosis type 2: Case reports and review of the literature.

Mucopolysaccharidosis type II (MPS II) results from the genetic deficiency of a lysosomal enzyme and is associated with central nervous system (CNS) dysfunction. In Japan, in addition to intravenous enzyme administration, intracerebroventricular enzyme delivery through the Ommaya reservoir has recently gained approval. Nevertheless, the ideal approach for safely implanting the reservoir into the narrow ventricles of infantile MPS II patients remains uncertain. In this report, we present two cases of successful reservoir placement in infantile MPS II patients using ultrasound guidance via the anterior fontanelle, coupled with flameless electromagnetic neuronavigation.

Anterior fontanel size in Korean nursery newborns and clinical implications of large anterior fontanel: A retrospective cohort, observational study.

Anterior fontanel (AF) sizes in newborns are influenced by ethnicity, gender, genetics, nutrition, and other pathological conditions. However, AF sizes in recent Korean newborns have not been reported yet. Thus, this study aimed to understand variation in AF size and clinical implications of large AF sizes in newborns. This cohort study was conducted on nursery newborns born at a University Hospital between September 2019 and August 2020. AF size was measured at 24 to 48 hours after birth. Newborns with a large AF (> 3.6cm) were examined for other pathological reasons using radiological and laboratory tests. Demographic data were analyzed in relation to AF size. A total of 573 newborns were investigated. Their mean gestational age was 38.5 ± 1.2 weeks at birth and their mean birth weight was 3140 ± 450 g. Their mean AF size was 1.85 ± 0.83 cm (90 and 97-percentile of AF size were 2.96 and 3.65 cm, respectively). Among demographic factors, small for gestational age (SGA) weight, SGA head circumference, and multiple births were correlated with larger AF size. Among 18 infants with a large AF, 2 had intracranial abnormalities and 11 had vitamin D deficiency. This is the first recent study on AF sizes of Korean newborn infants. Their mean AF size was the smallest so far. For the largest AF size, a cutoff of 3.65 cm met the 97-percentile of the cohort. Both SGA weight and head circumference were risk factors for large AF size. For the largest AF size, intracranial lesions and vitamin D deficiency as well as SGA presented clinical implications.

The Discovery of a Bone in the Anterior Fontanelle of the Skull of the Sheep (Ovis aries) / Descubrimiento de un Hueso en la Fontanela Anterior del Cráneo de la Oveja (Ovis aries)

SUMMARY: A comparative study of the skull morphology was conducted using 270 prenatal and 750 postnatal skull samples from three breeds of sheep in Nigeria namely, Balami, Uda and Yankasa. A unique bone peculiar to the Yankasa breeds of sheep was found consistently at the centre of the anterior fontanelle in the young (day-old to 1 year). At two years of age and above, the bone was fused and disappeared completely. This brings the total numbers of the neurocranium bones of the skull in the Yankasa breeds to 8, as against the 7 bones documented in the ovine species. Due to the fact that this bone has not been described in the literature, we venture to name it the anterio-fontanelle bone (of Atabo).

Se realizó un estudio comparativo de la morfología del cráneo utilizando 270 muestras de cráneos prenatales y 750 postnatales de tres razas de ovejas en Nigeria, Balami, Uda y Yankasa. Un hueso único peculiar de las razas de ovejas Yankasa se encontró consistentemente en el centro de la fontanela anterior en las crías (de un día a 1 año). A los dos años de edad o más, el hueso se fusionó y desapareció por completo. Esto eleva el número total de huesos del neurocráneo en el cráneo en las razas Yankasa a 8, frente a los 7 huesos documentados en la especie ovina. Debido a que este hueso no ha sido descrito en la literatura, nos aventuramos a denominarlo hueso antero-fontanela (de Atabo).

Transillumination of an Anterior Fontanelle Dermoid Cyst.

Dermoid cysts are slowly growing benign lesions of ectodermal tissue that often occur in the anterior fontanelle. Clinicians often rely on a negative transillumination test to begin the process of correctly diagnosing a dermoid cyst. However, here the authors present a case of a 7-month-old girl who presents with a transilluminating dermoid cyst.

Bulging Anterior Fontanelle Caused by Severe Acute Respiratory Syndrome Coronavirus-2.

Neurologic manifestations of the 2019 novel coronavirus disease in children are varied. We present the case of a 9-month-old child with bulging anterior fontanelle caused by severe acute respiratory syndrome coronavirus-2.

Pediatric ventriculoperitoneal shunt: a comparative study between anterior fontanel ultrasound-guided versus conventional cranial end insertion.

PURPOSE: Ventriculoperitoneal (V-P) shunt is one of the most common neurosurgical procedures in pediatrics for the treatment of hydrocephalus. Shunt failure is one of the common mechanical complications which lead to major morbidities. This study aims to compare between cranial part insertions of the V-P shunts guided by trans-anterior fontanel ultrasound versus conventional insertion. METHODS: A prospective comparative randomized study was conducted on 60 pediatric patients aged ≤ 2 years who suffered hydrocephalus and allocated into 2 groups. In the first group (n = 30), the cranial parts of the ventriculoperitoneal shunts were inserted guided by trans-anterior fontanel ultrasound, and in the second group (n = 30), the insertions were by the conventional method. The follow-up duration of the patients was 3 months. RESULTS: Proximal part obstruction of the V-P shunt was found in 3 cases of the conventional group during follow-up with statistical insignificance (p = 0.237) while adequate proximal part location recorded statistical significance (p = 0.0005) in favor of ultrasound-guided group. CONCLUSION: The use of the anterior fontanel ultrasound guide during ventriculoperitoneal shunt insertion is a feasible, safe, and effective technique for the placement of ventricular catheters in pediatric patients with a patent anterior fontanel.

Delayed closure of the anterior fontanelle in Iron Age children from Zaghunluq, northwestern China.

Delayed closure of the anterior fontanelle is often associated with various disorders. However, the phenomenon might be a normal variation. In this study, the anterior fontanelle was investigated in children from the Iron Age Zaghunluq cemetery in Xinjiang, northwestern China. Age at death was estimated by tooth development/eruption in the children. The anterior fontanelle was visually assessed for delayed fusion. Three out of nine children aged between 3-6 years old from the cemetery had signs of open anterior fontanelle. However, there were no signs of craniofacial pathology or developmental disruption. Delayed closure of the anterior fontanelle might have been a norm in the Iron Age Zaghunluq population. However, it is impossible to determine the reasons behind the high prevalence of delayed AF closure at Zaghunluq. Additional studies are warranted to determine whether this phenomenon is population specific, or diet specific, or just an individual variation.

The neurodevelopmental profile of healthy children with premature anterior fontanel closure.

BACKGROUND: We aimed to assess the neurodevelopmental status of healthy children with premature anterior fontanel closure. METHODS: This retrospective observational study was conducted on 40 (20 M, 20 F) children admitted to Mersin University Pediatric Neurology Outpatient Clinic between 2015-2020 with complaints of premature fontanel closure. Patients with dysmorphic features, microcephaly, craniosynostosis, hypoxic-ischemic sequelae, infections, metabolic disorders, intracranial hemorrhage, epilepsy, endocrine problems, additional congenital anomalies, intrauterine growth retardation (IUGR), prematurity, and postmaturity were excluded. The Denver II and Bayley III tests were applied to all patients and controls. RESULTS: The Denver II identified retardations in gross motor skills (p = 0.015) and personal-social skills (p = 0.042) and Bayley III in cognitive (p = 0.030) and motor skills (p = 0.007) in the study group. None of the participants in the study group had neurodevelopmental retardation, according to the Bayley III normal standards. DISCUSSION: Our results suggest that children with premature fontanel closure may develop motor retardation. These children should, therefore, be closely monitored for neurodevelopmental aspects.

Anterior fontanelle closure and diagnosis of non-syndromic craniosynostosis: a comparative study using computed tomography.

OBJECTIVE: Suspicion of early anterior fontanel (AF) closure is a common reason for referral to a pediatric neurosurgeon because of the suspected increased risk of developing craniosynostosis (CS) in spite of the absence of evidence in the literature. The aim of this study was to analyze the association between AF closure and the diagnosis of non-syndromic CS in Brazilian children. METHODS: An observational and case-cohort study was conducted to compare the incidence of closed AF between healthy children (group 1) and children diagnosed with non-syndromic CS (group 2) at a pediatric neurosurgery referral center. The accuracies of completely closed AF and diagnosis of CS were assessed. RESULTS: High-resolution three-dimensional reconstruction computed tomography scans were obtained for 140 children aged < 13 months, of whom 62.9% were boys and 37.1% were girls (p < 0.001). The most common types of non-syndromic CS were trigonocephaly (34, 48%) and scaphocephaly (25, 35.7%). Closed fontanel (27, 38.6%) was observed in both groups, and a sensitivity of 36.1%, specificity of 72%, the positive predictive value of 59%, and negative predictive value of 51% were observed in the patients diagnosed with CS when AF closure occurred before the age of 6 months. CONCLUSION: The results of this comparative study of AF closure and CS diagnosis suggest that early AF closure does not imply a diagnosis of CS. Pediatricians should be aware of the risk of misdiagnosis of CS in cases with a widely open AF in spite of the presence of CS.

Diagnosis and Management of Suture-Related Concerns of the Infant Skull.

The cranial fontanelles and sutures have several benign variations, including most cases of "early" or "late" closure of the anterior fontanelle, bathrocephaly, overriding sutures, and benign metopic ridging. However, recognizing true craniosynostosis and referring the patient to a craniofacial specialist in a timely fashion are imperative, as minimally invasive options can be offered to most patients younger than 6 months of age. Gaining comfort with the physical examination of an infant with an abnormal head shape is best achieved through experience and pattern recognition and will frequently facilitate an accurate diagnosis without the need for ionizing radiation.

Influence of unfused cranial bones on magnetoencephalography signals in human infants.

OBJECTIVE: To clarify the effects of unfused cranial bones on magnetoencephalography (MEG) signals during early development. METHODS: In a simulation study, we compared the MEG signals over a spherical head model with a circular hole mimicking the anterior fontanel to those over the same head model without the fontanel for different head and fontanel sizes with varying skull thickness and conductivity. RESULTS: The fontanel had small effects according to three indices. The sum of differences in signal over a sensor array due to a fontanel, for example, was < 6% of the sum without the fontanel. However, the fontanel effects were extensive for dipole sources deep in the brain or outside the fontanel for larger fontanels. The effects were comparable in magnitude for tangential and radial sources. Skull thickness significantly increased the effect, while skull conductivity had minor effects. CONCLUSION: MEG signal is weakly affected by a fontanel. However, the effects can be extensive and significant for radial sources, thicker skull and large fontanels. The fontanel effects can be intuitively explained by the concept of secondary sources at the fontanel wall. SIGNIFICANCE: The minor influence of unfused cranial bones simplifies MEG analysis, but it should be considered for quantitative analysis.

Neurodevelopmental risk evaluation of premature closure of the anterior fontanelle.

PURPOSE: To evaluate neurological development of completely healthy children with anterior fontanelle premature closure via Denver Developmental Screening Test II and to compare the results with control group. METHOD AND RESULTS: The records of 140 patients applied to Mersin University Pediatric Neurology Outpatient Clinic between 2011 and 2019 with the complaint of premature closure of the anterior fontanelle were retrospectively reviewed. Patients with microcephaly, craniosynostosis, infection, sequelae of hypoxia-ischemia, metabolic disorders, intracranial hemorrhage, epilepsy, endocrine problems, and dysmorphic features were excluded from the study. Sixty-six completely healthy children with anterior fontanelle premature closure were included in the study. Denver Developmental Screening Test II was performed by the same developmental specialist to the children with premature closure of the anterior fontanelle as well as to the healthy control group. For each child included in the case and the control group, 90% of the values for each development area were calculated and recorded. Then, the results were compared. Denver II Developmental Screening Test (p < 0.001) and gross motor subtest (p < 0.001) results showed statistically significant retardation in the case group compared with the control group. CONCLUSIONS: The study was the first study in the literature on the gross motor development of children with premature closure of anterior fontanelle, and it has been found significantly undeveloped compared with the control group, and it has been concluded that similar patients should be evaluated from this view point in pediatric neurology department.

Improvement in ventriculomegaly following cervicomedullary decompressive surgery in children with achondroplasia and foramen magnum stenosis.

The role of cervicomedullary decompression (CMD) in the care of hydrocephalic achondroplastic children who present with simultaneous foramen magnum stenosis is not well understood. We sought to determine the percentage of symptomatic achondroplastic children with foramen magnum stenosis who had stabilization or improvement in ventriculomegaly following CMD. The authors retrospectively reviewed the records of pediatric patients at Cedars-Sinai Medical Center with achondroplasia and signs of progressive ventriculomegaly who underwent CMD for symptomatic foramen magnum stenosis between the years 2000 and 2018. Clinical outcomes included changes in fontanelle characteristics, head circumference (HC) percentile, and incidence of ventriculoperitoneal (VP) shunting. Radiographic outcomes measured included changes in Evans ratio. We excluded individuals who were shunted before CMD from our study. Sixteen children presented with symptomatic foramen magnum stenosis and full anterior fontanelle or jump in the HC percentiles. Two children underwent placement of a VP shunt before decompressive surgery and were excluded from further analysis. Of the remaining 14 children who underwent CMD, 13 (93%) showed softening or flattening of their fontanelles post-operatively. Ten of these 14 children had both pre- and post-operative HC percentile records available, with 8 showing increasing HC percentiles before surgery. Seven of those eight children (88%) showed a deceleration or stabilization of HC growth velocity following decompression of the foramen magnum. Among 10 children with available pre- and post-operative brain imaging, ventricular size improved in 5 (50%), stabilized in 2 (20%), and slightly increased in 3 (30%) children after decompression. Two children (14%) required a shunt despite decompression of the foramen magnum. A significant proportion of children with concomitant signs of raised intracranial pressure or findings of progressive ventriculomegaly and foramen magnum stenosis may have improvement or stabilization of these findings following CMD. CMD may decrease the need for VP shunting and its associated complications in the select group of hydrocephalic children with achondroplasia presenting with symptomatic foramen magnum stenosis.