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.

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.

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.

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.

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.

Temporal mapping of the closure of the anterior fontanelle and contiguous sutures using computed tomography, in silico models of modern infants.

The aim of this study is to quantify and statistically model the age-related decline in the fibrous connective tissue interface of the anterior fontanelle in modern Australian infants, using three-dimensional, semi-automated computed-assisted design protocols. Non-linear regression with variance models, using power functions, combined with quantile regression of the 5th and 95th population percentiles, were utilised to assess absolute anterior fontanelle surface area (AFSA) as a function of age, using multi-slice cranial computed tomography scans obtained from 256 infants aged < 30 months (males: n = 126, females: n = 109) from Brisbane children's hospitals. Normalised AFSA (NFSA), standardised for variation in cephalic size, followed a progressive decline from birth, the greatest velocity change occurring between the 3-6 and 6-9 month cohorts. Growth of the neurocranium is the most significant within the first 8 months postpartum, with a mean increase of 19.03 mm in maximum cranial length and 10.04 mm in breadth. Directionality of fontanelle closure, quantified using spline curves refutes fundamental assumptions that the anterior fontanelle is consistent with a quadrilateral, and contiguous sutures exhibit constant velocity of closure. The present study provides normative values for fontanelle size and diameters as well as new predictive non-linear models for age substantiation, screening of developmental abnormalities and indicators of suspected child maltreatment in modern infants aged birth to 30 months.

Giant Encephalocele in Sokoto, Nigeria: A 5-Year Review of Operated Cases.

OBJECTIVE: Encephalocele is a common congenital malformation of the central nervous system; however, giant encephaloceles are rare. The use of folic acid supplementation and termination of pregnancies, which are prenatally diagnosed with encephaloceles and other congenital malformation of the central nervous system, has significantly reduced the occurrence of this type of congenital malformation, especially in developed countries. METHODS: This was a retrospective review over a 5-year period from January 2006 to December 2010 at the Department of Neurosurgery, Regional Centre for Neurosurgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. The records of patients with giant encephalocele were retrieved from the case notes of patients who had excision and repair for encephalocele. RESULTS: Seventy-three patients had excision and repair of encephalocele over the study period. However, the records of only 50 patients were retrieved. Fourteen (28%) of the 50 whose records were retrieved had giant encephalocele. There were 4 male and 10 female patients (1:2.5). Thirteen (92.9%) had the lesion located in the occipital region, whereas in 1 patient (7.1%) the lesion was at the vertex. Three (21%) of the cases had microcephaly, 1 (7.1%) had macrocephaly, and 1 (7.1%) developed postoperative hydrocephalus. The average size of defect was 2.43 cm, and the size of the lesion ranged from 12 × 6 cm to 40 × 50 cm. The average maternal age was 20.3 years (n = 6), and the paternal age was 29 years (n = 4). Four out of 7 (57%) mothers had febrile illness in early pregnancy. Seven out of 10 patients (70%) did not have antenatal care. CONCLUSIONS: This condition is more common in children conceived during the period when farm products are yet to be harvested, and whose mothers did not attend antenatal care visits. It is recommended that mothers should be educated on the necessity of preconception folic acid. Implementation of a national strategy on food fortification is also advised. We recommend surgery after the first month of life to reduce poor early postoperative outcomes. In developing countries and centers with suboptimal pediatric intensive care units, surgical intervention is preferred after the first month of life with good temperature control, adequate fluid replacement following rupture of the sac, blood transfusion availability, and, only if necessary, complex cranial reconstruction.

Congenital dermoid inclusion cyst over the anterior fontanel in Chinese children.

Congenital dermoid inclusion cyst (CDIC) over the anterior fontanel is a rare and benign tumor. This study reports nine Chinese cases (three females and six males) with CDIC over the anterior fontanel. The clinical manifestations and imaging were analyzed retrospectively. Surgical resection was undertaken in all cases. The diagnosis of CDIC over the anterior fontanel was confirmed by histological examination. The cysts were all noticed soon after birth and enlarged gradually. They were soft, nontender with a sessile base without inflammatory signs and breaking. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed soft tissue mass over the anterior fontanel without intracranial extensions. The histopathological examination displayed stratified squamous epithelium with skin appendages. There were no complications or recurrence after operation during a follow-up for one year. CDIC over the anterior fontanel is a benign tumor. Imaging is recommended preoperatively to aid differential diagnosis. The main management is total excision with good prognosis.

Stress and strain propagation on infant skull from impact loads during falls: a finite element analysis.

Background and Objective: To simulate infant skull trauma after low height falls when variable degrees of ossification of the sutures are present. Methods: A finite elements model of a four-week-old infant skull was developed for simulating low height impact from 30 cm and 50 cm falls. Two impacts were simulated: An occipito-parietal impact on the lambdoid suture and a lateral impact on the right parietal and six cases were considered: unossified and fully ossified sutures, and sagittal, metopic, right lambdoid and right coronal craniosynostosis. Results: 26 simulations were performed. Results showed a marked increase in strain magnitudes in skulls with unossified sutures and fontanels. Higher deformations and lower Von Mises stress in the brain were found in occipital impacts. Fully ossified skulls showed less overall deformation and lower Von Mises stress in the brain. Results suggest that neonate skull impact when falling backward has a higher probability of resulting in permanent damage. Conclusion: This work shows an initial approximation to the mechanisms underlying TBI in neonates when exposed to low height falls common in household environments, and could be used as a starting point in the design and development of cranial orthoses and protective devices for preventing or mitigating TBI.

A new parameter for the management of positional plagiocephaly: the size of the anterior fontanelle matters.

PURPOSE: The rate of positional plagiocephaly has increased since guidelines for the prevention of sudden infant death have led to the recommendation of positioning infants on their back during sleeping. Therapy includes repositioning, physiotherapy, and helmet therapy. To date, there is no consensus on the treatment of positional plagiocephaly. Therefore, it was the goal of this study to compare the results of physiotherapy and helmet therapy and to investigate if the size of the anterior fontanelle can be used as an additional parameter for the indication of the helmet therapy. METHODS: We enrolled 98 infants with a diagonal difference of 7 mm or more and plagiocephaly classified as Argenta II or more. Patients were grouped into infants with a small anterior fontanelle (< 25mm2) and infants with a large anterior fontanelle (≥ 25mm2). The patients were observed for at least 18 months. Sixty-eight patients were treated with repositioning and physiotherapy, whereas 30 infants received helmet therapy. RESULTS: The remolding rate was significantly higher with the helmet therapy than with physiotherapy. In patients with a small fontanelle, a lower spontaneous remolding rate was seen pointing to their lower correction potential. Especially in these patients, plagiocephaly was reduced significantly more quickly with the helmet treatment than with physiotherapy, so that they may benefit from the helmet due to their otherwise reduced spontaneous remolding capacity. CONCLUSION: The helmet therapy led to a faster reduction of the asymmetry than physiotherapy in this study. In patients with a small anterior fontanelle and therefore lower remolding potential, the helmet treatment was more effective than physiotherapy.