V3 segment of the right vertebral artery taking an anomalous posterosuperior course and penetrating occipital bone (wall of the jugular foramen) diagnosed by magnetic resonance angiography.

PURPOSE: To describe a case of an anomalous posterosuperior course of the V3 segment of the right vertebral artery (VA) that penetrated the occipital bone (wall of the jugular foramen). METHODS: A 33-year-old healthy woman underwent cranial magnetic resonance (MR) imaging and MR angiography from the upper cervical to the intracranial region using a 3-Tesla scanner to screen for asymptomatic brain lesions, including cerebrovascular diseases. RESULTS: MR angiography showed no pathological arterial lesions such as aneurysms; however, there was an anomalous posterosuperior course of the V3 segment of the right VA. On MR angiographic source images and coronal reformatted images, the right VA was observed to penetrate the occipital bone lateral to the right hypoglossal canal and is located on the inferoposteromedial wall of the right jugular foramen and enter the posterior fossa at a higher level than the foramen magnum. CONCLUSION: We present a case in which the right VA showed an anomalous posterosuperior course at the craniovertebral junction. It is extremely rare for a VA to take a higher course. To our knowledge, this is the first report of such a VA variation in the relevant English-language literature. We speculated that the right VA of our patient was formed by the persistence of one more cephalad primitive artery than the first intersegmental artery, not by the persistence of the primitive hypoglossal artery. Careful observation of MR angiographic source is useful and important for identifying the VA penetrating the occipital bone.

Full-endoscopic technique for posterior fossa decompression in Chiari malformation type I: An anatomical feasibility study in human cadavers.

Although endoscope-assisted techniques have been described, a full-endoscopic approach is yet to be performed for posterior fossa decompression (PFD) in Chiari malformation type I (CM-I). This study aims to describe the full-endoscopic PFD technique and evaluate its feasibility. Five fresh-frozen anonymized adult human cadavers were operated on using an endoscope with an oval shaft cross-section with a diameter of 9.3 mm, a working length of 177 mm, and a viewing angle of 20°. It also had an eccentric working channel with a diameter of 5.6 mm, a light guide, a sheath for continuous irrigation, and a rod lens system. The instruments were introduced from the working channel. Posterior craniocervical structures were dissected, and PFD was achieved. The planned steps were performed in all five cadavers. The endoscope was introduced to the posterior craniocervical region, dissecting the structures to easily expose the suboccipital bone and C1 posterior arch. Important structures, such as the C1 posterior tubercle, rectus capitis posterior minor muscles, and posterior atlantooccipital membrane, were used as landmarks. PFD was feasible even with the dural opening. Using the full-endoscopic approach, posterior craniocervical structures can be reached, and PFD can be performed successfully. The instruments used are well-defined for spinal usage; thus, this full-endoscopic technique can be widely used in the surgical treatment of patients with CM-I.

Rectus capitis lateralis muscle revisited: a histological study using human fetuses.

BACKGROUND: Rectus capitis lateralis muscle (RCLM) is located at the border between the ventral and dorsal muscle groups, but the nerve topographical anatomy around the muscle is obscure. MATERIALS AND METHODS: We observed the RCLM in histological sections of 12 midterm and 10 near-term fetal heads (9-18 and 26-40 weeks of gestational age). RESULTS: At midterm, the RCLM wrapped around the inferiorly protruding inferolateral corner of the cartilaginous occipital bone. The muscle was adjacent to, or even continued to, the intertransversarius muscle between the atlas and axis. At near-term, the jugular process of the occipital bone, that is, the RCLM upper insertion, was either cartilaginous or bony, depending on age. The process formed a collar supporting the internal jugular vein from the inferior side. Moreover, the muscle is tightly attached to or inserted into the venous wall itself. The cartilaginous jugular process was adjacent to Reichert's cartilage, and the uppermost muscle fibers passed through a narrow space between these cartilages. The RCLM appeared to accelerate the jugular process elongation, resulting in complete union of the occipital and temporal bones. The ventral ramus of the first cervical nerve passed between the RCLM and rectus capitis anterior muscle to reach the longus capitis muscle. No nerve passed between the RCLM and the obliquus capitis superior muscle (a muscle at the suboccipital triangle). CONCLUSION: The dorsoventral position of the RCLM seemed to correspond to the scalenus posterior muscle in a laminar arrangement of the cervical axial musculature.

The foramen magnum in scaphocephaly.

PURPOSE: The foramen magnum (FM) presents various alterations in craniosynostoses, such as brachycephaly or Crouzon syndrome. However, to date, no study has been devoted to its morphology and morphometry in scaphocephaly, which is the most common of cranial deformities resulting from premature fusion of cranial sutures. METHODS: We assessed the morphology and morphometry of FM using preoperative thin-cut CT scans of 107 children with non-syndromic sagittal craniosynostosis aged 1-12 months (mean age 5.38 months). A series of sagittal and transverse dimensions were taken and the FM area was calculated in each case. Obtained data were compared to the age-matched control group of 101 normocephalic children. RESULTS: Dolichotrematous type of FM was dominant in the scaphocephaly group and observed in 63/107 cases (58.9%). The mean FM area in the scaphocephaly group was 519.64 mm2 and was significantly smaller compared to the control group (p = 0.0011). The transverse diameter and anterior sagittal diameter were also significantly smaller (p = 0.0112 and p = 0.0003, respectively). CONCLUSION: The area of FM in scaphocephaly is smaller compared to normal individuals. This is associated with a significant reduction of the width of FM in children with sagittal craniosynostosis. FM in scaphocephaly is larger than in other reported series of children with brachycephaly or Crouzon syndrome.

Reduction of giant parietooccipital fibrous dysplasia using dynamic mirror image guidance: a case report and review of the literature.

BACKGROUND: Craniofacial fibrous dysplasia (CFD) typically occurs in the facial bones and anterior cranial vault and can produce both disfigurement and functional limitations for patients disfigurement. Treatment consists of reducing the abnormal bone. Bone contouring can become challenging when the exposure does not extend to the corresponding normal contralateral structures for comparison or when normal landmarks are not available, which may compromise the overall aesthetic outcome. We describe a technique using dynamic mirroring to accurately contour the involved part of the cranium in a case of giant CFD. OBSERVATIONS: A 49-year-old male presented with a giant deforming fibrous dysplasia of the right mastoid and parieto-temporo-occiput that was causing functional limitations due to the size of the bony mass. This was managed with multidisciplinary bony reduction. Several neurovascular structures were in proximity to the areas of planned drilling of the expansile lesion, and dynamic mirroring of the uninvolved left skull was utilized to maximize safety and symmetry of reduction. High-speed drilling of the right occipital bone was performed until the navigation system alerted the surgeon that symmetric depth had been achieved. There were no complications from the procedure and this technique maximized the limits of symmetric reduction without significantly increasing surgical complexity or duration. LESSONS: Dynamic mirroring of bony structures in the posterior cranium is not commonly employed in neurosurgical practice. This technique may help improve the aesthetic outcomes of bony reduction in craniofacial dysplasia and a variety of similarly managed bony lesions, contour cranioplasties, and in unilateral craniosynostosis surgery.

Fixed posterior cranial vault expansion technique.

BACKGROUND: Different techniques to reshape the posterior skull vault have been developed in the last decades, all sharing the same goals of increasing the skull volume, decreasing the intracranial pressure (ICP), correcting the cranial dysmorphy, and contributing to a better growth of the skull. Though over the last years most refinements in these techniques have focused on the use of hardware as distractors or springs, the fixed posterior vault expansion remains a valuable procedure for cranial remodeling. METHODS: We describe in details the technique used for fixed posterior vault expansion in children that is applied at the French Referral center for Craniosynostosis of Lyon, France. DISCUSSION: The fixed posterior vault expansion increases the risk of perioperative complications due to the elevation of the posterior bone flap from the dura but allows an immediate decompression and correction of the shape, simplifying the postoperative course.

Developmental changes in the occipital cranial sutures of children less than 2 years of age.

PURPOSE: The occipital bone is located on the boundary between the membranous and cartilage bones and contains a wide variety of accessory sutures. In this study, we describe the age distribution of pediatric patients who are less than 2 years of age with occipital cranial sutures using a three-dimensional computed tomography (3D-CT). METHODS: A total of 167 consecutive patients who are less than 2 years of age and underwent computed tomography for head trauma were included in this study. RESULTS: Based on the results of this study, various types of sutures were observed among the pediatric participants. In particular, superior median fissures, mendosal sutures, other interparietal segment's accessory sutures, and interparietal sutures were noted in 21%, 35%, 9%, and 6% of the participants, respectively. Additionally, Wormian bones within the lambdoid suture were noted in 32% of the patients. The median age of children with superior median fissure and mendosal suture was 0 month. Meanwhile, superior median fissure was not observed among children older than 5 months of age. In this population, 13 patients (8%) were found to have skull fracture. CONCLUSIONS: Knowledge of the normal cranial anatomy and developmental patterns of cranial sutures is crucial in the evaluation of questionable fractures in the occipital region. A combination of 3D-CT and axial bone window imaging is useful in differentiating normal structures from pathological changes in the cranium.

Screening for Open Spina Bifida in a Routine Clinical Setting at the First-Trimester Scan: A Prospective Multicentre Cohort Study.

OBJECTIVE: The aim of this study was to investigate the performance of screening for open spina bifida (OSB) integrated into the routine first-trimester screening. METHOD: This is a prospective multicentre study of 4,755 women undergoing first-trimester ultrasound scans over a 4-year period. Measurements of the brainstem (BS) diameter and brainstem-to-occipital-bone (BSOB) distance were performed. The cisterna magna (CM) was measured in the tilted axial view. RESULTS: Pregnancy outcome data were available for 4,658 fetuses included in this study. There were 5 fetuses with OSB, and in all of them, the BS/BSOB ratio and the CM measurements were abnormal. The sensitivity and specificity of a BS/BSOB ratio >1 were 100%. The sensitivity of a CM width <5th centile was 100%, and the specificity was 95.1%. In 4.6% of cases, the BS/BSOB ratio was between the 95th percentile and 1. In 87.1% of these cases, the CM was normal, and 12.9% had a CM below the 5th percentile. CONCLUSION: Screening for OSB is feasible in routine first-trimester scans. The BS/BSOB ratio shows a very good sensitivity and specificity. In cases with near-normal values for the BS/BSOB ratio, the CM width might be helpful for further assessment.

The importance of first trimester screening of cranial posterior fossa in predicting posterior fossa malformations which may be identified in the following weeks of gestation.

PURPOSE: We aimed to investigate the value of posterior fossa ultrasonography measurements in predicting fetal posterior fossa anomaly at 11-14 weeks of gestation. METHODS: The study was performed at Zeynep Kamil Women and Children's Diseases Training and Research Hospital. Measurements were made in two groups: the control group consisted of 328 fetuses with normal postnatal outcome and the study group consisted of 22 fetuses with enlarged 4th ventricle. In the study group, we questioned the value of intracranial translucency (IT) and brainstem (BS) measurements and the BS/brainstem-to-occipital bone (BSOB) ratio in order to predict possible posterior fossa anomalies that may be identified in advanced gestational weeks. The differences of ultrasonographic measurements between groups with p < 0.05 were considered statistically significant. RESULTS: IT value, BSOB value, and BS/BSOB ratio were determined as ultrasonographic variables in predicting normal development of the fetal posterior fossa, with cutoff values of 2.7, 5.1, and 0.3. Negative predictive values of these three measurements for posterior fossa abnormalities were 100%. There was no statistically significant difference between the three variables for other diagnostic accuracy values (specifities and positive predictive values) (p > 0.05). CONCLUSION: IT, BSOB, and BS/BSOB ratio can be used as ultrasonographic markers to predict the normal development of the fetal posterior fossa.

Maturation of the human foetal basioccipital: quantifying shape changes in second and third trimesters using elliptic Fourier analysis.

During prenatal development, the brain is considered the best maturation criterion for the estimation of foetal physiological age, regardless of the conditions of pregnancy. Unfortunately, the brain lyses very quickly after death, but fortunately, the brain also has a major influence over osseous structures of the cranial base during development. Therefore, we considered the osseous structures of the cranial base potential indirect maturation indicators of foetal age. Because of its early formation and robustness, the basioccipital is a cranial base bone that is often used for studies in biological anthropology. Studies generally use conventional morphometry and bone size ratio to highlight morphological changes occurring during the foetal period and to create age estimation methods. These methods usually define thresholds beyond which the morphology of the basioccipital changes, but do not fully consider the form that might be valuable precisely to visualize its development or improve age estimation methods. Using geometric morphometric methods, the present study aims to analyse the development of the basioccipital during the second and third trimesters of foetal life by quantifying and visualizing shape changes in the inferior view. Basioccipital shapes are used as direct indicators of the maturation of the cranial base and as indirect indicators of the maturation of the brain and, by extension, the whole body. A sample of 221 anonymized computed tomographic (CT) scans of normal foetuses, ranging from 18 to 41 gestational weeks (GW), was used. Elliptic Fourier analysis (EFA) was used to quantify the basioccipital outline, and maturation stages were established to visualize shape changes with a principal component analysis. Our study allowed us precisely to quantify and continuously visualize shape changes occurring during prenatal life. Additionally, this study provides the first evidence of two distinct linear shape trajectories of the basioccipital. Foetuses aged between 18 and 26 GW have a rapid shape change with well-individualized stages, whereas shape changes are less visible in the second trajectory (27-41 GW). Furthermore, intra-stage shape variation is higher for the basioccipital at the beginning of the second and third trimesters than at the first trimester. By using geometric morphometric methods and EFA, this study shows that it was possible to go beyond classical methods. Indeed, the developed methodology enabled the first quantification of the overall shape changes of the basioccipital between gestational ages. The morphological shape changes throughout the foetal period can be useful for anthropological studies and provide new perspectives for immature age estimation methods.

Instrumented arthrodesis for non-traumatic craniocervical instability in very young children.

PURPOSE: Occipitocervical instrumentation is infrequently required for stabilization of the axial and subaxial cervical spine in very young children. However, when it is necessary, unique surgical considerations arise in children when compared with similar procedures in adults. METHODS: The authors reviewed literature describing fusion of the occipitocervical junction (OCJ) in toddlers and share their experience with eight cases of young children (age less than or equal to 4 years) receiving occiput to axial or subaxial spine instrumentation and fixation. Diagnoses and indications included severe or secondary Chiari malformation, skeletal dysplastic syndromes, Klippel-Feil syndrome, Pierre Robin syndrome, Gordon syndrome, hemivertebra and atlantal occipitalization, basilar impression, and iatrogenic causes. RESULTS: All patients underwent occipital bone to cervical spine instrumentation and fixation at different levels. Constructs extended from the occiput to C2 and T1 utilizing various permutations of titanium rods, autologous rib autografts, Mersilene sutures, and combinations of autografts with bone matrix materials. All patients were placed in rigid cervical bracing or halo fixation postoperatively. No postoperative neurological deficits or intraoperative vascular injuries occurred. CONCLUSION: Instrumented arthrodesis can be a treatment option in very young children to address the non-traumatic craniocervical instability while reducing the need for prolonged external halo vest immobilization. Factors affecting fusion are addressed with respect to preoperative, intraoperative, and postoperative decision-making that may be unique to the toddler population.

Ardipithecus ramidus and the evolution of the human cranial base.

The early Pliocene African hominoid Ardipithecus ramidus was diagnosed as a having a unique phylogenetic relationship with the Australopithecus + Homo clade based on nonhoning canine teeth, a foreshortened cranial base, and postcranial characters related to facultative bipedality. However, pedal and pelvic traits indicating substantial arboreality have raised arguments that this taxon may instead be an example of parallel evolution of human-like traits among apes around the time of the chimpanzee-human split. Here we investigated the basicranial morphology of Ar. ramidus for additional clues to its phylogenetic position with reference to African apes, humans, and Australopithecus. Besides a relatively anterior foramen magnum, humans differ from apes in the lateral shift of the carotid foramina, mediolateral abbreviation of the lateral tympanic, and a shortened, trapezoidal basioccipital element. These traits reflect a relative broadening of the central basicranium, a derived condition associated with changes in tympanic shape and the extent of its contact with the petrous. Ar. ramidus shares with Australopithecus each of these human-like modifications. We used the preserved morphology of ARA-VP 1/500 to estimate the missing basicranial length, drawing on consistent proportional relationships in apes and humans. Ar. ramidus is confirmed to have a relatively short basicranium, as in Australopithecus and Homo. Reorganization of the central cranial base is among the earliest morphological markers of the Ardipithecus + Australopithecus + Homo clade.

Torcular pseudomass: a potential diagnostic pitfall in infants and young children.

BACKGROUND: Incidental findings on brain MRI may constitute a diagnostic pitfall. We observed an incidental extra-axial midline rounded pseudomass between the torcular Herophili and the occipital squama, with spontaneous resolution, which we called "torcular pseudomass." OBJECTIVE: We investigated the frequency, imaging features, natural history and developmental background of this finding in a large group of infants and young children. MATERIALS AND METHODS: We conducted a single-center retrospective study by reviewing all brain MRIs performed in children younger than 3 years between 2007 and 2013 in a specialized pediatric hospital. We looked for soft tissue (minimum 2 mm thick) interposed between the torcula and the occipital squama on midsagittal T1 and T2 images; we recorded the maximal diameters and outcome. RESULTS: Of 2,283 the children who had brain MRIs during the study period, 291 (12.7%, 95% confidence interval [CI] 0.11, 0.14) presented with a torcular pseudomass (median age 4 months, range 0 days to 35 months, 56% male). MRI features were the same in all of these children: T1 isointensity and T2 hyperintensity to the cerebral cortex, facilitated diffusion on diffusion-weighted imaging and apparent diffusion coefficient maps, and contrast enhancement. The median diameters were: anteroposterior, 5.8 mm; transverse, 10.5 mm; cranio-caudal, 20.6 mm. Follow-up MRI was available in 34.7% (95% CI: 0.20, 0.40) of the children; median follow-up time was 18 months. Among these children, 35.6% (95% CI: 0.26, 0.45) had total involution, 52.5% (95% CI: 0.26, 0.62) had partial involution and 4.1% (95% CI: 0.05, 0.18) showed stability. CONCLUSION: Redundant soft tissue in the torcular region, or torcular pseudomass, is not an infrequent finding in infants and young children. It should be considered a physiological tissue, reflecting the postnatal developmental process of the brain and cranial vault, without the need for further investigation or follow-up imaging studies.

A new anatomic trait for identifying the mendosal suture in young children: the mendosal-lambdoidal angle.

PURPOSE: Radiologic diagnosis of skull fractures in young children is difficult due to numerous accessory sutures. This is especially true around the occipital bone because it has more than one ossification center. Normal anatomic variants, such as the mendosal suture, may be misinterpreted as a skull fracture. We investigated the anatomic traits of the mendosal suture in young children. METHODS: We retrospectively evaluated 52 children, aged between 1 month and 4 years, who had undergone head computed tomography with three-dimensional reconstructions. We evaluated the presence or absence of the mendosal suture. If present, then we measured the length of the suture and the angle between the lambdoidal and mendosal suture lines. RESULTS: The presence of the mendosal suture was bilateral in 12 children and unilateral in 5 children. The mendosal suture had a mean length of 13.9 ± 3.4 mm on the right side and 11.2 ± 4 mm on the left side. The angle between the mendosal and lambdoidal sutures had a mean value of 54.2° ± 11° for the right side and 53.6° ± 13.9° for the left side. The 95 % confidence interval for the mean value of the angle had a lower and upper bounds of 48° and 60° on the right side and 46° and 61° on the left side, respectively. CONCLUSIONS: The angle between mendosal and lambdoidal suture lines may help radiologists to identify the mendosal suture.

Giant Atretic Occipital Lipoencephalocele in an Adult with Bony Outgrowth.

BACKGROUND: We present unique case of a giant extracranial atretic occipital lipoencephalocele in an adult patient with new bone formation within it which was not associated with any developmental malformation of brain. Resection of the lipoencephalocele was performed for esthetic reasons. CASE REPORT: 18 year old female patient presented to the surgery OPD with complains of a large mass in the occipital region present since birth. It was of size of a betel nut at the time of birth and gradually increased in size over a long period of time. It was painless and not associated with any other constitutional symptoms. On examination the rounded fluctuant mass was present in the midline in occipital region covered with alopecic skin with dimpling in the overlying skin. On MRI there was mass showing both T1 and T2 hyperintense signal area suggestive of fat component. Herniation of meninges and atretic brain parenchyma was also seen through a defect in the occipital bone in the midline. There was a Y shaped bony outgrowth seen arising from occipital bone into the mass which was quite unusual in association with an atretic lipoencephalocele. CONCLUSIONS: A large lipoencephalocele with bony outgrowth in an adult patient is a rare presentation of atreic occipital encephalocele.

A Global Bibliometric and Visualization Analysis of Craniovertebral Junction Bony Abnormalities Based on VOSviewer and Citespace.

OBJECTIVE: Recent years have witnessed a rapidly growing interest in CVJ bony abnormalities, and a qualitative and quantitative analysis of relevant literatures is necessary. This study aims to identify and summarize the published articles related to craniovertebral junction bony abnormalities, to analyze and visualize the current research trends and major contributors. METHODS: We collected data from Web of Science, excluding certain article types. Two researchers screened articles for relevance. Data were organized with EndnoteX9, and analyzed using VOSviewer and CiteSpace for co-authorship, co-occurrence, keyword burst, and co-citation analyses to identify research trends and collaborations. RESULTS: A total of 2,776 articles were included, revealing an increasing trend in annual publications of CVJ bony abnormalities. The USA was the leading country. King Edward Memorial Hospital was the most prolific institution, and Seth GS Medical College had the most citations. The Spine is the most popular journal with the highest number of publications and citations. Professor Goel Atul from India emerged as the most influential pioneer in this field. Keyword analysis highlighted surgical techniques, diagnosis, and anatomy as the primary research hotspots and Fixation, Placement, and Basilar invagination gradually become the new research trend. However, there is a relative weakness in basic research and epidemiology. CONCLUSIONS: This study provides valuable insights into the current research trends and critical contributors in CVJ bony abnormalities, guiding evidence-based decisions and fostering international collaborations to advance knowledge in this field.

An Anatomorphometric Study of Occipital Spurs and Their Association With Dental Occlusion.

Background and objective The occipital spur (OS) can be described as an abnormal elongation of the external occipital protuberance (EOP); its etiology is multifactorial and may involve biomechanical, immunological, and/or genetic factors. This study aimed to determine the frequency and characteristics of elongated EOP or OS as well as the relationship of OS with occlusion in a group of Turkish dental patients. Materials and methods Lateral cephalometric radiographs of 1925 patients taken in 2022 were retrospectively analyzed. The frequency, types, and dimensions of OS were determined based on gender and age groups. Molar occlusion and incisal bite were also evaluated. Results Of the 1925 patients, 679 were males and 1246 were females. The mean age of the cohort was 18.17 ±5.03 years (range: 4-61). OS was detected in 483 (25.1%) patients and was more common in males (p<0.001); 133 (27.5%) of the OSs were flat, 247 (51.1%) crest, and 103 (21.3%) spin type. The incidence of OS increased depending on age groups (p<0.001). There was no statistically significant association between OS presence and molar occlusion (p>0.05). However, a statistically significant association was observed between anterior incisal bite (p=0.001) and OS presence. There was a statistically significant difference in terms of OS sizes in males and females; the sizes of OS were larger in males than in females (length: p<0.05, base and thickness: p<0.001). Conclusions The frequency of OS was quite high in our cohort; it was more common and of larger size in males and older age groups. The most common type was the crest type. While there was no statistically significant association between OS frequency and molar occlusion, there was a significant relationship with incisal bite. The frequency of OS was highest in people with anterior crossbite.

Management of paracondylar process fracture in three horses.

BACKGROUND: Fractures of the paracondylar process of the occipital bone may cause headshaking, neck pain and neurologic deficits. The condition is being recognised more frequently with increasing availability of computed tomography. However, to date only limited information is available as to presentation, treatment, surgical approach and outcome. OBJECTIVES: To describe the clinical signs, imaging findings, treatment, surgical approach and outcome in three horses diagnosed with paracondylar process fracture. STUDY DESIGN: Retrospective case series. METHODS: Clinical records and diagnostic images of affected cases were reviewed. RESULTS: Two cases had ventral nonunion fractures-one of these presented with neck pain, headshaking and behavioural changes, while in the other the fracture was a suspected incidental finding in a case of poor performance. A third case with a more dorsal fracture presented with acute facial nerve paralysis. Diagnosis was by computed tomography in all cases, although imaging of ventral fractures by radiography was found to be feasible. Where clinical signs could be associated confidently with the fracture, conservative management resulted in improvement but not complete resolution. Repeated recurrence of clinical signs after prolonged periods of remission necessitated surgical removal in one case, which was readily accomplished with the aid of ultrasound guidance, and led to rapid resolution of clinical signs without significant post-operative complications. The surgical approach is described. MAIN LIMITATIONS: Limited follow-up was available. CONCLUSIONS: Paracondylar process fracture should be considered as a differential diagnosis for headshaking, neck pain, poor performance and facial paresis, and is a justification for performing computed tomography in such cases. A multi-disciplinary approach is beneficial due to the potential for orthopaedic, neurologic, ophthalmologic and behavioural clinical signs, with additional need for expertise in diagnostic imaging and pain management. Surgical fragment removal should be considered for ventral fractures.

Hinge Craniotomy for Posterior Cranial Vault Expansion: Using the Keel to the Surgeon's Advantage.

Cranial vault reconstructions are a common craniofacial procedure utilized to treat chronically elevated intracranial pressure and its sequelae for children with craniosynostosis. These surgeries often involve split-thickness autologous grafts to facilitate intracranial volume expansion. The hinge craniotomy was developed by neurosurgeons in the early 2000s as an alternative to the hemicraniectomy to allow for greater space and simplified re-securing of the bone flap. In our report, we introduce a novel application of hinge craniotomy in total cranial vault reconstruction for a pediatric patient with microcephaly secondary to congenital cytomegalovirus infection. We performed bilateral barrel stave cuts to the occipital bone as well as an undercut along the midline keel to form a hinge craniotomy. Complex reconstruction followed to augment intracranial volume and restructure the cranial vault. This technique maximized intracranial volume expansion while minimizing the need for prolonged reconstruction. It also allowed for retained vascularization of the bone flap by maintaining the connection with the intact cranial base and pericranium to further support bony healing. Our study presents a novel utilization of hinge craniotomy, using the occipital keel as a natural hinge, to create ample space during cranial vault reconstruction. This technique offers potential advantages in terms of intracranial volume expansion and bony healing.

Correlation of spheno-occipital synchondrosis and mandibular condylar cortication with chronological age using computed tomography in Indian population- A cross-sectional study.

BACKGROUND: Forensic age estimation is a procedure which utilises many methods to estimate the age of both living and deceased individuals, including those who have died in natural disasters or man-made catastrophes. The pattern and closure of spheno-occipital synchondrosis (SOS) fusion, along with subchondral ossification of the mandibular condyle, can be used to estimate age. AIM AND OBJECTIVES: This study aims to estimate age using computed tomographic (CT) images of spheno-occipital synchondrosis fusion (SOS) and mandibular condylar cortication (MCC), and to correlate these findings with chronological age. MATERIALS AND METHODS: The present study included 435 CT images of individuals aged 10-25 years. SOS fusion was assessed using a four-stage system, and MCC was assessed bilaterally using a three-stage system on the sagittal plane. Data on fusion stages and cortication types were entered along with chronological age, and then statistically analysed. RESULTS: SOS fusion stage 2 occurred at similar age in males (19.82 ± 2.67 years) and females (19.23 ± 2.93 years). Earlier fusion of other stages was observed in females by a mean age of 2 years. MCC was completed 1 year earlier in females, with statistically significant differences (p ≤ 0.001). When comparing cortication types and different fusion stages, only type II cortication showed statistically significant differences compared to different fusion stages (p ≤ 0.001). CONCLUSION: Mandibular condylar cortication (MCC) and spheno-occipital synchondrosis (SOS) fusion were positively correlated with chronological age, suggesting that these parameters can be used as an adjunct method for age estimation.