significance of beaten copper appearance on skull radiographs in children with isolated sagittal...
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Significance of Beaten Copper Appearance on Skull Radiographs in Children with Isolated Sagittal
Synostosis
Deepak Agrawal, Paul Steinbok, D Cochrane
Division of Neurosurgery, UBC and BC Children’s Hospital, Vancouver, Canada
Raised ICP in Single suture Synostosis• Noted in 14% - 24% of the children
Renier D, Sainte-Rose C, Marchac D, Hirsch JF: Intracranial pressure in craniostenosis. J Neurosurg 57:370-377, 1982.
• Another 38% have ‘borderline’ ICP
Thompson DN, Malcolm GP, Jones BM, Harkness WJ, Hayward RD: Intracranial pressure in single-suture craniosynostosis. Pediatr Neurosurg 22:235-240, 1995.
Measuring ICP problematic
• Absence of normative values
• Ethical considerations
• Increase in ICP in children with single suture craniosynostosis is low-grade and chronic
Camfield PR, Camfield CS: Neurological aspects of craniosynostosis, in Cohen MM (ed) Craniosynostosis: diagnosis, evaluation, and management. New York, Raven Press, 1986, pp 215-226.
In absence of ICP monitoring…
Indirect E/O raised ICP
• Symptoms of ↑ICP
• Beaten Copper Appearance (BCA) on skull radiographs
Symptoms of chronic ↑ICP
• Headache-Classical symptom
• Head banging, episodic screaming
Beaten Copper Appearance (BCA)
• Thought to correspond to the gyral pattern of the underlying brain
• Significance has been debated, but is generally felt to be a ‘normal’ finding in children
Du Boulay G: The significance of digital impressions in children's skulls. Acta Radiol 46:112-122, 1956.
• Although the authors concluded BCA to be normal in children with craniosynostosis
• However, in children <18 months, BCA highly specific for ↑ICP
Also….
• Raised ICP was defined as >15mmHg even in infants (normal <5mmHg)
• No attempt made to correlate with symptoms of ↑ICP
OBJECTIVE
Look for any correlation between BCA and symptoms suggestive of intracranial hypertension in children operated for isolated sagittal synostosis
Materials & Methods
• Retrospective study (1987-2000)
• Children operated for isolated sagittal synostosis
• Postoperative skull radiographs available
COHORTS
BCA Group
• Children who had beaten-copper appearance on skull radiographs at follow up
Non-BCA Group
• Children who did not have this finding
BCA SCORE
• Depth
(0 = none, 1 = mild to moderate, 2 = severe)
• Extent
(0 = none, 1 = ≤ 50%, 2 = >50%)
3 + 4=7
Study Design
48 Children
BCA Groupn=20
Non-BCA Groupn=28
BCA scoreSymptoms of ICP
Serial HC
BCA scoreSymptoms of ICP
Serial HC
Operative procedure
• 39 children - vertex craniectomy plus parietal osteotomies and/or craniectomies.
• 9 children operated in a delayed fashion (after eight months of age)
Operative procedure
• N=4
replacement of the strip of bone over the sagittal suture
• N=5
cranial vault remodeling
RESULTS
Median age at surgery:
• 4.8 months -BCA group
• 4 months -Non-BCA group
• Radiological follow up 4 - 156 months (mean of 36.2
months)
Results
• 40/48 had preoperative skull X-rays & none had BCA preoperatively
• 9/20 (45%) symptomatic in BCA group
• 3/28 (10.7 %) symptomatic in the non-BCA group(p=0.00684)
BCA Score• In 18/20 (90%) children the BCA was ‘diffuse’
with five (25%) children having the maximum possible score of 8.
• 28.6% (n=6) of the children with follow up radiographs done at ≤ 18 months of age had BCA
• No difference was found between the mean BCA score in the symptomatic (score of 5.77) and non-symptomatic (score of 5.90) children (p=0.722)
BCA in various age groups
Number of children with skull radiographs available
Number of children with BCA(%)
Number of children with diffuse BCA (%)
Number of children with BCA & Symptoms(%)
≤ 18 months
21 6 (28.6) 5 (23.8) 4 (19.0)
18-48 months
15 4 (26.6) 4 (26.6) 1 (6.7)
> 48 months
12 10 (83.3) 9 (75) 6 (50)
16 months postop 30 months postop
Head Growth Curve
• 5/48 (10.41%) children had deceleration in head growth in the follow up period, of which only one child was symptomatic for raised ICP and that child had BCA as well.
• Deceleration on the head growth curve was not predictive of possible raised ICP (symptoms + BCA) in our patients.
CONCLUSIONS
• Significant number of children with BCA on radiographs develop symptoms suggestive of raised ICP following surgical treatment for sagittal synostosis in infancy
• 28.6% of the children ≤ 18 months of age in our study had BCA
• Prolonged follow up may be warranted in this group of patients.
THANK YOU
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