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Significance of Beaten Copper Appearance on Skull Radiographs in Children with Isolated Sagittal Synostosis PowerPoint Presentation
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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.

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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
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
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
In absence of ICP monitoring…

Indirect E/O raised ICP

  • Symptoms of ↑ICP
  • Beaten Copper Appearance (BCA) on skull radiographs
symptoms of chronic icp
Symptoms of chronic↑ICP
  • Headache-Classical symptom
  • Head banging, episodic screaming
beaten copper appearance bca
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.

slide7
Although the authors concluded BCA to be normal in children with craniosynostosis
  • However, in children <18 months, BCA highly specific for ↑ICP
slide8
Also….
  • Raised ICP was defined as >15mmHg even in infants (normal <5mmHg)
  • No attempt made to correlate with symptoms of ↑ICP
objective
OBJECTIVE

Look for any correlation between BCA and symptoms suggestive of intracranial hypertension in children operated for isolated sagittal synostosis

materials methods
Materials & Methods
  • Retrospective study (1987-2000)
  • Children operated for isolated sagittal synostosis
  • Postoperative skull radiographs available
cohorts
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
BCA SCORE
  • Depth

(0 = none, 1 = mild to moderate, 2 = severe)

  • Extent

(0 = none, 1 = ≤ 50%, 2 = >50%)

  • + 4
  • =7
operative procedure
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 procedure15
Operative procedure
  • N=4

replacement of the strip of bone over the sagittal suture

  • N=5

cranial vault remodeling

results
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)
results17
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 score18
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)
head growth curve
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
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.