No abstract

Plagiocephaly has recently received increased attention in pediatric neurosurgical circles and its treatment has been controversial. Lack of uniformity persists in the treatment of neonates with occipital plagiocephaly. Plagiocephaly resulting from synostosis is rare. Many patients with nonsynostotic plagiocephaly have been treated surgically. Cranial remodeling orthotic devices (such as headbands and helmets) have also been reported to correct nonsynostotic plagiocephaly. The cost of orthotic treatment has risen and its validity has been contested by many third-party insurance payers. The effectiveness of orthotic treatment has not been adequately compared to the natural history of nonsynostotic plagiocephaly. The first phase of a natural history study was initiated in June 1995 at Phoenix Children's Hospital. All new patients referred with a diagnosis of plagiocephaly were categorized into two groups: those with mild-to-moderate asymmetry and those with moderate-to-severe asymmetry. Categories were determined by cephalic measurements. The patients with moderate-to-severe asymmetry were offered orthotic treatment with a cranial remodeling band. Those patients with mild-to-moderate asymmetry were observed with repeated measurements. Data in patients left untreated and followed for natural history were compared to our data published in 1994 for those treated with external cranial orthosis. Our published data in 47 patients treated with a headband during the period from 1988 to 1993 indicated that cranial vault asymmetry improved from a mean of 8.9 mm to 4 mm over an average treatment period of 4.3 months beginning when the average age of the patient was 5.9 months. Seventy-two neonates treated with neck stretching exercises and repositioning of the head without surgery or orthotic devices showed improvement in cranial vault asymmetry from 10.6 mm to 5.5 mm over an average treatment period of 4.5 months beginning when the average age of the patient was 4.5 months. This study indicates that neonates with mild-to-moderate asymmetry who are less than 6 months of age and who are treated with physiotherapy and repositioning have similar improvement in cranial vault asymmetry as those treated with orthotic devices. The second phase of our study deals with neonates who have moderate-to-severe plagiocephaly.

Management of neonates with nonsynostotic occipital plagiocephaly has been controversial, and there has been a lack of uniformity concerning its treatment. Patients with nonsynostotic occipital plagiocephaly have been treated surgically or with cranial remodeling orthotic devices and have shown improvement in asymmetry. The cost of orthotic treatment has risen, and its validity has been contested by many third-party insurance payers. The effectiveness of orthotic treatment has not been adequately compared to the natural history of nonsynostotic occipital plagiocephaly. A nonsurgical, nonorthotic treatment study was initiated in June 1995 at Phoenix Children's Hospital. All new patients referred with a diagnosis of nonsynostotic occipital plagiocephaly were categorized into two groups: those with mild-to-moderate asymmetry and those with moderate-to-severe asymmetry. Categories were determined by cephalic measurements. The patients with moderate-to-severe asymmetry were offered orthotic treatment with a cranial remodeling band. Those patients with mild-to-moderate asymmetry were treated with physiotherapy, repositioning of the head, and repeated notation of cephalic measurements without orthotic devices or surgery. Seventy-two neonates, seen consecutively, with mild-to-moderate, nonsynostotic occipital plagiocephaly were evaluated by noting cephalic measurements. The parents of six of these patients elected treatment with a cranial remodeling band and results in these patients were excluded from our data. The remaining 66, treated without orthotic devices, showed improvement in average cranial vault asymmetry (CVA) from 9.2 to 4.7 mm over an average treatment period of 4.5 months that commenced when the average age of the patient was 6.4 months. A comparison of the present data with data published in 1994 for neonates treated with a headband indicates that neonates with mild-to-moderate asymmetry who are treated aggressively with physiotherapy and repositioning have similar improvement in CVA.

Successful surgical management of a neoplastic or nonneoplastic seizure focus in close proximity to or within eloquent brain areas relies on precise delineation of the relationship between the lesion and functional brain areas. The aim of this series was to validate the usefulness and test the efficacy of noninvasive presurgical PET mapping of eloquent brain areas to predict surgical morbidity and outcome in children with seizures. To identify eloquent brain areas in 15 children (6 female and 9 male; mean age 11 years) with epileptogenic lesions PET images of regional cerebral blood flow were performed following the administration of [¹⁵O]water during motor, visual, articulation, and receptive language tasks. These images with coregistered magnetic resonance (MR) images were then used to delineate the anatomic relationship of a seizure focus to eloquent brain areas. Additional PET images using [¹⁸F]fluoro-2-deoxy-D-glucose (FDG) and [¹¹C]methionine (CMET) were acquired to help localize the seizure focus, as well as characterize the lesion. Patient surgical management decisions were based on PET mapping in combination with coregistered MR images, PET-FDG findings, and the anatomic characteristics of the lesion. At follow-up 1–26 months after surgery, all patients that underwent temporal lobectomy (9 patients) and extratemporal resection (4 patients) for a neoplastic or nonneoplastic seizure focus are seizure-free with minimal postoperative morbidity. Of prime importance, no child sustained a postoperative speech or language deficit. PET imaging was also well tolerated without procedural complications. Based on PET mapping, a nonoperative approach was used for 2 children and a biopsy only was used in one child. When cortical injury involved prenatally determined eloquent cortex, PET demonstrated reorganization of language areas to new adjacent areas or even to the contralateral hemisphere. Integration of anatomical and functional data enhanced the surgical safety, defined optimal surgical approach, delineated the seizure focus from eloquent brain areas, facilitated maximum resection and optimized the timing of surgery, thereby minimizing surgical morbidity while maximizing surgical goals. PET measurements of FDG and CMET uptake were also helpful in localizing the seizure focus and grading the tumors. PET used for brain mapping in children provides the surgeon with strategic preoperative information not readily attainable with traditional invasive Wada testing or intraoperative cortical stimulation. PET mapping may also improve the outcome of extratemporal resections by allowing aggressive seizure focus resection. In addition, serial brain maps may optimize timing for surgical intervention by demonstrating reorganization of eloquent cortex often seen in younger children after cortical injury. Our results suggest that noninvasive presurgical brain mapping has the potential to reduce risk and improve neurologic outcome.