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Richard Hayward, Jonathan Britto, David Dunaway, and Owase Jeelani

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Ghassan S. Abu-Sittah, Owase Jeelani, David Dunaway, and Richard Hayward

OBJECT

Patients with Crouzon syndrome (CS) are at risk for developing raised intracranial pressure (ICP), which has the potential to impair both vision and neurocognitive development. For this reason, some experts recommend early prophylactic cranial vault expansion on the basis that if ICP is not currently raised, it is likely to become so. The aim of this study was to examine the justification for such a policy. This was done by analyzing the incidence, causes, and subsequent risk of recurrence in a series of patients with CS, in whom raised ICP was treated only after it had been diagnosed.

METHODS

This study was a retrospective review of the medical records and imaging data of patients with a clinical diagnosis of CS.

RESULTS

There were 49 patients in the study, of whom 30 (61.2%) developed at least 1 episode of raised ICP. First episodes occurred at an average age of 1.42 years and were attributable to craniocerebral disproportion/venous hypertension (19 patients), hydrocephalus (8 patients), and airway obstruction (3 patients). They were managed, respectively, by vault expansion, ventriculoperitoneal shunt insertion, and airway improvement. Fourteen of the 30 patients developed a second episode of raised ICP an average of 1.42 years after treatment for their initial episode, and 3 patients developed a third episode an average of 3.15 years after that. Causes of subsequent episodes of raised ICP often differed from previous episodes and required different management. Patients who were < 1 year old when the first episode was diagnosed were at increased risk of recurrence.

CONCLUSIONS

Although the incidence of raised ICP in CS is high, it did not occur in nearly 40% of children during the course of this study. The several possible causes of CS require different management and may vary from episode to episode. The authors recommend an expectant policy toward these children with careful clinical, ophthalmological, respiratory, and radiological monitoring for raised ICP, reserving intervention for when it has been detected and the appropriate treatment can be initiated.

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David J. Mowatt, Dominic N. P. Thomson, and David J. Dunaway

Object

Numerous techniques for the soft-tissue closure of large myelomeningoceles have been described. When patients present for delayed repair beyond the neonatal period, the indications for surgery are both different and less immediate.

Methods

Six patients between 6 weeks and 3.5 years of age with defects ranging from 27 to 49 cm2 (mean 37 cm2) were referred to the authors' institution and were successfully treated by direct skin closure after tissue expansion.

Conclusions

In this paper the authors describe the technique and advantages of expansion compared with those of locoregional flaps in this subgroup of patients with myelomeningoceles.

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Christopher R. Forrest

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Richard Hayward, Jonathan A. Britto, David Dunaway, Robert Evans, Noor ul Owase Jeelani, and Dominic Thompson

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Irene Mathijssen, Robbin de Goederen, Sarah L. Versnel, Koen F. M. Joosten, Marie-Lise C. van Veelen, and Robert C. Tasker

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Alessandro Borghi, Silvia Schievano, Naiara Rodriguez Florez, Roisin McNicholas, Will Rodgers, Allan Ponniah, Greg James, Richard Hayward, David Dunaway, and N. u. Owase Jeelani

OBJECTIVE

Scaphocephaly secondary to sagittal craniosynostosis has been treated in recent years with spring-assisted cranioplasty, an innovative approach that leverages the use of metallic spring distractors to reshape the patient skull. In this study, a population of patients who had undergone spring cranioplasty for the correction of scaphocephaly at the Great Ormond Street Hospital for Children was retrospectively analyzed to systematically assess spring biomechanical performance and kinematics in relation to spring model, patient age, and outcomes over time.

METHODS

Data from 60 patients (49 males, mean age at surgery 5.2 ± 0.9 months) who had received 2 springs for the treatment of isolated sagittal craniosynostosis were analyzed. The opening distance of the springs at the time of insertion and removal was retrieved from the surgical notes and, during the implantation period, from planar radiographs obtained at 1 day postoperatively and at the 3-week follow-up. The force exerted by the spring to the patient skull at each time point was derived after mechanical testing of each spring model—3 devices with the same geometry but different wire thicknesses. Changes in the cephalic index between preoperatively and the 3-week follow-up were recorded.

RESULTS

Stiffer springs were implanted in older patients (p < 0.05) to achieve the same opening on-table as in younger patients, but this entailed significantly different—higher—forces exerted on the skull when combinations of stiffer springs were used (p < 0.001). After initial force differences between spring models, however, the devices all plateaued. Indeed, regardless of patient age or spring model, after 10 days from insertion, all the devices were open.

CONCLUSIONS

Results in this study provide biomechanical insights into spring-assisted cranioplasty and could help to improve spring design and follow-up strategy in the future.

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Ahmed Elawadly, Luke Smith, Alessandro Borghi, Khaled I. Abdelaziz, Adikarige Haritha Dulanka Silva, David J. Dunaway, Noor ul Owase Jeelani, Juling Ong, and Greg James

OBJECTIVE

Endoscopic strip craniectomy with postoperative helmet orthosis therapy (ESCH) has emerged as a less invasive alternative to fronto-orbital remodeling for correction of trigonocephaly. However, there is no standardized objective method for monitoring morphological changes following ESCH. Such a method should be reproducible and avoid the use of ionizing radiation and general anesthesia for diagnostic imaging. The authors analyzed a number of metrics measured using 3D stereophotogrammetry (3DSPG) following ESCH, an imaging alternative that is free of ionizing radiation and can be performed on awake children.

METHODS

3DSPG images obtained at two time points (perisurgical and 1-year follow-up [FU]) of children with metopic synostosis who had undergone ESCH were analyzed and compared to 3DSPG images of age-matched control children without craniofacial anomalies. In total, 9 parameters were measured, the frontal angle and anteroposterior volume in addition to 7 novel parameters: anteroposterior area ratio, anteroposterior width ratios 1 and 2, and right and left anteroposterior diagonal ratios 30 and 60.

RESULTS

Six eligible patients were identified in the operated group, and 15 children were in the control group. All 9 parameters differed significantly between perisurgical and age-matched controls, as well as from perisurgical to FU scans. Comparison of FU scans of metopic synostosis patients who underwent surgery to scans of age-matched controls without metopic synostosis revealed that all parameters were statistically identical, with the exception of the right anteroposterior diagonal ratio 30, which was not fully corrected in the treated patients. The left anterior part of the head showed the most change in surface area maps.

CONCLUSIONS

In this pilot study, ESCH showed satisfactory results at 1 year, with improvements in all measured parameters compared to perisurgical results and normalization of 8 of 9 parameters compared to an age-matched control group. The results indicate that these parameters may be useful for craniofacial units for monitoring changes in head shape after ESCH for trigonocephaly and that 3DSPG, which avoids the use of anesthesia and ionizing radiation, is a satisfactory monitoring method.

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Alexandra Valetopoulou, Maria Constantinides, Simon Eccles, Juling Ong, Richard Hayward, David Dunaway, Noor ul Owase Jeelani, Greg James, and Adikarige Haritha Dulanka Silva

OBJECTIVE

Endoscopic strip craniectomy with postoperative molding helmet therapy (ESC-H) and spring-assisted cranioplasty (SAC) are commonly used minimally invasive techniques for correction of nonsyndromic sagittal craniosynostosis, but it is unclear which, if either, is superior. Therefore, the authors undertook a systematic review to compare ESC-H with SAC for the surgical management of nonsyndromic single-suture sagittal craniosynostosis.

METHODS

Studies were identified through a systematic and comprehensive search of four databases (Embase, MEDLINE, and two databases in the Cochrane Library). Databases were searched from inception until February 19, 2021. Pediatric patients undergoing either ESC-H or SAC for the management of nonsyndromic single-suture sagittal craniosynostosis were included. Systematic reviews and meta-analyses, single-patient case reports, mixed cohorts of nonsyndromic and syndromic patients, mixed cohorts of different craniosynostosis types, and studies in which no outcomes of interest were reported were excluded. Outcomes of interest included reoperations, blood transfusion, complications, postoperative intensive care unit (ICU) admission, operative time, estimated blood loss, length of hospital stay, and cephalic index. Pooled summary cohort characteristics were calculated for each outcome of interest. Methodological quality was assessed using the Newcastle-Ottawa Scale. The study was reported in accordance with the 2020 PRISMA statement.

RESULTS

Twenty-two studies were eligible for inclusion in the review, including 1094 patients, of whom 605 (55.3%) underwent ESC-H and 489 (44.7%) underwent SAC for nonsyndromic sagittal craniosynostosis. There was no difference between the pooled estimates of the ESC-H and SAC groups for operative time, length of stay, estimated blood loss, and cephalic index. There was no difference between the groups for reoperation rate and complication rate. However, ESC-H was associated with a higher blood transfusion rate and higher postoperative ICU admission.

CONCLUSIONS

The available literature does not demonstrate superiority of either ESC-H or SAC, and outcomes are broadly similar for the treatment of nonsyndromic sagittal craniosynostosis. However, the evidence is limited by single-center retrospective studies with low methodological quality. There is a need for international multicenter randomized controlled trials comparing both techniques to gain definitive and generalizable data.