Estelle Vergnaud

Anterior fronto-orbital remodeling for trigonocephay

IntroductionTrigonocephaly secondary to the premature fusion of the metopic synostosis is associated to a risk of cerebral compression and several craniofacial morphological alterations. Numerous surgical techniques have been proposed. They all carry a risk of secondary temporal hollowingPurpose The aim of this paper is to describe the surgical technique used for trigonocephaly at the craniofacial unit of Hopital Necker Enfants Malades (French National Referral Center for Faciocraniosynostosis) focusing on its advantages and limitations. Resorbable osteosynthesis should be part of the current techniques.

Posterior remodeling flap for posterior plagiocephaly

IntroductionNonsynostotic posterior plagiocephaly has become the most common skull deformation since pediatricians have suggested the supine position for the newborns to reduce the risk of sudden death. Prevention of such a “positional” deformation or its management once it has occurred is mainly based on physical maneuvers such as physiotherapy and active positional corrective measures.Selection criteriaSurgical correction, however, may be suggested in rare cases where deformation of the skull is so severe or the referral of the child is so late that physical corrective treatment cannot be taken into consideration. Surgical management is based on the creation of a posterior bone flap to be repositioned after the opportune contouring and rotation.PurposeThe aim of this paper is to describe the surgical technique used for posterior vault remodeling in posterior plagiocephaly at the craniofacial unit of Hopital Necker Enfants Malades (French National Referral Center for Faciocraniosynostosis) focusing on its advantages and limitations.

Reducing blood losses and transfusion requirements in craniosynostosis surgery: an endless quest?

To the Editor: We read with great interest the recent papers and the joint editorial reporting intraoperative tranexamic acid use in craniosynostosis surgical repair, and we do agree with Holcomb’s point of view: “It works, but how?” and in whom? In our pediatric craniofacial surgical center we, as many others involved in cranisosynostosis surgical management, are still facing two problems that could be finally considered incompatible: uncompressible large blood losses proportional to suture involvement and surgical techniques, that remain difficult to precisely evaluate, and limited total blood volume in low-weight children. Reducing blood losses and transfusion requirements has been a major issue in the past 20 yr with active research on development of minimally invasive surgical techniques, autologous transfusion methods, and adjunctive medical treatments. Eliminating the need for intraoperative homologous blood transfusion could be considered as the final goal of these attempts, but remains, in daily practice, an inaccessible dream in malformations with multiple sutures, requiring complex surgical procedures. It could be only considered as a reasonable objective in children with scaphocephaly, requiring simple linear craniotomies. To be relevant, clinical studies have some prerequisites. The first one is the need for a valuable evaluation of peroperative blood losses, based upon calculation of estimated erythrocyte volume lost, that was used by Goobie et al., after others, but not by Dadure et al. The second one is a need for strict hemodilution guidelines with commonly defined transfusion thresholds, eliminating the biases related to overhydratation with inadequate fluid loading and underestimation of minimally required hemoglobin level. These issues are illustrated in the two papers that both concluded that tranexamic acid could reduce the need for blood transfusion. In Goobie et al.’s study, hematocrit threshold for blood transfusion was 30% (estimated hemoglobin 9 to 10 g/dl), all children were finally transfused, and calculated blood losses were significantly reduced with tranexamic acid. In Dadure et al.’s study, hemoglobin threshold was 7g/dl, 63% of the children did not have transfusions, and even though blood losses, which were not really estimated, did not differ between the two groups, the questioning conclusion was that tranexamic acid did decrease the need for transfusion. It could be concluded by readers either that tranexamic acid 50 mg/kg could reduce blood transfusion requirement by the means of reduced preoperative blood losses, or that tranexamic acid 15 mg/kg reduces blood transfusion requirement but not blood losses by the means of an unknown mechanism in children with acute normovolemic hemodilution. Despite well-designed, double-blinded, randomized studies, the authors should be aware that important issues for determining the efficiency of a medical treatment are the homogeneity of the study population, the size of the sample, and the reproducibility of the protocol in clinical practice. Both these studies included around 40 patients, with various surgical conditions ranging from severe syndromic faciosynostosis to simple scaphocephaly, and requiring various types of procedures. It has been previously clearly demonstrated that the type of malformation and the type of resulting surgical procedure is the main determinant of preoperative blood losses. Including, in a small sample of patients, numerous subgroups requiring various surgical managements could significantly attenuate the statistical power of a study. It could be therefore more efficient to further determine the benefit of tranexamic acid in a large, homogenous series of patients with simple suture involvement, the population who may most benefit from efficient adjunctive techniques to reduce intraoperative blood losses in craniosynostosis surgical repair. Finally, asunderlinedbyHolcomb,an importantquestion remains unanswered: If tranexamic acid could be efficient to reduce intraoperative blood losses and transfusion requirements in infants, how does it work?

The management of birth-related posterior fossa hematomas in neonates.

BACKGROUND Symptomatic posterior fossa hematoma in the term newborn is rare. OBJECTIVE To report on the management and outcome of posterior fossa subdural hematoma (PFSDH) in neonates. METHODS A retrospective analysis of the department database and clinical notes of neonates admitted since 1985 with a PFSDH was performed together with a literature review of similar case series. RESULTS Sixteen patients were included. The median gestational age was 40 weeks with a high proportion of primiparous mothers (n = 9) and forceps delivery (n = 9). Nine neonates had symptoms of brainstem dysfunction within the first 24 hours of life, whereas the other 7 had a delayed presentation (median 4 days) with signs of raised intracranial pressure due to hydrocephalus. Each patient had a cranial ultrasound followed by computed tomography scan that showed the PFSDH. Eleven neonates required surgical evacuation of the PFSDH, whereas hydrocephalus was managed by transient external ventricular drainage in 2 further patients. Eventually, 2 neonates required a permanent ventriculoperitoneal shunt. Five neonates had no operative intervention. With a mean follow-up of 7.8 years, 2 patients had mild developmental delay and 1 had severe developmental delay. The 13 other patients had a normal development. CONCLUSION In neonates with a PFSDH, surgery can be safely performed in those who have clinical and radiological signs of brainstem compression or hydrocephalus. A small number of neonates require a ventriculoperitoneal shunt in the long term. Initial aggressive resuscitation should be performed even in cases of initial severe brainstem dysfunction because of the good long-term neurological outcome.