Journal article relating to the timing of metopic suture closure...

[Mindy]

and it isn't really old. One of the authors is actually the CFS we took Shane to at CHOP.

Metopic synostosis: Defining the temporal sequence of normal suture fusion and differentiating it from synostosis on the basis of computed tomography images.

<!--AuthorList-->Weinzweig J (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Weinzweig%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus), Kirschner RE (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kirschner%20RE%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus), Farley A (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Farley%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus), Reiss P (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Reiss%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus), Hunter J (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Hunter%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus), Whitaker LA (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Whitaker%20LA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus), Bartlett SP (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bartlett%20SP%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).
Division of Plastic Surgery, University of Pennsylvania Medical Center, Children's Hospital of Philadelphia, 19104, USA.
Only the metopic suture normally fuses during early childhood; all other cranial sutures normally fuse much later in life. Despite this, metopic synostosis is one of the least common forms of craniosynostosis. The temporal sequence of normal physiologic metopic suture fusion remains undefined and controversial. Therefore, diagnosis of metopic synostosis on the basis of computed tomography images alone can prove misleading. The present study sought to determine the normal sequence of metopic suture fusion and characterize both endocranial and ectocranial suture morphology. An analysis of computed tomography scans of 76 trauma patients, ranging in age from 10 days to 18 months, provided normative craniofacial data that could be compared to similar data obtained from the preoperative computed tomography scans of 30 patients who had undergone surgical treatment for metopic synostosis. Metopic suture fusion was complete by 6 to 8 months in all nonsynostotic patients, with initiation of suture fusion evident as early as 3 months of age. Fusion was found to commence at the nasion, proceed superiorly in progressive fashion, and conclude at the anterior fontanelle. Although an endocranial ridge was not commonly seen in synostotic patients, an endocranial metopic notch was virtually diagnostic of premature suture fusion and was seen in 93 percent of synostotic patients. A metopic notch was not seen in any nonsynostotic patient. The morphologic and normative craniofacial data presented permit diagnosis of metopic synostosis based on computed tomography images obtained beyond the normal fusion period.

http://www.ncbi.nlm.nih.gov/pubmed/14504503?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed

[*jules*]

thanks for sharing! :)

[Shar]

Wow! So interesting! I wonder what a "metopic notch" is or looks like.

Thanks for posting this, Mindy!

[Mindy]

Sharla, my daughter has what I believe to be a metopic notch which I first noticed when she was 5 months old. It kind of looks like she bumped her forehead. Its still there (and she's 3 1/2), but never was that noticable. I don't think her suture was fused when I first saw it, but I now know that it is since she has a faint metopic ridge. See if you can make out the notch on this picture:
http://i5.photobucket.com/albums/y175/mdion/riana51months011.jpg

[Shar]

First off, WHAT A SWEET GIRL!!! Love those eyes and her pink sweater outfit is adorable!

Okay, so I am confused because the article says "A metopic notch was not seen in any nonsynostotic patient" as in only patients with synostosis had the notch and 93% of synostotic patients had it, but no nonsynostotic patients did.:dunno

I googled:google metopic notch and mainly got your article as a result but also got a book that was explaining the frontal bones and mentioned that there are notches in the orbits. Do you think a metopic notch could be like a little crevice in the skull somewhere along the metopic? I saw one pic of a ct scan that showed a little u shape at the very front of the forehead. I'll look for it...

So, what'dya think???

[*jules*]

When Alex was born he had a huge bump between his eyes, right above the nose. I wonder if that is a metopic notch. I also don't think Alex's suture was completely fused at birth. I remember the pedi feeling his soft spot on his first couple well visits and said it felt fine. ???

[Shar]

Sorry for the crazy link but here it is...

http://books.google.com/books?id=ok_zi95JjPMC&pg=PA69&lpg=PA69&dq=metopic+notch&source=bl&ots=AGsPTPqH95&sig=Hbl_RaPxLvHVUHylyglNlNqKXYI&hl=en&ei=IVPhSfLsHobNlQeIqMXgDg&sa=X&oi=book_result&ct=result&resnum=2#PPA68,M1

[Shar]

On page 69:
"And the endocranial metopic notch in the region of the anterior portion of the superior sagittal sinus (fig. 14D2)"

Then, if you scroll up to page 68, you'll see figure 14 D2 that has the ct scan of the bird's eye and a little "u" shape notch???

[mummybeelee]

Wow! Interesting study. I think you are right that it is the little U shaped notch that can be seen on the CT. Endocranial means the inside of the skull iirc so an endocranial metopic notch wouldn't be seen or felt on the outside but could be seen on CT.

[Mindy]

Ok...I totally agree. The metopic notch is that teeny U shaped piece of missing bone in the last CT picture. And it is endocranial meaning that its inside the skull. So, I made up the metopic notch on my daughter :lol. But she did have some bump along her metopic suture. Thanks for clarifying this since I don't believe her to by synostotic anyway.

There was one other study with a smaller sample size which also showed the metopic suture closure early on in non-synostotic subjects. Here's the link:

http://www.ncbi.nlm.nih.gov/pubmed/11711818

[Shar]

That is so funny, Mindy! :laughing

So, now I want to break out H's CT scan and see if she has a notch! Wouldn't that be cool? I mean, not the notch itself, but just knowing something new about metopic synostosis and my dd, ha ha!

[Mindy]

Yes, please share with us!!! Do you have a digital copy of them?

[Shar]

I have a cd/DVD of her ct scan but I'm not on a computer right now. I'm on a iPod touch :) So, later I will check it out and if there's anything interesting, I'll either figure out how to post it or I'll just tell you about it.

[Shar]

Well, there were over 700 images on the disk and while it was cool to see, I couldn't tell if she has a notch or not. I didn't see one, but some of the pics were hard to tell what angle they were coming from.

[Mindy]

Well, it was worth a try!

[Mother of boys]

Ok, either I am just tired or maybe it is because I have a slight sinus headache or maybe I am just stupid, but what does all that mean? :o)

[Monica]

My head hurts too. I'm glad I didn't have all that info in front of me when I was trying to make a decision.

Sharla, I have an ipod touch too, but I can't imagine scrolling around it enough to actually type something significant. I hate that tiny keyboard. You have so much patience.

[Shar]

Monica, I love it for checking out ck! It's so much quicker than my pc! The keyboard isn't too bad since I'm usually typing with one finger even on a full size keyboard because I'm holding a kid or nursing the baby :o)

[mummybeelee]

Basic summary from my understanding of it (and bearing in mind that I have only read the Abstract and not the full study):

It is normal for the metopic suture to begin fusing as early as 3 months of age.
It is starts fusing at the nose and fuses up towards the anterior fontanelle.
It is normal for the metopic suture to be completely fused by 6-8 months ofmage.
On a CT scan, an "endocranial metopic notch" could be seen on 93% of patients with metopic cranio but not on any of the childen with no metopic cranio.
It appears that the metopic notch (U shaped notch on the inside of the metopic suture) is a permanent feature of metopic synostosis.
Therefore, using a CT scan to look for the metopic notch can diagnose metopic cranio even after the normal age of the suture being fused.

Obviously this is important info when looking at children past the age of normal closure (6-8mths for normal complete fusion) as at that stage, the suture being fused is not indicative of cranio. Seeing the metopic notch on CT however *is* indicative of cranio. (CT is needed as the notch is on the inside of the skull so not able to be felt or seen on the outside)

[Mindy]

Great summary, Bee!! I still think that experienced surgeons do not need a CT to diagnose metopic cranio. I actually went to one of the CFS's for Shane who coauthored the first article and he was completely against a CT. Said it wasn't necessary. I think the point of these studies was to show that the metopic suture does indeed close earlier than once expected. I believe that when we see a moderate to severe case of metopic cranio, the suture closed sometime in utero. But, if you read previous studies, they mainly state the closure between 1-2 years, where newer research is showing it to close sooner.

I was happy to find these studies since I first noticed Shane's ridge at around 3 months of age. So, to have these studies say that it can be normal to start closing this early, was reassuring.

[Shar]

I agree about the not always needing a ct scan for mild metopics. With H, she developed the ridge in utero. She was being watched by a ped. NS and a ped. CFS since she was 2 mo old. Neither recommended the ct scan until @ 12 mo old we and both drs were concerned that H might have partial sagittal closure. So at that point a ct scan was recommended and completed. We are glad we did it as it gave a clear view of H's skull and now we know that although she has a longer head than usual, the metopic is the only suture fused.

[Mindy]

I completely agree Sharla! If there is ANY doubt of it being more than the metopic fused, then I would absolutely agree to a CT scan.

[mummybeelee]

Oh yes ITA. The experienced surgeons can tell by looking and feeling what is going on and whether surgery is needed.
I think these studies are interesting both in giving a more accurate indication of when the metopic fuses (as you said far earlier than previously thought) and in giving a clear diagnostic indication if the surgeon is unsure for any reason.

It would be interesting to know if the mild metopic kids who don't need surgery have the metopic notch or if the presence of the notch would be one way to distinguish which kids will need the surgery. I guess for those of us in the mild camp, anything that would give a clear and difinitive answer would be good:lol

[Shar]

Yep!

Hey, Bee, when does your son go for the ct scan? That's strange that both he and my dd have (had, in our case) the questioning on whether they had sagittal along with metopic. Cool, tho that we can relate to each other :o) And Mindy, you too girl! I am so glad to have all your awesome insight and you posting these studies and such is so helpful!

[mummybeelee]

Yep!

Hey, Bee, when does your son go for the ct scan? That's strange that both he and my dd have (had, in our case) the questioning on whether they had sagittal along with metopic. Cool, tho that we can relate to each other :o) And Mindy, you too girl! I am so glad to have all your awesome insight and you posting these studies and such is so helpful!

Well we go to see the NS next week (Tue) and he will decide whether we need a CT or not apparently. I am guessing he may decide we don't need one as he is an experienced surgeon so might be able to diagnose without. If he is not sure then I guess he will refer us for a CT. If there is any doubt, then I think I will push for the CT for my peace of mind. Dr Fearon felt (from seeing the pics) that he has mild sagittal but was not sure whether he would need surgery. I am just praying that the NS next week can give us clear answers.

Your dd's sagittal was/is open right? Does she have a ridge along the sagittal? I have always susspected something going on with ds's sagittal due to his head shape but since he has developed the ridge is what has made the doctors more concerned.

It is so great to have this place for info and support and to know that you girls really do "get it" :adore