Child's Nervous System

https://doi.org/10.1007/s00381-019-04288-9

FOCUS SESSION

The role of ICP overnight monitoring (ONM) in children

with suspected craniostenosis
J. Zipfel 1,2 & B. Jager 2 & H. Collmann 2 & Z. Czosnyka 3 & M. U. Schuhmann 1 & T. Schweitzer 2

Received: 17 May 2019 / Accepted: 30 June 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Purpose Secondary craniostenosis is a relevant problem pediatric neurosurgeons are confronted with and poses challenges
regarding reliable diagnosis of raised ICP, especially in case of absent or questionable papilledema. How to identify children
with elevated ICP is still controversial and diagnostics vary. We report on our experience with computerized ICP ONM in relation
to imaging derived parameters.
Methods Thirty-four children with primary or secondary craniostenosis and clinical suspicion of raised ICP were investigated.
We compared clinical signs, history, and radiographic assessment with the results of computerized ICP ONM. Differences were
significant at a p < 0.05.
Results Baseline ICP was significantly higher in patients with combined suture synostosis, who also had a higher rate of
questionable papilledema. Children with narrowed external CSF spaces in MRI had significantly higher ICP levels during
REM sleep. Mean RAP was significantly elevated in patients with multi-suture synostosis, indicating poor intracranial compen-
satory reserve. Syndromal craniostenosis was associated with elevated ICP, RAP was significantly lower, and skull X-rays
showed more impressions (copper beaten skull). RAP increased with more severe impressions only to decline in most severe
abnormalities, indicating exhaustion of cerebrovascular reserve at an upper ICP breakpoint of 23.9 mmHg. Headaches correlated
to lower ICP and were not associated with more severe X-ray abnormalities.
Conclusion Narrowed external CSF spaces in MRI seem to be associated to elevated ICP. Skull X-rays can help to identify
patients at risk for chronically elevated ICP. Severe X-ray changes correlate with exhausted cerebrovascular reserve as indicated
by RAP decline. Only ICP monitoring clearly identifies raised ICP and low brain compliance. Thus, in cases with ambiguous
imaging, ONM constitutes an effective tool to acquire objective data for identification of surgical candidates.

Keywords Craniosynostosis . ICP monitoring . Intracranial hypertension . Secondary craniostenosis

Introduction report on “normal” ICP levels in one-third of patients,

In 1982, Renier et al. performed ICP (intracranial pres-
sure) monitoring in 92 cases with craniosynostosis. They
M. U. Schuhmann and T. Schweitzer contributed equally to this work.
* J. Zipfel
julian.zipfel@med.uni-tuebingen.de
1
Division of Pediatric Neurosurgery, Department of Neurosurgery,
University Hospital of Tuebingen, Hoppe-Seyler-Str. 3,
72076 Tuebingen, Germany
2
Section of Pediatric Neurosurgery, Department of Neurosurgery,
University Hospital of Wuerzburg, Wuerzburg, Germany
3
Department of Clinical Neurosciences, Division of Neurosurgery,
Cambridge University Hospital, Hills Road, Cambridge, UK
borderline results in another third, and clearly pathologi-
cal measurement in the last third [20]. Identifying children
at risk for raised intracranial pressure is a relevant prob-
lem pediatric neurosurgeons are confronted with and
poses challenges regarding reliable diagnosis, especially
in case of absent or questionable papilledema. How to
identify children with elevated ICP is still controversial
and diagnostics vary from department to department.
Studies with intraoperative monitoring of ICP at primary
surgery have been conducted, showing a mean ICP pre-
decompression of 14.7 mmHg. The postoperative course,
though, is largely unknown [28]. The incidence of secondary
coronal synostosis approximates 10% in scaphocephaly after
craniectomy not involving the coronal sutures, with 1% re-
quiring surgical decompression in this series [2].

In untreated nonsyndromic unicoronal synostosis, raised ICP
shows no correlation with clinical and radiographic findings [12].
Syndromic craniosynostosis is associated with more frequent
ICP elevation. In Apert syndrome, up to 83% as cases had path-
ological intracranial hypertension. These cases usually show
higher rates of additional ICP raising pathologies like venous
hypertension, airway obstruction, and hydrocephalus [17].
Signs of raised ICP in patients with suspected secondary
craniostenosis can include headaches, fatigue, and papilledema.
In nonsyndromic single-suture synostosis, signs of postopera-
tive intracranial hypertension are reported to occur in about
6.2% of patients. The rate in patients with sagittal suture syn-
ostosis is highest, followed by metopic and unicoronal synos-
tosis. Children in need of re-operation were younger at first
surgery. In syndromic synostosis, the incidence of secondary
ICP elevation was between 10 and 37% [6].
Non-invasive methods of indirect assessment of ICP include
CT and MRI with their known severe limitations. ONSD con-
stitutes a valid sonographic tool to assess ICP; however, cut-off
values for the scenario of secondary craniostenosis are not yet
defined. Ophthalmological evaluation for papilledema is one of
the most important examinations with the known limitations
regarding compliance, age dependency, and especially the
known low sensitivity, implying that absence of papilledema
does not rule out ICP elevation [27].
Elevated mean ICP and increased B-wave height as well as
frequency are considered to be meaningful indicators of clinically
relevant raised ICP [3]. The definition of pathological ICP-
findings is not standardized, however. Some authors suggest a
mean ICP greater than 15 mmHg or more than three plateau
waves in 24 h as evidence of intracranial hypertension [17].
Others define the threshold at 20 mmHg [12] or use a combina-
tion of baseline as well as overnight ICP and plateau waves [22].
Evaluation of invasive ICP monitoring showed in cases with
inconclusive ophthalmologic findings that this technique can
help to identify children at risk, which was more frequent in
syndromic craniosynostosis [21]. In a study investigating
syndromic craniosynostosis, invasive monitoring showed a prev-
alence of 33.9% raised ICP [22]. Complex craniosynostoses
show intracranial hypertension in 47–64% of cases.
Secondary craniostenosis is an issue which seems to be
underrepresented in literature regarding clinical management
and follow-up of patients after surgery for single craniosynos-
tosis. In trigonocephaly, an incidence of 1.9% for raised ICP is
reported in patients after surgical correction. Stagnation of
head circumference correlates to intracranial hypertension [8].
In sagittal synostosis, prevalence of secondary
craniostenosis with elevated ICP is reported in about 5% and
in 4% of nonsyndromic children [7]. Interestingly, a rate of
postoperative secondary coronal suture synostosis has been
reported postoperatively in 89% of cases after nonsyndromic
sagittal suture repair with only a 3% incidence of intracranial
hypertension [15]. Other studies show an incidence of 6.9% of
Childs Nerv Syst
intracranial hypertension16 Thus, the rate of secondary
craniostenosis seems not high, but annual follow-up after sur-
gical repair of synostosis is recommended [16].
Some surgical techniques have been associated with higher
incidence of postoperatively raised ICP, as shown especially
for modified strip craniectomy [18]. In these cases, the role of
skull X-ray, especially after isolated sagittal synostosis repair,
has been evaluated and beaten copper appearance seems to be
suggestive for development of raised ICP.19 Syndromal multi-
suture synostosis, like in Saethre-Chotzen is more prone to
postoperative recurrence of raised ICP [1, 26].
The goal of this study was to evaluate—in the setting of
presumed secondary craniostenosis after primary surgery of
single-suture and syndromic synostosis or in primary
craniostenosis (untreated craniosynostosis in infancy)—the
correlation between routine diagnostics, comprising clinical
evaluation, skull X-ray and MRI, and computerized ICP over-
night monitoring (ONM), which offers apart from the ICP
values further calculated parameters for diagnostic assessment
like ICP amplitude and the correlation index between changes
of ICP and changes of ICP amplitude, called RAP as a param-
eter describing intracranial reserve capacity [10].
Materials and methods
Thirty-four children with clinical suspicion of mostly
secondary but also primary craniostenosis (older chil-
dren with craniosynostosis which were primarily left
untreated) and suspected raised ICP were included. We
compared clinical signs, symptoms, radiographic assess-
ment of skull X-rays, and MRI results with the results
of computerized ICP ONM. ICP monitoring was per-
formed using ICM+® (Cambridge Enterprise, https://
icmplus.neurosurg.cam.ac.uk/).
During ONM, ICP and associated parameters were calcu-
lated for total monitoring time, and separately for the so-called
baseline periods (non-REM sleep) and during REM sleep with
increased vasogenic ICP dynamics as published previously.24
ICP amplitude was calculated and expressed as AMP (first
harmonic of ICP amplitude after Fourier transformation),
and RAP is the correlation coefficient between 30 samples
of 10 s ICP averages and corresponding AMP values.
Twenty-five cases were monitored at the University
Hospital of Wuerzburg and 9 cases at University
Hospital of Tuebingen. Standard postoperative follow-up
of patients after craniosynostosis surgery comprises regu-
lar outpatient visits, photo documentation, morphometric
head measurements, and skull X-rays. Ophthalmologic
assessment was performed every six months. Clear
papilledema constituted an indication for surgery without
further ICP assessment.
Childs Nerv Syst
The used grading system for evaluation of skull X-rays is
based on previously unpublished own data [19]. Skull X-rays
were evaluated based on interpretation of Impressiones
digitatae by Davidoff 1936 [20] and Macaulay 1951 [21].
Four areas were examined separately: frontal, parietal, tempo-
ral, and occipital. Grade 0 is chosen for a skull without
impressiones. Grade I constitutes radiographs with mild
impressiones. In grade II, we include skull X-rays with
impressiones significantly over the average of grade I cases
in the first two life years. Grade III is chosen when extreme
impressions are seen in all quadrants. Also, localized and gen-
eralized impressiones can be differentiated, the latter compris-
ing abnormalities in at least two areas [25].
In Wuerzburg, skull X-rays play a major role in assessing
the likelihood of secondary craniostenosis and were routinely
performed as a screening tool. In cases with suspicious find-
ings, MRI imaging was often performed, followed by ICP
ONM. If skull X-rays showed minor changes without any
clinical signs or symptoms, there was only clinical and oph-
thalmologic follow-up. CT scans were not performed on a
regular basis.
In Tuebingen, skull X-rays were only performed when clin-
ical signs and symptoms pointed towards secondary
craniostenosis; otherwise, follow-up was comparable with
Wuerzburg.
Fig. 1 Examples of skull X-rays
and grading. a No abnormalities,
unsuspicious. b Mild abnormali-
ties. c Moderate abnormalities. d
Severe abnormalities
All skull X-rays were evaluated retrospectively and in
blinded fashion by a senior pediatric neurosurgeon (H.C.)
with extensive experience in craniofacial disorders and skull
X-ray diagnostics. X-rays were classified as still normal, as
mildly changed (grade 1), as moderately abnormal (grade 2),
and as severely abnormal (grade 3). Figure 1 shows corre-
sponding X-ray examples.
MRI scans were graded in a blinded retrospective fashion
with regard to the existence of normal or narrowed external
CSF spaces alongside the cortical surface.
Results
Patient characteristics
The mean age was 6.7 years (2.3–15, interquartile range 3.75).
The underlying synostosis was in 14 cases (41.2%) sagittal, in
9 cases (26.5%) coronal, in 8 cases (23.5%) combined sagittal
and coronal, in one combined frontal and sagittal, one
pansynostosis, and one parietotemporal suture synostosis.
Twenty-three cases (67.6%) were non-syndromal, 6 (17.6%)
were associated with Saethre-Chotzen-syndrome, two with
Crouzon syndrome, one with microdeletion syndrome, one
with neurofibromatosis type 1, and one with monosomy 9p.

Headaches were reported in 52.9% of patients. Three patients
(8.8%) had a questionable non-unambiguous papilledema.
Imaging results
In 4 cases (12%), a skull X-ray was not available. X-
rays were classified as normal in 3 cases (9%), in 10
cases (29%) as grade 1, in 9 cases (27%) as grade 2,
and in 8 cases (24%) as grade 3. There was no signif-
icant difference in the frequency of pathological skull
X-ray findings between non-syndromal and syndromal
children. Combined sagittal and coronal synostosis
showed significantly lower scores than isolated coronal
craniosynostosis (mean 1.29 ± vs 2.43±, p = 0.047).
There was no significant difference between other com-
bined or isolated craniosynostosis types.
MRI was classified as normal or abnormal (with
narrowed external CSF spaces) in 12 (35%) and 13
(39%) cases, respectively. Nine children did not receive
MRI. There was no significant difference in the fre-
quency of pathological MRI findings between non-
syndromal and syndromal children or between combined
and isolated craniosynostosis.
In children with moderate skull X-rays, narrowed external
CSF spaces were more common than in mild or none (82 vs
36% p = 0.030). Children with severe skull X-ray abnormali-
ties (group 3) on the other hand show significantly less
narrowed external CSF spaces (82 vs 50%, p = 0.040).
Pathological skull X-ray findings correlated with a higher
frequency of questionable papilledema, although the severity
of the findings did not (none vs mild p = 0.002, none vs mod-
erate p = 0.003, none vs severe p = 0.003).
Fig. 2 Comparison of ICPtotal in
different forms of synostosis. An
asterisk indicates significant
difference to sagittal synostosis
Childs Nerv Syst
Overnight monitoring
Regarding total monitoring time, mean ICPtotal in all cases was
18.0 ± 4.1 mmHg (range 13.1–32.0), mean RAPtotal was 0.58
± 0.11 (0.38–0.83), and mean AMPtotal (first harmonic of ICP
amplitude after Fourier transformation) was 1.59 ± 0.60
(0.90–6.0) mmHg.
Baseline ICP during non-REM sleep (ICP base ) was
15.7 mmHg (11–26, standard deviation 3.21), mean RAPbase
0.50 (0–1, 0.13), and mean AMPbase 1.15 ± 0.27 (1.0–2.0)
mmHg.
During REM sleep, mean ICPREM was 20.8 mmHg (14–
38, 5.12), with a mean maximum ICP of 38.28 (19–70, 9.72),
mean RAPREM was 0.69 (0–1, 0.13), and mean AMPREM was
2.08 (1.0–6.0, 1.0) mmHg.
Figure 2 shows the distribution of total ICP in sagittal,
coronal, and combined sagittal/coronal synostosis cases.
Comparing sagittal with combined sagittal and coronal synos-
tosis, we found significantly higher median ICPtotal (19.1 ±
4.73 vs 16.1 ± 2.35 mmHg, p = 0.049), and higher median
ICPbase (18.2 ± 3.75 vs 15.1 ± 2.12 mmHg, p = 0.020) in the
latter group. However, RAP and AMP were not significantly
different. Questionable papilledema was only found in com-
bined cases (38% vs 0%, p = 0.012).
When comparing isolated coronal synostosis with com-
bined cases, the differences in ICP were not significant any-
more. However, mean RAPbase was significantly higher (0.43
± 0.09 vs 0.54 ± 0.11, p = 0.040).
Comparing syndromal (n = 11) and non-syndromal chil-
dren (n = 23), median ICPtotal was significantly higher in
syndromal cases with values of 19.5 ± 5.46 vs 16.4 ±
2.94 mmHg (p = 0.033). The same was seen with mean
ICPREM (23.39 ± 7.00 vs 19.56 ± 3.50 mmHg, p = 0.039).
Childs Nerv Syst
All mean RAP parameters (total, baseline, REM) were signif-
icantly lower in syndromic children (e.g., mean RAPtotal: 0.49
± 0.07 vs 0.62 ± 0.10, p < 0.0001).
When RAP values were categorized according to X-ray
abnormality score, increasingly higher RAP values were seen
in group 1 (mild) and group 2 (moderate) as compared with
group 0 (normal), only to decrease in group 3 with severe
abnormalities (see Fig. 3). Analysis showed significantly
higher mean RAPtotal in both mild and moderate as compared
with none (mild 0.45 vs 0.61, p = 0.003, moderate 0.45 vs
0.65, p = 0.018). No difference in RAP was seen between
severe and no X-ray abnormalities.
All mean RAP parameters were significantly higher in mild
and moderate craniosynostosis as compared with severe (e.g.,
RAPtotal: mild 0.61 vs 0.53 p = 0.036, moderate 0.65 vs 0.54
p = 0.026). During baseline and REM sleep, the differences of
ICP were not significant. In mild and moderate compared with
severe abnormalities, the difference of mean RAPbase was sig-
nificant (0.42 ± 0.104 vs 0.54 ± 0.117, p = 0.021) (see Fig. 3).
During baseline and REM sleep, the differences of ICP were
not significant.
Choosing an ICP cut-off of 20 mmHg over the total measur-
ing time to dichotomize our data resulted in a significant differ-
ence in median as well as mean RAP during REM sleep (mean:
0.71 ± 0.10 vs 0.58 ± 0.17; p = 0.013, median: 0.76 ± 0.10 vs
0.65 ± 0.16; p = 0.031). This correlation was also true the other
way around. An RAP during REM sleep under 0.6 was asso-
ciated with significantly higher ICP during total monitoring
time as well as REM sleep (total: 21.5 ± 6.56 vs 16.53 ± 2.76
p = 0.013; REM: 25.3 ± 8.70 vs 19.8 ± 3.54, p = 0.015).
We plotted ICP and AMP during ICP plateau waves (REM
sleep phases) to estimate the upper breakpoint using bilinear
approximation in all X-ray groups according to Fig. 4. The
average upper breakpoint in cases with severe X-ray
Fig. 3 RAP value distribution
according to skull X-ray abnor-
mality score; an asterisk indicates
significant differences to both
none and severe abnormalities
abnormalities (group 3) was found to be at a mean of
23.9 mmHg during ICP plateau waves. In radiographically
moderate craniosynostosis (group 2), such a breakpoint could
be found at a mean of about 25.4 mmHg, in some cases
reaching values of 30 mmHg and higher. In cases with none
or mild radiographic features, no reliable breakpoint could be
identified.
In 4 cases (12%), ONM results were interpreted as still
normal and surgery was not recommended. In 11 cases
(32%), findings were judged as borderline, and in 4/11 cases
(45%), parents decided against surgery. In 19 patients (56%),
monitoring indicated significantly raised intracranial pressure
and surgery was strongly recommended. In all cases, parents’
decisions were in favor of surgery (Fig. 5).
Discussion
Non-invasive imaging techniques like skull X-ray and MRI
can help identify children with craniosynostosis at risk for
chronically elevated ICP by describing indirect signs possibly
related to raised intracranial pressure. However, images can-
not replace pressure recordings, especially in cases of absent
or questionable papilledema, since an as much unambiguous
finding as possible should back any decision to a major sur-
gical intervention. This study shows that ONM of ICP consti-
tutes a safe and unequivocal tool to prove or rule out chroni-
cally or periodically (at REM sleep) elevated ICP. Similar
findings showed a case series of intraoperative ICP monitor-
ing in delayed sagittal synostosis cases and showed a rate of
81.8% cases with significantly raised ICP [22].
As described earlier, the cut-off values for pathological ICP
monitoring are considered to lie between 15 and 20 mmHg
and 3–5 plateau waves over a 24-h monitoring period [3, 12,
 Childs Nerv Syst

Fig. 4 Example of severe plateau

wave in a child with
craniosynostosis, starting from a
baseline situation with already
elevated ICP and AMP and high
RAP during this baseline. RAP
drops during the plateau wave.
The bilinear approximation
determines an ICP breakpoint of
about 38 mmHg. Case example
provided by MC from
Cambridge, not included in this
series

17, 22]. In our series, ICP values were generally high with a
mean ICP over the total monitoring time of 18 mmHg.
Tamburrini et al. using intracranial pressure monitoring
with calculation of derived parameters showed that the role
of copper beaten appearance on skull X-ray has a low sensi-
tivity and specificity regarding identification of children with
intracranial hypertension. Furthermore, as confirmed by this
study, they saw the highest diagnostic value in prolonged—
not just intraoperative—ICP monitoring. The diagnostic lim-
itation [23, 24] of skull X-ray findings to rule out pathological
intracranial pressure can be re-evaluated by this study which
provides a good correlation of imaging data not to ICP but to
the derived parameter RAP.
RAP as an index of compensatory reserve was increased in
patients with syndromic craniosynostosis, pathological X-ray
findings (group 1 and group 2), and more than one premature
closed suture, indicating an increasing impairment of reserve
capacity. Most importantly, the most severe X-ray findings in
group 3 correlated to a decrease of RAP.
One problem with skull X-rays is the shortcoming of
imaging classification systems, which are always subjec-
tive as long as they do not contain measurable variables.
Furthermore, more obvious impressiones digitatae are
physiologically seen between five and eight years of age
[19]. In our study, the senior surgeon that scored the
images was blinded to the case information and to the
ICP results, so we considered the correlations found as
valid, which is a relevant finding. However, in the indi-
vidual patient’s case, when the surgeon is affected by
clinical information, a skull X-ray information might not
be sufficient to decide alone about surgery.
The fact that RAP had a good correlation to increasing
skull X-ray abnormalities (none–mild–moderate) indicates
that the low compensatory reserve situation, which per se
results in an unphysiological intracranial “tightness” and
higher ICP dynamics, is probably a major driving force for
the chronic changes of the bone. This supports the use of skull
X-ray as an easy screening approach to the problem.
The finding that RAP decreases or was lower in those
cases with the most severe skull X-ray changes can be
explained by either a compensatory effect of the thinning
of the skull by gaining some additional intracranial space
or creating unexpected elasticity of the skull (by creating
holes in the bone), which both might increase the intra-
cranial compliance again. In favor of this hypothesis is the
fact that the external CSF spaces were more often normal
in the group of patients with severe X-ray changes than in
those with mild or moderate changes.
Alternatively, it has been described in TBI patients that the
positive correlation of higher ICPs to higher AMP values

Fig. 5 Overnight recording of a

child with craniosynostosis and
multiple plateau waves during the
night. RAP is low during low
ICPs at baseline, increases at
increasing ICP to decrease at the
plateau pressure, when
cerebrovascular reserve is
exhausted and CBF most likely
compromised. Case example
provided by ZC from Cambridge,
not included in this series
Childs Nerv Syst
(which results in higher RAP values) has an upper breakpoint,
where the compensatory reserve is exhausted, autoregulation
fails, which results in loss of correlation of ICP amplitude
(AMP) to mean ICP, with a decreasing RAP despite higher
ICP values [11].
The ICP values associated with an upper break point of
RAP in TBI cases are described in the range of 19–
25 mmHg [5]. When ICP reaches a critical level the AMP-
ICP relationship can thus become negative [9, 19]. Indeed,
choosing an ICP cut-off of 20 mmHg over the total measuring
time to dichotomize our data resulted in a significant differ-
ence in median as well as mean RAP during REM sleep. This
correlation was also true the other way around. An RAP dur-
ing REM sleep under 0.6 was associated with significantly
higher ICP during total monitoring time as well as REM sleep.
The fact that the breakpoint-associated ICP values in group
3 were lower than in group 2—and were corresponding more
to those described in TBI patients—might indicate that there is
a more compromised pathophysiology as in TBI, e.g., on the
venous outflow side in the specific setting of secondary or
primary craniostenosis in older children. This means, that in
group 2, cases reserve capacity seems to be, although already
compromised, still greater and later exhausted than in group 3,
so that decompensation happens at higher ICPs. In cases with
none or mild radiographic features, no reliable breakpoint
could be identified.
In support of the hypothesis that a lower RAP is a sign of
more severe compromise of reserve capacity is the fact that
syndromic children with multiple suture synostosis had more
severe changes in skull X-ray, higher ICPs, and lower RAP
values.
Up to this day, it is difficult to recommend a uniformly
valid follow-up algorithm for children with craniosynostosis.
Especially in non-syndromal craniosynostosis, no proper
guidelines exist concerning the diagnosis of possible chroni-
cally elevated ICP. Long-term follow-up of nonsyndromic
craniosynostosis shows that children lie within the normal
range of intelligence but a discrepancy between verbal and
performance IQ has been reported [4].
Hyward elaborated on the interaction between ICP, CPP,
and obstructive sleep apnea in complex craniosynostosis in
syndromal children [13]. Even in mild craniosynostosis, high
rates of developmental delay and learning disability have been
shown [14]. It remains however unclear, if those
neurocognitive deficits are either related to chronically elevat-
ed ICP or to underlying genetics or even result from early ICP
increases in the first months of life before initial treatment.
Conclusion
Thus, we conclude that ICP monitoring is able to create ob-
jective data on the existence of generally or periodically raised
ICP in cases with moderate to severe skull X-ray changes. The
addition of ICP amplitude derived computed information on
intracranial reserve capacity (RAP Index) enhances the diag-
nostic gain by the identification of an exhausted status. Higher
RAP especially during REM sleep can be considered a sign
for a diminished compensatory capacity, but with still some
reserve. Existence of a rather lower RAP in moderate to severe
skull X-ray changes indicates that the reserve capacity is al-
ready exhausted, and cerebrovascular integrity affected by
rising ICP, and that surgery should be performed rather earlier
than later.
Compliance with ethical standards
Conflict of interest On behalf of all authors, the corresponding author
states that there is no conflict of interest.
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