172 Chapter 10 This suggest aberrant venous outflow is congenitally defined in these patients, and remain recruited, even in a situation of normalized or treated ICP or ventriculomegaly. To answer the second question ‘Are there any secondary effects of ICH and treatment on the brain of operated syndromic craniosynostosis patients, focusing on ventriculomegaly, chiari and cortical thickness?’ with the studies undertaken in this thesis, ventriculomegaly and TH could be found as a cause of ICH with brain imaging. Screening on CBF reduction in relation to ventriculomegaly may be helpful in the follow up and treatment of ventriculomegaly in these children. We did not find a difference in the effect on cortical thickness (regional or global) comparing frontal and occipital primary vault expansion using brain imaging. Lambdoid suture synostosis showed to have a significant effect on the cortical thickness of the frontal lobe and cingulate gyrus. The possible impact of cortical thinning on neurocognitive development in craniosynostosis patients, needs to be investigated before drawing conclusions with respect to treatment. Also investigating the correlation of cranial shape and cortical thinning would give us information on the functional value of remodeling and reducing excessive height or volume. Future perspectives The identification of primary, inborn disorders of the brain as well as the identification of secondary brain disorders, their causes and their impact on outcome could guide us to a better screening policy with earlier and proper treatment to prevent sequelae. To gain more understanding about the development of the brain in patients with trigonocephaly, future work should focus on several areas. At the age of 0-2 years old, we did not identify a significant difference in brain properties between trigonocephaly patients and controls using DTI and ASL. However, we may have missed subtle anomalies. Next to genetic screening on syndromic trigonocephaly patients, it would be of value to look at new techniques for more detailed analysis. With the new baby free surfer pipeline future studies could assess white matter volumes, cortical thickness volume and the brain by a voxel-based analysis. At this age from 0-2 years old, new opportunities open up in DTI as well. The baby Freesurfer has just been released to allow automated segmentation and surface extraction pipeline for T1-weighted neuroimaging data of infants 0-2 years. 54 In the Erasmus MC an extension of segmentation and skull stripping training datasets using T2w samples is now studied, as well as the registration of the deformed brain. Cortical thickness as well as cortical surface are both still powerful biomarkers that have been used in many clinical studies to assess a variety of neurologic and neurodevelopmental outcomes.55, 56 Taking all of the above together, new innovative MRI techniques in relation to neurocognitive development assessment could improve risk stratification and expectation management of parents at the initial pre-operative MRI.
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