59 Cerebral Blood Flow | Trigonocephaly matched healthy pediatric population is important and essential if we want to translate cerebral blood flow values to the clinical treatment or surgical approach. Second, our control group consisted of patients who underwent magnetic resonance imaging examination for clinical reasons in which magnetic resonance imaging and clinical course showed no cerebral pathology. Patients and controls were not agematched exactly. There was a small age difference between the groups, which may have produced an additional mean cerebral blood flow difference of −0.3, 0.12, and −0.06 ml/100 g/min (for the three presented models) between the groups, which would have either reduced the group difference or not changed it significantly.25 Third, we did not differentiate between gray and white matter when evaluating the mean regional cerebral blood flow due to the absence of T1-weighted image segmentation. Instead, the mean parenchymal cerebral blood flow was assessed per region. Gray matter perfusion is around two times higher than white matter perfusion in pediatric populations, and joint evaluation of gray matter and white matter signals can bias the cerebral blood flow analysis if gray matter and white matter volumes differ significantly between groups.25, 26, 28 However, such volumetric difference between gray matter and white matter is not expected; thus, we estimate that this had no influence. More advanced analysis is planned that uses T2-weighted and diffusion tension imaging magnetic resonance images to aid the segmentation and study the partial volume- corrected gray matter cerebral blood flow.29 As the study of Carsin-Vu et al. among pediatric patients found no difference in cerebral blood flow between patients using different types of anesthesia, we did not take these factors into consideration in our analysis.25 We did not find a significant effect of sex on cerebral blood flow in our cohort (p = 0.09). This finding is similar to that of other pediatric arterial spin labeling studies, such as those by Duncan et al. (p = 0.70), Wong et al. (p = 0.683), and Carsin-Vu et al. (p = 0.16), which also demonstrated that sex did not have a significant effect on cerebral blood flow.25, 27, 30 CONCLUSIONS The fact that we were unable to detect abnormalities in cerebral blood flow in untreated moderate to severe trigonocephaly patients less than 18 months of age as compared to control subjects supports a more conservative approach to prevent potential overtreatment of patients with reported very low prevalence of papilledema and impaired skull growth, this finding further supports our hypothesis that craniofacial surgery for trigonocephaly is rarely indicated for signs of raised intracranial pressure or restricted perfusion in patients younger than 18 months. Future studies should focus on assessing outcomes related to Cerebral blood flow, intracerebral hemorrhage, and neurocognition in unoperated versus operated trigonocephaly patients during follow-up. 3
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