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Updated: Aug 15, 2026
Midface Hypoplasia and Cranial Base Morphology in Syndromic Craniosynostosis: A Comparative Analysis Study Using a Predictive Regression Model
Published on: November 4, 2025
Positional skull deformities in children: skull deformation without synostosis
Juan F Martínez-Lage1, Antonio M Ruíz-Espejo, Amparo Gilabert
1Regional Service of Neurosurgery, Virgen de la Arrixaca University Hospital, 30120 Murcia, Spain. juanf.martinezlage@carm.es
Insights
Positional skull deformities in infants may be linked to cerebrospinal fluid (CSF) space changes, with enlarged spaces tending to resolve with age. Brain pulsations may influence these skull shape developments.
Area of Science:
- Pediatric Neurosurgery
- Developmental Pediatrics
- Neuroradiology
Background:
- Craniosynostosis is diagnosed clinically and via neuroimaging; surgical intervention prevents neurological deficits and corrects deformities.
- Nonsynostotic skull deformities, particularly positional plagiocephaly, are increasingly common, prompting neurosurgical consultation.
- Abnormalities in cerebrospinal fluid (CSF) spaces have been noted in children with craniosynostosis.
Purpose of the Study:
- To investigate the association between cerebrospinal fluid (CSF) space alterations and the development of positional skull deformities in children.
- To compare CSF space findings in infants with nonsynostotic skull deformities versus those with benign extracerebral fluid collections.
Main Methods:
- Retrospective review of demographic, clinical, and neuroimaging data from 23 infants with nonsynostotic skull deformities (Group A).
- Comparison with 9 infants diagnosed with benign extracerebral fluid collections (Group B).
- Analysis included head circumference (HC) measurements and clinical presentation details.
Main Results:
- Sixteen of 23 infants (69.5%) with nonsynostotic deformities had enlarged subarachnoid CSF spaces.
- Infants with positional deformities presented later (mean 12.7 months) than those with fluid collections (mean 7.17 months).
- Enlarged CSF spaces in nonsynostotic cases were age-related and tended to resolve over time.
Conclusions:
- Positional head deformities are primarily attributed to infant sleeping positions, not macrocephaly.
- Brain pulsations transmitted to CSF accumulations may contribute to the development of infant skull deformities.
- Abnormalities in CSF spaces in positional deformities differ from those in benign extracerebral collections and are age-dependent.
Background:
Patients with craniosynostosis are readily diagnosed by clinical and neuroimaging findings. Surgical treatment is indicated for preventing neurological deficits and for correcting esthetically unacceptable head deformities. In recent years, we have witnessed a progressive number of neurosurgical consultations for abnormal head shapes unrelated to premature fusion of the cranial sutures, especially of positional plagiocephaly. There have been descriptions of abnormalities in the cerebrospinal fluid (CSF) spaces in children with craniosynostosis.
Objectives:
The aim of the present study was to investigate the role of the changes of the CSF spaces in the development of positional skull deformities in children.
Patients And Methods:
The authors reviewed demographic, clinical, and neuroimaging data of 23 patients assessed for some form of nonsynostotic skull deformity (group A). The results were compared with those of a simultaneous group of nine infants diagnosed with benign extracerebral collections of fluid (group B).
Results:
The study group was composed of 11 boys and 12 girls, aged 3 years or younger. Seventeen children had plagiocephaly, four scaphocephaly, and two brachycephaly. Sixteen children (15 with plagiocephaly and 1 with brachycephaly) exhibited enlarged subarachnoid CSF spaces. In group B, the boy/girl ratio was of 7:2. Infants in group A presented at an older age (mean 12.7 months) than group B (mean age at presentation of 7.17 months). Children with benign extracerebral fluid collections were born with a head circumference (HC) greater than infants with positional skull deformities (p=0.005). The percentile of the children's HC at consultation was also larger for children of group B (p=0.03). The form of clinical presentation differed between the two groups. Most infants of group A were seen because of a type of head deformity, and children in group B were studied for macrocephaly. Long-term follow-up assessment showed better outcomes for patients in group B than for children of group A in regard to regression of initial symptoms (p=0.03).
Conclusions:
Most positional head deformities appear to be related with the children's positioning for sleeping. We have not confirmed macrocephaly as a contributing factor for positional deformities. The distribution of extracerebral CSF and the presence of abnormal collections of fluid in children with positional head deformities do not seem to be related with the findings of pericerebral CSF encountered in children with benign extracerebral collections of fluid. In our view, brain pulsations, transmitted to these accumulations of CSF, play an important part in the development of the infants' skull deformities (p=0.02). The findings of enlarged CSF spaces in children with nonsynostotic skull deformation constituted an age-related event, as these collections tended to disappear as the children grew older (p=0.04).
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