Babies’ heads can look odd for a variety of reasons, some benign and some requiring prompt, expert care. Winson Ho, MD, describes the head conditions he commonly sees as referrals; explains how to evaluate macrocephaly and other issues; and describes current practices when treatment is needed, including the importance of timing. Bonus: View a remarkable video of endoscopic ventriculostomy for hydrocephalus.
Great. So, yes, so I'm gonna just talk a little bit about some of the most common referrals that I uh got for, get from the community, um, as mentioned, you know, I'm Winston Ho with the uh new faculty here at UCSF actually, um, and we're gonna talk about your, uh, we're gonna talk about macrocephaly, plagiocephaly, and hydrocephalus and cranial cystosis, some of the more common conditions we treat in pediatric neurosurgery. Um, just said as an introduction, I'm one of 4 pediatric neurosurgery faculty, um, Doctor, uh, Curtis Degas, Doctor Norman Gupta, Doctor Peterson and, my partner. Uh, we all 4 of us cover both the San Francisco, um, campus as well as the Oakland campus. Um, 2 of us are based mostly in San Francisco and 2 of us are Based mostly in Oakland. Um, and as mentioned, I also have a research, you know, effort. I have an NIH funded laboratory studying, uh, immuno, you know, immunotherapy for adult and pediatric brain tumors. Uh, so that's one of the, uh, reason I actually came here, um, just as a quick background, um, did my education in at Yale for both my undergrad and MD. I did my residency at the joint UVA NIH program followed by pediatric nursery fellowship at Salt Lake City. And then I've been in faculty at UT Austin, one of the new medical school actually, um, um, one of the first faculty who joined the department for about 3 years before I came here. Um, you know, in terms of the cases that I treat, this is a summary of the cases I did, you know, during that three years, um, you know, of course, as a pediatric neurosurgeon, one of the most common thing we deal with is CSF diversion, VP shunt, ETVs. I'm also doing a fair number of epilepsy followed by everything else that, um, sort of we deal with in the pediatric neurosurgical, um, uh, uh, practice. So, uh, as mentioned, I'm gonna talk to you about frequent referrals, uh, things that I see most often in my clinic here, and the first and foremost is big heads, macrocephaly, and, um, and, uh, oftentimes, uh, it is a typical, uh, of a growth curve like this when, um, you know, the head circumference or jumping percentile. So, um, so this is sort of a really, um, I think a good framework to think about macrocephaly. Um, most of the time, as we all know, uh, macrocephaly is benign, um, but usually we get concerned when you see that crossing percentile curve. On the head circumference chart. Um, and so I think it's very reasonable, depending on the age of the patient, obviously, um, to get an ultrasound if the fontanelle is still open or get a rapid MRI, um, and if the scan is normal and there's no signs of, of increased. Criminal pressure, uh, I think it's totally reasonable to follow. Now, um, of course, if there are signs of increased intralear pressure, um, referring to me, uh, or to us, it's, it's absolutely, um, I think the right thing to do, or if, you know, there's concern, um, you know, we could also be the ones who order those imaging as well. Uh, but usually I would, uh, the first thing I would do is get a head ultrasound or rapid MRI. So distinguish between macrocephaly and hydrocephalus obviously is very important because one is a benign condition and one is a malignant uh is a condition that required treatment. And the nice thing about infants is that unlike in kids, uh, unlike in adults, where if you have hydrocephalus, oftentimes it's sort of an emergency because you have increased acute increase in uh intracranial pressure. However, in infants because you have an open fontanelle, almost never is it an emergency where, um, even with somebody who had pretty significant hydrocephalus, um, and the reason is because the open fontanelle allow the, um, uh. to be alleviated like a sort of safety valve. And also the skull is pretty malleable, so, uh, it would manifest as an increase in, in head circumference rather than, you know, acute increase in intracranial pressure. Um, there are certainly times when, um, you know, we have to do things a little bit more urgently. It's pretty rare, but it's usually in the setting of, you know, persistent, uh, apneas and bradycardia, for example, or, you know, there's such a bad vomiting that you have dehydrate. or really severe down gaze palsy, those are kind of signs that we'd be more worried that there's sort of imminent, you know, um, you know, herniation and things like that, but it's pretty rare. Uh, but one of the physical signs and clinical signs that you look for between a benign microcephaly versus hydrocephalus, and the most important is a fontanel examination, obviously, you know, it's like a window to the pressure of the brain, um, you know, if, if hydrocephalus often is much more. Tends, usually the rule of thumb is that if the fontanella is pooching up above the level of the skull, um, uh, in a, a non-pulsating manner, that's something that you'd be worried about, um, uh, you know, on imaging finding, you know, hydrocephalus often, uh, more associated with the ventricular size, uh, whereas, uh, benign microcephaly is often associated with extraaxial fluid collection, which I'm gonna show you a little bit about. Um, other clinical signs including descended scalp veins, um, in hydrocephalus, um, slate sutures, uh, again, the rule of thumb is you run your finger over the sutures and you can fit your finger in there, um, that usually suggests that the sutures are splayed. Um, and of course the treatment, uh, is very different. Now this is obviously Concerning if you get an imaging like this, if you have vents that are this big, um. And that we would be concerned about hydrocephalus. Um, the, so the most common cause of hydrocephalus that we tend to see, um, is actually posthemorrhagic hydrocephalus, um, you know, as we know that are associated with premie IVH, um, so kids that are, uh, pre uh premature has higher uh higher, uh, tend to increased risk of having intraventricular hemorrhage, and that intraventricular hemorrhage is associated as posthemorrhagic. Hydrocephalus. Um, the other, uh, rather common things that we sometimes could see is a congenital reason of hydrocephalus is aqueductal stenosis, as you can see here in this image, where the, you know, this is the 3rd ventricle, this is the 4th ventricle, and this is aqueduct and kind of see a little veil, uh, right over the aqueduct that's blocking the normal flow of spinal fluid from the 3rd ventricle to the 4th ventricle and, and to the spine. Um, other, um, causes, common causes include post-traumatic, post infectious, spina bifida obviously is one, and then other things, other obstruction like tumor, uh, pusher fossil tumor or Dandy-Walker syndrome. The position to treat hydrocephalus is a critical one that's faced by pediatric neurosurgeon frequently. Sorry, um, it's acute adult setting. I'm sorry, hold on a second. Um, OK, and so when do we, so even if it's hydrocephalus, we oftentimes don't immediately, um, commit ourselves to treatment, um, because, um, because, as mentioned, You know, there's a a a a malleability of the of the skull. And so, um, even when I see big vents, unless, you know, there's, you know, clearly signs of increased hydrocephalus, we don't necessarily have to immediately uh uh um perform CSF diversion, uh, because, you know, doing a Ventricular part shunt or CSF diversion is, it's often, it's a lifelong commitment, right? And so there are definitely instances where you have what's called a reset hydrocephalus, where the ventricles are large, but then the patient do not have signs of increased hydrocephalus. In those cases, I would actually watch and wait. Now, what are the treatment of hydrocephalus? And I think, I think we all probably know the most common tried and true treatment strategy is uh ventricular peritoneal shunt. It's been done since the 60s. Um and it's really just, you know, uh, you know, establishing a bypass. Of the CSF from the brain to the belly to peritoneal space, uh, the peritoneal is the most common one, but of course it could be atrial or um uh um or a pleural if for whatever reason the the peritoneal space is not available or is hostile, um. Now, the other option that um we actually really want to consider when it's possible is uh what's called an endoscopic ventriculostomy. Um, and the idea is that um Uh, if there is some kind of obstruction, like, you know, aqueductostenosis that I've shown you, uh, we could actually go and create a space at the floor of the third ventricle to bypass any obstruction. So, um, as you would imagine, uh, it works better for certain types of, of hydrocephalus, such as obstructive hydrocephalus. If you have a tumor here, if you have a tectoglioma, for example, which oftentimes just block off the aqueductal space, um, this would be a great option because you just create an Bypass, um, that it could that the CSF that are produced up here can then drain into the precluntine cistern that could ultimately get reabsorbed into the into um uh into the uh venous uh outflow. Um. Uh, however, um, that's not, you know, 100%. There's certainly communicating hydrocephalus that could be treated, uh, with ETVs, um, that have a little lower success rate, but it still sometimes works. It's, you know, it goes to show that we don't completely understand the ideology, the path, uh, mechanism of, um, you know, hydrocephalus. Um, here's a, just a quick video, a quick picture in a video later on of what ETV is like. Uh, this is an endoscope that's placed in, uh, the lateral ventricle, and you're looking at the foramen roll here. This is the sep uh the septum, and this is the cord plexus. Um, and, you know, first we, you know, put the camera into the lateral ventricle, we'll be looking at the foramen monroe, and then we through the foramen monroe would be the uh the third ventricle, as you can see here, uh, we would then advance the camera a little bit further into the third ventricle. And then, uh, you know, identify the sort of anatomical structure with the mammary bodies, the infindibular recess, and then there's little veil that represents the floor of the third ventricle. And then we, uh, generally then, you know, insert an instrument and basically just poke a hole into the 4th on the floor of the 3rd ventricle. Um, the only thing that we sometimes most worry about anatomically is that the hole needs to be made right in front of the basal artery was kind of, uh, you know, socked in between the mammary bodies. So anatomically there are certain Uh, people who are, you know, very hard to do the ETV because there's not a very nice space between uh basil artery and the space that we could create. So we oftentimes get an MRI or even sometimes a CTA to identify that basil artery, cause, um, you know, while the risk is low, um, and it hasn't happened to me personally, but it's certainly reported that you could, you know, perforate a basil artery, and that could oftentimes be a fatal complication. Um, this is a sort of video of, of, so what we, you know, do during the, the case, you know, we already made a hole in the third of the ventricle. We can see how the, the, you know, the floor of the third ventricle sort of pulsate, uh, along the flow of the pulse uh pulsate. CSF and we put a little full uh uh a um a balloon through the hole that we created and try to expand that a little bit further. And then sometimes we could use an instrument to do that, as you can see here, um, and then. As we make the hole a little bit more bigger, we can actually then um put the camera in a little bit more closely, and then you would actually see a very beautiful anatomy where you can see the vasal artery, and sometimes you could actually see some pre-pontine scarring, uh, that oftentimes is, you know, a negative predictor of how likely the ETV is gonna. Work or not. Um, here you can see that we're repeating and putting a balloon in, try to, you know, expand that ostomy a little bit more, um, you know, with the idea that you don't want, you know, the, the tissue to be flopping around too much that it could scar back, um, cause that would be the primary reason why the ETV could fail. Um, and you can see. Now here we would then usually advance scope a little bit further, so we can actually take a peek uh at, you know, the anatomy and making sure that, you know, the membranes is all dissected off the liliquid membrane is dissected off, but that's the basil artery right there, that when you make the hole initially, you will try to avoid, uh, you know, injuring that cause that would be, um, you know, devastating. So, when this ETV works, you know, obviously, ETV is appealing for various reasons, right? Number one, it doesn't, um, uh, it doesn't require any foreign body, so it's not something that, um, you know, have, you know, high risk of infection and need for, um, uh, potential. vision in the future. Um, and so, um, however, it doesn't work that well in all circumstance. Um, most importantly, the age of the patient is a big predictor of whether the ETV success, uh, is successful or not. So this is called ETV success score score and the three main, uh, Variables the age, etiology, and whether that previous shunting or not. Um, and each point, uh, after you add it up, adds up to the percentage of success, uh, over, you know, in, in, in 2 years after the ETV. So, as you can see here, there's a big jump in success rate, uh, once you get past 1 year of age. Um. And then we know that, you know, as as mentioned, the etiology is important, so if you have a clearly obstructive etiology like ethmoductostenosis or tumor, that has, you know, high rate of success. Um, and then, um, and then whether you have a history of previous shunting or not, uh, alters that success a little bit, not that much, but by about 10%. Um, and so, um, oftentimes when I see infants who, um, who, uh, need hydro, uh, who need CSF diversion, I would offer, you know, VP shunt, uh, when they're really young, because ETV doesn't work that well in those situations. Uh, and then as they get older, It's always possible to go back and uh consider doing ETV, uh, because, um, uh, uh, because at that point, uh, you can the the ETV success is higher, and so, um, you could potentially render them shunt free. Uh, you take a little bit of a hit in terms of having a previous shunt, but not that much, by about 10%. So, um, so that's hydrocephalus, we talked about that, um, but what about the benign condition? The benign condition of, uh, of macrocephaly, um, it's often associated with this, um, enlarged subdural collection, um, and there's various names that you probably have heard. I call it bestie, benign enlarged subdenar space. Other people call it, you know, benign subdural effusion, benign hygroma, um, and it's oftentimes congenital. Um, one of the most common, the first thing I've often asked when I see someone with massrocephaly is, is there family members who have big heads, um, because oftentimes that's, uh, something that, that you that you have that family history. Um, and this is very characteristic. You, you know, see this jump in the percentile, and then it falls back to the, uh, and then it goes up to a very high percentile, and then it follows a growth curve and settled in a very high percentile. And so this is what the imaging often looks like, um, so instead of the being big, it's a subrenoid space that's enlarged and um however, it is important to distinguish a benign, you know, Bessie or subdural hygroma from a chronic subdural which we sometimes see with non-accidental trauma. Um, in this case, um, you could have increased increased pressure from a chronic subdural, in which case sometimes we have to put in either a temporary drain or even a subdural shunt. And the way you tell the difference is that because the cortical draining vein is in the subachnoid space, um, if you have an enlarged subachnoid space, you can clearly see the the draining veins in that in that enlarged space, whereas if uh if you have a subdural, which is Uh, more one layer superficial to the subarachnoid, um, layer, um, you have blood that's pushing the subarachnoid, the, the, the draining veins inside into the brain. You can see here, you don't see any veins or, you know, you see flow voids in the In the MRI that's, you know, suggests those are the veins, and here all the veins are pushed down against the surface of the brain. And so this is a picture of a chronic subdural compared to a benign enlarged nonar space. And almost always, um, you know, Bessie is something that you could continue to observe, um, very, very, very, very rarely do I have to treat, and I don't think I personally treated one, who have, you know, truly Bessie. Um, but, you know, as I said, chronic subdural is a different, it, uh, it's a different, um, condition that sometimes need treatment. And so the other frequent referral is a big uh is the odd head shapes, um, and Um, and so I'm just go over some of the most common, um, you know, craniosynostosis, uh, that we, uh, see, and, uh, what are the treatment options for those. Um, as we all know, um, our skull comprises of various different sutures. The sutures allows the skull to expand as the skull matures and enlarge, uh, to accommodate the growth of the brain. Um, so you have your metopic sutures, your coronal sutures, your sagittal sutures, your lamboid sutures. Each of these and, and squamosal, um, each of these sutures kind of have a different timing of, uh, fusion, uh, in a normal, uh, situation. I mean topic usually close pretty quickly within the first couple of months of, of life, and then sagittal close when you're in your 30. Um, so if you have premature closure of the sutures, then your skull is unable to expand in that, um, uh, orthogonal direction that the sutures are allowing you to expand. As a result, you have this abnormal head shape that are very characteristic of, uh, of one or if multiple sutures were to fuse. So, just go over quickly, um, uh, you know, each of those, um, the topic synososis, um, usually present fairly early on, as I said, because it closes, you know, uh, you know, the first few months of life. And so, when they prematurely close, it's usually when They're either fusing, you know, in uh fetally or soon after birth. And because, um, and the most characteristic head shape that it gives you is trigencephaly. And so you have this very, you know, characteristic, you know, triangle like head shape. Um, um, it's also not uncommon that we see this, uh, Um, metopic ridges that we see, which is, uh, which we sometimes see when the when this, uh, when the metopic sutures closed just a little bit, uh, earlier than usual, you see a very tiny, uh, uh, or sometimes palpable ridge that doesn't look like that, but it looks. Little bit sort of odd. Um, and in those cases, most of the time, they kind of even out over time, and we rarely have to operate on those. And, and so you generally, I would have a little bit higher threshold to really operate on topics and associates and that there's a pretty significant trigencephaly. And then sagittal, um, sagittal synostosis is the most common, um, this is the most common synostosis that we deal with, um, is when the sagittal suture closes prematurely. The satchel sutures allow you to expand your biparietal dimension. When this fuse prematurely, that cannot happen, and your skull kind of compensate and instead elongate um this way. And so it's very characteristic, you see this so long head shape. Uh the other characteristics include, you know, pretty significant frontal bossing or what. Called occipital bullet. Um, some people have more prominent, uh, frontal bossing. People think that that's because, you know, the anterior part of the, the sagittal stricture is what fused first, and that's what can get you the frontal bossing, or if you're further back, then you have a very prominent occipital bullet, so really pointy occipi. Um, um, but so this is very, very characteristic. And then the second more most common is after sagittal is a chronal synostosis, um, and oftentimes more commonly as a unilateral premature fusion, um, and in the in that case is the the side where it's fused, you can't expand, you can't expand your frontal, uh, your frontal bone so that the contralateral frontal bone become more prominent. And you also have this very characteristic sort of, you know, Harlequin deformity where your your orbital rim is kind of malformed compared to the other side. On the other hand, if you have, you know, fusion of both coronal sutures, then you have this sort of brachycephaly because both of your frontal, uh, bone cannot expand, and so you kind of compensate by having this really tall, you know, head shape. And, um, and, and so, you know, when you have um uh when you have more than one suture that fuses, oftentimes we worry about what's called a syndromic uh uh synostosis, uh, where in addition to just having isolated, you know, uh, a fusion of the uh of the suture, you have other Um, features associated with that as well. Uh, and in those cases, it's more likely that you would have increased intracranial pressure because, um, you have more than one sutures that are fused. And then the least common is the lambdoid synostosis. Um, it is important because, you know, it's just important to distinguish this from the way more, much more common thing which is the position of uh plegycephaly. When you have the lambdoid sutures being fused, um, your, um, what you see is that your ear, so on this side, which is the flat side of your head, which is the side where the suture is fused, your ear actually, um, um, uh, it's a pushed posteriorly, whereas you have contralateral frontal bossing. Um, so you almost have this trapezoid kind of head shape, um, and this is important because, you know, we also have flat head and as I said, you know, positional uh plegiocephaly is a more common thing, you know, we see, um, in which case, um, the head, the ears actually pushed forward and you have con uh you have ipsilateral frontal bossing rather than contra frontal bossing, and I'll have a picture of that to illustrate that in a bit. Um, and as I mentioned, when you have, um, multiple cranous, uh, sutures that fuse, oftentimes you worry about whether they're syndromic, and the syndromes are the ones that, um, have other associated abnormality, and the more common of the three syndromes of the Croissant. The aprons and the Pfeiffer, um, and as you probably know, um, these are associated with, uh, um, a lot of times, you know, cranial facial abnormalities such as, you know, a hyper hypertealarism or hyperplasia in croisson, uh, for apert, you have the syndactyly of, of the limbs. And, and for fiber you sometimes get some uh syndectomy must have this sort of peak nose and and sort of big toes, um, and as um. And as mentioned, um, you know, one of the things that we, uh, often talk about in treating, uh, cranial synostosis is whether, you know, there are two reasons to treat them, right? 11 is you know the deformity of the head, um, the the psychosocial aspect of your development, um, that's number 1. The number 2 is whether, um, there's increased intracranial pressure. Uh, when you only have a single suture cranous associated sporadic cases, um, the rate of increasing your pressure is probably not very high. Um, the studies that were done, you know, and, you know, years ago when they actually put an ICP monitor to actually measure, you know, in intracranial pressure in kids with Um, crinosynosis suggests probably 15-20% of the time you actually have borderline or high ICP, but when you actually have, um, uh, multiple crinosynosis that or in the setting of syndromic crinostosis. That rate is much higher. So obviously, if you have increased cranial pressure or signs of increased pressure, then we have to treat that. Uh, but I think in this country, you know, anybody who has even a sporadic cranial cystis would be offered treatment. Now, uh, this is one thing that I would actually is very important in terms of Timing of referral because um the treatment for craniocystosis is different if we get them early, um, because the skull at the at that time is less mature and we actually have more minimally invasive option to treat craniocystosis when they're between 3 to 6 months. And when they're older, beyond 6 months, um, the traditional method of doing a cranial vault reconstruction would be the sort of the only option, and I'll just quickly show a couple of pictures. Um, so when they're really young, um, at least over the last 1015 years, um, uh, we try to Identify more minimally invasive way to treat this, uh, these conditions. And now there are really two major, um, methods in, in addressing this. Um, it's, you know, in, in, in both of those is we'll first do a strip craniectomy to remove the few sutures. And then, um, in one option is to put in what's called springs. Um, so they are basically, you know, just like springs that you, um, that you can actually place to continually expand, um, the, the uh the the skull. After it's a temporary implant, so we usually, you know, place them here, for example, uh, between 3 to 6 months of age, and then we'll follow them up over several months and to see that the spring will continue to expand, uh, over several months. And most of the time, um, once the expansion is complete, your skull would almost, you know, have a pretty normal shape at the time, and then we go back and remove the springs. Now the other possibility is do a strip craniectomy and then uh do helmeting. Um, just doing cra strip craniectomy have been shown to not work, unfortunately. Uh, you do need help to sort of mold the shape into the shape that you want to correct that schirocephaly, in this case with the, uh, in, in this case with the sagittal cranial surfaces. Um, so in those cases, you would just take off the bone and then you put the patient in a helmet over several months. Um, every center do it a little bit differently. I've seen centers do it for, you know, 2 to 3 months, and I've, you know, also seen places where they do it 8 to 9 months. Uh, but obviously you have to be placed on a helmet for most. Uh, hours of the day. Um, and you also need to have a good ortho uh um uh orthotic company to help you potentially to modify the helmet, uh, depending on how, uh, how the outcome is, uh, how the progression of the head shape is. Um, so, when I was in Austin, Texas, um, you know, I've been doing mostly springs, but in training, I've done a lot of this helmeting. Uh, both works pretty well. Most of the papers that are looking at it, you know, demonstrate they have pretty equal effectiveness in, in terms of adequate correction of the deformity, at least for sagittal. And so these are, these are some of my, you know, cases and examples, you know, this is a very typical, you know, you know, sagittal stenosis you can see here, um, the sagittal suture is, is fused and have this really elongated head. Um, so what we did, as you can see here, you know, do a strict craniectomy and then we put in 3, sometimes 4 springs to basically yank this, uh, the skull apart so that you can increase the biparietal dimension. Of the skull. Um, and, you know, uh, and as I said, we generally put them in around 3 to 4 months of age, and usually by, you know, 6 to 9 months, the expansion is completed, and then we go back as a very small procedure to, you know, take the, take the, take the, um, the springs out. Now, uh, you know, obviously the, the downside of doing the sprints is that you basically commit yourself to two procedures, you have to go back and take them out. Uh, the upside is that you don't have to wear a helmet all the time. Uh, with the helmeting, uh, you're only doing one, procedure, but then you have to be on a helmet for a few months. Uh, this is another example of a single suture, a single cronal craniocentosis. Uh, we put the 22 springs in, um, and, uh, and I think this patient did quite well. We don't have to go back and do a cranial vault reconstruction, um, for that. And this is a helmet that you, uh, would have to place if you're gonna do the, um, helmeting. Um And then, uh, and, and if patients present, you know, older, um, older than 6 months, then uh we generally, because the skull at the time is already much more matured and the, um, malleability of the skull is much less than when they're younger, uh, the springs or the helmeting would not work, um, and so this is the typical, uh, queen of vault. Construction, um, where we basically remodel the, the, the, the skull by making bone cuts, um, and, you know, and, and plate them together, and there are very various ways to do this. Almost every center has some their little flavor of what they think makes it better, but oftentimes we just, um, you know, uh, you know, most of the data suggests that, you know. Those procedures are pretty comparable in efficacy. And then, um, and then, and then how to, um, as I mentioned, to distinguish the cranial cystosis from the positional plagiocephaly, which is a much more common phenomenon that we see, especially after the back to sleep, um, uh, uh, campaign that to show that, um, sleeping in the back is, is, is better. Um, it's often associated with torticollis, and it's most commonly you can just treat that with repositioning and tummy time. Um, and as I mentioned, the one important thing, um, to distinguish the positional platerocephaly is with, uh, lambdoid sutracranous synostosis, and it's a really easy way, um, to distinguish it, um, cause you remember, um, the, the previous picture where the um flat side, um. Uh, of, of the skull, have your, um, um, as your ear is being pushed posteriorly, uh, by the flat, you know, by the side that's, um, uh, fused, but in this case, uh, on the flat side, the ears pushed forward and so is your frontal bone, and so your, your frontal bossing is on the same side of your flat flat side of the head. And so, uh, that's sort of how you, um, distinguish, um, uh, positional plegycephaly from lambdoid craniocystosis. Now, again, lambdoid craniocystosis is the most rare type of single suture cranial cystosis, so it's way more likely and much more common to have positional plegycephaly. And how about treatment for positionally successfully as mentioned, conservative management is the most common. You can do reposition techniques if the patient has torticollis, um, you know, physical therapy. Now, if, um, if the improvement, uh, does not, uh, if The head shape doesn't improve over several months, and by age 6 to 9 months, there's still pretty significant for bossing or ear asymmetry, uh, then helmeting is also an option. Um, uh, you know, the downside to that is that a lot sometimes you, sorry. Um, sometimes the, the insurance doesn't cover it and it may require some adjustment, and also it needs to be worn, you know, as often as possible, you know, say about more than 23 hours a day. Um, uh, but it, it, but it is a benign condition and it's mostly for cosmesis that you do that for. So, that's all I have today and I'd be happy to answer any questions. Hopefully that's helpful and um Uh, be of some use, um.
