Neurodevelopmental Outcomes in Infants with Non-Syndromic Trigonocephaly: A Comparative Study of Surgical and Non-Surgical Management

Neurodevelopmental Outcomes in Infants with Non-Syndromic Trigonocephaly: A Comparative Study of Surgical and Non-Surgical Management | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Neurodevelopmental Outcomes in Infants with Non-Syndromic Trigonocephaly: A Comparative Study of Surgical and Non-Surgical Management Omid Yaghini, Reyhane Eslamian, Reza Nejad Shahrokh Abadi, Neda Hosseni Moshkenani, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8631558/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Objective This study investigates the neurodevelopmental outcomes of infants with non-syndromic trigonocephaly managed surgically and conservatively. The aim is to assess whether earlier surgical intervention influences cognitive, language, and motor development at 12 months of age. Methods This retrospective cohort study included 16 children diagnosed with non-syndromic trigonocephaly. Seven underwent surgical intervention between three and six months, while nine were managed conservatively. Neurodevelopmental assessment was performed at 12 months using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III). Composite scores for cognitive, language (receptive and expressive), and motor (fine and gross) domains were compared using parametric or non-parametric tests based on Shapiro–Wilk normality assessment. Results No statistically significant differences were observed between surgical and non-surgical groups across all composite domains. Cognitive composite scores were 109.29 ± 11.34 (surgical) versus 101.67 ± 15.21 (non-surgical; p = 0.288). Receptive language scores were 107.00 ± 13.64 versus 100.78 ± 11.69 (p = 0.299); expressive language scores were 107.00 ± 13.64 versus 101.11 ± 12.18 (p = 0.378); fine motor scores were 99.86 ± 10.24 versus 93.22 ± 15.59 (p = 0.348); and gross motor scores were 99.86 ± 10.24 versus 96.22 ± 16.39 (p = 0.528). Mean scores in both groups fell within the normative range (100 ± 15), and classification into normal (≥ -1 SD) or below-normal ( 0.05 for all domains). Conclusion In this small cohort, surgical correction of non-syndromic trigonocephaly performed at or before six months did not result in statistically significant differences in neurodevelopmental outcomes at 12 months compared with conservative management. Non-syndromic trigonocephaly Neurodevelopmental outcomes Surgical intervention Pediatric neurology Figures Figure 1 1. Introduction Non-syndromic trigonocephaly, a subtype of single-suture craniosynostosis, results from the premature fusion of the metopic suture, leading to a distinct triangular forehead shape and potential intracranial and developmental complications ( 1 ). It characteristically presents with a triangular forehead, bi-parietal widening, and hypotelorism, with metopic synostosis being reported as the second most common isolated suture craniosynostosis ( 2 ). Although the principal indication for surgical correction has classically been aesthetic restoration of fronto-orbital shape, clinicians have also been concerned about the potential for intracranial hypertension (ICP) and restricted cranial growth to adversely affect neurodevelopment. Reported prevalence of raised ICP in trigonocephaly varies widely across studies, and direct evidence linking raised ICP in isolated metopic synostosis to later neurocognitive outcomes is inconsistent ( 3 – 6 ). Independent of ICP, several cohort studies have demonstrated modest but reproducible increases in the risk of neurodevelopmental and learning problems among children with single-suture craniosynostosis when compared with unaffected peers ( 3 – 6 ). These deficits are often subtle in infancy and may become more apparent at preschool or school age. Therefore, routine developmental surveillance has been recommended for affected children ( 7 , 8 ). Despite these concerns, the neurodevelopmental implications of early surgical intervention remain a topic of ongoing debate. Some studies have reported improvements following surgical intervention, while others suggest minimal or no benefit compared to conservative management ( 9 – 13 ). Furthermore, while most children with non-syndromic craniosynostosis perform within the normative range on developmental assessments, they may remain at a higher risk for subtle delays compared to their peers ( 9 – 13 ). The Bayley Scales of Infant and Toddler Development (BSID) are widely used to evaluate developmental domains in infancy, providing valuable insights into cognitive, language, and motor outcomes ( 14 ). Assessing these outcomes in children with trigonocephaly is crucial to understanding the role of surgery in shaping developmental trajectories and guiding clinical decision-making. In this study we compare BSID-III composite scores at 12 months between infants with non-syndromic trigonocephaly managed surgically at or before 6 months, and those managed conservatively, with the aim of characterizing short-term neurodevelopmental outcomes and informing the need for longer-term surveillance. 2. Methods 2 − 1. Study Design and Participants This retrospective cohort study was conducted at a tertiary children’s hospital. All infants diagnosed with non-syndromic trigonocephaly over a period of 2 years were eligible for inclusion. Diagnosis was established by a pediatric neurologist based on clinical examination and confirmed with cranial imaging when indicated (Fig. 1 ). Exclusion criteria included syndromic craniosynostosis, other craniosynostosis (e.g. scaphocephaly or plagiocephaly), multiple suture involvement, or comorbid conditions that could confound neurodevelopmental outcomes (e.g., genetic disorders or prematurity). The study protocol was approved by the ethics committee (ethics ID: IR.MUI.MED.REC.1402.187) 2–2. Interventions and Assessments A total of 16 infants were identified and divided into two groups, and were classified based on their surgical history into two distinct groups: those who have undergone surgical intervention and those who have not. Infants in the surgical group underwent treatment between 3 and 6 months of age, performed by a pediatric neurosurgeon. The conservative group received routine monitoring without surgical intervention. Head circumference was measured at birth and 12 months of age using standardized techniques and reported in centimeters. Neurodevelopmental assessments were conducted at 12 months of age using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III; published 2006) ( 14 ). This allowed for standardized assessment for raw, scaled, and composite scores across cognitive, receptive and expressive language, fine motor, and gross motor domains. Composite scores, which standardize performance to a mean of 100 ± 15, served as the primary outcome measures. 2–3. Statistical Analysis Data were analyzed using IBM SPSS Statistics version 26. Continuous variables are presented as means ± standard deviations (SD), and categorical variables as frequencies and percentages. Normality of composite scores was assessed using the Shapiro-Wilk test. Between-group comparisons were performed using independent t-tests for normally distributed variables and Mann-Whitney U tests for non-normally distributed variables. All tests were two-tailed with a significance level of P-value < 0.05. 3. Results 3 − 1. Participant Characteristics A total of 16 infants were included in the study (9 males, 7 females). The study population included all patients that met the inclusion criteria admitted over a 2-year period to the children’s hospital, whose parents gave explicit permission for study. Seven underwent surgical intervention (4 males, 3 females), and nine were managed conservatively (5 males, 4 females). No significant baseline differences were noted between groups except as reported below. Two patients, one in each group, had a positive family history of trigonocephaly. Five of the participants were part of twin births, wherein 2 pairs both had trigonocephaly, while only one of the last pair was affected. 3 − 2. Head Circumference Measurements Head circumference measurements at birth and 12 months, along with growth from birth to 12 months, are summarized in Table 1 . The surgical group had a slightly higher mean head circumference at birth (34.19 ± 0.95 cm) compared to the non-surgical group (33.14 ± 1.31 cm; P-value = 0.1). At 12 months, means were 46 ± 1.41 cm (surgical) and 45.16 ± 1.82 cm (non-surgical; P-value = 0.329). Head circumference growth was comparable between groups (11.81 ± 0.56 cm surgical vs. 12.01 ± 1.92 cm non-surgical; P-value = 0.798). Table 1 Comparison of head circumferences (cm) between groups. Measurement Surgical Non-Surgical P-value At Birth 34.19 ± 0.95 33.14 ± 1.31 0.1 At 1 Year 46.00 ± 1.41 45.16 ± 1.82 0.329 Growth 11.81 ± 0.56 12.01 ± 1.92 0.798 3–3. Neurodevelopmental Outcomes Composite scores from the BSID-III at 12 months are presented in Table 2 and Graph 1. No statistically significant differences were observed between groups across any domain (all P-values > 0.05). The surgical group had numerically higher mean scores in all domains, but these differences were not significant: cognitive (109.29 ± 11.34 vs. 101.67 ± 15.21; P-value = 0.288), receptive language (107.00 ± 13.64 vs. 100.78 ± 11.69; P-value = 0.299), expressive language (107.00 ± 13.64 vs. 101.11 ± 12.18; P-value = 0.378), fine motor (99.86 ± 10.24 vs. 93.22 ± 15.59; P-value = 0.348), and gross motor (99.86 ± 10.24 vs. 96.22 ± 16.39; P-value = 0.528). Mean scores in both groups were within the normative range (100 ± 15). A composite score of < 70 and 70–84 were classified as standard deviation (SD) of -2 and − 1, respectively. Seeing as how none of the patients fell within the − 2 SD range, all participants were classified as normal (≥ -1 SD) or below-normal (< -1 SD) based on composite scores (Table 3 ). The proportions of below-normal scores were similar between groups, with no significant associations between surgical status and atypical outcomes (Fisher’s exact test, P-values > 0.05 for all domains). Table 2 Domain scores between groups based on BSID-III. Domain Score Type Surgical (Mean ± SD) Non-Surgical (Mean ± SD) P-value Cognitive Raw 46.71 ± 10.13 45.33 ± 5.34 0.918 Scaled 11.86 ± 2.27 10.33 ± 3.04 0.288 Composite 109.29 ± 11.34 101.67 ± 15.21 0.288 Receptive Language Raw 17.14 ± 7.03 17.22 ± 4.24 0.918 Scaled 10.86 ± 2.04 10.33 ± 2.50 0.299 Composite 107.00 ± 13.64 100.78 ± 11.69 0.299 Expressive Language Raw 18.14 ± 8.61 16.22 ± 5.17 0.837 Scaled 11.43 ± 2.76 10.00 ± 2.24 0.271 Composite 107.00 ± 13.64 101.11 ± 12.18 0.378 Fine Motor Raw 31.14 ± 7.20 32.00 ± 6.46 0.606 Scaled 10.29 ± 3.15 9.00 ± 2.65 0.389 Composite 99.86 ± 10.24 93.22 ± 15.59 0.348 Gross Motor Raw 43.57 ± 8.79 46.22 ± 7.84 0.351 Scaled 9.29 ± 1.70 9.44 ± 2.83 0.898 Composite 99.86 ± 10.24 96.22 ± 16.39 0.528 Table 3 Developmental classification based on composite scores. Domain Surgical (Normal) Surgical (< -1 SD) Non-Surgical (Normal) Non-Surgical (< -1 SD) P-value Cognitive 7 0 7 2 0.475 Receptive Language 6 1 8 1 1 Expressive Language 6 1 8 1 1 Fine Motor 5 2 6 3 0.212 Gross Motor 5 2 7 2 0.212 4. Discussion In this retrospective cohort of infants with non-syndromic trigonocephaly, we found no statistically significant differences in BSID-III composite scores at 12 months between surgically treated and conservatively managed infants. Mean composite scores in both groups were generally within the normative range, and classification into normal ( ≥ − 1 SD) versus below-normal ( < − 1 SD) categories did not differ by treatment. 4 − 1. Trigonocephaly and Neurodevelopment Trigonocephaly, resulting from premature fusion of the metopic suture, typically manifests as a triangular forehead with associated biparietal widening and hypotelorism ( 15 ). More broadly, single-suture craniosynostosis (SSC) as a group has been associated with modest but reproducible neurodevelopmental vulnerabilities in infancy and later childhood in several cohort studies, with these vulnerabilities not fully being explained by obvious clinical factors and persist in some studies despite surgical correction ( 8 , 16 ). Large multicenter and longitudinal studies report elevated odds of developmental problems compared with population controls, but the magnitude and clinical significance vary across cohorts ( 8 , 16 ). These observations suggest that the relationship between cranial suture fusion, cranial morphology, intracranial dynamics, and neurodevelopment is complex and multifactorial. However, its influence on short-term and long-term neurodevelopmental outcomes remains a matter of ongoing debate. Speltz et al. reported that infants with single-suture synostosis had modest but consistent delays in motor and mental development compared to controls, a finding that supports the need for monitoring even when scores appear normal ( 8 ). These early deficits are often mild and may be linked to restricted brain growth or secondary factors like elevated intracranial pressure (ICP), which occurs in small group of non-syndromic cases ( 3 , 4 ). In our study, both surgical and conservatively managed infants showed composite BSID-III scores within the normative range at 12 months, with no significant group differences, aligning with observations that overt impairments are rare in infancy but warrant monitoring. As children progress into childhood, neurodevelopmental effects may become more pronounced, particularly in executive function, attention, and language processing. Multicenter longitudinal studies, such as Starr et al. assessed 3-year-olds with single-suture craniosynostosis and reported consistently lower mean neurodevelopmental scores compared with controls ( 16 ). However, our study population consisted of infants, and neurodevelopmental vulnerabilities may not be fully apparent at this period (particularly in vulnerable populations like preterms), and as children reach school age, specific deficits in executive function and language processing tend to emerge, particularly with pre-term births ( 17 ). As such longer cohort and follow-up studies need to be performed on larger groups to truly elucidate this correlation. 4 − 2. Surgical Treatment of Trigonocephaly and Neurodevelopment While surgical intervention is often justified by concerns about elevated intracranial pressure (ICP) and its impact on brain development, the condition is primarily cosmetic in mild cases, with debate on its neurodevelopmental benefits ( 3 , 18 , 19 ). In our study, we found no statistically significant differences in cognitive, language (receptive and expressive), or motor (fine and gross) composite scores between children who underwent surgery at or before six months and those managed conservatively. Magge et al. reported that when adjusted for age, sex, and socioeconomic status, there was no statistically significant difference between General Conceptual Ability of children with single-suture craniosynostosis undergoing open or endoscopic repair ( 20 ). This was also generally true when comparing treatment groups with the unaffected controls ( 20 ). Bottero et al. evaluated functional outcomes in 76 children operated on for trigonocephaly, who were at least 3 years old, and categorized into 3 groups. Overall, the results should that about a third of the patients had evidence of some degree of learning disability, behavioral disturbances, or school difficulties ( 21 ). Overall, surgical treatment may mitigate risks in severe cases by expanding intracranial volume, but for mild trigonocephaly, neurodevelopmental trajectories appear largely unaffected by intervention. Given the environmental effect on development and the constant change during early childhood, larger prospective cohorts need to be done, with adjustments for a variety of confounding factors to truly evaluate the effect that surgical correction has on outcomes of these populations. 4 − 3. Surgical Timing and Outcomes The timing of surgical intervention in trigonocephaly is critical, with earlier procedures (before 6 months) often advocated to capitalize on skull malleability and minimize ICP duration, potentially optimizing neurodevelopmental outcomes. Bruce et al. analyzed complication rates in craniosynostosis repairs and found that surgery within the first year of life was most optimal at minimizing complication rates, particularly when performed in the first six months ( 9 ). Our study, with surgery between 3 and 6 months showing no short-term differences from conservative management, suggests that very early correction may not yield immediate neurodevelopmental benefits. In a study by Warschausky et al. no associations between severity of deformity in infants and decreased cognitive and motor development at a mean age of around 12 months, suggesting that early surgical treatment might not be crucial in this population ( 18 ). Given our small cohort's lack of short-term disparities, larger studies are needed to clarify if earlier timing prevents emerging childhood vulnerabilities, such as those in executive function. 5. Conclusion This study has several important limitations. The small sample size reduces statistical power, making it difficult to detect subtle neurodevelopmental differences that may exist. The retrospective design prevented randomization and introduced possible selection bias, as the decision to operate was based on clinical judgment rather than standardized severity criteria. Potential confounding factors such as family socioeconomic status, parental education, home stimulation, degree of trigonocephaly severity, and access to early intervention services were not recorded or controlled. Despite these limitations, our findings indicate that, in this cohort, surgical correction performed between 3 and 6 months of age did not confer measurable short-term neurodevelopmental advantages over conservative management at 12 months. Both groups achieved Bayley-III composite scores within the normal range across cognitive, language, and motor domains. These results suggest that, for many infants with non-syndromic trigonocephaly, surgery may primarily offer cosmetic benefits and possible prevention of later intracranial hypertension rather than clear early developmental gain in neurodevelopment. Clinicians should therefore adopt an individualized approach, carefully weighing aesthetic concerns and signs of raised intracranial pressure against surgical risks, while ensuring systematic developmental surveillance for all affected children regardless of treatment choice. Larger, prospective, long-term studies remain essential to determine whether differences emerge later in childhood and to clarify the optimal role and timing of surgical intervention. Declarations 6-1. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. 6-2. Competing Interests The authors have no relevant financial or non-financial interests to disclose. 6-3. Author Contributions Omid Yaghini: Conceptualization, Methodology Reyhane Eslamian: Investigation, Data curation Reza Nejad Shahrokh Abadi: Writing - original draft, Writing - review & editing Neda Hosseni Moshkenani: Supervision, Data curation Ali Riazi: Supervision, Validation 6-4. Ethics Approval and Consent to Participate The study protocol was approved by the ethics committee of the Isfahan University of Medical Sciences under the study ID of IR.MUI.MED.REC.1402.187, and is in full compliance with the Helsinki Declaration. Informed consent from the parents was obtained by the corresponding author. 6-5. Consent to publish Informed consent from the parents was obtained by the corresponding author. 6-6. Availability of data and materials All data used is available within the manuscript. 6-7. Acknowledgements The authors would like to thank the participants of the study and their families, for their cooperation in this study, as well as the Child Growth and Development Research Centre, for their valuable aid. 6-8. Clinical Trial Number Not applicable. References van der Meulen J. Metopic synostosis. Child’s Nerv Syst ChNS. Off J Int Soc Pediatr Neurosurg. 2012;28(9):1359–67. Jaskolka MS. Current Controversies in Metopic Suture Craniosynostosis. Oral Maxillofac Surg Clin North Am. 2017;29(4):447–63. Cornelissen MJ, Loudon SE, van Doorn FEC, Muller RPM, van Veelen M-LC, Mathijssen IMJ. Very Low Prevalence of Intracranial Hypertension in Trigonocephaly. Plast Reconstr Surg. 2017;139(1):e97–104. Shimoji T, Tomiyama N. Mild trigonocephaly and intracranial pressure: report of 56 patients. Child’s Nerv Syst ChNS Off J Int Soc Pediatr Neurosurg. 2004;20(10):749–56. Kelleher MO, Murray DJ, McGillivary A, Kamel MH, Allcutt D, Earley MJ. Behavioral, developmental, and educational problems in children with nonsyndromic trigonocephaly. J Neurosurg. 2006;105(5 Suppl):382–4. Kronig ODM, Kronig SAJ, Van Adrichem LNA. Intracranial Volume Not Correlated With Severity in Trigonocephaly. Cleft palate-craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc. 2022;59(6):794–9. Collett BR, Kapp-Simon KA, Wallace E, Cradock MM, Buono L, Speltz ML. Attention and executive function in children with and without single-suture craniosynostosis. Child Neuropsychol J Norm Abnorm Dev Child Adolesc. 2017;23(1):83–98. Speltz ML, Kapp-Simon K, Collett B, Keich Y, Gaither R, Cradock MM, et al. Neurodevelopment of infants with single-suture craniosynostosis: presurgery comparisons with case-matched controls. Plast Reconstr Surg. 2007;119(6):1874–81. Bruce WJ, Chang V, Joyce CJ, Cobb AN, Maduekwe UI, Patel PA. Age at Time of Craniosynostosis Repair Predicts Increased Complication Rate. Cleft palate-craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc. 2018;55(5):649–54. Kalantar-Hormozi A, Mohammadi Mofrad R, Noori M, Kalantar Hormozi H. Surgical Treatment of Trigonocephaly, Simplified Technique for Moderate Cases. J Craniofac Surg. 2024;35(1):e78–81. Wójcicki P, Prudel B, Trigonocephaly. Long-term results after surgical correction of metopic suture synostosis. Adv Clin Exp Med. 2019;28. Sader N, Mehta V, Hart S, Bliss L, Moore H, DaSilva M, et al. Quality of life and satisfaction in surgical versus conservative treatment of nonsyndromic children with craniosynostosis. J Neurosurg Pediatr. 2022;29(1):60–5. Shim K-W, Park E-K, Kim J-S, Kim Y-O, Kim D-S. Neurodevelopmental Problems in Non-Syndromic Craniosynostosis. J Korean Neurosurg Soc. 2016;59(3):242–6. Fontana SC, Belinger S, Daniels D, Tuttle M, Camarata PJ, Andrews BT. Longitudinal Assessment of Developmental Outcomes in Infants Undergoing Late Craniosynostosis Repair. J Craniofac Surg. 2018;29(1):25–8. Fernández-de Thomas R, De Jesus O. Trigonocephaly. StatPearls. 2023. Starr JR, Collett BR, Gaither R, Kapp-Simon KA, Cradock MM, Cunningham ML et al. Multicenter Study of Neurodevelopment in 3-Year-Old Children With and Without Single-Suture Craniosynostosis. Arch Pediatr Adolesc Med [Internet]. 2012;166(6):536–42. Available from: https://doi.org/10.1001/archpediatrics.2011.1800 Davis BE, Leppert MO, German K, Lehmann CU, Adams-Chapman I, COUNCIL O N CHILDREN WITH, DISABILITIES et al. Primary Care Framework to Monitor Preterm Infants for Neurodevelopmental Outcomes in Early Childhood. Pediatrics [Internet]. 2023;152(1):e2023062511. Available from: https://doi.org/10.1542/peds.2023-062511 Kelleher MO, Murray DJ, McGillivary A, Kamel MH, Allcutt D, Earley MJ. Non-syndromic trigonocephaly: surgical decision making and long-term cosmetic results. Child’s Nerv Syst ChNS Off J Int Soc Pediatr Neurosurg. 2007;23(11):1285–9. Engel M, Castrillon-Oberndorfer G, Hoffmann J, Mühling J, Seeberger R, Freudlsperger C. Long-term results in nonsyndromatic unilateral coronal synostosis treated with fronto-orbital advancement. J cranio-maxillo-facial Surg Off Publ Eur Assoc Cranio-Maxillo-Facial Surg. 2013;41(8):747–54. Magge SN, Fotouhi AR, Allhusen V, Collett BR, Skolnick GB, Naidoo SD, et al. Cognitive Outcomes of Children With Sagittal Craniosynostosis Treated With Either Endoscopic or Open Calvarial Vault Surgery. JAMA Netw open. 2024;7(4):e248762. Bottero L, Lajeunie E, Arnaud E, Marchac D, Renier D. Functional outcome after surgery for trigonocephaly. Plast Reconstr Surg. 1998;102(4):952–60. Graph 1 Graph 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Graph1.png Graph 1. Mean domain scores in the two groups. S: Surgical, NS: Non-surgical, R: Receptive, E: Expressive, F: Fine, G: Gross. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 08 Apr, 2026 Reviews received at journal 07 Mar, 2026 Reviewers agreed at journal 07 Mar, 2026 Reviewers invited by journal 08 Feb, 2026 Editor assigned by journal 08 Feb, 2026 Editor invited by journal 30 Jan, 2026 Submission checks completed at journal 29 Jan, 2026 First submitted to journal 29 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8631558","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588029257,"identity":"7aeea225-0b2f-49a2-959a-1d4b7eda0838","order_by":0,"name":"Omid Yaghini","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Omid","middleName":"","lastName":"Yaghini","suffix":""},{"id":588029258,"identity":"71501aa3-e03e-47f2-868c-5e7992a70feb","order_by":1,"name":"Reyhane Eslamian","email":"data:image/png;base64,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","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Reyhane","middleName":"","lastName":"Eslamian","suffix":""},{"id":588029259,"identity":"4c075f6a-5fbb-40b5-99a8-9b94c4ded648","order_by":2,"name":"Reza Nejad Shahrokh Abadi","email":"","orcid":"","institution":"Ghaem Hospital, Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Reza","middleName":"Nejad Shahrokh","lastName":"Abadi","suffix":""},{"id":588029260,"identity":"1c0f07c7-e26f-4655-99c7-489934cfaefe","order_by":3,"name":"Neda Hosseni Moshkenani","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Neda","middleName":"Hosseni","lastName":"Moshkenani","suffix":""},{"id":588029261,"identity":"c7f41d39-39d4-4fa0-91ab-509d041579e5","order_by":4,"name":"Ali Riazi","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Riazi","suffix":""}],"badges":[],"createdAt":"2026-01-18 13:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8631558/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8631558/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102596156,"identity":"469ebcc9-05d7-4818-abfa-8f25b0823481","added_by":"auto","created_at":"2026-02-13 12:14:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":468394,"visible":true,"origin":"","legend":"\u003cp\u003eCranial Axial (A\u0026amp;E), Coronal (B\u0026amp;F), Sagittal (C\u0026amp;G), and 3D view (D\u0026amp;H) CT scans of two patients showing Trigonocephaly.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8631558/v1/ecb5dc632832af85c77d2da2.png"},{"id":102747439,"identity":"34bd91e3-b939-424e-bd1b-7133c8f5445b","added_by":"auto","created_at":"2026-02-16 09:04:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1314156,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8631558/v1/dc77d328-c943-43bf-a54a-9e020bfbcbc8.pdf"},{"id":102596155,"identity":"20fbcb19-200a-48c1-b5fd-763896ab1042","added_by":"auto","created_at":"2026-02-13 12:14:58","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20947,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraph 1. \u003c/strong\u003eMean domain scores in the two groups. S: Surgical, NS: Non-surgical, R: Receptive, E: Expressive, F: Fine, G: Gross.\u003c/p\u003e","description":"","filename":"Graph1.png","url":"https://assets-eu.researchsquare.com/files/rs-8631558/v1/cc6a9e1106b51b9fa77a09dc.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Neurodevelopmental Outcomes in Infants with Non-Syndromic Trigonocephaly: A Comparative Study of Surgical and Non-Surgical Management","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eNon-syndromic trigonocephaly, a subtype of single-suture craniosynostosis, results from the premature fusion of the metopic suture, leading to a distinct triangular forehead shape and potential intracranial and developmental complications (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It characteristically presents with a triangular forehead, bi-parietal widening, and hypotelorism, with metopic synostosis being reported as the second most common isolated suture craniosynostosis (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Although the principal indication for surgical correction has classically been aesthetic restoration of fronto-orbital shape, clinicians have also been concerned about the potential for intracranial hypertension (ICP) and restricted cranial growth to adversely affect neurodevelopment. Reported prevalence of raised ICP in trigonocephaly varies widely across studies, and direct evidence linking raised ICP in isolated metopic synostosis to later neurocognitive outcomes is inconsistent (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Independent of ICP, several cohort studies have demonstrated modest but reproducible increases in the risk of neurodevelopmental and learning problems among children with single-suture craniosynostosis when compared with unaffected peers (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). These deficits are often subtle in infancy and may become more apparent at preschool or school age. Therefore, routine developmental surveillance has been recommended for affected children (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite these concerns, the neurodevelopmental implications of early surgical intervention remain a topic of ongoing debate. Some studies have reported improvements following surgical intervention, while others suggest minimal or no benefit compared to conservative management (\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Furthermore, while most children with non-syndromic craniosynostosis perform within the normative range on developmental assessments, they may remain at a higher risk for subtle delays compared to their peers (\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The Bayley Scales of Infant and Toddler Development (BSID) are widely used to evaluate developmental domains in infancy, providing valuable insights into cognitive, language, and motor outcomes (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Assessing these outcomes in children with trigonocephaly is crucial to understanding the role of surgery in shaping developmental trajectories and guiding clinical decision-making.\u003c/p\u003e \u003cp\u003eIn this study we compare BSID-III composite scores at 12 months between infants with non-syndromic trigonocephaly managed surgically at or before 6 months, and those managed conservatively, with the aim of characterizing short-term neurodevelopmental outcomes and informing the need for longer-term surveillance.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cb\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;1. Study Design and Participants\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis retrospective cohort study was conducted at a tertiary children\u0026rsquo;s hospital. All infants diagnosed with non-syndromic trigonocephaly over a period of 2 years were eligible for inclusion. Diagnosis was established by a pediatric neurologist based on clinical examination and confirmed with cranial imaging when indicated (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Exclusion criteria included syndromic craniosynostosis, other craniosynostosis (e.g. scaphocephaly or plagiocephaly), multiple suture involvement, or comorbid conditions that could confound neurodevelopmental outcomes (e.g., genetic disorders or prematurity). The study protocol was approved by the ethics committee (ethics ID: IR.MUI.MED.REC.1402.187)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003e2–2. Interventions and Assessments\u003c/h3\u003e\n\u003cp\u003eA total of 16 infants were identified and divided into two groups, and were classified based on their surgical history into two distinct groups: those who have undergone surgical intervention and those who have not. Infants in the surgical group underwent treatment between 3 and 6 months of age, performed by a pediatric neurosurgeon. The conservative group received routine monitoring without surgical intervention. Head circumference was measured at birth and 12 months of age using standardized techniques and reported in centimeters. Neurodevelopmental assessments were conducted at 12 months of age using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III; published 2006) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This allowed for standardized assessment for raw, scaled, and composite scores across cognitive, receptive and expressive language, fine motor, and gross motor domains. Composite scores, which standardize performance to a mean of 100\u0026thinsp;\u0026plusmn;\u0026thinsp;15, served as the primary outcome measures.\u003c/p\u003e\n\u003ch3\u003e2–3. Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eData were analyzed using IBM SPSS Statistics version 26. Continuous variables are presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD), and categorical variables as frequencies and percentages. Normality of composite scores was assessed using the Shapiro-Wilk test. Between-group comparisons were performed using independent t-tests for normally distributed variables and Mann-Whitney U tests for non-normally distributed variables. All tests were two-tailed with a significance level of P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e \u003cb\u003e3\u0026thinsp;\u0026minus;\u0026thinsp;1. Participant Characteristics\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA total of 16 infants were included in the study (9 males, 7 females). The study population included all patients that met the inclusion criteria admitted over a 2-year period to the children\u0026rsquo;s hospital, whose parents gave explicit permission for study. Seven underwent surgical intervention (4 males, 3 females), and nine were managed conservatively (5 males, 4 females). No significant baseline differences were noted between groups except as reported below. Two patients, one in each group, had a positive family history of trigonocephaly. Five of the participants were part of twin births, wherein 2 pairs both had trigonocephaly, while only one of the last pair was affected.\u003c/p\u003e\n\u003ch3\u003e3 − 2. Head Circumference Measurements\u003c/h3\u003e\n\u003cp\u003eHead circumference measurements at birth and 12 months, along with growth from birth to 12 months, are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The surgical group had a slightly higher mean head circumference at birth (34.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95 cm) compared to the non-surgical group (33.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31 cm; P-value\u0026thinsp;=\u0026thinsp;0.1). At 12 months, means were 46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41 cm (surgical) and 45.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.82 cm (non-surgical; P-value\u0026thinsp;=\u0026thinsp;0.329). Head circumference growth was comparable between groups (11.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56 cm surgical vs. 12.01\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92 cm non-surgical; P-value\u0026thinsp;=\u0026thinsp;0.798).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of head circumferences (cm) between groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasurement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-Surgical\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt Birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e34.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e33.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt 1 Year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e46.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e45.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.329\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrowth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e11.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e12.01\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.798\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e3–3. Neurodevelopmental Outcomes\u003c/h3\u003e\n\u003cp\u003eComposite scores from the BSID-III at 12 months are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Graph 1. No statistically significant differences were observed between groups across any domain (all P-values\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The surgical group had numerically higher mean scores in all domains, but these differences were not significant: cognitive (109.29\u0026thinsp;\u0026plusmn;\u0026thinsp;11.34 vs. 101.67\u0026thinsp;\u0026plusmn;\u0026thinsp;15.21; P-value\u0026thinsp;=\u0026thinsp;0.288), receptive language (107.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.64 vs. 100.78\u0026thinsp;\u0026plusmn;\u0026thinsp;11.69; P-value\u0026thinsp;=\u0026thinsp;0.299), expressive language (107.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.64 vs. 101.11\u0026thinsp;\u0026plusmn;\u0026thinsp;12.18; P-value\u0026thinsp;=\u0026thinsp;0.378), fine motor (99.86\u0026thinsp;\u0026plusmn;\u0026thinsp;10.24 vs. 93.22\u0026thinsp;\u0026plusmn;\u0026thinsp;15.59; P-value\u0026thinsp;=\u0026thinsp;0.348), and gross motor (99.86\u0026thinsp;\u0026plusmn;\u0026thinsp;10.24 vs. 96.22\u0026thinsp;\u0026plusmn;\u0026thinsp;16.39; P-value\u0026thinsp;=\u0026thinsp;0.528). Mean scores in both groups were within the normative range (100\u0026thinsp;\u0026plusmn;\u0026thinsp;15). A composite score of \u0026lt;\u0026thinsp;70 and 70\u0026ndash;84 were classified as standard deviation (SD) of -2 and \u0026minus;\u0026thinsp;1, respectively. Seeing as how none of the patients fell within the \u0026minus;\u0026thinsp;2 SD range, all participants were classified as normal (\u0026ge; -1 SD) or below-normal (\u0026lt; -1 SD) based on composite scores (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The proportions of below-normal scores were similar between groups, with no significant associations between surgical status and atypical outcomes (Fisher\u0026rsquo;s exact test, P-values\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all domains).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDomain scores between groups based on BSID-III.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScore Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Surgical\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCognitive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRaw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e46.71\u0026thinsp;\u0026plusmn;\u0026thinsp;10.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e45.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScaled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComposite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e109.29\u0026thinsp;\u0026plusmn;\u0026thinsp;11.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e101.67\u0026thinsp;\u0026plusmn;\u0026thinsp;15.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eReceptive Language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRaw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.14\u0026thinsp;\u0026plusmn;\u0026thinsp;7.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e17.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScaled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComposite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e107.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e100.78\u0026thinsp;\u0026plusmn;\u0026thinsp;11.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eExpressive Language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRaw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e18.14\u0026thinsp;\u0026plusmn;\u0026thinsp;8.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e16.22\u0026thinsp;\u0026plusmn;\u0026thinsp;5.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.837\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScaled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.271\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComposite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e107.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e101.11\u0026thinsp;\u0026plusmn;\u0026thinsp;12.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFine Motor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRaw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e31.14\u0026thinsp;\u0026plusmn;\u0026thinsp;7.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.606\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScaled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.29\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e9.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.389\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComposite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e99.86\u0026thinsp;\u0026plusmn;\u0026thinsp;10.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e93.22\u0026thinsp;\u0026plusmn;\u0026thinsp;15.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eGross Motor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRaw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e43.57\u0026thinsp;\u0026plusmn;\u0026thinsp;8.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e46.22\u0026thinsp;\u0026plusmn;\u0026thinsp;7.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScaled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e9.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.898\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComposite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e99.86\u0026thinsp;\u0026plusmn;\u0026thinsp;10.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e96.22\u0026thinsp;\u0026plusmn;\u0026thinsp;16.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.528\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDevelopmental classification based on composite scores.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical (Normal)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003cp\u003e(\u0026lt; -1 SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Surgical (Normal)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNon-Surgical\u003c/p\u003e \u003cp\u003e(\u0026lt; -1 SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceptive Language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpressive Language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFine Motor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGross Motor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this retrospective cohort of infants with non-syndromic trigonocephaly, we found no statistically significant differences in BSID-III composite scores at 12 months between surgically treated and conservatively managed infants. Mean composite scores in both groups were generally within the normative range, and classification into normal (\u0026thinsp;\u0026ge;\u0026thinsp;\u0026minus;\u0026thinsp;1 SD) versus below-normal (\u0026thinsp;\u0026lt;\u0026thinsp;\u0026minus;\u0026thinsp;1 SD) categories did not differ by treatment.\u003c/p\u003e\n\u003ch3\u003e4 − 1. Trigonocephaly and Neurodevelopment\u003c/h3\u003e\n\u003cp\u003eTrigonocephaly, resulting from premature fusion of the metopic suture, typically manifests as a triangular forehead with associated biparietal widening and hypotelorism (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). More broadly, single-suture craniosynostosis (SSC) as a group has been associated with modest but reproducible neurodevelopmental vulnerabilities in infancy and later childhood in several cohort studies, with these vulnerabilities not fully being explained by obvious clinical factors and persist in some studies despite surgical correction (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Large multicenter and longitudinal studies report elevated odds of developmental problems compared with population controls, but the magnitude and clinical significance vary across cohorts (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These observations suggest that the relationship between cranial suture fusion, cranial morphology, intracranial dynamics, and neurodevelopment is complex and multifactorial. However, its influence on short-term and long-term neurodevelopmental outcomes remains a matter of ongoing debate. Speltz et al. reported that infants with single-suture synostosis had modest but consistent delays in motor and mental development compared to controls, a finding that supports the need for monitoring even when scores appear normal (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These early deficits are often mild and may be linked to restricted brain growth or secondary factors like elevated intracranial pressure (ICP), which occurs in small group of non-syndromic cases (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In our study, both surgical and conservatively managed infants showed composite BSID-III scores within the normative range at 12 months, with no significant group differences, aligning with observations that overt impairments are rare in infancy but warrant monitoring. As children progress into childhood, neurodevelopmental effects may become more pronounced, particularly in executive function, attention, and language processing. Multicenter longitudinal studies, such as Starr et al. assessed 3-year-olds with single-suture craniosynostosis and reported consistently lower mean neurodevelopmental scores compared with controls (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, our study population consisted of infants, and neurodevelopmental vulnerabilities may not be fully apparent at this period (particularly in vulnerable populations like preterms), and as children reach school age, specific deficits in executive function and language processing tend to emerge, particularly with pre-term births (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). As such longer cohort and follow-up studies need to be performed on larger groups to truly elucidate this correlation.\u003c/p\u003e\n\u003ch3\u003e4 − 2. Surgical Treatment of Trigonocephaly and Neurodevelopment\u003c/h3\u003e\n\u003cp\u003eWhile surgical intervention is often justified by concerns about elevated intracranial pressure (ICP) and its impact on brain development, the condition is primarily cosmetic in mild cases, with debate on its neurodevelopmental benefits (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In our study, we found no statistically significant differences in cognitive, language (receptive and expressive), or motor (fine and gross) composite scores between children who underwent surgery at or before six months and those managed conservatively. Magge et al. reported that when adjusted for age, sex, and socioeconomic status, there was no statistically significant difference between General Conceptual Ability of children with single-suture craniosynostosis undergoing open or endoscopic repair (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This was also generally true when comparing treatment groups with the unaffected controls (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Bottero et al. evaluated functional outcomes in 76 children operated on for trigonocephaly, who were at least 3 years old, and categorized into 3 groups. Overall, the results should that about a third of the patients had evidence of some degree of learning disability, behavioral disturbances, or school difficulties (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Overall, surgical treatment may mitigate risks in severe cases by expanding intracranial volume, but for mild trigonocephaly, neurodevelopmental trajectories appear largely unaffected by intervention. Given the environmental effect on development and the constant change during early childhood, larger prospective cohorts need to be done, with adjustments for a variety of confounding factors to truly evaluate the effect that surgical correction has on outcomes of these populations.\u003c/p\u003e\n\u003ch3\u003e4 − 3. Surgical Timing and Outcomes\u003c/h3\u003e\n\u003cp\u003eThe timing of surgical intervention in trigonocephaly is critical, with earlier procedures (before 6 months) often advocated to capitalize on skull malleability and minimize ICP duration, potentially optimizing neurodevelopmental outcomes. Bruce et al. analyzed complication rates in craniosynostosis repairs and found that surgery within the first year of life was most optimal at minimizing complication rates, particularly when performed in the first six months (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Our study, with surgery between 3 and 6 months showing no short-term differences from conservative management, suggests that very early correction may not yield immediate neurodevelopmental benefits. In a study by Warschausky et al. no associations between severity of deformity in infants and decreased cognitive and motor development at a mean age of around 12 months, suggesting that early surgical treatment might not be crucial in this population (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Given our small cohort's lack of short-term disparities, larger studies are needed to clarify if earlier timing prevents emerging childhood vulnerabilities, such as those in executive function.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study has several important limitations. The small sample size reduces statistical power, making it difficult to detect subtle neurodevelopmental differences that may exist. The retrospective design prevented randomization and introduced possible selection bias, as the decision to operate was based on clinical judgment rather than standardized severity criteria. Potential confounding factors such as family socioeconomic status, parental education, home stimulation, degree of trigonocephaly severity, and access to early intervention services were not recorded or controlled. Despite these limitations, our findings indicate that, in this cohort, surgical correction performed between 3 and 6 months of age did not confer measurable short-term neurodevelopmental advantages over conservative management at 12 months. Both groups achieved Bayley-III composite scores within the normal range across cognitive, language, and motor domains. These results suggest that, for many infants with non-syndromic trigonocephaly, surgery may primarily offer cosmetic benefits and possible prevention of later intracranial hypertension rather than clear early developmental gain in neurodevelopment. Clinicians should therefore adopt an individualized approach, carefully weighing aesthetic concerns and signs of raised intracranial pressure against surgical risks, while ensuring systematic developmental surveillance for all affected children regardless of treatment choice. Larger, prospective, long-term studies remain essential to determine whether differences emerge later in childhood and to clarify the optimal role and timing of surgical intervention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6-1. Funding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6-2. Competing Interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6-3. Author Contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eOmid Yaghini: Conceptualization, Methodology\u003c/li\u003e\n \u003cli\u003eReyhane Eslamian: Investigation, Data curation\u003c/li\u003e\n \u003cli\u003eReza Nejad Shahrokh Abadi: Writing - original draft, Writing - review \u0026amp; editing\u003c/li\u003e\n \u003cli\u003eNeda Hosseni Moshkenani: Supervision, Data curation\u003c/li\u003e\n \u003cli\u003eAli Riazi: Supervision, Validation\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6-4. Ethics Approval and Consent to Participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the ethics committee of the Isfahan University of Medical Sciences under the study ID of IR.MUI.MED.REC.1402.187, and is in full compliance with the Helsinki Declaration. Informed consent from the parents was obtained by the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6-5. Consent to publish\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent from the parents was obtained by the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6-6. Availability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data used is available within the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6-7. Acknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the participants of the study and their families, for their cooperation in this study, as well as the Child Growth and Development Research Centre, for their valuable aid.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e6-8.\u003c/em\u003e\u003c/strong\u003e \u003cstrong\u003e\u003cem\u003eClinical Trial Number\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003evan der Meulen J. Metopic synostosis. Child\u0026rsquo;s Nerv Syst ChNS. Off J Int Soc Pediatr Neurosurg. 2012;28(9):1359\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaskolka MS. Current Controversies in Metopic Suture Craniosynostosis. Oral Maxillofac Surg Clin North Am. 2017;29(4):447\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCornelissen MJ, Loudon SE, van Doorn FEC, Muller RPM, van Veelen M-LC, Mathijssen IMJ. Very Low Prevalence of Intracranial Hypertension in Trigonocephaly. Plast Reconstr Surg. 2017;139(1):e97\u0026ndash;104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShimoji T, Tomiyama N. Mild trigonocephaly and intracranial pressure: report of 56 patients. Child\u0026rsquo;s Nerv Syst ChNS Off J Int Soc Pediatr Neurosurg. 2004;20(10):749\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelleher MO, Murray DJ, McGillivary A, Kamel MH, Allcutt D, Earley MJ. Behavioral, developmental, and educational problems in children with nonsyndromic trigonocephaly. J Neurosurg. 2006;105(5 Suppl):382\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKronig ODM, Kronig SAJ, Van Adrichem LNA. Intracranial Volume Not Correlated With Severity in Trigonocephaly. Cleft palate-craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc. 2022;59(6):794\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollett BR, Kapp-Simon KA, Wallace E, Cradock MM, Buono L, Speltz ML. Attention and executive function in children with and without single-suture craniosynostosis. Child Neuropsychol J Norm Abnorm Dev Child Adolesc. 2017;23(1):83\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpeltz ML, Kapp-Simon K, Collett B, Keich Y, Gaither R, Cradock MM, et al. Neurodevelopment of infants with single-suture craniosynostosis: presurgery comparisons with case-matched controls. Plast Reconstr Surg. 2007;119(6):1874\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBruce WJ, Chang V, Joyce CJ, Cobb AN, Maduekwe UI, Patel PA. Age at Time of Craniosynostosis Repair Predicts Increased Complication Rate. Cleft palate-craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc. 2018;55(5):649\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalantar-Hormozi A, Mohammadi Mofrad R, Noori M, Kalantar Hormozi H. Surgical Treatment of Trigonocephaly, Simplified Technique for Moderate Cases. J Craniofac Surg. 2024;35(1):e78\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eW\u0026oacute;jcicki P, Prudel B, Trigonocephaly. Long-term results after surgical correction of metopic suture synostosis. Adv Clin Exp Med. 2019;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSader N, Mehta V, Hart S, Bliss L, Moore H, DaSilva M, et al. Quality of life and satisfaction in surgical versus conservative treatment of nonsyndromic children with craniosynostosis. J Neurosurg Pediatr. 2022;29(1):60\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShim K-W, Park E-K, Kim J-S, Kim Y-O, Kim D-S. Neurodevelopmental Problems in Non-Syndromic Craniosynostosis. J Korean Neurosurg Soc. 2016;59(3):242\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFontana SC, Belinger S, Daniels D, Tuttle M, Camarata PJ, Andrews BT. Longitudinal Assessment of Developmental Outcomes in Infants Undergoing Late Craniosynostosis Repair. J Craniofac Surg. 2018;29(1):25\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFern\u0026aacute;ndez-de Thomas R, De Jesus O. Trigonocephaly. StatPearls. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStarr JR, Collett BR, Gaither R, Kapp-Simon KA, Cradock MM, Cunningham ML et al. Multicenter Study of Neurodevelopment in 3-Year-Old Children With and Without Single-Suture Craniosynostosis. Arch Pediatr Adolesc Med [Internet]. 2012;166(6):536\u0026ndash;42. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/archpediatrics.2011.1800\u003c/span\u003e\u003cspan address=\"10.1001/archpediatrics.2011.1800\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis BE, Leppert MO, German K, Lehmann CU, Adams-Chapman I, COUNCIL O N CHILDREN WITH, DISABILITIES et al. Primary Care Framework to Monitor Preterm Infants for Neurodevelopmental Outcomes in Early Childhood. Pediatrics [Internet]. 2023;152(1):e2023062511. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1542/peds.2023-062511\u003c/span\u003e\u003cspan address=\"10.1542/peds.2023-062511\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelleher MO, Murray DJ, McGillivary A, Kamel MH, Allcutt D, Earley MJ. Non-syndromic trigonocephaly: surgical decision making and long-term cosmetic results. Child\u0026rsquo;s Nerv Syst ChNS Off J Int Soc Pediatr Neurosurg. 2007;23(11):1285\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngel M, Castrillon-Oberndorfer G, Hoffmann J, M\u0026uuml;hling J, Seeberger R, Freudlsperger C. Long-term results in nonsyndromatic unilateral coronal synostosis treated with fronto-orbital advancement. J cranio-maxillo-facial Surg Off Publ Eur Assoc Cranio-Maxillo-Facial Surg. 2013;41(8):747\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMagge SN, Fotouhi AR, Allhusen V, Collett BR, Skolnick GB, Naidoo SD, et al. Cognitive Outcomes of Children With Sagittal Craniosynostosis Treated With Either Endoscopic or Open Calvarial Vault Surgery. JAMA Netw open. 2024;7(4):e248762.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBottero L, Lajeunie E, Arnaud E, Marchac D, Renier D. Functional outcome after surgery for trigonocephaly. Plast Reconstr Surg. 1998;102(4):952\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Graph 1","content":"\u003cp\u003eGraph 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Non-syndromic trigonocephaly, Neurodevelopmental outcomes, Surgical intervention, Pediatric neurology","lastPublishedDoi":"10.21203/rs.3.rs-8631558/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8631558/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study investigates the neurodevelopmental outcomes of infants with non-syndromic trigonocephaly managed surgically and conservatively. The aim is to assess whether earlier surgical intervention influences cognitive, language, and motor development at 12 months of age.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study included 16 children diagnosed with non-syndromic trigonocephaly. Seven underwent surgical intervention between three and six months, while nine were managed conservatively. Neurodevelopmental assessment was performed at 12 months using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III). Composite scores for cognitive, language (receptive and expressive), and motor (fine and gross) domains were compared using parametric or non-parametric tests based on Shapiro\u0026ndash;Wilk normality assessment.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNo statistically significant differences were observed between surgical and non-surgical groups across all composite domains. Cognitive composite scores were 109.29\u0026thinsp;\u0026plusmn;\u0026thinsp;11.34 (surgical) versus 101.67\u0026thinsp;\u0026plusmn;\u0026thinsp;15.21 (non-surgical; p\u0026thinsp;=\u0026thinsp;0.288). Receptive language scores were 107.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.64 versus 100.78\u0026thinsp;\u0026plusmn;\u0026thinsp;11.69 (p\u0026thinsp;=\u0026thinsp;0.299); expressive language scores were 107.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.64 versus 101.11\u0026thinsp;\u0026plusmn;\u0026thinsp;12.18 (p\u0026thinsp;=\u0026thinsp;0.378); fine motor scores were 99.86\u0026thinsp;\u0026plusmn;\u0026thinsp;10.24 versus 93.22\u0026thinsp;\u0026plusmn;\u0026thinsp;15.59 (p\u0026thinsp;=\u0026thinsp;0.348); and gross motor scores were 99.86\u0026thinsp;\u0026plusmn;\u0026thinsp;10.24 versus 96.22\u0026thinsp;\u0026plusmn;\u0026thinsp;16.39 (p\u0026thinsp;=\u0026thinsp;0.528). Mean scores in both groups fell within the normative range (100\u0026thinsp;\u0026plusmn;\u0026thinsp;15), and classification into normal (\u0026ge; -1 SD) or below-normal (\u0026lt; -1 SD) categories showed no significant differences (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all domains).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn this small cohort, surgical correction of non-syndromic trigonocephaly performed at or before six months did not result in statistically significant differences in neurodevelopmental outcomes at 12 months compared with conservative management.\u003c/p\u003e","manuscriptTitle":"Neurodevelopmental Outcomes in Infants with Non-Syndromic Trigonocephaly: A Comparative Study of Surgical and Non-Surgical Management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 12:14:53","doi":"10.21203/rs.3.rs-8631558/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"185134323867449437142522093155527981703","date":"2026-04-08T22:43:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-07T20:52:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339537633008958666744169475044217577863","date":"2026-03-07T16:55:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T04:44:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-09T04:39:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-30T19:41:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-29T11:12:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-01-29T10:31:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"015ebc08-666a-4ab0-b692-6f3b4b07f88d","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-13T12:14:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 12:14:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8631558","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8631558","identity":"rs-8631558","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}