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NATURAL HISTORY OF CRANIAL MORPHOLOGY IN NONOPERATIVE ISOLATED SAGITTAL CRANIOSYNOSTOSIS USING MACHINE LEARNING
Tiffany E. Jeong^*1, Jonathan Cho¹, Sean Lee¹, Alzbeta Novotna¹, Michael Hernandez¹, Victoria García Rodríguez¹, Viraj Govani¹, Zhazira Irgebay¹, Shelby Nathan¹, Nawazish Khan², Mokshagna Karanam², Shireen Elhabian², Jesse A. Goldstein^1
1Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; ²SCI, University of Utah, Salt Lake City, UT

Introduction
Surgery is not always indicated in isolated sagittal craniosynostosis, particularly in the absence of increased intracranial pressure, delayed diagnosis, or parental preference for nonoperative management. Untreated cases result in a persistently elongated, narrow skull (scaphocephaly), but natural history knowledge remains limited. Machine learning-based measures, including cranial morphological descriptors (CMD) and sagittal severity scores (SSS), allow more precise quantification of cranial shape and can guide shared decision-making. This study describes the natural history of cranial morphology in untreated isolated sagittal craniosynostosis using CMD and SSS.
Methods
We retrospectively reviewed patients treated at a single institution for isolated sagittal synostosis from January 1993 to December 2024. CT scans meeting CranioRate™ quality standards were analyzed to generate CMD and SSS across multiple timepoints. Scans obtained for other clinical indications without cranial deformity were included, enabling the largest cohort and longest follow-up of non-operative isolated sagittal synostosis to date. Group comparisons used non-parametric tests at p<0.05.
Results
Twenty-eight patients met inclusion criteria, with a median age at diagnosis of 4.06 years [IQR 2.50-6.47]. Most were male (64.3%) and non-syndromic (78.6%). Follow-up imaging was performed at a median of 3.08 years [IQR 1.70-7.09] after baseline, when patients were a median age of 8.71 years [IQR 4.86-15.70]. Baseline CMD was 127.83 [IQR 106.3-135.78] and showed a mean increase of 3.50, resulting in 129.47 [IQR 102.33-157.04] at follow-up; this change was not statistically significant (p=0.711). SSS did not change significantly either, with a baseline of 1.61 [IQR 0.68-2.75] and follow-up of 2.14 [IQR 0.98-2.77] (p=0.849).
Conclusion
These findings suggest cranial dysmorphology remains largely stable over long-term follow-up, informing shared decision-making for families considering non-operative management of isolated sagittal craniosynostosis.

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