No evidence-based guidelines exist for the imaging of patients with positional plagiocephaly.


The objective of this systematic review and evidence-based guideline is to answer the question, Is imaging necessary for infants with positional plagiocephaly to make a diagnosis.


The National Library of Medicine Medline database and the Cochrane Library were queried with the use of MeSH headings and key words relevant to imaging as a means to diagnose plagiocephaly. Abstracts were reviewed, and an evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). Based on the quality of the literature, a recommendation was rendered (Level I, II, or III).


A total of 42 full-text articles were selected for review. Of these, 10 were eliminated; thus, 32 full-text were manuscripts selected. There was no Class I evidence, but 2 Class II and 30 Class III studies were included. Three-dimensional cranial topographical imaging, ultrasound, skull x-rays, computed tomography, and magnetic resonance imaging were investigated.


Clinical examination is most often sufficient to diagnose plagiocephaly (quality, Class III; strength, Level III). Within the limits of this systematic review, the evidence suggests that imaging is rarely necessary and should be reserved for cases in which the clinical examination is equivocal. Many of the imaging studies were not designed to address the diagnostic utility of the imaging modality, and authors were actually assessing the utility of the imaging in longitudinal follow-up, not initial diagnosis. For this reason, some of the studies reviewed were downgraded in Level of Evidence. When needed, 3-dimensional cranial topographical photo, skull x-rays, or ultrasound imaging is almost always sufficient for definitive diagnosis. Computed tomography scanning should not be used to diagnose plagiocephaly, but it may be necessary to rule out craniosynostosis. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_2.

Infants may present with abnormal head shape any time after birth. The most common reason for referral is to rule out craniosynostosis. The diagnosis of true craniosynostosis is important because this condition is amenable to surgical correction, whereas positional, posterior plagiocephaly without synostosis is adequately treated with repositioning, physical therapy, or, in moderate to severe cases, a cranial molding helmet.1, 2

It has been the experience of many craniofacial specialists, including those on the Plagiocephaly Task Force (herein referred to as the task force), that most infants with plagiocephaly can be adequately diagnosed through a detailed clinical examination. Three-dimensional topographical scanning may be useful for diagnosis and baseline assessment of severity. In those rare cases in which the clinical examination is equivocal, skull x-rays or an ultrasound of the suture in question could be used to rule out craniosynostosis. A computed tomography (CT) scan of the head should be performed only if those radiological studies are equivocal.


The Congress of Neurological Surgeons (CNS) and the Section on Pediatric Neurosurgery initiated a systematic review of the literature and evidence-based guideline relevant to the management of positional plagiocephaly (https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_1).

Literature Search

The task force members collaborated with medical librarians to search the National Library of Medicine/PubMed database and the Cochrane Library for the period from 1966 to October 2014 using the MeSH subject headings and PubMed search strategies provided in Appendix A. Manual searches of bibliographies were also conducted. The search resulted in 204 abstracts. The task force selected 42 full-text articles for review. Of these, 10 were rejected for not meeting inclusion criteria or for being off-topic. Thirty-two articles were selected for systematic review (https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_2).

Rating Quality of Diagnostic Evidence

For diagnostic-type articles, evidence classification had definitions targeted toward diagnosis. The issues addressed by articles on diagnosis are related to the ability of the diagnostic test to successfully distinguish between patients who have and those who do not have a disease or pertinent finding (https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_2). Additional information on the hierarchy classification of evidence can be located here: https://www.cns.org/guidelines/guideline-procedures-policies/guideline-development-methodology.


1. Clinical examination is recommended for the diagnosis of plagiocephaly, and imaging is rarely necessary, except in cases in which clinical diagnosis is equivocal.

Strength of recommendation: Level III—low clinical certainty

2. In cases in which the clinical examination is equivocal, skull x-rays or ultrasound imaging of the suspect suture is recommended.

Strength of recommendation: Level II—moderate clinical certainty

3. In cases in which the clinical examination is equivocal, surface imaging (computer-based topographical scans) or stereophotogrammetry is recommended for the assessment of infants with plagiocephaly without synostosis.

Strength of recommendation: Level III—low clinical certainty

4. Only for infants in whom x-rays or ultrasound is nondiagnostic, a computed tomography scan is recommended for definitive diagnosis.

Strength of recommendation: Level III—low clinical certainty


Within the limits of this systematic review, the authors found that imaging is unnecessary as a first step in infants with plagiocephaly and should be reserved for when the clinical examination is equivocal. In these clinical scenarios, skull x-rays or ultrasound is almost always sufficient for definitive diagnosis. Although CT is the gold standard, treating clinicians should use it sparingly, always making sure that the benefit of making a diagnosis is worth the radiation exposure. Magnetic resonance imaging plays no role.

Disclaimer of Liability

This clinical systematic review and evidence-based guideline was developed by a physician volunteer task force as an educational tool that reflects the current state of knowledge at the time of completion. The presentations are designed to provide an accurate review of the subject matter covered. This guideline is disseminated with the understanding that the recommendations by the authors and consultants who have collaborated in its development are not meant to replace the individualized care and treatment advice from a patient's physician(s). If medical advice or assistance is required, the services of a physician should be sought. The recommendations contained in this guideline may not be suitable for use in all circumstances. The choice to implement any particular recommendation contained in this guideline must be made by a managing physician in light of the situation in each particular patient and on the basis of existing resources.


The guidelines task force would like to acknowledge the Congress of Neurological Surgeons Guidelines Committee for their contributions throughout the development of the guideline, the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Guidelines Committee for their review, comments, and suggestions throughout peer review, as well as Pamela Shaw, MSLIS, MS, for assistance with the literature searches. Throughout the review process the reviewers and authors were blinded from one another. At this time the guidelines task force would like to acknowledge the following individual peer reviewers for their contributions: Sepideh Amin-Hanjani, MD; Maya Babu, MD; Kimon Bekelis, MD; Faiz Ahmad, MD; Daniel Resnick, MD; Patricia Raksin, MD; Jeffrey Olson, MD; Krystal Tomei, MD.


Computer tomography determined intracranial volume of infants with deformational plagiocephaly: a useful “normal”?
J Craniofac Surg
) :
Objective outcome analysis of soft shell helmet therapy in the treatment of deformational plagiocephaly
J Craniofac Surg
) :