Surgical Separation of Craniopagus Report of a Case

Craniopagus (head-conjoined twins) is one of the most infrequent malformations. The following case report demonstrates the application of surgical separation resulted in deaths in a pair of craniopagus. The pair were boys delivered at full term by cesarean section of February 8, 1971. Their parents were healthy and the family history was negative for malformation or twinning. The union of heads involved the entire vertex and the anteroposterior axes of the heads were rotated relative to one another so that faces were directed to opposite sides. They had obviously independent activities, but one twin (Twin A) were larger and more active than the other (Twin B). Because clinical examinations such as GAG, PVG, pan-aortography and indigo-carmine test revealed that there might be marked cerebral deformities, a considerable amount of cross circulation between the twins and abnormal drainages of venous blood to sinuses, the surgical separation was considered very difficult. However, the physical conditions of Twin B deteriorated gradually and there occurred the posibility that Twin Bs conditions might threaten Twin As life. After careful considerations, the performance of the surgical separation as a three stage procedure designed by OConnell was decided. Circumferential skin incision and resuture as the first stage operation and linear craniectomy through conjoined skull as the second operation were performed on March 24, and April 9, respectively. Though pneumonia led to further deterioration of Twin Bs conditions in the postoperative course of the second operation, the final operation which consisted of separation of the twins was carried out on June 4. Exposing the brain hemispheres, it was evident that superior sagittal sinuses of each twins were conjoined partially in the vertex and the deformities of the left hemispheres brought the left frontal lobe of Twin A into contact with the tentorium of Twin B. After superior sagittal sinus of Twin B was ligated and devided at the communicating points with the conjoined sinus, separation was performed as quickly as possible. At the time of ligaturing of the sinus, however, Twin Bs conditions deterirated steadily and he died. TwinA, also, went into shock so soon after Twin Bs death and died about 30 minutes after separation without responding to resuscitative procedures.