Imaging in the preoperative assessment of conjoined twins

Conjoined twins are rare and present a unique challenge to pediatric surgeons and radiologists. Planning of surgical separation is aided by accurate preoperative imaging. Such twins are classified according to the most prominent site of connection: the thorax (thoracopagus), abdomen (omphalopagus), sacrum (pygopagus), pelvis (ischiopagus), skull (craniopagus), face (cephalopagus), or back (rachipagus). The area of fusion largely determines the imaging modalities used. Thoracic conjunction is most common and requires cardiac assessment. Magnetic resonance imaging and computed tomography provide excellent anatomic and bone detail, demonstrating organ position, shared viscera, and limited vascular anatomy. Contrast material radiography allows evaluation of the gastrointestinal and urogenital tracts, and a shared liver requires assessment of anatomy, vascularization, and biliary drainage. Angiography helps define specific vascular supply, which is useful in determining the distribution of shared structures between the twins at surgery. Each set of conjoined twins is unique. An imaging strategy to accurately define anatomic fusion, vascular anomalies, and other associated abnormalities is important for surgical planning and prognostic information.