Circumferential venous sinus: an innovative separation method for total vertical type II craniopagus twins

Area of Science:

• Neurosurgery
• Congenital Malformations
• Vascular Surgery

Background:

• Craniopagus twins, especially type II, present rare and complex surgical challenges.
• Successful separation of conjoined twins is contingent on intricate surgical planning and execution.
• Shared vascular structures, like venous sinuses, pose significant risks during separation.

Purpose of the Study:

• To present a novel surgical strategy for the staged separation of craniopagus twins.
• To report the successful separation of the oldest craniopagus twins to date.
• To highlight the importance of adaptive surgical planning based on venous anatomy.

Main Methods:

• Advanced imaging (CT, MRI) and 3D modeling for surgical planning.
• Virtual reality simulation for pre-operative rehearsal between international teams.
• A staged surgical approach with a paradigm shift based on intraoperative findings of venous dependency.
• 7 staged surgeries, culminating in a 31-hour final separation.

Main Results:

• Successful staged separation of craniopagus twins at 3 years 9 months, the oldest documented.
• Division of a shared circumferential venous sinus without neurological compromise.
• Achievement of independent circulations and successful recovery for both twins.
• Demonstration of an adaptive surgical protocol prioritizing critical venous outflow.

Conclusions:

• Individualized surgical planning and international collaborative simulation are crucial for complex conjoined twin separations.
• Adapting separation strategies based on detailed venous architecture is vital for patient safety.
• This case expands the possibilities for surgical intervention in craniopagus twins, even at advanced ages.