How I Do It: Unveiling the Imaging Spectrum of Craniopagus Twins Using Multiparametric Assessment

Craniopagus twins are conjoined twins fused at the cranium. Separating these twins is a challenging undertaking, often associated with high levels of morbidity and mortality. Inadequate preoperative planning can lead to suboptimal outcomes, with survival rates reported at approximately 60%. A detailed multiparametric radiologic analysis is essential for understanding the complex anatomy involved in presurgical planning before the separation. Stratifying risk profiles and planning a multistaged separation, when appropriate, is vital to improving the chances of a successful separation. Performing these surgeries requires a careful balance between risks and benefits, making comprehensive and structured radiologic assessments imperative for accurate evaluation. This article presents a systematic, multiparametric approach to the radiologic presurgical planning of craniopagus twins, based on the largest imaging-focused series to date, which includes 15 sets of twins from two tertiary pediatric hospitals, using CT angiography and venography, MRI and MR angiography, and conventional angiography with the aid of virtual and/or augmented reality. The radiologic examination is organized into separate assessments of the bone, dura, shared vessels, and brain parenchyma, highlighting critical anatomic challenges for surgeons, emphasizing the appropriate use of multiparametric radiologic assessments and virtual and/or augmented reality. This article serves as a guide for radiologists and surgeons managing these rare and complex cases.