Craniopagus twins are a rare phenomenon and present numerous challenges in separation. Due to the paucity of data, it is paramount to evaluate outcomes based on case studies to continue improving medical and surgical management of these patients. We present a case report of craniopagus twins cared for by the senior author (A.K.G.). The patients underwent extensive surgical planning and 2 attempts at cerebroendovascular embolization to reroute shared venous sinus drainage. After the 2 endovascular procedures, attempted separation at age 41 months was aborted due to intraoperative hemodynamic instability. Eleven-year follow-up shows the twins to be developing well in regard to social and cognitive development. Nonetheless, they have had numerous physical challenges including a fall in 2016 resulting in C1-C2 subluxation in twin B leading to partial spinal cord ischemia and left-sided weakness. The separation of craniopagus twins is fraught with technical, medical, and ethical challenges. Surgical separation of the twins is not always possible without significant risk of devastating consequences to one or both twins. Follow-up of the twins 11 years later raises the question: are some craniopagus twins better off without separation?
Keywords: craniofacial morphology; quality of life; surgical complications.