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Clinical Image
Isolated congenital bilateral occipital perforations
Stuart A. G. Roberts1, Guirish A. Solanki2
1MB ChB BSc (Hons) MRCS, Clinical Research Fellow, Department of Paediatric Neurosurgery, Birmingham Children's Hospital, Birmingham, West Midlands, United Kingdom, B4 6NH.
2MBBS FRCS (SN), Consultant Neurosurgeon Department of Paediatric Neurosurgery, Birmingham Children's Hospital, Birmingham, West Midlands, United Kingdom, B4 6NH, Guirish.

Article ID: 100021Z09SR2016

Address correspondence to:
Stuart A. G. Roberts
Department of Neurosurgery, Birmingham Children's Hospital
Birmingham, West Midlands
United Kingdom, B4 6NH

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Roberts SAG, Solanki GA. Isolated congenital bilateral occipital perforations. J Case Rep Images Med 2016;2:59–61.

Case Report

A seven-month-old male Asian baby presented with headache and a large right parietal scalp hematoma after falling from a bed onto a wooden floor. The infant was previously well, born via non-traumatic vaginal delivery following uneventful pregnancy. Normal developmental and growth milestones were met. On examination, Glasgow Coma Scale was 15 with no neurological deficits. In accordance with local guidelines, the infant was investigated via low-dose computed tomography (CT) scan of the head. This showed a right-sided linear non-depressed skull fracture with normal intracranial appearances, seen in a volume-rendered 3D-CT scan (Figure 1). This was managed conservatively via overnight admission to a pediatric unit for observation, and discharged home at 24 hours with post-head injury advice for his parents. Isolated bilateral symmetrical occipital perforations were noted as an incidental finding. The foramina could be palpated gently without discomfort, and were not visibly pulsatile. The volume rendered 3D-CT scan shows full thickness bilateral 6 mm circular foramina with smooth contours in the occipital bone (closed arrows), each 25 mm from the midline (Figure 1). At final follow-up, the infant was well, all scalp hematoma had resolved, however, perforations could still be palpated. No further investigations or treatment were performed.

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Figure 1: A volume rendered 3D-CT scan of the skull of a seven-month-old male-pediatric case, performed following head injury. The arrowheads showing a horizontal right-sided linear parietal skull fracture extending posteriorly and terminating at the lambdoid suture. Also noted are bilateral 6 mm circular full-thickness foramina with smooth contours in the occipital bone (tailed arrows), each 25 mm from the midline.


Cranial foramina are holes within the skull, formed during development, permitting passage of blood vessels and nerves. Animal studies suggest they are formed during cranial development via a process independent of apoptosis, reliant upon local nerve/blood vessel-derived restriction of intramembranous ossification [1]. Historically, midline or slightly mesial symmetrical apertures of the occipital bone related to occipital emissary veins are described [2]. This is inconsistent with our findings. Occipital emissary veins connect the transverse sinus to the occipital vein, draining into the vertebral venous plexus. Larger studies of occipital emissary foramina have not shown bilateral symmetrical foramina, with single foramen consistently closer to the foramen magnum than the occipital protuberance in all specimens, not the case here [3]. Unlike occipital foramina, parietal foramina are well described, resulting from delayed or deficient intramembranous ossification of the parietal bone. Parietal perforations occur as an isolated autosomal dominant trait or as part of a syndrome, and this normally is of no clinical significance [4] [5] . Comparative osteoarchaeological studies describe occipital perforations occurring commonly in cattle but rarely in other species. These perforations are variously attributed as congenital, secondary to tumors, parasites, trauma or infection [6].


In view of radiological and clinical findings, we believe these isolated symmetrical occipital perforations are a rare congenital abnormality of the occipital bone, possibly resulting from delayed or deficient intramembranous ossification of the occipital bone. With no apparent precedent, we believe they are of no clinical significance and will resolve as the child grows. This could interest trainees as an anatomical variant they may see whilst reviewing pediatric imaging. To the best of our knowledge, this is the first described case of bilateral symmetrical occipital perforations, with this distribution in the cranium.

Keywords: Congenital, Occipital, Perforations

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  2. Sper JR, Silverman FN. Symmetrical occipital apertures: A case report. Radiology 1964 Dec;83:1071–2.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Murlimanju BV, Prabhu LV, Pai MM, et al. Occipital emissary foramina in human skulls: an anatomical investigation with reference to surgical anatomy of emissary veins. Turk Neurosurg 2011 Jan;21(1):36–8.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Stibbe EP. Skull showing Perforations of Parietal Bone, or Enlarged Parietal Foramina. J Anat 1929 Jan;63(Pt 2):277–8.   [Pubmed]    Back to citation no. 4
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  6. Fabiš M, Thomas R. Not just cattle: Cranial perforations revisited. International Journal of Osteoarchaeology 2011;21(3):347–50.    Back to citation no. 6
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Author Contributions
Stuart A. G. Roberts – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guirish A. Solanki – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
Conflict of interest
Authors declare no conflict of interest.
© 2016 Stuart A. G. Roberts et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.

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