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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 51-54

Beaten silver appearance: Normal or pathognomic in children?


1 Department of oral Medicine and Radiology, Private Practice, Jind, Haryana, India
2 Department of Prosthodontics, Private Practice, Jind, Haryana, India

Date of Web Publication9-May-2018

Correspondence Address:
Dr. Swati Phore
Department of Oral Medicine and Radiology, Private Practice, Jind, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_28_17

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  Abstract 


Variations and abnormalities of skull appearance and shape are generally related to a primary maldevelopment of the brain. The copper-beaten skull appearance is typically associated with craniosynostosis, where premature fusion of the cranial bone sutures results in the growing brain exerting pressure on the malleable cranium, producing a pattern known as the beaten silver appearance or copper-beaten skull appearance. In this article, we have reported a case of 5-year-old child with classical features of beaten silver skull.

Keywords: Beaten silver appearance, copper beaten, skull


How to cite this article:
Phore S, Panchal RS. Beaten silver appearance: Normal or pathognomic in children?. Int J Oral Health Sci 2018;8:51-4

How to cite this URL:
Phore S, Panchal RS. Beaten silver appearance: Normal or pathognomic in children?. Int J Oral Health Sci [serial online] 2018 [cited 2018 Aug 14];8:51-4. Available from: http://www.ijohsjournal.org/text.asp?2018/8/1/51/232168




  Introduction Top


The skull is composed of many bones that are separated by sutures. These sutures allow the skull to expand and develop in synchrony with the growth of the brain. If one or more sutures close early, especially before the complete growth of brain, they may exert pressure on the skull and may grow in the direction of the other open sutures. This can result in an abnormally shaped head and in severe cases can also cause increased pressure on the growing brain.[1] The order and rate of suture fusion determine the degree of deformity and disability.[2],[3] Premature sutural fusion may occur alone or together with other anomalies, making up various syndromes such as Apert syndrome, Crouzon syndrome, and Pfeiffer syndrome.[4]

These markings are mostly seen in the inner surface of calvarium which is marked by depressions corresponding to gyri of brain and thicker intervening bony ridges corresponding to cerebral sulci. The prominence of these features is dependent on constituent and age of the patient. Skull radiographs in children consistently demonstrate inner table convolutional marking and cerebral ridges which is most adequately evaluated for surgical planning with CT and 3D reconstructions.[5]

The skull radiographs can be used as an important diagnostic method for detecting increased intracranial pressure (ICP). These markings are normal impressions of the gyri, seen predominantly posteriorly. If they are pronounced and over anterior part of the skull, it is referred to as copper-beaten skull.


  Case Report Top


A 5-year-old female patient visited dental clinic with the chief complaint of carious upper front teeth. Her family and medical history was noncontributory, and she was born to nonconsanguineous parents. History revealed that she had normal birth but the different facial features started appearing with age. There were no deleterious habits such as thumb sucking or tongue thrusting.

On examination [Figure 1], gross facial asymmetry was seen, with slight hypertelorism, antimongoloid slant of the palpebral fissures, flat nasal bridge, dolichocephalic skull, and convex facial profile. The cranial vault gave the impression of scaphocephaly with signs of synostosis of the sagittal suture. Auricles were normally positioned. The mandible was retrognathic, with midfacial hypoplasia with deficient zygomas; lips at rest position presented a fishmouth-like picture and incompetent lips. The maxillary dental arch was narrow, and the palatal vault was very high. Maxillary central incisors were decayed. The patient height was similar to kids of her age. The shoulders were droopy, and his developmental milestones were normal.
Figure 1: Extraoral profile of the patient

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The patient was advised for lateral cephalograms [Figure 2] and anteroposterior skull radiograph [Figure 3] to evaluate the facial profile and for any pathology related to the skull. All the investigations were done with due consent of the patient's parents. There was scalloping of the inner table of calvarium along with convolutional markings and thick sclerotic borders. She was referred to the general physician for complete mental and neurological evaluation but was noncontributory. Serum alkaline phosphatase levels were normal ruling out hypophosphatasia. Computed tomography scan was suggested to rule out raised intracranial tension which revealed no definitive evidence of intracranial pathology.
Figure 2: Lateral cephalogram of the patient showing prominent convolutional marking

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Figure 3: Anteroposterior view of the patient showing copper-beaten appearance of skull

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Taking all the features into notice, the patient was provisionally diagnosed as a variant of copper-beaten skull. As all the physical, mental, neurologic, radiographic, and blood investigations showed no abnormality, this condition is considered to be a normal appearance of the developing skull and is normal in accordance with the patient's age. The patient is kept under observation to evaluate any further change in the features or appearance of any abnormality or complications.


  Discussion Top


Variations and abnormalities of skull appearance and shape are generally related to a primary maldevelopment of the brain. This is the result of growing brain which exerts pressure on the malleable cranium, producing a pattern known as the copper-beaten skull (also known as beaten brass skull).

However, the "copper-beaten" appearance of the skull has poor sensitivity in detecting increased ICP as such an appearance can also be seen in normal patients. Prominent convolutional markings of the skull may be first seen at approximately 1 year of age, and their persistence until the 13th year of life is not uncommon. These markings are secondary to pulsations transmitted to the overlying calvaria by the rapidly growing brain. Convolutional markings are inner table indentations that conform to the cerebral surface of the growing brain in infants. The pattern was initially assumed to have resulted from chronically elevated ICP, but currently, it is widely considered to be a reflection of normal brain growth, without pathological significance.[6]

Van der Meulen et al.,[7] Pemmaiah [8] Amant and Gaillard et al.,[9] Mahomed et al.,[10] and Dalfardi et al.[11] stated that these convolutional markings may be normal during periods of rapid brain growth between age 2–3 and 5–7 years, same as in our case. They become less prominent after approximately 8 years of age.

Underlying cause is thought to be related to increased ICP resulting from such processes as craniosynostosis, obstructive hydrocephalus, and/or intracranial masses. However, the copper-beaten appearance of the skull has poor sensitivity in detecting increased ICP as such an appearance can also be seen in normal patients.[12]

Diffuse, severe beaten-copper pattern is an indicator of chronic elevated ICP, which is more common in patients with craniosynostosis. Additional findings associated with a chronic increase in ICP include macrocrania, splitting of the sutures, skull demineralization and erosion or enlargement of the sella turcica. The appearance is more frequent in children with complex, rather than simple, craniosynostosis.[13] In children <18 months, the presence of a diffuse copper-beaten pattern on skull radiography, together with narrowing of the basal cisterns and obliteration of the anterior sulci, increases the likelihood of raised ICP. Imaging plays a key role because the clinical presentation is variable and early diagnosis is essential for proper management and prevention of complications. ICP may be elevated in isolated (55% increased risk) or multiple synostosis that increases risk by 90%, including signs as papilledema, vomiting, and lethargy. Furthermore, esthetic deformity, mental retardation, seizures, and other neurological impairments have also been stated.

Convolutional markings are inner table indentations that are caused by the cerebral surface of the growing brain in infants, particularly during periods of rapid brain growth. They become less prominent after 8 years of age. Convolutional markings are now considered to reflect normal brain growth. If they become prominent and are evident throughout the skull rather than the posterior parts, they reflect a pathologic condition, the so-called copper-beaten skull. Copper-beaten skull can be an indicator of chronic elevated ICP resulting from craniosynostosis, hydrocephalus, and intracranial masses. Rather than the inner table of the skull being smooth, there are convolutions that sit adjacent to the underlying gyri. Convolutional changes may be normal if they are confined to the posterior calvarium and are subtle.

In short, convolutional markings that may be seen at or around the expanding sutures may be considered "normal". The presence of copper-beaten skull appearance may signify a disturbance in normal brain development. They may normally disappear around puberty and should not be interpreted as abnormal unless definite signs of raised intracranial tension are present, such as suture spreading or serial changes are present, which include macrognathia, splitting of the sutures, skull demineralization, and erosion or enlargement of the sella turcica.[6]


  Conclusion Top


The presence of beaten skull appearance may signify a disturbance in normal brain development. They may normally disappear around puberty and should not be interpreted as abnormal unless definite signs of raised intracranial tension are present, such as suture spreading or serial changes are present, which include macrognathia, splitting of the sutures, skull demineralization, and erosion or enlargement of the sella turcica. Thus, this is a classical case where no such pathologies are associated with beaten skull appearance or it could be a varied feature of some syndrome too but is still questionable.

Declaration of patient consent

These authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arathi R, Sagtani A, Baliga M. Crouzons syndrome: A case report. J Indian Soc Pedod Prev Dent 2007;25:s10-2. ISSN 0970-4388.  Back to cited text no. 1
    
2.
Cohen MM Jr. Craniosynostosis and syndromes with craniosynostosis: Incidence, genetics, penetrance, variability, and new syndrome updating. Birth Defects Orig Artic Ser 1979;15:13-63.  Back to cited text no. 2
    
3.
Cohen MM Jr. Craniosynostosis: Diagnosis, Evaluation and Management. New York: Raven Press; 1986.  Back to cited text no. 3
    
4.
Cohen MM Jr. Craniosynostosis update 1987. Am J Med Genet Suppl 1988;4:99-148.  Back to cited text no. 4
[PUBMED]    
5.
Agrawal D, Steinbok P, Cochrane DD. Significance of beaten copper appearance on skull radiographs in children with isolated sagittal synostosis. Childs Nerv Syst 2007;23:1467-70.  Back to cited text no. 5
[PUBMED]    
6.
Available from: https://www.cappskids.org/convolutional-markings-or-copper-beaten-skull/. [Last accessed on 2016 Oct 7].  Back to cited text no. 6
    
7.
van der Meulen J, van der Vlugt J, Okkerse J, Hofman B. Early beaten-copper pattern: Its long-term effect on intelligence quotients in 95 children with craniosynostosis. J Neurosurg Pediatr 2008;1:25-30.  Back to cited text no. 7
[PUBMED]    
8.
Pemmaiah DC. Copper beaten skull. J Med Sci Health 2015;1:46-8.  Back to cited text no. 8
    
9.
Amant MS, Gaillard F. The Copper Beaten Skull. Available from: http://www.radiopaedia.org/articles/copper-beaten-skull. [Last accessed on 2015 Jan 23].  Back to cited text no. 9
    
10.
Mahomed N, Sewchuran T, Mahomed Z. The copper beaten skull. SA J Radiol 2012;16:25-6.  Back to cited text no. 10
    
11.
Dalfardi B, Daneshfard B, Sarikhani S. Craniosynostoses presenting as copper beaten skull appearance. Iran Red Crescent Med J 2016;18:e27545, 1-4.  Back to cited text no. 11
    
12.
Tuite GF, Evanson J, Chong WK, Thompson DN, Harkness WF, Jones BM, et al. The beaten copper cranium: A correlation between intracranial pressure, cranial radiographs, and computed tomographic scans in children with craniosynostosis. Neurosurgery 1996;39:691-9.  Back to cited text no. 12
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13.
Glass RB, Fernbach SK, Norton KI, Choi PS, Naidich TP. The infant skull: A vault of information. Radiographics 2004;24:507-22.  Back to cited text no. 13
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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