Diffuse cranial vault hyperostosis associated with long-term antiepileptic therapy: Autopsy findings and differential diagnostic considerations.
Maria Piagkou, Athina Tousia, George Triantafyllou et al.
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Case in brief
A 53-year-old woman with longstanding epilepsy treated with phenytoin and sodium valproate collapsed and died despite resuscitation. At autopsy, the frontal, parietal, and occipital bones were markedly and symmetrically thickened, with vault thickness of approximately 20 mm. Histology showed expanded diploë with preserved lamellar architecture and no marrow hyperplasia; the dura had focal fibrosis and ossification. Trauma, neoplasia, metabolic bone disease, and hematologic disorder were not identified. Chronic medication-related remodeling, most plausibly associated with phenytoin, was considered the explanation. Death was attributed to recent myocardial ischemia with pneumonia and cerebral atrophy.
What made this case unusual
The combination of diffuse, symmetrical cranial vault thickening and focal dural fibrosis and ossification, with preserved lamellar architecture and no marrow hyperplasia, framed the differential diagnosis in this forensic autopsy.
Diagnostic / clinical pearl
Evaluate marked cranial thickening with clinicopathological correlation, including medication history and histology, while excluding neoplastic, metabolic, hematologic, and traumatic causes.
Why it matters
Recognizing possible medication-associated cranial remodeling may help prevent unusual skull thickening from being misinterpreted in forensic practice.