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Convolutional Markings or “Copper Beaten Skull”?

“Copper beaten” skull refers to the prominent convolutional markings seen in multiple bones of the skull.

Underlying cause are thought to be related to increased intracranial pressure 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 intracranial pressure 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 intracranial pressure but currently it is widely considered to be a reflection of normal brain growth, without pathological significance.

Diffuse, severe beaten-copper pattern is an indicator of chronic elevated intracranial pressure, which is more common in patients with craniosynostosis. Additional findings associated with a chronic increase in intracranial pressure include macrocrania, splitting of the sutures, skull demineralisation and erosion, or enlargement of the sella turcica. The appearance is more frequent in children with complex, rather than simple, craniosynostosis. 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 intracranial pressure.Screen Shot 2016-02-14 at 10.45.22 AM

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Imaging plays a key role because the clinical presentation is variable and early diagnosis is essential for proper management and prevention of complications. Intracranial pressure (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, aesthetic deformity, mental retardation, seizures and other neurological impairments have also been stated.

CT, MRI, and plain radiography are all techniques available to diagnosing and managing craniosynostoses. Plain radiography can be used to visualize the primary as well as secondary signs of craniosynostosis including fingerprinting and copper beating. CT imaging has the advantage of providing visualization of brain parenchyma and potential malformations. 3D CT reconstructions provides a powerful tool for planning complex surgical interventions. MRI is most appropriate in assessing syndromic types of craniosynostoses, midline anomalies, and intracranial herniation. Alteration to CSF flow dynamics from hindbrain herniation is best assessed by MRI.

Normal convolutional markings or copper beaten?

Increased convolutional markings, and copper beaten skull are confusing terms.

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 eight years of age. Convolution- al 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 intracranial pressure 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.

It is best to discuss this finding with your specialist.  The information here is from a variety of resources and studies and is not necessarily the opinion of one particular study.