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PubMed This is a summary of 36 peer-reviewed journal articles Updated
Pediatrics

Understanding Enlarged Parietal Foramina (EPF)

At a Glance

Enlarged Parietal Foramina (EPF) is a rare but typically harmless condition where natural small openings in a child's skull do not close properly, leaving holes larger than 5mm. The brain remains safely protected by a tough membrane and the scalp, and most isolated cases require no treatment.

It can be incredibly startling for a parent to be told their child has “holes in their skull.” However, Enlarged Parietal Foramina (EPF) is a rare but typically benign (harmless) structural condition [1][2]. In many cases, these openings are discovered purely by accident during an X-ray or CT scan for an unrelated reason, such as a minor bump on the head [2][3].

Understanding the Skull’s Openings

To understand EPF, it helps to know what is “normal” for a developing skull:

  • Parietal Foramina: Most people (up to 60%) actually have tiny pin-sized holes near the top-back of their skull [4]. These allow small veins to pass through. Normally, these are only about 1 millimeter (mm) wide—about the size of a pencil tip [4].
  • The “Soft Spot” (Fontanelles): Infants are born with larger gaps between their skull bones called fontanelles, which allow the brain to grow. These usually close by 18 months of age.
  • Enlarged Parietal Foramina (EPF): In children with EPF, the small holes mentioned above do not close as expected during development. Instead, they remain as larger, symmetric openings. By definition, EPF refers to these holes when they are larger than 5mm in diameter [4].

Important Facts for Parents

If your child has been diagnosed with “isolated” EPF—meaning the holes are the only unusual finding—here are the most important things to know:

  1. They Are Usually Asymptomatic: Most children with EPF do not have any pain, neurological issues, or developmental delays caused by the holes [2][3].
  2. The Brain Is Protected: While there are openings in the bone, the brain is still covered and protected by the dura mater (a thick, leather-like membrane) and the scalp.
  3. Hair Grows Normally: The skin and hair follicles over the openings develop exactly as they do on the rest of the scalp. The areas will not be bald or look noticeably different from the outside.
  4. No Treatment Is Often the Best Treatment: In isolated cases, doctors often recommend “watchful waiting” rather than surgery, as the holes do not typically cause medical problems [2].

While EPF is usually harmless on its own, doctors may perform additional checks. To fully understand your child’s diagnosis and what it means for their future, please read through the following sections of this guide:

01

Diagnosis, Imaging, and What the Results Mean

Learn how to interpret your child's Enlarged Parietal Foramina (EPF) radiology report. Understand CT and MRI findings, corticated margins, and venous anomalies.

02

When EPF is Part of a Syndrome

Learn when Enlarged Parietal Foramina (EPF) is part of a genetic syndrome like Potocki-Shaffer. Understand signs, symptoms, and when to seek genetic testing.

03

Management, Treatment, and the Long-Term Outlook

Learn about the long-term outlook and management for Enlarged Parietal Foramina (EPF). Understand helmet use, routine monitoring, and when surgery is considered.

Common questions in this guide

What are enlarged parietal foramina (EPF)?
Enlarged parietal foramina are symmetric openings near the top-back of the skull that measure larger than 5 millimeters across. They occur when small natural holes in a developing skull fail to close completely as a child grows.
Are holes in my child's skull dangerous?
In most isolated cases, these skull openings are completely harmless. They typically do not cause pain, neurological problems, or developmental delays, and are often discovered by accident during routine imaging.
Is the brain exposed if a child has EPF?
No, the brain is perfectly safe and not exposed to the outside. Even though there is a gap in the bone, the brain is fully covered and protected by the scalp and a thick, leather-like membrane called the dura mater.
Will my child have normal hair growth over the holes?
Yes, the skin and hair follicles develop completely normally over these skull openings. There will be no bald spots, and the area will not look noticeably different from the rest of your child's head.
How is enlarged parietal foramina treated?
For isolated cases without other symptoms, doctors generally recommend watchful waiting rather than surgical intervention. Your pediatric specialist will guide you on whether any specific monitoring or follow-up imaging is necessary.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.How large are my child's parietal foramina, and do they meet the criteria for EPF (>5mm)?
  2. 2.Are these holes 'isolated,' or are there signs of other associated conditions or syndromes?
  3. 3.Is there any evidence of vascular (blood vessel) malformations near the openings?
  4. 4.Do you recommend any follow-up imaging or consultation with a specialist, like a pediatric neurosurgeon or geneticist?
  5. 5.Should we schedule follow-up imaging, or simply monitor through routine physical exams?

Questions For You

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References

References (4)
  1. 1

    Bilateral Foramina Parietalia Permagna - A Calvarial Defect Caused by Haploinsufficiency of the Msh Homeobox 2 Gene: A Case Report and Current Literature Review.

    Kahl N, Lüsebrink N, Schubert-Bast S, et al.

    Neuropediatrics 2024; (55(3)):205-208 doi:10.1055/s-0044-1781465.

    PMID: 38447947
  2. 2

    Teaching NeuroImages: Enlarged parietal foramina inadvertently labeled as burr holes.

    Fernandez J, Woodson S, Cannard K

    Neurology 2019; (93(8)):e827-e828 doi:10.1212/WNL.0000000000007978.

    PMID: 31427498
  3. 3

    A retrospective study of incidental findings occurring in a consecutive case series of lateral cephalograms of 12- to 20-year-old patients referred for routine orthodontic treatment.

    MacDonald D, Patel A, Zou B, et al.

    Imaging science in dentistry 2022; (52(3)):295-302 doi:10.5624/isd.20220402.

    PMID: 36238700
  4. 4

    Foramina parietalia permagna: Clinical radiological evaluation of a Spanish family with an undescribed mutation in the ALX4 gene.

    Bote Gascón M, Martínez Del Río C, García Ron A

    Anales de pediatria 2021; (95(2)):121-122 doi:10.1016/j.anpede.2020.07.018.

    PMID: 34315693

This page provides an educational overview of Enlarged Parietal Foramina (EPF). It is not a substitute for professional medical advice, diagnosis, or treatment from your pediatrician or pediatric neurosurgeon.

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