The authors report on their experience with a series of 15 cranial dermal sinus tracts associated with intradural extension that underwent surgical excision. Ten were located in the posterior and five in the anterior cranial fossa. As expected, the anterior locations were associated with an obvious nasal pit, whereas the posterior locations presented with a more variegated clinical pattern (dimple, lump, or sinus tract). Most patients were diagnosed in their early infancy, although in a few cases, the diagnosis was obtained only at a later stage. Also in our experience [1], these lesions were usually diagnosed in early childhood and only exceptionally later than 3 years of age. Likewise, anatomical distribution was quite similar with about 2/3 of the lesions located in the posterior and 1/3 in the anterior cranial fossa. Although rare, these lesions deserve special attention, particularly in a pediatric neurosurgical setting, for the potential adverse effects of infection; actually, also in the authors’ experience, the few negative outcomes were related to sinus infection complicated by leptomeningeal involvement. This risk should prompt the neurosurgeon to remove the sinus tract as soon as the diagnosis is defined. In fact, not only a timely operation eliminates the risk of infection, but also offers the obvious advantage of performing intradural surgical dissection within an intact arachnoid space, before inflammatory scarring has been produced. This is not a minor aspect when considering the need for a radical resection to prevent late recurrences. Actually, dense adhesions of the associated intracranial dermoid to the nervous and vascular structures are a major problem when attempting at a radical cyst removal and can represent the single most important reason for leaving behind some fragments of cyst capsule [2]. The reportedly elevated infectious risk is more important at present in relation to spontaneous infection of the sinus tract (that can occur whenever preoperatively), rather than to an intraoperative contamination that, although still possible, is to be considered far less common as a consequence of the more refined surgical technique and of the antibiotic therapy. One can agree that MRI is fundamental in achieving a correct diagnosis, although, most frequently, it simply confirms what clinical examination has already discovered. These congenital abnormalities probably represent the single field of pediatric neurosurgery where clinical examination still plays as an important role as sophisticated neuroradiological investigation.