Sinking skin flap syndrome visualized by upright computed tomography

Yoshida, Keisuke; Toda, Masahiro; Yamada, Yoshitake; Yamada, Minoru; Yokoyama, Yoichi; Fujiwara, Hirokazu; Kosugi, Kenzo; Fukumura, Mariko; Koike, Kotaro; Takahashi, Satoshi; Yoshida, Kazunari; Jinzaki, Masahiro

doi:10.1007/s00701-020-04459-7

“…Meanwhile, patients can be symptomatic even without radiological signs in supine position 14 , 19 , 25 . Aggravation of symptoms in upright position is a typical characteristic of SSFS 26 , 27 , and a previous case report has shown that upright imaging is effective in obtaining a diagnosis 3 . Although there was no statistically significant difference regarding the extent of PBS between patients with and without symptoms probably due to the small number of symptomatic individuals, it is reasonable to consider that a large PBS is responsible for orthostatic symptoms in SSFS.…”

Section: Discussionmentioning

confidence: 99%

Cranial defect and pneumocephalus are associated with significant postneurosurgical positional brain shift: evaluation using upright computed tomography

Yoshida

¹

,

Toda

²

,

Yamada

³

et al. 2022

Sci Rep

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Only few studies have assessed brain shift caused by positional change. This study aimed to identify factors correlated with a large postneurosurgical positional brain shift (PBS). Sixty-seven patients who underwent neurosurgical procedures had upright computed tomography (CT) scan using settings similar to those of conventional supine CT. The presence of a clinically significant PBS, defined as a brain shift of ≥ 5 mm caused by positional change, was evaluated. The clinical and radiological findings were investigated to identify factors associated with a larger PBS. As a result, twenty-one patients had a clinically significant PBS. The univariate analysis showed that supratentorial lesion location, intra-axial lesion type, craniectomy procedure, and residual intracranial air were the predictors of PBS. Based on the multivariate analysis, craniectomy procedure (p < 0.001) and residual intracranial air volume (p = 0.004) were the predictors of PBS. In a sub-analysis of post-craniectomy patients, PBS was larger in patients with supratentorial craniectomy site and parenchymal brain injury. A large craniectomy area and long interval from craniectomy were correlated with the extent of PBS. In conclusion, patients who undergo craniectomy and those with residual intracranial air can present with a large PBS. In post-craniectomy patients, the predisposing factors of a large PBS are supratentorial craniectomy, presence of parenchymal injury, large skull defect area, and long interval from craniectomy. These findings can contribute to safe mobilization among postneurosurgical patients and the risk assessment of sinking skin flap syndrome.

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“…Post-craniectomy syndrome, trephination syndrome or sunken skin flap syndrome is defined as neurological deterioration or dysfunction after craniectomy, which symptoms worsen when the patient is positioned vertically and improve or disappear once cranioplasty is performed [13]. Its pathophysiology has not been established; however, some studies maintain that elements such as the reduced volume of cerebrospinal fluid, the action of atmospheric pressure that, in the absence of a segment of the cranial vault, alters the content/container balance and leads to changes in intracranial pressure, the amplitude of the craniectomy and the period between it and the cranioplasty participate in the development of the clinical manifestation [13][14][15]. Its diagnosis supposes the precedent of craniectomy accompanied by neurological symptoms such as motor weakness, cognitive deficit, language deficit, altered level of consciousness, headache, seizures, cranial nerve alterations, psycho-emotional symptoms, in a patient who has not undergone cranioplasty.…”

Section: Postcranectomy Syndromementioning

confidence: 99%

“…Despite the relationship that can be established between the appearance of symptoms and the history of craniectomy, it is believed that the syndrome is under diagnosed due to the dissociation between the manifestations and the radiological findings [13]. Findings such as ''paroxysmal'' herniation, deviation of structures from the midline and sunken flap have been reported as non-specific for this syndrome.…”

Section: Postcranectomy Syndromementioning

confidence: 99%

Mccune Albright Syndorme/Craniofacial Fibrous Dysplasia And Postcraniectomy Syndrome: Case Report And Literature Review

Tovar¹,

Rodriguez²,

Valencia³

et al. 2023

ACMR

0

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“…Post-craniectomy syndrome, trephination syndrome or sunken skin flap syndrome is defined as neurological deterioration or dysfunction after craniectomy, which symptoms worsen when the patient is positioned vertically and improve or disappear once cranioplasty is performed [13]. Its pathophysiology has not been established; however, some studies maintain that elements such as the reduced volume of cerebrospinal fluid, the action of atmospheric pressure that, in the absence of a segment of the cranial vault, alters the content/container balance and leads to changes in intracranial pressure, the amplitude of the craniectomy and the period between it and the cranioplasty participate in the development of the clinical manifestation [13][14][15]. Its diagnosis supposes the precedent of craniectomy accompanied by neurological symptoms such as motor weakness, cognitive deficit, language deficit, altered level of consciousness, headache, seizures, cranial nerve alterations, psycho-emotional symptoms, in a patient who has not undergone cranioplasty.…”

Section: Postcranectomy Syndromementioning

confidence: 99%

“…The exacerbation of these symptoms seems to be related to postural changes, especially those that involve standing vertically, as well as the progressive sinking of the skin flap [15][16][17][18]. Despite the relationship that can be established between the appearance of symptoms and the history of craniectomy, it is believed that the syndrome is underdiagnosed due to the dissociation between the manifestations and the radiological findings [13]. Findings such as ''paroxysmal'' herniation, deviation of structures from the midline and sunken flap have been reported as non-specific for this syndrome.…”

Section: Postcranectomy Syndromementioning

confidence: 99%

Mccune Albright Syndrome/Craniofacial Fibrous Dysplasia and Postcraniectomy Syndrome: Case Report and Literature Review

Rodríguez¹

2022

Arch Clin Trial & Case Rep.

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Introduction: McCune Albright syndrome (MAS) is a rare pathology caused by a genetic mutation of the GNAS1 gene that causes fibrous dysplasia (FD) among other endocrinological and metabolic manifestations (1). Here is presented a case report, in which craniofacial dysplasia (CFFD) produces functional alteration, its treatment, and the management of underlying complications. Case report: A 10-year-old female patient who presented with CFD with progressive involvement of the orbital cavity, compression of the optic nerve and right oculomotor cranial nerves, associated with precocious puberty and the appearance of ‘’café-au-lait’’ spots on the skin and finally, the diagnosis of MAS is made. Right front-parieto-temporal craniectomy and intracanalicular decompression of the optic nerve was performed getting partial improvement of functional alteration. Subsequently, cranioplasty is performed to manage postcraniectomy/trephined syndrome. Discussion: MAS is a genetic postzygotic disease that occurs in early stages of embryonic development, which explains its mosaicism. Among its manifestation is FD, which is explained by the hyperfunctioning nature of the mutation. In the case of DCF, continuous surveillance is required by a multidisciplinary team that includes a neurosurgeon, whose intervention is reserved for cases in which functional alterations occur, following the recommendations given by medical literature regarding the approach and type of surgery. Decompressive craniectomy can be associated with complications such as postcraniectomy/trephined syndrome, which shows improvement or resolution with cranioplasty. Conclusion: The diagnosis of MAS is clinical, and its mosaicism is explained by its early presentation in embryonic development. In the case of FCD with functional compromise, neurosurgical intervention is required, seeking the recovery and preservation of the compromised cranial nerves, avoiding prophylactic decompressions. In case of complications such as postcraniectomy/trephination syndrome, timely cranioplasty should be performed as it turns out to be highly effective as a treatment, however, the need for studies aimed at its characterization and diagnosis arises.

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Sinking skin flap syndrome visualized by upright computed tomography

Cited by 5 publications

References 21 publications

Cranial defect and pneumocephalus are associated with significant postneurosurgical positional brain shift: evaluation using upright computed tomography

Cranial defect and pneumocephalus are associated with significant postneurosurgical positional brain shift: evaluation using upright computed tomography

Mccune Albright Syndorme/Craniofacial Fibrous Dysplasia And Postcraniectomy Syndrome: Case Report And Literature Review

Mccune Albright Syndrome/Craniofacial Fibrous Dysplasia and Postcraniectomy Syndrome: Case Report and Literature Review

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