Sinking skin flap syndrome with delayed dysautonomic syndrome—An atypical presentation

Abstract

INTRODUCTIONSinking skin flap syndrome or “syndrome of the trephined” is a rare complication after a large craniectomy, with a sunken skin above the bone defect with neurological symptoms such as severe headache, mental changes, focal deficits, or seizures.PRESENTATION OF CASEWe report a case of 21 years old man with trefinated syndrome showing delayed dysautonomic changes.DISCUSSIONOur patient had a large bone flap defect and a VP shunt that constitute risk factors to develop this syndrome. Also, there is reabsorption of bone tissue while it is placed in subcutaneous tissue. The principal symptoms of sinking skin flap syndrome are severe headache, mental changes, focal deficits, or seizures. Our patient presented with a delayed dysautonomic syndrome, with signs and symptoms very characteristics. Only few cases of this syndrome were related in literature and none were presented with dysautonomic syndrome.CONCLUSIONWe reported here a very uncommon case of sinking skill flap syndrome that causes a severe dysautonomic syndrome and worsening the patient condition.

The Effect of Cranioplasty on Cerebral Hemodynamics as Measured by Perfusion Computed Tomography and Doppler Ultrasonography

“…Further, in recent years, we have witnessed a growing number of papers reporting neurological improvement of patients who underwent a cranioplasty or not whether they suffered from a previous worsening 6,8,16,18,31,34,[47][48][49][50][51] (as originally described by Grant and Norcross). 10,11,13,15,25,27,29,33,35,37,39,48 We decided to measure the improvement between 24 h and 72 h after the procedure because these patients might continue to improve despite the absence of the calvarial bone, and we observed a striking 42% objective improvement and 57% subjective improvement.…”

Syndrome of the trephined, a case report

“…In a similar manner, Yamaura and Makino in 1977 described in patients a sudden improvement of neurological deficits after cranioplasty and invented the term ''syndrome of the sinking scalp flap'' [5][6][7].…”

“…Several researchers have tried to explain the complex pathophysiology of this phenomenon and several factors were identified as being related to this syndrome. Some authors [2,3,5,[7][8][9] promote the theory that atmospheric pressure would be directly transmitted to the brain structures in the absence of the bone flap. It would be responsible for the internal displacement of Patients with small-surface craniectomy are usually older with a greater infarct volume thus more sensitive to atmospheric pressure.…”

“…This clinical picture can be aggravated by orthostatism and dehydration. A characteristic neurological improvement of the patient's neurological state after having replaced the skull bone flap will validate the diagnosis [1][2][3][4][5].…”

Can cranioplasty be effective in improving cognitive and motor function in patients with chronic disorders of consciousness? a case report

“…The "trephined" syndrome (or sinking skin flap, SSF) is due to a defect in the skull bone, and it is characterized by neurological symptoms such as seizures, severe headache, focal deficits and cognitive and behavioral changes. Unfortunately, SSF may lead to paradoxical herniation with consequent coma or death (8).…”